WORKING IN THE FIELD OF AGING:

CHALLENGES & OPPORTUNITIES

Patrick Arbore, Ed.D.

Director & Founder Center for Elderly Suicide Prevention and Grief Related Services

Institute on Aging, San Francisco, CA

1

Friendship Line – 800.971.0016

24-Hour Accredited Crisis Intervention Telephone

Hotline/Warm-line – Founded in 1973:

• Call-In Service – Confidential telephone discussions for

people 60+ (their caregivers or younger disabled) who

may be lonely, isolated, bereaved, depressed, anxious

and/or thinking about death or suicide

• A caller does not need to be in a suicidal crisis to use the

call-in service

• Mia Grigg, Friendship Line Director, mgrigg@ioaging.org

• Patrick Arbore, parbore@ioaging.org or 415.750.4133

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Friendship Line

• Call-Out Service – Friendship Line Staff or Trained

Volunteers will make phone calls to older adults for

emotional support – Referrals can be arranged by calling

IOA Connect 415.750.4111

• Grief Services – Saturday Morning Drop-In Traumatic

Loss Group – 10:30 a.m. – Noon – 8-week Traumatic

Loss Grief Group and 8-week Advanced Traumatic Loss

Grief Group – Contact IOA Connect for more Information:

415.750.4111

3

NO EXPERIENCE IS LOST

"Aging is far from being only a process of reducing, wilting

and fading. Old age, like every other stage of life has its own merits,

its own magic, its own wisdom, its own sorrow. In the peak periods

of all cultures, old age was revered for good reasons. Today we

worship adolescence and we won't hold it against the young that

they see their phase as the best, but let us not believe this nonsense

propaganda that old age is worthless... Whoever becomes old

consciously, can observe that in spite of diminishing powers and

potencies, every year brings an increase and an enhancement in

the infinite web of relations and connections. As long as one is

conscious, nothing temporary, no past experience is ever truly lost."

-Hermann Hesse, The Seasons of the Soul

4

Aging

• We begin aging at birth

• The meaning of aging and those who are

identified as older adults are determined by

society and culture

• Aging is influenced by history and gender

5

January 2016 The Population Reference

Bureau report, "Aging in the United States"

• The number of Americans ages 65 and older is projected

to more than double from 46 million today to over 98

million by 2060, and the 65-and-older age group’s share

of the total population will rise to nearly 24 percent from

15 percent.

• The older population is becoming more racially and

ethnically diverse. Between 2014 and 2060 the share of

the older population that is non-Hispanic white is

projected to drop by 24 percentage points, from 78.3

percent to 54.6 percent.

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Key Findings "Aging in the United States"

• By 2014, 23 percent of men and about 15 percent

of women ages 65 and older were in the labor

force, and these levels are projected to rise

further by 2022, to 27 percent for men and 20

percent for women.

• More than one-fourth (27 percent) of women

ages 65 to 74 lived alone in 2014, and this share

jumps to 42 percent among women ages 75 to

84, and to 56 percent among women ages 85

and older.

7

Sexual Minority Status and Aging

According to Teaster, White, & Kim (2016):

• There are approximately 1.4 to 3.8 million

LGBT elderly in the US

• By 2030, this number is expected to

increase to between 3.6 and 7.2 million as

the Baby Boomers age

Minority Status & Sexual Minority Status

• Because it has taken decades for evidence

to emerge (this population is often unseen),

data suggest that social isolation affects a

disproportionate number of older

individuals who continue to deal with

stigma, discrimination ageism, racism,

homophobia, and transphobia

Real Old Age

According to Jacoby (2011):

• Is it realistic to think that both a billionaire and a nonunion hotel maid ought to be able to save enough money to finance a 30-year retirement?

• Are doctors candid with people about their chances of survival after a specific treatment or procedure? What are the consequences of continuing aggressive medical treatment?

• Are our oldest elders capable of leading fully independent lives?

10

Retirement – According to James et al (2016)

• Current retirees are living longer than did

members of previous cohorts

• This “third age” is a time during which older

adults have new opportunities for self-

realization and fulfillment

• This new reality has left many older adults

wondering how they will live, what they will

do and who they will be for the next 20 to

30 years

11

Retirement

• For workers over the age of 55, the labor

force participation rate is up about 10%

compared with about 20 years ago

• Pre-retirees indicate a need or desire to

work past-conventional retirement ages

• Approximately 18% of non-retired

Americans aged 50 and older indicated that

they do not plan to retire at all

12

Key Findings "Aging in the United States"

• Demand for elder care will also be fueled by a

steep rise in the number of Americans living

with Alzheimer’s disease, which could nearly

triple by 2050 to 14 million, from 5 million in 2013.

• The large share of elderly also means that Social

Security and Medicare expenditures will

increase from a combined 8 percent of gross

domestic product today to 12 percent by 2050.

13

According to Data Compiled by the Social Security

Administration:

• Very advanced age will be the experience for

many of us

• Average U.S. life expectancy:

• A man reaching age 65 today can expect to live, on

average, until age 84.3.

• A woman turning age 65 today can expect to live, on

average, until age 86.6.

• And those are just averages. About one out of every four

65-year-olds today will live past age 90, and one out of 10

will live past age 95.

14

Life-Expectancy and Society

According to Moody and Sasser:

“A society in which life expectancy is believed to

increase at every age and in which one becomes

increasingly feeble as one grows older is a society

heading for trouble. …a society moving toward a

world in which there is little or no disease, and

individuals live out their natural life span fully and

vigorously, with a brief period of

infirmity…Dramatic changes in mortality patterns

result in equally dramatic social changes.”

Life-Expectancy Continued

• “The numerical increase in the size of the

aged population over the next 30 years will

mean that the number of older persons who

are dependent, disabled, and suffering the

functional consequences of multiple chronic

conditions will be larger than it has ever

been, far larger than most countries are

prepared to manage.” – Moody and Sasser

DE-PEOPLING THE WORLD

"Every person seventy-eight years old lives in

a somewhat de-peopled world. The trouble for me

is that I often loved people much older and wiser

than I. So I'm left now in the lurch, being, trying to

be, the old wise one and feeling like a great

goose."

May Sarton, Endgame: A Journal of the Seventy-Ninth Year

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The report National Health Expenditure Data,

2015:

• NHE grew 5.8% to $3.2 trillion in 2015, or $9,990 per person, and accounted for 17.8% of Gross Domestic Product (GDP).

• Medicare spending grew 4.5% to $646.2 billion in 2015, or 20 percent of total NHE.

• Medicaid spending grew 9.7% to $545.1 billion in 2015, or 17 percent of total NHE.

• Private health insurance spending grew 7.2% to $1,072.1 billion in 2015, or 33 percent of total NHE.

• Out of pocket spending grew 2.6% to $338.1 billion in 2015, or 11 percent of total NHE.

• Hospital expenditures grew 5.6% to $1,036.1 billion in 2015, faster than the 4.6% growth in 2014.

• Physician and clinical services expenditures grew 6.3% to $634.9 billion in 2015, a faster growth than the 4.8% in 2014.

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NHE Continued

• Prescription drug spending increased 9.0%

to $324.6 billion in 2015, slower than the

12.4% growth in 2014.

Real Old Age

• The most significant forms of impairment

are ADL disabilities (basic self care tasks,

such as bathing, dressing, getting in and

out of bed, eating) – physical or mental

decline prevents people from managing

important aspects of their lives

• ADL disabilities produced by dementia are

most strongly associated with the need for

institutional care

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Instrumental Activities of Daily Living (IADLs)

• IADLs are tasks necessary to conduct the

business of daily life and also requiring

some cognitive competence, such as

telephoning, shopping, food preparation,

housekeeping, and paying bills

• The proportion of older adults with these

limitations rises sharply with age

21

Real Old Age

• More than 5 million Americans suffer from

Alzheimer’s Disease

• By the year 2050, there will be 13.4 million

Americans with AD

• There is no cure at this time

• Currently, AZD can be delayed but not

stopped

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Real Old Age

• Older adults have one of the highest rates

of suicide

• Age related sensory changes affect one’s

view of self and one’s ability to relate to

others

• Substance abuse is a hidden epidemic

among the elderly

23

Denial of Aging

According to Gillick (2006): “When we

believe we will stay young forever, and

when we purchase special vitamins, herbs,

and other youth-enhancing chemicals to

promote longevity, we are engaging in

massive denial.”

24

Denial

• Americans spend an extraordinary $6 billion

annually on “anti-aging” remedies

• Aging (baby) boomers and their aging cohort take

pills and dietary supplements that purport to

prevent illness, cure diseases and promote long

life

• There is overwhelming evidence that the

remedies are ineffective at best, harmful at worst

– and a phenomenal waste of money

25

Physical Characteristics Associated With Older

People

• Wrinkled Skin

• Gray or White Hair

• Slow Movement

All of these assist rapid identification of

people based on their (old) age

The labels we give to these social

categories vary but include: old people,

elders, seniors, senior citizen and the elderly

26

People Watching

• What happens almost automatically when you

glance at people you pass walking down the

street? We tend to categorize people along three

dimensions – race, gender and age

• The study of racism has been and continues to

be a major focus of research

• Studies of prejudice based on gender are also

prevalent

• There has been comparatively little research

based on prejudice related to age (Nelson,2005)

27

Ageism

According to Butler:

“Ageism can be seen as a process of systematic stereotyping of and discrimination against people because they are old, just as racism and sexism accomplish this with skin color and gender. Old people are categorized as senile, rigid in thought and manner, old-fashioned in morality and skills…Ageism allows the younger generations to see older people as different from themselves; thus they subtly cease to identify with their elders as human beings.” p. 12

28

Ageism

• Although ageism is found cross-culturally, it is essentially prevalent in the US where aging is associated with depression, fear, anxiety, impotence, senility, impoverishment and unhappiness

• It is important for those who care for older people to be aware of their own attitudes toward aging and recognize how their beliefs may influence communication

29

Ageism Continued

• Ageism promotes the idea that older people

are a burden and this can lead to neglect

and social exclusion

• Ageism can reduce older people’s self-

esteem, reduce their participation in society

and restrict the types and quality of

services available to them

30

Facebook Study

A 2014 published study by Yale researchers on

content analysis of Facebook groups that had

descriptions about individuals aged 60 years of

age and older (mean age of group creators was

20-29 and no one > than 59) netted the following

results:

• 74% of the total descriptions harshly criticized

older people “they do not contribute to modern

society at all”

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Facebook Study Continued

• 41% of the descriptions referred to physical

debilitation, 27% to cognitive debilitation, and

13% to both forms of debilitation

• An example: “I hate everything about them (old

people), from their hair nets in the rain to their

white Velcro sneakers. They are cheap, they

smell like {expletive deleted}…they are senile…

• 37% of the descriptions advocated banning older

people from public activities

• 26% of the descriptions infantilized older people

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Facebook Study Continued

• In 37% of the groups, the creators

advocated banning older individuals from

various types of public activities

• Among the banning groups, driving was the

activity most frequently targeted (35%)

• THE MEAN AGE OF THE GROUP CREATORS

WAS 20-29 – Had a total of 25,489 members –

65% were men

Ageism in the Workplace

According to an AARP Study (2013), “approximately two-thirds of workers ages 45-74 state that they have seen or experienced age discrimination in the workplace. Of those, a remarkable 92% state that age discrimination is very, or somewhat, common”

34

Co-Occurrence of Ageism and Abuse

• The negative attitudes that lead to ageist

behavior also make it easier for the

perceiver to regard the welfare and

humanity of adults as less important than

that of younger adults

• As such, ageism may indeed be a

contributing factor that leads some younger

adults to neglect, exploit, or otherwise

abuse older adults

35

Ways In Which You Can Reduce Ageism

• Examine your own attitudes toward aging

• Gather information on facts of aging

• Avoid use of ageist terms

• Refuse to support those who discriminate

against older adults

• Join or support groups that oppose ageism

36

Modern Gerontology

According to Schachter-Shalomi (1995):

• M.G. treats aging as a problem of social engineering to be solved through technological means

• The one-sided drive to alter, reverse, or somehow control the biological process of aging actually impoverishes its meaning.

• So-called positive aspects of aging turn out to be disguised efforts to restore youth instead of appreciating growing old as a fundamental part of the human experience

37

A Future with Dignity

According to Al-Jen Poo (2015):

• We must achieve a profound cultural shift in how Americans feel about aging and care.

• Our new stories about care and aging must be told so that many different kids of people can relate to them on an emotional level

• Actually seeing older people as the complex people they are will be a huge relief for younger and middle-age adults who, consciously or unconsciously are plagued by unease about their own later years

38

Chronic Conditions

• Chronic illness is much more common

among the old than among the young

• Rates of chronic illness are 46%for those

>65 compared with only 12% for those <65

39

Question

How do older adults manage to accept

declines and losses yet still feel whole and

complete and anticipate death with calm

composure?

40

One Possible Answer

41

Spirituality and Religiosity

According to Gallup News Service (2012),

over 70% of Americans >65 said that religion

is very important in their lives – late life

increase in religiosity is modest, however

Challenges

• If the aging process reveals to us the

mystery of life, then life’s ultimate meaning

cannot lie in speed, consumerism, youth,

achievement, celebrity, and physical beauty

• The present situation of many older people,

old and young alike, has been described as

a disease of the imagination

42

Challenges

• Some people have accepted the negative images of old age, made them their own, and begun to live out of these images of incompetence and insignificance

• The task of a spirituality of aging is to convert the imaginations of both old and young to a new vision of the human

• This can only happen if the old themselves refuse to let society define them – and instead internalize new images of the later years

43

According to Ram Dass

• All people involved in spiritual traditions

agree that preparation for death is the

single most important spiritual practice

available to us throughout our lives

• In recognizing our own mortality, we are

forced to ask the question: Is there

something beyond this body? If yes, what is

it?

44

A Buddhist Perspective on Death

According to Pema Chodron:

• We are raised in a culture that fears death and hides it from us. Nevertheless, we experience it all the time

• We experience death in the form of disappointment, in the form of things not working out.

• We have endless moments to practice letting go, to learn about grieving, and to prepare for death

• We prepare for birth but for the miracle of death, we rarely prepare at all.

45

The Two Unfixables According to Dr. Gawande

• Aging

• Dying

The story of aging is the story of our parts.

The Meaning of Life

• For human beings, life is meaningful

because it is a story – A story has a sense

of a whole, and its arc is determined by the

significant moments, the ones where

something happens.

• In stories, endings matter p.

238-239

A Monumental Transformation

• People have an alternative to withering in old age homes

and dying in hospitals

• We’ve begun rejecting the institutionalized version of

aging and death

• No matter how miserable the old system has been, we’re

experts in it

• You agree to become the patient; the doctor agrees to try

to fix you despite the misery, damage, or cost p.

193

Courage in Aging and Sickness

There are at least two kinds of courage in

aging and sickness:

1. Courage to confront the reality of

mortality

2. The courage to act on the truth we find

Gawande wonders: One has to decide

whether one’s fears or one’s hopes are what

should matter most

Shaping Our Stories

• Our most cruel failure in how we treat the

sick and the aged is the failure to recognize

that they have priorities beyond merely

being safe and living longer; that the

chance to shape one’s story is essential to

sustaining meaning in life; that we have the

opportunity to refashion our institutions, our

culture, and our conversations in ways that

transform the possibilities for the last

chapters of everyone’s lives p. 243

Vital Questions

Where you or your loved one would prefer to

spend their last days? At Home? In

Hospice? In Hospital? Cultural/Ethnic

Considerations?

• Who will the person want to take care of

him/her?

• What kind of funeral services do they want?

• Do they want to be buried? Cremated?

Mental Health Concerns of the Dying

• People fear that their pain, symptoms, anxiety, emotional suffering, and family concerns will be lost

• In hospitals, many dying people receive unwanted treatment that prolongs pain

• Many patients fear that their wishes (Advanced Directives) will be ignored

• People fear that they will face death alone and in misery

• Anxiety and depression may result from the stress of the disease and fears about death

Death in the ICU

Based upon research from the Dana Farber

Cancer Institute:

• Was associated with 11 times higher rates

of post-traumatic stress disorder and 9

times higher rate of generalized anxiety

disorder among bereaved caregivers

• Hospital deaths were associated with 10

times higher rates of prolonged grief

disorder in bereaved caregivers

Advance Care Planning

• Average ACP conversation in hospital is 5.6

minutes with MDs doing most of the talking;

there is little exploration of patient values

• Medical perception is that patient’s don’t

want to talk about this

• Uncertainty regarding prognosis &

outcomes

• Perception that palliative care & aggressive

care are mutually exclusive

Advance Care Planning

• Unrealistic expectations on the part of the

physicians, patients, and caregivers

• Death implies “giving up” = “failure”

• Conversations happen too late, without

patient preparation, and at times when

patients and caregivers are at their “worst”

• Focus on procedures are unimportant –

patients are experts on personal values

End-Of-Life (EOL) Conversations

Principles:

• EOL conversations are about managing anxiety and decision-making

• Decisions require re-negotiation over time

• Patients need time to cope with anxiety

• Decision-making is a process

• Focus on what is important to the patient rather that on what is important to the physician

The Debate

• At root, the debate is about what mistakes

we fear most – the mistake of prolonging

suffering or the mistake of shortening

valued life

• Only a minority of people saved from

suicide make a repeated attempt

• The terminally ill who face suffering that we

know will increase, only the stonehearted

can be unsympathetic p. 244

Becoming Aware

• Become aware of your fears – Whatever the feeling you must go to the root of the emotion, which is a part of your personality that you do not know about, or are too frightened or ashamed to acknowledge

• We need to become aware because older age is a time for the cultivation of wisdom and integrity – older age is a time for going deeper into the self

Becoming Aware

• Recognize how your body feels when it

experiences the sensation of anger,

sadness, disappointment, joy, delight etc. –

speak with someone who will listen about

your “inner” experience

• If you do not challenge your negative

feelings, you will die with them – so change

an aspect of yourself now

Ability to Care for Oneself

1. What are the expectations and limitations for myself in this work?

2. What are the most stressful aspects of work with the old, the sick, the suffering, the dying and the bereaved?

3. What am I doing to help myself cope with the stressful aspects of my work?

4. What are personal warning signs indicating I am being stressed?

5. How do I nurture and replenish myself in this work?

Developing an Interest in Spirituality

According to Zukov:

• This begins with an experiment in trusting

• Trusting that your life is meaningful and that your experiences happen for a reason

• You must challenge your anger, jealousy, vengefulness, greed, and all other forms of fear

• It does not require blind faith or believing any expert or authority

Readings

Anderson, M. (2003). Sacred Dying: Creating rituals for embracing the end of life. New York: Marlow and Company.

Coutts, M. (2014). The Iceberg. New York: Black Cat.

Gawande, A. (2014). Being Mortal: Medicine and what matters in the end. New York: Metropolitan Books.

Jenkinson, S. (2014). Die Wise: A manifesto for sanity and soul. Berkeley: North Atlantic Books.

Joseph, E. (2014). In the Slender Margin: The intimate strangeness of death and dying. New York: Arcade Publishing.

Readings

Kalanithi, P. (2016). When Breath Become Air. New York:

Random House.

Katz, R., & Johnson, T. A. (eds). (2016). When

Professionals Weep: Emotional and countertransference

Responses in palliative and end-of-life care. New York:

Routledge.

Neumann, A. (2016). The Good Death: An exploration of

dying in America. Boston: Beacon Press.

Readings

Moody, H.R. & Sasser, J.R. (2015). Aging: Concepts and

controversies (8th ed).

Rosowsky, E. (2005). Ageism and professional training in

aging; Who will be there to help? Generations.

Currey, R. (2008). Ageism exists everywhere… Aging well,

vol 1.

Wink, P. & Dillon, M. (2003). Religiousness, spirituality, and

psychosocial functioning in late adulthood: Findings from a

longitudinal study. Psychology and aging, 18(4).

Readings

Harley, D. & Teaster, P., (eds). (2016). Handbook

of LGBT elders: An interdisciplinary approach to

principles, practices, and policies. N.Y.: Springer.

Jahn, D., Poindexter, E.K., Graham, R.D., and

Cukrowica, K.C. (2012). The moderating effect of

the negative impact of recent life events on the

relation between intrinsic religiosity and death

ideation in older adults. Suicide and life-

threatening behavior, 42(6).

Readings

Reiff, D. (2008). Swimming in a Sea of

Death: A son’s memoir. New York: Simon &

Schuster.

Schillace, B. (2015). Death’s Summer Coat:

What the history of death and dying teaches

us about life and living. New York: Pegasus

Books LLC.