In the new year, I always like to begin the Round Table Discussion with a piece on normal aging. Frequently we get bogged down in the negative aspects of the aging process – the expected losses, illness and disease, poor mental health or the fragmented health care system. But I like to keep in mind that aging is part of a developmental process and despite illness, there is something we can call “normal aging” which is the expected accumulation of unavoidable physical changes including muscle weakness and joint paint, vision and hearing changes, and a slowing down of thought processes. Not only are there physical changes, but also multiple role changes – retirement, grandparenting and downsizing. Basically, nothing dramatic or crisis driven – just expected aging changes. And with “normal” changes come transitions and decision making.
It is rather a mantra that normal aging implies loss. How many times have we as clinicians heard or used the phrase, “loss of independence” to describe a person’s depression or anger or insistence on not accepting help. In trying to help a person adjust to these losses we often need to support and convince someone that there is still much to look forward to, reasons to be alive and meaningful activities to engage in. But the biggest hurdle to overcome seems to be loss of independence – the inability to continue to do things on one’s own without assistance. This journal article re-frames the concept of independence using, instead, the idea of control. It was helpful to consider about someone might be able to shift their perspective and recognize there are aspects of their lives they can control and over which they do have choice. Or having met challenges in the past, both personal and historical, reflecting on those experiences and using those strengths as they meet the challenges of aging.
What makes one person resilient while another unable to move ahead? Why do some people accept their limitations with grace? The author of this journal article attempts to put a generational perspective on this. We at the table thought it had much more to do with one’s personal narrative and psychology. We spoke of one gentleman who is wheelchair bound but is determinedly stuck on wanting to be able to walk despite the reality. It is his singular focus. I wonder if this gentleman could be helped to see aspects of life that he can control, such as choosing who cares for him, what he chooses to read or eat, with whom does he choose to interact. I wonder if expressing these choices might help him get beyond his admittedly profound disability and limitations. While these are apparently simple choices perhaps this too is an aspect of normal aging – accepting and appreciating the smaller parts of life. Having control over certain domains, the author defines as miniaturization. Unfortunately, the word has a slight negative connotation, but the concept is an important one.
Certainly, we’ve all known people who have tried to take utmost control of situations. I’m thinking especially of people I knew in a nursing home environment who became demanding and difficult. Had we been able to give these people a sense of control about when they woke up or given a bath or with whom they shared meals, might that have given them a sense of control – again, small and miniature, nevertheless important and meaningful.
A continuing theme of our discussion was maintaining a positive sense of self in spite of change. One very poignant example was raised describing how an older adult who has lived with the secret of being LGBT. Now in the context of enormous cultural change, it may be difficult to confront one’s identity and story at the same time as becoming increasingly vulnerable as an aging adult. Incorporating one’s sense of self into a changing society was also highlighted in the journal article as expressed in the interviews with people of color. The historical changes they have lived through suggests that their experiences of discrimination earlier in life have had a positive impact and instilled a resilient attitude that was accessed while moving through the challenges of aging.
The author speaks of generativity as an important component in personal control and adds, “Kotre (2005) later expanded Erikson’s (1963) concept of generativity to include having faith in life itself, which is an apt description of older adults’ belief that there is always someone who needs their love, encouragement, or expertise.” I’m not sure that knowing that someone always needs your love and encouragement would necessarily make one feel more in control, but I do think it speaks to the importance of having elders in our circle of relationships.
The Round Table Discussion Group meets monthly for an interdisciplinary conversation with experienced professionals in the field of aging. Each conversation uses one or two journal articles as a reference point. The article read for this discussion was
Managing Threats Against Control in Old Age: A Narrative Inquiry, Helen K. Black, Holly R. Santanello, Christa J. Caruso, Nursing Research, November/December 2013, Vol 62, No 6, 430–437
Expands on concept of generativity “having faith in life itself, always someone who needs their love, encouragement or expertise.
Though not exactly pertinent to the discriminating between control and independence, the author has also reconsidered the meaning to the word “suffering.” In another journal article by the same author she quotes from a 1997 journal article and defines suffering “as a subjective experience…linked to the loss of primary life values, such as health, relationships, independence, money, etc. As these values are interpreted as meaningful, their diminishment may be perceived as a threat to the ‘integrity of self.’” (Graneheim, e al, Description of suffering in connection with life values, Scandinavian Journal of Caring Sciences, 1977) How to maintain one’s self esteem in the face of change. Aging really does effect one’s sense of self. How to hold on to that. This is integrity. Suffering takes an emotional toll on one’s sense of self. Can you still tell the same narrative?
This journal article raised two other concepts that were intriguing to me, though not directly related to control and independence.
If I can recognize that interests change in “normal” ways, then my choices change as well and what I have control over also shifts. Can and do interests change? I’m no longer interested in cooking and preparing elegant meals? My reading choices have changed. My interest in making social connections and friendships have changed, I’m looking for more deeper and meaningful connections. My husband’s drive and ambition has shifted. These are changes – call them loss, call them change/shift in narrative and perspective. But if I can accept these changes – in fact look forward to them – do I also recognize that I may be giving up part of my independence?
But if we could reframe this and talk about how much control someone does have over their life choices and in fact, daily choices, recognizing that in fact they have more control than they thought.
The narrative of one’s life determines how one will accept changes in ability.
Because “normal” aging is a diffuse topic, it led us in many directions.
She considers multiple effects on self and narrative – the life story and the social context.
And so we talked about future planning and how people don’t want to do it. Don’t want to think about crises or “this could never happen to me.” Planning for the future. I never thought this would happen to me. Thinking ahead, thinking about multiple variables. Accepting the unknown. Making choices, voices preferences before a crisis.
Depending on one’s support system – both social supports and financial and economic resources – will effect how you transition through the losses – which I suppose is the point of having social workers in settings.
What is it like for people who have lived in the shadows because of discrimination – people of color, LGBT – to now “come out” at a time of their increasing vulnerability as they age.
Suicidal ideation as a form of control/ manipulation.
Loss as similar as stages of grief.
Disability they have received differently.
Is it possible to reframe the discussion to control, not independence. What parts of your life can you control now. How