Assessment 2 EXCERCISES Choose one exercise to submit from Module 2 (exercise 2.2 or 2.3) and Module 3 (exercise 3.1 or 3.2). See the modules for details 23 Apr 20% 2 x 500 word exercise submissions from Module 2 and Module 3 GER4FSG Foundation Studies in Gerontology Module 2: Perspectives on Ageing This material is based on copyright material prepared for the Public Health Education and Research Program, Department of Health and Ageing, in 2005. Since 2008, it has been developed and regularly updated by Dr Angela Herd of the Australian Institute for Primary Care & Ageing for teaching purposes. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 2 Contributors The University of Newcastle Professor Julie Byles Dr Lynne Parkinson Professor Kichu Nair Mr Bob Kucera Ms Jane Gibson Victoria University Ms Susan Feldman Professor John McCallum Curtin University of Technology Ms Barbara Horner Professor Duncan Boldy Department of Health & Ageing Mr Kevin Vassarotti Ms Wendy Banham Ms Felicity Barr Felicity Barr Consultancy Services Authors ‘Perspectives on Ageing’ Dr Colleen Cartwright Dr Lynne Parkinson ISBN 0-9757622-4-9 The University of Sydney Associate Professor Cherry Russell Professor Robert Cumming Professor Hal Kendig Associate Professor Susan Quine La Trobe University Associate Professor Colette Browning Professor Rhonda Nay Southern Cross University Dr Colleen Cartwright Mrs Barbara Squires Director, Centre on Ageing, The Benevolent Society Mrs Jill Hall, MP Federal Member for Shortland, NSW Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 3 CONTENTS SCENARIO .................................................................................1 YOUR SITUATION .......................................................................2 OBJECTIVES ..............................................................................3 INTRODUCTION..........................................................................4 SOCIOLOGICAL PERSPECTIVES ON AGEING...................................5 BIOLOGICAL PERSPECTIVES ON AGEING.....................................11 ECONOMIC PERSPECTIVES ON AGEING.......................................16 POLICY DEVELOPMENT..............................................................23 Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 1 SCENARIO Part A Bill is a 76-year-old man whose wife Jean died three months ago, after a long, drawn-out illness. Bill’s daughter, Meg, lives in the same large regional town as Bill does; his son, David, lives in Sydney. Both Meg and David are married. Meg has three children and David has one. Bill lives in his own home, and, while Jean was ill, took great pride in his ability to look after her and their home. He particularly enjoyed working in the garden and won prizes at the local show for his orchids. A few weeks ago Bill went to visit his local GP, as he had not been feeling well. He has been having a few “dizzy turns” and has also complained to Meg of soreness in his hands and feet. He has also had a bad cold for a few weeks, which he is finding hard to shake off. Bill tells Meg that the GP gave him several prescriptions for medication but he is not exactly sure what they are for. Meg is worried about Bill, as he doesn’t seem to be looking after himself—the house is not as clean as it used to be and he seems to have lost interest in the garden. Meg has very little time to spend with Bill as both she and her husband work full-time and their three children have a lot of school and sporting activities. She also has to look after her own home and family needs. She sometimes feels that David could come up more often and spend time with Bill, but David tells her that his work and family take up all his time. Part B Since Jean died, Bill hasn’t really felt that life is worth living. He has very few friends—as he and Jean lived out on the farm for most of their lives—and the few friends he had have either died or moved to the coast when they retired. Meg phones him once or twice a week but she doesn’t have time to visit him very often as she works full-time and has her own home and family to look after. Bill is adamant that he will not be a burden on Meg. Meg is worried about what will happen if Bill becomes really ill or develops dementia. She promised her mother that she would take care of him but she doesn’t think she and her husband could manage financially unless she stays at work full-time. Neither she nor her husband have built up very much superannuation, as they owned their own small business until a few years ago; when the drought hit their region the business went broke. Meg’s husband is quite a lot older than she is, and he wants to retire in about 10 years’ time, when the children have finished school. Meg wants to keep working as long as she can, so that she will have enough money to live reasonably when she retires. She knows that the government has changed the policy about the retiring age for women and wants people to continue to work past 65. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 2 YOUR SITUATION You are a journalist who has been asked to write a feature article on “Ageing in Regional Australia”. You decide to conduct some interviews in a large regional town with a range of people who have regular contact with older people, to find out their perspectives on ageing. To put your story into context, you are hoping to base it on a “real” older person. As you are trying to decide which town to visit, you think about your friend Meg, who lives in Mackay, Queensland. When you last spoke to Meg on the phone she mentioned that Bill, her father, has not been well lately and she is worried about him, especially as he now lives on his own since Meg’s mother died. You ring Meg and ask her if she thinks Bill would be prepared to talk to you, and to give you permission to base your interviews on his situation. Meg phones you back in a few days and tells you that Bill has agreed to talk to you, “if you think he can be of any use”. You decide to start your story by interviewing one of the social workers attached to the Aged Care Assessment Team (ACAT). When you ring her to make the appointment, she suggests that you should also interview one of the GPs in the town, as well as a psycho-geriatrician who often works with the ACAT. You also decide to interview some members of the local community, and to look at stories about older people that have appeared in the local and state newspapers. In preparation for your interviews you do some research into ageing and find there are many perspectives on ageing, including sociological, biological, psychological and economic, and that how an older person is seen—or how older people generally are regarded—will depend on the perspective taken. That in turn affects the policies and services that are developed for older people. For Consideration What is your view of ageing? What are some of the important perspectives on ageing from your experience? Who do you think would be the most appropriate people to interview? Why is that? What are some of the issues you would have to consider if you want to base your story on a real person? Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 3 OBJECTIVES Cognitive Affective/ Behavioural Knowledge To describe and differentiate the four main perspectives of ageing (sociological, biological, psychological, economic) To discuss the fundamental trends in longevity and some of the implications of longevity To outline some of the economic issues and concerns related to an ageing population Comprehension To discuss: the many ways that ageing can be perceived how older people may be viewed differently at different times and from different perspectives Application To apply different perspectives on ageing to: describe the assumptions underlying current predominant international and national policies use evidence-based arguments to counteract the negative stereotyping about the physical and psychological wellbeing of older people that currently exists in some sections of society describe how dominant perspectives shape policy and planning decisions Evaluation To discuss: • the way that meanings of ageing are socially constructed • the impact community attitudes have on feelings of self-worth in older people Synthesis To give a brief overview of: the major biomedical challenges faced by people as they grow older the inter-relatedness of factors that impact on the health, wellbeing and quality of life of older people Responses To keep a journal record of the your responses to the learning activities (the exercises and questions posed) in this module Values To respect different perspectives on ageing Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 4 INTRODUCTION This module explores a range of constructions and meanings of ageing. Definitions and meanings of “ageing” are complex and diverse, and can be quite controversial. HOW WOULD YOU DEFINE AGEING? As a starting point, the meanings you attach to ageing and your views on ageing are likely to reflect your past experience and your current relationships with older people, whether in your work, family or community life. Words and phrases that we might use to characterise aspects of ageing can reveal our perceptions, priorities and biases. There is clear evidence in Australia and most of the developed world that the number and proportion of people aged 65 years and over is rapidly increasing relative to other age groups. This issue was discussed in detail in the Introduction Module to this course so only a brief reminder will be presented here. The population aged 65 years and over will increase from 13% at June 2006 to approximately 27% in 2051 (Australian Bureau of Statistics [ABS], 2006a). However, after this rapid increase, rates of growth in the aged population and the proportion of older people in the population are expected to level out (Family and Community Development Committee, 1997, p. 33). McCallum and Geiselhart (1996, p. 13) noted that “by 2051 we expect that the Australian population will no longer be an ageing one but will have reached a stable state”. As discussed in Module 1, responses to the ageing of the population, and the policies developed to deal with that, depend on the perspectives of those leading the discussion and/or making the policies. For example, if you work in the social sciences or in regional planning you may think of the ageing population in relation to the way people in the community interact with each other, or the services and facilities that older people may require; if you are an aged care or health care professional you are likely to think about what happens to someone’s body or mind as they age, and if you are a health planner you may think about an ageing population in terms of the need for hospital and medical services, or the need for residential aged care facilities, or the need for an increase in the size of the aged care workforce. Policies and programs for older people in Australia have generally been developed from a medical/disability model of ageing, so that needs are assessed in terms of functional impairment and dependency. However, a very broad range of possible perspectives can be brought to bear on the issue of an ageing population. They include historical, religious, sociological (including cultural), biological, psychological and economic (Bromley, 1966). While all these aspects are of interest, the major focus of this module will be on the sociological, biological, psychological and economic perspectives of ageing. Exercise 2.1 As a first step in developing ideas for your article, identify your own views about ageing. What symbolises ageing for you? List key words or phrases that you associate with ageing in relation to mind, body, social and economic roles, life stages, etc. (Do not try to “censor” what you write, or try to give “politically correct” answers—just write whatever comes into your mind).Consider this list—what it means in terms of your biases and how it may impact on your reporting—as the module explores the different perspectives on ageing. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 5 WHY ARE PERSPECTIVES IMPORTANT? Policies and programs that are developed to address issues and concerns, whether relating to older people or to any other sector of society, will be determined by the perspectives and priorities of those in positions of power. This can result in inequitable distribution of resources, which in turn can impact on the quality of life of people affected by the policies and programs. SOCIOLOGICAL PERSPECTIVES ON AGEING Sociology is concerned with the relationship between the individual and society. There are different sociological perspectives or ways of trying to understand the social world and the experience of ageing individuals within it. This section provides an introduction to some of the most important approaches, including theoretical perspectives and some consideration of societal views on ageing. THEORETICAL PERSPECTIVES ON AGEING Theories and terms which have been used in the literature to encourage a particular sociological approach to ageing have included “successful ageing”, “healthy ageing”, “positive ageing”, “active ageing” and more recently, “productive ageing”. Successful ageing Trends in societal views on ageing and health status interact and change over time, and these views influence theoretical perspectives on what constitutes “successful” ageing. A number of early theories of successful ageing were based on the adaptive outcomes of old age (Baltes & Carstensen, 1996), with “successful adaptation” in many cases requiring a diminished social life (e.g., disengagement theory) or acceptance of decline. Disengagement theory In 1961, US gerontologists Cumming and Henry proposed the highly influential “disengagement theory”, which was based on the assumption that ageing brought with it inevitable mutual withdrawal and decreased interaction between older people and others. However, this theory was strongly criticised because of its potential to marginalise older people. In addition, while the initial theory was based on research, later research found little evidence that older people disengage from their surroundings and so did not support this theory. Rather, it was found that, while the number of their significant social relationships may diminish, the depth of those relationships was frequently deeper than previously (Qualls & Abeles, 2002). Where disengagement does occur it may be due to other factors such as disability, poverty, retirement or widowhood (Davies, 1994). Acceptance of decline Butler and Gleason have claimed that: “Aging is a predictable, progressive, universal deterioration of various physiological systems, mental and physical, behavioural and biomedical” (Butler & Gleason, 1985, p. 7). Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 6 It was proposed that, in order to age successfully, older people need to accept this inevitable decline, but, as discussed in the following section, this theory has recently been challenged. Healthy ageing The terms “successful ageing” and “healthy ageing” have both been used to describe positive health outcomes in old age (Peel, Bartlett, & McClure, 2004). Ryff (1989) argued that multiple aspects of life must be considered when assessing successful ageing and proposed an integrative model based on developmental, clinical, and mental health perspectives. Rowe and Khan (1997, p. 439) proposed a model of successful/healthy ageing that is “multi-dimensional, encompassing three distinct domains: avoidance of disease and disability, maintenance of high physical and cognitive function, and sustained engagement in social and productive activities”. Although endorsing the biological and sociological components of Rowe and Kahn’s model, Crowther, Parker, Achenbaum, Larimore, and Koenig (2002) claimed that, by not including spirituality as one component of the model, Rowe and Kahn have ignored the growing body of research which supports the interaction between spirituality and health outcomes. In addition, the model was criticised because of its restrictive nature and the fact that it did not allow for a subjective rating of “successful”. Strawbridge, Wallhagen, and Cohen (2002) reported that, in their study, only 18.8% of respondents would have been classified as successful using the Rowe and Kahn model, whereas subjectively, 50.3% of respondents, including many with chronic conditions and functional difficulties, rated themselves as ageing successfully. An alternative model of successful ageing was offered by Baltes and Baltes (1990, p. 69), who developed a concept of “selective optimization with compensation”, which argues that individuals optimise, or make the best use of, the physical, mental and situational resources and capacities they still have, while finding ways to compensate for their limitations. Based on models such as Rowe and Kahn’s, the terms “successful ageing” and “healthy ageing” have often been used interchangeably. However, as noted above, by linking successful ageing and healthy ageing together, illness or disability could be regarded as “failure”, and “successful ageing” could thus be used as a pejorative term. Peel et al. (2004, p. 116) also noted that, in Western culture, success is usually associated with economic achievement or psychosocial outcomes only, noting that: “Successful ageing is not considered appropriate for describing positive health outcomes in old age and ‘healthy ageing’ is preferred”. Activity theory Another concept of healthy ageing is activity theory, which proposes, in part, that a pathway to healthy ageing is the maintenance of middle-aged roles and values, as well as the activity that accompanied such roles. There is some evidence that increased activity is associated with higher morale. The term “active ageing” has been adopted by the World Health Organization (WHO), to express the process of achieving the vision of ageing as a positive experience of “longer life … accompanied by continuing opportunities for health, participation and security” (WHO, 2002, p. 12). This will be further discussed here in relation to policy. Positive ageing The term “positive ageing” is one that has been eagerly embraced by many government and non-government agencies in the Western world. In February, 2017 a Google web search of Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 7 the term produced 537,000 results in 48 seconds of search time. Interestingly, a high percentage of these results related to policies, grants and activities in Australia (see for example http://www.whitehorse.vic.gov.au/IgnitionSuite/uploads/docs/Whitehorse%20Positive%20Ag eing%20Strategy%202012-2017.pdf Almost all the papers found included advice for older people on remaining healthy, active and productive, as well as describing processes to ensure that older people’s voices are heard at all levels of government planning. This is also occurring more frequently an organisational level. For one current example see www.unitingagewell.org Productive ageing Recently there has been a focus on “productive ageing”. The National Seniors Association refers to productive ageing as promoting: “the choices and capacity of Australians, as they age, to engage in valued activities, whether through work, learning, volunteering or community activity. Productive ageing recognises the contribution of seniors to economic, social and cultural growth” (National seniors, nd). For further details go to http://www.productiveageing.com.au). For a government perspective see for example the Abbott government’s announcement (http://ministers.employment.gov.au/node/%206309 ). While these are laudable goals, this perspective also has political overtones. The term “productive ageing” is also used in conjunction with the term “mutual obligation”; older people are being encouraged to remain in or return to the workforce, or at the very least to undertake significant volunteer activities, with a concomitant risk that they will be made to feel guilty if they are in receipt of an age pension. This issue will be considered further in relation to economic perspectives. Note: While considering all these terms it is important to keep in mind that they are, in most cases, presented from an ethno-centric Western viewpoint. Wray (2003, p. 1) challenged this approach, claiming that: “current gerontological and sociological theories and concepts of ageing (do not) adequately represent ethnic and cultural differences in what it means to grow older”. Reading A very interesting paper by Liang and Luo (2012) critiques the western perspective of successful ageing and proposes a concept of harmonious ageing inspired by the Yin–Yang philosophy. The authors attempt to explore what constitutes a good old age and to capture more cross-cultural diversities in the context of global ageing. See Liang J and Luo B (2012) Toward a discourse shift in social gerontology: From successful aging to harmonious aging, Journal of Ageing, 25 (3) 327-334. http://ac.els-cdn.com/S0890406512000230/1-s2.0-S0890406512000230- main.pdf?_tid=5597d480-b8d2-11e5-a004- 00000aab0f27&acdnat=1452565102_069046e9f9b29a97468227d6b97c3bf6 Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 8 SOCIETAL VIEWS ON AGEING On many different fronts, the realities of ageing as experienced by older people conflict with entrenched socially determined views. The social construction of ageing carries a whole complex of meanings. Values related to gender roles, bodily appearance and working life are interlinked in stereotypes of ageing. Reflecting social values about ageing, the media tends to focus either on “super grannies/grandpas” (i.e., older people who are still climbing mountains or running marathons into their 80s), or provide “gloom and doom” stories containing negative images of dependency and ill-health (Steinberg, Donald, Clark, & Tynan, 1995, p. 187). More than 35 years ago, Kalish (1979, p. 399) argued against both approaches; that is, the Incompetence Model of progressive enfeeblement and the Geriactivist Model of continued robust productivity and vigorous leisure, claiming that they are both “failure models”. The first considers ageing itself a failure while the second considers older people themselves as failures if they are unable to embrace such a model. Negative social values towards ageing can also be seen in the agedenying, death-denying industries that have burgeoned in recent times, such as the demand for cosmetic surgery, and, in an attempt to obtain immortality, cryogenics. Ageism Negative attitudes to ageing often become socially entrenched. Ageism can range from discrimination in a particular area such as employment (Steinberg, Donald, Najman, & Skerman, 1996) to the more pervasive ageist traditions of Australia as a whole. McCallum and Geiselhart (1996, p.18) claimed that Australia’s origins may make this country “one of the most ageist cultures in the developed world”, in part because, in our earlier history, few people had contact with grandparents, who were often in another country. They noted that, while this historical lack of relationship and ignorance about older people was generally accompanied by a benevolent attitude to their support, which helped older people, it excluded them from the workforce, and, later, gave them the derogatory label of “old age pensioners”: While their numbers may be large, older adults are often the focus of negative social attitudes, which makes them vulnerable towards a form of prejudice known as ageism…Age should be [seen as] a component of a complex framework of social relations between individuals. Ageism can be defined as a set of social practices [based on the ways that] society has transformed biological and chronological age into social and cultural signs. Newman, Faux, & Larimer, 1997, p. 412 McCallum and Geiselhart (1996) argued that to change negative images of older people to match more positive realities would require a multi-factored approach to the definitions of ageing and healthy ageing, based on recognition of differences and interactions of a wide range of attributes and processes. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 9 Exercise 2.2 How old is an older person? What do you expect your life to be like when you reach that age? Discuss these questions with someone at least 10 years younger than you and someone at least 10 years older than you. Write a brief summary of these three perspectives (yours and the two interviewees), to develop your ideas for article. Briefly analyse the interview data you have gathered and compare your findings with at least two or three relevant papers. In your submission for this subject, include the references you used and the transcript of the two interviews, as an appendix. Uniform images of older people Older people are often seen as a much more homogeneous group than they really are, and there is a tendency to inadequately differentiate groups among older people in policy and practice. In reality, older people share the same degree of commonalities and differences as any other age group in society. Stereotypes are unhelpful and ageist attitudes can negatively impact on the health of older people. Older people are frequently portrayed by the media or government as one grey, tax-draining, dependent group. However, this is a distortion of the facts: “Many are well off and exercise power in family and social groups” (McCallum & Geiselhart, 1996, p. ix). Reading Australian Institute of Health and Welfare. (AIHW). (1999). Older Australians at a Glance. Canberra: AGPS. Read Section 15, which examines these questions about the images of old age and how more adequate differentiation might be made. Where categories are used to distinguish between different groups among older people, they tend to be applicable only to a specific focus at a particular time, so that delineations of subgroups among older people are unlikely to suit all purposes or circumstances. Examples of categories that have been found useful in gerontology include: The Young Old (e.g., 60s–70s) The Healthy Old Old (e.g., 80s–90s) Frail Older People in the community Older People in long-term residential care Older Indigenous People Older People from culturally and linguistically diverse (CALD) backgrounds. The heterogeneity of the ageing population and the implications this has for policy and service delivery is discussed in depth in the “Diversity in Ageing” Module of this course. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 10 Older people’s self-perceptions of ageing Kendig (1996, p. 1) noted that “the real meanings of old age can only emerge from older people themselves”. However, while most older people “perceive themselves as fit, well and active (and many) maintain the persona of middle age for as long as possible” (Biggs, 1993, p. 54), others “accept the widespread negative stereotypes about older people, reinforced [by] the mass media” (AIHW, 1999, Section 15, p. 2). As well, people’s own perceptions may not fit with official designations of the onset of old age and the loss of official social or economic roles. For example, until recently, the official retirement age for men – at which a man could draw an age pension – was 65, yet many people now live relatively healthy lives into their 80s, 90s and beyond. In fact, many people in their 60s and 70s continue to enjoy the same health and activity patterns as they did in their 40s and 50s: “It is becoming increasingly evident that the losses and frailties associated with old age occur ‘normally’ or unavoidably much later and closer to the end of life, in ‘old’ old age” (Walker-Birckhead, 1996, p. 4). In one innovative project, researchers interviewed and filmed 56 older people about their perceptions of ageing. Participants spoke about what is important to them as they age; and what it feels like to be getting older - physically, mentally and in their social context. The older people talked about their changing personal relationships, pragmatic life decisions, health, illness and death. To hear the voices of older people on their experience of ageing go to: http://research.healthtalkaustralia.org/experience-ageing/overview For Consideration How does the concept that middle-aged health and activity patterns are likely to continue up until “old old” age (over 80 years) accord with your own observations and experience? Consider your own views of ageing. Does this concept conflict or support the views you articulated earlier in Exercise 2.1? What does this mean to your concept of how old an older person is, as explored in Exercise 2.2? Older people’s adaptations to societal views on ageing In responding to socially constructed meanings of ageing, physical health issues become enmeshed with psychosocial and mental health issues. Older people themselves feel that health means having a positive outlook on life and maintaining physical and social activity and that healthy ageing means they are able to be independent and active participants in Australian society (AIHW, 1999, Section 15). Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 11 Gender differences The majority of 65 year-old women today did not work in paid employment full time, so the “passages” of their lives were not marked by work-related activity: “For some cohorts of older women, retirement has no real meaning. Widowhood and other family events such as children leaving home or the appearance of grandchildren are more significant markers of increased age” (Biggs, 1993, p. 58). More recently, these findings were echoed in a report on preparing for healthy ageing for the Australian’s Women’s Coalition (Howe, 2008). Women comprise 70% of the population aged 85 and older, making old old age a largely female phenomenon and giving rise to the “feminisation of ageing” as a critical issue for policy and services. Older women are much more likely to be among the impoverished, the widowed, alone or the disabled. They account for three-quarters of older people with disabilities in health care establishments (Heycox, 1997, p. 105). This picture is not expected to change significantly. BIOLOGICAL PERSPECTIVES ON AGEING Biology is the science that studies living organisms, including the characteristic life processes and phenomena of living organisms. Many different biological explanations for ageing have been proposed, and much research into ageing remains firmly based within the medical model derived from these explanations. This section provides an introduction to some of the important biological perspectives on ageing. The concepts of old age and illness are often fused and considered inseparable. This is a biomedical model of ageing which has become a dominant and accepted paradigm, where the focus in relation to older people is often on illness, disease, disability and physiological decline. Where such a model is dominant, scant attention is paid to other social and environmental factors that impact on older people. In fact, the vast majority of older people are neither frail nor in need of long-term care and assistance, and only 7.8% of those aged 65 and over were in residential aged care facilities (RACFs) at some point over the 2013-2014 financial year (AIHW, 2015 http://www.aihw.gov.au/aged-care/). From 2000 to 2006, for all ages, there was a decrease in usage rates of RACFs, which was particularly apparent among older groups. To some extent this reflected an increase in the availability and use of community care services. NORMAL AGEING It is important to understand that age and ill-health are not synonymous terms. The majority of older people are healthy, active and participate in the community. Most older people consider themselves to be in good health. For example in the 2014–15 National Health Survey nearly three-quarters (72%) of older Australians (aged 65 and over) reported they had good, very good or excellent health. Two in 5 (39%) older people self-assessed their health as being very good or excellent (AIHW, 2015). In comparison, in the 2004-05 National Health Survey, 69% of people aged 65-74, and 65% of those aged 75 and over rated their health as good, very good, or excellent (ABS 2006b) Even older people with chronic illness generally maintain satisfaction with life by adjusting their expectations and daily routines. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 12 However, there are factors that impact on the health, wellbeing and independence of older people. These include: biomedical factors such as disease-related or functional changes; systemic factors such as health promotion and disease prevention programs; discrimination and attitudinal factors; quality-of-life factors such as social interaction; structural factors such as housing, transport, income support, education, leisure and recreation; and behavioural factors such as exercise and nutrition. BIOLOGICAL THEORIES OF AGEING The predominant biological theories of ageing have included: Stochastic theories: Random changes such as cell loss or mutation cause ageing and may be under genetic control. Genetic programming: The genotype determines the frequency of defects or the ability of the body to remove defects. Biological programming: Normal cells have a memory or capability determining life span. Prior to 1961 the accepted dogma was that cells and tissues were potentially immortal. In 1961, Hayflick and Moorhead demonstrated that a culture of normal human fibroblasts had a finite replicative capacity and that older donor cells divide fewer times than younger cells (Hayflick phenomenon). Error theory: Production errors accumulate and the body loses the capacity to deal with them. Immune incompetency: The immune system has decreased competence and regulation with age; decreased surveillance by the immune system leads to failure to eliminate abnormal cells, which then leads to tumour growth and/or increased susceptibility to infection. Free radical theory: First proposed by Harman in 1956, this theory relates to a molecule with unpaired electron, which is highly reactive and destructive; these molecules are ubiquitous but cells have defences, including enzymes. The ability of the cells to defend themselves decreases over time because of DNA damage, cross-linkage of collagen and accumulation of age pigments. Physiological changes and ageing When using the term “healthy ageing”, this module is taking the World Health Organization’s very broad definition of health as a state of: “physical, mental and social wellbeing, and not solely the absence of disease”. (Retrieved from www.who.int/suggestions/faq). While remaining fit and healthy is a goal to be encouraged for people in all age groups, it would be foolish to pretend that the human body does not deteriorate as we age. Assisting older people to maximise their wellbeing within realistic parameters is a better goal. A physiological definition of ageing is the “progressive, generalised, impairment of function resulting in loss of adaptive responses to stress (e.g., homeostatic mechanisms) and increasing risk of age-related disease” (Davies, 1998, p. 53). Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 13 The overall effect of these changes is that the older we get the more likely we are to die. But mortality rates rise throughout life from puberty and the rate is uniform; ageing therefore begins around puberty. However, there are certain older-age-related changes that are recognised in terms of the function of different organs. In general, as a person grows older the body loses some elasticity and size diminishes (atrophy), there is reduced efficiency in the lungs and immune system, as well as some degenerative changes in the heart and vascular system. With increasing age also come some sensory changes—in hearing, vision, smell, taste, touch. In relation to intellectual function, neuro-psychological testing shows slowing of “fluid intelligence” (i.e., central processing time and acquisition of new information), but “crystalised intelligence” (i.e., knowledge, wisdom, vocabulary), is maintained. Slight memory loss is common with ageing, but not usually sufficient to cause problems with daily functioning. There are older people in the general community with mild cognitive impairment (MCI), who nevertheless have normal physical and mental functioning, although people with MCI have an increased risk of developing dementia (Hogan & McKeith, 2001). True ageing changes can be divided into intrinsic processes, which means that they occur independent of environmental or “outside the person” conditions, and extrinsic processes, indicating that they are influenced strongly by environmental conditions. Examples of agerelated physiology leading to “disease” include that older people exposed to low ambient temperatures during the winter months may develop hypothermia; they may also be more prone to heat strokes in the summer. Tissues in the body vary in their degree of renewability; for instance, teeth that grow following loss of baby teeth are present till they fall out, break, are extracted or are knocked out, but do not re-grow when lost. Organs such as the liver and bone marrow have considerable regenerative/repair capacity, while organs such as the heart are intermediate between the nonregenerative and regenerative ones (Nair & Cartwright, 2003). Main medical conditions of ageing In the “Ageing and the Body” module of this course (Module 3) the most common medical conditions experienced by older people are discussed in depth. These include cardiovascular conditions (coronary heart disease and stroke), musculoskeletal conditions (falls, osteoporosis and fractures), osteoarthritis and neuro-degenerative conditions (dementia and Parkinson’s disease). It is estimated that in 2015 there were 342,800 people with dementia. Among Australians aged 65 and over, almost 1 in 10 (9%) had dementia, and among those aged 85 and over, 3 in 10 (30%). The number of people with dementia is projected to reach almost 400,000 by 2020, and around 900,000 by 2050 (AIHW, 2017 see http://www.aihw.gov.au/dementia/about/ ). Other conditions outlined in module 3 will include iatrogenic illness, incontinence and sensory impairment. Depression is identified by some as a major problem among older people and will be discussed further under psychological perspectives of ageing. Physical activity and balanced nutrition have been shown to offer some protection against a number of diseases and physical conditions affecting older people (Munro, Brazier, Davey, & Nicholl, 1997), including arthritis and depression. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 14 Presentation of ill health in old age It is common for older patients to have up to six or seven separate medical conditions, all of which may interact. The situation may be further exacerbated by the contribution of multiple medication use and the concomitant potential for medication interactions and side effects. Older patients with acute illnesses frequently present with functional disability—immobility, instability (leading to falls), incontinence and/or intellectual impairment. These are termed the “Giants of Geriatrics” (Isaacs, 1972) and they cause disability, loss of independence and institutionalisation. None of these “giants” is caused by old age. They are the result of pathology. Rehabilitation from day one is a fundamental principle of geriatric medicine, as many of these conditions can be remedied, or at least their effects can be ameliorated, thus restoring functional capacity to the patient and restoring independence. The Active Service Model in Victoria is a recent example of a restorative approach. See https://www2.health.vic.gov.au/ageing-and-aged-care/home-and-community-care/haccprogram-for-younger-people/hacc-program-guidelines/hacc-quality-and-servicedevelopment/active-service-model Health status among older people Longevity comes at a cost; it is not necessarily being matched by improvements in disability and handicap-free survival, especially in the old old age group. Reducing deaths from cardiovascular and similar diseases exposes individuals to chronic and degenerative diseases. For example, in 1924, 23% of deaths were attributed to the circulatory system and to cancer, compared to 75% in 1965. These substitutions change the nature, type and length of care required, and raise ethical issues of how people die, particularly in relation to use of technology extending the dying process. Policy targeting: bio-medicalised health indicators Determination of health status in ageing is now becoming a three-tiered process, which, despite changes in terminology, continues to allocate older people to states of success or failure on the basis of low- or high-cost burden respectively. Under the pervasive bio-medicalisation of ageing, the following indicators for policy targeting and health budget expenditure are coming into use: “Healthy ageing” (the fittest, most self-reliant and most active – requiring low or no medical intervention). “Normal ageing” (fairly stable, homogeneous degeneration and disengagement – requiring regular and increasing medical intervention). “Senility or frailty” (severe decline and degeneration – requiring very high medical intervention). Hence, healthy ageing, although encompassing a much wider range of factors than physical health status alone, may be subsumed under the bio-medicalisation of ageing. As a consequence—particularly in tight fiscal climates—it may be difficult to achieve a mesh of policies that address indicators other than physical or mental health. Those who are classified as among the healthy ageing—on a medical basis—may be largely ignored by policy-makers. With an increasing emphasis on acute care, this exclusion may well extend to prevention, health promotion and community care. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 15 PSYCHOLOGICAL PERSPECTIVES OF AGEING Psychology is concerned with the scientific study of behaviour and mental processes and how they are affected by an organism’s physical state, mental state and external environment. The word “psychology” is derived from two other words: “psyche” (meaning mind or soul) and “logia” (meaning the study of). Psychology tries to explain why people act, think and feel the way they do. Older age is often mistakenly viewed as a time of psychological decline, with many older people expected to be depressed about their life circumstances and the approaching end of life, and to have mental health problems. In his Life Stages theory, Erikson (1968) proposed that in the last stages of life older people face a crisis of “integrity vs. despair” and that they achieve integrity by accepting the inevitability of life’s end and find meaning in the life they have lived. He argued that this is the final developmental task of life. While there is objective evidence—as outlined above—of some inevitable physical decline as people age, and that in the oldest old group rates of dementia increase significantly, older people actually rate their emotional and mental health as better than younger people. In the Australian Bureau of Statistics (ABS) 2004–2005 National Health Survey, people over 65 scored the highest in terms of their mental health. This result has been noted consistently over the past few decades. For example, in 1994, a telephone survey of 12,793 adults using the SF- 36 Health Survey found that while physical functioning decreased with age, primarily because of physical and general health problems, scores for emotional and mental health increased with age and were highest for both men and women in those over 65 (Watson, Firman, Baade, & Ring, 1996). In addition, there was very little difference across age groups in terms of vitality and social functioning (Watson et al., p. 361). DEPRESSION One of the most frequently experienced psychological conditions of ageing is depression. General population studies have shown that approximately 10–20% of older people report significant depressive symptoms and Byrne (1993) estimated that, depending on how diagnostic criteria are applied, between 0.5 and 3 % of older people living in the community could be expected to be suffering from a major depressive episode at any one time. Depression is one of a spectrum of mood disorders and is characterised by low or depressed mood and loss of interest in usual activities, and is often accompanied by a range of symptoms including appetite and weight disturbance, as well as difficulty concentrating and negative thoughts. Loss and grief in older age can trigger a depressive episode and it is important that older people receive counselling and support for these losses, and that they not be seen as just a “normal” part of ageing. Depression is one of the few “reversible” causes of cognitive impairment. It is not always easy to diagnose, and mild depression is frequently missed in general practice assessments of older people. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 16 ECONOMIC PERSPECTIVES ON AGEING Economics is the branch of social science that deals with the production, distribution and consumption of goods and services and their management. It is concerned with the study of how individuals, firms, governments, and other organisations make choices, and how those choices determine the way the resources of society are used, and in particular how commodities are distributed for consumption, now or in the future, among various people and groups in society. Economists analyse the costs and benefits of patterns of resource allocation, and economics provides the language, principles and a way of thinking to help people unravel why they have to make choices. DEMOGRAPHIC CHANGES AND THE ECONOMY The major issues relating to the ageing of populations and changing demographics in Australia and throughout the world are presented in the Module 1. A number of issues are raised by population ageing. Borowski and Hugo (1997) noted the impact of demographic change on such issues as intergenerational relationships and exchange, the size and composition of households, and policies on the allocation of economic, social and health care resources. To a large extent, our responses to these issues depend on the perspective we take. Overall, Australia is ageing more slowly than a number of other countries, giving us an opportunity to “watch and learn”. Rates of change in the numbers of “Old Old” [A] significant aspect of population ageing in Australia is the ageing of the aged population itself. Borowski & Hugo, 1997, p. 26 The “old old”—those aged 85 years and over—are increasing in number most rapidly. As Gibson (1998) pointed out, service use is most heavily concentrated in the 80+ age group and it is here that Australia has experienced, and will continue to experience, high rates of growth; around 3–4% per year, compared with less than 1% in many European countries. The rate of adjustment required of Australian services has been and will continue to be quite dramatic for the next decade. The “demographic time-bomb” of an ageing population Battersby (1998, p. 3) described fearful reactions to projections for a rapidly increasing population of older people in the media, and to some extent in the academic literature, as “apocalyptic demography”, noting that “we often see reference to the ‘demographic time bomb’, to the ‘problems of ageing’ … and to the ‘burdens to society of older people’.” Scenarios presented in the media help to reinforce such fear. Walker-Birckhead (1996, p. 6) expressed concern that: The language used by the media and many professionals…describes the “ageing” of our society as if there were an approaching social disaster or “plague” of oldness. It seems that old age is—like pollution and over-population—an unwanted and unintended consequence of modern development, with old people caught up in a “paradox of longevity”. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 17 Some members of the media and the public applaud the life-saving advances of bio-medical science, but then fear or question the potential costs of older people living longer, particularly the anticipated cost burden on working age generations and on governments. Longevity and preservation of health are seen as desirable, but are also seen as threatening our health and welfare systems: “Some social commentators view population ageing as a ‘demographic doomsday’ and call for policies that would ‘cure’ this ‘social problem’” (Kendig, 2004. p. 18– 19). The “time-bomb” metaphor suggests there will be an “explosion” of older people, and that our health and welfare system may collapse under the weight of massively increased pension payments and health care costs. Kendig noted that older people can be subject to “scapegoating” and can be made to feel responsible for the economic costs of population ageing. Undoubtedly, ageing will present challenges to the health-care system, given the larger number of older people, the fact that many health conditions and associated disability become more common with age, and that older people are higher users of health services. However, the majority of Australians consider themselves to be in good health, and manage to live independently—with or without community-based supports—until their final days (AIHW, 2014). How real is the demographic time-bomb of an ageing population? Battersby suggested that much of this reaction has occurred without proper recourse to statistical analysis at a more detailed level than simple population age projections. Where such analysis has been conducted, much of the time-bomb pessimism has been refuted (Mathers, 1998). Supporting this assertion is the work carried out by Access Economics (2001), which clearly demonstrated that older people are not generally a drain on community resources. The report noted that “[t]he over 65s head up households owning almost half of the deposits in the nation’s financial institutions” (Access Economics, p. 54). In policy-making, and in the media and marketing, individual responsibility, including a “userpays” response to future demand for aged care, is being emphasised. This response places an emphasis on private medical insurance to cover health care costs, and superannuation and savings to lower or eliminate reliance on publicly funded income support needs in later life. While it will be important to ensure that older people without private economic resources are not marginalised, it is likely that many future generations of older people will be able to finance their own health care: “The over 55s account for 21 per cent of Australia’s population [but] they head up households that already own an astounding 39 per cent of the nation’s household wealth” (Access Economics, 2001, p. 54). Changes in families and households Substantial and significant changes have occurred in family structures and functions with population ageing. They are the result not only of demographic factors, such as changes in fertility, mortality and geographic mobility, but also of related social changes in family formation and marital patterns, labour supply and socio-culturally shaped preferences. These Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 18 strongly influence socialisation, accumulation and allocation of resources and provision of support and care for family members (Myers & Eggers, 1996, p. 410). For most of the 20th century, extended family structures incorporated three generations (grandparents, parents and children), with grandparents in some cases living in the same household as parents and children and in other cases living separately. It is now being argued that a new intergenerational structure of four-generation families is emerging as a result of demographic ageing. This four–generation family may comprise frail old old people over 80 years of age (greatgrandparents), a next generation of grandparents nearing or in early retirement (55- to 65 yearolds), an early or mid-career generation (parents in their 30s or 40s), and a youngest generation of fewer children or adolescents. This new family structure has more generations alive at the same time, but fewer members of the same generation—the “beanpole family”, as described by Myers (2000). There is also a worldwide trend towards smaller households, resulting partly from lowered fertility, but also from shifts in living arrangements away from co-residence with adult children (Myers & Eggers, 1996) and other social factors, such as divorce. For Consideration Is your family a four–generation family? Do you know of any other families of four or even five generations? Who are the main caregivers for older family members? Consider how this may vary for different areas of Australia; for example, between urban, regional or remote areas. The issue of intergenerational relations The changing balance of needs, roles and responsibilities within families raises many new issues for society to address, including the provision of care and other informal transfers of assistance that occur within families and across generations (Ozanne, 2007). As a result of the demographic time-bomb scenarios that have emerged in the media and in the literature on ageing, as outlined above, Battersby (1998, p. 5) noted the expected effects on intergenerational relations: A further example of how apocalyptic demography can distort and mislead, relates to the assumptions that are often made about the … relationship between the ageing of the population, rising health and aged care costs and how all of this is contributing to inequity among the generations. Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 19 What is meant by “intergenerational transfer”? Intergenerational transfers relate to the exchanges of financial, material and social support provided by one generation to another. This exchange may sometimes be seen as a one-way flow; at other times as a more reciprocal process. The term is primarily used to refer to the costs of support for generations that are not in working age groups—for example, children and retirees—and their imposition of financial and taxation burdens on those who are employed. In the media and in the literature, intergenerational transfer is often seen as a one-way flow of capital to older people. Much of the debate is imported from other countries with different demographic trends, and workplace, social welfare and health insurance conditions. However, financial and taxation burdens also tend to be overstated in standard measures of dependency rates. Rowland (1991, p. 26) noted that older people are not the only dependent age group apart from children: [Standard] demographic dependency ratios … can create unwarranted impressions that the elderly are a burden on society and that the funding of social welfare inevitably entails a transfer of payments from younger to older generations. [In fact], in Australia a substantial proportion of social expenditure is directed to persons of workforce age [which] in 1981 … amounted to 32 per cent of Commonwealth and state outlays. Unemployment, participation in tertiary education, and labour force participation rates of women and people in their fifties and sixties are major determinants of dependency with the working ages. … Accordingly, dependency levels in all age groups need to be considered, not just children and the elderly. Borowski and Hugo (1997, p. 7) argued that: “Concerns about the burden the aged will impose on the working age population have been exaggerated (and that) the increase in age dependency will be substantially offset by the decline in youth dependency”. They claim that the most sophisticated analysis of older people’s dependency on younger people shows there will be no significant increase in dependency ratios by 2041. In addition, recent economic analyses are beginning to acknowledge the contribution of older people to many sectors of the community: “Far from being net receivers of help and support, older people are, in fact, net providers, at least up to the age of 75 years” (Healy, 2004, p. ix). Healy identified a number of studies which indicate that the unpaid caring and voluntary work provided by older people adds up to around 7 per cent of GDP (compared to the 3-4.5% of GDP paid—or expected to be paid—in pensions, as noted below): Australia has, and will continue to have, one of the youngest populations of any western country; its ageing will proceed slowly until 2011; and. … the social expenditure implications … are manageable, even if they require some adjustment in social policy settings (Family and Community Development Committee, 1997, p. 46). Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 20 COSTS OF AN AGEING POPULATION Costs of income support International experience suggests that the cost increases of income support for older people in Australia can be managed: Countries with older populations and more expensive retirement income systems are already coping or making the necessary adjustments to an older population. … Sweden seems to be satisfactorily coping with an age structure that Australia will not realise for four decades, and is providing considerably higher levels of public income support, bodes well for Australia’s ability to provide for its ageing population in the future. Family and Community Development Committee, 1997, p. 46 Taking into account superannuation and other policy changes in Australia’s retirement income arrangements, Borowski and Hugo (1997, p. 49) predicted “an increase in aggregate welfare expenditure of only 1.5% between 1990 and 2041”. Healy (2004, p. viii) presented a similar argument: With around 90 per cent of workers now in compulsory superannuation schemes, it is anticipated that the cost of pensions will only need to rise from the current three per cent of GDP to around 4.5 per cent by 2051. Costs of health service provision Increased costs in health care provision occurring at the same time as population ageing have caused concern both in Australia and internationally. Current health care costs rise dramatically with age, particularly from age 70 onwards. Nevertheless, an ageing population, with greatest increases in the old old age group, will not necessarily add as substantially to future per capita costs of health as might be expected. This is because the major rise in health care costs occurs in the last two years of life. With increased longevity in the future, this high cost period will largely shift into the 80s and 90s rather than commencing in the 70s, as it does currently. In addition, Healy (2004, p. vii) argued that, rather than such costs increasing as people die at older ages: “Health costs associated with the last year of life may actually be less in older age groups because elderly people are treated less extensively”. It is important to note that ageing accounts for only a portion of the growth in total health costs (Family and Community Development Committee, 1997, p. 41). McCallum and Geiselhart (1996, p. 56) emphasised that, consistent with findings in 20 other countries: The evidence is strongly against a crisis in health costs due to ageing. … Cost increases in health (in those countries) were found to be attributable to rising per capita income, technological changes and other trends which affect people of all ages and so cannot be attributable to ageing. Nevertheless, some causes of disability among older people, such as Alzheimer’s disease, have sharply increasing rates at ages 80 and above, and may therefore have an associated cost burden: Foundation Studies in Gerontology GER4FSG: Perspectives on Ageing Module 2: Semester 1, 2017 21 Health expenditures are projected to grow somewhat more rapidly [than income support] … by 2041 … from 8.4 per cent of GDP to 11.1 percent of GDP, or by 2.7 per cent. While these expenditure increases are certainly not inconsequential … growths in expenditure of this size [are] sustainable. (Borowski & Hugo, 1997, p. 49) Provision of care Between 1988 and 1993, the proportion of people aged 80 and over living in the community increased from 50% to 59%; and the 65–79 age group increased from 79% to 84% (AIHW, 1997, Section 19). The 1996 Census showed that 91% of people aged 65 and over lived in private dwellings; for those 80 and over the figure is 76% (AIHW, 1999, Section 2). In 2002- 03 in Australia, 83% of older people (aged 65+) lived in their own home and a further 13% lived in rented accommodation (ABS, 2005). In 2011, most people aged 65 years and over lived in private dwellings (94%) in the community (ABS, 2013). These changes have important implications for home-based care services, residential care services, the informal care network and society at large. Special consideration in policy development and planning in the field of aged care services may be required for at least some older overseas-born Australians, particularly as they move into the 80 years and over age groups. They are a diverse population, culturally, linguistically and geographically. Factors affecting the number and type of services required include not only the size of the population, but also its characteristics, such as location, age and sex structure, living arrangements, health and disability status and proficiency in spoken English. Older workers A Morgan and Banks survey (1997) indicated that Australian companies were adopting an attitude that the ideal age of employees is between 25 and 35 years, with almost a third of employers believing the over 40s to be less flexible in their work practices. Such perceptions lead to age discrimination in workplace practices, resulting in premature loss of employment, problems in recruitment and re-entry into the workforce, and exclusion from training (Steinberg, Najman, Donald, McChesney-Clark, & Mahon, 1994). There is now a growing political consciousness of the rights of older people in the workforce. This is most obviously reflected in legislation that protects against age as a ground for discrimination and which bans compulsory retirement. A new image of older workers—one of independence and economic and social productivity—is being promoted. Many United Kingdom and European businesses are recognising that discriminatory work practices prevent the harnessing and developing of multiple abilities at all levels for the benefit of both business an