Demographics of Aging

Older adults represent a large and growing segment of the population, both in the United States and worldwide. Recent population demographic estimates suggest that by the year 2030, 20 percent of the U.S. population will be 65 years old and older. Adults aged 85 years and older are the fastest growing segment of the population. These demographic shifts are due to many factors, including improved health care, greater longevity, and declining birth rates in industrialized countries. The projected population increase is substantial and will likely have a large impact on the health care system. In particular, there is expected to be growing demand for specialized clinicians and appropriately adapted interventions to provide health services for older adults. As psychologists have responded to these demographic trends, recent years have seen a growing research interest in understanding behavioral changes that occur with age and how behavior affects the health and well-being of older adults.

Psychological Changes with Age

Studies have found some areas of psychological change with age, whereas other dimensions demonstrate stability. Changes encompass positive aspects of development as well as declines in some areas of functioning. The slowing that occurs with greater age on all cognitive tasks where speed is required is a well-established finding. Fluid intelligence, which is usually measured by tasks that involve a timed component, shows clear evidence of change with developmental aging. Inferential reasoning (e.g., as measured by questions that ask what comes next in a series) is an aspect of fluid intelligence. However, crystallized intelligence, which includes intellectual capacities such as general fund of information and vocabulary, shows relatively little change as a result of the aging process. With the accumulation of experience, older adults have a considerable store of knowledge, especially in their individual areas of expertise, informed by a lifetime of work and family experiences.

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Changes in memory with age have received much study. In particular, working memory has been found to decline with age. Working memory is the limited-capacity resource through which information must be processed before being registered in long-term memory. Although there are clearly increasing numbers of older adults suffering from dementia with each decade of advanced age, the practical impact of normal memory changes is less clear. Research suggests that differences between younger and older adults in memory performance are not large when the material is meaningful and relevant to the older adult and the older adult is motivated to learn. For those working with older adults in a clinical context, reduced capacity in working memory and speed of processing implies slower pace of speaking, with greater repetition of material, to ensure effective communication.

Personality and emotion have also been studied among older adults. Studies on personality development in adulthood and later life have found stability on the major personality dimensions introversion/extroversion, neuroticism, openness to experience, dependability, and agreeableness. Some researchers have argued that the accumulation of experience leads to more complex and less extreme emotional experiences in later life. Whereas previously, older adults were thought to become disengaged from others, more recent research has found that adults increasingly focus on emotionally close relationships as they get older, whereas casual relationships become less important.

Some psychological phenomena associated with age appear to put older adults at risk for maladaptive health behaviors. In particular, an inadequate sense of control over life circumstances (and low self-efficacy to effect change) may significantly interfere with health. Unfortunately, sense of control may decrease with age, especially if there are losses that limit the choices available to an older person (e.g., bereavement, illness, disability). Nursing home environments may encourage dependency and inhibit a healthy sense of self-efficacy. Older adults with a reduced sense of control may be less motivated to alter health-damaging behaviors, even after diagnosis with a chronic illness. For example, research has found that older adults who perceive less control over their disease engage in fewer healthy behaviors during the course of a serious and painful medical illness such as coronary heart disease even after suffering through coronary artery bypass graft surgery. Low self-efficacy has also been linked to depression and poor memory performance.

Cohort Effects

In the study of aging, it is important to distinguish which psychological changes are due to the effects of getting older and which are due to generational effects or “cohort effects.” Researchers have found that many of the differences between older and younger adults that society has attributed to the aging process are actually due to cohort effects. Cohort differences are explained by membership in a birth-year-defined group that is socialized into certain abilities, beliefs, attitudes, and personality dimensions that remain stable as it ages and that distinguish the cohort from those born earlier and later. For example, in the United States, later-born cohorts have more years of formal education than groups of individuals born earlier in the century. In terms of thinking skills, later-born cohorts tend to be superior in reasoning ability and spatial orientation, but some earlier-born cohorts (people who are now older) are superior in arithmetic ability and verbal fluency. These examples illustrate that the absence of developmental change (change due to aging) does not necessarily mean that today’s older people are comparable to today’s younger people. In addition, some differences between cohorts favor the older groups.

The Social Context of Older Adults

Professionals and lay people who work with older adults should be familiar with social aspects of aging. For example, research on older adults’ social adaptation indicates that as adults age, they become more selective about the people with whom they interact. Thus, older adults tend to have small and close social networks. In the United States, the social context of older adults includes specific environments (community living, age-segregated housing, age-segregated social and recreational centers, the aging services network, long-term care facilities, etc.). Many localities also have community-based networks of aging services that are very useful for older adults. These services may include specialized transportation and medical and counseling centers. Developing familiarity with these aspects of older adults’ lives is very useful in providing optimal physical and mental health services.

On an individual level, many older adults face changes to familiar social resources and established social roles. For example, bereavement related to the loss of a spouse is very common. Likewise, the functional and emotional challenges to family members posed by dementing illnesses such as Alzheimer’s disease are specific to later life. Caregiving for a loved one who is chronically ill, loss of long term friends to illness and death, retirement, and relocation to new living environments are additional significant life events that may pose particular challenges for older adults.

Other social contextual aspects include a number of specific laws and regulations that may significantly affect the lives of older adults. For example, Medicare, a national health insurance plan for older adults, has many regulations that may influence when and where older adults may receive clinical services. On both the state and the national level, legislation outlines the proper handling of identified elder abuse and conservatorship regulations for older adults who have become unable to take care of themselves or their finances.

Disorders Associated with Aging

Estimates of the prevalence of adults over the age of 56 years with at least one chronic illness range from 50 to 86 percent. As a result, older adults are more likely than younger adults to have ongoing health problems and to take multiple medications in order to manage these illnesses. Individuals who work with the elderly should have substantial familiarity with chronic illnesses and their psychological impact, control of chronic pain, adherence to medical treatment, rehabilitation strategies, and assessment of behavioral signs of medication reactions. Fortunately, professionals skilled in health psychology are able to make substantial contributions to care for older adults with physical and psychological disorders.

A frequent component of working with chronically ill or disabled elders is addressing comorbid depression. Contrary to some stereotypes, physically healthy older adults in the general population do not suffer from depression at higher rates than younger adults. However, prevalence studies of depression among chronically ill elderly have found rates of depression up to 59 percent. Conversely, depression may actually increase vulnerability to physical health problems, and has been associated with increased disability, poorer rehabilitation, and greater risk of mortality. If depression is identified in a clinical setting, immediate treatment should be sought—depression in older people is highly treatable with either psychotherapy or medication, or a combination of these two interventions.

Problems in thinking and memory increase as people age, and among an increasing proportion of older adults, cognitive dysfunction and dementing conditions may interfere with community living and other activities. Prevalence of dementia, including Alzheimer’s disease and vascular dementia, increases with age. Depression and dementia may present similar symptoms, such as problems in memory for recent events. As a result, older adults in clinical settings who are suspected of dementia should be screened for depression. To detect dementia, clinicians who work with older adults may routinely use a brief screening instrument such as the Folstein Mini Mental State Exam. If there is evidence of both depression and thinking problems during a brief assessment, a more extensive neuropsychological evaluation should be considered. If a dementing condition is present, early identification will allow medical treatment and long-term planning. For spouses and children providing care to an older adult suffering from dementia, psychological interventions such as support groups may help to reduce stress.

Chronic pain is a widespread problem among older adults. It is estimated that 25 to 50 percent of community-dwelling elderly suffer from chronic pain. Chronic pain is associated with rheumatoid arthritis and poor healing following injury. Although medication is frequently indicated to help relieve pain in older adults, there are medical risks associated with these medications that are amplified for the elderly. For this reason, it is fortunate that there are cognitive and behavioral treatments that are effective in helping older clients manage pain. These include methods such as distracting oneself from the pain, reinterpreting pain sensations, using pleasant imagery, using calming self-statements, and increasing daily pleasurable activities. Employment of these psychological techniques, all of which serve to increase a sense of control over the chronic pain symptoms, may help clients reduce dependence on medication to manage pain.

Insomnia is a frequent problem for older adults, and has adverse consequences for physical and emotional health. Between 12 and 25 percent of adults over the age of 65 years complain of chronic sleep difficulties. In sleep-maintenance insomnia, the individual may awaken in the middle of the night and be unable to get back to sleep. He or she may then take naps during the day to make up the sleep time lost, resulting in greater and greater time spent in bed to receive a normal amount of sleep. A combination of educational and behavioral interventions has been recommended in treating this type of insomnia in older adults. This combined intervention has been useful in reducing insomnia without use of drugs.

General Treatment Issues with Older Adults

Research has demonstrated that older adults benefit from psychological interventions to address a range of problems. However, older adults are faced with social, medical, and time constraints that can influence participation in formal psychotherapy. Therefore, several adaptations have been recommended. Treatments should be flexible with regard to structure, location, and presentation. Slower pace and simplified content of information presented to older adults may help to maximize effective communication. These adaptations help to ensure that older adults get the maximum benefit from the interventions offered them.

The complexity of older adults’ health issues should be reflected in care models. For example, it is common for interventions to incorporate case management strategies, such as connecting patients with additional resources (e.g., medical referrals, housing and nutritional services, transportation, and respite care for patients who are also caregivers). In medical settings, one effective treatment strategy is an interdisciplinary team approach in which health professionals with different specialties in the same clinic (such as medicine, psychology, physical therapy, and social work) provide coordinated care for older patients. Because problems of older adults may be complex, clinicians should assess a broad range of outcomes including activity engagement, disability level, life satisfaction, and psychosocial functioning.

Aging and Health Behaviors

Health behaviors include actions that affect an individual’s physical and psychological functioning. Smoking, drinking alcohol, and using caffeine are all health behaviors that may negatively affect health, particularly among physiologically vulnerable populations such as older adults. Other important health behaviors include screening for cancer, medication adherence, and safer sexual behavior. Poor medication adherence may also be a problem for older adults, who often are taking a complex regimen involving multiple medications. Cognitive changes such as worsening memory skills may also interfere with medication adherence. With regard to sexual activity and HIV risk, a sizable proportion of HIV infections have been diagnosed among older adults. Contrary to popular stereotype, many older adults are sexually active. Those individuals who report risk factors for HIV infection should be offered sexual health and safety interventions.

Lifestyle factors such as exercise, diet, and stress management have a significant impact on healthy aging. Moderate exercise has the potential to prevent obesity; improve physical strength, circulation, and cardiac health; and reduce depression. For these reasons, recent research has focused on the development of psychoeducational interventions to increase healthy behaviors (e.g., physical activity/exercise interventions) among older adults. These interventions focus on increasing knowledge about healthy behaviors, getting regular exercise, and maintaining adequate social support. Among older adults at risk for alcohol problems, brief interventions about the health dangers of excessive drinking have been effective in reducing consumption.

Use of Health Services by Older Adults

Although older adults generally use health services more than younger adults, there are also age-associated factors that may negatively affect treatment access. Practical barriers to health service use among the elderly include the cost of services, the distance to sites providing services, and the availability of transportation. Access to mental health services has unique challenges. In addition to practical barriers, stigma associated with mental health problems is common in the current cohort of older adults and may negatively affect treatment seeking. Potential misunderstandings around psychological services may be reduced by clear explanation of the nature and the usefulness of the interventions offered. In addition, sociocultural factors also influence access to care. Ethnic minority elderly often have problems with access and engagement in the health system due to language difficulties, cost, and cultural beliefs about mental illness and caregiving. For example, many Asian cultures attach greater stigma to mental health problems than is typical of White American culture and have more reluctance to share problems with non-family members. Providers need to be sensitive to these barriers and their impact on access to health care.

Primary care settings are key settings for psychoeducational interventions focused on reducing unhealthy behaviors such as alcohol abuse and smoking among both healthy and medically ill older adult populations. Primary care health care providers also have the opportunity to identify depressed older adults who might benefit from mental health services and who are at risk for functional decline and/or suicide. Physical illness and depression are major risk factors for suicide among older adults. Studies have shown that older males have the highest rate of completed suicide in the United States. Therefore, suicide assessment is an important aspect of older adult mental health screening in primary care.

In addition to providing substantial benefit to individuals, connecting older adults to effective psychological services is desirable to reduce strain on the health care system. Older adults with mental illnesses such as depression or psychologically treatable medical disorders such as insomnia and chronic pain use primary care health services more frequently than healthy older adults. Older adults with dual diagnoses of substance abuse and other mental health problems are particularly heavy users of health services. Appropriate psychological intervention with these individuals therefore has the potential to reduce need for medical services. To assist individuals with the challenges associated with aging and to maximize the effective functioning of health care systems, providers of psychological interventions clearly have much to offer in health care settings serving older adults.


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