Older persons form a growing segment of the population within Australia. But while this demographic is increasingly the focus of research, professional practice and the education of new psychologists within the discipline of psychology, the need for all psychologists to upskill their awareness of ageing issues is acute. Demographic data and health and wellbeing trends are important baseline information when consulting with older adults, whether in healthcare settings, organisational environments, orcommunity contexts (Laidlaw & Pachana, 2009).
In Australia, life expectancy is around 81 years for males and 85 for females. Inthe past two decades, the median age of the population has increased from 34to 37, and the percentage of adults aged 65 and over has increased from 12to15 per cent (ABS, 2015).
In terms of the Australian population, Aboriginal and TorresStrait Islander people aged 65 and over represent only 0.7 per cent of the total population. Aboriginal and Torres Strait Islanders experience a range of age-related chronic diseases, including dementia, at an earlier age than non-Indigenous Australians (e.g.,Smith et al., 2008). Understanding these health trends is key to providing needed healthcare delivery and carer support for the older Aboriginal and Torres Strait Islandercommunity.
The accelerated ageing of the populations of developed countries is being matched in the developing world. In 2017, for the first time in history, the number of persons aged 65 and over will outstrip those aged five and under. This population trend is not a temporary blip or due to a short-term outcome of the baby boomer generation. What we are seeing is the increasing lifespan of older persons and the decreasing number of births (but also better survival of infants and young children) worldwide, leading to greater equality in the numbers of those two groups over time. By 2050, approximately 25 per cent of the population of Australia will be over 65. As a discipline, psychology has been adjusting to these changing demographics, with increasing interest in research and practice with older persons.
How old is old?
In the scientific community, an agreed upon age at which one is first considered ‘old’ is 65, and this age is an historical artifact of the very earliest pension schemes in Europe, which set it as the minimum age to collect a pension. Gerontologists have divided the decades following into bands to facilitate studying different groups of older people in greater depth. Those aged 65-74 are referred to as the ‘young-old’, the ‘old-old’ group is 75 to 84, and the ‘oldest-old’ are aged 85 plus.
Social relationships are an important element of wellbeing in later life (see the article on social connectedness on p. 14). Despite ageist myths that later life is a time of loneliness and disconnection, older persons derive greater social support from smaller social networks, compared with younger persons (Charles & Carstensen, 2010). Older adults with adequate social relationships are 50 per cent more likely to survive than those with insufficient social support, an effect comparable with quitting smoking and of greater benefit than avoiding obesity and lack of exercise (Warburton, Nicol & Bredin, 2006). Data from the Organisation for Economic Co-operation and Development (OECD) suggest that, compared with other OECD countries, Australia ranks below average in terms of work-life balance (OECD, 2014b). The fourth General Social Survey (GSS) was conducted with Australians aged 15 years and over in 2014; it showed that Australians over the age of 75 had the highest overall life satisfaction (compared with the total and with other age bands) (GSS, 2014). This survey data also showed that older adults aged 55 plus have relatively high rates of social contact.
Psychological wellbeing in later life.
According to the 2011 census (ABS, 2012-2013), most people aged 65 years and over lived in a private dwelling with ahusband, wife or partner (56 per cent), and women were over-represented in the 25 per cent of this group who lived alone. Only about five per cent of persons over 65 lived in nursing homes or other assisted living accommodation. With increasing age, women are over-represented due to theirincreased longevity. Understanding that institutionalisation is the exception in later life is important, but so too is appreciation for the great benefits thatpsychologists can provide in terms of innovative interventions in aged care, impacting everything from the design of therapeutic environments to the provision of much-needed interventionsto improve mental health and quality of life in such settings (see the article on innovation inaged-care facilities, pp. 12-13).
How old do you feel?
Many older adults feel more vibrant as they age. One common experience across cultures is that of feeling younger than one’s chronological age, which has been demonstrated in several studies internationally. Also, the older one is, the greater the gap between one’s actual age and how old one feels. Typically, after age 65 people feel about 10 years younger than their chronological age.
Despite varying contexts and circumstances, individual factors – particularly physical and mental wellbeing, both objective and subjective – contribute to one’s subjectively imagined age. A longitudinal study found the higher the person’s subjective age, the higher their chance of experiencing poor health and higher mortality, even after adjusting for multiple potential contributing factors. In other words, the closer our perceived and actual ages are, the worse off we are likely to be.
Health of older persons
In the face of increasing years of living, both middle-aged and older persons are concerned with having the ability to pursue their goals and have high quality of life as they age, and to preferably age in their own home for as long as possible. Health plays a large role in being able to lead the life you want to, particularly after retirement.
Primary ageing reflects changes in the organism that are a result of the passage of chronological time. Over time, parts of our physical, psychological and social make-up will change as a result of ageing. For example, visual acuity declines and most people need reading glasses to read fine print after a certain age. But not everyone suffers from macular degeneration, the incidence of which increases with age. Macular degeneration is an example of secondary ageing changes that are due to a specific disease process, or occur as a result of trauma, or due tolifestyle choices.
The same is true for depression, type 2 diabetes, high blood pressure – not everyone will experience these. They are symptoms or conditions that are due to an illness, and/or lifestyle choices such as lack of exercise or high caloric intake over time. Dementia is also the result of a disease process, with only approximately six per cent of those over 65 experiencing this illness.
People can act to lower the risk of many secondary age-related illnesses, including dementia. Lifestyle modifications, in particular exercise, are important factors (see article on reducing dementia risk by targeting lifestyle factors in middle-aged adults on p. 15). But both primary and secondary age-related changes in health can cause distress. Often times psychologists can assist older persons they are working with by informing them about facts about ageing and health, and which life changes they may be experiencing are due to disease states and which are due to primary ageing changes. This can assist efforts to develop coping skills. Becoming comfortable with aspects of ageing may lead to the older adult being more open to assistance or assistive devices, and this may enable enhanced mobility, social interaction and quality of life.
Both physical and mental health issues impact upon older persons. Table 1 (below) presents the main causes of death in older Australians by age band. It demonstrates the important role that chronic illnesses, such as cardiac conditions, as well as dementia, play later in life. Again, many of these illnesses are amenable to positive lifestyle changes, in terms of reducing risk and decreasing the impact of symptoms.
Cause of death is perhaps not as telling with respect to impact on quality of life as burden of disease. In Australia, chronic diseases associated with increasing age, such as coronary heart disease, stroke and dementia, as well as poor mental health reflected in anxiety and depression, contribute to disease burden and poor quality of life. Diabetes and dementia contribute increasingly to the burden of disease in Australia. Burden of disease impacts on the ability to stay in the workforce, health-care utilisation, risk of premature institutionalisation, and impact on carers, whose own health may suffer under the burden of caring (see article on family carers of older adults onp.16)
It’s a myth that older people are more likely to be depressed and anxious than younger people. Actually, the reverse is true, and this is a global phenomenon, not simply a cohort effect. But among those who are older and experiencing poor mental health, the unfortunate fact is that they are less likely to be referred for psychological treatment than pharmacological treatment of such illnesses. This is true in Australia, despite the fact that older people would rather seek talking therapies for such issues (e.g., Woodward & Pachana, 2009). Mental ill-health forms a component of burden of disease, and addressing mental health issues in later life is a growing part ofthe practice of psychologists, with increasing numbers making a point of developing age-friendly practices (see article on developing an age-friendly psychology practice pp. 18-19).
If you heard of an older person with memory problems – would you consider depression or anxiety to be at the root of the problem, or would dementia be the first potential cause to spring to mind? Memory impairment is a key presentation in later life for both depression and anxiety, but unfortunately, this makes it more likely that older adults will be misdiagnosed with dementia. There is a real need for psychologists who interact with older adults in any context to understand that although in general older adults are in good mental health, changes in mood or cognition later in life may be more likely to be due to depression or anxiety than dementia (Knight & Pachana, 2015). This is why the education of the next generation of psychologists must encompass learning about ageing, and the experiences of older persons (see article on building a competent geropsychology workforce p. 17).
Mental health interventions
Key risk factors for depression in later life include: disability, newly diagnosed medical illness, poor health status, poor self-perceived health, prior depression and bereavement. Protective factors include greater perceived social support, regular physical exercise and higher socioeconomic status. Anxiety is actually more common later in life when compared to the incidence of depression, and many risk factors are the same for both anxiety and depression. Key risk factors for anxiety include poor self-rated general health status, and physical or sexual abuse in childhood. Protective factors include greater perceived social support, regular physical exercise and higher level ofeducation.
The intervention research points to several evidence-based psychotherapeutic interventions for anxiety in older adults, including cognitive behaviour therapy, relaxation training and supportive therapy (Ayers et al., 2007). Several psychotherapies are also effective with older adults with depression: cognitive behaviour therapy again, as well as interpersonal psychotherapy, problem-solving therapy and brief psychodynamic psychotherapy (Ellison, Kyomen, & Harper, 2012). Across many complex presentations in later life, interdisciplinary team approaches often have good efficacy as well as economic advantages in terms of indicators such as hospital readmissions (e.g., Karlin & Zeiss, 2010).
Unfortunately, the global geriatric health and mental health workforce will fall far short of the healthcare needs of older adults going forward. The projected needs for mental health specialists in general and geropsychologists in particular has been a concern for many years (Karel, Gatz, & Smyer, 2012). However, psychology as a discipline also needs to focus research and practice on wellness and adaptation in late life, including the concepts of ‘successful’ or ‘positive’ ageing (Bar-Tur & Malkinson, 2014; Hill, 2011). As older adults take increasing interest in pursuing strategies for optimising physical, cognitive and emotional health, psychology needs to provide a solid empirical base to guide both consumers, as well as health-care providers, governments and policymakers.
Research directions
Over the past two decades, there has been a steady increase in journals and an explosion of books worldwide with later life as a focus. Australian psychologists are a vibrant part of this global dialogue in ageing research. There have been (to date, and accessed via Scopus) more than 21,400 articles with ‘aging’ or ‘ageing’ in the title, abstract, or keywords, and with ‘Australia’ as at least one of the authors’ affiliation country. Ofthese over 1100 were in psychology (all publication types, but 85 per cent were peer-reviewed journal publications, and 9.5 per cent were reviewarticles).
Conclusion
If the potential of those entering later life is to be realised, understanding the process of ageing is important for individuals, but also for societies and nations. Practice, education and research on later life will increasingly form apart of psychologists working lives in Australia, reflecting a global trend. Listening to the voices of older adults, in all their broad and influential range, will be an important task for the profession going forward.
