HSC 3110 Ch.22-23

Dealing with the changes of aging

DEALING WITH THE CHANGES OF AGING As we age, we experience many losses. Loss is painful—whether it's a loss of independence, mobility, health, a long-time career, or someone you love. The changes that occur with aging have repercussions that must be grappled with and resolved. Just as you can act now to prevent or limit the physical changes of aging, you can also begin preparing yourself psychologically, socially, and financially for changes that may occur later in life. If you have aging parents, grandparents, and friends, the following information may give you insight into their lives and encourage you to begin cultivating appropriate and useful behaviors now. Planning for Social Changes Retirement marks a major change in the last quarter of life. As Americans' longevity has increased, people spend a larger proportion of their lives—17 years or more—in retirement. By 2030, 18% of the population will be over age 65, up from 13% in 2010. In 2056, for the first time, the older population (age 65 and over) is projected to outnumber the younger population (age 18 and under). This shift has implications for reestablishing important relationships, developing satisfying interests outside work, and saving for an adequate retirement income. People who have well-developed leisure pursuits adjust better to retirement than those with few interests outside work. Changing Roles and Relationships Changes in social roles are a major feature of life as we age. Children become young adults and leave home, removing the duties of daily parenting. Parents experiencing this empty-nest syndrome must adapt to changes in their customary responsibilities and personal identities. And although retirement may be a desirable milestone for most people, it may also be viewed as a threat to prestige, purpose, and self-respect—the loss of a valued or customary role—and often requires some adjustment. Retirement and the end of child rearing also bring about changes in the relationship between marriage partners. The amount of time a couple spends together will increase, and activities will change. Couples may need a period of adjustment in which they get to know each other as individuals again. Discussing what types of activities each partner enjoys can help couples set up a mutually satisfying routine of shared and independent activities. Increased Leisure Time Although retirement confers the advantages of leisure time and freedom from deadlines, competition, and stress, many people do not know how to enjoy their free time. If you have developed diverse interests, retirement can be a joyful and fulfilling period of your life. It can provide opportunities for you to expand your horizons, try new activities, take classes, and meet new people. Volunteering in your community can enhance self-esteem through opportunities to contribute to society. The Economics of Retirement Retirement is usually accompanied by a new economic situation. It may mean a severely restricted budget or possibly even financial disaster if you have not taken stock of your finances and planned ahead. Financial planning for retirement should begin early in life. People in their twenties and thirties should estimate how much money they need to support their standard of living, calculate their projected income, and begin a savings program. The earlier people begin such a program, the more money they will have at retirement. Financial planning for retirement is especially critical for women. American women are much less likely than men to be covered by pension plans, 401(k) plans, and other retirement plans, reflecting the fact that many women have lower-paying jobs or work part time during their childbearing years. Although the gap is narrowing, women currently outlive men by about five to six years, and they are more likely to develop chronic conditions that impair their daily activities later in life. The net result of these factors is that older women are almost Page 623twice as likely as older men to live in poverty. Women should investigate their retirement plans and take charge of their finances to be sure they can provide for themselves as they age. The retirement years can be the best part of your life socially, with increased opportunities to meet and interact with new and different people through volunteer work. © KidStock/Getty Images RF Retirement calculators can be helpful in determining how much money you will need to have prior to retirement. They can be found on several websites. Adapting to Physical Changes As described earlier in the chapter, a person can do many things to avoid or minimize effects of the physical changes associated with aging. However, some changes in physical functioning are inevitable, and successful aging involves anticipating and accommodating these changes. Decreased energy and changes in health mean that older people have to develop priorities for how to use their energy. Rather than curtailing activities to conserve energy, they need to learn how to generate energy. Generating energy usually involves saying yes to enjoyable activities and paying close attention to the need for rest and sleep. Adapting rather than giving up favorite activities may be the best strategy for dealing with physical limitations. For example, if arthritis interferes with playing an instrument, a person can continue to enjoy music by taking up a different instrument or attending concerts. If running or jogging no longer seems possible, a person can switch to walking for exercise. QUICK STATS Over 120,000 Americans are blind due to glaucoma, accounting for 9-12% of all blindness. —Glaucoma Research Foundation, 2015 Hearing Loss The loss of hearing is a common physical change that can have a particularly strong effect on the lives of older adults. Some people lose their hearing slowly as they age—a condition known as presbycusis. Hearing loss affects a person's ability to interact with others and can lead to a sense of isolation and depression. Hearing loss should be assessed and treated by a health care professional. In some cases, hearing can be restored completely by dealing with the underlying causes of the loss. In other cases, hearing aids may be prescribed; but many older adults, especially women, resist wearing hearing aids. The cost of hearing aids may be another limiting factor. Protect your hearing by avoiding exposure to noises above 85 decibels, such as are made by lawnmowers, motorcycles, gunshots, and loud music (see Chapter 19). Wear earplugs when you must be around loud noises, limit your time of exposure, be alert to hazardous noise in the environment, and stay as far as possible from the sound's source. Vision Changes Vision usually declines with age. For some people, this can be traced to conditions such as glaucoma or age-related macular degeneration (AMD) that can be treated medically. For others, the effects of a decline in vision can be managed using strategies to make the most of remaining vision. Glaucoma is caused by increased pressure within the eye due to built-up fluid. The optic nerve can be damaged by this increased pressure, resulting in a loss of side vision and, if untreated, blindness. Medication can relieve the pressure by decreasing the amount of fluid produced or by helping it drain more efficiently. Laser and conventional surgery are other options. Of the more than 3 million Americans with glaucoma, only half know that they have it; others lose the opportunity to control it and preserve their sight. At risk are people over age 60, African Americans over age 40, and anyone with a family history of glaucoma. AMD is a slow disintegration of the macula—the tissue at the center of the retina where fine, straight-ahead detail is distinguished. AMD usually occurs after age 60, but it affects more than 1.5 million Americans over age 40 and is the leading cause of blindness in people over age 75. Losing vision makes it difficult to read, drive, or perform other close-up activities. Risk factors for AMD are age, gender (women may be at higher risk than men), smoking, elevated cholesterol levels, and family history. Some cases of AMD can be treated with injections or laser surgery. Both glaucoma and AMD can be detected with regular screening. Vision can also be affected by other conditions that are products of aging. By the time they reach their forties, many people have developed presbyopia—a gradual decline in the ability to focus on objects close to them. This decline occurs because the lens of the eye no longer expands and contracts as readily. Cataracts, a clouding of the lens caused by lifelong oxidation damage (a by-product of normal body chemistry), may dim vision by the sixties. Surgery often offers relief. Arthritis More than 50 million American adults (about one in five) report having doctor-diagnosed arthritis. This degenerative disease causes joint inflammation leading to chronic pain, swelling, and loss of mobility. Its symptoms include swelling, pain, redness, warmth, tenderness, changes Page 624in joint mobility, early-morning stiffness, and unexplained weight loss, fever, or weakness in combination with joint pain. Arthritis is a disease that affects people of all ages, although it affects older adults and women more often than younger adults and men. As the U.S. population ages, the number of adults with arthritis is expected to increase sharply from 50 million to 67 million by 2030. There are more than 100 types of arthritis; osteoarthritis (OA) is by far the most common. (Rheumatoid arthritis, an autoimmune disorder, is described in Chapter 17.) In a person with OA, the cartilage that caps the bones in joints wears away, forming sharp spurs (Figure 22.1). It most often affects the hands and weight-bearing joints of the body—the knees, ankles, and hips. FIGURE 22.1 Osteoarthritis. When cartilage wears away within a joint, sharp spurs form and the amount of fluid increases, causing pain and swelling. source: Handout on Health: Osteoarthritis. National Institute of Arthritis and Musculoskeletal and Skin Diseases. National Institutes of Health, April 2015. Strategies for reducing the risk of arthritis and, for those who already have OA, for managing it include exercise, weight management, and avoidance of heavy or repetitive muscle use. Weakness of the muscles around joints is linked to arthritis. This connection is why exercising is helpful. Exercise lubricates joints and strengthens the muscles around them, protecting them from further damage. Swimming, walking, cross-country skiing, cycling, and tai chi are good low-impact exercises; knitting and crocheting are excellent for the hands. Maintaining an appropriate weight is important to avoid placing stress on the hips, knees, and ankles. Assistive devices such as kitchen utensils and repair tools with large handles can also help. It is also important to visit a physician as soon as arthritis symptoms occur so that appropriate treatment can be started to reduce pain and swelling, keep joints moving safely, and prevent further joint damage. If joints are severely damaged and activity is limited, surgery to repair or replace joints may be considered, but medication is usually the first treatment. Many people with OA take medication to relieve inflammation and reduce pain. Because arthritis is a chronic condition, researchers are trying to find medications that are effective and safe when used over the long term. Nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen can help but can irritate the digestive tract; prescription drugs that relieve pain without damaging the stomach may have other dangerous side effects. Acetaminophen can also reduce pain without upsetting the stomach, but exceeding the recommended dosage can cause liver damage. Menopause The natural process of menopause usually occurs during a woman's forties or fifties. The ovaries gradually stop functioning, estrogen levels drop, and eventually menstruation ceases. Several years before a woman stops menstruating, her periods usually become irregular, and she may experience hot flashes, vaginal dryness, sleep disturbances, and mood swings. This period, called perimenopause, can be troublesome for many women, some more than others. Lifestyle strategies to reduce menopause-related problems include many of the healthy habits discussed throughout the text: Stop smoking, exercise, eat a healthful diet, lose excess weight, and perform relaxation techniques regularly. For more information about menopause, refer to Chapters 5, 15, and 16. Sexual Functioning The ability to enjoy sex can continue well into old age, particularly if people make the effort to understand and respond to the various changes that age brings to the natural pattern of sexual response. All too often, older people give up intercourse because they mistakenly interpret these changes as signs of impending impotence. Lovemaking may become a more leisurely affair as a couple gets older, but the benefits of maintaining the sexual aspect of the relationship into old age can be great. The older adult who is exploring new sexual horizons after divorce or death of a spouse should still practice safe sex. A growing number of adults over age 50 have sexually transmitted infections. Osteoporosis As described in Chapter 12, osteoporosis is a condition in which bones become dangerously thin and fragile over time. Fractures are the most serious consequence Page 625of osteoporosis; up to 20% of all people who suffer a hip fracture die within a year. Other problems associated with osteoporosis are loss of height and a stooped posture due to vertebral fractures, severe back and hip pain, and breathing problems caused by changes in the shape of the skeleton. More than 40 million people in the United States either already have osteoporosis or are at high risk due to low bone mass. Women are at greater risk for osteoporosis than are men because they have 10-25% less bone in their skeletons. As they lose bone mass with age, women's bones become dangerously thin sooner than men's bones (although more men will probably develop osteoporosis in the future as they live into their eighties and nineties). Bone loss accelerates in women during the first 5-10 years after the onset of menopause because of the drop in estrogen production. (Estrogen improves calcium absorption and reduces the amount of calcium the body excretes.) Black and Latino women have higher bone density and fewer fractures than white or Asian women but may be at increased risk of osteoporosis due to lack of vitamin D (a condition caused by high levels of melatonin). Other risk factors include a family history of osteoporosis, early menopause (before age 45), abnormal or irregular menstruation, a history of anorexia, and a thin, small frame. Regular consumption of more than two alcoholic drinks a day increases the risk of osteoporosis, possibly because alcohol can interfere with the body's ability to absorb calcium. Thyroid medication, corticosteroid drugs for arthritis or asthma, and long-term use of certain contraceptives can also negatively affect bone mass. Preventing osteoporosis requires building as much bone as possible during your young years and then maintaining it as you age. Girls aged 9-18 are in their critical bone-building years, and they should eat foods rich in calcium and vitamin D and get adequate exercise. Weight-bearing aerobic activities must be performed regularly throughout life to have lasting effects. Strength training improves bone density, muscle mass, strength, and balance, protecting against both bone loss and falls, a major cause of fractures. Even for people in their seventies, low-intensity strength training has been shown to improve bone density. Two other lifelong strategies for reducing the effects of osteoporosis are avoiding tobacco use and managing depression and stress. Smoking reduces the body's estrogen levels and is linked to earlier menopause and more rapid postmenopausal bone loss. Some women with depression experience significant bone loss. Researchers have not identified the reason, but it may be linked to increases in the stress hormone cortisol. Bone mineral density testing can be used to gauge an individual's risk of fracture and help determine if any treatment is needed. It is recommended for all women over age 65 and for younger postmenopausal women who have a fracture or one or more risk factors. Below-normal bone density may be classified as osteopenia, which is usually treated with medication, exercise, and nutrition. A greater loss of bone mass is classified as full-blown osteoporosis and is often treated with medications. Handling Psychological and Mental Changes Many people associate old age with forgetfulness, and slowly losing memory. However, we now know that many older adults in good health remain mentally alert and retain their capacity to learn and remember new information. Occasional confusion or forgetfulness may indicate only temporary information overload, fatigue, or response to medications. Many people appear to become even smarter as they age and gain knowledge from life experience. Dementia Dementia is a loss of brain function that occurs with certain diseases. It affects memory, thinking, language, judgment, and behavior. About 4-5 million people in the United States have some degree of dementia, and that number will increase over the next few decades with the aging of the population. Dementia affects about 1% of people aged 60-64 years and as many as 30-50% of people older than 85 years. Early symptoms of dementia include slight disturbances in a person's ability to grasp the situation he or she is in. As dementia progresses, memory failure becomes apparent, and the person may forget conversations, the events of the day, or how to perform simple tasks. It is important to have any symptoms evaluated by a health care professional because some of the over 50 known causes of dementia are treatable (e.g., depression, dehydration, malnutrition, vitamin B-12 deficiency, alcoholism, and misuse of medications). The most common forms of dementia among older people—Alzheimer's disease, Lewy-Body disease, and multi-infarct dementia—are irreversible. The most common, Alzheimer's disease (AD), is a progressive brain disorder that damages and eventually destroys brain cells, leading to loss of memory, thinking, and other brain functions. Alzheimer's is not a part of normal aging but results from a complex pattern of abnormal changes. It usually develops slowly and gradually gets worse as more brain cells wither and die. Autopsies reveal that the interiors of the affected neurons are filled with clusters of proteins known as tangles; the spaces between the neurons are filled with protein deposits called amyloid plaques. Although it's not yet known for certain what causes these changes, many scientists believe the deposits of plaque trigger the following events: As the brain's nerve cells are destroyed, the system that produces the neurotransmitter acetylcholine breaks down, and communication among parts of the brain deteriorates. Page 626In 2013, an estimated 5.2 million Americans of all ages had Alzheimer's disease, which usually occurs in people over age 60 but can occur in people as young as age 40. By 2050, the number of people age 65 and over who currently have the disease may nearly triple from 5 million to a projected 13.8 million. Alzheimer's is ultimately fatal, and currently there is no cure. However, a worldwide quest to find new treatments to stop, slow, or even prevent the disease is currently under way. Because new drugs take years to produce—and because drugs that seem promising in early-stage studies may not work as hoped in large-scale trials—research for cures or prevention are vigorously accelerating. Alzheimer's changes typically begin in the part of the brain that affects learning. Early symptoms include trouble remembering new information and retrieving old information. As Alzheimer's advances, it leads to increasingly severe symptoms, which can include disorientation; mood and behavior changes; deepening confusion about events, time, and place; unfounded suspicions about family, friends, and professional caregivers; more serious memory loss and behavior changes (hallucinations with major personality changes); and difficulty speaking, swallowing, and walking. Scientists do not yet know what causes Alzheimer's disease. Both age and genetics have been identified as risk factors, but many questions still remain. Lewy-Body dementia is an umbrella term for a form of dementia that resembles Alzheimer's disease but has two or more distinctive features. Symptoms that differentiate Lewy-Body dementia from Alzheimer's include unpredictable levels of cognitive ability, attention, or alertness; changes in walking or movement; visual hallucinations; and a sleep disorder called REM sleep behavior disorder, in which people physically act out their dreams. Multi-infarct dementia results from a series of small strokes or changes in the brain's blood supply that deprive the brain of oxygen and destroy brain tissue. Symptoms may appear suddenly and worsen with additional strokes; they include disorientation in familiar locations; walking with rapid, shuffling steps; incontinence; laughing or crying inappropriately; difficulty following instructions; and problems handling money. High blood pressure, cigarette smoking, and high cholesterol are some of the risk factors for stroke that may be controlled to prevent vascular dementia. Even for these incurable forms of dementia, treatment can improve an affected person's quality of life. Evidence indicates that some cases of dementia are hereditary, but experts say genetics are not always a sure sign that a person will develop the disease. QUICK STATS Nearly 1 in 5 Medicare dollars is currently spent on people with Alzheimer's and other dementias. In 2050, it will be 1 in every 3 dollars. —Alzheimer's Association, 2016 Grief Another psychological and emotional challenge of aging is dealing with grief and mourning. Aging is associated with loss—the loss of friends, family and spouse, peers, physical appearance, possessions, and health. Grief is the process of getting through the pain of loss, and it can be one of the loneliest and most emotionally intense times in a person's life. It can take years to completely come to terms with the loss of a loved one. (See Chapter 23 for more information about responses to loss and how to support a grieving person.) Unresolved grief can have serious physical and psychological or emotional health consequences and may require professional help. Signs of unresolved grief include hostility toward people connected with the death (physicians or nurses, for example), talking about the death as if it occurred yesterday, and unrealistic or harmful behavior (such as giving away all of your own belongings). Many people become depressed after the loss of a loved one or when confronted with retirement or a chronic illness. But after a period of grieving, people are generally able to resume their lives. Depression Unresolved grief can lead to depression, a common problem in older adults (see Chapter 3). If you notice the signs of depression in yourself or someone you know, consult a mental health professional. A marked loss of interest in usually pleasurable activities, decreased appetite, insomnia, fatigue, and feelings of worthlessness are signs of depression. Listen carefully when an older friend or relative complains about being depressed; it may be a request for help. Suicide Although the elderly (age 65 and over) comprise about 13% of the U.S. population, they account for over 18% of all suicides. People age 85 and over have the highest suicide rate of any age group. Older white men have a suicide rate almost six times that of the general population—more than women and minorities at any age. The act of completing suicide is rarely preceded by only one cause or one reason. Factors include the recent death of a loved one; physical illness, uncontrollable pain, or the fear of a prolonged illness; perceived poor health; social isolation and loneliness; and major changes in social roles (such as retirement). Depression is probably the single most significant factor associated with suicidal behavior in older adults. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION If scientists discover the gene that causes Alzheimer's disease or other debilitating forms of dementia, would you want to know whether you carried this gene?

Generating vitality as you age

GENERATING VITALITY AS YOU AGE As we age, physical and mental changes occur gradually. Biological aging includes all the normal, progressive, irreversible changes to our bodies that begin at birth and continue until death. Psychological aging and social aging usually reflect more abrupt changes in circumstance and emotion: relocating, changing homes, losing a spouse and friends, retiring, having less income, and changing roles and social status. Although they may be challenging or difficult, these changes represent opportunities for growth throughout life. Not all these changes happen to everybody, and their timing varies, depending in part on how we have prepared for Page 619our later years. Some people never have to leave their homes and appear to be in good health until they die. Others have great adjustments to make—to entirely new surroundings with fewer financial resources, to new acquaintances, to the changing physical condition of their bodies and new health problems, and possibly to loneliness and loss of self-esteem. Successful aging requires preparation. People need to establish good health habits in their teens and twenties. During their twenties and thirties, they usually develop important relationships and settle into a particular lifestyle. By their mid-forties, they generally know how much money they need to support the lifestyle they've chosen. At this point, they must assess their financial status and perhaps adjust their savings in order to continue enjoying that lifestyle after retirement. In their mid-sixties, they need to reevaluate their health insurance plans and may want to think about retirement housing. In their seventies and beyond, they need to consider ways of sharing their legacy with the next generation. Throughout life, people should cultivate interests and hobbies they enjoy, both alone and with others. What Happens as You Age? Many characteristics associated with aging are not due to aging at all. Rather, they result from the neglect and abuse of our bodies and minds. These assaults lay the foundation for later psychological problems and chronic conditions such as arthritis, heart disease, diabetes, hearing loss, vision problems, and hypertension. According to the National Council on Aging, 92% of older adults have at least one chronic disease, and 77% have at least two. Among Americans aged 60 and over, 77%, or 12.2 million of the older population, are affected by diabetes. We sacrifice our health by smoking, ignoring our nutritional needs, overeating, abusing ourselves with alcohol and drugs, bombarding our ears with excessive noise, and exposing our bodies to too much ultraviolet radiation from the sun. We also jeopardize our bodies through inactivity, encouraging our muscles and even our bones to wither and deteriorate. And we endure abuse from the toxic chemicals in our environment. QUICK STATS The world's older population continues to grow at an unprecedented rate. Today, 8.5% of people worldwide (617 million) are age 65 and over. —National Institute on Aging, 2016 Even with the healthiest behavior and environment, aging inevitably occurs. It results from genetic and biochemical processes we don't yet fully understand. The physiological changes in organ systems are caused by a combination of gradual aging and impairment from disease. Because of redundancy in most organ systems, the body's ability to function is not affected until damage is fairly extensive. Studies of healthy people indicate that functioning remains essentially constant until after age 70. Further research may help pinpoint the causes of aging and develop therapies to repair damage to aging organs. Life-Enhancing Measures: Age-Proofing Through good habits you can prevent, delay, lessen, or even reverse some changes associated with aging. Simple, daily practices can make a great difference to your level of energy and vitality—your overall wellness. The following suggestions have been mentioned throughout this text, but because they are profoundly related to health in later life, we highlight them here. Challenge Your Mind Numerous studies show that older adults who stay mentally active have lower levels of the brain protein linked to Alzheimer's and dementia. Reading, writing, doing puzzles, learning a language, and studying music are good ways to stimulate the brain. The more complex the activity, the more protective it may be. Several other studies have shown that mental exercises during childhood and late adulthood contribute to slower mental decline in old age. Develop Physical Fitness Exercise significantly enhances both psychological and physical health. A review of more than 70 scientific studies cited in the 2008 Physical Activity Guidelines Advisory Committee Report found that physically active people have about a 30% lower risk of dying prematurely compared with inactive people. Poor fitness and low physical activity levels were found to be better predictors of premature death than smoking, diabetes, or obesity. The committee found that about 150 minutes (2.5 hours) of physical activity per week is sufficient to decrease all causes of death and that it is the overall volume of energy expended, rather than the kinds of activities that require the energy expenditure, that makes a difference in risk of premature death. Regular exercise is a key to successful, healthy aging. © Indeed/Getty Images Page 620Exercise produces positive effects such as the following: Lower blood pressure and healthier cholesterol levels Better protection against heart attacks and an increased chance of survival if one occurs Sustained or increased lung capacity Weight control through less accumulation of fat Maintenance of strength, flexibility, and balance Improved sleep Longer life expectancy Protection against osteoporosis and type 2 diabetes Increased effectiveness of the immune system Maintenance of mental agility and flexibility, response time, memory, and hand-eye coordination The stimulus that exercise provides also seems to protect against the loss of fluid intelligence, which is the ability to find solutions to new problems. Fluid intelligence depends on rapidity of responsiveness, memory, and alertness. Individuals who exercise regularly are also less susceptible to depression and dementia. Regular physical activity also fends off sarcopenia, which is age-related loss of muscle mass, strength, and function (see Chapter 13). The weaker a person becomes, the less he or she can do; this condition can rob you of self-sufficiency and lead to greater dependence on others. The muscle wasting that occurs in sarcopenia also leads to weight gain because muscle burns more calories than does fat, even at rest. Regular physical activity is essential for healthy aging, as it is throughout life. The 2008 Physical Activity Guidelines for Americans include recommendations for older adults that are the same as for all adults: All older adults should avoid inactivity. Some physical activity is better than none. For substantial health benefits, older adults should do at least 150 minutes a week of moderate-intensity activity, or 75 minutes a week of vigorous-intensity activity, or a combination of both. For additional and more extensive health benefits, older adults should increase their aerobic physical activity to 300 minutes a week of moderate-intensity, or 150 minutes a week of vigorous-intensity, aerobic physical activity. Older adults should also do muscle-strengthening activities that are moderate or high intensity and involve all major muscle groups on two or more days a week because these activities provide additional health benefits. QUICK STATS The direct health care costs attributed to fall-related injuries totaled $34 billion in 2013. —National Council on Aging, 2015 There are also guidelines just for older adults: When older adults cannot do 150 minutes of moderate-intensity aerobic activity a week because of chronic conditions, they should be as physically active as their abilities and conditions allow. Older adults should do exercises that maintain or improve balance if they are at risk of falling. Older adults with chronic conditions should understand whether and how their conditions affect their ability to do regular physical activity safely. Older adults should perform flexibility exercises necessary for regular physical activity and activities of daily life. For more about the beneficial effects of exercise for older adults, see the box "Can Exercise Delay the Effects of Aging?" TAKE CHARGE: Can Exercise Delay the Effects of Aging? As people age, they often experience declines in functional health—the ability to perform the tasks of everyday life—and related declines in the quality of life. According to the Centers for Disease Control and Prevention (CDC), more than 24% of Americans over age 65 report their health as only "fair" or "poor." Similarly, according to a Medicare survey, 19% of men and 30% of women age 65 and over reported problems with basic physical tasks in 2010 (meaning they had difficulty with things such as walking two to three blocks, lifting 10 pounds, or stooping or kneeling). Can physical activity and exercise combat the degenerative effects of aging in middle-aged and older adults? The evidence indicates that they can. In reviewing the research, the U.S. government's Physical Activity Guidelines Advisory Committee concluded that physical activity can prevent or delay the onset of limitations and declines in functional health in older adults, can maintain or improve functional health in those who already have limitations, and can reduce the incidence of falls and fall-related injuries. One mechanism by which physical activity prevents declines in functional health is through maintenance or improvement of the physiological capacities of the body, such as aerobic power, muscular strength, and balance—in other words, through improvements in physical fitness. Declines in these physiological capacities occur with biological aging and are often compounded by disease-related disability. But evidence shows that older adults who participate in regular aerobic exercise are 30% less likely than inactive individuals to develop functional limitations (such as a limited ability to walk or climb stairs) or role limitations (such as a limited ability to be the family grocery shopper). Although studies found that both physical activity and aerobic fitness were associated with reduced risk of functional limitations, aerobic fitness was associated with a greater reduction of risk. Evidence also suggests that regular physical activity is safe and beneficial for older adults who already have functional limitations. Numerous studies have shown that regular exercise—particularly strength training, balance training, and flexibility exercises—can improve muscular strength, muscular endurance, and stability and provide some protection against falls. Aerobic activity, especially walking, also helps reduce risk of falls, and some evidence indicates that tai chi exercise programs are beneficial as well. Regular exercise not only reduces the incidence of falls but also greatly enhances mobility, allowing older people to live more independently and with greater confidence. Research also shows that regular physical activity can reduce anxiety and depression in older adults. Exercise stimulates blood flow to the brain and can even increase brain mass, helping the brain to function more efficiently and improving memory. There is some evidence that exercise may stave off mental decline and the occurrence of age-related dementia. Current physical activity recommendations for older adults from the American Heart Association and the American College of Sports Medicine include moderate- to vigorous-intensity aerobic activity, strength training, and flexibility exercises, as well as balance exercises for older adults at risk for falls. Unfortunately, more than 70% of Americans aged 65 and over do not get the recommended amounts of physical activity, and many get no exercise at all beyond the activities of daily living. Older adults are the least active group of Americans. Although it is important to exercise throughout life, the evidence indicates that older adults who become more active even late in life can experience improvements in physical fitness and functional health. sources: Physical Activity Guidelines Advisory Committee. 2008. Physical Activity Guidelines Advisory Committee Report, 2008. Washington, DC: U.S. Department of Health and Human Services; Simonsick, E. M., et al. 2005. Just get out the door! Importance of walking outside the home for maintaining mobility: Findings from the Women's Health and Aging Study. Journal of the American Geriatrics Society 53(2): 198-203. Eat Wisely Good health at any age is enhanced by eating a varied diet full of nutrient-rich foods (see Chapter 12). For many adults, that means eating more fruits, vegetables, and whole grains while eating fewer foods high in saturated and trans fats and added sugars. Special guidelines for older adults include the following: Get enough vitamin B-12 and extra vitamin D from fortified foods or supplements. Limit sodium intake to 1500 mg per day (3/4 teaspoon salt), and get enough potassium (4700 mg per day). Older adults tend to have higher blood pressure and to be salt-sensitive. Eat foods rich in dietary fiber and drink plenty of water to help prevent constipation. Pay special attention to food safety. Older adults are often more susceptible to foodborne illness. Maintain a Healthy Weight Weight management is especially difficult if you have been overweight most of your life. A sensible program of expending more calories through exercise, cutting calorie intake, or a combination of both will work for most people who want to lose weight, but there is no magic formula. Obesity is not physically healthy, and it leads to premature aging (see Chapter 14). Control Drinking and Overdependence on Medications Alcohol abuse ranks with depression as a common hidden mental health problem, affecting about 10% of older adults. (The ability to metabolize alcohol decreases with age.) The problem is often not identified because the effects of alcohol or drug dependence can mimic disease, such as Alzheimer's disease. Page 621Signs of potential alcohol or drug dependence include unexplained falls or frequent injuries, forgetfulness, depression, and malnutrition. People who retire or lose a spouse and have few interests to replace their work lives are especially at risk. Problems can be avoided by not using alcohol to relieve anxiety or emotional pain and not taking medication when safer forms of treatment are available. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Where would you wish to spend your "golden years"? Do you look forward to this stage of your life, or are you anxious about it? What influences have shaped your feelings about aging? Don't Smoke The average pack-a-day smoker can expect to live about 13-14 fewer years than a nonsmoker. Furthermore, smokers suffer more illnesses that last longer, and they are subject to respiratory disabilities that limit their total vigor for many years before their death. Premature balding, skin wrinkling, and osteoporosis have been linked to cigarette smoking. Smokers at age 50 often have wrinkles resembling those of a person aged 60. Schedule Physical Examinations to Detect Treatable Diseases When detected early, many diseases, including hypertension, diabetes, and many types of cancer, can be successfully controlled by medication and lifestyle changes. Regular testing for glaucoma after age 40 can prevent blindness from this eye disease. Recommended Page 622screenings and immunizations can protect against preventable chronic and infectious diseases (see Chapters 15-17). Recognize and Reduce Stress Stress-induced physiological changes increase wear and tear on your body. Cut down on the stresses in your life. Don't wear yourself out through lack of sleep, substance abuse or misuse, or overwork. Take five minutes every so often throughout the day to close your eyes and focus on your breathing. Practice relaxation using the techniques described in Chapter 2. If you contract a disease, consider it your body's attempt to interrupt your life pattern; reevaluate your lifestyle, and perhaps slow down.

understanding and accepting death and dying

UNDERSTANDING AND ACCEPTING DEATH AND DYING From a personal point of view, death challenges our emotional and intellectual security. We may acknowledge the fact that all living things die eventually and that this is nature's way of renewal, but this recognition offers little comfort when death touches our own lives. Questions about the Page 637meaning of death and what happens when we die are central to the great religions and philosophies of the world. Some promise a better life after death. Others teach that everyone is evolving toward perfection or divinity, a goal reached after successive rounds of life, death and rebirth. Still others suggest that it is not possible to know what—if anything—happens after death and that any judgment about life's worth must be made on the basis of satisfactions or rewards we create for ourselves in our lifetimes. Death awaits all of us, and accepting and dealing with it are difficult but important tasks. © Tom Mareschal/Getty Images Even for the most secular individuals, religious beliefs and traditions can shape attitudes and behaviors surrounding death. Religion offers solace to the extent that it suggests meaning in dying. And the mourning ceremonies associated with various religions ease the pangs of grief for many people. Dying and death are more than biological events; they have social and spiritual dimensions. Our beliefs—religious or philosophical—can be a key to how we relate to the prospect of our own death as well as the deaths of others. Ultimately we have no completely satisfying answer to the question of why death exists. When we look at the big picture, we see that death promotes variety through the evolution of species. The average human life is long enough to allow a person to reproduce and ensure that the species continues. Yet it is brief enough to allow for new genetic combinations, thereby providing a means of adaptation to changing conditions in the environment. From the perspective of species survival, the cycle of life and death makes sense. Senescence, the biological process of aging, is complex, rooted in genetics, and universal in all mammals, including humans. Organisms age on both a cellular and a whole-organism level, ultimately resulting in death. Although scientific understanding of senescence is progressing, and average life spans are increasing, death remains an inevitable event for humans. Defining Death Paradoxically, as our scientific understanding of death increases, defining death has become increasingly difficult. Traditionally death has been defined as cessation of the flow of vital body fluids. This cessation occurs when the heart stops beating and breathing ceases, referred to as clinical death. These traditional signs are adequate for determining death in most cases. However, over the past several decades, the use of cardiopulmonary resuscitation (CPR) and other medical techniques have brought many "dead" people (by the traditional definition) back to life. The use of ventilators, artificial heart pumps, and other life support systems allow many body functions to be sustained artificially. In such cases, making a determination of death can be difficult and often controversial. The concept of brain death was developed to determine whether a person is alive or dead when the traditional signs are inadequate because of supportive medical technology. The Uniform Determination of Death Act, developed in 1981, provides criteria for determining brain death, which is defined as the complete and irreversible loss of function of the entire brain. The concept of brain death is particularly crucial for organ transplantation. Medical technologies such as ventilators are used so that organs will remain viable over the hours or days that are needed to arrange for transplantation. Some organs—hearts, most obviously—must be harvested from a human being who is legally determined to be dead. Timing is critical in removing a heart from someone Page 638who has been declared dead and transplanting it into a person whose life can thereby be saved. Safeguards are necessary to ensure that the determination of death occurs without regard to any plans for subsequent transplantation of the deceased's organs. Several thorough examinations need to be performed over a period of time in order to determine that both higher brain and brain-stem functions (which regulate heartbeat and breathing) have ceased irreversibly. The American Academy of Neurology published guidelines in 2010 for determination of brain death, but a 2015 study showed that hospital policies and practices regarding brain death still vary considerably throughout the United States. The way death is defined also has potential legal, ethical, and social consequences, including potential effects on criminal prosecution, inheritance, taxation, treatment of the corpse, and even mourning. Determining that someone is dead is simple and obvious in the vast majority of cases, but at times it can be difficult and controversial, as illustrated by the recent case of a 13-year-old girl who was declared brain dead following surgical complications that included massive blood loss and cardiac arrest. Her body has been maintained on life support since 2013 at the insistence of her family members, who believe she is still alive. As of this publication, she remains on life support. This case is extremely unusual, in that the vast majority of patients who are declared brain dead become obviously dead within a few days or weeks, with total cessation of heart and bodily functions, even if mechanical ventilation and other forms of life support are continued. As medical and technological advances occur, it has become increasingly obvious that death consists of a series of biological events that occur over a period of time. In contrast to clinical death (irreversible cessation of heartbeat and breathing) or brain death, cellular death refers to a gradual process that occurs when heartbeat, respiration, and brain activity have stopped. Many cells throughout the body continue to survive for seconds, minutes, or hours after clinical and brain death, but gradually die as they utilize remaining oxygen and glucose. Cellular death encompasses the breakdown of metabolic processes and results in complete nonfunctionality at the cellular level. In a biological sense, therefore, death can be defined as the cessation of life due to irreversible changes in cell metabolism. Learning about Death Our understanding of death changes as we grow and mature, as do our attitudes toward it. Very young children view death as an interruption and an absence, but their lack of a mature time perspective means that they do not understand death as final and irreversible. A child's understanding of death evolves greatly from about age 6 to age 9. During this period, most children begin to understand that death is final, universal, and inevitable. A person who consciously recognizes these facts is said to possess a mature understanding of death. Based on work done by Mark Speece and Sandor Brent, a formal understanding of the empirical, or observable, facts about death includes four components: Universality. All living things die eventually. Death is all-inclusive, inevitable, and unavoidable (although unpredictable with respect to its exact timing). The bottom line is that we know we will die, but we don't know when. Irreversibility. Organisms that die cannot be made alive again. Nonfunctionality. Death involves the cessation of all physiological functioning, or signs of life. Causality. There are biological reasons for the occurrence of death. However, even individuals who possess a mature understanding of death commonly also hold nonempirical ideas about it. Such nonempirical ideas—that is, ideas not subject to scientific proof—deal mainly with the notion that human beings survive in some form beyond the death of the physical body. What happens to an individual's personality after he or she dies? Does the self or soul continue to exist after the death of the physical body? If so, what is the nature of this afterlife? Developing personally satisfying answers to such questions, which involve what Speece and Brent term noncorporeal continuity, is also part of the process of acquiring a mature understanding of death. In the United States, with its relative affluence and orderliness, death is not a part of the day-to-day existence of most young people. The death of a beloved pet is often a child's first experience of the reality and permanence of death. Even by college age, most Americans have experienced few, if any, deaths among their loved ones. There are exceptions, however, especially among those who have grown up in relatively dangerous environments, such as neighborhoods in the inner city, where violent deaths among young people may be agonizingly frequent. Rural kids may also experience close encounters with death at a young age, as they lose loved ones to fatal automotive crashes on dangerous country roads. However, even when death strikes those around us, many of us continue to feel a sense of invulnerability—that is, "It won't happen to me." By the time we reach old age, reminders of aging and death are frequent, especially as older adults experience the loss of many of their contemporaries. The very old have often lost nearly everyone of significance in their lives. Coping with the death of loved ones and contemplating their own impending deaths are central developmental tasks for the very elderly.Page 639 Denying versus Acknowledging Death Understanding death in a mature fashion does not imply that we never experience anxiety about the deaths of those we love or about the prospect of our own deaths. The news of a friend's or loved one's serious illness can shock us into an encounter with mortality—not only that of our friend or loved one, but also of our own. The ability to find meaning and comfort in the face of mortality depends not only on having an understanding of the facts of death but also on our attitudes toward it. Many people avoid any thought or mention of death. The sick and old are often isolated in hospitals and nursing homes. Relatively few Americans have been present at the death of a loved one. Where the reality of death is concerned, "out of sight, out of mind" is often the rule of the day. Instead of facing death directly, we amuse ourselves with unrealistic portrayals in movies, television, and video games. The fictitious deaths of characters we barely know do not cause us to confront the reality of death as it is experienced in real life. Moreover, these faked deaths are often presented as reversible. Children watch a daily fare of superhuman heroes, invincible to bullets and other weapons. In their games, they reenact these false ideas about death—falling down dead and jumping up again unharmed. Cartoons and video games present death in a two-dimensional world where you can die and then be reborn to play seconds later. Although some commentators characterize the predominant attitude toward death in the United States as "death denying," others are reluctant to generalize so broadly. People often maintain conflicting or ambivalent attitudes toward death. Those who view death as a relief or release from insufferable pain may have at least a sense that death is sometimes welcomed, but few people wholly avoid or wholly welcome death. In the past several decades, attitudes toward death in our culture have begun to change slowly. The hospice movement (discussed in this chapter) has provided support and guidance for many families who choose to be present during the dying process of their loved ones, often in their own homes. Dying in a home setting fulfills the wishes of many patients and can also be a great comfort to friends and family. Not all cultures are reluctant to publicly acknowledge death. For example, traditional Mexican culture honors the dead by remembering them often and even including them in family activities. Día de los Muertos (Day of the Dead) is an annual holiday in Mexico, in which families celebrate their departed loved ones. This holiday is festive, tinged with some sadness, but mostly full of love, fun, and good humor. Similar celebrations that honor the dead in a festive manner are common in many cultures throughout the world. It is interesting that in the United States Halloween is a "spooky" holiday; witches, ghosts, and scary entities of all types abound, but our own departed loved ones are not invited to the party. Although specific religions have their own ways of honoring the dead, the general American culture lacks outlets for remembering departed loved ones and honoring their place in our hearts. In Mexico, individuals publicly celebrate departed loved ones on the annual holiday Día de los Muertos (Day of the Dead). © fitopardo.com/Getty Images Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION What situations or events make you think seriously about your own mortality? Is this something you consider now and then, or do you avoid thinking about death? What has influenced your willingness or reluctance to think about death?

coping with imminent death

COPING WITH IMMINENT DEATH There is no one right way to live with or die of a life-threatening illness. Every disease has its own set of problems and challenges, and each person copes with these problems and challenges in his or her own way. Much suffering experienced by people with a life-threatening illness comes from overwhelming feelings of loss on all levels. Besides the many physical and emotional losses, there are usually concerns about costly medical care, loss of income, hospitalization, and physical pain. How a person copes with such an experience is likely to reflect his or her personality and life history, as well as the nature of family relationships and patterns of interaction in the person's wider social environment. Spiritual strength can be a major factor in how we deal with these losses. The support of loving family, friends, clergy or other spiritual guides, and health care professionals, including a hospice team, can make the journey easier to bear. Awareness of Dying Living with an illness that is life-threatening and incurable can be described as a living-dying experience. From the time discomforting symptoms are first noticed and a person's worst fears are confirmed by a life-limiting diagnosis, through the ups and downs of treatment, and on to the final days or hours of life, honesty and hope are often delicately balanced—honesty to face reality as it is, and hope for a positive outcome—a state that psychiatrist Avery Weisman described as middle knowledge. The object of hope changes. The early hope that the symptoms are not really serious gives way to hope that a cure is possible. When the illness is deemed incurable, there is hope for more time. As time begins to run out, one hopes for a pain-free death—a "good death." Maintaining a sense of self-worth, setting goals and striving to reach them, engaging in fruitful interactions—all of these reflect a coping strength that sustains the will to live fully despite a bleak prognosis. The Tasks of Coping In her groundbreaking 1969 book On Death and Dying, Elisabeth Kübler-Ross, a Swiss American psychiatrist and one of the first medical experts to focus on the topic of end of life, suggested that the response to an awareness of imminent death involves five psychological stages: denial, anger, bargaining, depression, and acceptance. The notion that these five stages occur in a linear progression has since become a kind of modern myth of how people ought to cope with dying. Unfortunately, such thinking can lead to the idea that a person's task is to move sequentially through these stages, one after another, and that if this is not accomplished, the person has somehow failed. In fact, however, Kübler-Ross said that individuals go back and forth among the stages during the course of an illness, and stages can occur simultaneously. The stage-based model devised by Kübler-Ross almost 50 years ago has been a stimulus toward a better understanding of how people cope with dying. Today the notion of stages has been deemphasized in favor of highlighting the tasks that require attention in order to cope well with a life-threatening illness. Psychologist and author Charles Corr, for example, distinguishes four primary dimensions in coping with dying: Physical. Satisfying bodily needs and minimizing physical distress Psychological. Maximizing a sense of security, self-worth, autonomy, and richness in living Social. Sustaining significant relationships and addressing the social implications of dying Spiritual. Identifying, developing, or reaffirming sources of meaning and fostering hope Helping a dying person, and her or his loved ones, requires attention and support to all four of these dimensions. In addition, though, we must remember that a person's death is as unique as his or her life. Thus, although models can help us gain understanding, they need to be balanced by paying attention to the dying person's own unfolding life story. Each person's pathway through life-threatening illness is determined by factors such as the specific disease and its course, his or her personality, and the available supportive resources. Some people with life-threatening illness respond with a fighting spirit that views the illness not only as a threat but also as a challenge. These people strive to inform themselves about their illness and take an active part in treatment decisions, as much as they are able. They are optimistic and have a capacity to discover positive meaning in ordinary events. Holding to a positive outlook despite distressing circumstances, these people attempt to continue to accomplish goals, maintain relationships, and sustain a sense of personal vitality, competence, and power despite life-threatening illness. Other people with terminal disease, particularly in the later stages, tend to withdraw, and sometimes find their peace in quietly letting go of striving. Many people who are nearing the end of life develop dementia or delirium, which can greatly limit their ability to cope cognitively and emotionally with the challenges of dying.Page 649 Supporting a Person in the Last Phase of Life People often feel uncomfortable in the presence of a person who is in the final stage of life. How should we act? What can we say? Perhaps the most important and comforting thing we can do for a dying person is to simply be present. Sitting quietly and listening carefully, we can take our cues from the person who is dying. If the person is capable of speaking, and wishes to talk, attentive listening is an act of great kindness. If the person doesn't wish to talk, or is not able to, physical touch such as holding hands or putting a hand on the person's shoulder can be the most effective way to express your love and concern. Attempting to cheer up a dying person by saying something like "you are going to be just fine" or "you can fight this and be well again" can be frustrating for a patient at the end of life, who knows that your words are simply not true. You cannot fix all the difficulties your dying loved one is facing, but you can listen, and show by your loving presence that you care. Simple words that come from the heart can be healing for the speaker and for the loved one whose time is short. The level of alertness of a dying person often fluctuates. A patient who has been nonverbal may have moments of clear speech in the days or hours before death. People with dementia may have lucid periods. Even those who appear to be in a coma or deep sleep may be able to hear what is going on around them. Most experts think that hearing and touch are the last senses to go. Always assume that a dying person can hear what you say; be sure to keep that in mind when you speak to others in the room. Don't hesitate to speak lovingly to a dying person whether or not she or he shows outward signs of hearing you. Besides having the loving presence of friends and family, the dying person may need other supportive resources. Trained individuals who have experience with dying patients, such as clergy and hospice workers, can provide invaluable support. The Trajectory of Dying Your ideas about dying may be quite different from what most people actually experience. The concept of a trajectory of dying is useful for understanding people's experiences as they near death. Although sudden death from an unexpected cause—a massive heart attack or an unintentional injury, for example—is one type of dying trajectory, our focus here is on deaths that occur with forewarning. Among these, some trajectories involve a steady and fairly predictable decline. This is the case with many cancers, which tend to follow the course of a progressive disease with a rapid terminal phase. Other kinds of advanced, chronic illness involve a long period of slow decline marked by episodes of crisis, the last of which proves to be fatal. The simple acts of listening and loving touch can be extremely supportive to someone who is facing death. © John Walker/The Fresno Bee/ZumaPress/Newscom We can also distinguish between stages in a dying trajectory—namely, a period when a person is known to be terminally ill but is living with a life expectancy of perhaps weeks or months, possibly years, and a later period when dying is imminent and the person is described as actively dying. The way in which such trajectories are estimated—their duration and expected course—can affect both patients and caregivers and influence their actions. Deaths that happen much sooner or much later than the patient and family expected may pose special difficulties. A family may experience more shock and guilt if the death occurs before they have had time to "say their good-byes" and emotionally prepare. When death is slow in coming, and the dying individual lingers for days, weeks, or months longer than anticipated, families and the dying person may become physically, emotionally, and spiritually exhausted. The support of extended family, friends, hospice, and clergy can make the difference between an unbearable situation and one that is tolerable. In the best scenarios, the dying process can be a time when bonds of family and friendship are strengthened, and personal growth occurs for the dying individual and his or her loved ones. When a person is actively dying, his or her death is expected to occur within hours or, at most, a few days. During the last phase of a fatal illness, a dying person may exhibit irregular breathing or shortness of breath, decreased appetite and thirst, nausea and vomiting, incontinence, restlessness and agitation, disorientation and confusion, and diminished consciousness. These symptoms usually can be managed by skilled palliative care. Pain, if it is present, should be treated aggressively as part of a comprehensive approach to comfort care. Narcotic pain medications are generally the most effective and are routinely used at the end of life at whatever dose is needed to provide the pain control the patient desires. The stopping of eating and drinking is a normal part of the last phase of a terminal condition. As the body shuts down, food Page 650cannot be assimilated and may only contribute to the patient's discomfort. Forcing food or liquids often results in choking or nausea. If a person's mouth is dry, giving ice chips, dropping small amounts of water into the mouth from a straw or syringe, or using a moistened swab can help. As death is drawing near, the patient's extremities may feel cold to the touch; lips, fingers, and toes may appear bluish; urination becomes less frequent; and the ability to communicate may be lost. In the final hours, purple blotches (mottling) may appear on the legs or arms. Simple steps—such as repositioning the patient, covering him or her with a light blanket, dimming the room's lighting, playing soft favorite music, or holding hands—can provide great relief and reassurance in the last moments. Just before death, the person may take a deep breath and sigh or shudder. It is not unusual for a dying person to seem to wait until loved ones have left the room before taking her or his last breath. You should not feel guilty or rejected if you are not present at the moment of death. Some dying people seem to need to be alone in the moment of passing. The Hollywood version of death, where the dying person speaks meaningful last words to loved ones, then dies immediately, is much less common than a period of hours or days of apparent unresponsiveness before death finally comes. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION What is your notion of a "good death?" In what setting does it take place, and who is there? In the last days of your life, what do you think you'll need to say, and to whom will you want to say it? If you were terminally ill, what would be the most supportive things others could do for you?

Inro

Aging does not begin at some specific point in life, and there is no precise age at which a person becomes "old." Although youth is not entirely a state of mind, your attitude toward life and your attention to your health significantly affect the satisfaction you will get from life and even your ability to come to terms with death. This effect is especially significant when new physical, mental, and social challenges occur in later years. If you optimize wellness during young adulthood, you can exert greater control over the physical and mental aspects of aging, and you can better handle your response to events that might be out of your control.

coping with loss

COPING WITH LOSS Even if you have not experienced the death of someone close, you have experienced loss because of changes and endings. The loss of a job, the ending of a relationship, transitions from one school or neighborhood to another—these are the kinds of losses that occur in all our lives. Such losses are sometimes called little deaths, and in varying degrees they all involve grief. As noted earlier in the chapter, for many people, the first really significant loss is that of a pet. The intensity of grief after losing a beloved companion animal is often comparable to the grief experienced following the loss of a human loved one. Never assume that the loss of a pet is "no big deal." The pain following the loss of a pet may be made even harder to bear if the experience of the grieving person is belittled. The comments here about grief are relevant to many types of loss, not just the loss of a human friend or relative. Experiencing Grief Grief is the reaction to loss. It encompasses thoughts and feelings as well as physical and behavioral responses. Mental distress may involve disbelief, confusion, anxiety, disorganization, and depression. The emotions that can be present in normal grief include not only sorrow and sadness, but also relief, anger, guilt, and self-pity, among others. Bereaved people experience a range of feelings, even conflicting ones. Observing the faces of families at the funeral of a beloved relative often reveals smiles and moments of laughter in addition to solemn expressions and tears. Recognizing that grief can involve many feelings—not just sadness—makes us more able to cope with it. Common behaviors associated with grief include crying and talking repetitively about the deceased and the circumstances of the death. Bereaved people may be restless, as if not knowing what to do with themselves. Outward signs of grief may involve frequent sighing, crying, inappropriate laughter, insomnia, loss of appetite, and marked fatigue. Grief may also evoke a reexamination of religious or spiritual beliefs as a person struggles to make meaning of the loss. Guilt is a common emotion after the death of a loved one. People may blame themselves in some way for the death, or for not doing enough for the deceased, or for feeling a sense of relief that their loved one is gone. All such manifestations of grief can be present as part of our total response to bereavement—that is, the event of loss. Mourning is closely related to grief and is often used as a synonym for it. However, mourning refers not so much to the reaction to loss but to the process by which a bereaved person adjusts to loss and incorporates it into his or her life. How this process is managed is determined, at least partly, by cultural and gender norms for the expression of grief. The Course of Grief Grieving, like dying, is highly individual. In the first hours or days following a death, a bereaved person is likely to experience shock and numbness, as well as a sense of disbelief, especially if the death was unexpected. Consider the ways in which people die: a young child pronounced dead on arrival after a bicycle crash, an aged grandmother dying quietly in her sleep, a despondent executive who commits suicide, a young soldier killed in battle, a chronically ill person who dies a lingering death. The cause or mode of death—natural, accidental, homicide, or suicide—influences how grief is experienced. Even when a death is anticipated, grief is not necessarily diminished when the loss becomes real. The death of a loved one is frequently a severe physical as well as emotional stressor. For example, the rate of heart Page 651attack in the first day after the death of a significant person in an individual's life increases by as much as 21 times. The risk decreases gradually over time but still remains above normal for several months after a loved one dies. After a death, grieving people often have difficulty sleeping, may neglect to eat nourishing food, and may forget to take their usual medications. These factors add to the health risks associated with recent loss. Recent loss also has a cognitive impact on many grievers. People often report that they feel confused and have difficulty concentrating following a significant loss. After the initial shock begins to fade, the course of grief is characterized by anxiety, apathy, and pining for the deceased. The pangs of grief are felt as the bereaved person deeply experiences the pain of separation. Mourners often experience despair as they repeatedly go over the events surrounding the loss, perhaps fantasizing that somehow everything could be undone and be as it was before. During this period, the bereaved person may also begin to look toward the future and take the first steps toward building a life without the deceased. Psychiatrist Colin Murray Parkes points to three main influences on a person's course of grieving: The urge to look back, cry, and search for what is lost The urge to look forward, explore the world that emerges out of the loss, and discover what can be carried forward from the past into the future The social and cultural pressures that influence how the first two urges are inhibited or expressed As these influences interact, at times the bereaved tries to avoid the pain of grief and at other times confronts it. The goal is to achieve a balance between avoidance and confrontation that facilitates coming to terms with the loss. Attaining this goal can be seen as an oscillation between what researchers Margaret Stroebe and Henk Schut call loss-oriented and restoration-oriented mourning. From this perspective, looking at old photographs and yearning for the deceased are examples of loss-oriented coping, whereas doing what is needed to reorganize life in the wake of the loss—for example, learning to do tasks that the deceased had always managed, such as finances—is part of restoration-oriented coping. As time goes on, the acute pain and emotional turmoil of grief begin to subside. Physical and mental balance are reestablished. The bereaved person becomes increasingly reintegrated into his or her social world. Sadness doesn't go away completely, but it recedes into the background much of the time. Although reminders of the loss stimulate waves of active grieving from time to time, the main focus is the present, not the past. Adjusting to loss may sometimes feel like a betrayal of the deceased loved one, but it is healthy to engage again in ongoing life and the future (see the box "Coping with Grief"). TAKE CHARGE: Coping with Grief Recognize and acknowledge your loss. React to grief in the way that feels most natural to you. There is no "right" way to grieve. Take time for nature's process of healing. The odds are good that you will be functioning well again before long. Be patient with yourself. Know that powerful, overwhelming feelings will change with time. Grief is often experienced as a long series of ups and downs, with the intensity of feelings decreasing gradually over time. Beware of the lure of drugs and alcohol to reduce the pain of your grief, especially if you have had substance abuse issues in the past. Using alcohol or drugs to numb yourself will ultimately backfire and make your recovery more difficult. Honor your loved one in a way that is meaningful to you. Consider creating a small memorial with a photo and flowers, start a scholarship in your loved one's name, plant a memorial tree, or write a song or poem in his or her honor. Consider joining a bereavement support group to connect with others who have had recent losses. Surround yourself with life: plants, animals, friends, and family. If you are having difficulty functioning at school, work, or home after a few weeks, consider counseling or a support group. People who have had a recent loss are at higher risk for suicide. If you are having thoughts of suicide, or feeling hopeless, seek help right away. Care for yourself by finding time to eat, sleep, and move your body. Don't be afraid to let laughter and joy remain in your life. Experiencing positive feelings during mourning does not indicate a lack of respect or love for the deceased. Social support for the bereaved is as critical during the later course of grief as it is during the first days after a loss. In offering support, we can reassure the grieving person that grief is normal, permissible, and appropriate. The anniversary of the loved one's death, birthdays, and major holidays following a significant loss can renew grieving, and the support of others is important and appreciated. Knowing that Page 652others remember the loss and that they take time to connect is usually perceived as comforting. Bereaved people may find it helpful to share their stories and concerns through organized support groups. Hospices provide bereavement support groups and counseling, usually for 13 months after the death. Many online and in-person support groups are organized around specific types of bereavement. The Compassionate Friends, for example, is a nationwide organization composed of parents who have experienced a child's death. This organization provides both local and online support groups. The American Association of Suicidology has an online directory of suicide survivor support groups. Losing a loved one to suicide is an especially traumatic loss that is often best understood by others who have had a similar loss. Suicide support groups are available in most communities. If you have lost a loved one to drugs or alcohol, GRASP (Grief Recovery After Substance Passing) has support groups in many communities as well as online support. (See "For More Information" at the end of this chapter for web addresses for these groups.) There is no hard and fast "normal" amount of time that grief should last, but when the duration and intensity far exceed what is usually expected, it is often referred to as complicated grief. If the griever remains seriously impacted by disabling grief many months or years after a death, she or he may be experiencing complicated grief. Rates of complicated grief in Western countries tend to be highest when a child is lost, or when the death was violent and unexpected (see box "Surviving the Violent Death of a Loved One"). A history of depression or other mood disorder increases the risk for complicated grief. People who experience complicated grief are at increased risk for suicide and serious functional impairment. Psychotherapy is recommended for the treatment of complicated grief. TAKE CHARGE: Surviving the Violent Death of a Loved One Coping with the death of a loved one is among the greatest challenges a person faces in a lifetime. When the death is due to violent causes, such as unintentional injury, homicide, or suicide, the challenges of grieving are multiplied many fold. Experts estimate that one of three of us will experience the traumatic loss of a close friend or relative to violent death and the challenges it presents. Motor vehicle crashes, by their nature sudden and unpredictable, are the most common cause of traumatic death in young people. Hardly anyone makes it through high school without losing at least one classmate in an automotive crash. A fatal car crash leaves behind many victims besides those who died. Friends and relatives are devastated by the loss of a beloved young person. Any occupants of the vehicle who survive the crash typically suffer from injuries and psychological trauma, in addition to their grief for the ones who died. Posttraumatic stress is a common outcome for survivors. If the driver was intoxicated, or otherwise at fault for the crash survivors must also cope with that difficult knowledge. Feelings of anger and guilt are often mixed in with the sadness and loss. Although homicide is far less common in the United States than motor vehicle crashes, young people who grow up in high-crime neighborhoods all too often experience the loss of relatives, friends, or acquaintances due to killings. When a loved one is murdered, grievers may agonize over the circumstances of the crime and imagine the horrible suffering their loved one might have endured. Survivors may be haunted by memories of the person's mangled body or may obsess over missing details of the crime. Survivors may also fear for their own safety. The police and legal system may add to the trauma through insensitivity at best, and offensive behavior toward survivors at worst. People who survive a loved one's suicide also experience great suffering as a result of the stigma attached to suicide. They often feel terrible guilt, wondering if they were in part responsible for their loved one's distress, or whether they could have done something to prevent the suicide. Perhaps the most difficult aspect of coping with violent death, and suicide in particular, is the societal stigma frequently directed at the survivors. The spouse or parent of someone who has committed suicide is often suspected of having been a source of the victim's unhappiness, or at least guilty for not sensing the trouble and doing something about it. Thus, beyond the challenges of coping with a "natural" death, those who lose a loved one to a violent death face many additional sources of anguish. The sense of the world as a benevolent, safe, and predictable place is often lost when loved ones die in traumatic circumstances. Survivors often face questions of blame, legal issues, financial distress, and lack of social support. A grieving survivor may be called upon to relive the trauma and its horrifying memories over and over again during encounters with police and in legal proceedings. Moreover, friends and community members often avoid survivors, or respond with morbid curiosity or judgmental comments, rather than providing the loving support that is so desperately needed. Or they may back away from someone whose loss is too frightening to contemplate. The instinct to blame the deceased and the survivors for some aspect of a violent death is also common and often represents our attempt to reassure ourselves that if only we are vigilant, and do the right thing, this kind of tragedy won't happen to us or our loved ones. Some experts refer to the grief experience related to violent loss as "traumatic grief," a term used by Marilyn Armour, a prominent researcher in the field. Traumatic grief involves symptoms of separation-related distress, resulting from the loss of a loved one, as well as symptoms of traumatic distress related to the horrible ordeal the mourner has experienced. Posttraumatic stress often complicates a survivor's ability to recover, and severe, prolonged grief may result. Finding meaning in a sudden and violent death is much more challenging than in a death from old age or a lengthy illness. When someone dies of natural causes, the survivors are often comforted by the belief that at least their loved one is no longer suffering or that the person "died peacefully." In the case of violent death, there are no similar thoughts to soften the blow. Despite the great challenges, most of those who lose someone to a violent death do eventually recapture a sense of normalcy. Helping survivors starts with all of us reaching out with nonjudgmental love and kindness. For all survivors, the support of friends and community is crucial for regaining a sense of peace. A number of excellent organizations support survivors of loved ones' deaths through accidents, suicide, homicide, and other types of violent death (see "For More Information" at the end of this chapter). Most of these organizations provide information about joining online and in-person support groups, as well as finding professional help for those who are having difficulty coping with traumatic loss. Supporting a Grieving Person When a person finds out that a loved one has died, the initial reaction may be profound shock and overwhelming distress. Such a person may initially respond best to the physical comfort of hugging and holding. Later, simply listening may be the most effective way to help. Talking about a loss is an important way that many survivors cope with the changed reality, and they may need to tell their story over and over. The key to being a good listener is to avoid speaking too much, and to refrain from making judgments about whether the thoughts and feelings expressed by a survivor are right or wrong, good or bad. The emotions, thoughts, and behaviors evoked by loss may not be the ones we expect, but they can nonetheless be valid and appropriate within a survivor's experience of loss. If a grieving friend or relative talks about suicide, or seems in danger of causing harm to himself or herself or others, seek professional help right away. Most people are resilient and cope well with loss, but the recent loss of a loved one is a major risk factor for suicide and self-harm. Be alert to signs that a grieving person is in serious danger. Although some people respond to loss with a feeling of helplessness, other people may react by taking charge. Making arrangements, taking care of tasks, and generally keeping busy may help them cope. Be aware that some people do not find it helpful to dwell on their feelings or talk a lot about their loss. Find out what they want to do—when the time is right, take a walk, go shopping together, go to a ball game, or see a movie. Your companionship while doing everyday activities may be the best gift you can give. Remember also that some grieving people may not appear sad or distressed. This lack of outward grieving does not mean that they didn't care about the deceased, are "in denial," or have a cold personality. Accept that this response is their way of coping with loss and show your support with your loving presence. When a Young Adult Loses a Friend Among young people aged 18-24 in the United States, the three leading causes of death tend to be sudden and unexpected: unintentional injuries, homicide, and suicide. Losing a close friend to an unexpected death can be particularly traumatic. As a friend, you may feel unsupported and left out of the family's grieving. Also, you may blame yourself in some way for your friend's death or feel you should have somehow prevented the tragedy. If you lose a friend, be sure to look for support from friends, family, clergy, or health professionals, especially if the intense sadness or guilt feelings last for more than a few days or weeks. Friends can often help each other by working together to create their own way of celebrating the life of their lost friend. Helping Children Cope with Loss Children tend to cope with loss in a healthier fashion when they are included as part of their family's experience of grief and mourning. Although adults may be uncomfortable about sharing potentially disturbing or painful news with children, a child's natural curiosity usually negates the option of withholding information. Mounting evidence shows that it is best to include children from the beginning—as soon as a terminal prognosis is made, for example—to help them understand what is happening. Children should spend time with the dying person, if possible, to learn, share, offer, and receive comfort. In talking about death with children, the most important guideline is to be honest. Offer an explanation at the child's level of understanding. Find out what the child wants to know. Keep the explanation simple, stick to basics, and verify what the child has understood from your explanation. A child's readiness for more details can usually be assessed by paying attention to his or her questions. Many hospices and other organizations, such as the Dougy Center in Portland, Oregon, provide bereavement help for children, utilizing art, games, music, and other activities appropriate to a child's developmental stage.Page 653 Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever been in a close relationship with a bereaved person? What kind of support did he or she seem to appreciate most? Why do you think that was the case? How did the experience affect you?

Life in an aging america

LIFE IN AN AGING AMERICA As life expectancy increases, a larger proportion of Americans will be in their later years. This change will necessitate new government policies and changes in our general attitudes toward older adults. America's Aging Minority People over age 65 are a large minority in the American population—over 40.2 million people and about 14% of the total population in 2012. That number is expected to more than double by the year 2050 (Figure 22.2). In that same year, 4.3% of the population will be older than 85 years. Many older people are happy, healthy, and self-sufficient. Changes that come with age, including negative ones, normally occur so gradually that most people adapt, some even gracefully. Bar graph of population age 65+.[D] VITAL STATISTICS FIGURE 22.2 Number of persons age 65+, 1900-2060 (in millions). source: Administration on Aging. 2014. A Profile of Older Americans: 2014 (www.aoa.acl.gov/aging_statistics/profile/2014/docs/2014-profile.pdf); U.S. Census Bureau. 2014. Population Estimates and Projections (http://www.census.gov/population/projections/). The enormous increase in the over-65 population is markedly affecting our stereotypes of what it means to grow old. The misfortunes associated with aging—frailty, forgetfulness, poor health, isolation—occur in fewer people in their sixties and seventies and are shifting instead to burden the very old: those over age 85. The homeownership rate exceeds 80% for those aged 65-84, declining slightly to about 76% for those older than 85. This rate is much higher than the homeownership rate for those under age 65 (about 65%). Older people's living expenses are lower after Page 629retirement because they no longer support children and have fewer work-related expenses; they consume and buy less food. Some continue practicing their expertise for years after retirement and receive some income: Thousands of retired consultants, teachers, technicians, and craftspeople work until their middle and late seventies. They receive greater amounts of assistance, such as Medicare, pay proportionately lower taxes, and have greater net worth from lifetime savings. Even so, according to the Administration on Aging, nearly 9.5% (4.2 million) of elderly people live below the poverty level; another 5.6% (2.5 million) are "near poor," with incomes reaching 125% of the poverty level. Older women are more likely to live in poverty than are older men. People over age 65 who live alone are much more likely to be poor than are those who live with families. As the aging population increases proportionately, however, the number of older people who are ill and dependent rises. Health care remains the largest expense for older adults. On average, they visit a physician 10-12 times a year, are hospitalized more frequently, and require twice as many prescription drugs as the general population. Most older Americans have at least one chronic condition and many have multiple conditions. Retirement finds many older people with incomes reduced to subsistence levels. This is especially true of the very old and women. The majority of older Americans live with fixed sources of income, such as pensions, that are eroded by inflation. Expenses tend to increase more rapidly, especially those resulting from circumstances over which people have little or no control, such as deteriorating health. Social Security is the major source of income for most of the elderly. Social Security was intended to serve as a supplement to personal savings and private pensions, not as a sole source of income. It is vital to plan for an adequate retirement income. QUICK STATS Approximately 34.2 million Americans have provided unpaid care to an adult age 50 or over in the prior 12 months. —AARP, 2015 Family and Community Resources for Older Adults With help from friends, family members, and community services, people in their later years can remain active and independent. Over half of noninstitutionalized older Americans live with a spouse (Figure 22.3); some live with a family member other than a spouse, and about 28% live alone. Only 3.4% live in institutional settings, but among those over age 85, about 10% live in a nursing home. Among men, 72% living with spouse, 19% living alone, and 9% other. Among women, 46% living with spouse, 35% living alone, and 19% other. VITAL STATISTICS FIGURE 22.3 Living arrangements of persons age 65+, 2014. The majority of older noninstitutionalized Americans live with their spouses, although the rate is significantly higher for men than women. The gender gap is due in part to women's longer life expectancy; in addition, men are less likely than women to be widowed and more likely than women to remarry if their spouse dies. source: Administration on Aging. 2014. A Profile of Older Americans: 2014 (www.aoa.acl.gov/aging_statistics/profile/2014/docs/2014-profile.pdf); U.S. Census Bureau. 2014. Population Estimates and Projections (http://www.census.gov/population/projections/). Family Involvement in Caregiving Studies show that in about three out of four cases, a spouse, a grown daughter, or a daughter-in-law assumes a caregiving role for elderly relatives. Older caregivers over age 65 provide 31 hours of caregiving in an average week. With more parents living into their eighties and with fewer children per family, many people, especially women, will face the dilemma of how best to care for an aging relative. Surveys indicate that the average woman will spend about 17 years raising children and 18 years caring for an aging relative. Caregiving can be rewarding, but it is also hard work. If the experience is stressful and long term, family members may become emotionally exhausted. Corporations are increasingly responsive to the needs of their employees who are family caregivers by providing services such as referrals, flexible schedules and leaves, and on-site adult care. Professional health care advice is another critical part of successful home care. Caregivers need to give special consideration to issues such as hearing and vision loss, even sleep loss, which can make an elderly person feel disconnected or isolated, and dementia, which can make caregiving extremely challenging. The caregiver must work with the older person's doctors and pharmacists to ensure that medication is available and taken as prescribed. (Studies show that older adults commonly skip their cholesterol and blood pressure medications, for example.) The caregiver may need to acquire a legal status Page 630called medical power of attorney, which enables him or her to make decisions about the patient's medical care. The best thing a family can do is talk honestly about the obligations, time, and commitment required for caregiving. Families should also explore community resources and professional assistance that may be available to reduce the stress associated with this difficult job. Other Living and Care Options If living together is not possible for aging parents and adult children, other living and care options are available. There are agencies that recruit and match like-minded individuals for shared living situations. Homesharing offers older adults who are in fairly good health the opportunity for new relationships, either with peers or with a younger family. Intergenerational homesharing may relieve elders of transportation problems and demanding physical tasks, which can be taken care of by younger household members. Conversely, elders in good health can help busy, working families with child care and household chores. Long-term care insurance is another way to ensure you can afford your choice in provider and housing environment, whether it's independent living, assisted living, or another housing option. Experts suggest consumers should be looking at long-term care insurance at age 40 and own it by age 50. Retirement communities are an option for individuals in good health and with a good income who want to maintain homeownership. Other types of facilities are available for people who need more assistance with daily living (see the box "Choosing a Place to Live"). CRITICAL CONSUMER: Choosing a Place to Live Later in life, many older people need help with everyday activities like shopping, cooking, walking, or bathing. Help from family and friends may be all that some people need to stay active and healthy in their own homes, whereas others may choose to move to a place that offers more services. A variety of options is available: Retirement communities allow maximum independence with very little supervision. They may offer transportation, activities, and other services but do not routinely offer assistance with basic needs. Residential care homes (or adult foster care homes) are licensed to provide services to three or more residents in a smaller environment, typically in a private home. They may provide assistance with medications, bathing, dressing, transportation, daily laundry, daily housekeeping, and meals. Assisted living facilities allow independence with supervision and are licensed by the state. They provide some meals, housekeeping and laundry, transportation, medication management, security, activities, and care management and monitoring. Nursing homes provide 24-hour medical care and rehabilitation for residents, who are mostly very frail or suffer from the later stages of dementia. Some providers offer all levels of care at one site. These continuing care communities allow people to move from one level to another as their needs change. Some homes or communities cater to specific groups of seniors, based on factors such as veteran status, language, ethnicity, sexual orientation, or profession. © Ryan McVay/Getty Images Finding the right place to live takes some investigation. Because the best homes often have a waiting list, plan ahead. Don't wait until your family member is too sick to function. Once you have an initial list of facilities in your area, start visiting the homes, keeping the following evaluation points in mind: Ask questions about specific facilities. Doctors, friends, relatives, local hospital discharge planners, social workers, and religious organizations can help. The ombudsperson at your state's office of long-term care can let you know if there have been problems in a particular nursing home. Residential care homes and assisted living facilities do not follow the same licensing requirements as nursing homes. Talk to people in the community to find out about these options. Contact the places that interest you. Ask basic questions about vacancies, number of residents, cost, and any services of interest to you, such as transportation and meals. Visit several places. Talk to the staff, residents, and, if possible, family members of residents. Set up an appointment, but also go unannounced and at different times of the day. Make sure residents are clean, well groomed, involved in activities, and treated with respect. Evaluate the facility's financial agreements. Have a lawyer look them over before you sign. Nursing homes may accept Medicare or Medicaid, but most other facilities are private-pay only. According to the U.S. Department of Health and Human Services, costs for nursing-home care vary by location but average about $7000 per month; costs for assisted living average about $3300 per month. For most seniors, the home is the biggest asset. One option is to sell or rent the home and use the proceeds or rental payments to fund senior living. The less-known, less-understood alternative is the reverse annuity mortgage, which allows seniors to use the value of the home without giving it up. With this option, instead of the resident paying a mortgage, the financial institution pays the homeowner a lump sum or monthly payment. The homeowner can then use this payment for senior housing. (Learn more about reverse mortgages from the Federal Trade Commission website at https://www.consumer.ftc.gov/articles/0192-reverse-mortgages). Moving is a big change that affects the whole family. Take time for everyone to talk about how they feel. Once a family member has moved to a new home, visit often and pay attention to the quality of care. Say something nice when care is good, and speak up when care is poor. If you or your family member have trouble resolving a complaint, the local ombudsperson or citizen advocacy groups may be able to help. QUICK STATS Social Security benefits account for about 34% of the aggregate income of the older population. —Social Security Administration, 2015 Community Resources Community resources are available to help older adults remain active and in their own homes. Typical services include the following: Senior citizens' centers or adult day care centers provide meals, social activities, and health care services for those unable to be alone during the day. Homemaker services offer housekeeping, cooking, errand running, and escort services. Visiting nurses provide basic health care. Household services perform household repairs. Friendly visitor or daily telephone reassurance services provide contacts for older people who live alone. Home food delivery services such as "Meals on Wheels" provide meals to homebound people. Adult day hospital care provides day care plus physical therapy and treatment for chronic illnesses. Low-cost legal aid helps people to manage their finances and health care. Transportation services offer rides at low rates. Case management helps seniors navigate confusing health care services. Transportation Because they tend to be more cautious, older drivers usually have safer driving records than young adults. However, crashes in the older age group are more likely to be fatal. Many states require special driver's testing for people over age 70 and may restrict some drivers as to the time, distance, or areas in which they may drive. Because of vision changes or other health problems, some older drivers may be required to give up their licenses before they feel ready. Elderly people report that the loss of a driver's license, and the loss of the independence it brings, is one of the most severe hardships they face. Government Aid and Policies The federal government helps older Americans through several programs, such as food assistance, housing subsidies, Social Security, Medicare, and Medicaid. Social Security, the life insurance and old-age pension plan, has saved many people from destitution, although it is intended as a supplement to other income rather than as a sole source of income. Social Security funds have been used to cover other government financial deficits, so the future solvency of the program is uncertain. Medicare is a major health insurance program for older adults and disabled persons. Medicare Part A is financed by part of the payroll (FICA) tax that also pays for Social Security. Medicare Part B is financed by monthly premiums paid by people who choose to enroll. Part A helps pay for inpatient hospital care, some inpatient care in a skilled nursing facility, and some types of home and hospice care. Medicare Part B helps pay for physicians' services and other services not covered by Part A. Medicare Part D is a prescription drug coverage plan. Overall, Medicare pays about 64% of all health care costs for older Americans as a group. It provides basic health care coverage for acute episodes of illness that require skilled professional care. It pays for some preventive services, including an initial physical exam, vaccinations, and screenings for cardiovascular disease, certain cancers, osteoporosis, diabetes, and glaucoma. It does not pay for many office visits, dental care, or dentures. Over 1.6 million older people currently live in nursing homes, but Medicare pays less than 2% of nursing home costs, and private insurers pay less than 1%, creating a tremendous financial burden for nursing home residents and their families. When their financial resources are exhausted, people may apply for Medicaid. Created by a 1965 amendment to the Social Security Act, Medicaid provides medical insurance to low-income people of any age. Funded by state and federal contributions, the services vary from state to state but typically include hospital, nursing home, and home health care; physician services; and some medical supplies and services.Page 632 A crucial question regarding aid for the elderly is who will pay for it. The government picks up many of these health care expenses, primarily through Medicare and Medicaid. Total health care expenditures are 18% of the U.S. gross domestic product; about one-third of these expenditures go to care for older Americans. Health care policy planners hope that rising medical costs for older adults will shrink dramatically through education and prevention. Health care professionals, including gerontologists and geriatricians, are beginning to practice preventive medicine, just as pediatricians do. They advise older people about how to avoid and, if necessary, how to manage disabilities. Changing the Public's Idea of Aging Aging people may be one of our least used and least appreciated resources. How can we use the knowledge and productivity of our growing numbers of older citizens, particularly those who retire from the work force early, whether through pressure or not? To start, we must change our thinking about what aging means. We must learn to judge productivity rather than age. Capacity to function should replace age as a criterion for usefulness. Instead of singling out age 65 as a magic number, we could consider ages 50-75 as the third quarter of life. Changes occur around age 50 that signal a new era: Children are usually grown and gone, and a person may have achieved a level in career, earnings, and accomplishments that meets his or her ambitions. The upper end of this quarter is determined by the fact that most people today are vigorous, in good health, mentally alert, and capable of making a productive contribution until they are at least in their seventies. However we define old age, the costs of losing what older adults can contribute to our national productivity and quality of life are too high. When older workers retire early, we forfeit substantial income tax and Social Security tax revenues on their earnings. Those who retire at 62 start using their Social Security benefits earlier than they otherwise would, and they receive lower monthly benefit amounts. A far better arrangement would be to make more full-time and part-time volunteer and paid employment available to older people. Retraining programs for both occupational and leisure activities would be beneficial, as well. Volunteer opportunities, such as preparing recordings for the blind, helping with activities for the disabled, and performing necessary tasks in hospitals, could be expanded. At the same time, we could possibly change both public and private pension programs to make partial retirement possible. In such cases, people could be allowed to borrow against their Social Security benefits to finance retraining or enrollment in new educational programs. Aging can offer benefits, but they don't come automatically. They require planning and wise choices earlier in life. One octogenarian, Russell Lee, founder of the Palo Alto Medical Clinic in California, perceived the advantages of aging as growth: "The limitations imposed by time are compensated by the improved taste, sharper discretion, sounder mental and esthetic judgment, increased sensitivity and compassion, clearer focus—which all contribute to a more certain direction in living. ... The later years can be the best of life for which the earlier ones were preparation." Older adult is shown water skiing. Some individuals defy all preconceived ideas about age and continue to live vigorous lives into their seventies, eighties, and beyond. © Durdenimages/123RF Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION What do you want your life to be like when you are old? Do you hope to retire, or keep working indefinitely? Where would you like to live? How much time do you spend thinking about these questions? What have you planned for your later years?

planning for death

PLANNING FOR DEATH Acknowledging the inevitability of death allows us to plan for it. Adequate planning can help ensure that a sudden, unexpected death is not made even more difficult for survivors. Even when death is not sudden, individuals with a debilitating illness may become unable to make decisions. Many decisions can be anticipated, considered, and discussed with close relatives and friends. Basic tasks in planning for death include making a will, anticipating medical care needs, expressing preferences for end-of-life care, considering whether to become an organ donor, and helping survivors manage responsibilities. It is reasonable to begin some of these plans during the college years, particularly with regard to organ donation, and to review and revise these decisions periodically throughout life. Young people can also help their older relatives by urging them to complete these important tasks. Making a Will Surveys indicate that about 55% of adult Americans do not have a will. Common reasons for not making a will include not wanting to deal with a "depressing subject," wanting to Page 640avoid the expense of legal services, and the idea that "I don't need a will because I don't have much money." Whatever the reason, dying without a will can lead to unnecessary hardships for survivors, even when an estate is modest in size. A will is a legal instrument expressing a person's intentions and wishes for the disposition of his or her property after death. It is a declaration of how your estate—that is, money, property, and other possessions—will be distributed after death. During the life of the testator (the person making the will), a will can be changed, replaced, or revoked. When the testator dies, it becomes a legal instrument governing the distribution of the estate. When a person dies intestate—that is, without having left a valid will—property is distributed according to rules set up by the state. The failure to execute a will may result in a distribution of property that is not compatible with a person's wishes or best suited to the interests and needs of heirs. If you haven't yet made a will, start thinking about how you'd like your property distributed in the case of your death. If you have a will, consider whether it needs to be updated in response to a key life event such as marriage, the birth of a child, or the purchase of a home. In making a will, involving close family members may prevent the kinds of problems that can arise when actions are taken without the knowledge of those who will be affected. A person making a will can also help family members by completing a testamentary letter. This document includes information about personal affairs, such as bank accounts, credit cards, insurance policies, the location of documents and keys, the names of professional advisers, passwords for online accounts, the names of people who should be notified of the death, and so on. You may feel that you are too young to be thinking about your own will, and if you are a young student, that may be reasonable. But this is a good time to be courageous and broach the subject with family members. Do your parents have a will? Do you know where they keep their important information should something happen to them? Let your family members know that you will greatly appreciate their efforts to plan ahead and keep you informed. Considering Options for End-of-Life Care The timeline of dying has changed radically over the past several generations. Not only do we, on average, tend to live longer, but we also are much more likely to live with chronic disease and disability for months or years before we die, compared to past generations who tended to be relatively healthy to nearly the end of life, and die after a brief, acute illness. Most of us will need some sort of care during our last days, weeks, months, or even years of life. As life draws to a close, care may involve any combination of home care, hospital stays, nursing home care, and hospice care. By becoming aware of the options, we and our families are empowered to make informed, meaningful choices. Hospice care focuses on relieving pain and other distressing symptoms in dying people and on providing support for family members. © Jahi Chikwendiu/The Washington Post/Getty Images Home Care The majority of people express a preference for at-home care during the end of life. An obvious advantage of home care is the fact that the person is in a familiar setting, ideally in the company of family and friends. Care for a person in the last stage of life is often a 24-hour-a-day job and requires varying degrees of skill, medical knowledge, and physical strength. Family members may or may not be capable of providing the level of care that is needed. Professional at-home caregivers can often make a huge difference in allowing a person to continue to live at home. This type of home care can be quite expensive, especially if it is needed on a 24-hour-per-day basis, and is usually not covered by private or government health insurance plans. Although private long-term care insurance is available, fewer than 1 in 10 Americans over age 50 have this type of insurance, in part because it is costly. When a patient requires sophisticated medical procedures or does not have access to qualified caregivers, institutional care may be more appropriate. When suitable, however, home care is generally the most satisfying option for care as a person's life comes to a close. Currently about 25% of Americans die at home, about 25% die in nursing facilities, and about 50% die in hospitals, including more than 20% in intensive care units. Terminally ill people who wish to die at home, in their assisted-living residence, or in a more peaceful hospital environment are often aided by hospice programs, Page 641which are widely available throughout the United States and are providing a growing number of terminally ill patients with much-needed assistance. Hospice is a system of palliative care, a collaborative, team-based approach to treatment that aims to prevent and relieve suffering in patients with serious or life-threatening illness. The overarching goal of palliative care is to improve the quality of life for the patient and his or her family during this period in their lives. The care team generally draws from physicians, nurses, pharmacists, chaplains, social workers, home-health aides, and trained volunteers. Hospice Programs Hospice is a special kind of compassionate care for people in the final phase of a terminal illness, specifically for patients who are likely to die within six months or less. Hospice focuses on providing comfort care to patients at the end of life rather than continuing curative treatments. Most hospice patients have previously undergone extensive medical efforts at curing their illnesses. The decision to switch from curative efforts to hospice care usually comes when cure is no longer a likely possibility, and the downsides of aggressive medical intervention outweigh the benefits of comfort care in a homelike setting. About two-thirds of hospice patients receive care in the place they call "home," which is most frequently their private residence, but also can be a nursing home or a residential facility. Hospice care is also offered in hospitals and freestanding hospice facilities. Hospice care is available to people of all ages who are judged to be in their last six months of life. Typically a patient who lives at home is cared for primarily by family members, with support from hospice workers who make regular visits to the home. Hospice does not routinely provide round-the-clock physical care, but hospice services often make it possible for family, friends, and paid caregivers to care for patients in their own homes until death. Hospice staff members are available on call 24 hours per day, seven days a week. If there are concerns about the patient, the family or other caregivers can call at any time of day or night. A hospice nurse will come to the home to evaluate the patient and provide treatment as needed. This service generally makes it possible for the patient to avoid going to the emergency room or being admitted to the hospital. The availability of hospice care in the United States has grown at a remarkable rate since the first hospice program in the United States was established in 1974. Today more than 5800 such programs serve an estimated 1.6 million terminally ill patients and their families each year. More than 45% of people who died in the United States in 2014 were under the care of a hospice program. Referrals to hospice can be made by physicians, family members, friends, clergy, other health professionals, or the patients themselves. Qualifying for hospice care usually requires that two physicians certify that a patient's life expectancy is six months or less, and both patient and physician agree to forgo treatment aimed at prolonging life. Should the patient decide that he or she wishes to resume curative treatment, hospice care can be revoked and regular Medicare coverage reinstated immediately. When hospice care first became available in the United States, most hospice patients had cancer. Today cancer accounts for only a little more than a third of hospice diagnoses. Other common diagnoses include heart disease, dementia (such as Alzheimer's disease), debility (physical weakness, especially as a result of illness), and lung disease. Any patient who is likely to die within six months is eligible for hospice care, regardless of the specific diagnosis. About 67% of hospice patients are over 75 years old, although hospice programs take care of patients of all ages, including children. The emphasis is on enhancing the quality of life rather than extending its length. Despite this, hospice patients commonly live longer than expected, at least in part due to the extra care and support they receive. In addition to helping patients achieve a good and peaceful death, an important gift of hospice care is the potential to help patients and families discover how much can be shared at the end of life through personal and spiritual connections. Difficult Decisions at the End of Life The decision to stop doing tests and treatments is often a difficult one for patients and their families. Many people owe their lives to the advanced medical technologies now available. Yet a medical stance that strives to keep people alive by all means and at any cost is increasingly being questioned. In addition, medical diagnostic procedures and treatments often cause discomfort and can reduce the quality of life for people who are likely to die soon whether or not they receive further medical intervention. As noted earlier, modern medicine can sometimes keep the human organism alive despite the cessation of normal heart, brain, respiratory, or kidney function. But should a patient without any hope of recovery be kept alive by means of artificial machine support? At what point does such treatment become futile? What if a patient has fallen into a persistent vegetative state, a state of profound unconsciousness, lacking any sign of normal reflexes and unresponsive to external stimuli, with no reasonable hope of improvement? Ethical questions about a person's right to die have become prominent since the landmark case of Karen Ann Quinlan in 1975. At age 22 she was admitted in a comatose state to an intensive care unit, where her breathing was sustained by a mechanical ventilator. When she remained unresponsive, in a persistent vegetative state, her parents asked that the respirator be disconnected, but the medical staff Page 642responsible for Karen's care denied their request. The request to withdraw treatment eventually reached the New Jersey Supreme Court, which ruled that artificial respiration could be discontinued. Since then, courts have ruled on removing other types of life-sustaining treatment, including artificial feeding mechanisms that provide nutrition and hydration to permanently comatose patients who are able to breathe on their own. Notable was the case of Terri Schiavo in 2003. Terri had been diagnosed as being in a persistent vegetative state. Contending that she would not want to continue living on life support, Terri's husband requested that her feeding tube be removed. Terri's parents contested the request, and a series of legal actions ensued. Finally, in 2005, after intervention by the U.S. Supreme Court, physicians were allowed to remove the tube. Cases like this highlight the importance of expressing your wishes about life-sustaining treatment, in writing, before the need arises. QUICK STATS 218 prescriptions were written for lethal drugs under Oregon's Death with Dignity Act in 2015; 125 of those patients actually took the drugs. —Oregon Public Health Division, 2016 Withholding or Withdrawing Treatment The right of a competent patient to refuse unwanted treatment is now generally established in both law and medical practice. The consensus is that there is no medical or ethical distinction between withholding (not starting) a treatment and withdrawing (stopping) a treatment once it has been started. The right to refuse treatment remains constitutionally protected even when a patient is unable to communicate. Although specific requirements vary, all states authorize some type of written legal document, referred to as an advance directive, in which individuals can record their wishes, and those wishes will be honored if and when those individuals cannot speak for themselves. (Advance directives are discussed later in this chapter.) Physician-Assisted Death and Voluntary Active Euthanasia In contrast to withdrawing or withholding treatment, physician-assisted death and voluntary active euthanasia refer to practices that intentionally hasten the death of a person; both assume the full informed consent of the patient. Physician-assisted death is legal in five states in the United States (Oregon, Washington, Vermont, Montana, and California). Some form of voluntary active euthanasia is legal in the Netherlands, Luxemburg, Belgium, Columbia, and Canada (as of February 2016). Physician-assisted death (PAD) occurs when a physician provides a prescription for a lethal dose of medication (usually a sedative medication)—at the patient's request—with the understanding that the patient plans to use the medication to end his or her life. The patient chooses if and when he or she wishes to take the fatal dose, usually in a home setting without the physician present. Oregon was the first state to legalize PAD following a citizens' initiative called the Death with Dignity Act, which Oregon voters approved in 1994 and again in 1997. Even though PAD has been legally available in Oregon since 1994, the practice remains rare; in 2015, only 125 deaths occurred in Oregon in this way. Oregon's Death with Dignity Act has many regulations and safeguards. A patient who wishes to pursue an assisted death must orally request PAD from the attending physician on two occasions at least 15 days apart. The request must also be submitted in writing to the attending physician and signed in the presence of two witnesses. Additionally, the attending physician plus a consulting physician must confirm the patient's diagnosis and prognosis (which must be a terminal illness that will lead to death within six months), whether the person is capable of making such a decision, and whether the patient may have a psychological disorder (such as depression). If either physician suspects a psychological disorder, the patient must be referred for a psychological evaluation. The patient must be informed of alternatives to PAD such as pain control and comfort and hospice care. A patient can rescind a PAD request at any time, and experience has shown that about one-third of patients who have received lethal medication from their physician have chosen not to use it. Some patients who end up not using the medication have said that merely having the means to end their own suffering gave them great comfort, and in the end they chose to let nature take its course. Of the 218 Oregon patients for whom prescriptions were written during 2015, 125 ingested the medication and died from that; 50 did not ingest medication and died from other causes; and the ingestion status is unknown of the other 43 people who had prescriptions. In 1997, and again in 2006, the U.S. Supreme Court affirmed that individual states have the right to craft policy concerning PAD—either prohibiting it, as most states now do, or permitting it under a regulatory system. This decision meant that Oregon's Death with Dignity Act remained legal. Since then the states of Washington, Vermont, Montana, and California have also chosen to allow PAD. Patients who choose PAD generally have strong beliefs in personal autonomy and a determination to control the end of their lives. PAD is not an option for patients with diseases that affect their mental functioning, such as dementia or psychiatric disorders. In addition, physicians can choose whether they themselves wish to participate in the Death with Dignity Act. In Oregon, physicians employed by the Page 643Veterans Administration and many Catholic hospitals are not allowed to participate in PAD as terms of their employment. When the Supreme Court ruled on PAD in 1997, it also ruled on the concept of double effect in the medical management of pain. The doctrine of double effect states that a harmful effect of treatment, even if it results in death, is permissible if the harm is not intended and occurs as a side effect of a beneficial action. Sometimes the dosages of medication needed to relieve a patient's pain (especially those in the end stage of some diseases) must be increased to levels that can cause respiratory depression, which could hasten the patient's death. Thus, the relief of suffering, the intended good effect, may have a potential bad effect, which is foreseen but is not the primary intention. The Court said that giving medication as needed to control pain, even if it hastens death, is not considered PAD if the intent is to relieve pain. The doctrine of double effect allows physicians throughout the United States to do what is necessary to relieve a patient's pain, even if there is a chance that the medication may hasten death. Unlike PAD, active euthanasia is the intentional act of killing someone who would otherwise suffer from an incurable and painful disease. Active euthanasia can be involuntary, nonvoluntary, or voluntary. Involuntary euthanasia (or involuntary active euthanasia) refers to the ending of a patient's life by a medical practitioner without the patient's consent. The most notorious example of this is the medical killing programs of the Nazi regime. Nonvoluntary euthanasia occurs when a surrogate decision maker (not the patient) asks a physician for assistance to end another person's life. Voluntary euthanasia (also known as voluntary active euthanasia, or VAE) is the intentional termination of life at the patient's request by someone other than the patient. In practice, this generally means that a competent patient requests direct assistance to die, and he or she receives assistance from a qualified medical practitioner. Voluntary active euthanasia is legal under very strict guidelines in Belgium, Luxembourg, the Netherlands, and Canada (as of February 2016) but is currently unlawful in the United States and the rest of the world. In the United States, taking active steps to end someone's life is a crime—even if the motive is mercy. In practice, polls of U.S. physicians show that physicians do sometimes quietly prescribe or administer medication to hasten a suffering person's death. Many people believe that the demand by some patients for PAD or euthanasia results from the health care system's inattention to the needs of the dying. Advocates of hospice and palliative care have highlighted the need for adequate pain management, not only for patients with terminal illness, but for all patients with untreated or undertreated pain and suffering. Increasingly, pain is being viewed as a "fifth vital sign" that should be added to the four vital signs—temperature, pulse, respiration, and blood pressure—now recorded and assessed as a standard part of patient care. Unfortunately, health care providers vary tremendously with respect to how they assess and manage pain. Many physicians are uncomfortable prescribing or administering strong pain medications because they lack experience and may fear scrutiny by authorities such as the U.S. Drug Enforcement Agency. Physicians also worry about causing addiction and contributing to the illegal use of narcotics. Even when physicians are aggressive in treating pain, adequate pain control may be difficult to achieve. When a patient is near death and still suffering despite optimal treatment with pain medications, sometimes palliative sedation will be used. Palliative sedation involves giving a sedative that keeps the patient in an unconscious or semiconscious state until pain is brought under control or the patient dies as a result of his or her underlying disease. Palliative sedation is not meant to hasten death; rather it is used as a last resort when physician, patient, and family agree that this is the best way to relieve otherwise intractable suffering. Palliative sedation is legal in the United States and is accepted by the American Medical Association and many other medical organizations when used as a last resort in appropriately selected cases. Completing an Advance Directive To make your preferences known about medical treatment, you need to document them through a written advance directive, which becomes a legal document. In a general sense, an advance directive is any statement made by a competent person about choices for medical treatment should he or she become unable to make such decisions or communicate them at some time in the future. Two forms of advance directives are legally important. First is the living will, which enables individuals to provide instructions about the kind of medical care they wish to receive or prohibit if they become incapacitated or otherwise unable to participate in treatment decisions (Figure 23.1). Many people believe that living wills are appropriate only for stating a desire to forgo life-sustaining procedures or to Page 644avoid medical heroics when death is imminent; indeed, most standard forms for completing a living will reflect this purpose. In fact, however, a living will can be drafted to express a range of ideas about the kinds of treatment a person would or would not want, and they can be written to cover various contingencies. This sample is for New York; requires a statement of being of sound mind, states when to withdraw treatment, and must be signed and witnessed. FIGURE 23.1 A sample living will. Because of differences in state law, each state has its own format for advance directives. source: Valid copies of this and other state-specific advance directives can be found at www.caringinfo.org. Reprinted with permission of the National Hospice and Palliative Care Organization. Copyright © 2005 National Hospice and Palliative Care Organization. All rights reserved. Reproduction and distribution by an organization or organized group without the written permission of the National Hospice and Palliative Care Organization is expressly forbidden. The second important form of advance directive is the health care proxy, which is also known as a durable power of attorney for health care. This document makes it possible to appoint another person to make decisions about medical treatment if you become unable to do so. This decision maker may be a family member, a close friend, or an attorney with whom you have discussed your treatment preferences. The proxy is expected to act in accordance with your wishes as stated in an advance directive or as otherwise made known. If no proxy is chosen, most states assign the task to the patient's spouse, parents, or closest relative. For advance directives to be of value, you must do more than merely complete the paperwork. Discuss your wishes ahead of time with caregivers and family members as well as with your physician. A number of forms have been developed to help people make an advance directive, including the popular "Five Wishes" form created by the nonprofit organization Aging with Dignity. Even with an advance directive, a patient's wishes to avoid aggressive medical interventions are frequently not followed. One reason is that, when every minute counts, emergency responders do not waste time looking for paperwork. Even if the advance directive is readily available, it does not constitute medical orders. For this reason, a separate document, called the Physician Orders for Life-Sustaining Treatment (POLST), has been developed and is available in most states. This document contains actual medical orders and is more likely to be followed, even in the event of an emergency situation. The POLST is intended primarily for people who are relatively near the end of life. In addition, people who are near the end of life and wish to avoid resuscitation and other forms of aggressive treatment often keep a signed document stating in bold letters "Do Not Resuscitate" or "Allow Natural Death" displayed in their home or hospital room. Page 645Planning ahead means different things at different stages of life. For the elderly, or those with a potentially terminal illness, making specific plans for what lies ahead becomes an urgent matter. For most students reading this book, specific planning for your eventual death is probably not a reasonable priority. But thinking about some of these issues now will help you down the road, both in dealing with your own life and in helping your loved ones as they near the end of their lives. Completing an advance directive is appropriate at any age. If you fill out an advance directive and share it with your parents (or grandparents), they may be encouraged to follow your example. Giving the Gift of Life People at all stages of life should consider the pros and cons of becoming an organ donor. A human body is a valuable resource. Of all the advances in medical techniques for helping patients who were formerly beyond recovery, perhaps the best known, and most effective, is the transplantation of human organs. Yet the demand for organs continues to dramatically outpace the number of organ donations. Each day about 79 people receive an organ transplant, but another 22 people on the waiting lists die because not enough organs are available. As of January 2016, more than 123,000 Americans were waiting for organ transplants. Many of these people will wait months or even years for a transplant, and many will die while they wait. Organs and tissues that are used for transplant come from several sources. Living donors can donate a single kidney, and parts of organs such as the liver, lungs, intestine, and pancreas. Living donors can also donate blood and bone marrow. Deceased donors are the only source of hearts, whole lungs, or other body parts that can't be removed from living donors. Eyes, bone, tendons, skin, and heart valves are some of the tissues that can be donated. Organ and tissue donors are matched with potential recipients based on many factors including blood and tissue types. Generally, the most successful transplants occur when the donor and recipient are as genetically similar as possible. To help prevent rejection, transplant recipients often must take powerful drugs to suppress their immune systems. There are many reasons for the current shortage of donor organs. The number of people in need of transplants is growing because modern medical care tends to keep people with serious health problems alive longer. In addition, as transplant technology improves, more medical conditions can be treated effectively with transplantation. Although the need for transplantation grows, the supply of organs has not kept pace. Not enough people register as donors. In addition, improved medical care of the victims of trauma and widespread use of safety devices, such as seat belts and motorcycle helmets, have reduced the number of individuals who might otherwise have been potential donors of many organs. The shortage of organs is particularly acute among some racial and ethnic groups, including African Americans, Asians and Pacific Islanders, and Hispanics/Latinos. This is mostly because the incidence of conditions such as high blood pressure and diabetes is disproportionately high in these groups, leading to an increased incidence of organ failure. For example, the incidence of kidney failure is three times higher in these groups than in non-Hispanic whites. Although organs are not matched by race, the chances for compatible blood type and tissue markers are more likely to be found among members of the same racial/ethnic group. This makes it crucial that people of all ethnicities contribute to the pool of organ donors. People of any age or health status can register as donors. Even an elderly person or someone with cancer may be able to donate some types of tissue. It is crucial that people of all ages, young and old, who are willing to donate organs and tissue, let their families know and register as donors (see below). In particular, it is important that young people consider becoming donors. The sudden unexpected death of a young person, usually due to some form of trauma, is a horrendous tragedy to her or his family, friends, and society as a whole. But some good can come from such a loss by donating organs. Knowing that their loved one saved or improved the life of one or many people can be a lasting comfort to grieving family and friends. There are several long-standing myths and fears about organ donation. A common unfounded fear is that if you are seriously injured, physicians won't work as hard to save your life if they know you are a donor. This is definitely not true! Saving a life is always the first priority. Another common myth is that organ donation disfigures the body and makes an open-casket funeral impossible. In fact, donated organs are removed surgically, which does not change the appearance of the body for the funeral service. In addition, some people are concerned that their religion may prohibit organ donation. When in doubt, you can discuss this with your clergy. But all major organized religions approve of organ and tissue donation, and most consider it an act of great kindness and charity. If you decide to become an organ donor, the first step is to indicate your wish by completing a Uniform Donor Card (Figure 23.2); alternatively, in many states you can indicate your wish on your driver's license. Because relatives are Page 646called on to make decisions about organ and tissue donation at the time of a loved one's death, your second step is to discuss your decision with your family. If your family does not know your wishes, they are more likely to refuse organ donation. Surveys show that most Americans would donate a family member's organs if they knew that was what their loved one wanted. Card requires donor to select to donate any needed organs and tissues OR specifiy which ones. Must be dated and signed by donor and two witnesses. FIGURE 23.2 A sample organ/tissue donor card. source: U.S. Department of Health and Human Services (http://www.organdonor.gov/index.html). QUICK STATS One deceased donor can save up to 8 lives through organ donation and can save or improve the quality of 100 more people's lives through tissue donation. —American Transplant Foundation, 2016 Planning a Funeral or Memorial Service Funerals and memorial services are rites of passage that commemorate a person's life and acknowledge his or her passing from the community. Funerals and memorials allow survivors to support one another as they cope with their loss and express their grief. The presence of death rites in every human culture suggests that these ceremonies serve innate human needs. Disposition of the Body When a death occurs, one of the immediate concerns of survivors is how to care for the body of their loved one. The care of the body after death varies greatly in different cultures. In the United States, the body is usually taken away from the home, hospital, or other site of death within a matter of minutes or hours. Contrary to popular myth, having a dead body in a home for a few hours, or even a few days, does not constitute a health risk. Keeping a loved one's body at home, at least for a few hours, can give the family a final chance to be with and care for the deceased. When the family is ready, the body can be transported for cremation or burial. The body is typically transported to a funeral home or mortuary, where it is prepared for burial or cremation. In some cases, an autopsy (medical procedure performed after death to determine the cause of death or the extent of disease) may be performed. Families may request an autopsy in order to learn more about the cause of a loved one's death. An autopsy may be required by law if the death was sudden or unexpected, or if the death was due to injury, drug overdose, poisoning, or suspicious circumstances, such as possible homicide or suicide. People generally have a preference about the final disposition of their own body. For most Americans, the choice is either burial or cremation. Burial involves a grave dug into the earth or entombment in a mausoleum. If the body is to be buried and the family wishes that the body be viewed during a wake or in an open-casket funeral, embalming is generally done. Embalming involves replacing body fluids with chemicals that disinfect and delay decomposition. Many of these fluids are toxic, and may pose environmental hazards as the body eventually decomposes and the chemicals slowly leach into the soil and water. Embalming is neither necessary nor legally required. Bodies that are to be buried are generally placed in a casket, which can be made of almost anything from cardboard to steel. Caskets can cost thousands of dollars, and bereaved family members are sometimes convinced by unscrupulous funeral homes to buy very expensive caskets that they cannot afford. No casket can prevent a body from decomposing. A less expensive and more environmentally friendly option is an inexpensive wooden or cardboard casket that can be draped with cloth or a flag if desired. Some religions, such as Judaism and Islam, mandate very simple burials, with plain wooden coffins (or no coffin at all) and no embalming. Cremation involves subjecting a body to intense heat, thereby reducing its organic components to a mineralized skeleton. The remaining bone fragments are then usually put through a cremulator, which reduces them to a granular state, often referred to as ashes (which actually resemble coarse sand). In some parts of the United States, especially in the West, cremation is now more common than burial. Cremation is acceptable to many, but not all, religions (for more on cremation, see the box, "A Consumer Guide to Funerals"). CRITICAL CONSUMER: A Consumer Guide to Funerals A traditional funeral with a casket costs about $7000, and many funerals cost $10,000 or more. When no preplanning has been done, as often occurs, family members have to make decisions under time pressure and in the grip of strong feelings. As a result, they may make poor decisions and spend more than they need to. To avoid these problems, millions of consumers are now making funeral arrangements in advance, comparing prices and services so that they can make well-informed purchasing decisions. Many people see funeral planning as an extension of will and estate planning. Alternatives to traditional funerals exist. Cremation is now used in nearly 50% of deaths in the United States, with the rate of cremation increasing rapidly in recent years. Cremation is also a much less expensive alternative to a traditional burial. A direct cremation (no service or visitation at the funeral home) can cost as little as $600 in some cities and has a lower environmental impact than traditional burial. Cremated remains can be buried, placed in a columbarium niche, put into an urn kept by the family, interred in an urn garden, or scattered at sea or on land. Whole-body donation (usually to a medical school) is another option chosen by many people for altruistic reasons, as well as for the fact that there is usually no cost. Another alternative to an expensive traditional funeral is a more personalized, "do-it-yourself" family-centered funeral, with minimal costs because most or all of the tasks needed to care for the deceased person are provided by family and friends. To ensure that you make the best possible decisions when planning a funeral, follow these guidelines: Plan ahead. Think about what type of funeral you want, and ask your loved ones about their preferences. Shop around. If you are going to use a funeral home, look for one that belongs to the National Funeral Directors Association (NFDA), and compare prices from at least two funeral homes. Ask for a price list. The Funeral Rule requires funeral directors to give you an itemized price list when you ask either in person or over the telephone. Many funeral homes offer package funerals that cost less than individual items, but you may not need or want everything included in the package. Decide on the goods and services you want. Basic services include planning the funeral and coordinating arrangements with the cemetery or crematory. Embalming is not necessary or legally required if the body is buried or cremated shortly after death. The casket is usually the single most expensive item; an average casket costs slightly more than $2000, but some caskets sell for as much as $10,000. You do not have to buy the casket from the funeral home you use. Many "big box" stores now sell caskets at much lower cost than funeral homes. Special body bags are also used and can cost under $1000. Resist pressure to buy goods and services you don't really want or need. Funeral directors are required to inform you that you need buy only those goods and services you want. If you feel you are being pressured, go elsewhere. In choosing a cemetery, consider its location, religious affiliation, if any, the types of monuments allowed, and cost. Visit the cemetery ahead of time to make sure it's suitable. If cremation is chosen, use of a cemetery is optional. Once decisions have been made, put them in writing, give copies to family members, and keep a copy accessible. Review these decisions every few years and revise them if necessary. © David Warren/Alamy Arranging a Service Commemorating a person's life and death may involve a traditional funeral ceremony or a simple memorial service. Whereas the casketed body is typically present at a funeral, the body is not at a memorial service. In some cases, both a funeral and a memorial service are held, the former occurring within a few days after death and the latter being held sometime later. Some individuals express a preference for not having any sort of service, but in general, bereaved relatives and friends derive important benefits from having an opportunity to honor the deceased and express their grief through ceremony. A funeral or memorial service can be a healing experience that allows loved ones to share memories and support one another. Memorial services can be held almost anywhere, including outdoors, in a home, or in a chapel. The service is often led by clergy, but many nontraditional services are led by a family member or close friend. The more the service fits the personality of the deceased person and meets the practical Page 647needs of the family, the better. A memory book or other photo display is common, and such items help bring back cherished memories of the person at different stages in his or her life. A home-based or outdoor service with a potluck meal or snacks afterward can be meaningful and healing while not placing a great financial burden on the grieving family. People who have a terminal illness sometimes find comfort and satisfaction in helping to plan for their own memorial services. A memorial service can be the joint creation of the dying person and family members who wish to be part of Page 648the project. Making at least some plans ahead of time can help ease the burden on survivors, who will undoubtedly face a great number of tasks and decisions when the death occurs. If your loved one has hospice care, the social worker and chaplain can often help guide you through the process of planning a memorial service. Ask Yourself QUESTIONS FOR CRITICAL THINKING AND REFLECTION Have you ever been involved in a funeral? What role did you play? Did you feel that the service reflected the values and beliefs of the deceased person? Did the service provide healing and comfort to family and friends? Did the experience cause you to think about your own funeral and what it should be like?

aging and life expectancy

Page 627 AGING AND LIFE EXPECTANCY Life expectancy is the average length of time we can expect to live. It is calculated by averaging mortality statistics—the ages at death of a group of people over a certain period. In 2014, life expectancy for the total U.S. population was 78.8 years, but those who reach age 65 can expect to live even longer—about 20 more years. A man reaching age 65 today can expect to live, on average, until age 83. A woman turning age 65 today can expect to live, on average, until age 86. Women have a longer life expectancy than men do (see the box "Why Do Women Live Longer?"). DIVERSITY MATTERS: Why Do Women Live Longer? Women live longer than men in most countries around the world, even in places where maternal mortality rates are high. In the United States, women on average can expect to live about five years longer than men (see the table in this box). Worldwide, women comprise 85% of the population that is more than 100 years old. The reason for the gender gap in life expectancy is not entirely understood but may be influenced by biological, social, and lifestyle factors. Medical consensus used to be that estrogen contributed to women's longevity. Not only has this theory been disproved, but research also indicates that estrogen supplements may be detrimental to postmenopausal women. However, estrogen production and other factors during a woman's younger years may protect her from early heart disease and from age-related declines in the heart's pumping power. Another theory suggests that menstruation has contributed to women's longer life expectancy. Because women excrete excess iron during menstruation, it is thought that women tend to experience a later onset of cardiovascular disease than do men. Men have higher iron levels in their bloodstreams throughout life, and iron can damage cells and cause free radicals to form, leading to cardiovascular conditions such as heart disease or stroke. Research findings made by a team of Japanese scientists suggest that women live longer than men partly because women's immune systems age more slowly. Additionally, women may have lower rates of stress-related illnesses because they cope more positively with stress. The news for women is not all good, however, because not all their extra years are likely to be healthy years. They are more likely than men to suffer from chronic conditions like arthritis and osteoporosis. Women's longer life spans, combined with the facts that men tend to marry younger women and that widowed men remarry more often than widowed women do, mean there are many more single older women than men. Older men are more likely to live in family settings, whereas older women are more likely to live alone. Older women are also less likely to be covered by a pension or to have retirement savings, so they are more likely to be poor. Social and behavioral factors may be more important than physiological causes in explaining the gender gap; for example, among the Amish, a religious sect that has strict rules against smoking and drinking, men usually live as long as women. This finding suggests that the longevity gap could be narrowed substantially through lifestyle changes. For example, men in general tend to take more risks than women—from driving more recklessly to using drugs and alcohol. These Tlingit women participate in a traditional dance group, which helps them stay active and maintain social and community ties, enhancing wellness as they age. © Jeff Greenberg/Photo Edit - All rights reserved. Life Expectancy Year of Birth Men Women Life expectancy at birth 1900 46.3 48.3 1950 65.6 71.1 2000 74.1 79.3 2007 75.4 80.4 2010 76.2 81.1 Life expectancy at age 65 1900 11.5 12.2 1950 12.8 15.0 2000 16.0 19.0 2010 17.7 20.3 2014 18.0 20.5 sources: National Center for Health Statistics. 2016. Health, United States, 2015. Hyattsville, MD: National Center for Health Statistics; World Health Organization. 2012. Gender, Health, and Aging. Geneva: World Health Organization. Life expectancy also varies among racial and ethnic groups; reasons for these differences include socioeconomic, genetic, Page 628and lifestyle factors. Between 2001 and 2014, life expectancy didn't change for people in the lowest 5% of income, but it increased by about 3 years for men and women in the top 5%. Those changes, and life expectancy in general, varied substantially by region. Life expectancy in the United States increased dramatically in the 20th century, as described in Chapter 1. This increase does not mean that every American lives longer now than in 1900. Rather, far fewer people die young now because childhood and infectious diseases are better controlled and diet and sanitation are much improved. Only 30% of people born in 1900 would live to age 70; of those born today, most people can expect to live that long. How long can humans expect to live in the best of circumstances? It now seems possible that our maximum potential life span is 100-120 years. Our health span, by contrast, is the period of life when we are generally healthy and free from chronic or serious disease. The major difference between life span (how long we live) and health span (how long we stay healthy) is freedom from chronic or disabling disease. Failure to achieve our life span in good health results to some degree from destructive environmental and behavioral factors—factors over which we can exert considerable control. Longevity appears to be partly influenced by genetics. Studies of identical twins and other research suggest that life span is strongly heritable when parents and other relatives live beyond age 90. Long life does not necessarily mean a longer period of disability, either. People often live longer because they have been well longer. A healthy old age is very often an extension of a healthy middle age. However, behavior changes cannot extend the maximum human life span, which seems to be built in to our genes. No one really knows how and why people change as they get older. Different theories claim that aging is caused by accumulated injuries from ultraviolet light, wear and tear on the body, by-products of metabolism, and so on. Other theories view aging as a predetermined, genetically programmed process. No theory, however, sufficiently explains all the changes of the aging process. Aging is complex and varies in how it affects different people and even different organs. Most gerontologists (scientists who study aging and its effects) feel that aging is the cumulative result of the interaction of many lifelong influences, including heredity, environment, culture, diet, exercise and leisure, past illnesses, and many other factors. QUICK STATS Men with the top 1% in income lived 15 years longer than men with the lowest 1% in income; for women, that gap was 10 years. —Chetty et al, 2016

coming to terms with death

COMING TO TERMS WITH DEATH We may wish we could keep death out of view and protect others from the pain associated with it. But this wish cannot be fulfilled. With the death of a beloved friend or relative, we are confronted with emotions and thoughts that relate not only to the immediate loss but also to our own mortality. Page 654Our encounters with dying and death teach us that relationships are more important than material possessions and that life offers no guarantees. In discovering the meaning of death in our own lives, we find that life is both precious and precarious. Allowing ourselves to make room for death, we discover that it touches not only the dying or bereaved person and his or her family and friends but also the wider community of which we are all part. We recognize that dying and death offer opportunities for extraordinary growth in the midst of loss. Denying death, it turns out, results in denying life.

intro to ch.23

Whether it is victims of a terrorist attack, an earthquake or a car crash, or a woman in her nineties dying peacefully with her family close by, images of death are all around us. Nevertheless, we rarely think about the inevitability of death in our own lives. Most of us live as if we are immortal, especially because in our 20s and 30s we haven't peaked yet on the arc toward death, and are not yet on the downhill. Accepting and dealing with death presents unique challenges to our sense of self, our relationships with others, and our understanding of the meaning of life itself. Although pain and distress may accompany the dying process, facing death also presents an opportunity for growth as well as affirmation of the preciousness of our daily lives. Dealing with the death of a loved one can tear families apart, but it can also bring them together, healing old wounds in the process. The way we choose to confront death can greatly influence how we live. This chapter discusses some of the many questions surrounding the end of life, including its meaning and function, steps individuals can take to make their death a bit easier for their loved ones, and tasks you may need to consider in preparing for your own death. This chapter also examines the process of grieving and provides advice that can help in dealing with the death of a loved one.