BEHAVIORAL SCIENCE
Izben C. Williams, MD, MPHInstructor
The Life Cycle - III
AGEING, DEATH and
BEREAVEMENT
WHO or WHAT IS OLD
In contemporary urban societies, chronological boundaries for life phases (youth, middle age, and old age) are continuously being revised upwards as medical and social advances extend the vitality and productivity of older adults
WHO or WHAT IS OLD
Truth is that aging proceeds at different rates in different individuals and at different rates with specific organ systems.
Many persons seem old in body or spirit at age 50 and others scarcely so at age 65 or 70
Whence 65+The common practice of designating
people over age 65 as “old” began in Germany in the 1880s when Otto von Bismarck selected 65 as the starting age for certain social welfare benefitsThe question is: “Should this continue to be
the qualifying standard?"............Gerontologists as well as politicians
continue to struggle with this question
Life Expectancy USA 150 years
Life expectancy USA 100 yrs
Aging EpidemiologyIn the USA the fastest growing segment of
the population is over age 85The 65+ population now comprises about
12% of the US populationProjections suggest that by 2020 more
than 15% of the US population would be more than 65 years old
Contrast this with US census 1900
Age – Just a number
To avoid undue emphasis on chronological age, it may be useful to think of each person as having several different ages, eg: biological, psychological and social (bio-psycho-social paradigm)
And to recognize that individuals may be “aged” in one continuum and “youthful” in another
Biology of Aging -1
Aging is not a disease, though often it is accompanied by dis-ease
But irreversible changes including some disease changes often accompany aging
Distinguishing between changes due to normal aging and those due to disease processes is not always straightforward
Biology of Aging -2
Distinguishing between normal senescence and senility (by way of example):Senescence involves slowing, varying from
scarcely noticeable to moderate changes. Relationships not impaired
Senility is a serious illness with progressive cognitive compromise and often death within a few years (incidence 10% over 65; 20% over 85)
Biology of Aging -3Some changes in aging process
Nervous system: The nervous system demonstrates, possibly
more clearly than any other system, the poorly defined borderline between normal, expected and tolerable changes due to aging and the pathologic changes due to disease
Biology of Aging -3Some changes in aging process
Neurochemical changes of aging include: Decreased availability of some major
neurotransmitters (NEpi, Dopamine, GABA, Ach) and increased availability of MAO.
These changes may be associated with specific psychiatric symptomatology.
Biology of Aging -3Some changes in aging process
Nervous system: Brain changes include:
Decreased weight, enlarged ventricles and sulciDecreased cerebral blood flow Senile plaques and neurofibrillary
tangles are present in all normally aging brain but these changes are exaggerated in Alzheimer type dementia
The aging brain
Biology of Aging -4Some changes in aging process
Skin and hairMusclesSpecial SensesCardiovascular SystemRespiratory SystemGastrointestinal TractUrinary Tract
Biology of Aging -4Some changes in aging process
Psychological changes of aging include:Life stage issuesLongevity and Existential issuesPsychopatholgy and related problemsSleep pattern changesAlcohol and other psychoactive agents
(including TxBest to evaluate elderly in familiar
surroundings
Healthy AgingHealthy aging practices should begin
early Factors associated with Longevity
Family historyContinuation of physical and occupational
activityAdvanced educationSocial support system including supportive
partnership
DEATH & DYING -1A. CHILD’S PERSPECTIVE
1. A child’s response to death is based on his level of awareness. An awareness of the meaning of death becomes more concrete (7-11 reversibility and irreversibility) with developing comprehension abilitiesa. Children younger than 5 years tend to view
death as abandonment They fail to appreciate the finality and irreversibility. Hence don’t mourn fully these important individuals
DEATH & DYING -2CHILD’S PERSPECTIVE
b. By middle childhood, a more realistic view of death begins to emerge, with children understanding the finality of the event.(1) The anxiety at this point about death
concerns not only the loss of (separation from) loved ones but also fears of mutilation (castration anxiety) and suffering and pain
DEATH & DYING -3
CHILD’S PERSPECTIVE1b (2) Because of the egocentric thinking
of children they tend to feel guilty and to view themselves as responsible for their own or other’s illness and death. Frequently the illness or death is viewed as a punishment for having been bad.
DEATH & DYING -4CHILD’S PERSPECTIVE
1c. By adolescence comes an adult cognitive view of death, and with it a clear understanding of its irreversibility. In addition, there is a capacity to mourn, especially by mid-adolescence.(1) Adolescents with chronic physical
illnesses, eg cystic fibrosis, precociously develop a sense of finiteness to life, often living while waiting for the final stage
DEATH & DYING -5CHILD’S PERSPECTIVE
1c. (2). With a decrease in egocentricity of their thinking and a diminished tendency to see their illness or death as justified or deserved, adolescents experience alterations of resentment and despair as they struggle to accept their own death
DEATH & DYING -6CHILD’S PERSPECTIVE
2. Parental response to child’s death. A child’s death is certainly one of the most devastating experiences that could befall any parent.
If the death is not a sudden one, there is a tendency for the parents unconsciously to undergo anticipatory mourning, resulting in the gradual relinquishment of strong emotional ties to the child. This can be hurtful to the child and parent alike
DEATH & DYING -7CHILD’S PERSPECTIVE
2a. The parent may be physically in attendance but emotionally disengaged and the child experiences the dreaded sense of abandonment The relationship becomes bland and lacks
intensity as the parents try not to let the child see them “upset”
An emotional barrier is erected, the talk is superficial, and the subject most on the child’s and the parents minds becomes taboo
DEATH & DYING -8CHILD’S PERSPECTIVE
2b. When the child dies, the parents may feel guilty that they are not more upset by the child’s death or that they may be relieved to have the ordeal over
Unless properly counseled they may think of themselves as callous or non-loving when in fact they have already grieved, albeit unconsciously in advance
DEATH & DYING -9ADULT’S PERSPECTIVE
1. Adults tend to be anxious about their own death because of:The dread of being separated from loved onesConcern about pain and suffering, andBecause of the narcissistic injury associated
with the end of existenceThere is often also a sense of not having left an
indelible mark on the world that will assure “perpetual existence” thereby avoiding a sense of nothingness.
The Process of DyingPeople die as they lived (cum defenses
and all)Mortal man can’t imagine his mortalitySome investigators, particularly Elizabeth
Kubler-Ross have proposed a series of five psychological stages through which the dying patient progresses
These stages should be viewed only as representative of emotional reactions experienced by the terminally ill
DEATH & DYING -10ADULT’S PERSPECTIVE
2. Elizabeth Kubler-Ross: Describes five stages that the dying patient experiences before demise:
a. The Stage of denial and isolation– can’t be, not true
b. The Stage of anger with rage, bitterness, why me, etc
The Stage of bargaining including miracles and magicThe Stage of depression
preparatory grief (emotional detachment, withdrawal) final grief (existential reflections)
The Stage of acceptance with calm and even euphoria
DEATH & DYING -11PHYSICIAN RESPONSE
C. There are several common responses observed in physicians who care for the dying.1. Sense of failure. In spite of rationally
knowing otherwise, many physicians harbor a belief that if they had tried harder perhaps the outcome would have been different
2. When the patient reminds the physician of someone significant then the additional emotional strain may be impactful.
BEREAVEMENTTerminal illness exacts a heavy toll on
all those involve with the dying personPhysician’s role should be to assist the
family in achieving adequate adjustment to loss, recognizing that:Family members are an integral part of the
experience of terminal illness and deathTerminal illness may result in major changes
in family structure and dynamics
BEREAVEMENT -2Patient’s problems have ended and
the family problems escalate. Some probable emergent issues:Implications if patient was family provider.Loneliness, resentment, guilt and fear must
be facedSurvivors need to reassess the meaning
and direction of their own lives (in the absence of lost member)
BEREAVEMENT -3
The essential task of mourning or grieving is the withdrawal of emotional concern and attachment from a lost object (person) and preparation for relationships with new objects.
BEREAVEMENT -4Five stages of bereavement recognizedThese share similar characteristics
with:Reactions of the dying patient, and withCharacteristics of the stress syndrome (qv)
These stages and phenomena vary in sequence, duration, intensity and even occurrence in any given individual
BEREAVEMENT -5Five stages of bereavement:
Alarm (Denial)Numbness (Anger)Pining and searching for the lost object
(bargaining – with hallucinations and pseudohallucinations)
Depression and disorganization (Depression)
Recovery and reorganization (Acceptance)
BEREAVEMENT -6The major mourning period lasts 6-18
months , with most people able to resume usual functioning in less than 6 months
In truth, however, the time course of the mourning process is lifelong, but with time memories become less painful and less intrusive
BEREAVEMENT -7The role of the physician:
Work with the family starts well before the ill person’s death
Offer realistic appraisal of the situation but at the same time allow for hope
The concept of anticipatory grief encourages family members to verbalize their thoughts and feelings
Grief ReactionsNormal and abnormal grief
See comparison in table of text.
Top Related