Behavior and Emotions of Aging

Module 2: Behavior and Emotions of Aging

What you will learn

1. Recognize normal aging
2. Recognize common experiences of aging including adjustments to change and loss
3. Identify the stages of grief with an emphasis on the unique nature of grief in older adults
4. Use techniques to support the emotional and adjustment of older adults to the experience of aging
5. Identify the causes of depression and respond to the signs and symptoms suggesting depression
6. Respond to difficult behavior changes of older family members

Index and Content of this Module  

In this module you will review common changes that may take place in later life, adjustment to change, grief, depression, behavior changes, and the importance of attitude in successful aging. You will also review what you can do as a caregiver to support and encourage successful aging.

Click on a topic below to go to that area of the page:

1  The Process of Aging
Change and Loss
Responses to Loss or Change
Grief Stages
Signs and Symptoms Suggesting Depression
Possible Causes of Depression
Treatment of Depression
8  Suicide Rates and Older Adults
9  Assessing Risk of Suicide
10 Recognize Signs, Involve a Doctor, Get Treatment
11 Behavioral Changes and What to Do
12 Examples of Difficult Behaviors
13 Possible Causes of Difficult Behaviors and How to Cope
14 Is It Normal Aging or Dementia or Alzheimer’s Disease
15 How Caregivers Help Older Adults
16 Resources for Caregivers

The Process of Aging

Aging is another stage of life like childhood, adolescence or young adulthood. People age differently and experience aging differently based on heredity, lifestyle, and attitudes.

Aging means change – physical, psychological, relationships, social, environment, situation, behavior, spiritual, and intellectual.

Everyone adjusts to aging differently Chances are good that a demanding 80 year-old was a demanding 35 year-old. So the best way to predict how an older person will act is to look back at her behavior in earlier life.

People who did not like change when they were younger don’t generally like it any better as they age.

The challenge for older adults (and their caregivers) is accepting and adjusting to changes or building “resilience”.

Change and Loss 

Aging is a process of adjusting to continual changes.

· Retirement. Retirement is not the same for everyone. While some people adjust very well to retirement, others find the transition more difficult. In general, those who retire to meaningful activities are more satisfied than those who retire from a job and have no outside interests.

· Physical changes in vision, hearing, and other senses. All of our senses tend to change with age. Our eyes have more difficulty focusing on near objects and adjusting to changes in light intensity. Our lenses gradually become clouded. We may have difficulty hearing tones that have a high pitch. Such changes may be especially disruptive for those who have never experienced sensory loss.

· Health. As we grow older, we become more likely to develop chronic health problems. Adjusting often depends on our prior health and how well the conditions can be controlled. Someone who has been healthy most of his life may struggle with accepting health problems as he gets older.

· Mobility. Those who are inactive and/or have health problems may experience declines in strength, endurance, and mobility. These may limit daily activities.

· Memory. We process and retrieve information in different ways as we grow older. For example, we may take longer to recall information. Such changes are usually slight. However, stress, medication interactions, depression, dementia and a number of other conditions can cause serious memory problems. Any significant change in memory should be evaluated by a physician.

· Death of spouse, other family, and friends. One of the most difficult changes is loss of significant people in one`s life.

· Home and personal possessions. Moving is a chore at any age, but it can be especially difficult for someone older. One may be leaving a home of several decades or moving into a smaller home that can’t accommodate all of one’s personal possessions. The loss of familiar surroundings or things requires adjustment.

· Income. Incomes usually decline at retirement. Since older people don’t know long they’ll live or what their expenses will be, they may be reluctant to spend money and/or worry about their financial security. 

The changes that many older adults experience can affect how they see their lives. Many feel that they have lost their independence. They may experience a loss of self-esteem and may lose a clear image of who they are at this time in their lives. So many changes and adjustments can lead to a lack of confidence in their ability to live a meaningful life and continue to make valuable contributions to the community.  And there may also be a sense of loss of the respect of others.    

Responses to Loss or Change

We all have different ways of coping with loss and change. If we have adjusted fairly well during the first 50 years of our lives, we`re likely to be able to adjust during the next 50 years. On the other hand, if we`ve resisted change throughout our lives, we will probably continue doing so-and experience negative effects that may include the following:

· Physical complaints: There`s a clear relationship between mental and physical well-being. Those who have undergone losses are more likely to experience both minor and major illnesses.

· Denial: Some people cope by refusing to acknowledge that change has occurred. They may have an “ignore it and it will go away” philosophy.

· Guilt: People may feel that they could have prevented a loss by acting in a different way.

· Loneliness: Isolating oneself may be a way of mourning the loss of familiar people and a former lifestyle.

· Sense of helplessness: People may feel that they are at the mercy of their health problems, living arrangement, income limitations, or negative events.

· Overly critical, suspicious behavior: Some people become overly critical, suspicious, and/or paranoid. They do not trust easily and may feel that they are being taken advantage of.

· Rigidity/stubbornness: Those who feel out of control may try to regain control by taking on an attitude of “my way or no way.”

· Selective memory: Some people may cope by remembering either the best or the worst about events and people in their life. They may distort the reality of how the events happened or who the people were. They hold on to a fantasy instead of a reality.

· Regression: Going back to old behaviors or ways of coping may be ways to deal with painful events.

· Reminiscence:  Dwelling on how things used to be and how they have changed.  Wishing for things to be as they were when they were younger.

· Rage: When people feel that they have little control over the present or have regrets about the past, they may react in anger. They may lash out at family members-sometimes being most critical of those who are most supportive, since they know that these people will still love them in spite of their anger.

· Depression and anxiety: Although not something that most people want to discuss these are very real reactions to loss and uncertainty for anyone at any age. It is important to help someone know that these feelings are normal and to get help if the feelings interfere with daily living beyond a few days of feeling sad.

· Grief. Grief is a normal reaction to the loss of people, former lifestyles, relationships, health, vision, hearing, ability level, mobility, or independence. 

Grief and Grief Stages 

Both older adults AND family caregivers experience grief.  Different people experience grief and loss in different ways.

Groundbreaking research on death and dying by Elizabeth Kubler Ross identified stages of grief that are now recognized as normal for any type of loss or change. The grieving process does not take place in steps but in cycles. People move in and out of the following stages at their own pace.

· Shock. In this stage of grief the individual describes a sense numbness and not being herself. She may not believe that she is experiencing a loss.

· Denial. In this stage a person is unwilling or unable to accept the loss. She does not want to talk about the loss and often does not realize that the loss has occurred.

· Emotional release. During the stage of emotional relief, someone may cry, become enraged, or be overly critical or sarcastic. In this stage a person`s usual behavior and emotions may be magnified.

· Depression, loneliness, and sense of isolation. In this stage the individual may withdraw, sleep more than usual, overeat or not eat enough.

· Physical symptoms. A person may experience headaches, stomach ailments, ‘heartburn` sensation, fatigue, or a general sense of not feeling well.

· Panic. In this stage a person may feel fear and a lack of control over her situation and environment.

· Guilt related to the loss. A person may think that she caused the change or loss. A person may also experience ‘survivor guilt` because she has been spared from death or illness and is less “deserving” than a loved one who has died or gotten sick.

· Hostility. Part of the emotional reaction may be hostile behavior, starting arguments, verbal attacks, and “acting out.”

· Inability to resume usual activities. A normal stage of grief is a difficulty in “moving on” after the loss.

· Glimpse of hope. Gradually, those who`ve experienced losses begin to have better days and assume more normal activities.

· Acceptance. In this stage the person is able to accept that the loss has occurred or the change has happened and that things will not be the same. The person begins to live the new life after the change although the memory of the old life or the person who is gone remains.  Problems happen when a person is ‘stuck` and is unable to work through the grief or denies that there are problems. Knowing these stages will help caregiver understand what is normal. As caregivers we can help the person struggle with the loss. We also may be experiencing loss ourselves. We may have lost a parent or spouse as we once knew them or the loss of a lifestyle because of our caregiving responsibilities.

For further information see ” Loss and Grief” ~ Module 13

Signs and Symptoms Suggesting Depression 

Depression is more than an occasional feeling of sadness or the natural grief associated with a loss. It is a group of long-lasting or recurring emotions and behaviors that interfere with a person`s normal activities. If you or someone you know has experienced several of the following signs of depression for two weeks or more, professional help should be considered:

   · Depressed mood
   · Feelings of worthlessness, hopelessness, helplessness, and/or inappropriate guilt
   · Changes in eating habits with significant weight loss or gain
   · Changes in sleeping habits (sleeping too little; disturbed sleep; or sleeping too much)
   · Decreased energy or increased fatigue
   · Change in movement – either slowed or agitated
   · Inability to concentrate or make decisions
   · Memory loss, confusion, disorientation
   · Irritability, short-temperedness
   · Persistent sadness or anxiety
   · Neglect of self care
   · Too much concern with physical problems
   · Chronic aches or pains not related to diagnosed illness
   · Loss of pleasure in daily activities
   · Withdrawal from usual activities and relationships   

Possible Causes of Depression   

Following are possible causes of depression:

· Stress and loss: As people grow older, their losses can multiply. Losses may be manageable by themselves but overwhelming when combined with other losses.  Note: What often adds to the grief of the elderly is that these losses are likely to: a) be multiple or b) come one right after another. 

· Substance Abuse: Alcohol, prescription and non-prescription drugs.

· Physical Illness:
Research has established a clear link between brain chemistry and depression.
Medical illnesses can increase the likelihood of depression.
Known causes can be Parkinson`s Disease, thyroid changes, strokes, diabetes, and certain forms
of cancer.
Hormonal changes.

· Medications:
Some blood pressure medications increase the risk.
Interactions of medication causing unwanted side effects that can trigger depression.

· Lack of physical activity.

· Lack of emotional and social outlets.

· Poor stress management tools.

· History of a major depression increases risk of recurrence.

· Family history of depression.

· Substance abuse: alcohol, prescription and non-prescription drugs.  

Treatment of Depression  

• Depression is one of the most successfully treated illnesses, usually with medication
• When properly diagnosed and treated, more than 80% improve
• Untreated, depression is likely to persist and may cause
• Distress
• Disability
• Wasted health care dollars
• Substance abuse
• Increased risk for suicide
• Medical complications of chronic illness or even death

Get help! Talk to your relative`s physician:
• Ask your relative`s doctor about possible side effects of medications.
• Talk about changes in how the person is feeling and changes in his usual behavior and routines.
• Ask the doctor about a referral to a mental health professional who understands older adults.
• Ask the doctor if your older relative can benefit from medication therapy.

Medications frequently prescribed by physician include the serotonin uptake inhibitors (SSRIs): Zoloft, Paxil and other anti-depressants. These medications have fewer side effects that many older medications.

Suicide Rates and Older Adults 

As many as 70% of older persons who completed suicide visited their primary care doctor within the previous 4 weeks.  As many of 40% saw a doctor within the week before the suicide.

• Depression is the most common risk factor for suicide
• Older adults have the highest suicide rate of any group in America – 50% higher than the general population
• Each year, 6,000 older Americans kill themselves
• Older adults are less likely than younger people to seek or respond to offers of help designed to prevent suicide
• Older adults make fewer suicide gestures but more often succeed at suicide attempts, planning over a period of time
• The highest rates of suicide occur in persons over age 70.  There are some suicide trends based on gender or race/ethnicity:
· Suicide rates do not increase with age among women
· White men – 45% more common among those aged 65 to 69 years, 85% more common among those aged 70 to 74, and more than three and a half times more common among those 85 and older than among white men aged 15 to 19 years
· Suicide rates among black men peak late in life
· No data found for older Hispanic/Latino older male suicide  

Risk of Suicide 

These factors can be red flags warning of potential for suicide if they are a pattern of behavior over a period of time:
• Talk about or preoccupation with death
• Give away prized possessions
• Take unnecessary risks
• Have had a recent loss or expect one
• Increase use of alcohol, drugs or other medications
•  Fail to take prescribed medicines or follow required diets
• Acquire a weapon
• Make comments such as “my family would be better off without me”
• Neglect  self-care and personal hygiene
• Take a sudden interest in putting affairs in order
• Give away possessions (although sometimes older adults begin to “pass along” family items which may be normal)
• Take a sudden interest or disinterest in religion.

Recognize Signs, Involve a Doctor, Get Treatment 

Don’t accept that depression is normal as people grow older!  Get help! Talk to a physician:

• Ask about possible side effects of medications
• Talk about changes in how the person is feeling and changes in usual behavior and routines
• Ask about a referral to a mental health professional who understands older adults
• Most importantly, seek treatment promptly  Medications that may be prescribed by a physician may include Serotonin uptake inhibitors (SSRIs): Zoloft, Paxil and other anti-depressants.

Contact 2-1-1, Mental Health Association or local Mental Health Mental Retardation (MHMR) Center for more information and referrals.  Find support systems from friends, family and the community.

Behavioral Changes and What to Do

Behavioral Changes Handout 
Changes in a person`s usual behavior and routine can indicate a change in health and mental status.   Be observant and think about what the behavior may mean. Take some practical steps:

· Really listen to his/her concerns. For example, stop cleaning the house or driving or preparing a meal and sit down, make eye contact, and really listen.
· Ask your family member what he/she needs and work with him/her to come close to meeting their need.
· If your older relative is no longer able to do something that he wants to do, help him find alternatives.  · Set some healthy limits for yourself. Tell your family member what you can and cannot do based on your skills and your other time, work, and family commitments.
· Talk to siblings and other family members and ask for their help.
· Set up a Job Jar or “To Do” list. Talk to your older relative and ask him/her to make a list of things that need to be done. Ask for help from other family members, church volunteers, neighbors, or other people who have offered to help.

Difficult Behaviors

These are some examples of difficult behaviors you might encounter:
·Combativeness, aggressiveness
·Restlessness and wandering
·Mood swings
·Over-controlling behavior
·Critical and demanding behavior.

Possible Causes of Difficult Behaviors and How to Cope

Look for the cause of the behavior, including major changes and losses:

Pain, undiagnosed physical illness such as constipation, urinary tract infections, dehydration, etc
Watch for signs of pain or illness and seek medical care

Medication side effects
Ask the doctor to change the dosage or switch to another medication

Lack of proper nutrition – Is it related to physical illness or that food does not taste good?
Make sure dentures are properly fitted
If cooking is a problem, check with the Area Agency on Aging about congregate meals in senior
centers or home delivered meals through Meals on Wheels

Uncomfortable environment – Is it too cold, hot, bright, loud, etc?
Adjust the temperature, dim lights, close blinds, turn volume down

Provide an atmosphere and opportunity for rest. Ask the doctor if medication might be appropriate

Sensory loss – Visual problems or hearing loss may result in hearing or seeing things. Insufficient
lighting may play tricks. Unfamiliar noises or changes in the surrounding may lead to fear
Provide corrective lenses or hearing aids as needed

Lack of activity
Encourage physical activity as tolerated

Feelings of powerlessness and loss of control
Provide assistive devices and allow the elder to make choices as appropriate

Confusion or memory Loss
Maintain a calm environment and reassure the person. Use memory aids
Be consistent
Keep household furnishings and objects in the same place
Do things the same way at the same time each day
When changes must be made, prepare and support the elder

Is It Normal Aging or Dementia or Alzheimer’s Disease

The Normal Aging Brain  
These changes are generally part of the normal aging process.  The age of loss varies with individuals but there generally is not much loss before the age of 70.
• Some memory loss is normal but gradual – “Senior Moments” and “It’s on the tip on my tongue”
• Short term memory most affected
• Long term memory least affected
• Forget names but not faces.
• Confuses timing of events
• Affected by
• Poor nutrition
• Lifelong stress
• Other illnesses such as Parkinson’s Disease
• Depression
• Alcoholism

Dementia is a neurological disorder that causes general and progressive problems affecting memory, ability to learn new information, communication, judgment and coordination.
• Usually accompanied by personality and behavior changes
• Onset is gradual
• Condition gets progressively worse
• Other medical conditions such as hypothyroidism and B12 deficiency do need to be ruled out since they can produce similar symptoms.

Alzheimer’s Disease
Alzheimer’s is a disease that causes injury to nerve cells in the brain. It results in disrupted memory, thinking and functioning.

• Everyone who has Alzheimer’s Disease has dementia
• Not everyone who has dementia has Alzheimer’s Disease
• Not the same progression for everyone but the stages are predictible
• Somewhat greater risk for people with family history of Alzheimer’s Disease
• Race or ethnicity does not seem to be a factor

How Caregivers Help Older Adults

Caregivers can help older adults remain as independent as possible as long as possible by:

• Helping maintain independence and self-sufficiency

• Reducing risk
–Health:  regular checkups and immunizations to prevent illness:  influenza, tetanus, and others; dental care; diet and exercise (stretching, balance, endurance, and strength
–Safety:  removing obstacles to prevent falls,  checking smoke alarms, checking water temperature; regular driving tests, monitoring citations, observing affects of alcohol

• Using health care, family and community support

• Increasing knowledge of illness or disability

• Reinforcing a sense of productivity and involvement

• Helping make choices to determine the course of his/her own life

• Being supportive

• Bringing a positive attitude

• If necessary, learning how to perform first aid and CPR; lift without injury; use hoyer and chair lifts; do bed transfers and use bathroom chairs

• Taking care of yourself and clearly defining your role and limitations

• Use resources such as Area Agency on Aging

Resources for Caregivers

•2-1-1 throughout Texas. Provides information and access to health and human service information for all ages
•1-800-252-9240 to find local Texas Area Agency on Aging
•1-800-677-1116 – Elder Care Locator to find help throughout the U.S.

• Online education, resources, links, frequently asked questions
• Benefits Check-up for an online way to determine benefits for which someone qualifies.

Assistance available through the Area Agency on Aging for caregivers:
• Information and referral
• Caregiver education and training
• Caregiver respite
• Caregiver support coordination
• Case management
• Transportation assistance 

Assistance available through the Area Agency on Aging for persons age 60 and older:
• Benefits counseling
• Ombudsman – advocacy for those who live in nursing homes and assisted living facilities
• Home delivered meals
• Congregate meals
• Light housekeeping

Written by:  Zanda Hilger, M. Ed., LPC, Family Caregiver Education, contractor to Dallas Area Agency on Aging and North Central Texas Area Agency on Aging, Revised 2021. Includes materials adapted from As People Grow Older, Jane Oderberg and Sue Smith, 1995 and as cited in the materials.

Permission is granted to duplicate any and all parts of this program to use in education programs supporting family members caring for elders.