Journal of Gerontological Nursing

AS YOUNG AS YOU FEEL AGE IDENTIFICATION AMONG THE ELDERLY

Tammy L Terpstra, RN, MS; Terry L Terpstra, RN, MS; Henry M Plawecki, RN, PhD; Jean Streeter, RN, BSN

Abstract

In 1900 there were 4.9 million people over the age of 65 in the United States.1 The 1980 census counted more than 25 million people age 65 and over.2 It has been estimated that by the year 2030, the elderly will account for 20% of the population. Life expectancy after age 65 has also increased due to improvements in health care for those in middle or early old age. As a result of these improvements, the over-75 age group has grown twice as fast as the total elderly population.3

With advancing age, many individuals experience illness, restricted mobility, and a reduced self-care capacity.2 Eighty-six percent of the elderly have at least one chronic illness, and 50% have two or more.4 Older adults occupy about 70% of this nation's acute care hospital beds and 95% of its nursing home beds. Older adults utilize home care services at a rate double or triple that of the population as a whole.1·5

The increasing size of the older adult population and the variety of healthcare services they require has generated a great demand for nursing services. Moreover, regardless of practice settings, nurses are encountering increasing numbers of older adults who have unique and complex health concerns, changing needs, and varying responses to illness as well as individualized perceptions of age and health. These perceptions are influenced by a number of biological, social, and psychological factors. Understanding and integrating an individual's perceptions about age and health status is fundamental to making accurate assessments and implementing interventions that are personally acceptable and clinically appropriate.

The nurse and the patient bring unique perceptions, expectations, knowledge, and past experiences to their interactions. Establishing achievable patient goals and meeting them depends on the appropriateness of the goals and the patient's perception of his ability to accomplish them. According to King, "an important area of professional behavior is the need for nurses and patients to verify perceptions as they plan together to achieve goals."6

DISCUSSION

There are many possible explanations for the tendency among these older adults to perceive themselves as mentally and physically younger than their chronological age. Older individuals may use denial of old age to insulate themselves from society's stereotypical attitude toward older adults and the negative stereotype of old age.7·16 The general belief that physical attractiveness and prowess wane with advancing years might discourage some individuals from identifying themselves with an older age group. In addition, society's inclination to associate senility with old age may account for the disparity between chronological age and perceived mental age reported by these respondents.

Role models for individuals over the age of 75, sometimes referred to as the old-old, are rare since this is the first large group to experience such longevity. The old-old have no one with whom they can compare themselves and thus may be forced to identify with younger age groups. In addition, while there is considerable variation among older persons, the occurrence of widowhood, retirement, social isolation, deteriorating health, growing dependence, and death become cumulatively more probable for older persons who survive into or beyond their 70's. One must also consider that denial of advanced age may be a psychological defense mechanism since one's identification with an older self-image may be synonymous with acceptance of (or resignation to) that status.13

Some active, independent aged persons truly do perceive themselves as younger and refuse to accept the role expectation of an elderly person. These individuals may actually feel and behave like younger persons. For such individuals, denial of old age may be an affirmation of reality and be consistent with self-concept.16

People's actions and expectations tend to…

In 1900 there were 4.9 million people over the age of 65 in the United States.1 The 1980 census counted more than 25 million people age 65 and over.2 It has been estimated that by the year 2030, the elderly will account for 20% of the population. Life expectancy after age 65 has also increased due to improvements in health care for those in middle or early old age. As a result of these improvements, the over-75 age group has grown twice as fast as the total elderly population.3

With advancing age, many individuals experience illness, restricted mobility, and a reduced self-care capacity.2 Eighty-six percent of the elderly have at least one chronic illness, and 50% have two or more.4 Older adults occupy about 70% of this nation's acute care hospital beds and 95% of its nursing home beds. Older adults utilize home care services at a rate double or triple that of the population as a whole.1·5

The increasing size of the older adult population and the variety of healthcare services they require has generated a great demand for nursing services. Moreover, regardless of practice settings, nurses are encountering increasing numbers of older adults who have unique and complex health concerns, changing needs, and varying responses to illness as well as individualized perceptions of age and health. These perceptions are influenced by a number of biological, social, and psychological factors. Understanding and integrating an individual's perceptions about age and health status is fundamental to making accurate assessments and implementing interventions that are personally acceptable and clinically appropriate.

The nurse and the patient bring unique perceptions, expectations, knowledge, and past experiences to their interactions. Establishing achievable patient goals and meeting them depends on the appropriateness of the goals and the patient's perception of his ability to accomplish them. According to King, "an important area of professional behavior is the need for nurses and patients to verify perceptions as they plan together to achieve goals."6

REVIEW OF THE LITERATURE

In our society, there seems to be a direct relationship between chronological age and expected, acceptable behaviors. It is believed that as an individual gets older, his repertoire of behaviors should become more restricted and increasingly predictable.7 The concept of chronological age, however, might have limited validity for the explanation of behavior because it wrongly assumes homogeneity in individual lifestyles among age cohorts. Simply because two people have lived the same number of years does not mean that they are alike in respect to their life conditions.8 Butler states:

The idea of chronological aging... is a kind of myth. It is clear that there are great differences in the rates of physiological, chronological, psychological, and social aging within the person and from person to person. In fact, physiological indicators show a greater range from the mean in old age than in any other age group, and this is true of personality as well. Older people actually become more diverse rather than similar with advancing years.9

Society, however, tends to consider all elderly persons as a homogeneous group. Stereotypical attitudes are directed toward this group and have so permeated the national consciousness that they are applied to anyone classified as elderly regardless of each individual's perception of age, health, and status.10 In general, our culture regards aging as a process that results in a reduction of economic security, a loss of productivity, a disintegration of the family, a progressive diminution of physical attractiveness, and a deterioration of intellectual capacity. Older persons are often stigmatized as being lonely, senile, absent-minded, dependent, irritable, and in poor health.11"16 King remarks that stereotyped images will affect behavior toward a person or group.6 Stereotypes may influence not only one's behaviors and reactions toward others, but also an individual's subjective interpretation of self.14 Nurses who accept society's limited, negative, illness-oriented perception of older individuals may unknowingly initiate a self-fulfilling prophecy of dependency among their older patients. Once older persons accept the expectation of being dependent, nonproductive, and sickly, they may cease all efforts to maintain health and efforts at rehabilitation could become futile.17

Plawecki and Plawecki state, "As the primary care providers for many older adults, nurses have the opportunity to either reinforce society's negative expectations of aging or interact with patients as individuals."7 As individuals, older persons' self-perceptions of aging may vary considerably. Age identification can be defined as a self-orientation or self-perception of one's physical and mental capacities. In simple terms, it is how a person "feels" with regard to age, rather than one's actual chronological age, that determines the individual's attitudes and behaviors.18

Having individuals place themselves into broad age categories is one method researchers have used to assess age identification. In 1968, Zola reported the actual discrepancy in years between perceived and chronological age among older adults. A gerontological research project interviewed 219 older adults, who were asked their actual chronological age and how old they felt. The mean chronological age was 70 years for the male participants and 67 years for the females. Although a mean "felt" age was not reported, results of Zola's study indicated that a majority of both sexes identified themselves as younger than their actual chronological age.19

Some research studies indicated that there is a strong bias toward reporting personal age as more youthful than chronological age, and that this tendency becomes more conspicuous as individuals become older. The discrepancy between one's chronological age and the number of years one feels younger was noted by Kastenbaum et al in 1972, 20 Plawecki and Plawecki in 1980,21 and Underbill and Cadwell in 1983. 22

Determining how elderly adults perceive their health is important to nurses in the formulation of appropriate care plans . An older adult 's perception of his health status is an important factor in determining the behaviors, expectations, and relationships to the social world.23 As Andrews and Wìtney point out "[it is] people's perceptions of their own well-being or lack of well-being that ultimately define the quality of their lives."24 Among older adults, selfassessment of health is the strongest single predictor of life satisfaction.25 How elderly persons perceive their health also determines, at least in part, their feelings about the future.26 Identifying oneself as "old" can be linked to subjective feelings of illness, fatigue, and lack of vim and vigor; whereas, younger age self-perceptions are synonymous with the subjective feelings of wellness.27 Among the elderly, younger age perception coincides with greater life satisfaction and self-esteem until disability and impairment occur. Ill health tends to diminish the older person's feelings of control and changes one's outlook from a future to a present orientation.28 In 1977, Keith examined die influences of certain life changes such as declining health on the age- identification of persons over 65 years of age. This study reported that detrimental changes in health were associated with a self-definition as old.29

Maintaining some control over one's life is associated with maintaining a younger self-image. Perceiving oneself as younger may be a denial of reality, but one that might be necessary for good psychological functioning.28 Plawecki, Krueger, and Plawecki compared the age and health perceptions of diabetics and non-diabetics and found that only a minority of the diabetics perceived themselves as older than their chronological age.30 These authors hypothesized that, in spite of the presence of a chronic illness, a majority of individuals expect their physical and mental capabilities to decline with advancing age and, as a result, avoid placing themselves into older age categories.

THE STUDY

Becoming knowledgeable about an older adult's self-perceptions of his mental and physical age and health status would assist nurses to more accurately assess, plan, and implement personally acceptable and clinically appropriate health-care interventions. The authors designed a descriptive study to determine the health status and what difference, if any, existed between the chronological age and perceived physical and mental age of a group of older adults who resided in either a nursing or a retirement home.

Table

TABLE 1COMPARISON OF CHRONOLOGICAL AGE AND PHYSICAL AGE PERCEPTION BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

TABLE 1

COMPARISON OF CHRONOLOGICAL AGE AND PHYSICAL AGE PERCEPTION BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

Instrument

The instrument used in this study was an interview schedule adapted from Plawecki and Plawecki.21 Demographic and perceptual questions specifically related to this topic were included in the 18-item instrument. Reliability in this study was examined by the test-retest method conducted with two convenience samples (n=10) randomly selected from the original respondent group. The test-retest interval was 9 months. Pearson productmoment retest correlations for the samples were sought between the following variables: perceived physical age (.86), perceived mental age (.88), and perceived health status (.61). With the exception of heaJth status, these coefficients were statistically significant (/*<.05). A variety of factors may have served to lower the retest coefficient for perceived health status. Actual changes in health as well as seasonal differences at the testing times may nave affected these ratings. Content validity was assured by methods used to generate the items. Items were drawn from the literature and reviewed by two expert gerontological researchers.

Methodology

The data collection methodology allowed one researcher to conduct the interviews at the nursing home while another interviewed participants at the retirement home. Prior to each interview, the researchers repeated the same introductory remarks. Each schedule's questions were read as written and were repeated when the participants hesitated over their replies. The consent form and corresponding interview schedule for each participant were coded with a three-digit number. All participants were informed at the onset about the nature of the study and gave their informed consent to participate. Participants were also assured that their participation was voluntary and anonymous and that responses would only be reported in the aggregate.

Prior to use, the interview schedule and the consent form were reviewed and approved by the administrators of both cooperating facilities. The purposes of the study were outlined for all of the retirement home residents when they gathered for the noon meal in a main dining area. Researchers and staff identified nursing home residents who would be capable of answering the interview questions and sought volunteers from this group on an individual basis. Of those residents approached, two refused to participate. Residents who agreed to be questioned were interviewed either in their rooms or, when privacy was a problem, in an office.

Each interview session lasted about 30 minutes.

Sample

This descriptive study utilized a total sample consisting of 67 persons. Fortytwo participants resided in a 310-unit residential retirement center and 25 participants were residents of a 166-bed skilled and intermediate care nursing home. Both facilities are affiliated with and owned by a religious organization and are located near one another in a suburb of a large metropolitan area.

Residents of both facilities are predominantly of Dutch ancestry.

Table

TABLE 2COMPARISON OF CHRONOLOGICAL AGE AND MENTAL AGE PERCEPTION BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

TABLE 2

COMPARISON OF CHRONOLOGICAL AGE AND MENTAL AGE PERCEPTION BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

The sample (N = 67) consisted of an all Caucasian group of 13 men and 54 women. The age range for the total group was from 69 to 96 years with an average age of 82.5 years; 63 respondents were 75 years of age or older. Thirty-four persons reported having physical problems with limited mobility and, of that total, 18 indicated use of a wheelchair, 13 a cane, and 3 used another type of assistive device. All respondents were retired with 51 reporting that their retirement income was adequate, 12 less than adequate, and 4 more than adequate. Six respondents reported having no illnesses, 11 indicated having one illness, 17 two illnesses, 15 three illnesses, 11 four illnesses, and 7 responded that they had five or more illnesses. The mean number of illnesses per respondent was 2.7. The most common medical conditions identified were arthritis/rheumatism, hypertension, heart trouble, glaucoma/visual disturbances, urinary disturbances, diabetes mellitus, and effects of stroke. Twenty-five respondents stated that they were depressed and 20 reported feelings of loneliness.

RESULTS

Of the 67 participants, 45 stated that they felt physically younger than their actual chronological age. Although the average age of this group was 83.5 years, the participants indicated that they felt physically younger by 11.9 years (Table 1). The calculated self-perceived physical age for this group was 71.6 years. Seventeen participants stated they felt physically the same as their stated age, while five reported they felt physically older than their chronological age by an average of 6.7 years.

Similar findings were noted when responses regarding perceived mental age were examined (Table 2). Fifty-two of the 67 participants stated that they felt mentally younger than their stated age. The average chronological age of those who felt younger mentally was 83.0 years and they felt younger by an average of 15.5 years. The calculated self-perceived mental age of the group was 67.5 years. Fifteen respondents stated that they felt mentally the same as their chronological age, while none indicated that they felt older mentally.

The participants were asked to describe their health status. The following 4-point scale was assigned to their descriptions: excellent (4 points); good (3 points); fair (2 points); and poor (1 point). Of the 67 respondents , five rated their health as excellent, 38 as good, 22 as fair, and 2 as poor. The average health status rating for the total sample was 2.69. When age and health perceptions were considered together, it was found that respondents who stated they felt physically younger had an average health status rating of 2.82 (Table 3). Those who stated they felt mentally younger had an average health rating of 2.71. Respondents who stated they felt physically and mentally the same as their chronological age had an identical average health status rating of 2.53. Respondents who stated they felt physically older than their chronological age had a mean health status rating of 1 .75. None of the respondents reported feeling mentally older than their chronological age. These findings seem to indicate that those older adults who felt younger also felt healthier. The fact that 43 of the 67 nursing home and retirement center respondents reported feeling that their health was either good or excellent is surprising, particularly since 50 respondents indicated that they had two or more illnesses.

Table

TABLE 3COMPARISON OF PHYSICAL AGE PERCEPTION, MENTAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

TABLE 3

COMPARISON OF PHYSICAL AGE PERCEPTION, MENTAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

DISCUSSION

There are many possible explanations for the tendency among these older adults to perceive themselves as mentally and physically younger than their chronological age. Older individuals may use denial of old age to insulate themselves from society's stereotypical attitude toward older adults and the negative stereotype of old age.7·16 The general belief that physical attractiveness and prowess wane with advancing years might discourage some individuals from identifying themselves with an older age group. In addition, society's inclination to associate senility with old age may account for the disparity between chronological age and perceived mental age reported by these respondents.

Role models for individuals over the age of 75, sometimes referred to as the old-old, are rare since this is the first large group to experience such longevity. The old-old have no one with whom they can compare themselves and thus may be forced to identify with younger age groups. In addition, while there is considerable variation among older persons, the occurrence of widowhood, retirement, social isolation, deteriorating health, growing dependence, and death become cumulatively more probable for older persons who survive into or beyond their 70's. One must also consider that denial of advanced age may be a psychological defense mechanism since one's identification with an older self-image may be synonymous with acceptance of (or resignation to) that status.13

Some active, independent aged persons truly do perceive themselves as younger and refuse to accept the role expectation of an elderly person. These individuals may actually feel and behave like younger persons. For such individuals, denial of old age may be an affirmation of reality and be consistent with self-concept.16

People's actions and expectations tend to reflect the norms of their cohort groups. The respondents' health selfassessments, then, may reflect the norms of a particular, relevant reference group. These reference groups can be based on sex, age, and/or residence.31 Older adults' comparisons of themselves with age peers are often based on what they believe to be the situations of others rather than on actual personal knowledge. Beliefs about the situation of age peers may be influenced by the negative stereotypes about the elderly. These stereotypes might actually influence one's self-perceived health status in a positive way, since, regardless of their situation, many aged persons feel advantaged by comparison.15

The older person's general community is important because it provides the context and the norms for that particular group.31 Becoming ill means recognizing that one's physical or mental condition limits the pursuit of normal daily activities. The extent to which illness causes a disruption in life activities is determined by the level of physical and mental functioning required in a certain environment.32 Residents of nursing homes or retirement centers are not usually required to maintain high activity levels and, as a result, may find it easier to perceive their health as good since they can be active enough to meet the expectations of those who reside in the same environment or community.23 Moreover, if health perceptions are relative to the environment, one can expect institutionalized persons who live among others who are more impaired to self-evaluate their status as better than their peers. For example, a nursing home resident with impaired health may perceive his status as "good" while it would be rated as only "fair" or "poor" by a community dweller who has more frequent contact with healthy people,31 As Fillenbaum points out, "If all the older people in the community climb mountains, walking with a cane will indicate severe impairment, but where all are in wheelchairs, then the one with the cane is only minimally impaired."31

With regard to gender-related reference groups, one must recall that the sample in this study consisted largely of women (76%) who were 75 years of age or older. Previous research has demonstrated that women, whose health tends to be objectively poorer than that of men, seem to tolerate more health problems for a given self-assessment than do men. In other words, a woman's assessment of good health may indicate a greater extent of impairment than a similar assessment made by a man.31 Ferraro reported that old-old females in particular tend to be more optimistic with regard to their health status than other aged persons.32

LIMITATIONS OF THE STUDY

One of the difficulties in applying the results of this study to other groups of the same age in different settings centers around the characteristics of this sample. The respondents at the retirement home were all volunteers who might have had a more optimistic outlook than their counterparts who did not wish to participate. In addition, nursing home participants were included only if the investigators and staff deemed them mentally and physically capable of completing the interview schedule. This selection process automatically excluded those older persons who were too impaired to participate and who might have had a more pessimistic outlook. The sample was also predominantly composed of persons of Dutch ancestry who are known for strong family bonds and commitment to the Christian faith. These characteristics might have affected the responses obtained. The influence of religious beliefs and practices on feelings of well-being among older persons is an interesting topic for future research.

IMPLICATIONS OF THE STUDY

Society and the media have promoted the idea that youth is beautiful and old age is tragic and ugly.10 Nurses can either reinforce society's stereotypes or interact with older adults as individuals.21 Nurses who interact with individuals in a manner based solely on their chronological ages may exhibit disrespect and underestimate the potential for the client's involvement in self-care activities. Nurses need to examine age perceptions of older adults and their own attitudes toward the elderly with whom they interact to develop truly individualized plans of care. Positive attitudes about aging should be combined with a wellness approach in providing appropriate gérant ological nursing care. Nursing activities must be both individually acceptable and clinically appropriate and, whenever possible, should be directed toward maintaining independence, activity, and pursuit of interests.17

Finally, Baum conceptualized age identification as a clinical continuum of subjective wellness. Ineffectiveness and powerlessness characterize the negative, or "old" end of the continuum whereas feelings of control and vital purpose characterize the positive, or "young" end. Research that identifies factors correlating with younger age perceptions and feelings of wellbeing could one day create a host of strategies to promote younger age identification.27

REFERENCES

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TABLE 1

COMPARISON OF CHRONOLOGICAL AGE AND PHYSICAL AGE PERCEPTION BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

TABLE 2

COMPARISON OF CHRONOLOGICAL AGE AND MENTAL AGE PERCEPTION BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

TABLE 3

COMPARISON OF PHYSICAL AGE PERCEPTION, MENTAL AGE PERCEPTION, AND HEALTH STATUS BETWEEN RETIREMENT AND NURSING HOME RESIDENTS

10.3928/0098-9134-19891201-04

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