Addressing issues related to geropsychiatry and the well-being of older adults
Making connections with fellow human beings can be complicated or even difficult for anyone, but older adults often face new and specific challenges. They may retire to a new city and state, moving far away from neighbors, friends, and community connections. Many older adults have chronic illness or physical impairment that renders them less able to participate in shared activities or engage with their friends. In such cases, the frequency of contact with friends may decrease (Ha, Kahng, & Choi, 2017). Adults in retirement communities are likely to find themselves trying to connect with fellow residents who may at first seem to have little in common with them. Older adults with dementia may have more difficulty participating in leisure activities or hobbies, which can limit their social options, and they may have more trouble performing tasks outside the home that would connect them to others, such as shopping, driving, or riding the bus (Giebel, Challis, & Monttaldi, 2016; Innes, Page, & Cutler, 2016). Feelings of loneliness may be more prevalent in women and older adults who are divorced or widowed (Domènech-Abella et al., 2017), and anxiety caused by the death of a spouse has been shown to negatively affect connectedness to social networks (Jacobson, Lord, & Newman, 2017).
It is important to recognize that although connections for older adults may become fewer or less frequent, there are also ways in which connections can become stronger in this stage of life. Even as network size decreases, older adults may engage more frequently with neighbors and become more involved in church or volunteer work. Furthermore, life events such as retirement or death of a spouse have been shown to increase socializing with neighbors as a result of reduced obligations (Cornwell, Laumann, & Schumm, 2008). Although marginalized populations may be less inclined to pursue more traditional social connections, even in these cases, there can be positive outcomes. One study showed that older lesbians are less inclined to pursue connection through formal channels yet have good results seeking out informal support networks (Richard & Brown, 2006).
Human Connectedness and Health
Lack of human connectedness can lead to feelings of loneliness and, in turn, deterioration of physical health (Cornwell & Waite, 2009). Loneliness has been shown to have a negative impact on executive functioning, sleep, and overall mental and physical well-being, leading to higher rates of morbidity and mortality (Cacioppo & Cacioppo, 2014). A review of literature on loneliness and lack of connectedness found that these factors correlate with high blood pressure, alterations in immune system functioning, increased probability of heart conditions, and higher risk for dementia-like symptoms, along with being a predictor of diabetes in older adults (McCausland & Falk, 2012).
In contrast, connectedness through social networks and community support systems has been shown to boost mental and physical health and overall quality of life. Older adults with diabetes have been shown to have a significantly lower risk of death if they have medium or high levels of social support (Zhang, Norris, Gregg, & Beckles, 2007). Satisfaction with social support has been identified as a predictive factor for quality of life in rural adults (Wedgeworth, LaRocca, Chaplin, & Scogin, 2017). In bereaved spouses, emotional social support has been shown to decrease depressive symptoms 2 years after bereavement (Jacobson et al., 2017).
Anthropology and Neuroscience on Connectedness
The importance of connectedness for mental and physical health is not surprising given the history of the human species. Human reliance on community dates back at least 50,000 years. Archaeologists have uncovered evidence that Neanderthals cared for members of their tribe who were aging or sick. A recently discovered skeleton of a male Neanderthal was missing many teeth and showed signs of back and hip problems that would have necessitated assistance from others in the years before he died (Than, 2013). In addition, current anthropological theories suggest the reason Homo Sapiens survived at the cost of Homo Neanderthal is our aptitude for human connection. Our ability to understand others in our tribe and to join in larger groups by sharing everything from gossip to values to religious beliefs allowed us to outnumber and outmaneuver the less socially developed Neanderthal (Harari, 2015).
Today, languages around the world portray social pain as a type of physical pain, as expressed in phrases such as “she broke my heart” and “he hurt my feelings” (Cook, 2013). The fact that individuals experience social pain as real pain suggests that evolutionarily, social conflict was recognized as a threat to survival. Current neuroscience provides evidence for this evolutionary trend. Functional magnetic resonance imaging research has demonstrated that the human brain has two distinct networks, one for social thinking and one for non-social thinking (Cook, 2013). When using one of these networks, the other becomes mostly dormant. However, after focusing on a non-social task, the social-thinking network comes immediately and automatically back online. This switch may be a reflex developed in evolution due to the importance of always being aware of social context and the likely thoughts and actions of others (Cook, 2013). Human beings are hardwired to be socially connected creatures.
Philosophy and Human Connectedness
In ancient Athens, the birthplace of democracy, Socrates, Plato, and Aristotle devoted much of their philosophical work to studying what it means to live a good life—“good” in the sense of a moral and high quality of life—within a society. Aristotle's work in biology, politics, and ethics consistently defined humans as social animals. In his Nicomachean Ethics (∼340 BCE/2014), Aristotle described the nature of human happiness and flourishing and tried to determine what kind of life such flourishing requires; that life would be the highest human good. He rejected a life of pleasure as the ideal human good because such a life was just as fitting for non-human animals and it was too unpredictable and unstable. Instead, he argued, the human good must be based in activity which uses human reason within a polis, a society. For Aristotle, humans can only be at their best and happiest in a community. Interconnection with other humans provides the basis for moral works, good habits, a chance to work on flawed character traits, and a chance to use reason and good will (Aristotle, ∼340 BCE/2014).
In the 20th century, Hannah Arendt, in her philosophical writings, called back to Aristotle's line of thought and examined its implications for modern society. Arendt saw humans as beings who engage in labor to sustain themselves in the natural world and work to make a world of fabricated conveniences. Beyond such work and labor, though, Arendt said it is action with others that is the truly human activity. In such action, she said, “with word and deed we insert ourselves into the human world…and this insertion is like a second birth” (Arendt, 1987, p. 39). To live in the human world and not merely the natural world or the fabricated world we have built, we must engage with our fellow human beings. In doing so, “we share with all other entities the quality of Otherness” (Arendt, 1987, p. 39). The people we speak and act with are Other to us, just as we are Other to them. Rather than seeing this inescapable otherness as a negative, Arendt saw it as an essential and defining feature of human connection. What each person through words and deeds inserts into the company of their own kind is uniqueness. This insertion of ourselves into the human world, Arendt argued, is not necessary for us in the same sense food is necessary, and it is not merely desired as are material goods and comforts. The insertion of ourselves into human interactions is an unconditioned human impulse. We are born into the human world for action in the context of the Other (Arendt, 1987).
As Arendt (1987) explored the human world composed of human interactions, she found that “although everybody starts his own story, at least his own life-story, nobody is the author or producer of it” (p. 40). Each of us lives out a life that can be shared and understood as a story with a beginning, middle, and end. She stated that “it is precisely in these stories that the actual meaning of a human life finally reveals itself” (Arendt, 1987, p. 41). When any of us tries to understand our lives as something other than randomly connected events, to understand our lives as meaningful, we do so by seeing ourselves as living out a story. And “the real story in which we are engaged as long as we live has no visible or invisible maker because it is not made” (Arendt, 1987, p. 41). The story of each of our lives is not made but rather is lived through interaction with others.
As we interact with our fellow human beings, we are inevitably confronted with the frailty and unreliability of human affairs caused by the irreversibility of our actions and the unpredictability of those actions' consequences. Human connections involve successes and failures, good intentions producing bad results, and sometimes even bad intentions producing good results. As humans connect with each other in a society, we strive to find a way to survive and thrive despite this unreliability of our actions. For this reason, Arendt (1987) argued, “we find at the heart of human action promising and forgiveness” (p. 42). In making promises, we aim to add predictability and stability to human interactions. In seeking or granting forgiveness, we find ways to move on when actions have caused pain. It is in promises and forgiveness, Arendt (1987) believed, that each of us expresses our unique human self, for “without being bound to the fulfillment of promises we would never be able to achieve that amount of identity and continuity which together produce the ‘person’ about whom a story can be told” (p. 42).
The philosopher Emmanuel Levinas also emphasized the importance of human interaction to the development of the self, and he took the idea a step further, arguing that the only way any of us can understand ourselves is through understanding the Other. In the truest, most complete sense, we cannot be ourselves without human connection. Levinas (1969) believed that it is only when we find ourselves looking upon the face of another human being that we form a sense of self. By seeing that the Other is a self, we recognize our own self and come to understand ourselves as something other from the Other; we find our own self reflected in the face of the Other. When we discover our self through the face of the Other, that discovery and interaction form the pre-condition for all our ethical choices, for doing things that are good or bad and therefore doing something meaningful (Levinas, 1969).
Through Aristotle, Arendt, Levinas, and others, philosophers for 2,400 years have defined human beings as creatures who live for connectedness. In a society, we form our character through our interactions with others and in this way find activities that allow us to flourish and be happy. As we live our lives, we intersect with others who will help us shape our story and who will then tell that story when we are gone. In the face of the Other, we find our own self reflected back to us, and in this way we come to understand ourselves. Thus, connectedness is at the absolute heart of what it is to be human. No wonder that with a loss of connectedness comes loneliness, depression, and poorer physical health. In losing connectedness, humans lose a key part of their humanity.
Implications for Practice
Recognizing the importance of connectedness, nurses and other health professionals can reach out to older adults to help them seek new opportunities for connection. YMCAs and other pool and fitness centers are often places where older adults gather for physical exercise. Support groups for specific diseases or bereavement offer a chance to interact with others dealing with similar challenges and difficulties. For those so inclined, book clubs or library events may offer a chance to connect through conversation and mutual interest. For older adults who are shy or introverted or who have hearing impairment, connecting in ways where verbal interaction is not the primary component can provide key emotional and spiritual connections. Such options include gathering with others in seated or walking meditation or joining a group that attends sporting events. Many local colleges offer special “quiz-less” classes for retired adults at low or no cost, and they are likely to allow auditing of regular college classes for no cost. These classes give older adults the opportunity to interact with a variety of generations and, ideally, to engage in a mutual exchange of ideas and experiences. Volunteering for a charity or other non-profit organization can offer older adults new and rewarding challenges that may include physical exercise or mental stimulation.
Older adults are ideally suited for roles as mentors, either formal or informal. Mentorships offer a mutually beneficial relationship where the older adult is valued and the person being mentored can learn from their wisdom and experience. A study of retired nurses serving as mentors found that mentors had a rewarding experience that allowed them to stay connected with their former career, enjoy new challenges, and find validation in seeing others helped by their support (McDonald, Mohan, Jackson, Vickers, & Wilkes, 2010). Community-engaged arts may also provide a good option for older adults, helping them make new connections and develop a strong sense of community as they collaborate on arts projects (Moody & Phinney, 2012). Although in-person connections are ideal, the internet and social networking sites offer increased opportunities for older adults to stay connected with family and friends and even to reconnect with friends from earlier years. Social networking is particularly good for intergenerational connections with children and grandchildren (Nef, Ganea, Müri, & Mosimann, 2013).
Nurses and other caregivers can also be conscious of the importance of connection in their own interactions with older adults. In their caregiving work, there can be great value in including a few extra minutes to acknowledge older adults' personhood, perhaps by asking questions not directly related to health assessment or sharing a personal anecdote. Alkema (2017) argues for the championing of person-centered care in which care providers “see and engage with those living with chronic health conditions and daily living challenges as people with variable needs that shift over time, not solely as health-care patients” (p. 99).
Nurses and other health care professionals can work to ensure that older adults in their care have connections that allow them to live as part of society—to laugh, argue, and exchange promises and forgiveness. Nurses and other health care professionals can also work to ensure there are others with whom older adults in their care are living out their story; caregivers can help make connections with others who will share or even help shape a client's story. And the professional caregiver, simply through interacting as a fellow human being and not merely as a caregiver, becomes a partner in the client's story. As health care becomes more technical and potentially dehumanizing, and as chronic illness or dementia reduces an older adult's sense of personhood, a caregiver can be the Other in whose face the client can see her- or himself reflected. There is great value in such a chance for reflection and for recognition as a Self.
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