Living Well, Aging Well, And Dying Well,
Navigating the Transitions that occur in Older Adulthood
Through
Accepting, Anticipating, and Adapting
To Age Related Changes
Aging Well
"Some things are in our control and others not." Epictetus
The controllable factors of living well, aging well, and dying well are the focus of this resource. The challenges of aging, physical and cognitive decline, illness, and death are real. The reality of human mortality, and the uncontrollable aspects of mortality cannot be ignored. However, the factors that are under our control are well documented by modern medical studies and historic spiritual teachings. Living well, while recognizing and navigating the realities of aging, can be achieved.
Taking Control of Thoughts
Historic spiritual traditions from various faiths, and modern Cognitive Behavioral Therapeutic techniques , teach that we can become the masters of our thoughts. Thoughts that are unhelpful or factually inaccurate can be replaced by thoughts that are in our own best interest.
The New Testament
αἰχμαλωτίζοντες πᾶν νόημα (aichmalotizontes pan noema) translates to "bringing every thought into captivity" or "taking every thought captive." or "we take all thoughts captive". That phrase from Second Corinthians contains the idea of using a "mental sword" to assist our ability to take unhelpful thoughts captive (something like how a Roman soldier may have taken a foe captive). We then replace unhelpful thoughts with values-based replacement thoughts.
CBT
Cognitive behavioral therapy has specific methods of replacing unhelpful thoughts.
Are your thoughts both factually accurate and helpful?
Do you have a decision matrix to test if your current thoughts are factually accurate and helpful?
What methods to you use to test your own thoughts?
Some of the following methods may be of assistance to replace unhelpful thoughts with thoughts that are both helpful and factually accurate:
* Disputation: What actual "evidence" do I have that my thought is factually accurate and helpful regarding addressing my concerns?
* Dichotomy of Control: What portion of my current concerns can I control or influence or change? Furthermore, if there is some portion of my concerns that I cannot change at all....how much time is useful for me to spend on this portion of my concerns?
* Downward Arrow: If this (undesirable) thing actually happened, what would I do or what would that mean to me?
Taking Control of Behaviors
From a practical perspective of aging well-being, it is useful to explore the issue from two perspectives: increasing what is right, and addressing what will benefit from change. Below are some models of well-being:
CBT and Behavioral Activation
There are various models of well-being or living well. One way of exploring well-being is through a model from Cognitive Behavioral Therapy (a psychotherapeutic intervention that will be referred to often) known as "Behavioral Activation" . Under this theory, there are two umbrella domains of well being: 1) Fun, pleasure, happiness, and 2) Meaning and/or achievement. Note: some activities are fun and meaningful. Furthermore, Behavioral Activation Theory teaches us that engaging in those activities with others who we care for also increases well being. But, the key to this model, and much of what this website will recommend, is actively engaging in these activities as a consistent and intentional habit. Some people achieve consistent habits through the use of SMART goals (specific, measurable, attainable, relevant, time-oriented) such as, "I will walk a mile with a friend at least three times a week".
PERMA Model of Happiness
There is another theory of happiness, or well being, from someone who has made happiness a life work. This is Seligman's (M. Seligman who developed the theory of Positive Psychology) PERMA model of authentic happiness:
P -Positive emotions such as gratitude, hope, love, happiness.
E- Engagement in activities that bring a sense of absorption, timelessness and euphoria.
R-Relationships are also a key portion of this model. Engaging with others who one loves, feels valued by, and supported, etc.
M-Meaning, engaging in behaviors or activities that are meaningful, or serving something greater than ourselves.Purposeful activities that are values-based.
A-Achievement. An accomplishment, successfully reaching one's goals. This can also involvement celebrating past achievements.
Importance of Relationships
Relationships are vitally important to our well being, therefore cultivating those relationships is crucial. The current director the longest running prospective longitudinal study of adult development , The Harvard/Grant Study, cites our relationships as the single most important factor affecting aging well.
Engaging in well being enhancing activities multiple times weekly is within our power.
Navigating Aging Well
There are many factors in our control that will maximize our ability to experience well-being while accepting, anticipating, and adapting to the realities of aging. The following seven domains (The 7 E's) can be a useful tool of exploring methods of increasing well-being in the context of aging. Note: There is more on the 7 E's in the self help section.
1. Environment (home and immediate environment).
Is my home environment safe? Is my home environment going to meet my anticipated future needs? If my home environment will benefit from change, will I modify my current residence or will I move? Can I access experts in this domain who can assist me in this process? How have others successfully explored this concern? If I desire to remain in my current home, what does a certified aging-in-place specialist (CAPS) say should be done to ensure my home is a safe place to reside?
2. Eating (dietary choices).
What are my current dietary habits and what are my ideal dietary habits? What changes would be useful? Are there experts in this domain who know my particular physiological needs and/or health challenges? How have others successfully explored this concern?
3. Exercise.
Exercise is a significant benefit in studies of "successful aging". Do I have an exercise regime approved by a medical provider? What is my walking regime? There are numerous books on "successful aging" or "aging well" . The majority of those books have a chapter on exercise, and the majority of those chapters discuss the importance of a foundational walking regime (approved by your medical provider). As humans, we have been walking a very long time!
What is my approved:
* Strength regime?
* Cardio regime?
* Balance regime?
* Flexibility regime?
What are my barriers to actively engaging in the domain of healthy and safe exercise?
Can my doctor/medical provider help me to begin engaging in a safe routine?
4. Engagement. Am I engaged in meaningful relationships and meaningful activities on a weekly basis? What activities are meaningful to me? What relationships are meaningful to me. Am I intentional regarding my participation with those people and in those activities?
5. Education. Am I learning and teaching?
* Learning: Am I engaged in education my regarding "successful aging"? What do successful aging experts say about the common factors of aging well? Do I know the various "fall risks"? Do I know the relationship of taking various medications and the risk of falling? Have I explored the many benefits of exercise for the aging adult? Do I understand the importance of sleep?
* Teaching: Am I passing on my knowledge/wisdom to others? Are my valuable life lessons being taught to the next generation?
6. End game planning. Given the reality of human mortality, have I made plans regarding living well (will I downsize? Assisted living options?
In-home care options? Have I made clear plans regarding what do do when I pass? Have I communicated and documented those plans? If I could not express my wishes verbally to medical personal, are my wishes documented in a way that medical personal traditionally accept (Advance Directives, POLST, Last Will, Medical Power of Attorney, Financial Power of Attorney, etc.)?
7. Effective emotional health. Do I focus on what is in my control? Do I work to change what can be changed? Do I actively engage with others that are helpful to my emotional health? Have I given thanks for my blessings?
Controllable Factors of Aging Well Found in Longitudinal Studies
There are many controllable factors found to maximize well-being in the context of successfully navigating the aging, and dying, process. This resource has utilized historic and modern data to assist the successful navigation of aging realities.
Three longitudinal studies of aging that focused on the controllable factors of aging well.
The Harvard/Grant Study: “Aging Well”
The Harvard/Grant study is made up of three cohorts: 268 Harvard males, 500 inner city males, and 90 “gifted” high-IQ women. These groups were studied for over 50 years and the controllable factors involved in aging well were identified. Aging well was determined through data derived from physical and psychosocial health measured both subjectively and objectively.
Six domains were measured:
- Objective physical disability - Physical exam every 5 yrs performed by study internist. (4 point scale - points 1-3 are not “disabling”. To have a “4” the study internist thought health was disabling and irreversible) .
- Subjective physical health - Based on iadl’s (15 point scale), what a member thought could be accomplished independently.
- Length of objective or subjective “undisabled” life.
- Objective Mental Health - 4 domains (work, love, play, interventions). One does not need to score well in all 4 domains.
- Objective Social Supports (ie family, social, religious)
- Subjective Life Satisfaction - 8 domains (min 2 needed “very satisfying”): “Over the last 20 years, how do you rate marriage, children, work, friendships, hobbies, community service, religion, recreation?”.
The Harvard study found that that those who were aging well (regarding the above six domains) had the majority of the following characteristics:
- Successfully progressed through Erikson’s stages of social maturation. Social maturation - “Successful navigation of developmental “tasks” (stages) means one has: become my own identity, shared reciprocal intimacy, engaged in fulfilling work, passed on knowledge to the next generation (caregiver), kept meaning (caretaker), and have done so with integrity (an understanding or meaning of my existence).
- Used mature, rather than immature, Freudian defense mechanisms in the domain of emotional maturation. “Mature defense mechanisms” are used in various life domains and allow one to adapt to difficult thoughts, emotions, and circumstances.
- An absence of alcohol abuse.
- Healthy weight/BMI (obesity vs not obese).
- Longtime marriage, or intimacy, or meaningful friendships (10 plus years).
- Engaged in exercise (min 2 days per week).
- Engaged in education as an adult. This factor alone was a strong predictor of successful aging and included any four year degree from any university.
- Either was not a smoker or stopped smoking before 50.
* The Adventist Religion and Health Study/Bio-psychosocial Religion and Health Study (ARHS/BRHS).
The ARHS/BRHS found 10 factors that contributed to Adventists psychosocial health. Four of those are religious factors, and six are mediating variables.
The four religious variables include:
- Affective: belief in a loving (vs. controlling) God, gratitude, forgiveness, eschatological attitude.
- Cognitive: positive religious coping, spiritual meaning.
- Behavioral: prayer, sabbath keeping, church attendance, organizational activities.
- Social engagement in the religious domain: participating in a sense of community, active engagement with religious supports.
The six mediating variables are:
- Healthy behaviors and personal lifestyle variables.
- Social integration and social support.
- Personal efficacy, self-esteem, including the belief that, “I am capable”.
- Positive (vs. negative) emotions (through methodologies such as reframing).
- Healthy beliefs including optimism (vs. pessimism).
- Coping resources and behaviors.
The MacArthur Study of Successful Aging
1,189 high functioning adults ages 70-79 were studied for 11 years. Eligibility to participate was determined through a six point screening process (physical and cognitive). The highest functioning third were asked to participate in the study. Successful aging was defined by three outcome domains. The study also identifies controllable factors within those three outcome domains. The domains are:
- Low risk of disease and disease-related disability,
- High cognitive and physical functioning, and
- Active engagement with life.
Each of those three outcome domains consist of sub-domains and many of those sub-domains are controllable.
The domain low risk of disease does refer to absence of disease, but also refers to addressing/avoiding the various risk factors for disease along with addressing the severity of any of those risk factors. For example, coronary heart disease and cancer (the number one and number two causes of death) have risk factors associated with these diseases. Many of those risk factors are controllable. Addressing those controllable risk factors are a crucial component of MacArthur’s model of successful aging.
The domain of high cognitive and physical functioning also contains subdomains. One sub-domain regarding high levels of cognitive and physical functioning focuses on moving beyond the functional potential for an activity. It involves actively engaging consistently in cognitive and physical activities. For example, high levels of physical functioning would mean that one doesn’t only have the potential to walk a mile, it means that one is actually walking a mile as a practice. Furthermore, as with disease risk, another sub-domain of high cognitive and physical functioning involves addressing any risk regarding one’s present and future cognitive and physical functioning levels. For example, some cognitive risk factors include drinking alcohol daily, poor sleep, social withdrawal, etc. In the cognitive domain, successful cognitive aging would involve adopting a lifestyle that minimizes those controllable risk factors and maximizes active cognitive engagement.
The third domain, active engagement with life, can take many forms, but the MacArthur Study found two domains of activity to be preferable regarding successful aging. Those two sub-domains are meaningful socialization and engagement in productive activities. Meaningful socialization/social engagement includes active exchange of information, emotional support, and giving and receiving various types of assistance to others, etc. Productive activities are activities that have a societal value (even if the activity is unpaid) such as volunteer work, teaching, etc. One important note regarding engagement with life is that sustained or consistent engagement in those activities is crucial.
Takeaways from the Modern Longitudinal Studies
Longitudinal studies identify many factors involved in aging well that are within one’s locus of control. Psychosocial functioning, behavioral health, maintaining a healthy lifestyle are factors leading to increased well being and do contain numerous aspects that are controllable.
Gleaning from those three longitudinal studies the following factors stand out:
- Importance of socialization, social support, and meaningful relationships.
- Active and consistent engagement in activities that have meaning/purpose.
- Mindset regarding self-efficacy ("I can maximize my well being").
- Methodologies of navigating life stages and conflict.
- Coping strategies, or problem solving strategies, that are solution focused.
- Maintaining one’s cognitive health through active engagement in various cognitive domains (education is one method that tends to bring significant benefit).
- Maintaining physical health (lifestyle, diet, exercise, etc.) which assists mental health.
What "Dying Well" Studies Tell Us
Various modern publications focused on dying well have highlighted that hospice medical directors, geriatricians, etc. have much agreement regarding the concept of dying well. That agreement includes: planning for the inevitable leads to better outcomes; one’s desires must be clearly articulated (preferably in a formal manner such as AD or DNR) to ensure that one’s desires are respected; terminally ill patients want to maximize meaningful engagement with loved ones; pain management; and location of passing (the majority of terminal patients would prefer to die at home or in a home-like environment).
There are many common factors present in literature, discussions, and advice regarding "Dying Well" including:
1. Remember your body is mortal.
2. Understand what you do want regarding your passing.
3. Understand what you do not want regarding your passing.
4. Document what you do, and do not, want regarding your passing and share those documents with trusted medical providers and family/friends.
5. Taken steps so that your loved ones can say, "UNDER THESE CIRCUMSTANCES, MY ______'S WISHES ARE..."
6. Addressing difficult questions such as , "IF I AM DIAGNOSED WITH A TERMINAL CONDITION AND I NEED ARTIFICIAL LIFE-SUSTAINING INTERVENTIONS PERMANENTLY, MY WISHES ARE____" , and documenting your wishes using your state specific forms in a manner that will be accepted by medical providers.
During the various Black Plague periods, death manuals (Ars Moriendi) were created.
The Ars Moriendi tradition explores six specific steps to achieve a good death. Those six steps are: understanding that death is not something to be afraid of; a warning of the temptations experienced prior to death; various spiritual teachings and interrogative questions to the dying person regarding those teachings; imitation of the dying Christ; the necessity for the sick, and caregivers, to prepare for the inevitable; and specific prayers to be said by caregivers at the time of death. The acceptance of human mortality, the hope of an afterlife, and living well (in accordance ecclesiastical teachings) in order to die well are overarching themes of this tradition.
Terminal Patient Desires
The data regarding terminal clients' desires contain significant commonalities regarding “dying well”. Those desires include pain management, autonomy of decision making, and continued engagement in meaningful relationships. Exploring those desires regarding dying well did elucidate an inescapable dichotomy: though the majority of terminal patients desire extensive pain management, personal autonomy, etc., many have not taken basic steps (Advance Directives, MPOA, POLST, exploring use of a DNR, etc.) that could lead to that desired outcome.
Aging in Place
"Aging in place" is a term used to describe methodologies older adults employ in order to safely remain in one's own home as one grows older. There are various resources and professionals who assist with this.
AGING IN PLACE RESOURCES
Aging in Place, staying in one's home safely as one ages, is a goal that various organizations assist with.
Below is a list of some of those organizations
Aging In Place. org
Habitat for Humanity's Aging in Place webpage
https://www.habitat.org/our-work/aging-in-place
The National Aging in Place Council's website
https://ageinplace.org/resources
The National Institute on Aging's Aging-in-Place page
https://www.nia.nih.gov/health/aging-place/aging-place-growing-older-home
The National Council of Aging's Aging in place website
https://www.ncoa.org/aging-in-place/
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