This article was written and contributed as a community service by Dr. Erlene Rosowsky, a licensed psychologist who is a core faculty member of the Massachusetts School of Professional Psychology (MSPP) and an Assistant Clinical Professor in Psychology, Department of Psychiatry, Harvard Medical School.

Founded in 1974 and located in West Roxbury, MSPP is a graduate school of psychology that integrates rigorous academic instruction with extensive field education and close attention to professional development.  For further information, please visit www.mspp.edu.

There will be a Part II of this article tomorrow. 

Difficult (But Necessary) Conversations:

“When will I be old and what will my life be like when I am old?”  

For adults when they see their aging parents become more frail, and not able to live as independently as in the past, this raises complex questions about and situations we all will face.

In my practice as a psychologist specializing in the assessment and treatment of emotional problems at middle age through old age, I am quite familiar with these difficult topics and the conversations they promote for my patients and their families. 

Each one of us harbors an age to which we expect to live. This expectation plays an essential part in the script we hold for our older years. Hard questions push into consciousness:  How do I want to live if I can’t live independently? Who will help me when I need help? With whom do I feel I can have these difficult conversations?

The point is that, although not easy, difficult conversations are most useful if they take place before a crisis occurs.  It is generally useful that adults ask their elderly parents  “way ahead” how their parents would like to live if they could no longer live independently.

There are three general types of responses and no perfect solutions: 

1. a parent wants to remain at home (with hired help);
2. a parent wishes to live with a family member;
3. a parent desires to live in a community setting for older adults. 

All of these have implications for the entire family including financial implications.  Skilled nursing facilities can cost $80,000 per year or more.  Around the clock 24/7 home health aides cost about the same, to say nothing of skilled nursing care at home. Most older adults do well with little help, but as we progress through our 80’s and beyond, we can anticipate needing increased assistance with the activities of daily living.

Another “difficult” conversation relates to documents that address our wishes for “when the time comes.” They include in addition to a will covering one’s estate, also Living Wills, Health Care Proxy and funeral or memorial plans. 

“Mom and Dad, do you have these documents and in what location?” 

There can also be an ethical will. This is a document stating the values or principles the older adult wishes to impart to children and grandchildren.

Parent to Your Parents:

Adult children of aging parents often observe a process of change that feels as though they are becoming parents to their parents. No matter what condition our parents are in, they are always our parents. Even if dementia occurs, an aging parent will know well into the disease process that “this is my child.” It is so important to treat them with respect, to seek their advice and counsel, to reinforce their parental role, even when you may be helping them, for example, to get in and out of the bathtub.

Ah, Nostalgia...

Sometimes children may say of their aging parents, “it is so annoying, they repeat the same thing over and over again.” It is important, however, for people to recognize that the process of reminiscence is helpful to the older adult. A guiding principle throughout life is that “it is important to be me” and that challenge to perpetuate that “me-ness” becomes difficult as we lose the roles and relationships that sustain this, and even begin to not look like the image we hold of ourselves.   

Memory Changes in Older Age: What’s Normal; What’s Not

It’s OK to forget where you put your car keys. It’s not OK if you forget what car keys are for. The fact is that changes are normal especially in memory and attention as we get older and that these changes probably begin earlier than most people realize — certainly by age 50 and usually before. Ten percent of those older than 65 have clinically significant memory loss and nearly about 50 percent of those who are older than 85.

What happens as we get older is that everything becomes slower, including word-finding and retrieval. Name retrieval is a common (and annoying) problem.  While the information is “in there,” it becomes slower to retrieve it, and the harder you attempt to remember something, the more elusive it becomes. 

There are changes, however, that can suggest pathology, rather than normal aging.  These include:

• Extreme, repeated difficulty recalling names, objects places and times
• Trouble recognizing places and people that should be familiar
• Getting confused in places near one’s home
• Difficulty in maintaining one’s usual hygiene
• Observable general intellectual and linguistic decline
• Episodes of poor judgment
• Increased suspiciousness
• Depression and/or anxiety
• Delusions, false beliefs

We are coming to learn that mental health has less to do with genetics than we once thought, and that more than we had thought, is under the individual’s control. Here are a few protective factors:

• Health and fitness. Physical activity is not just good for the body, but is valuable to brain health.
• Education. The habit of continuing to learn and challenge one’s intellect and greater self-confidence.
• Personality variables. Attitude and personality matter in terms of sociability, flexibility, humor, self acceptance and age-acceptance.

To maintain these functions here are some suggestions: 

• Mental exercises. Valuable exercises include games, puzzles, reading and learning anything new.
• Adequate social interaction. One of the important findings of the MacArthur Foundation Study of Aging was the impressive contribution that social connectedness makes to the individual’s overall health.
• Self-efficacy and control. If you believe that what you do makes a difference in your life and that you have choices and that these choices matter, you are supporting good mental health.

Resources:  It is important that one appreciates the responsibility and complexity inherent to the aging process, whether as caregiver or older adult.

 The following resources can be helpful:

American Association for Retired Persons (AARP) – www.aarp.org

MSPP Brenner Center for Psychological Assessment and Testing:  For Older Adults – www.mspp.edu

National Association of Professional Geriatric Case Managers – www.caremanager.org

 National Council on Aging – www.ncoa.org ( excellent -local Councils on Aging)

National Institute on Aging – www.nia.nih.gov