Aging in America is a complex, ongoing process that reveals how American society feels towards old age. Through the examination of the way society interacts, perceives, and cares for old Americans, one can understand clearly what America’s true feelings and fears are towards not only the aging process, but death itself. The documentary “Living Old” (2006), dives into the lives of elderly people in order to illustrate not only what old age looks like, but what it intrinsically means to be an old person in a society that struggles to find a place for them (Navasky & O’Connor, 2006). The aging population in America is the fastest-growing population segment in the US and, “…over the next thirty years, the number of people over the age of sixty-five will actually double” (Navasky & O’Connor, 2006). Yet, there is a large gap in understanding the elderly, which leads to many elderly people being devalued and taken advantage of.
Problems within American institutions such as nursing homes continue to plague the “oldest old” (eighty-five and up). While at-home care is what many elderly people prefer, it is often difficult to manage with smaller families that are geographically spread out (Hillier & Barrow, 2015), Additionally, there is an insufficient number of doctors trained to care for old patients properly, meaning one of five old patients will lack the proper care they need (Navasky & O’Connor, 2006). In addition to these problems, old America faces other difficulties, such as loss of power, cultural devaluation, and chronic illnesses.
Women and minorities are especially vulnerable to this, women face intense devaluation much earlier than men. “Successful aging assumes a “feminine” aspect in the ideal that the good elderly woman be healthy, slim, discreetly sexy, and independent” (Calasanti & Slevin, 2006, p. 51), this directly stigmatizes aging as an ugly process for women, and marks them useless for society Women must also face the double standard of aging, that deems them as “old” far younger than men are, this can be seen in media as well as in the workplace (Calasanti & Slevin, 2006). Ethnic minorities face similar challenges, as representation and equal opportunity are cumulative disadvantages for ethnic groups that cost losses of wealth and power in old age (Hillier and Barrow, 2015).
The vast aging population is also growing older with longer life expectancies. Due to the biomedicalization of aging, living longer is a cultural expectation (Hillier & Barrow, 2015). While advanced medicine can help keep people alive, chronic illnesses like Dementia and Parkinson’s, as well as a loss of function, are seen increasingly in old populations (Navasky & O’Connor, 2006). Rather than dying younger from natural diseases, old people with chronic illness live in states of deterioration for longer amounts of time (Navasky & O’Connor, 2006). This is a problem many families face: the cost of stopping curative treatments for fewer years of chronic illness. Ultimately, this problem leads to the discussion of one’s own personal and cultural fears of death, as well as what rights elders have in the death process.
In order to answer these questions, this Critical Analysis will examine the contexts of aging seen in American society through multiple perspectives to understand the problems facing the oldest-old population. Through an examination of the Frontline documentary, “Living Old” (2006), the effects aging has on policy, caregiving, and family will be explored, as well as how special cases such as gender and ethnicity impact the aging process. The inevitability of death for elders will be discussed alongside other end of life issues in order to reconcile the clashes between fears of death and one’s own right to die, in relationship to family decisions about treatment and care.
Issues of the oldest old
The oldest-old population is projected to rise to 19 million by the year 2050, which means problems concerning the current care of the oldest-old will continue to persist (Hillier & Barrow, 2015). Elder activities fall into two categories: personal activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Personal activities of daily life are everyday tasks like bathing, dressing, and eating (Hillier & Barrow, 2015). Instrumental activities of daily living are more involved and include shopping, housework, and managing finances (Hillier & Barrow, 2015). While “less than half of the oldest-old…need some help in performing ADLs… about 60 percent need help with IADLs” (Hillier & Barrow, 2015, p. 303). To get this help, many elderly people turn to informal caregiving, or care that is from relationships that are within a person’s environment; this could be family, friends, or groups like garden clubs or churches (Hillier & Barrow, 2015). Informal caregiving is not professional; however, it is still incredibly expensive, “more than 44 million adult caregivers provide $375 billion worth of unpaid services annually, twice the amount…spent on nursing home and home care service combined” (Cohen & Eisdorfer p. 104). Families that decide to use informal care are at risk for depression, lower immune systems, and life disruptions in work and family (Cohen & Eisdorfer p.105). Elders can also suffer from weakened family support, as overtime, family dynamics and patterns have changed (Hillier & Barrow, 2015). Support for elders has decreased due to family demography, women’s changing societal roles, and differences in intergenerational relationships (Hillier & Barrow, 2015). Trends such as lower birthrates mean there are fewer children older parents can rely on for care (Hillier & Barrow, 2015). In the past, having a daughter meant guaranteed assistance for older parents; but, now as women are less resigned to gendered roles, the availability of women to be the prime caregivers is diminishing (Hillier & Barrow, 2015). Intergenerational norms are the behaviors that are expected of one generation to another (Hillier & Barrow, 2015). While intergenerational norms can be different depending on a family’s culture and values, they are universally changing (Hillier & Barrow, 2015). In the past, children relied on their parents for economic inheritance or property; as society has moved away from this system, children have moved further from their parents in search of education and school (Hillier & Barrow, 2015).
Some families opt for formal caregiving which is paid care provided by professionals and comes in a variety of settings such as hospitals or nursing homes. This segment of care is smaller, as only about eight percent of elderly people rely fully on formal care (Hillier & Barrow, 2015). Additionally, as stated by Doctor Jeffrey Farber in “Living Old”, there is a lack of professionals able to provide care. Farber explains that there are only fifty geriatric students at Mount Sinai, which is an extremely small number (Navasky & O’Connor, 2006). Some professionals look at paraprofessional caregivers to help lead the future of geriatric care; paraprofessionals are groups of trained health care workers with high turnover rates, however, they are not as permanent or specified as geriatric professionals and have “minimal training at best” (Hillier & Barrow, 2015, p. 320) that varies state by state.
Caregiving is not easy work for professionals or families. Caregivers distress is a term used to describe the negative feelings of role strain, burden, anxiety, depression, and stress that comes from providing care (Hillier & Barrow, 2015). There are many ways of coping, or responding to stressors from the demands of a current situation, all aimed at targeting the main problems caregivers face (Hillier & Barrow, 2015). One coping strategy is psychosocial interventions, which are various types of counseling for groups, individuals, or families (Hillier & Barrow, 2015). These can include specific support groups and problem-solving groups for caretakers and patients (Hillier & Barrow, 2015). Respite care is the second form of caregiver care and is designed to give short-term breaks to workers (Hillier & Barrow, 2015). One way to use respite care is to have the caregiver go on a vacation while the patient stays in a nursing home for a short period of time, like two weeks (Hillier & Barrow, 2015). It is important to note that coping and caregiver distress is varied, so programs that are able to use multiple approaches to solve these issues are currently the most effective (Hillier & Barrow, 2015).
The role of women and ethnic issues of the aged
Until recently, the study of minority and ethnic group aging was not a priority; this was a gross devaluation of ethnic and minority experiences, as “being old and a member of a minority group, or to be an old white woman, is to experience…the context of aging—in ways strikingly different than that experienced by older white males” (Hillier & Barrow, 2015, p. 349).
Ethnicity is comprised of three factors: “a culture and an internalized heritage not shared by outsiders…social status; and…the composition and function of support systems” (Hillier & Barrow, 2015, p. 350). Discrimination is not inherently a part of ethnicity; however, it plays a role in what constitutes a minority (Hillier & Barrow, 2015). Minorities are defined by characteristics: such as culture, physical appearance, or language, that have been used in a discriminatory way against them (Hillier & Barrow, 2015). This is why women are able to be classified as a minority group, despite not being an ethnic group, due to the “sexism that pervades U.S. society” (Hillier & Barrow, 2015, p. 351). This is contrary to people of German or Southern European ancestry who, due to a lack of discrimination based on their characteristics, are not considered minority groups in the United States despite being an ethnic group (Hillier & Barrow, 2015).
Older women are affected by many sexist issues conflated with ageist ideas that make being an aging woman very difficult. One of the main issues that exist for older women is the double standard of aging (Hillier & Barrow, 2015). The double standard of aging is the idea that women are devalued and considered older sooner than men; this plays into the extreme judgment aging female bodies are put under, which only perpetuates the idea that aging female bodies are unattractive (Calasanti & Slevin, 2006). Sexism and ageism affect women in other ways as well, as in professional settings they are harassed and underpaid, leading to more economic hardships (Hillier & Barrow, 2015). Women, on average, only make seventy-six cents to every dollar a man makes, and unmarried women are four times more likely to live in poverty than married persons (Hillier & Barrow, 2015). Women are more likely to stop working earlier than men, due to caregiving or family commitments, which means they miss out on retirement benefits (Hillier & Barrow, 2015). Widowed women are, “less likely than are men to remarry…This results in women being more likely than men to spend old age in poverty—in part because many have spent their lives at an economic disadvantage” (Hillier & Barrow, 2015, p. 353). Women who never marry at not only at a higher chance of living in poverty, as over 25% of women over sixty-five live under the poverty line, but they also face social stigmas of being seen as, “piteous, tragic, and lonely people with miserable lives” (Hillier & Barrow, 2015, p. 353).
There are many differences in aging by ethnic and racial groups, as discrimination deeply hurts and mistreats ethnic populations, especially in older age. The African American population is the largest ethnic minority group in for older populations in America (Hillier & Barrow, 2015). In 2007, this population was three million and this is projected to grow to ten million in 2050 (Hillier & Barrow, 2015). While economic security has improved for African Americans in the last three decades, the African American “underclass” is still incredibly disadvantaged and plagued by, “chronic welfare recipients, the unemployed, high school dropouts, and struggling single-parent families” (Hillier & Barrow, 2015, p. 359). While the African American middle class has grown, this has left behind many elders that still live in neighborhoods full of crime, violence, and subpar living conditions (Hillier & Barrow, 2015). The poverty rate for older African Americans in 2007 was 23%, this is due to life-long wage discrimination as, “families headed by black people aged 65 or older reported a median income of $32,025 in 2007…the comparable figure for all older households was $41,851” (Hillier & Barrow, 2015, p. 359) as well as higher rates of unemployment and mortality for African Americans. This means as a group African Americans are making less money and not living long enough to receive any benefits they may have earned during their lifetime (Hillier & Barrow, 2015).
The Hispanic population in the United States is one of the fastest-growing ethnic groups, which made it the largest minority in the United States (Hillier & Barrow, 2015). This high volume is reflected in the Hispanic elder population, in 2007 Hispanic elders made up 6.9% of the total old population (Hillier & Barrow, 2015). Hispanic elders are more likely to live with family, almost two times the rate of the rest of the population (Hillier & Barrow, 2015). This could be contributed to the value of La Familia seen in Hispanic homes it reflects the importance of helping and respecting the family and one’s elders; however, this strong reliance on family could mean Hispanic elders are less likely to use social services and other resources compared to non-Hispanics (Hillier & Barrow, 2015). Hispanic elders face fears of legal status and are, “…suspicious of governmental institutions and of service workers and researchers not of their culture,” (Hillier & Barrow, 2015, p. 366) meaning that they underutilize social services and isolate themselves more. A high number of Hispanic elders live in poverty, as they make less money on average and work in lower-level jobs with little to no benefits, like unskilled laborers and farm workers (Hillier & Barrow, 2015).
Of the 14.4 million population of Asian Americans and Pacific Islanders, 6% of these are elders (Hillier & Barrow, 2015). There has been a long history of discrimination against Asian communities within America, like the Chinese Exclusion Act of 1882, that created feelings of prejudice and mistrust among the Asian community, especially elder Asian people (Hillier & Barrow, 2015). Similar to Hispanic elders, this sense of mistrust leads to the underutilization of social services (Hillier & Barrow, 2015). Another problem faced by Asian communities is the strong sense of family obligation within Asian Culture, this is clearly demonstrated by the concept of filial piety (Hillier & Barrow, 2015). Filial Piety is, “a custom demanding that family members respect and care for elders,” (Hillier & Barrow, 2015, p. 369) this traditional approach can clash with younger generations who are more Americanized, creating large intergenerational differences between young and old Asian Americans (Hillier & Barrow, 2015).
Native American elders are one of the smallest ethnic minority groups in the United States, however, this does not make their struggle any smaller; in fact, Native American populations are “are possibly the most deprived of all ethnic groups in the United States” (Hillier & Barrow, 2015, p. 372). Unemployment rates are extremely high on reservations, and reservation housing is subpar (Hillier & Barrow, 2015). Unfortunately, there are more deep-rooted issues culturally that affect Native American populations. The systematic decimation of Native American culture has created many problems including poverty, alcoholism, drug abuse, and high suicide rates (Hillier & Barrow, 2015). Leaving reservations was common for younger generations during the 1950s and 1970s, which left elders alone and isolated with fewer benefits and services available for them on reservations (Hillier & Barrow, 2015).
Issues around the process of death and dying
The United States is a society that fears death. A death denying society is a society that is uncomfortable with accepting death, euphemisms like “passed away” is a popular example of this (Hillier & Barrow, 2015). This attitude towards death has made the subject incredibly sensitive and difficult to discuss in many American homes. When dealing with the process of dying, families and patients go through the stages of grief; which are denial and shock, anger, bargaining, depression, and acceptance (Hillier & Barrow, 2015). Contrary to most portrayals of these stages, they do not have to occur linearly; many people can jump back and forth between them, or even experience multiple stages at the same time (Hillier & Barrow, 2015). Hospice Care emerged in the mid to late 1970s in the United States and uses various systems to focus care on patients’ and families’ mental health by effectively using models of pain relief (Hillier & Barrow, 2015). Hospice can provide services in several settings including nursing homes and adult living facilities (Hillier & Barrow, 2015). Nursing homes especially have mixed reputations among seniors and their families, 60% of people that live past eighty-five will end up in a nursing home (Navasky & O’Connor, 2006). While some seniors see nursing homes as “waiting rooms” (Navasky & O’Connor, 2006) for death, other patients are able to adapt and benefit from socialization and group activities (Navasky & O’Connor, 2006). Patients’ rights are important when making not only decisions about care and living arrangements, but also in the process of dying. Medical ethics is the examination of key questions that help professionals make end of life decisions, such as “…at what point should the decision not to prolong life be made…and does an individual have the right to choose death when life could be extended in some fashion” (Hillier & Barrow, 2015, p. 395). The right to die lets a doctor ask a patient whether or not they want to live. Similar to rights to die, advance directives are instructions for how doctors should care for patients who are unable to make decisions for themselves, like if the patient is in a comatose state (Hillier & Barrow, 2015). One specific type of advance directive is a living will, this is a legal document that explains what treatment a patient would want in the case that they become terminally ill (Hillier & Barrow, 2015). In these cases, patients exercise their right of patient self-determination, the patient self-determination act (PSDA) allows patients the power to accept or reject medical care (Kelley, 1995). Suicide and assisted suicide take the idea of patient self-determination to a higher level. In cases of assisted suicide doctors lethally inject patients who have decided to end their lives (Hillier and Barrow, 2015). A large number of physicians support assisted suicide, around forty to fifty percent; however, assisted suicide is still seen as a “slippery slope” that is a step closer to forced euthanasia (Hillier & Barrow, 2015). Even without assistance, older adults are still committing suicide in disproportionate amounts, older Americans only make up 13% of America’s population, but they account for 20% of the suicide rate (Hillier & Barrow, 2015). When older relatives do eventually die, there is a long and often difficult process of bereavement families face. Bereavement is, “the experienced loss of someone important in our lives, and the adjustment to that loss” (Hillier & Barrow, 2015, p. 408) families typically feel grief and mourning for deceased family members and go through different death rituals such as funerals (Hillier & Barrow, 2015).
Summary and conclusions
The older population is growing, and so are the problems facing them. The oldest old face discrimination in many forms, including economic, social, and medical. The rise of the anti-aging industry, “reflect the dominant cultural discourse in the West that denigrates old age and dying” (Higss & Jones, 2009, p.216). This culture allows ageist views and policies to prevail in American society. Women and ethnic groups each have their own unique problems that, coupled with being old, make life harder for these groups; poverty, workplace discrimination, and sexual devaluation are some of the main problems these minorities face (Hillier & Barrow, 2015). The old populations also must learn to navigate their own process of death, while simultaneously dealing with their own grief and their family’s grief. There are many issues facing the dying process that are still being heavily debated in American society, and these decisions can greatly alter a person’s process and right to die.
There are, however, many advances taking place within gerontology designed to help alleviate the strain of the problems discussed. In “Living Old” Doctor Muller is one of the founders of the Mount Sinai visiting doctors program, this program has doctors make house calls to patients who are too frail to go to the doctor’s office (Navasky & O’Connor, 2006). The documentary also discusses how the level of care for homecare has become more complex, meaning family members are able to provide more care for elders and doctors can also do more for patients at home than they could before (Navasky & O’Connor, 2006). Many of the advances within the field of gerontology have to do with changing society’s attitude about the aged community and the process of aging itself. The idea of the “health span” is a way gerontologists are rethinking the “lifespan” (Leslie & Makela, 2008). The idea of the health span is essentially increasing the amount of time a person is considered healthy for longer, rather than just trying to increase the lifespan, or the number of years a person is alive (Leslie & Makela, 2008). The health span shifts focus from medical interventions to things like, “diet, exercise, weight control, and stress management along with a sense of meaning and purpose” (Leslie & Makela, 2008, p. 291). This ideology is reflected in the five key areas the AARP has begun to focus on: health, financial security, community, and making contributions (Leslie & Makela, 2008). Other organizations like Metlife have created the MindAlert program, which “awards grants to community-based programs that enhance mental vitality of older adults.” (Leslie & Makela, 2008, p. 295) Programs like these helps keep older community members involved and helping their communities, and by giving them a sense of recognition for outstanding achievement, the issue of elder neglect is lessened.
In “Living Old”, the issue of a crisis of care is addressed and subsequently analyzed. The United States is a mass geriatric society, and yet it is difficult for elder persons to find their voice in matters concerning their own health and way of life (Navasky & O’Connor, 2006). Many patients feel they are a burden to their family, or that they do not want to live without purpose (Navasky & O’Connor, 2006). “Living Old” serves as a way to inform people on the plights of elder people and to advocate for their recognition and rights. Activism and recognition are two areas that can help to resolve and shine a light on the issues within the elder community. The Older Americans Act (or OAA), ensure that state and local social services represent the needs of older Americans (Hillier & Barrow, 2015). Over the years the funding for the OAA has fluctuated, with its greatest defunding in the 1990’s (Hillier & Barrow, 2015). Activism in elderly causes, however, is alive and necessary to see a change for the old population. Those interested in helping the old population and its causes participate in activism “by serving on boards of trustees, advisory councils, and committees in all kinds of social service agencies.” (Hillier & Barrow, 2015, p. 427). Pushes for legal responses to discrimination are important as well, class-action lawsuits against discriminatory institutions and practices can be one way to better the elder population’s standard of living, as well as help to enact policy around controversial issues of ethics: such as informed consent to treatment and assisted suicide (Hillier & Barrow, 2015). Elder Americans can also exercise their right to vote by supporting officials and representatives that care about issues such as Medicare, the OAA, and patient’s rights to die (Hillier & Barrow, 2015). As with most any issues plaguing society, education and advocacy are essential to making a difference to those marginalized. By teaching younger generations about the prevalent ageism in our society, they can be sure to help enact policy and programs that will ultimately help themselves in the long run, while also preventing the “crisis of care” described in the documentary (Navasky & O’Connor, 2006). By erasing the stigma around aging and rejecting our death denying society, we can learn to understand the aging process and not age gracefully, but age in a healthy, happy, and more hopeful way.
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Rachel Loring 