Older people generally have fewer psychological problems than the rest of the population. They also have shown the least increase in anxiety and depression during the pandemic, despite being most vulnerable to COVID-19.
Resilience among the elderly has been attributed to their ability to better regulate emotions, higher acceptance of the ups and downs of life and wisdom that comes from having learned to see the big picture. But old age brings many challenges that can harm mental health.
Nancy Landrum, 76, from Murrieta, Calif., was always an active person.
Even after she lost her second husband to cancer, she kept engaged by providing relationship coaching, gardening, walking her dogs, hiking and doing house repairs. “But when my left knee started giving me more and more trouble, so that eventually I could hardly walk, I felt really discouraged and depressed,” Landrum said.
Many older people do suffer from considerable mental health problems. Among those living outside group settings, the rate of clinically significant depressive symptoms is 8 to 16% and anxiety disorders is 10 to 15%. The elderly living in nursing homes fare worse. Most older adults with depression and anxiety do not receive treatment for it.
Late life depression, in turn, has been found by researchers to increase self-neglect, cardiovascular problems, morbidity and risk of suicide. It also leads to worse social and cognitive functioning and compromised quality of life. And geriatric anxiety has been linked to heart problems and high blood pressure, among other problems.
Studies have illuminated some risk factors for geriatric depression and anxiety.
The elderly who deal with significant physical problems or cognitive decline, who are lonely, or who are grieving or dealing with multiple losses are more likely to experience psychological problems, especially depression. So are older people who have a lot of regret about a life not well-lived and who struggle to find meaning in their lives.
Many existential concerns come to the forefront of people’s minds as they near the end of their lives.
They confront questions such as, “Have I led a meaningful life?” “What has my role been in this world?” or “Am I leaving something behind?” How people perceive, explore, process, and talk about these questions can affect their emotional well-being.
Here are four approaches that psychologists like me find can facilitate these explorations and consequently bolster or improve mental health.
Engage in life review
It is a truism that the older people get, the more they reminisce about the events that took place in the past, sometimes very long ago. Psychologically, there is a purpose to looking back.
One of the most influential psychologists of the 20th century, Erik Erikson, considered the last stage of life to be focused on reviewing life, integrating positive and negative memories, and coming away with a coherent sense of a purposeful life. He postulated that people who had a particularly hard time with this process could end up feeling despair.
“In my work with older patients, we often engage with the question, ‘What has it all been about?’” said Herbert Rappaport, a clinical psychologist in the Philadelphia area and the author of “Marking Time.” “It is powerful to help them construct their life stories and to witness how this leads to a sense of peace and acceptance of whatever comes next.”
Research shows that life review improves mental health.
But depressed individuals have a hard time recalling positive events or reflecting back on their lives in ways that are not negative and self-critical. They also tend to remember things in a more general, abstract way, without much detail.
A strategy that counteracts this tendency is to intentionally remember positive situations and times in your life, recalling as much concrete and sensory information as possible.
“I worked with an older woman in my practice who was worried about her daughter’s well-being once she’s gone, and she questioned if she’s done anything to help the next generation, and now it was too late,” said Jason Holland, a clinical psychologist in Gallatin, Tenn. “Writing about and discussing these feelings and reviewing her life in totality helped her realize that it’s not all negative and that she’s leaving an important legacy with her grandkid.”
Autobiographical writing or recording, storytelling, scrapbooking, making art that honors your life, family genealogy, oral history interviews, arranging old photographs and creating legacy projects are all ways that promote life review.
Consider sources of meaning
Much of popular psychology and self-help urges us to discover or create meaning in life. “I fear that this just adds more pressure for people, that this can become another reason to feel guilty and ashamed — ‘I’ve failed because I haven’t found the meaning of my life,’” said psychologist Joel Vos, author of “Meaning in Life: An Evidence-Based Handbook for Practitioners.”
He suggested that people engage instead with the meaningful activities that they are already doing.
In my own psychology practice, I have found that, during the pandemic, many people have gained more clarity about what really matters in their lives. This often centers on going beyond oneself: connecting with others, with the past and future, with God or spiritual concepts or with nature. Another source of transcendence includes creating something in the world, from a tenderly tended garden to a painting to a nonprofit organization.
“It is never too late to orient yourself toward what’s meaningful. At 90 years old, I am a living example,” said Irvin Yalom, emeritus professor of psychiatry at Stanford University and the author of “Existential Psychotherapy” and “Staring at the Sun: Overcoming the Terror of Death.”
“I still see some patients, but just for a session each because my memory and energy are not what they used to be,” he said. “I connect with my children and play chess and talk with friends. Human connections make life worth living.”
A common misconception I hear is that acceptance equals passive resignation or giving up. It actually means the opposite; it’s an active process of facing the limitations that come with age, employing courage and wisdom.
“One of the best predictors of successful aging is the ability to disengage from unattainable goals,” said Carsten Wrosch, a psychology professor at Concordia University in Montreal. “While grit and perseverance might be most important for younger people, the elderly with the best psychological outcomes let go of things they can’t do any more and shift toward things they can still do that are purposeful.”
Older adults often struggle with physical or cognitive limitations, with a loss of freedom, and with the ability to control their lives. “Losing control can be the most demoralizing. I suggest adjusting your expectations and finding anything, however small, that you can control,” Holland said.
Dealing with the hardships commonly faced in old age can even be a catalyst for growth. Illness, grief or another negative change sometimes results in an important reckoning. “Significant transition or change can lead to an existential crisis, a chance to reevaluate life and to eventually align it more with your values,” Rappaport said.
Deal with death anxiety
With the coronavirus death toll of at least 750,000 in the United States, many people here have faced death more immediately and more acutely than at any point in recent history. And yet, many still find it hard to talk about death and dying, avoiding news that could trigger death anxiety.
“Numerous studies show that people who have high death anxiety suffer from psychological problems and disorders,” said Rachel Menzies, clinical psychology postdoctoral research fellow at the University of Sydney and a co-author of “Mortals: How the Fear of Death Shaped Human Society.” “In general, death anxiety subsides later in life. But for some elderly, it can be very high and contribute to their depression and anxiety.”
To confront death anxiety, Menzies suggests reading obituaries or watching shows that involve death and dying, especially if these had been previously avoided.
“Visit cemeteries, nursing homes, or funeral homes — anything that will bring you in contact with death,” she said. “That way death becomes a normal part of life.”
Another often evaded topic is a discussion of one’s will and end-of-life preferences and directives. Tackling this now could decrease your fear of death, and provide a sense of dignity and control. And it will be a gift to the ones you are leaving behind.
An exercise I often use with patients, derived from Acceptance and Commitment therapy, a type of therapy which helps people to live with purpose and to stop being hostages of their anxiety and depression — is to have someone imagine their funeral and write their own eulogy and tombstone inscription. This may sound ghoulish, but it not only tends to reduce death anxiety, but also crystallizes the values that are important to people and urges them to put them in place before it is too late.
“Life well lived is the best antidote to death anxiety,” Yalom said.
Jelena Kecmanovic is the founding director of the Arlington/DC Behavior Therapy Institute and an adjunct professor of psychology at Georgetown University.