Myth #17 Older people are hypochondriacs

What a negative thing to say about someone! Even the American Psychiatric Association has noticed, and it has eliminated hypochondriasis as a psychiatric diagnosis. In the most recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) the American Psychiatric Association admits that the term hypochondriasis is “pejorative and not conducive to an effective therapeutic relationship” (American Psychiatric Association, 2013, p. 11). Most people previously diagnosed with hypochondriasis would now receive a diagnosis of “somatic symptom disorder.” These folks would have physical symptoms and also abnormal thoughts, feelings, and behaviors; they may or may not have a diagnosed medical disorder. There is also “illness anxiety disorder.” In DSM-5, this diagnosis is for people with high health anxiety but without specific physical symptoms. Nevertheless, considerable research up until now has used the terms hypochondriac and hypochondriasis. Therefore, in our discussion of the myth we too will use these terms.

Why might the myth that older adults are hypochondriacs be so pervasive? First, there is little doubt that entry into older adulthood brings an increase in chronic diseases, some of which may be accompanied by pain. An excellent example is osteoarthritis, a degenerative joint disease that most commonly affects weight-bearing joints (e.g., knees, hips, and spine but also fingers, wrists, elbows, and neck), which can cause pain with physical movement. Although rarely fatal in and of itself, mild cases of arthritis can cause stiffness and discomfort. Severe arthritis can have a major impact on quality of life and sometimes even leads to a loss of independence. So if an older person voices a physical complaint (or two or three), is it more likely that he or she is a hypochondriac or that he or she is really afflicted with a painful condition that has not been properly diagnosed?

Not only are older people more likely than younger people to suffer from real health problems, but also it is realistic for older adults to be more concerned about their health when something seems to be not quite right. So are some older adults misinterpreting symptoms that could just be the result of normal aging and then fearing the worst? According to Stein (2003), concern with physical symptoms can be an adaptive strategy older adults use to cope with their changing health; visits to medical providers reduce their anxiety because doing so assures them that they are being proactive in attempting to maintain their health. Many older adults have witnessed friends' illnesses. It is a matter of good judgment, then, for them to be watchful over their own symptoms and to check up on minor complaints that may develop into major illnesses. Rather than being a sign of hypochondriasis, going to the doctor with a new symptom could be a way for older adults to gain a sense of control over a troubling change from their previous physical hardiness.

As with all age groups, older adults vary in their pain thresholds, and it is usually the level of discomfort that triggers visits to health-care providers. Thus, it is important to take into account how people perceive, interpret, and report their symptoms. One person (at any age) may be the type to pass out before calling an ambulance. Another may go to the doctor with a stubbed toe. It's not fair to give the second individual a psychiatric label and assume that the toe is not broken. People vary in their sensitivity to pain, and such individual differences are likely to persist throughout life.

The view that individual differences are stable over time seems to be the hallmark of personality itself. McCrae and Costa's (1997) Five-Factor Model (FFM) is a highly influential framework within which to consider personality in general as well as a useful perspective from which to view several myths about personality in the older years. Initially, FFM, which was based on findings from the Baltimore Longitudinal Study, proposed a personality structure consisting of five dimensions, or factors: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness (NEO-AC). Individual personalities fall somewhere along each dimension, or factor. Table 3.1 shows the five personality factors as well as the traits typical of a person who scores high on each.

McCrae, Costa, and their colleagues have gathered evidence that the FFM personality model can be applied not only in the United States but in many other countries as well (McCrae, 2002). They demonstrated that the five-factor structure holds true for individuals in countries such as Germany, Italy, Portugal, Croatia, South Korea, Estonia, Russia, Japan, Spain, Britain, Turkey, and the Czech Republic. Not only do these factors describe residents of various countries, but also they seem to apply to adults of various ages and stages of life. We will revisit the FFM in several of the myths that follow. However, the factor most relevant to hypochondriasis is neuroticism (N) – individuals high on the N factor tend to be high in traits such as anxiety, depression, hostility, self-consciousness, impulsiveness, and vulnerability. They generally show various signs of emotional distress, one of which may be manifested in somatic complaints. With regard to the myth that older people are hypochondriacs, the findings of longitudinal research indicate that where an individual stands on each FFM factor does not change significantly over the years, particularly after middle age (Roberts & DelVecchio, 2000). This means that individuals high on the neuroticism factor earlier in life tend to maintain the same relative position over their adult lifespan. If a person shows signs of hypochondriasis in older adulthood, this will most likely be so only to the extent that he or she always did – not more so with age – although the specific nature of that individual's complaints may vary over time. According to the FFM, neuroticism tends to remain stable across the adult lifespan. Thus, the idea that hypochondriasis is especially prevalent in the older adult age group is just plain inaccurate; rather, unfounded complaints, or the over-reporting of medical symptoms, are probably nothing new even for an 85-year-old person with hypochondriasis.

Research on prevalence rates of hypochondriasis bears this out. For example, in a study of general medical outpatients in a Boston hospital, 4.2% to 6.3% were estimated to warrant a diagnosis of hypochondriasis, but the rate did not differ by age (over 65 vs. under 65) or sex (Barsky, Wyshak, Klerman, & Latham, 1990). Furthermore, other studies indicate that older people are no more likely than the young to suffer from hypochondriasis (e.g., Barsky, Frank, Cleary, Wyshak, & Klerman, 1991; Boston & Merrick, 2010; McCrae, 2002).

Costa and McCrae (1985) published an important article on the subject of hypochondriasis specifically, entitled “Hypochondriasis, Neuroticism, and Aging.” They discuss the “difficulties in conceptualizing and assessing both subjective perceptions of health and objective medical conditions” and also how “preconceptions and stereotypes can exert undue influence in so ambiguous an area” (p. 26). These investigators compare three models that describe the relationship between somatic complaints and medical conditions. The first and simplest model, naïve realism, represents the view we generally hold about ourselves, but possibly about other people as well: we take people's medical complaints at face value; that is, we believe that someone with symptoms has a physical illness – the greater the number of symptoms, the more dire the illness.

A second model, psychiatric-categorical, refers to a scenario in which a person lists so many symptoms that anyone would find these complaints unbelievable. Such individuals may indeed be suffering from hypochondriasis: they believe, probably incorrectly, that they are physically ill. For these individuals, symptom self-reports may not be trustworthy, but a medical professional needs to decide if there is physical and/or mental illness. After all, a hypochondriac actually can have a physical disease as well. (Obviously, this fact is inconvenient for relatives and for health-care providers.)

According to a third and more sophisticated model, dimension of somatic concern, there are “consistent and enduring individual differences in the perception, interpretation, and reporting of bodily symptoms” (Costa & McCrae, 1985, p. 20). Thus, each individual's self-reported symptoms must be evaluated in light of his or her characteristic style of reporting, which may be anywhere on a continuum from underreporting to overreporting.

Clearly, it is important that health-care professionals be able to tell the difference between actual illness and complaints that are unfounded. It might contribute to family harmony if relatives could do so as well. Unfortunately, it is often difficult to know for sure whether an older relative is really in pain or not. So let's say that your Aunt Tillie complains that this hurts and that hurts, or that something just doesn't feel right in her chest, or that her back aches when she sits but not when she stands. For starters, ask yourself whether she was always a little bit over the top about medical issues. If not, then do not assume late-onset hypochondriasis; instead, assume that it's time for her to see the family doctor.

Finally, let's remember that some people face new symptoms with denial rather than hypervigilance. For example, if older adults fear that their cognitive symptoms are related to dementia, they may prefer to avoid getting a diagnosis – even when a diagnosis might mean that they have a condition less dire than they feared, or an illness that would respond positively to medical and/or psychological intervention.

In sum, the preponderance of the evidence does not support the assumption that people are more likely to suffer from hypochondriasis when they are older. Of course, some older adults do complain a lot, but it is likely that that these are the very same people who complained a lot when they were younger. A blanket statement that older adults are hypochondriacs is, unambiguously, a myth. By the way, an important consideration is this: if older people actually do have more physical symptoms to complain about, yet do not complain any more than younger people do, perhaps they are behaving in a way that is actually the opposite of hypochondriasis!

Myth #18 Older people are stingy

“Old people are stingy!” There is little doubt that we have all heard a comment like this at some time or other. It seems that stinginess is an entrenched myth that many people attach to aging.

First, let's take a moment to consider the meaning of the word “stingy.” Stingy can apply to many things, but most commonly it refers to money. On the most basic level, it suggests giving or spending money reluctantly and/or being overly careful in money matters. Synonyms for stingy include parsimonious, penny-pinching, and frugal. However, “stingy” has connotations beyond the idea of special care when it comes to spending money, and these are mostly negative. Stingy implies an absence of generosity and an inclination to be grudging, petty, and annoyingly cautious in money matters. It also suggests a tendency to be greedy and to hoard wealth for its own sake. In short, referring to someone as stingy is hardly complimentary.

We've probably all heard the “greedy geezer” stories that come our way every so often. Sometimes these stories are about older people who vote against the tax increases needed to fund schools or libraries or to improve roads. How could older people have so little concern for children or for the larger community? Or maybe the stories are about older adults skimping on tips in restaurants. How could older adults not care about a wonderful, deserving wait staff forced to work for the minimum wage or less if it weren't for the gratuities diners are expected, though not strictly required, to pay?

An extreme example of what might be viewed as stinginess was featured in an episode of the popular television comedy show Seinfeld, in which Jerry spies his old Uncle Leo shoplifting in the local bookstore. This episode has regular reruns and rarely fails to elicit a chuckle from viewers. In actuality, shoplifting is not funny, so why do we find this episode so humorous? We know from other Seinfeld episodes that Uncle Leo is not a wealthy man, but neither is he poverty-stricken to the extent he would be unable to pay for the books he so stealthily appropriates. So should we consider Uncle Leo to be a “greedy geezer”? In other shoplifting scenarios, older adults steal hearing-aid batteries from pharmacies or stash raw steaks under their clothing in grocery stores. Some people make allowances for older shoplifters that stem from sympathy (see Cuddy & Fiske, 2002), whereas others believe that older adults mean to pay for items but are simply absentminded and forget to do so (see Erber, Szuchman, & Prager, 2001). Even so, many people have nothing but scorn for those who behave this way, and reports of older adults shoplifting simply fuels the negative stereotypes they already hold for this age group.

The reality is that shoplifting is not confined to older adulthood; according to the National Association for Shoplifting Prevention (n.d.), an estimated 25% of shoplifters are teenagers. Furthermore, many adult shoplifters started down this path much earlier in life. One of the longest criminal shoplifting careers ever reported was that of an 83-year-old woman who began shoplifting at the age of 6, swiping small gifts just to get her mother's attention and affection. She continued to shoplift for decades while raising a family of five and working as a nurse. She did not have a financial need to shoplift; in fact, she often felt guilty afterward and returned the items to the stores from which they had been taken. The happy ending is that, at the age of 83, she was finally able to kick the habit with the help of psychotherapy and anti-anxiety medication (Adler, 2002, February 25).

Widrick and Raskin (2010) asked people to choose between generous and stingy to describe a number of different identities (e.g., lawyer, homeless person, nurse, senior citizen, elderly person, retired person, and grandparent). Not surprisingly, more people chose stingy than generous for “senior citizen” and “elderly person.” It is possible that “senior citizen” is associated with marketplace discounts (“senior discounts”), which trigger the “greedy geezer” stereotype about older adults. As for “elderly person,” Widrick and Raskin contend that in general, “negative connotations are associated with the term elderly” (p. 281). However, it is interesting to note that the negative adjective, stingy, was not attributed to “retired person” or to “grandparent,” both of whom were more likely to be labeled generous. Why the more positive label for these two? “Retired person” is associated with the workforce – even though that association has actually been terminated – which may trigger a positive stereotype. And one's own grandparent may not be perceived as a member of the stigmatized class. “Grandparent” is more personal than that. In a meta-analysis (a statistical summary of many research studies) on attitudes toward older adults, Kite, Stockdale, Whitley, and Johnson (2005) found that people are not likely to have negative perceptions about or responses to individual older adults for whom they have some prior information (e.g., health, employment and/or financial status, or personal familiarity). In contrast, negative bias is more probable when minimal information is available (Braithwaite, 1986).

If older adults are indeed more careful than are younger adults when it comes to spending money, another word that comes to mind is frugal, a term mentioned earlier. Frugal is sometimes considered a synonym for stingy, although usually without the added implication of greediness or lack of generosity. Frugal usually refers to someone who is thrifty, meaning that he or she generally avoids unnecessary expenditure of money. So you may think your grandmother and your great aunt Bessie are frugal, but at the same time you may consider older adults in general to be stingy.

It is conceivable that today's older adults are more frugal than today's young or middle-aged adults, so let's explore some possible explanations for why this could be so. A cohort is a group of individuals, or a generation, born at approximately the same time and likely to encounter similar societal influences throughout their development. The present-day cohort of older adults was raised by parents who came of age in the Great Depression, which began in 1929. Many were taught by their parents, either by word or deed, that being frugal is an important virtue. Not only were their parental role models careful about money, but credit cards were not readily available when today's older adults were in their adolescent, young adult, or even middle-aged years. These older adults were accustomed to paying in full for most purchases. There may have been payment plans for large purchases, but these were usually specific to the store the item came from. Some stores had layaway plans, but taking possession of an item from layaway was permitted only when the total payment (plus some type of fee) was paid. It is entirely possible that today's older adults have not aged into frugality; rather, they are just a frugal generation accustomed all along to paying for the majority of their purchases using cash or checks.

Hummert, Garstka, Shaner, and Strahm (1994) investigated traits that would be named most frequently by young, middle-aged, and older adults when they were asked to describe a “typical elderly adult.” “Worried about finances” was among the 20 most frequently mentioned traits. It was named by 7.5% of young adults and 5% of middle-aged adults, but by 35.5% of older adults. It seems that concern with money, which Hummert at al. categorized as a trait, had especially high priority among older adults themselves.

In addition to cohort influences, a tendency toward frugality could well be strengthened by older adults' realistic fear that they might outlive their savings. There is no dearth of publicity on the baby boom generation, with the oldest members now in their mid- to late 60s but others still in their 50s. Many are caught in a “generation squeeze” because they may be working to support aged parents as well as unemployed or underemployed adult children. They are well aware that life expectancy has increased noticeably during their own lifetime, and also that there have been years of notable inflation. Added to their concern are headlines driving home the fact that medical expenses are on an upward spiral and questioning whether older adults, or anyone for that matter, will be able to afford medical care. These constant reminders, combined with an awareness of their own economic circumstances, give older adults good reason to worry that the cost of health care is rising faster than they had anticipated. As for older adults who have already retired, a large number derive the bulk of their income from Social Security. Although originally intended only as an economic safety net, Social Security in the U.S. constitutes approximately 90% of the income received by 36% of those who are presently Social Security beneficiaries. Furthermore, in 2011, almost 3.6 million older adults, or approximately 8.7% of the older population, had incomes below poverty level. However, according to a Supplemental Poverty Measure (SPM) that takes into account regional variations in living costs and items such as out-of-pocket medical expenses, this figure rises to 15.1% (U.S. Department of Health and Human Services, Administration on Aging, Administration for Community Living, 2012).

Finally, it may be the case that older adults who are not well off, and even some who are, do have the benefit of senior discounts, early-bird specials, lower property taxes, and even reduced library fines. But let's not forget that many older adults who enjoy a bit more affluence are contributing to charity, cultural organizations, and religious groups. Keep in mind that approximately 25% of Americans aged 65 and older volunteer in places such as hospitals, schools, public gardens, zoos, and museums. And it is estimated that with the baby boomers entering their older adult years in large numbers, approximately 50% will contribute to their communities through some type of voluntary work (Morrow-Howell, 2006). In short, the older age group represents a considerable source of free labor that benefits many people and institutions in our society! Furthermore, older adults who are sufficiently well off, and perhaps some who are not so well off, contribute to the financial well-being of upcoming generations by paying for grandkids' orthodontia, school tuition, college expenses, and so on.

In sum, older adults who are seen as stingy might actually just be saving for a rainy day because they do not want to become a financial burden to their children now or in the future. Frugal means prudent, not wasteful. Unfortunately, for a stigmatized group, frugal may be translated to stingy (ungenerous) in many people's minds, so the myth that “older people are stingy” takes on a life of its own. It may well be the case that older people are more frugal than their children and grandchildren. Perhaps because of their frugality, they will not need to call upon adult children or grandchildren for financial support. Furthermore, they may even serve as a source of financial aid to the younger generation.

Myth #19 Older people are grouchy

The stereotype of the grouchy oldster is so blatant in our culture that even a movie entitled Grumpy Old Men doesn't sound politically incorrect. For the stereotypical grouchy old woman, one need look no further than the scores of Hallmark cards and related gift items (e.g., coffee mugs, t-shirts, and calendars) featuring Maxine. Hallmark calls her “The Queen of Crabbiness” (http://www.hallmark.com/maxine/). Even children don't escape exposure to the stereotype of grouchy older people – Robinson, Callister, Magoffin, and Moore (2007) surveyed 34 Disney animated films and found that 25% of the older characters were angry, grumpy, or stern.

By definition, a grouchy person tends to grumble and complain, and to be sulky and peevish. Remember the big five factors – NEO-AC? The “A” stands for agreeableness. According to McCrae (2002), agreeableness increases up to age 30 and then levels off or increases more slowly. It would seem that a person who is agreeable is not likely to be grouchy. Furthermore, older adults often focus on the sunny side of things. For example, when making decisions, they tend to pay more attention to positive information and less attention to negative information. In one study, Löckenhoff and Carstensen (2007) asked young and older adults to choose among descriptions of four different physicians and also four different health plans. Left to their own devices, older adults were more likely than younger adults to focus on the positive rather than the negative information about each physician and health plan prior to making a choice. Later on, older adults were able to recall more positive than negative information about the physician and health plan they had selected. The tendency to focus on positive information seems to be nullified only when older adults are specifically instructed to pay attention to all of the facts and details available to them.

A number of studies have investigated how young and older adults resolve dilemmas that are high in interpersonal emotional significance, such as conflicts with family members or friends. In these studies, older adults were less likely than younger adults to confront the interpersonal dilemma directly. Rather, they tended to deny a problem exists, or they either withdrew from an emotionally laden situation or passively accepted it. Birditt, Fingerman, and Almeida (2005) contend that when there is interpersonal conflict, older adults are more likely than younger adults to pick their battles and to refrain from arguing and yelling; they often prefer to wait until situations improve on their own. This same tendency seems to apply to marital relationships. Carstensen, Gottman, and Levenson (1995) videorecorded middle-aged and older married couples as they interacted during a 15-minute conversation about a problem that each couple claimed was causing continuing disagreement in their marriage. Later on, objective observers of these videorecordings rated older couples as showing less emotional affect with regard to verbal content, voice tone, facial expression, and gestures. In short, compared with middle-aged couples, older couples showed more emotional regulation, or greater control of their negative feelings (Gross et al., 1997).

Despite the losses we may incur as we grow older (e.g., deterioration in vision and hearing, and perhaps declining health), the emotional changes we experience tend to be positive. In summarizing several cross-sectional and longitudinal studies, Scheibe (2012) concludes that older adults tend to be happier, calmer, and more emotionally balanced than younger adults. Older adults achieve a higher level of affective well-being and often report feeing more positive, happy, and content, and less sad, angry, and anxious in their everyday lives.

Charles (2011) proposed the strength and vulnerability integration (SAVI) theory as a way to account for age-related gains (strengths) but also age-related losses (vulnerabilities) when it comes to dealing with stress. According to SAVI, as long as the level of stress is not too high and/or stress is not too chronic, older adults can use their lifetime of experience in dealing with difficult situations and their well-honed ability to regulate their emotional responses to overcome the negative effects of stress and thus maintain a high level of well-being. Nevertheless, SAVI concedes that experience and emotional regulation may be less effective when stress is too severe and/or too chronic. Scheibe (2012) points out that in very advanced old age, people may become less effective at emotional regulation, especially in unavoidable situations that are highly stressful.

Before we leave our discussion of the myth that older people are grouchy, let's not completely rule out the possibility that under some circumstances, they certainly can be. First, some health conditions (e.g., arthritis) that affect a greater number of older than younger people are associated with chronic pain. Also, older adults might suffer from diffuse pain that they cannot really explain. When this happens, it can seem to an observer that the person is just in a bad mood for no reason – grumpy.

Another possibility is that older adults in the early stages of dementia may still be capable of functioning with regard to many tasks of everyday life, but they may start to be forgetful. When this happens, it can be more protective of their self-esteem to blame others for missing items, forgotten mail, or for the misplaced keys or eyeglasses. If the person getting the blame does not recognize the onset of dementia, then it will likely appear that the older person is grouchy.

What if the perception of grouchiness comes from noticing that an older person doesn't laugh at your jokes? It's possible that older adults do experience some decline in the ability to appreciate jokes (Mak & Carpenter, 2007). Hearing loss could play a role. If part of the communication is missed, older adults with age-related hearing loss (termed presbycusis, which is characterized by missing some high-frequency speech sounds and also having difficulty in processing rapid speech) may seem grouchy when indeed they have simply missed out on the part of a “humorous” communication that makes it funny.

In sum, as a rule, older people are not grouchy unless some of the above circumstances apply, such as physical pain or cognitive or perceptual changes that may come with aging. Scheibe (2012) contends that, overall, older adults have a high level of emotional well-being, and “old age is likely to be a happy and balanced time, rather than a grouchy and distressed one” (p. 21).

Myth #20 Older adults prefer to be taken care of – they don't want a lot of responsibilities

Suppose we gave you a plant and said, “Here is a nice plant. Enjoy it. We'll take care of it for you.” Very pleasant, right? Or would it be better to say, “Here's a plant. You should probably water that thing if you want it to live!” Actually, in a classic real-world experiment conducted quite some time ago (Langer & Rodin, 1976), nursing home residents were given just this choice. Half of them were given the plant and instructed that they were responsible for taking care of it; the other half were given the plant without being told to care for it. After some period of time, residents who had been charged with caring for the plant and keeping it healthy were more cheerful and alert, participated more in activities, and reported a greater general sense of well-being than did those who simply sat by while the nursing home staff cared for the plant. The findings of this study certainly contradict the myth that having no responsibilities is ideal.

In yet another widely cited real-world study (Schulz, 1976), nursing home residents were visited by college students. One group of residents was allowed to control the frequency and duration of the college students' visits. A second group of residents got the same number of visits that lasted the same amount of time as the visits to the first group. However, this second group had no choice about either the frequency or the duration of the college students' visits. When Schulz controlled for the number, duration, and quality of these visits, he found that the positive impact the college students' visits had on the well-being of the residents was significantly higher when the residents were given control over their frequency and duration.

What about older adults who live in the community rather than in nursing homes or assisted living facilities? Gruenewald, Karlamangla, Greendale, Singer, and Seeman (2007) followed a sample of older adults (aged 70–79) from the MacArthur Study of Successful Aging over a seven-year period. At the outset, all participants were required to meet criteria that corresponded to the top third of their age group with regard to physical and cognitive functioning. Those who reported at the beginning of the seven-year period that they felt useful to others were, at end of the seven years, less likely to have become disabled and more likely to have survived than those who had said they did not feel useful to others.

Along the same vein, Thomas (2010) used data from a national sample of 689 older adults who participated in the Social Networks in Adult Life survey to determine whether it was better to give support or to receive support. Survey participants named people who were members of their social network; they also reported whether they had given and/or received emotional support (e.g., confiding, reassuring) and/or instrumental support (e.g., sick care) with respect to each one. Overall, older adults who gave more support than they received had a higher level of well-being than did older adults who received more support than they gave. Providing support seems to promote feelings of independence and usefulness, and being able to provide support to adult children and to friends has an especially positive effect. Interestingly, however, Thomas also found that receiving support is not necessarily negative for well-being – receiving support from a spouse or sibling was associated with positive feelings. In contrast, receiving support from adult children was not associated with positive feelings – presumably, it violates the natural order of expectations and takes away from older adults' feelings of independence. Overall, however, Thomas concluded that it is better for older adults to give than to receive.

By now you may be ready to concur that feeling useful and in control is a good thing, so let's delve into some views on how this may work. Investigators (Heckhausen & Schulz, 1995; Schulz & Heckhausen, 1996) differentiate between primary control processes and secondary control processes. Primary control processes refer to the actions and behaviors people use proactively to influence and shape a situation to fit their needs and desires. For example, if you live in a nursing home, the ability to choose the frequency and duration of college students' visits is a good example of exercising primary control. If your choices are honored, this is all to the good. Regardless of age, however, primary control processes cannot be applied in all situations. Furthermore, primary control processes are not uniformly successful when they are applied. When primary control processes are not possible, or when their success is unlikely, people often turn to secondary control processes, which depend more on internal resources. In general, secondary control processes involve accepting existing realities that cannot be changed and, in many instances, altering goals and expectations.

In the present context, the concepts of primary versus secondary control may be best illustrated using the example of the home environment. An 85-year-old woman who is determined to remain in her own home, living independently, may install a grab bar in her bathroom shower and strobe lights on her telephone in case she cannot hear it ring, both proactive efforts at primary control. She may otherwise continue living as she always has, doing her own housework and driving herself to the market to purchase groceries and other necessities. At some point, however, living with complete independence may become extremely difficult, and she may decide to redefine her conception of independence to mean just being able to continue residing in her home but perhaps not doing everything herself. Once she has revised her conception of independent living (a form of secondary control), she can hire someone to perform some of the tasks that she has always done herself but that have become too difficult, like cleaning the oven or changing the sheets. She can also engage someone to drive her to the grocery store and help her unpack the purchased items when they get home. Even though she is receiving some help, she is still able to view herself as independent.

Heckhausen (1997) proposed the optimization of primary and secondary control model to explain what people can do to maintain feelings of satisfaction and well-being. According to this model, age-related physical, cognitive, or social losses may reduce the likelihood that older adults will be successful in achieving all of their goals solely by exerting primary control. Therefore, older adults should be selective in their efforts at primary control. Being selective is adaptive because it allows older adults to direct their efforts at primary control in aspects of life in which the probability of success is highest. If they try to exert primary control in too many domains, some more difficult to control than others, they are likely to become frustrated and unfulfilled. Lachman (2006) concurs that older adults have the best chance of enjoying a high level of life satisfaction if they are adept at modifying what they hope to achieve in accordance with what is possible, and also if they select a small number of domains in which to exert primary control efforts.

In sum, research on control does not support the idea that older adults have a particularly strong desire or need for others to take care of them. For the frail elderly, even control over watering a plant in a nursing home promotes greater well-being than having someone else take responsibility for this task. When primary control fails or is not possible, secondary control is still a good thing. Furthermore, older people are more satisfied if they can provide support for someone else, rather than receive support and never reciprocate. It is important for younger and middle-aged adults to learn this lesson. It is natural for many people to want to take care of the older adults in every aspect of their lives and to have no expectations that they can exert control in any domain whatsoever. In the long run, however, that attitude does not do older adults any favors.

Myth #21 Older people are introverted and prefer to spend time alone

The myth that older adults are introverted and prefer to spend time alone may have originated in the early 1960s. Around that time, investigators from the University of Chicago Committee on Human Development were conducting the Kansas City Study of Adult Life, a project involving interviews with community-living residents of this mid-western city who ranged from 40 to 70 years of age. Included in this study was the Thematic Apperception Test (TAT) – participants were shown photos of characters pictured in ambiguous social situations and were asked to tell stories about them. Individuals in their 40s tended to tell stories about characters who were energetic and eager to take risks in order to master the challenges of the outside world. In contrast, individuals in the older age groups told stories in which characters were less willing to deal with challenging situations and less eager to make emotional investments in other people. On tests like the TAT, the responses people make to ambiguous pictures may reflect something about themselves that they would not otherwise be willing or able to articulate. If so, these TAT findings suggested that as people move from their 40s to their 70s, they become more reflective and preoccupied with inner life, a tendency referred to as increased interiority (Neugarten, Havinghurst, & Tobin, 1968). This view complemented that of the Swiss psychiatrist Carl Jung (1875–1961), who contended that in later adulthood the demands of the external world are reduced, and there is a shift from extraversion to introversion, which allows older adults to be more reflective (Stevens, 1994).

Based in part on the Kansas City Study TAT results, Cumming and Henry (1961) introduced disengagement theory. The main tenet of this theory is that as people grow older, they withdraw from society. At the same time, society withdraws from older adults, expecting that they will step aside to make room for the younger generation. Thus, older adults meet with societal approval when they take a back seat, and older adults who comply with this expectation end up with a high level of life satisfaction (Passuth & Bengston, 1988). Disengagement theory created quite a stir among gerontological investigators – it triggered a controversy regarding whether older adults are happier when they remain engaged in social activity (which had been assumed previously) or whether they would prefer to disengage from social activity.

Are older people happiest when they stay active socially, or would they prefer to withdraw from social engagement and spend time alone? Further inspection of the other tests that the Kansas City Study participants completed regarding both activity level and degree of life satisfaction revealed no single pattern associated with happiness. Some individuals reported being happy as well as active and involved, whereas others – a smaller proportion – reported being happy but with only a low level of involvement. In short, what makes one older adult happy may not work for another. It most likely depends on the personality traits of the individual.

Let's revisit McCrae and Costa's (1997) Five-Factor Model, which we introduced in the discussion of Myth #17, “Older people are hypochondriacs” (see Table 3.1). Recall that the FFM categorizes personality traits along five broad dimensions, or factors: neuroticism, extraversion, openness, agreeableness, and conscientiousness. The factor directly relevant to the present myth is E (extraversion); typically, individuals who score high on this factor (extraverts) are outgoing, sociable, talkative, and warm. In contrast, those who score low (introverts) are reserved, inhibited, taciturn, and sober.

When investigating age and personality, we can compare people of different ages at the same point in time (cross-sectional method) or we can follow the same people over time as they grow older (longitudinal method). When researchers compare people of different ages, the same personality factors and corresponding traits seem to emerge. Also, in studies that follow the same people over a period of years, the personality traits within each of the five factors tend to remain stable over time – people high on the traits that compose the extraversion factor when they were younger tend to remain so in their later years (McCrae & Costa, 1997). Likewise, those who scored low on extraversion when they were younger are not likely to become social butterflies in old age! In terms of extraversion, there is considerable stability across adult age groups.

But how would traits and behaviors associated with extraversion manifest themselves at various stages of life? For instance, a young extraverted adult may well enjoy a large network of friends with whom he or she socializes on a daily basis. In middle age, the same individual might be involved in many hours of work as well as countless hours of child-rearing, which leaves little time for socializing outside of co-workers or immediate family members. As an older adult, this person is likely to be retired from the paid workforce and less busy with childrearing, but there may be fewer opportunities for socializing. With retirement, the work-related social network is no longer available for most people. Also, children have usually left to form their own families and may live far away and visit only on occasion. Those who were married may now be widowed. Close friends may have passed away or relocated to be closer to family members or to reside in a more protected setting where help is available on the premises. People in late old age may have given up driving, and health problems could further restrict their mobility. In short, especially in the older years, most individuals experience a narrowing of their social network. This means there will probably be a reduction in the array of social opportunities that were readily available earlier in life.

Before we accept this rather dreary scenario at face value, let's look at some findings that could modify the picture of older adults as withdrawn and preferring to spend most of the time alone. Lang and Carstensen (1994) studied individuals between the ages of 70 and 104 and found that the older the person, the smaller the social network. But even into very late adulthood, most people still maintained a network of meaningful social/emotional ties. Lang, Staudinger, and Carstensen (1998) reported that even into the ninth decade of life, older adults who score relatively high on extraversion have larger social networks than age peers who score lower on extraversion. The absolute size of a social network may decline as people grow older, but it does not disappear. Rather, there is stability into late old age: compared with those who are low on extraversion (and probably always were), those who are relatively high on this factor tend to have larger social networks even if these networks are smaller in absolute size compared with their networks earlier in life. Extraverts do not become introverts in later life, although in an absolute sense perhaps they could be considered a little less extraverted.

Now let's consider age and social activity from the vantage point of socio-emotional selectivity theory (SST). SST is a contemporary lifespan model with direct relevance both to the nature of social activity and to the size of social networks (Carstensen, 1991, 1995; Carstensen, Gross, & Fung, 1997). According to SST, two main motives determine why people engage in social interactions: information-seeking and emotion regulation. The information-seeking motive – the need and desire to be exposed to something new – dominates early in life but begins to decline in importance prior to middle age. In contrast, emotion regulation (i.e., emotional fulfillment) takes a back seat to information-seeking early in life, but by middle age it becomes increasingly important. By late life, emotion regulation becomes the stronger motive for engaging in social interactions.

How does the motive for social interaction relate to the specific people with whom you prefer to socialize? If your main motive is information-seeking, you'll probably choose to make new acquaintances and participate in novel social interactions. Novel social interactions could end up adding an interesting new dimension to your social life. However, novel social interactions carry some risk, because people who are unfamiliar may turn out to be boring, annoying, or even insulting and threatening to your self-esteem. Alternatively, if your main motive for social interaction is emotion regulation, you might prefer to interact with people who are known to you and are not only enjoyable but also bolster your self-esteem. According to SST, the reduced social activity sometimes seen in old age is actually the result of an adaptive lifelong selection process: older adults prefer to spend time socializing with those already familiar to them, presumably individuals they can count on to make them feel good about themselves. Thus, important and emotionally fulfilling social relationships are maintained in older adulthood, but superficial relationships are filtered out. Even so, older adults high in extraversion are likely to maintain a larger network of meaningful social relationships into late old age, compared with those who are low in extraversion.

It may be the case that young adults with no pressing commitments are more likely than older adults to say they would prefer spending time with a new acquaintance. But when told to imagine they will be making a cross-country move in the near future, young adults tend to select a family member or close friend over a new acquaintance to socialize with in the little time they have in their old location (Fredrickson & Carstensen, 1990). The same finding was replicated in a study conducted in Hong Kong – young Asians told to imagine they would be emigrating in the near future were just as likely as older Asians to choose a familiar friend or family member with whom to socialize in the time remaining (Fung, Carstensen, & Lutz, 1999). In short, the social partner a person selects is influenced by perceived time left. Clearly, age and perceived time left are usually related – as we get older, we may feel that it is wiser to put our energy into social interactions that are familiar and known to give us pleasure, rather than taking a chance that socializing with a new acquaintance will be a worthwhile way of spending the time we have left.

In sum, the belief that older adults are introverted and prefer to spend time alone is clearly a myth. First, not all older adults are alike. Some are more outgoing and people-oriented than others and probably were that way even when they were younger. Even when they move into assisted living facilities, outgoing individuals will likely be the regular participants in scheduled social activities. Second, almost all older adults have a social network, albeit smaller in absolute size than it was earlier in their lives. A shrinking social network could be the result of losing relationships that older adults either cannot or do not want to replace. Nevertheless, they usually maintain close relationships with those who remain in their network.

Myth #22 Older adults have given up any hopes and dreams

Having no hopes and dreams for the future implies having no positive expectations and perhaps no vision for a future at all. But before we consider whether older adults have any hopes or dreams beyond the present, let's first look at what social scientists have to say about how people see themselves.

Self-concept is the term that social scientists use to refer to ideas that people have about themselves, or what people think they themselves are like. Although personality traits may remain relatively stable over time (McCrae & Costa, 1997), people can and do modify their self-concepts when they perceive that changes are occurring as they navigate the adult years. A self-concept is not just a general idea about what an individual thinks of himself or herself; rather, a self-concept has numerous components (schemas) that relate to domains as diverse as physical capability, appearance, cognitive/intellectual abilities, creative abilities, social roles, and social abilities. For example, a person can have a schema that he or she is very good at playing a musical instrument and good at making people laugh, but not very good at sports. Over the course of their adult years, individuals maintain an accurate picture of themselves by reassessing, and possibly revising, their schemas as well as reevaluating the relative importance, or priorities, of the schemas that make up their self-concept (Markus & Herzog, 1991).

It is safe to say that we have a variety of schemas when it comes to thinking about ourselves in the past (e.g., I was an excellent athlete when I was younger). We also have schemas about what we are like at the present time (e.g., I am a better athlete than most people my age). Furthermore, we have schemas about what we think we will be like in the future (e.g., I may not be as good at sports as I am now, but I will continue to be an active person as long as I can – so I'll probably be a better athlete than you). Future self-concepts have been termed possible selves (Cross & Markus, 1991), and they consist of schemas about what we hope we will be like (hoped-for selves) and perhaps also about what we are afraid of becoming (feared selves) in the future.

What about possible selves in late life? Do possible selves just disappear when the future seems foreshortened? Smith and Freund (2002) studied transcripts of interviews conducted over four years in which individuals aged 70 to 103 expressed their personal hopes and fears for the future. Even the oldest individuals showed evidence of dynamic possible selves, with schemas added and deleted over the four-year time period. However, in contrast to the possible selves of young adults, those of people over the age of 60 often have less to do with occupation and career and more to do with health, physical functioning, and leisure pursuits (Cross & Markus, 1991). For older adults, a hoped-for possible self might be the independent self and the healthy self; a feared possible self might be the dependent self or the unhealthy self.

Possible selves motivate individuals to do things that they think will bring them closer to their desired goal. But once again, possible selves include not only what people would like to become but also what they are afraid of becoming. For example, as a young or middle-aged adult, you might hope to be successful, rich, and loved. Therefore you will likely engage in activities and interactions that you think will improve your chances of achieving these goals. You might even have a specific hope, such as becoming a famous chef, in which case you will be motivated to work long hours perfecting your skills. Perhaps you will even be willing to spend the time and bear the expense of attending culinary school in order to realize this goal. With regard to feared possible selves, you might be afraid of becoming homeless, incompetent, or alone, in which case you are likely to engage in activities that will minimize these possibilities.

Older adults are no different from any other age group – they also envision possible selves. They too hope for success, but this hope is more likely to be associated with being healthy and maintaining independence or possibly continuing to enjoy a specific activity. Once again, hopes motivate behavior. For example, older adults who want to realize a hope of maintaining their independence by continuing to drive might take senior driving classes to maintain their driving skills (and lower insurance rates at the same time!). To realize the hope of maintaining physical mobility, they might take an exercise class. To realize the hope of maintaining cognitive skills and/or a social network, they might participate in playing bingo or chess. By working to realize these hopes, they will also be maximizing the chances that feared possible selves will be held at bay.

In sum, can we say that older people have no hopes or dreams for the future? Absolutely not! If they did not have hopes and dreams, how could they hold possible selves in their consciousness? Why would they engage in behaviors that they think will help them realize their hoped-for possible selves and minimize their feared possible selves? We cannot help but believe that older people are as conscious as anyone else that the future is coming, that they will be there to see it, and that they hope it will turn out well.

Myth #23 Older people are set in their ways

We frequently read or hear that older people are set in their ways. For example, on a website meant for people about to become caregivers for older adults, we found the following bit of advice for adult children who may be planning to move back in with their parents:

Will you be happy as “second fiddle” when it comes to managing the house? This will be their home, not yours. Many seniors become more stuck in their ways with every passing year. If moving an ottoman to prevent a fall will involve major warfare, what do you predict will happen when serious decisions need to be made? Will you have an equal voice? (http://www.eldercareteam.com/public/579.cfm)

Even advice for professionals reflects the existence this myth. According to the American Psychological Association (2013), Guidelines for Psychological Practice with Older Adults, those who deliver psychological services are reminded to be aware of the inaccuracy of negative stereotypes such as “older adults are inflexible and stubborn.” Apparently, the authors of this APA advice presume that even some professionals hold the stereotype of older people being set in their ways.

Let's begin by approaching this myth in the context of McCrae and Costa's (1987) Five-Factor Model, which was introduced in Myth #17, “Older people are hypochondriacs” (see Table 3.1). The factor directly relevant to the present myth is O, openness to experience. Being high on O would mean possessing traits such as being open to fantasy (e.g., having a vivid imagination), being open to aesthetics (e.g., appreciating art and beauty), being open to actions (i.e., willingness to try something new, being open to variety), and being open to ideas (e.g., valuing new knowledge, having curiosity, and having a broad range of interests). Recall that based on the FFM, we don't expect much change in these traits over an individual's lifespan; if so, older adults should be no less open to experience overall compared with younger adults.

Nevertheless, it is important to consider that beyond young adulthood there are probably fewer choices a person can make – there may be reduced opportunities to go down an entirely new path. Increased responsibilities, declining employment opportunities, and commitment to long-term relationships could well limit the array of options that are readily available. Thus, it follows that, as with extraversion, openness to experience may show some degree of absolute decline once individuals move beyond their younger years.

If “set in their ways” means being unwilling to try new things, there is certainly considerable evidence to the contrary for older adults. Huge numbers of older adults take advantage of extensive travel offerings, both national and international, which are sponsored by the AARP and other organizations. In addition, there is a high demand among the older population for educational programs sponsored by organizations such as Road Scholar. In 2010 alone, nearly 100,000 older adults participated in Road Scholar programs. That organization did a survey, and 90% of participants reported that they learned something new, 85% met interesting fellow participants, 45% were revitalized by their program experience, 25% stepped outside their comfort zone, 20% had their perspective on the world changed, and 15% fulfilled a lifelong dream (Elderhostel, 2010). Osher Lifelong Learning Institutes (OLLI) sponsor courses for older adults who, after years of long hours spent in the workplace, are grateful to finally have time to satisfy their curiosity for learning about new things and meeting new people.

When people think about older adults as “set in their ways,” they may have in mind a tendency for older adults to prefer to accomplish tasks using a method they are accustomed to. This could mean wanting things to be done “just so” around the house. It is possible that openness doesn't change in a basic sense, but perhaps life is a bit easier if routines are observed. After all, being open to new experience doesn't mean being open to flagrant disruption. When physical strength is waning, it might be a relief to get the house back in order after the grandchildren return home. After traveling to sightsee or visit, it might be a relief to come home and find one's favorite soap and shampoo where they belong. This is a matter of conserving one's resources, although it might look a bit like being resistant to change. Likewise, after preparing pot roast the same way for years, and noticing that everyone seems to love it, many people just might not be interested in trying a new recipe. After all, if it doesn't itch, why scratch? The same can be said for sticking with a favorite restaurant that offers good-quality food on a reliable basis. Especially if one is on a budget, the guarantee of a satisfying meal, as opposed to a disappointing one at a new eatery, could be particularly appealing. Furthermore, it is important to consider that older adults have likely been doing things a certain way for a much longer time than younger or even middle-aged adults have. Thus, switching to something new amounts to reversing a longer history of certain preferences or ways of doing things.

What about being easily persuaded? Strictly speaking, people who are set in their ways should be difficult to persuade. In contrast to what might be expected, Eaton, Visser, Krosnick, and Anand (2009) found that older adults are actually more open to persuasion than are middle-aged adults. This finding runs counter to the idea that older people are more set in their ways. Attitude strength is another aspect that could be viewed in light of being set in one's ways. Attitude strength is the extent to which an attitude is durable and impactful. Strong attitudes would seem to be a hallmark of individuals who are set in their ways. Even so, Eaton et al. found that attitudes seem to be strongest in middle age, as is resistance to attitude change. Eaton et al. suggest that social roles could be a partial explanation for this phenomenon; midlife is the time when people occupy powerful roles at work and in the community. Middle-agers make many of the decisions, and they are influential in defining social norms. As those who are in power, they are expected to be resolute, to hold firmly to their views. Eaton et al. point out that managers are more likely than subordinates to endorse having definite opinions. They would rather be stubborn than wishy-washy. As well, individuals like to see resoluteness demonstrated by individuals who are in power. People are encouraged to vote against politicians who flip-flop on issues: “He was for it until he was against it.”

Before leaving our discussion of the myth that older adults are set in their ways, we are obliged to consider the following reality: events that occur with increasing frequency in older adulthood often require a change in perspective and in many cases drastic life changes. Retirement from the workforce requires a revamping of daily life and possibly developing a new identity. Widowhood necessitates radical changes, especially after decades of living as half of a couple. The loss of good friends and relatives, either through death or through their or one's own relocation to a new community or new living arrangement, can also represent a dramatic change in an older adult's social network. Finally, health issues can necessitate major revisions in lifestyle (e.g., necessary changes in diet and changes in the ease of mobility). If they were so set in their ways, how would it be possible for older adults to deal with all the changes they face? As far being able to adapt to major life events that require unfamiliar ways of thinking and living, older adults are probably at the head of the class!

Myth #24 Growing old is depressing; no wonder older people are more depressed than younger people

Depression is a word that is used in more than one way. Lay people tend to use it freely to refer to everything ranging from having a mild case of the blues to harboring suicidal thoughts. In a study carried out in 26 countries (Chan et al., 2012), 3,323 participants rated old persons as being more depressed than any other age group. It seems clear that the perception people have that older adults are depressed is widespread.

When mental health professionals use the term, they distinguish between major depression and other depressive conditions. Major depression interferes with a person's ability to function normally. The person with this disorder can't work or study, sleep or eat as usual, or take pleasure in activities that were previously enjoyable. Most other depressive conditions are less severe, and though they can have a negative effect on quality of life, they are not disabling.

According to recent statistics from the Centers for Disease Control and Prevention (CDC, 2010), at a given moment in time, 4.1% of the U.S. population suffers from major depression and 5.1% from other depressive conditions. However, the statistics for the age 65+ group are lower than that, 2.1% and 4.8%, respectively. The group with the highest prevalence of any type of depression is aged 18 to 24, and for major depression it is those aged 45 to 64.

Mojtabai and Olfson (2004) examined the 12-month prevalence (rather than at a given moment) of major depression in nearly 1,000 community-dwelling adults who were aged 50 and over. These individuals were part of the U.S. Health and Retirement Study sponsored by the National Institute on Aging. Among these people, the rate of depression declined with age: 9.2% for ages 50 to 54, 7.7% for ages 55 to 59, 5.6% for ages 60 to 64, and 4.0% for 65+. The prevalence was somewhat higher than the CDC (2010) estimates, but that can be accounted for by the fact that over a period of one year there is more diagnosis of depression than there is at a single point during that year. Also, different diagnostic instruments can affect estimates of prevalence. Regardless, it appears that the diagnosis of major depression declines in community-living adults aged 50 and older.

We admit that it is surprising that older adults are not more depressed than they are. Their lives seem to have more depressing elements than those of younger people. Even researchers can be surprised: Mojtabai and Olfson (2004), who studied depression in that national sample we just mentioned, state that “in view of the personal losses, physical illnesses, and functional disabilities that commonly befall older age groups, it is surprising that major depression tends to decline rather than increase with advancing age” (p. 630). These authors also found that some correlates of major depression (factors that co-occur with depression but cannot be said to cause it) are similar across the age groups: depression affects predominantly women; people with less formal education; the unemployed; individuals who are separated, widowed, or divorced; and those with lower incomes.

So it seems that the myth that older people are more depressed than younger people is easily busted, at least for the community-dwelling older adults. But is this also the case for those who reside in assisted living facilities or nursing homes? Watson and colleagues (2006) studied 196 residents in 22 randomly selected large and small assisted living facilities in central Maryland. Residents' average age was 86, and most were over 80. Depression in this sample was pretty high: 24% were depressed and 8% were seriously depressed. Unfortunately, only 43% of the residents with depression were receiving treatment for it. People who were depressed were more likely to need help with activities of daily living (ADLs), such as bathing, dressing, and eating. It is not possible to say whether ADL dependency is a cause or a result of depression. These authors note that it has been argued that the two are mutually reinforcing.

What about nursing homes? Levin et al. (2007) studied documented depression in 921 nursing homes in Ohio (76,735 residents). In this group, 48% had an active diagnosis of depression. As in the assisted living sample just described, these folks were undertreated – 23% received no treatment at all. And the situation might even be worse than it sounds: disadvantaged nursing home residents, such as African Americans and those with physical and cognitive impairments, were less likely to be diagnosed, let alone treated. Thus, unless Ohio is especially depressing, nursing homes are where the depressed elderly are living.

In sum, the rate of depression in community-living older adults (who, by the way, are the majority in the older age group) is no higher and may even be lower than it is in younger adults. Thus, growing older is not, in and of itself, associated with depression. Unfortunately, however, those who reside in assisted living facilities and nursing homes are an exception. Perhaps the physical and cognitive disabilities of these older adults, which most likely lead them to reside in assisted living facilities and nursing homes in the first place, give them more reason to be depressed.

Myth #25 Older adults do not benefit significantly from therapy

When people think about psychotherapy, why don't they immediately envision older adults as typical clients? After all, older adults do have myriad issues that would seem to be amenable to therapy – loss, grief, adjustment to new living situations, adapting to physical changes, and so on. Yet there is a myth that older adults don't benefit from therapy. A belief that lurks behind this myth is that older adults are too rigid and set in their ways to be open to change. Yet, as described under Myth #23, “Older people are set in their ways,” there is little reason to assume that older adults are any less open to change than are other age groups. Another aspect of this myth is that mental health care is a limited resource, so therapy should be aimed at younger people, who will have more time to benefit from it.

But is mental health care a limited resource? In actuality, there is no longer any dearth of clinical psychologists or other mental health professionals, so resources are considerably less limited now than they were in the past. Careers in the mental health field are very popular, and many universities have initiated graduate programs or expanded those already offered. Each year, large numbers of students graduate with master's and doctoral degrees in clinical social work, counseling, and clinical psychology. These newly minted professionals are poised to enter the field, but they are vying for fewer jobs, especially those focusing on clients in younger age groups. At the same time, there is increasing realization that the American population is aging – and that mental health practitioners will of necessity have to adjust their views about who will require their services.

Mental health professionals, such as psychologists, counselors, and psychiatrists, all have the option to specialize in working with older people. There are workshops and other training programs that enable mental health professionals with limited experience in this area to gain competence in providing effective services for older adults. Contributing to the greater acceptance of older adults' need for mental health services and the willingness of professionals to treat the problems older adults face is the fact that Medicare, the primary source of health insurance for adults aged 65 and older, now reimburses providers for mental health services more extensively than it used to.

Professionals with expertise in working with older adults have been making efforts to broadcast the mental health needs of this age group (e.g., Cohen & Eisdorfer, 2011). According to Karel, Gatz, and Smyer (2012), approximately one in five adults aged 65 and older, including those who live in the community and in institutions such as nursing homes, meet the criteria for mental disorder, assuming both emotional dysfunction and cognitive impairment are included. It may surprise some people to learn that this figure (one in five) is about the same for younger adults. Although the proportion of the population meeting the criteria for mental disorders does not vary greatly with age, different disorders predominate at different points in the lifespan, with a higher rate of cognitive disorders such as dementia (which we described in Chapter 2) in the older group. Thus, therapists are likely to need specialized training if they work with the older population.

In all fairness, older adults may have received less attention than other age groups in the area of mental health not solely because of the attitudes of the mental health establishment. Older cohorts were not socialized to accept or seek psychotherapy. Unfortunately, some older adults have memories of people they once knew being “locked up” in “loony bins,” and they want no part of it. Many in the older generation assume that only people who are “crazy” need therapy, or that needing therapy is a sign of weakness or shame. For those in the very old group, it can feel unseemly to tell your problems to a stranger, and downright profligate to pay someone to listen.

Thanks to education and general exposure, individuals who are now moving into the older adult age range are more open to the benefits of therapy. In the not so distant future, the idea of “loony bins” (an image fostered so vividly by Jack Nicholson in the classic 1975 movie One Flew Over the Cuckoo's Nest) will no longer be the first thing people associate with mental health practitioners and therapy. Also, baby boomers will not think it is wasteful or embarrassing to tell their problems to a mental health professional rather than just confiding in friends.

A recent article published in the New York Times (Ellin, 2013, April 22) exemplifies the change in older adults' attitudes about therapy. The article describes an 83-year-old retired man who was not clinically depressed but felt he had “emotional issues,” which he wanted to explore with a therapist. For years he had suffered with migraine headaches, and he had experienced the sudden death of his first wife and the loss of a long-term business partnership. He had never considered seeking psychological help when he was younger. But now that he was in his later years, he was finding monthly visits with a professor of clinical psychiatry to be extremely beneficial in helping him improve his relationship with his current wife and with his adult children and grandchildren. He claimed his only regret was that he did not seek counseling earlier in life. This case highlights another reason it can be short-sighted to assume therapy is wasted on older adults – older adults are usually members of a family system. They may not live under the same roof with all their family members, but the state of their health (physical, cognitive, and emotional) does affect other family members. In short, it's never too late for therapy to have beneficial effects not only for someone in advanced old age but also for the larger number of people who are in that person's social network.

What are some problems older adults experience that may warrant treatment by mental health professionals? Older adults may be dealing with unresolved issues from the past, in which case reminiscence therapy could be an effective intervention (Bohlmeijer, Westerhof, & Emmerik-de Jong, 2008; Korte, Bohlmeijer, Westerhof, & Pot, 2011). Reminiscence therapy is an approach whereby older adults are encouraged to review and both re-evaluate and integrate facets of their earlier experiences. If properly conducted by a professionally trained therapist, this process may be helpful in alleviating feelings of depression and sadness not only in community-living older adults but also for nursing home residents (Haight, Michel, & Hendrix, 1998). In addition to unresolved issues from the past, older adults may also be experiencing immediate stressors such as health problems, spousal caregiving, financial problems, loss of loved ones, and having to adjust to new living arrangements. Under such circumstances, properly designed therapy can be highly effective in helping them deal with circumstances that might otherwise seem overwhelming.

In Myth #24 we discussed “Growing old is depressing; no wonder older people are more depressed than younger people.” As we explained there, although older adults do not suffer from depression at any higher rate than younger adults do, it is still the case that depression is probably the most common disorder affecting all adult age groups. Medications are available for this mood disorder, though these can have side effects, especially for older adults who suffer from other health issues and may not do well when additional items are added to an already full medicine chest. Psychotherapy, either alone or in conjunction with antidepressant medication, can be extremely beneficial (Knight, 2004). Even for severe depression, cognitive behavior therapy (CBT) can be highly effective for patients who cannot or do not want to take antidepressant medications but are dealing with stressful circumstances that could well be alleviated with therapy (see Cohen & Eisdorfer, 2011).

Cuijpers, van Straten, Smit, and Andersson (2009) investigated the effectiveness of psychotherapeutic intervention for young versus older adults who suffered from a mild to moderate level of depression. In searching the literature, they found 112 studies (20 of which focused on older adults) that compared people who received psychotherapy with people in a wait-list control group. Overall, psychotherapy was neither more nor less effective for the older adults than it was for younger adults. However, very few of the participants in any of these studies were over the age of 70, so Cuijpers et al. were unable to make a definitive statement about whether therapy would be equally effective for people in an even older age group.

We've heard a lot lately about the benefits of physical exercise for improving mood. Can't older adults just become more active instead of embarking on a costly and time-consuming course of therapy? Pinquart, Duberstein, and Lyness (2007) conducted a meta-analysis on the results of 57 studies that tested the effectiveness of therapy for older adults with depression. Overall, they found that CBT and other non-pharmacological treatments achieved better outcomes with regard to alleviating symptoms than did physical exercise alone, especially for individuals with milder forms of depression. They concluded that psychological interventions seem to be just as effective with people aged 60 to 80 as they are with younger adults.

Despite the growing evidence that psychotherapy can be helpful in treating depression, it is probably not used as often as it could be. Wei, Sambamoorthi, Olfson, Walkup, and Crystal (2005) analyzed Medicare claims from 1992 to 1999 that were filed for older adults diagnosed with depression. They found that the majority of the claims were for pharmacological antidepressants, but only 25% of the claims included psychotherapy. Also, as we noted in our discussion of Myth #24 above, people who reside in assisted living facilities and in nursing homes are vastly undertreated for depression (Levin et al., 2007; Watson et al., 2006).

Anxiety disorders and anxiety symptoms are another problem among older adults that accounts for a sizeable number of Medicare claims related to mental health. Sometimes, though not always, anxiety is comorbid with depression (that is, anxiety exists simultaneously with depression), but in some cases untreated anxiety can precede late-life depression (Ayers, Sorrell, Thorp, & Wetherell, 2007). According to Ayers et al., approximately 10% of community-living older adults suffer from diagnosable anxiety disorders, though the rate could be as high as 20% if those with anxiety symptoms but no specifically diagnosed anxiety disorder are counted. And this rate can escalate among older adults who have physical illnesses. Not only does anxiety have a negative impact on general feelings of well-being, but also it can have negative consequences for physical health (e.g., coronary heart disease) or even the ability to function in daily life. Furthermore, individuals suffering from anxiety often overuse medical services.

Unfortunately, it is not uncommon for anxiety to be treated solely with pharmacological interventions, but these can have a downside – there can be negative effects on cognitive functioning as well as physical functioning, such as causing falls. Thus, it is important to determine whether evidence-based psychological treatments could alleviate anxiety without such negative side effects and at the same time teach older adults skills they can employ on their own. There is less published research on late-life anxiety than there is on late-life depression, but Ayers et al. were able to locate 17 studies on the effectiveness of several types of psychological treatment for older adults with anxiety. The results of these studies indicated that relaxation training and CBT are especially helpful in treating anxiety.

Clearly, therapy for older adults must be tailored to their needs and capabilities. For example, for older adults still in the early stages of Alzheimer's disease, individual counseling can help with their anxiety, depression, and grief. Group therapy may also be beneficial – common problems and struggles can be shared in a discussion guided by a trained mental health professional. In the case of AD, however, older adults beyond the early stage may not be able to benefit from therapy that requires a great deal of cognitive processing (e.g., CBT). In such instances, behavioral therapy may be appropriate and also highly effective. With this type of therapy, attempts are made to manipulate environmental cues so that the individual receives positive reinforcement for engaging in desired behaviors such as feeding and toileting.

In sum, there is every reason to believe that making therapy available to the older adult population is a wise use of resources. Therapy can be effective in helping older adults to maximize their quality of life without the side effects of medications. And there are added benefits – the lives of family members and others in older adults' social network are often improved when older family members and friends are helped.