Late life is commonly a period of transitions (eg, retirement, relocation) and adjustment to losses.
Retirement is often the first major transition faced by older adults. Its effects on physical and mental health differ from person to person, depending on attitude toward and reason for retiring. About one third of retirees have difficulty adjusting to certain aspects of retirement, such as reduced income and altered social role and entitlements. Some people choose to retire, having looked forward to quitting work; others are forced to retire (eg, because of health problems or job loss). Appropriate preparation for retirement and counseling for retirees and families who experience difficulties may help.
Relocation may occur several times during old age—eg, to retirement housing with desirable amenities, to smaller quarters to reduce the burden of upkeep, to the homes of siblings or adult children, or to a residential care facility. Physical and mental status are significant predictors of relocation adjustment, as is thoughtful and adequate preparation. People who respond poorly to relocation are more likely to be living alone, socially isolated, poor, and depressed. Men respond less well than women.
The less control people perceive they have over the move and the less predictable the new environment seems, the greater the stress of relocation. People should become acquainted with the new setting well in advance. For the cognitively impaired, a move away from familiar surroundings may exacerbate functional dependence and disruptive behavior. Because of financial, social, and other complications, some older adults feel they must remain in problematic homes or neighborhoods despite their desire to relocate. Social workers can help such people assess their options for relocation or home modification.
Bereavement affects many aspects of an older person’s life. For example, social interaction and companionship decrease, and social status may change. The death of a spouse affects men and women differently. In the 2 years after death of a wife, the mortality rate in men tends to increase, especially if the wife’s death was unexpected. For women who lose a husband, data are less clear but generally do not indicate an increased mortality rate.
With bereavement, some sleep disturbance and anxiety are normal; these effects usually resolve in months without drug treatment. In contrast, prolonged, pathologic grief is characterized by the following:
Symptoms that are typical of a major depressive episode and that last > 2 months
Feelings of guilt about things not directly related to the loss
Thoughts of death unrelated to survivorship
Morbid preoccupation with worthlessness
Hallucinations other than hearing and seeing the decedent
Caregivers and health care practitioners should look for such symptoms and be aware that bereaved patients are at high risk of suicide and declining health status. Older adults comprise 13% of the population but account for 20% of all suicides, and the rate of suicide among older men is 5.25 times higher than among older women. Older adults often do not give warnings about suicide and seldom seek mental health treatment. Physicians are less likely to offer treatment for depression to older patients than to younger patients. Although older adults attempt suicide less often than those in other age groups, they have a much higher completion rate due to high likelihood of using firearms in the attempt (71.3% of completed suicides among older adults) as well as more health problems and frailty, avoiding interventions, and lower likelihood of living with others who might detect and respond to suicide attempts. Thus, the risk of suicide completion among older adults with suicidal ideation is very high.
Timely screening for depression and suicidal ideation is essential. Counseling and supportive services (eg, support groups for widows) may facilitate difficult transitions. Short-term use of anxiolytic drugs can help patients with excessive anxiety, and antidepressant therapies can reduce the intensity of depressive symptoms. However, excessive or prolonged use should be avoided because it may interfere with the process of grieving and adjustment. Prolonged, pathologic grief usually requires psychiatric evaluation and treatment.