Effects of Life Transitions on Older Adults

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 live alone after their move and/or to be socially isolated, poor, and/or 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 a problematic home or neighborhood 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 use of medications. In contrast, grief that is prolonged and overwhelming is considered pathologic grief. It is characterized by the following:

• Symptoms that are typical of a major depressive episode and that last > 2 months

• Strong and frequent feelings of yearning for the deceased and urges to join the deceased in death

• Preoccupation with thoughts about the deceased or the circumstances or consequences of the death

• Intense feelings of loneliness, shock, emptiness, numbness, unfairness, anger, or meaninglessness

• Continuing to hear or see the deceased, or experiencing the pain that the deceased suffered

• Avoiding or reacting intensely to reminders or memories of the deceased

Caregivers and health care professionals should look for such symptoms and be aware that bereaved patients are at high risk of suicide and declining health status. Worldwide in 2017, death by suicide was documented in about 16 per 100,000 people age 50 through 69 and in about 27 per 100,000 people age ≥70 worldwide, compared with about 11 per 100,000 people age 15 through 49 (1).

In the United States in 2020, the rate of suicide was about 4 times higher in older men than in older women (2). Rates of death by suicide for older adults are thought to be greatly underestimated because deaths secondary to opioid overdose are not investigated and intentional deaths due to voluntarily stopping eating and drinking are not documented (2). 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 rate of death by suicide because they are more likely to use firearms in the attempt (in 71.3% of suicide deaths among older adults [2]), have more health problems, be frail, and avoid interventions, and less likely to live with other people who might detect and respond to suicide attempts. Thus, the risk of death by suicide among older adults with suicidal ideation is very high.

Timely screening for depression and suicidal ideation is essential when working with older adults. Clinicians should ask directly about suicide (eg, “I know that you have been experiencing difficulties and that you spend quite a bit of time alone. I wonder if there are times you are thinking about suicide.”). Evidence of suicidal ideation should lead to immediate suicide safety planning. Before the end of an interaction with suicidal older adults, clinicians should do the following:

• Enter the Suicide Prevention Lifeline or Crisis Text Line into their phone (1-800-273-8255 or text the word “Hello” to 741741) and show them how to find and use the information in their phone.

• Discuss guns and other means of suicide that they have access to.

• Show caring and sensitivity to the patient's situation (eg, "I know you have been through a lot. I care about you and want to see you again; your safety matters.")

• Connect caregivers and family members to educational resources.

• Develop a suicide safety plan that helps people recognize what leads to suicidal ideation and provides a list of coping strategies and support resources, including tablet and smartphone apps for patients to use.

Counseling and supportive services (eg, National Widowers Organization) may facilitate difficult transitions. Short-term use of anxiolytic medications 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.