PSYCHOSOCIAL ISSUES
Posted by recep on March 26th, 2009PSYCHOSOCIAL ISSUES
Bereavement
The process of living alone usually begins when a spouse dies. Among both men and women, the mortality rate for a spouse left alone rises immediately. In the first week after the death of a spouse, the expected mortality rate doubles, and death usually results from ischemic heart disease. In the first 3 mo after the death of a spouse, the mortality rate increases 48% in men > 65 yr old and 22% in women > 65 yr old. Up to 10 yr after the death of a spouse, men have a higher rate of death than would be expected from infectious diseases, accidents, and suicide. Physicians who provide health care to bereaved elderly persons need to be watchful and supportive. Referral to self-help groups, such as Widow-to-Widow, may be helpful. For frail elderly persons, social support and sources of interaction should be identified and access to vital services secured.
Poverty
Many women become impoverished after an illness depletes savings and their husband’s death results in the loss of his pension benefits. As age increases, the likelihood of poverty rises (see FlG. 107-1). The poverty rate for those who live alone is 19% for whites, 40% for Hispanics, and 57% for blacks. Those who live in rural areas have a poverty rate of 29%.
In 1989, the median annual income for those who lived alone was $9400, compared with a median income of $22,800 for couples. About 45% of elderly persons living alone survived on < $171/wk. With a limited income and high health care costs, elderly persons often must choose among such basic necessities as food, heat, or medicine.
Loneliness
In addition to not having the social, emotional, and financial support of a spouse, many (> 25%) of elderly persons living alone have no living children. Of those who do have children, most see their children once a week, but almost 20% see their children only once a year or less.
About 60% of those > 75 yr old report being lonely. More than 73 of those living alone report feelings of depression, and almost 50% of those who are poor admit to feeling depressed. Physicians should routinely explore feelings of depression with elderly patients who live alone (see Ch. 95).
Despite the hardships, almost 90% of those living alone express a keen desire to maintain their independence. Many fear being too dependent on others, and despite the loneliness they want to continue to live alone. To help a patient maintain his independence, a physician should encourage regular physical activity and social interactions.
Social Support
Social interaction and a social network are vital to elderly persons who live alone. A social network is the aggregate of social relationships and can be described in. terms of size, frequency and intensity of contact with others, and directionality. One authority depicts a person’s social interactions and functional ability using three concentric rings. The outer ring represents social activities (visiting friends, attending church, pursuing hobbies); the middle ring represents domestic tasks (housecleaning, managing finances); and the inner ring represents personal care activities. By noting changes in the outer ring (eg, no longer attending church or being unwilling to travel to visit friends), the physician may detect an unreported problem and can intervene to prevent further functional decline.
Physicians can help patients assess their social support by asking questions such as “Could someone come to your home and help you during the day if it were necessary?” or “If you came home from the hospital, could someone stay overnight with you?” Of those who live alone and are unable to perform at least one activity of daily living, 74% receive no help at all (see FIG. 107-2). Among people who receive help, 43% rely on paid assistance, 54% rely on unpaid help (usually from family members), and 3% receive both paid and unpaid help. Physicians can encourage those living alone to create a broad support network of friends, neighbors, and family. Mutual dependency pacts—agreements between persons to help each other in times of need—are beneficial.
Older people who live alone are more likely than those living with others to attend senior centers, especially for meals, which can lessen social isolation. In addition, although persons who live alone are less likely than married persons to undertake volunteer activities, those who do report higher rates of satisfaction and enjoyment from these activities. In a program in Florida, volunteer activity is encouraged by having well elderly persons build up “bank accounts” of hours volunteered so that they can draw on the accounts in times of need.
