demographic shift will require commensurate increases in attention to health issues in this cohort, particularly aspects of mental health. The importance of attention to the psychological well‐being of the elderly becomes obvious when considering the established links between mental health problems (e.g. depression and life stress) and medical outcomes such as premature mortality, coronary heart disease, diabetes, disability, and other chronic conditions Steptoe (2006). More plainly stated, overall psychological well‐being (i.e. one’s sense of purpose and meaning in life) is strongly associated with longevity. For example, the English Longitudinal Study of Ageing (ELSA) found that almost 30% of those with the lowest levels of psychological well‐being had died by the end of the 8.5 year follow‐up period as compared to only 9% of those with the highest levels of psychological well‐being. Notably, this effect occurred independent of age, gender, demographic factors, and baseline mental and physical health (Steptoe, Deaton, & Stone, 2015). Older adults themselves recognize these effects and have rated preserved cognitive and functional abilities as essential elements to successful ageing (Nosraty, Jylhä, Raittila, & Lumme‐Sandt, 2015; Nosraty, Sarkeala, Hervonen, & Jylhä, 2012). Similarly, having a sense of purpose in life has been found to be associated with a 30% decreased risk of dementia in older adults (Sutin, Stephan, & Terracciano, 2018). Thus, it is apparent that psychological factors may have important implications for preventing chronic medical conditions, increasing longevity, and improving overall quality of life in older age. This chapter covers relevant psychological aspects of ageing that practitioners should be cognizant of when caring for this population. More specifically, we will discuss both normal and abnormal changes in mental health and cognitive function in older adulthood as well as interventions that can help with adapting to these changes and maintaining function.
Psychological development over the lifespan
When appraising patients’ psychological well‐being, it can be helpful to take a lifespan perspective and contextualize the individual against the typical developmental challenges of their current stage in life. Such perspective often provides insight into typical psychological conflicts that an individual might be struggling with. One of the most cited psychological theories of lifespan development proposed that individuals progress through eight distinct psychosocial stages (Erikson & Erikson, 1998). Each stage is defined by a basic conflict that purportedly must be resolved in order to move to the next stage. Erikson’s theory states that younger years are concerned with developing a basic understanding of the self in the world and developing personal identity. Age 40 marks the beginning of the middle adulthood stage, where the concern is to create something that is valuable and provides good in the world. These are typically the years of having families and developing a career. By their mid‐60s, individuals enter into the stage of ‘Maturity’. This is a period of reflecting on the prior events of their lives, both celebrating achievements and coming to terms with regrets, all in search of a sense of fulfilment. Meaning‐making is undertaken retrospectively. When life is perceived positively, feelings of satisfaction arise. However, when life is perceived negatively, a sense of despair and bitterness can prevail, which may lead to depression. These stages provide a larger framework within which to view individual characteristics and personality traits.
Personality changes in older adulthood
Attention to normal personality development also offers insight to those caring for older adults. Human personality is one of the longest‐studied topics in psychology, and contemporary theory has settled on the idea that most of the variation in personality between individuals can be accounted for by differences in five broad, cross‐cultural character traits (John & Srivastava, 1999). These so‐called Big Five personality factors are (i) Openness to Experience, (ii) Conscientiousness, (iii) Extraversion, (iv) Agreeableness, and (v) Neuroticism. In brief, Openness to Experience refers to the diversity of an individual’s mental and experiential life and is contrasted with closed‐mindedness. Conscientiousness refers to social impulse control and is typified by actions like goal‐directed behaviour and adherence to norms and rules. Extraversion refers to an energetic and engaged approach to the social world and is contrasted with introversion. Agreeableness refers to pro‐social and communally oriented behaviours and is contrasted with social antagonism. Finally, Neuroticism refers to a tendency for negative emotionality (e.g. anxiety, sadness) and is contrasted with emotional stability and even‐temperedness.
Several large‐scale cross‐sectional and longitudinal studies have investigated changes in the Big Five personality traits across the lifespan, and these studies have fairly consistently identified patterns of personality change that tend to occur in the later years of life. Specifically, people decline in their levels of Extraversion and Openness to Experience in older adulthood, while Agreeableness increases in this period of life (Donnellan & Lucas, 2008). Conscientiousness shows a curvilinear association with age, peaking in middle adulthood before declining in older age (Donnellan & Lucas, 2008). Neuroticism has shown a slight decline in later years (Donnellan & Lucas, 2008). These general trends have manifested in large samples across multiple cultures (e.g. America, Britain, Germany, Japan), albeit with more heterogeneity of change patterns observed in non‐Western cultures relative to Western cultures (Donnellan & Lucas, 2008; Chopik & Kitayama, 2018). Theoretical explanations for these patterns of change have typically emerged from the familiar dichotomy of nature versus nurture. The former contends that such changes are intrinsically programmed by our biology via countless years of evolution. The latter argues that personality change is driven by the situational demands of one’s current life stage. Through this lens, a mid‐life spike in Conscientiousness is viewed as an adaptive response to occupational pursuits in this period of life. As with most human behaviours, it seems reasonable that both intrinsic and contextual factors are at play in these changes.
Perhaps not surprisingly, several studies have linked Big Five personality factors to cognitive function and mood symptoms in older adulthood. One of the more consistent associations is that individuals with greater Openness to Experience tend to have higher overall cognitive ability and memory ability (Booth, Schinka, Brown, Mortimer, & Borenstein, 2006; Luchetti, Terracciano, Stephan, & Sutin, 2016). Openness also has been found to attenuate the effects of late‐life depression on cognitive function (Ayotte, Potter, Williams, Steffens, & Bosworth, 2009). High levels of Openness and Conscientiousness have each been associated with slower rates of cognitive decline (Curtis, Windsor, & Soubelet, 2015; Luchetti, et al., 2016). Finally, high levels of Agreeableness and Neuroticism have been negatively associated with memory and cognitive effort (Maldonato, et al., 2017). The overall effect of these personality factors on cognition is small but notable. One study found that as much as 2–7% of cognitive ability is predicted by personality factors (Booth, et al., 2006). Another study found personality factors to have a stronger correlation with cognitive performance than several medical and lifestyle factors including hypertension, diabetes, history of psychological treatment, obesity, smoking, and physical inactivity (Luchetti, et al., 2016).
Normal cognitive change with age
As discussed above, cognitive function is a major component in the psychological well‐being of older adults. Before turning our attention to abnormal cognitive ageing, we first discuss normal aspects of cognitive development in older adulthood. Ageing is associated with changes in memory and other cognitive functions throughout the lifespan. In older people, subjective cognitive complaints are common and in the lay population are typically referred to as ‘senior moments’. Specific benign cognitive changes associated with age include declines in processing speed, learning and memory, and executive functioning. Other investigators have demonstrated that declines in visual and auditory acuity contribute to cognitive change as well (Park & Schwarz, 2012). Research has demonstrated that the most pronounced function affected by ageing is processing speed, which reduces with advancing age (Salthouse, 1996; Salthouse, 2010). Importantly, normal cognitive ageing is by definition not associated with objective impairment on cognitive testing and does not result in impairment of individuals’ ability to complete
