Handbook of the Clinical Psychology of Ageing -  - E-Book

Handbook of the Clinical Psychology of Ageing E-Book

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The first authoritative reference on clinical psychology and aging, the Handbook of the Clinical Psychology of Ageing was universally regarded as a landmark publication when it was first published in 1996. Fully revised and updated, the Second Edition retains the breadth of coverage of the original, providing a complete and balanced picture of all areas of clinical research and practice with older people. Contributions from the UK, North America, Scandinavia and Australia provide a broad overview of the psychology of aging, psychological problems (including depression, anxiety, psychosis, and dementia), the current social service context, and assessment and intervention techniques.

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CONTENTS

Cover

Title page

About the Editors

Contributors

Preface

1 Introduction

WHO ARE OLDER PEOPLE?

AGEING IN SOCIETY

CLINICAL PSYCHOLOGY WITH OLDER PEOPLE

PERSONAL ISSUES

ACKNOWLEDGEMENT

REFERENCES

PART ONE: Ageing

2 Ageing and adaptation

INTRODUCTION

THEORIES OF ADAPTATION TO AGEING

PSYCHOLOGICAL SURVIVAL IN LATE LIFE

REFERENCES

3 Memory and cognition in ageing

INTRODUCTION

COGNITIVE CHANGE AND CONTINUITY – A LIFESPAN DEVELOPMENTAL MODEL

TYPES OF AGEING AND COGNITIVE OUTCOMES

AGEING – A MIXTURE OF GENETIC AND ENVIRONMENTAL INFLUENCES

MEMORY – ACQUISITION AND STORAGE OF INFORMATION

OTHER COGNITIVE ABILITIES

EVALUATIONS OF CURRENT FUNCTIONING RELATIVE TO PREVIOUS FUNCTIONING

REFERENCES

4 Ageing and physical health

WHAT IS HEALTH?

AGEING AND DISEASE

BEHAVIOUR AND HEALTH

BEING ILL AND ILLNESS OUTCOMES

PSYCHOSOCIAL MODERATORS OF ILLNESS OUTCOME

CONCLUSION

REFERENCES

5 Death, dying and bereavement

DEATH AND DYING IN THE TWENTY-FIRST CENTURY

THE CONTEXT OF BEREAVEMENT IN THE TWENTY-FIRST CENTURY

CONCLUSIONS

REFERENCES

PART TWO: Psychological Problems

6 Manifestations of depression and anxiety in older adults

INTRODUCTION

ASSESSING PSYCHOPATHOLOGY IN LATE LIFE

DEPRESSION

ANXIETY

ANXIETY AND DEPRESSION – CLINICAL CHALLENGES

REFERENCES

7 Suicide and attempted suicide in later life

SUICIDE RATES

METHODS

PRECIPITANTS

ATTEMPTED SUICIDE

HOPELESSNESS AND SUICIDAL IDEATION

PREVENTATIVE INTERVENTIONS

CONCLUSIONS

REFERENCES

8 Psychological trauma in late life: conceptualization, assessment and treatment

WHAT ARE THE MAIN INFLUENCES ON THE LIFESPAN PSYCHOLOGICAL EFFECTS OF TRAUMA?

SOME CENTRAL ISSUES IN KEEPING A TRAUMA ALIVE

PSYCHOLOGICAL ASSESSMENT OF THE TRAUMATIZED OLDER PERSON

TREATING THE OLDER PERSON WITH PTSD PSYCHOLOGICALLY

REFERENCES

9 Late onset psychosis

THE CONCEPT OF LATE ONSET PSYCHOSIS

PREVALENCE AND INCIDENCE OF LOP

AETIOLOGY AND RISK FACTORS

PSYCHOSOCIAL ASPECTS

PSYCHOLOGICAL UNDERSTANDING AND INTERVENTION

REFERENCES

10 Dementia as a biopsychosocial condition: implications for practice and research

NEUROLOGICAL ELEMENTS

PSYCHOSOCIAL ELEMENTS

IMPLICATIONS FOR PRACTICE OF VIEWING DEMENTIA AS A BIOPSYCHOSOCIAL CONDITION

ACKNOWLEDGEMENTS

REFERENCES

11 The neuropsychology of dementia: Alzheimer’s disease and other neurodegenerative disorders

ALZHEIMER’S DISEASE

NEURODEGENERATIVE DISORDERS CAUSING DEMENTIA OTHER THAN ALZHEIMER’S DISEASE

EXTRAPYRAMIDAL NEURODEGENERATIVE DISORDERS

CONCLUSION

REFERENCES

12 Parkinson’s disease

INTRODUCTION

HOW COMMON IS PARKINSON’S DISEASE?

WHAT ARE THE CARDINAL SIGNS OF PARKINSON’S DISEASE?

COGNITIVE IMPAIRMENT

PSYCHOLOGICAL AND NEUROPSYCHIATRIC DISTURBANCES IN PARKINSON’S DISEASE

DEPRESSIVE SYMPTOMS IN PARKINSON’S DISEASE

IS DEPRESSION IN PARKINSON’S DISEASE PSYCHOLOGICAL OR BIOLOGICAL?

TREATING DEPRESSION IN PARKINSON’S DISEASE

APATHY AND INSIGHT IN PARKINSON’S DISEASE

IMPORTANCE OF THE CAREGIVING ROLE IN PARKINSON’S DISEASE

PSYCHOLOGICAL INTERVENTIONS FOR CAREGIVERS IN PARKINSON’S DISEASE

THE EXPERIENCE OF LIVING WITH PARKINSON’S DISEASE

CASE STUDY

CONCLUSIONS

REFERENCES

13 Stroke

DEMOGRAPHICS

CLASSIFICATION OF STROKE

PSYCHOLOGICAL IMPACT OF A STROKE

COGNITIVE SEQUELAE OF STROKE

SPECIFIC COGNITIVE SEQUELAE

MOOD DISTURBANCE FOLLOWING STROKE

PSYCHOSOCIAL ADJUSTMENT

GOAL-PLANNING IN REHABILITATION AFTER STROKE

HOW WELL DOES PROVISION OF CLINICAL PSYCHOLOGY SERVICES MATCH THE PRESCRIPTION?

CONCLUSIONS

REFERENCES

14 Sleep and insomnia in later life

INTRODUCTION

INSOMNIA: DIAGNOSIS

INSOMNIA: NATURAL HISTORY

SLEEP AND AGEING

ORIGINS OF LATE-LIFE INSOMNIA

MANAGING SLEEP AND INSOMNIA

CONCLUSIONS

REFERENCES

PART THREE: Service Context

15 Values and diversity in working with older people

VALUES

HOW WE VALUE PERSONS

OUR ATTITUDES TOWARDS AGEING

AGEISM

DIVERSITY

FURTHER FORMS OF DISCRIMINATION

POSITIVE POSSIBILITIES

LATER LIFE: A DEVELOPMENTAL PERSPECTIVE

WHERE NOW?

REFERENCES

16 Family caregiving: research and clinical intervention

INTRODUCTION

BASIC DEFINITIONS

THE DEMOGRAPHICS OF CAREGIVING

CAREGIVING AT A DISTANCE

CHANGES IN FAMILY SIZE AND STRUCTURE

RESEARCH ON FAMILY CAREGIVING PROCESSES AND OUTCOMES

CLINICAL INTERVENTIONS

CONCLUSIONS

REFERENCES

17 Residential care

INTRODUCTION

QUALITY IN RESIDENTIAL CARE

IMPROVING THE CARE ENVIRONMENT FOR PEOPLE WITH DEMENTIA

CARE STAFF – THE KEY TO QUALITY

CHANGING STAFF ATTITUDES AND BEHAVIOUR

CONCLUSION

REFERENCES

18 Elder abuse and neglect

INTRODUCTION

DEFINITIONS AND TYPES OF ABUSE

PREVALENCE AND RISK FACTORS

PREVENTION AND INTERVENTION

CONCLUSION

REFERENCES

19 Primary care psychology and older people

INTRODUCTION

WHAT IS PRIMARY CARE?

HOW ARE HEALTH CARE SERVICES DELIVERED IN PRIMARY CARE?

THE HEALTH NEEDS OF OLDER PEOPLE

MENTAL HEALTH SERVICES FOR OLDER PEOPLE

PSYCHOLOGICAL THERAPIES IN PRIMARY CARE

WHAT FACTORS INFLUENCE THE DELIVERY OF PSYCHOLOGICAL THERAPIES TO OLDER PEOPLE?

MODELS OF SERVICE DELIVERY AND THE ROLE OF A CLINICAL PSYCHOLOGIST FOR OLDER PEOPLE IN PRIMARY CARE

CONSTRAINTS ON DEVELOPMENT

SUMMARY AND CONCLUSIONS

REFERENCES

20 Ageing, dementia and people with intellectual disability

THE SOCIAL AND HEALTH CONTEXT

VARIABILITY WITHIN INTELLECTUAL DISABILITY AND INTERACTIONS WITH AGEING

AGEING AND PHYSICAL HEALTH

AGEING AND PSYCHOLOGICAL CHANGE

DEMENTIA IN ADULTS WITH DOWN SYNDROME

ASSESSMENT AND DIAGNOSIS OF DEMENTIA IN DOWN SYNDROME

BEHAVIOURAL PRESENTATION OF DEMENTIA IN DOWN SYNDROME

THE SERVICE CONTEXT FOR OLDER ADULTS WITH INTELLECTUAL DISABILITY

MODELS OF SERVICE DELIVERY AND PROVISION

PSYCHOLOGICAL SERVICE RESPONSES

CONCLUSIONS

REFERENCES

21 Palliative care for people with dementia: principles, practice and implications

DYING WITH DEMENTIA

PRINCIPLES OF PALLIATIVE CARE

APPLICATION OF THE PRINCIPLES OF PALLIATIVE CARE FOR PEOPLE WITH DEMENTIA

PAIN AND SYMPTOM MANAGEMENT

MODELS OF SERVICE PROVISION

IMPLICATIONS FOR DEMENTIA CARE PRACTICE

CONCLUSIONS

ACKNOWLEDGEMENTS

REFERENCES

PART FOUR: Assessment

22 Neuropsychological assessment of the older person

PLANNING AND CONDUCTING A NEUROPSYCHOLOGICAL ASSESSMENT

ANSWERING COMMON REFERRAL QUESTIONS

CONCLUSIONS

REFERENCES

23 Assessing function, behaviour and need

WHY ASSESS?

HOW TO ASSESS?

ASSESSING EVERYDAY FUNCTION (SELF-CARE)

ASSESSING BEHAVIOUR

MULTIDIMENSIONAL ASSESSMENTS OF NEED

ASSESSING OUTCOMES

GOING BEYOND COGNITIVE ASSESSMENT

GLOSSARY OF MEASURES

REFERENCES

24 Assessing mood, wellbeing and quality of life

INTRODUCTION

PRESENTATION

SELF-REPORT COMPLETED BY A PROXY

ASSESSING WELLBEING AND QUALITY OF LIFE

ASSESSING MOOD

CONCLUSION

REFERENCES

25 Capacity and consent: empowering and protecting vulnerable older people

INTRODUCTION

KEY PRINCIPLES

PRACTICAL CHALLENGES

UK LEGAL BACKGROUND

PRACTICAL IMPLEMENTATION

WHAT NEXT?

REFERENCES

PART FIVE: Intervention

26 The socio-cultural context in understanding older adults: contextual adult lifespan theory for adapting psychotherapy

INTRODUCTION

INDIVIDUAL AND CONTEXTUAL FACTORS

CONCLUSION

REFERENCES

27 Cognitive behaviour therapy with older people

INTRODUCTION

DEMOGRAPHIC CHANGE: THE DYNAMICS OF AGEING

COGNITIVE BEHAVIOUR THERAPY

EMPIRICAL EVIDENCE FOR COGNITIVE BEHAVIOUR THERAPY WITH OLDER PEOPLE

THE APPLICATION OF CBT WITH OLDER PEOPLE

STRUCTURE IN CBT WITH OLDER PEOPLE

SUMMARY

REFERENCES

28 Psychoanalysis and old age

INTRODUCTION

CORE CONCEPTS

PSYCHOANALYTIC INTERVENTIONS IN PUBLIC SECTOR SERVICES

CONCLUSIONS

REFERENCES

29 Systemic interventions and older people

APPROACH

METHOD

CONCLUSIONS

REFERENCES

30 Neuropsychological rehabilitation in later life: special considerations, contributions and future directions

GENERAL PRINCIPLES OF REHABILITATION

SPECIAL CONSIDERATIONS FOR REHABILITATION WITH OLDER ADULTS

TRAUMATIC BRAIN INJURY

REHABILITATION FOLLOWING STROKE IN OLDER PEOPLE

OTHER AGE-ASSOCIATED HEALTH CONDITIONS RELEVANT TO REHABILITATION IN OLDER PEOPLE

EVALUATING AND PREDICTING REHABILITATION OUTCOME IN OLDER PEOPLE

EXAMPLES OF EMPIRICALLY-SUPPORTED PSYCHOLOGICAL INTERVENTIONS FOR REHABILITATION WITH OLDER PEOPLE

FUTURE DIRECTIONS IN REHABILITATION FOLLOWING BRAIN INJURY IN OLDER ADULTS

CONCLUSIONS

REFERENCES

31 Psychological interventions with people with dementia

INTRODUCTION

STIMULATION AND ACTIVITY APPROACHES

EMOTION-FOCUSED APPROACHES

BEHAVIOUR-FOCUSED APPROACHES

COGNITION-FOCUSED APPROACHES

CONCLUSIONS

REFERENCES

32 Interventions for family caregivers of people with dementia

INTRODUCTION

ELEMENTS OF INTERVENTION

OUTCOMES OF INTERVENTIONS

POSITIVE ASPECTS OF CAREGIVING

NURSING HOME PLACEMENT

CONCLUSIONS

REFERENCES

33 Challenging behaviour in dementia

INTRODUCTION

ASSESSMENT AND INTERVENTION

FOUR ILLUSTRATIVE CASES

TWO INTERVENTION STUDIES

CONCLUSIONS

REFERENCES

34 Interventions at the care team level

WHY PROVIDE INTERVENTION AT THE CARE TEAM LEVEL?

GENERAL PRINCIPLES AND MODELS

ASSESSMENT AND FORMULATION

BUILDING AN APPETITE FOR INTERVENTION

TYPES OF INTERVENTIONS

Consultancy, Advice, Mentoring and Supervision

ENSURING YOUR INTERVENTION STAYS ON TRACK

CONCLUSIONS

ACKNOWLEDGEMENTS

REFERENCES

Index

End User License Agreement

List of Tables

Chapter 01

Table 1.1 Population (thousands) and percentage of total population, aged 65 and over in selected countries

Table 1.2 Population (thousands) and percentage of total population, aged 80 and over in selected countries

Table 1.3 New cases seen by clinical psychologists in NHS, England, 2002/3 (rate per 1000 population)

Chapter 12

Table 12.1 Symptomatology in disorders of the extrapyramidal nervous system.

Chapter 18

Table 18.1 Comparison of prevalence rates by country found in random sample population studies of elder people

Chapter 19

Table 19.1 Suggested differences in service between primary care and secondary care mental health

Chapter 33

Table 33.1 Domains of assessment

Table 33.2 Suggested domains to target following assessment of behaviour

Table 33.3 Two cases from Bird

et al.

(2002)

Table 33.4 Two cases from Moniz-Cook (2001)

Chapter 34

Table 34.1 An example of a guided fantasy exercise to use in supervision to help formulate an effective intervention

Table 34.2 Levels of motivation within the ward team

List of Illustrations

Chapter 03

Figure 3.1 Types of ageing and cognitive outcomes. The modified cascade model.

Figure 3.2 Test performance in the Block Design Test relative to subsequent survival.

Figure 3.3 Perceptual speed performance relative to age and time to death. The age based trajectory is less pronounced compared to the time-to-death based.

Figure 3.4 Longitudinal test scores from age 85 to age 100. (Author’s own data from the H70 Study).

Figure 3.5 Differential trajectories of memory and cognitive change in later life in relation to everyday life task demands.

Chapter 14

Figure 14.1 Sleep-stage profiles for typical younger (above) and older (below) people. Note the decrease in Stages 3 and 4 (deeper sleep), and the reciprocal increase in Stages 1 and 2 (lighter sleep) with increasing age.

Figure 14.2 A simple daily sleep diary.

Chapter 16

Figure 16.1 A model of caregiver stress.

Chapter 18

Figure 18.1 Multidisciplinary service provision and interventions

Figure 18.2 Flowchart for physical abuse and neglect

Chapter 22

Figure 22.1 Neuropsychological assessment requires information from a range of sources.

Figure 22.2 Domains and functions to consider in a neuropsychological assessment.

Figure 22.3 Stages in cognitive processing of a face-name association.

Figure 22.4 A template for interpreting neuropsychological assessment results.

Chapter 23

Figure 23.1 Example of a hierarchy of everyday functions. Percentages refer to the percentage of Kay, Holding, Jones and Littler’s (1991) community sample who failed that task.

Figure 23.2 Need, demand or supply?

Chapter 26

Figure 26.1 Components of the Contextual Adult Life Span Theory for Adapting Psychotherapy (CALTAP).

Chapter 27

Figure 27.1 CBT conceptual framework for older people.

Chapter 29

Figure 29.1 Mnemonic Acronym to prompt therapeutic focus on the influence of social

Figure 29.2 Therapist Positioning, Intent, and Influence

Guide

Cover

Table of Contents

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Handbook of the Clinical Psychology of Ageing

Second Edition

Edited by

Bob Woods and Linda Clare

University of Wales Bangor, UK

 

 

 

 

 

 

 

 

 

 

 

This paperback edition first published 2015© 2008 John Wiley & Sons, Ltd.

Edition history: Handbook of the Clinical Psychology of Ageing, edited by Bob Woods and Linda Clare, John Wiley & Sons, Ltd (hardback, 2008)

Registered OfficeJohn Wiley & Sons Ltd, The Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

Editorial Offices350 Main Street, Malden, MA 02148-5020, USA9600 Garsington Road, Oxford, OX4 2DQ, UKThe Atrium, Southern Gate, Chichester, West Sussex, PO19 8SQ, UK

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The right of Bob Woods and Linda Clare to be identified as the authors of the editorial material in this work has been asserted in accordance with the UK Copyright, Designs and Patents Act 1988.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without the prior permission of the publisher.

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Library of Congress Cataloging-in-Publication Data

Handbook of the clinical psychology of ageing / edited by Bob Woods and Linda Clare. – 2nd ed.         p. ; cm.      Includes bibliographical references and index.

      ISBN 978-0-470-01230-7 (cloth : alk. paper); ISBN 978-1-119-05471-9 (Paperback) 1. Geriatric psychiatry. 2. Psychotherapy for older people. I. Woods, Robert T. II. Clare, Linda. [DNLM: 1. Aging–psychology. 2. Aged. 3. Health Services for the Aged. 4. Mental Disorders. WT 145 H235 2007]     RC451.4.A5H426 2007     618.97′689–dc22

          2007038232

A catalogue record for this book is available from the British Library.

Cover image: [Production Editor to insert]Cover design by [Production Editor to insert]

About the Editors

Bob Woods has been practising as a clinical psychologist with older people since 1975. His interest was activated prior to clinical training by his experience working as a nursing assistant in a long-stay ward for people with dementia. He trained and worked initially as a clinical psychologist in Newcastle-upon-Tyne, where there is a strong tradition of old age research. Subsequently he combined extensive clinical work with older people with academic appointments at the Institute of Psychiatry, London and University College, London. In both settings he was heavily involved in training clinical psychologists in work with older people. In 1996, he was appointed to the first Chair in Clinical Psychology with Older People in the UK, at Bangor University where he was also Director of the Dementia Services Development Centre Wales. From 2005 to 2015 he was Director of the Wales Dementias and Neurodegenerative Diseases Research Network (NEURODEM Cymru). His publications have included over 180 books, book chapters and journal articles. His research has involved the systematic development of evidence-based psychosocial interventions for people with dementia and their care-givers, including cognitive stimulation and reminiscence approaches and he leads a major epidemiological study of cognitive impairment in Wales. He received the Alzheimer’s Society 25th Anniversary Award: ‘for contributions to the Alzheimer’s Society and to the cause of people with dementia and their carers’ in 2004, and the British Psychological Society Division of Clinical Psychology: M B Shapiro Award, for a career contribution to the development of clinical psychology with older people in 2006.Linda Clare has been Professor of Clinical Psychology and Neuropsychology in the School of Psychology, Bangor University, UK, where she leads the Research in Ageing and Cognitive Health (REACH) group, since 2008. The group’s aim is to improve the lives of older people and people with dementia through research focused on promoting well-being, preventing or reducing age-related disability, and improving rehabilitation and care. Her interest in working with people who have dementia began when she joined a research project on memory rehabilitation at the MRC Cognition and Brain Sciences Unit in Cambridge, and had the opportunity to work with people who had been diagnosed with Alzheimer’s disease at the Addenbrooke’s Hospital memory clinic. As a result, she is particularly known for pioneering the application of cognitive rehabilitation approaches for people with early-stage Alzheimer’s disease. She continues to conduct intervention trials in this area as well as developing other intervention approaches for people with early-stage and severe dementia and behaviour change interventions aimed at reducing risk of dementia in currently healthy older people. She also leads the IDEAL study, a large UK-wide cohort study examining what helps people with dementia and carers to live well with the condition. Her publications include over 150 peer-reviewed journal articles, books and book chapters. In 2004 she received the May Davidson award from the British Psychological Society for her contribution to the development of clinical psychology in the UK. She is an Editor for the Cochrane Collaboration’s dementia group and for the journal Neuropsychological Rehabilitation. She serves as Senior Faculty for the Wales National Institute of Social Care and Health Research, is a Fellow of the British Psychological Society and of the Gerontological Society of America, and chairs the British Psychological Society Advisory Group on Dementia. In 2015 she will be taking up the post of Professor of Clinical Psychology of Ageing and Dementia at the University of Exeter.

Contributors

Dawn AdamsSchool of PsychologyUniversity of BirminghamEdgbastonBirminghamB15 2TT, UKKate AllanChartered Clinical PsychologistEdinburgh, UKElizabeth AndersonLecturer in Dementia Studies,Bradford Dementia GroupSchool of Health StudiesUniversity of BradfordBradford BD5 OBBWest Yorkshire, UKKaren BermanAcademic Department for Old AgePsychiatryPrince of Wales HospitalRandwick NSW 2031AustraliaGita E. BhutaniChartered Clinical PsychologistProfessional Lead for PsychologicalServicesLancashire Care NHSTrustSceptre PointSceptre WayWalton SummitBamber BridgePrestonPR5 6AW, UKMike BirdSenior Clinical PsychologistAged Care Evaluation UnitSouthern Area Health ServiceQueanbeyanNew South Wales 2620AustraliaHenry BrodatyProfessor of Aged Care PsychiatryEuroa CentrePrince of Wales HospitalAvoca Street (Gate 6)Randwick, NSW 2031AustraliaDawn BrookerProfessor of Dementia Practice andResearchBradford Dementia GroupDivision of Dementia StudiesSchool of Health StudiesUniversity of BradfordUnity Building25 Trinity RoadBradford, BD5 0BB, UKKevin D. BrowneProfessor of Forensic and Child PsychologySchool of PsychologyEleanor Rathbone BuildingUniversity of LiverpoolBedford Street SouthLiverpool L69 7ZA, UKAlice Campbell ReayClinical Practice Director/ProgrammeDirectorUniversity of GlasgowDepartment of PsychologicalMedicineGartnavel HospitalGlasgow G12 0XH, UKLinda ClareReader in PsychologySchool of PsychologyBrigantia BuildingUniversity of Wales BangorBangor LL57 2AS, UKJanet CockburnSenior Research FellowDepartment of PsychologySchool of Psychology and ClinicalLanguage SciencesUniversity of ReadingEarley GateREADINGRG6 6AL, UKPeter G. ColemanProfessor of PsychogerontologySchool of PsychologyShackleton BuildingUniversity of SouthamptonHighfieldSouthampton SO17 1BJ,UKMargaret CrossleyRegistered Clinical PsychologistAssociate Professor and Director ofClinical Psychology TrainingDepartment of Psychology9 Campus DriveUniversity of SaskatchewanSaskatoon, SK S7N 5A5CANADARachael DavenhillConsultant Clinical Psychologist/PsychoanalystAdult DepartmentTavistock Clinic120 Belsize LaneLondon NW3 5BA, UKSteve DaviesDeputy Course DirectorDoctorate in Clinical PsychologyUniversity of HertfordshireHatfield CampusCollege LaneHatfieldHertfordshire AL10 9AB, UKBreid DohertyFormerly of Psychology Department,Maudsley HospitalDenmark HillLondon SE5 8AZ, UKMurna DownsProfessor in Dementia Studies andHead Bradford Dementia GroupDivision of Dementia StudiesSchool of Health StudiesUniversity of BradfordTrinity RoadBradford, BD5 0BB, UKAnne B. EdwardsPurdue University CalumetIndianaUSAKatherine FroggattSenior LecturerInstitute for Health ResearchLancaster UniversityLancaster, LA1 4YT, UKSharon GiblinClinical PsychologistEngage ServiceStaffordshire Youth OffendingHQBeaconsideStaffordST18 OYW, UKPeter HobsonResearch PsychologistAcademic Unit, Geriatric MedicineGlan Clwyd HospitalSarn LaneBodelwyddanRhyl LL18 5UJ, UKBoo JohanssonProfessor of PsychologyGöteborg UniversityP.O. Box 500SE-405 30 GöteborgSwedenSunny KalsyConsultant Clinical Psychologist &Family TherapistBirmingham Learning DisabilitiesServiceSouth Birmingham PCT66 Anchorage RoadSutton ColdfieldWest MidlandsB74 2PH, UKBob G. KnightMerle H. Bensinger Professorof GerontologyAndrus Gerontology CenterUniversity of Southern CaliforniaLos AngelesCA90089USAKen LaidlawSenior Lecturer in Clinical PsychologyUniversity of EdinburghKennedy TowerRoyal Edinburgh HospitalMorningside ParkEdinburgh EH10 5HF, UKAdrienne LittleMental Health of Older AdultsEast Lambeth Community TeamSouth London & Maudsley NHS TrustMaudsley HospitalDenmark HillLondon SE5 8AZ, UKEsme Moniz-CookProfessor of Old Age ClinicalPsychologyUniversity of HullColtman Street Day Hospital39-41 Coltman StreetHull, UKKevin MorganProfessor of GerontologyDepartment of Human SciencesLoughborough UniversityLeicestershire LE11 3T, UKRobin G. MorrisProfessor of NeuropsychologyNeuropsychology UnitInstitute of Psychiatry. King’s CollegePO Box 078, Institute of PsychiatryDe Crespigny ParkLondon SE5 8AF, UKValerie MorrisonSenior LecturerSchool of PsychologyUniversity of Wales BangorBrigantia BuildingBangor LL57 2AS, UKInger Hilde NordhusProfessor of Clinical PsychologyInstitutt for klinisk psykologiUniversity of BergenChristiesgt. 125015 BergenNorwayAnn O’HanlonHARP Co-ordinator (Healthy AgeingResearch Programme)Dept of PsychologyDivision of Population HealthSciencesRoyal College of Surgeons in IrelandMercer St. LowerDublin 2, IrelandChris OliverProfessor of Clinical PsychologySchool of PsychologyUniversity of BirminghamEdgbastonBirmingham B15 2TT, UK Jan R. OyebodeDirectorClinical Psychology Doctorate, Universityof BirminghamConsultant Clinical Psychologist, OlderPeople’s DirectorateBirmingham and Solihull Mental HealthTrustSchool of PsychologyUniversity of BirminghamEdgbastonBirmingham, B15 2TT, UKCecilia Y. M. PoonAndrus Gerontology CenterUniversity of Southern CaliforniaLos AngelesCA90089USAAlison Roper-HallSouth Birmingham Psychology Services208 Monyhull Hall RoadKings NortonBirmingham B30 3QJ, UKNeil SmallProfessor and Head of Institute forCommunity and Primary CareResearchSchool of Health StudiesUniversity of Bradford25 Trinity RoadBradford, BD5 0BB, UKCharles TwiningFormerly of Psychology DepartmentWhitchurch HospitalWhitcurchCardiff CF14 7XG, UKBob WoodsProfessor of Clinical Psychology of OlderPeopleDementia Services Development CentreWalesArdudwyUniversity of WalesBangorHolyhead RoadBangor LL57 2PX, UKSteven H. ZaritProfessor of Human DevelopmentDepartment of Human Development andFamily Studies211 Henderson Bldg.SouthPenn State UniversityUniversity Park, PA 16802-6505USA

Preface

In the preface to the first edition of this handbook, which was published in 1996, one of us (BW) wrote: ‘Clinical psychology with older people has come of age . . . This book aims to celebrate the maturity of clinical psychology with older people, by indicating what has been achieved, and also to move the area onwards . . .’

A decade later, it is less easy to pinpoint the developmental stage that this specialism has reached, and it would be a folly to attribute a role to the handbook, well received as it was, in pushing back the frontiers of knowledge and practice. However, there is no doubt that development has continued apace, that the contribution of clinical psychology with older people is increasingly well recognized and that there is energy and creativity aplenty in this field. There are, no doubt, still uncharted territories in the psychological difficulties faced by older people where clinical psychology has yet to venture and much research and practice development that could be implemented more widely and uniformly, but the rate of progress has been very encouraging.

In considering a second edition, it was clear the growth in the field would make the editorial task even greater, and so, to the initial editor’s relief and delight, Linda Clare has joined him. Together, we have added a further five chapters to the 29 in the initial edition, and less than a third of those 29 will be recognizable as (extensively) updated versions of those appearing in 1996. Some topics have remained the same but we have asked different authors to present their approach on this occasion – sometimes through necessity, as with the untimely loss of Tom Kitwood in 1997, sometimes to reflect the diversity of the field and to bring on board authors newer to the field. However, over a third of the chapters in this edition are on topics that were not covered in the first edition, or that were subsumed in other chapters. Thus suicide, late-onset psychosis, assessment of mood and wellbeing, and interventions with care givers all now have chapters in their own right, and palliative care, primary care, Parkinson’s and learning disability in older people are topics covered essentially for the first time.

The volume has a similar structure to the first edition, with five sections, covering ageing, psychological problems of later life, the service context, psychological assessment and psychological intervention. The balance between sections is rather different in this edition, with the number of chapters in what was the ‘psychology of ageing’ section reduced by more than half, offering the opportunity for many more practice-related chapters distributed throughout the other sections. This does not reflect a reduced importance of the study of ‘normal ageing’ for the practice of clinical psychology with older people but rather a recognition that such a vast literature needs to be summarized succinctly for the clinician, providing a starting point for more extensive study where that is required.

Inevitably, in a book of this nature, there are areas of overlap between chapters. As editors, recognizing that chapters from the handbook are likely to be used as stand-alone sources of reference, we have not sought to remove such overlap completely but we have attempted to signpost within the book as to where more detailed coverage might be found. No doubt, there will at times be contrasting viewpoints, as is to be expected in a growing, dynamic field.

The first edition became a key reference text for clinical psychologists and clinical researchers working in this area, and generations of clinical psychology trainees welcomed it as a valuable resource. This edition, too, is targeted primarily at clinical psychologists working with older people, as a resource for practice, teaching and research. Clinical psychologists in training and assistant psychologists will find particular topics and chapters of interest and value in relation to their stage of training or the type of work or projects in which they become involved. Other practitioners, teachers and researchers – in psychiatry and medicine of old age, nursing and gerontology, for example – will find coverage of specific areas and topics of relevance and interest to their work.

As befits a handbook of clinical psychology of ageing, the majority of the authors are clinical psychologists, with, on this occasion, input from other fields including health psychology, psychology research and old-age psychiatry. This does not reflect a rejection of an interdisciplinary approach but emphasizes the need for a strong input from clinical psychology to provide a firm basis for effective multidisciplinary working. Both editors continue to practice clinically on a regular basis with older people and it is this commitment to bringing research and clinical practice closer together that is an essential part of the philosophy of clinical psychology, which has, we believe, so much to offer to older people and all those who provide care and support for them.

This edition continues to have a preponderance of authors from the UK, although, once again, we are delighted to welcome important and significant contributions from researchers in countries such as the US and Australia, where the practice of clinical psychology with older people (although not research) is acknowledged to be less well developed than in the UK and Scandinavia. Although there are some parts of a few topic areas where the UK focus is especially evident, in relation to service development or legal frameworks, for example, the literature and ideas drawn on in the majority of the book are truly international.

Although we have aimed to provide a breadth of coverage of the field, inevitably it has not proved possible to be entirely comprehensive; some areas of work are underdeveloped, or, for a variety of reasons, have yet to receive the attention they merit from clinical psychology research and practice. Much remains to be done and, as is documented in Chapter 1, the worldwide growth of the ageing population means that the demand for effective, responsive clinical psychology services for older people will continue to grow for many years to come.

Finally, we would like to thank all those who have made this edition of the handbook possible. First and foremost, we are most grateful to all the contributors who have been generous with their time and expertise in complying with editorial requests and have been patient with the delays that accompany such a project. Second, we thank all at John Wiley for their patience and encouragement. Finally, we thank our many colleagues and collaborators who have been a source of support, and our students and trainees for their interest and enthusiasm.

Bob Woods

Linda Clare

1Introduction

Bob Woods

University of Wales Bangor, Bangor, UK

This volume marks the continuing growth and development of clinical psychology with older people. Since the first edition of this handbook was published (Woods, 1996) research activity has continued to increase in relation to all aspects of ageing. Both ‘normal’ and ‘abnormal’ aspects have been extensively studied; the area of overlap between the two has become more evident, although still not well understood. Opportunities to develop clinical psychological services for older people have been apparent in the UK and elsewhere and no longer can the contribution of clinical psychology to services for older people be seen as simply one of ‘promising potential’. There is now ample evidence of psychological practice with older people in a wide range of contexts working with most of the common problems experienced by older people and their supporters. Within the broader family of clinical psychology, work with older adults has, perhaps belatedly, achieved recognition and is less likely to be seen as a rather esoteric, minority interest.

This volume stands as witness to a remarkable degree of progress in the field. Although there remain large gaps in the evidence base for interventions with older people, there are now sufficient indications of effectiveness to underpin a number of evidence-based reviews (e.g. Gatz et al., 1998; Livingston et al., 2005; Woods & Roth, 2005) and to inform evidence-based guidelines, such as the NICE-SCIE guideline on supporting people with dementia and their carers (NICE-SCIE, 2006). The latter document includes recommendations on psychological therapies for depression and anxiety in dementia, and for psychological distress experienced by family caregivers, a psychological approach to behaviour that challenges, and psychological interventions, such as cognitive stimulation, to enhance cognition in people with mild to moderate dementia. In addition, it is recommended that a neuropsychological assessment be carried out in all cases of suspected dementia.

This volume aims to provide an up-to-date review and synthesis of theory and research evidence relevant to clinical practice. Although there are a number of chapters that specifically address issues relating to dementia, the range of psychological problems experienced by older people is addressed. A brief first section covers the key aspects of the psychology of ageing, as well as providing a health psychology perspective on the physical health problems experienced by older people. This section provides the necessary underpinning for a consideration of psychological problems in later life. Detailed discussion of important aspects of the service context for clinical psychology in later life includes primary care, residential care and the situation of people with intellectual disabilities. Two sections address the key aspects of clinical practice – assessment and intervention. A wide range of intervention approaches are discussed, for the range of psychological problems, and interventions with family care-givers are addressed in Chapter 16, based on a well-developed model of understanding and assessing the care-giving situation and also in Chapter 32, based on an analysis of the extensive evidence-base.

However, for all that has been achieved, it is important to acknowledge some of the challenges that this now-mature specialism will be likely to face in its next phase of development. These challenges arise from several interacting factors. Firstly, there is the nature of the ageing population, which will define the target group for psychological services for older people. Second, there are challenges arising from the position of older people in society, and the diverse experiences of later life that results from a society that has embraced the active older person, but where disability and dependency lead to a risk of social exclusion. Third, there are developments and pressures specifically relating to the profession of clinical psychology, including training and issues of recruitment and service development. Finally, there are personal challenges that arise in working with older people, which are by no means new, but must be encountered by each new cohort of clinical psychologists entering this field.

WHO ARE OLDER PEOPLE?

Across the world, there are an unprecedented number of older people. Taking the age of 65 as an arbitrary dividing line, in 1950 there were, according to United Nations statistics (United Nations, 2006), just under 131 million older people in the world, representing 5.2% of the total population; by 2005, there were estimated to be 477 million (7.3% of the total population), and by 2025 older people are projected to form 10.5% of the global population, with 839 million older people – a six-fold increase in 75 years.

There are differences in the overall level and rate of change between regions of the world and individual countries. In general, northern European countries were at the vanguard of population ageing, with many parts of Africa showing the smallest proportions of older people. Population ageing is now very rapid in parts of Asia. Table 1.1 shows the changes in the population of people aged 65 and over in five selected countries from 1985–2025. The UK and Sweden represent the northern European countries, which have shown relatively little change over the last 20 years, already constituting over 15% of the population in 1985. The US has also shown relatively little change in this proportion, but has yet to reach the level seen in the UK and Sweden 20 years ago. Australia has had a slightly more rapid growth, but it is in Japan where the most dramatic changes have occurred, with the proportion of older people having nearly doubled in 20 years, almost reaching 20% by 2005. This trend looks set to continue in Japan, with more modest, but clear and important, growth in the population aged 65 and over in the other selected countries too. Table 1.2 indicates the changes over the similar time period in the population aged 80 and over. In the UK and the USA, the numbers of people in this age group are projected to have doubled over the period 1985–2025. Again, Japan is showing the most dramatic rate of change, with 10% of the population projected to be aged 80 and over by the year 2025.

Table 1.1 Population (thousands) and percentage of total population, aged 65 and over in selected countries

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2006 Revision and World Urbanization Prospects: The 2005 Revision, http://esa.un.org/unpp.

UK

US

Sweden

Japan

Australia

1985

8 578

28 423

1 491

12 450

1 588

15.2

11.7

17.9

10.3

10.1

1995

9 169

33 399

1 542

18 264

2 151

15.8

12.4

17.5

14.6

11.9

2005

9 684

36 751

1 557

25 255

2 662

16.1

12.3

17.2

19.7

13.1

2015

11 358

46 355

1 909

33 120

3 600

18.1

14.1

20.2

26.2

16.1

2025

12 986

63 203

2 155

35 835

4 788

19.9

17.8

21.9

29.5

19.6

Table 1.2 Population (thousands) and percentage of total population, aged 80 and over in selected countries

Source: Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat, World Population Prospects: The 2006 Revision and World Urbanization Prospects: The 2005 Revision, http://esa.un.org/unpp.

UK

US

Sweden

Japan

Australia

1985

1 802

5 916

332

2 215

267

3.2

2.4

4.0

1.8

1.7

1995

2 272

7 565

411

3 881

466

3.9

2.8

4.7

3.1

2.6

2005

2 685

10 625

482

6 178

712

4.5

3.5

5.3

4.8

3.5

2015

3 049

11 958

497

9 849

944

4.9

3.6

5.3

7.8

4.2

2025

3 597

14 642

638

12 929

1 254

5.5

4.1

6.5

10.6

5.1

Typically, at present, life expectancy at birth is greater for females than males. For example, in the UK, in 2005 it was 80.7 years for women and 76.1 years for men; in Japan, it was 85.2 for women and 78.3 for men. This is reflected in women out-numbering men, especially in the higher age groups. For example, in the UK, the sex ratio in those aged 65 to 69 is 1 male to 1.08 women, whereas in those aged 80–84 the ratio is 1:1.62, and amongst those aged 85 and over it is 1:2.47. In the US there are seven times as many female as male centenarians (United Nations, 2006).

However, this longer life expectancy may be at the cost of women living more years in poor health. For example, UK figures suggest that expected years lived in poor health from age 65 onwards are 5.8 years for women and 4.3 years for men (Evandrou, 2005). Limiting long-term illnesses are common in the older age groups (see Chapter 4, this volume). Over three-quarters of women (and 70% of men) aged over 85 have such a condition, whereas only around 20% of men and women aged 50–54 are similarly affected (Evandrou, 2005). Among those aged 65–74 and 75–84, 40% and 60% respectively have a limiting long-term illness. However, from a psychological perspective, it is important to note that subjective health is not necessarily poor: 56% of women and 58% of men aged 65 and over with a limiting long-term illness rate their own health as good or fairly good (Evandrou, 2005).

The Health Survey for England (2005) reports a number of health indicators for people aged 65 and over (excluding those living in institutional care settings). Arthritis was the most common chronic disease reported by women (reported by 47% of women and 32% of men), whilst for men cardiovascular disease is the most common condition (reported by 37% of men and 31% of women). Two-fifths of older people reported functional limitation in at least one area of activity. For more than half of these, the area of difficulty was being unable to walk 200 yards without stopping or experiencing discomfort. The prevalence of functional limitation increased with age, with around a quarter of men and women aged 65–69 having at least one functional limitation, compared with 65% of women and 57% of men aged 85 and over. Similarly, the proportion having multiple areas of functional limitation also increases with age. Nearly a fifth of women (19%) and 17% of men aged 85 and over report three or more areas of functional limitation, whereas the corresponding figures for those aged 65–69 are 2% and 4% respectively. The risk of falls increases with age, with 43% of men and women aged 85 and over having had a fall in the previous 12 months, compared with 18% of men and 23% of women aged 65-69.

Other chronic conditions that were common in the over 65 population included diabetes (13% of men, 10% of women), asthma (10% men, 12% women) and chronic lung disease (9% men, 7% women). Nearly two-thirds of people aged over 65 were hypertensive (62% men, 64% women), in that they either had raised blood pressure at the time of assessment or were taking medication for high blood pressure. It is important to note that of those taking medication, only 50% of men and 45% of women had blood pressure in the acceptable range. Over a fifth of people aged 65 and over had visited their general practitioner in the previous fortnight; this was related to their self-assessment of health, but not to their age.

Broadly comparable figures for chronic conditions are reported from the US (Federal Inter-agency Forum on Aging-related Statistics, 2006), for people aged 65 and over (again excluding those in institutions), with lower rates of self-reported hypertension (48% men, 55% women); higher rates of diabetes (men 20%, women 15%); slightly lower rates of asthma (8% men, 10% women); and higher rates of arthritis (43% men, 55% women). Nearly half of men aged 65 and over (48%) reported having some difficulty with hearing, and 14% had some difficulty with vision. For women, the corresponding figures were 34% and 19% respectively.

The Health Survey for England (2005) indicated that substantial numbers of older people had little contact with friends (reported by 36% of men and 31% of women) or with family members not living in the same household (reported by 31% of men and 24% of women). A severe lack of perceived social support was reported by 18% of men and 11% of women. Living in areas with limited access to local amenities such as supermarkets and post offices was more likely with increasing age, and was related to poor health in men. Participation in organizations was associated with better health, as was contact with friends and perceived social support for women in the sample. People over the age of 80 appear to be at particular risk from social exclusion on multiple indicators (HM Government, 2006). Thus, they were more likely to live in below-standard housing, experience fear of crime, have difficulty accessing important services, be on a low income, be less likely to meet up with friends, have access to transport, and participate in adult learning, volunteering or other physical and leisure activities.

In summary, the clinical psychologist working with older people in the second decade of the new millennium, in a developed country, will be working with many more people in their 80s and 90s than would have been the case 20 years ago. In these age groups, women will outnumber men, of course. Multiple chronic health conditions will be common and these may lead to reductions in the person’s ability to manage day-to-day activities, although they do not necessarily lead to a perception of poor health. Sensory impairments will also be common. A significant minority of older people will not have good social support and may feel isolated from contact with friends and family.

AGEING IN SOCIETY

The demographic changes and population projections documented in the previous section reinforce the assertion that we live in unprecedented times. Although areas of the world where population ageing has proceeded at a slower pace may hopefully learn from the experiences of the northern European countries, for example in planning health and social care services, on a global level society has never before included such proportions of older people.

Often these changes are viewed as a problem for society as a whole. In the UK, there is near-panic as to how it will be possible in the future to pay for the pensions earned over many years by those who will reach retirement age in the next decade or so. There is equal concern over the projected costs of long-term care to meet the anticipated costs of providing care for increasing numbers of older people predicted to require nursing and personal care and unable to live independently.

Equally, these changes provide a great resource to society, of experienced and mature individuals, able to contribute to the workforce directly, or through providing childcare for their grandchildren, allowing others to work, or contributing through volunteer activity, or performing other caregiving tasks for family members and friends.

It is these two faces of older people in society, which may be crudely characterized as ‘burden’ or ‘resource’, that reflect the ambivalence experienced at personal, professional and societal levels. We all have a personal investment in ageing and most people wish to avoid an early demise, but there is the concern that increased life expectancy will simply result in a longer period of life lived with disabling health difficulties. Brayne (2007) suggests that there is some limited evidence emerging that ‘compression of morbidity’ is occurring in population studies, with the average period spent prior to death in a disabled state not increasing with increasing life expectancy.

It is the fear of this aspect of ageing that Butler (1969) argued gave rise to ‘ageism’, which he described as reflecting ‘a deep seated uneasiness on the part of the young and the middle-aged – a personal revulsion to and distaste for growing old, disease, disability, and fear of powerlessness, uselessness and death.’ Ageism is now often more broadly defined, to include discrimination on the basis of age at any point in the lifespan (Bytheway, 1995) but the original sense of devaluing and distancing from older people and the negative features that have become associated with ageing, remains relevant and raises personal as well as professional issues. It is now also evident that such ageism is not confined to younger and middle-aged people; older people may well bring these powerful feelings to late life.

This tension is also apparent in the distinction that may be drawn between the ‘third age’ and the ‘fourth age’. The third age of life reflects the period beyond work and employment. It follows on from childhood and working life and allows for many, new opportunities for enjoyment and self-development. The University of the Third Age is well-established and well-known as a virtual learning community, where older people share knowledge, skills and wisdom in the pursuit of learning and development rather than to gain qualifications or degrees. Equally well known are the older people who post-retirement find opportunities for travel and exploration, or who establish themselves in places where previous holidays have been enjoyed. For a proportion of third agers (but by no means all), a good quality of life is attainable, with financial resources and health matching aspirations. There are certainly clear signs of current cohorts of older people making inroads into some of the disempowering forces that surround them, particularly in the roles of consumer and campaigner.

The fourth age, on the other hand, takes us again into the arena of disability and poor health, dependency and disease. It includes all the fears of ageing, embodied in Butler’s definition of ageism, which affect older people just as much as they do younger people (although the focus of fear of death in older people tends to be process orientated rather than the fear of nonexistence reported by younger people; see Woods, 1999). It can happen suddenly, such as when a person has a severe stroke, or develop gradually as multiple disorders combine and accumulate to a point where the person is no longer able to maintain a degree of independence satisfying to him/herself. It is not necessarily triggered by a limiting long-term health condition; as mentioned previously, many older people maintain a positive view of their health whilst having such a condition. It happens perhaps when changes can no longer be assimilated into the person’s self-concept as an independent, capable person, and the challenge becomes one of accommodation to receiving help with personal care and daily life, whilst maintaining dignity and individuality. Third age/fourth age transitions are not necessarily irreversible; there may be recovery from a stroke or mobility may be regained following an operation for fractured neck of femur, for example, but the fourth age is a period of great vulnerability. Maintaining control over even small aspects of daily life may become difficult; feelings of powerlessness and frustration may arise in situations where help must be asked for and received in carrying out activities that were previously easily accomplished. Decision making may seem to be taken over by others, and major decisions, such as moving into a care home, appear to have to be made quickly, at a time when all the consequences may not be clear. As one older person commented to the author regarding the process of being discharged following an acute admission to hospital: ‘I was offered a choice of what care home I went to, but I wasn’t offered the choice of going back home.’

Finding meaning and purpose in the fourth age is probably the greatest remaining challenge for gerontology. There is now no question that those older people who have reasonable health, economic and social resources can, and usually do, have a satisfying and fulfilling later life. Those who, for whatever reason, are less fortunate in these respects, will have a more difficult task in maintaining wellbeing in the final chapter of their lives (see also Chapter 2, this volume) as they face social exclusion and disempowerment.

These considerations illustrate something of the diversity of the experience of ageing. Conventional, but arbitrary, age thresholds for pensions, retirement, services or benefits, such as 60, 65 or even 75 mean that people with a range of ages of at least 25 to 40 years are being grouped together. An important gerontological finding is the greater variance shown by older people in many areas of life (e.g. Rabbitt, 2006). Older people have had longer to follow their own developmental path, to develop different skills, interests, motivations, preferences and abilities and to have different life experiences, and so may be more different from each other than groups of younger people. The influence of cohort effects is a further key aspect of gerontological research (see Chapter 3, this volume) which contributes to diversity. The 70 year old today is in a very different position from the 70-year-old person of 1980, in terms of life experiences, position within society and expectations of their phase of life. Each generation of older people brings to later life its own history and values and will accordingly influence and be influenced by the social culture of the time. Add to this differences arising from cultural and spiritual background, ethnicity, sexuality and gender, and the diversity is evident (see Chapter 26, this volume). Different individuals will have unique narratives of their lives, a life story to tell. They will have witnessed and been influenced by many changes in the socio-cultural-political environment, in technology, in the media, in world view, but the story will be fundamentally rooted in a network of relationships, varying in depth and nature. The movement away from the use of terms such as ‘the aged’ and ‘the elderly’ reflects the realization that generalizations about such a diverse population are of dubious validity.

Our preferred term ‘older people’ is remarkably vague, of course, potentially encom-passing almost the whole population. However, discrimination on the basis of age is now becoming the subject of the same scrutiny as racism and sexism, for example, in relation to employment and the provision of healthcare and social care services. There is an interesting paradox, in that, in both England and Wales, a National Service Framework for Older People has been published (Department of Health, 2001; Welsh Assembly Government, 2006), each setting the explicit target of rooting out age discrimination; however, these are the only National Service Frameworks for a population, rather than a disease or group of diseases, as if being older is, in itself, a disorder to be treated.