Depression in the Elderly [1 ed.] 9781443868662, 9781443846158

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Depression in the Elderly

Depression in the Elderly

By

Patricia-Luciana Runcan

Depression in the Elderly, by Patricia-Luciana Runcan This book first published 2013 Cambridge Scholars Publishing 12 Back Chapman Street, Newcastle upon Tyne, NE6 2XX, UK

British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library

Copyright © 2013 by Patricia-Luciana Runcan All rights for this book reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the copyright owner. ISBN (10): 1-4438-4615-5, ISBN (13): 978-1-4438-4615-8

TABLE OF CONTENTS

List of Tables............................................................................................. vii List of Illustrations ..................................................................................... ix Foreword .................................................................................................... xi

Part One Chapter One................................................................................................. 3 Depression in the Elderly Chapter Two .............................................................................................. 37 Ageing, Old Age and the Elderly Chapter Three ............................................................................................ 69 Depressed Old People and their Families Chapter Four.............................................................................................. 93 Social Protection of the Elderly in Europe and Romania: Preventing Depression

Part Two Chapter Five ............................................................................................ 119 Depression in the Elderly: Quantitative Research Chapter Six .............................................................................................. 155 Depression in the Elderly: Qualitative Research Chapter Seven.......................................................................................... 185 Conclusions and Recommendations References ............................................................................................... 193

LIST OF TABLES

Table 1-1. Suicide rates per hundred thousand by country, year and sex in 2009 (World Health Organisation).............................................................................. 6 Table 2-1. Subfields of gerontology ........................................................................38 Table 2-2. Categories of needs (after Bradshaw) ....................................................60 Table 5-1. Values of the Test Ȥ² and Significance of Differences between the Three Lots of the Quantitative Research ...................................................154

LIST OF ILLUSTRATIONS

Figure 1-1. Classification of depression ................................................................... 9 Figure 2-1. Chronological age.................................................................................41 Figure 2-2. Functional age.......................................................................................41 Figure 2-3. Positive and negative aspects of functional age ....................................42 Figure 2-4. Old people’s focus forms from the perspective of a SWOT analysis....43 Figure 2-5. Evolution of EU old population (millions of people)............................48 Figure 2-6. Evolution of Romania’s population (thousands of people)...................49 Figure 2-7. Need—Problem—Fear in the elderly ...................................................58 Figure 2-8. Categories of needs...............................................................................61 Figure 3-1. Roles the elderly can play in their families...........................................88 Figure 4-1. Forecast of age dependancy rate ...........................................................96 Figure 5-1. The three lots of old people ................................................................123 Figure 5-2. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on age group ......................................124 Figure 5-3. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on gender ...........................................125 Figure 5-4. Comparative analysis of depressed, institutionalised, and noninstitutionalised old people depending on the level of education....................126 Figure 5-5. Comparative analysis of depressed, institutionalised, and noninstitutionalised old people depending on occupation.....................................127 Figure 5-6. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on marital status.................................128 Figure 5-7. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on level of depression ........................129 Figure 5-8. Comparative analysis of answers about favourite pastimes ................130 Figure 5-9. Comparative analysis of answers about most important wishes .........131 Figure 5-10. Comparative analysis of answers about frequency of depression episodes...........................................................................................................132 Figure 5-11. Comparative analysis of answers about forced retirement effect......133 Figure 5-12. Comparative analysis of answers about the perception of retirement ........................................................................................................134 Figure 5-13. Comparative analysis of answers about acceptance of retirement ....135 Figure 5-14. Comparative analysis of answers for reasons to remain active .........136 Figure 5-15. Comparative analysis of answers about religious feelings................137 Figure 5-16. Comparative analysis of answers about church attendance ..............138 Figure 5-17. Comparative analysis of answers about the onset of depression as a result of the loss of the partner.................................................................139 Figure 5-18. Comparative analysis of answers about the onset of depression as a result of the loss of an adult child ............................................................140

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List of Illustrations

Figure 5-19. Comparative analysis of answers about the onset of depression as a result of the loss of health ........................................................................141 Figure 5-20. Comparative analysis of answers about the onset of depression as a result of several types of losses................................................................142 Figure 5-21. Comparative analysis of answers about the causes of discomfort.....143 Figure 5-22. Comparative analysis of answers about the perception of poverty ...144 Figure 5-23. Comparative analysis of answers about the causes of the loss of psychic balance ...............................................................................................145 Figure 5-24. Comparative analysis of answers about the fear of poverty..............146 Figure 5-25. Comparative analysis of answers about the effects of poverty .........147 Figure 5-26. Comparative analysis of answers about the frequency of suicidal attempts...........................................................................................................148 Figure 5-27. Comparative analysis of answers about the causes of loneliness......149 Figure 5-28. Comparative analysis of answers about the effects of loneliness......150 Figure 5-29. Comparative analysis of answers about the feelings about one’s family..............................................................................................................151 Figure 5-30. Comparative analysis of answers about the effects of the lack of social support from the family ....................................................................152 Figure 5-31. Comparative analysis of answers about the role of family support in avoiding depression, suicide, and other negative effects.............................153 Figure 5-32. Significance of differences (p) between lots per item.......................153 Figure 6-1. The sample used in the qualitative research........................................160 Figure 6-2. Psycho-social factors leading to onset of depression in the elderly ....183

FOREWORD

There are many books about depression in older people, but few capture the complexity of the issues in clearer, more practical and comprehensive terms than Depression in Elderly. Patricia Runcan’s book is both theoretical and practical, replete with practical examples and action guidelines on the complex issues of depression in the elderly. She enriches her studies with both qualitative and quantitative findings. The past five decades have witnessed remarkable progress in social and health studies in European countries. Much of this growth is associated with the economic growth and development of living conditions. Despite progress, the studies of depression in the older people are unexpectedly few, although the number of elderly with depression has increased since World War II. The World Health Organization (WHO) considers depression to be the second greatest cause of disability and one of the most serious public health issues among the elderly all over the world. WHO has projected that major depression will be the second cause of disability after heart diseases worldwide by 2020. Depression ranks third after socioeconomic factors and other health conditions among the causes of depression in the elderly. Depression is a serious medical condition that affects thoughts, feelings and the ability to function in everyday life. It can affect a person in a number of ways, such as altering their mood, reducing energy levels, decreasing level of interest in pleasurable activities, and increasing tiredness. Additionally, depression has a negative effect on sleep, appetite and life quality. Combined with old age, depression has a double negative impact on the mental, bodily and spiritual life of older people. Depression can prevent older adults from enjoying their lives. They complain of having little motivation, of lacking energy, or of having physical problems. In order to understand the extent to which depression affects the elderly, more research needs to be conducted on how it affects a person’s ability to live a decent life. In elderly people, depression affects mainly those with chronic illnesses and cognitive impairment; it causes suffering, family disruption, and disability; it worsens the outcomes of many medical illnesses and increases mortality.

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Foreword

At this point, Patricia Runcan’s book is crucial because she focuses on not only one or two dimensions of depression in the elderly, but also provides several approaches to depression in the elderly and applies qualitative and qualitative research methods to access more extensive information. The book has two parts and six chapters. The first chapter part one concludes the theoretical studies related to depression in the elderly. The author presents the comparative data of research results in depression, describes the types of depression and reviews risk factors, physical, emotional and psycho-social causes of depression. She also reflects on how depression is perceived and defined by the elderly. In the second chapter, Patricia Runcan discusses the relationship between depression and ageing. The author examines the issues from three perspectives: biogerontology, pychogerontology and social gerontology. These perspectives make it easier to understand the connection between depression and ageing. The next chapter examines depressed old people with their families from the perspective of the modern and traditional family structures and their impact on depression in the elderly. The biological, economic, family, pedagogical, educational and moral functions of the family are underlined in the study. In the fourth chapter, the social protection of the elderly in Europe and Romania are compared to show how they prevent depression. In the second part of the book, Patricia Runcan analyzes, using a quantitative research, the psycho-social factors generating depression in older people. She discusses four dimensions of depression from the perspective of the following hypotheses: retirement, loss, poverty and loneliness. The research on depression in the elderly is completed and strengthened by a qualitative research, which gives us an in-depth understanding. Patricia Runcan examines the situation of older persons under six headings: personal data, health state, life history, treatment, support network, and impact of disease. The data are analyzed case by case while giving some remarkable findings on depression, being strongly triggered by losses, forced retirement, poverty and loneliness. The results of the qualitative research overlap with the results of the quantitative research. The book indicates that depression in the elderly, caused by the reduction in social contact that occur with age, can also stem from a variety of conditions, such as loss of a person’s role in society, decline of the social network, different barriers (e.g. mobility problems) that hinder the ability to socialise, and decreased ability to engage in mutual relationships because of the increased frailty associated with the aging

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process. All these factors also increase the risk of loneliness in the elderly and result in living alone, decreased mobility from illness or loss of privileges, feelings of purposeless, illness and disability, cognitive decline, severe pain, and anxiety or fear of death. The gift of this book is the fine and rich detail of intentional, rigorous, valuable consideration on depression in the elderly. Here, the reader will learn about depression in the elderly in exquisite detail and salient findings. Serious minded researchers and readers both will appreciate and benefit from this exclusive book. Hasan ARSLAN

PART ONE

CHAPTER ONE DEPRESSION IN THE ELDERLY

Depression is a continuous burden, a deep trace left in someone’s soul, and can be fully understood only by those who experience it. “Depression” comes from the Latin depression, meaning “pressure,” a downcast mood of the soul accompanied by a lack of vigour, asthenia and a pessimistic evaluation of events (Avdeev 2005, 7). Depression has been defined as: -

-

-

“a wide range of thoughts, behaviours, and feelings … a wide range of negative moods” (Gurung 2000, 648). “an emotional state or mood characterized by one or more of these symptoms: sad mood, low energy, poor concentration, sleep or appetite changes, feelings of worthlessness or hopelessness, and thoughts of suicide” (Strickland 2001, 175). “the most common mental illness, with a lifetime prevalence rate of 16.6% for the general population and 10.6% for those aged 60 and above” (Ayres 2008, 269). “one of the most common psychiatric disorders” (Gotlib & Hammen 2009). “a mood disorder” (Ingleby 2010, 59).

Clinicians give a more refined definition of depression as being “most directly captured by three features: (i) a depressed mood, (ii) a lowering of self-esteem or self-worth, and (iii) an increase in self-criticism” (Parker & Manicavasagar 2005, 14). Le Petit Larousse de la médicine (1997) presents depression as a pathological state characterised by a sad, painful state of the soul associated with a diminution of psycho-motor activity. In its 2002 edition, Le Grand Dictionnaire de la psychologie, depression is presented as a mental illness characterised by a deep change in the thymus state and of mood, featuring sadness, moral suffering and psycho-motor slowing. Sometimes accompanied by anxiety, depression maintains in the patient a painful feeling of global impotence, of desperate fatality, and causes subdelirious meditation on such topics as culpability, lack of merit and lack of

4

Chapter One

self-appreciation, which leads to suicidal thoughts and, eventually, to suicide. We may be tempted to believe that depression is a recent malady, a condition that occurred only from the twentieth century, but nothing could be further from the truth—depression has been known from time immemorial, and is the most widespread symptom of conditions of the soul. It occurs in all social media and in the most diverse cultures, and can affect practically anybody. Depression is most definitely not a feature of modern times. In its major clinical, psychotic form, depression was identified in ancient times, and is the first psychic disease ever identified and described (Drimba 1998). It was first known under the name melancholy (from the Greek melankholia—“black bile”) because it was thought that a melancholic person suffered from black bile excess resulting from depression. In the fourth century BC, the famous Greek physician Hippocrates of Cos described, for the first time, melancholy and the strange changes of mood in a person that we now call bipolar disorder. In the second century AD, the Greek physician Aretaeus of Cappadocia (in Wright 1988) described his patients suffering from melancholy as sad, desperate and suffering, losing weight because of continuous agitation and insomnia. In a more advanced state, patients complained about “a thousand trifles” and wished to die. The feeling of sadness does not point to depression, but depression involves sadness, a feeling that can impact everyday life, and this is why we respond with hurt and loss in life matters. It is difficult to trace a clear borderline between normal and pathological sadness. Depression can lead to anxiety, and anxiety can predispose to depression. Depression is always accompanied by anxiety. Despair and sadness are normal and frequent in everyday life, but depression goes beyond normality in intensity, duration and manifestation. The difference between being upset (natural sadness) and being depressed (pathological sadness) is quantitative rather than qualitative (CornuĠiu 2003; Rubin & Babbie 2011). When somebody is unhappy, this does not necessarily mean somebody is depressive; for example, we may be sad when we miss somebody, but this does not mean we are depressed. However, when somebody loses forty pounds because they are not eating and does not leave the bed for two weeks, this is depression. Conversely, If one periodically faces disappointment and does not feel like going to work, or when one cannot sleep one night, it is normal to feel sad, but this does not mean one is depressed.

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As a pathological condition, depression is the most common psychical suffering experienced by everybody at least once in life. As a general rule, depression lacks hope and abounds in discouragement and despair. Nowadays, depression is the most frequent psycho-pathological syndrome in psychiatric practice, and some authors consider depression to be the most frequent psychiatric condition in the elderly. Depression is a psychic condition characterised by a serious emotional unbalance and by a considerable decrease in life quality that affects professional activity and interpersonal relationships over different periods (Beck 1970; Maslowski 1972). Depressive suffering is a “moral suffering” because it deeply affects a person’s value system (Dehelean 2001, 51). Depression is characterised by the lack of hope, and the depressed person is no longer capable of experiencing joy, feeling deeply sad. The depressed experience their suffering through despair. Depression impacts a person’s global life mentally, bodily and spiritually, and is a portmanteau word that covers a wide range of feelings from temperate despair to intense despair (Grunlan & Lambrides 1984, 121). Because it involves deep suffering and sadness, depression has a negative impact on sleep, appetite, life quality and patient’s opinion on their self and environment (Carp 2001). A depressive person lives in the past rather than in the present—in fact, there are no present or future for the depressed. Negative emotions and thoughts support each other, being the two sides of the depressive coin (Cungi & Note 2002, 47). The frequency of depression is steadily increasing, with studies showing that one in four subjects are susceptible, and up to 7 to 8% of the planet’s population suffer from depression-related disorders. In 1983, there were over one hundred million depressed people in the world. This number is larger nowadays, and 40 to 60% of the total psychic disorders in the elderly are depression-related. Diagnosing somebody as “depressed” has become more common simply because of its greater incidence (Avdeev 2005, 8). The World Health Organisation (WHO) estimated that there were, in 2004, 1,321 million depressed persons worldwide. According to international statistics, 15 to 25% of the total population are affected by depressive episodes at least once in their life. Specialists from Bethesda Public Health Institute warn that, in 2020, depression will be the second cause of global suffering, in all ages, after arterial hypertension. Scientific studies show that depression damages individuals’ life deeply. In recent years, the number of Romanians suffering from depression has almost doubled compared to 1989. According to WHO statistics, about 20% of the population suffer from psychic disorders. Psychic disorders are

Chapter One

6

not necessarily a serious disease such as schizophrenia or Alzheimer’s, but can result in serious conditions if not treated. One of the effects of depression—suicide—in 2009 reached the values shown in Table 1-1 below. The high suicide rates in Lithuanian males (61.3) and in South Korean females (22.1) are to be noted. In Romania, the suicide rate was about three times smaller in men than in Lithuania (21.0) and about six times smaller in women than in South Korea (3.5). Table 1-1. Suicide rates per hundred thousand by country, year and sex in 2009 (World Health Organisation) Country Austria China Costa Rica Croatia Czech Republic Ecuador Egypt Finland Georgia Greece Hungary India Ireland Japan Kuwait Kyrgyzstan Latvia Lithuania Netherlands Norway Portugal Republic of Korea Romania Serbia Slovenia Ukraine United Kingdom

Males 23.8 19.0 10.2 28.9 23.9 10.5 0.1 20.0 7.1 6.0 40.0 13.0 19.0 36.2 1.9 14.1 40.0 61.3 13.1 17.3 15.6 39.9 21.0 28.1 34.6 37.8 10.9

Females 7.1 10.7 1.9 7.5 4.4 3.6 0.0 10.0 1.7 1.0 10.6 7.8 4.7 13.2 1.7 3.6 8.2 10.4 5.5 6.5 4.0 22.1 3.5 10.0 9.4 7.0 3.0

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Across the Atlantic, suicide was the seventh leading cause of death for males and the fifteenth leading cause for females in 2007. Almost four times as many males as females die by suicide, and firearms, suffocation and poison are by far the most common methods of suicide, overall. However, men and women differ in the method used (Suicide in the U.S.: Statistics and Prevention 2010): “Psychic disorder affects a person’s ability to behave rationally; it limits its inner freedom, it hinders communication with other people, it decreases its ability to exercise his/her social roles” (Lăzărescu 1994, 27). Therapeutic statistics show that people from lower social classes demonstrate a higher rate of psychic disorders and a higher probability of long-term hospitalisation than people from medium social classes. At the E. Pamfil Clinic of Psychiatry of Timiúoara (Romania), of the total 1,204 people admitted in 2007, 481 (40%) were elderly with depression, while during the period January 1 to March 19, 2008, of the 254 patients admitted, 92 (36.2%) were elderly with depression (Admission and Release Record 2008).

Types of Depression There are four classical types of depression—normal, masked, neurotic and psychotic (Hunt 2006, 73–74): -

-

-

-

Normal or circumstantial or reactive depression is characterised by spontaneous, involuntary responses to painful pressure. It occurs when daily issues pressure the individual for short periods (sudden diseases, failure cases, rejection cases). It can also be triggered by transition episodes, by stressful periods (teenage years, departure of children from their home, menopause, major upheavals and retirement). Masked or hidden depression is, in fact, a state of conflict, of unresolved issues hidden somewhere in one’s heart, to be forgotten. In this case, painful feelings are denied or hidden. Escape from this state can be achieved by totally involving in other activities. Neurotic depression is a minor depressive disorder. It is a state of prolonged depression (lasting longer than the recovery period). Responses and symptoms of this type of depression negatively affect a person’s biological and social activities. The cause is somewhere in the person’s past. Psychotic or advanced depression is a major depressive disorder. It is a severe state of depression. At this stage, a person can lose contact with

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Chapter One

reality. Such a person can experience hallucinations, disillusions and/or schizophrenia. A simpler classification distinguishes between two types of depression (Treichler 1997, 1) (Figure 1-1): -

-

Reactive or neurotic or exogenous depression is a form of depression caused by an event induced by psycho-social factors. It occurs as a response to loss, mourning or frustration occurring in people with a neurotic background. The onset is insidious. The patient becomes irritable, anxious, discontent, yet still looks for social contact; they fall asleep with difficulty, but there are no signs of motor changes as in endogenous depression. There are no psychotic symptoms, the patient is not cut off from reality, they do not beat about the bush, and they do not have hallucinations. The patient responds to the stimuli from their environment. Suicide rate is low in exogenous depression patients, and it is rare that relatives have the same disorder. If the depressive person gets out of this condition, they tend to recover and become stronger. Endogenous depression is the disorder in which the patient wakes up in the morning feeling pressure. Endogenous depression has biological causes. It occurs in personalities previously either melancholic or healthy. It has an acute onset (there is a “break” inside the person). The patient does not fit affectively with others: they are an insomniac, waking very early in the morning; they have a motor inhibition or, on the contrary, are extremely agitated; they feel cut off from reality and tend to commit suicide. They feel depressed but, unlike patients suffering from reactive, exogenous depression, do not know why. Endogenous depression is caused by inner events. There is incidence of endogenous depression among family members.

In 1996 the WHO grouped depressive disorders into four types (in Loo & Loo 2003, 71–72): -

Light depressive episode (without somatic syndrome, with somatic syndrome) Medium depressive episode (with somatic syndrome) Severe depressive episode (without psychotic symptoms, with psychotic symptoms) Recurrent depressive disorder (without somatic syndrome, with somatic syndrome, without psychotic symptoms, with psychotic symptoms).

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Figure 1-1. Classification of depression

ENDOGENOUS DEPRESSION DEPRESSION

EXOGENOUS DEPRESSION

Depression is also called “depressive dementia,” “pseudo-dementia,” “affective disorder” and “unipolar depression” (Gal 2001, 71). Depression is much more than grief and sadness. It is a state of sadness that seems reluctant to go away. Older depressed people feel valueless, useless, helpless and hopeless, and withdraw from routine activities, their sleeping and eating patterns changing, and they experience difficulties in thinking properly and logically. Most often, depression seems to be accepted by society, by the patient and by the doctors as part of the ageing process, but this is not true. Depression is not part of normal, natural ageing. It is a medical disorder and, as such, it can and should be treated. Having a wide range of severity, it affects about 15% of the elderly. No matter the symptoms, the disorder can be treated successfully in more than 75% of the cases (Gal 2001).

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Chapter One

In many cases, the difference between the sadness caused by mourning and depressive disorders is subtle, and it can be carefully observed during longer periods. People suffering from depression (even severe) are aware of their lack of memory, while people suffering from senile dementia are not. Depression and dementia are quite different. People suffering from senile dementia are very prone to depression and, in most cases, treating depression can be useful.

Expressions of Depression There are a few signs specific to depression that allow us to identify it in a patient. Here are eleven warning signs of depression (Spencer Scott 2012): -

Persistent sad, anxious, or “empty” feelings Feelings of hopelessness, worthlessness, or helplessness Frequent crying episodes Increased agitation and restlessness Fatigue and decreased energy Loss of interest in activities or hobbies that were once pleasurable Difficulty concentrating, remembering details, and making decisions Sleeping too much or not enough Poor appetite or overeating Expressing thoughts of dying or suicide Persistent aches or pains, headaches, cramps or digestive problems that don’t ease with treatment.

All these are but a few signs of depression which usually associate with one another and can be identified in a sufferer. These states and feelings in the elderly experience should be taken seriously, each of them an alarm signal urging help for the depressed. Depression signs can differ from individual to individual and from country to country, and a depressive old person from Romania differs from a depressive old person from the United States of America. R. Held considers that no matter the form, depression expresses itself through dysfunction or somatic damage, endocrine trauma and failure, nutrition deficiencies, insomnia, cardiac and digestive disorders, moving the emphasis to the physical level (ùchiopu 1997, 83). Depression can affect people of all ages, and its signs differ in old and young (teenage) people. When an old person suffers from depression, he/she complains rather of physical symptoms than of depression; treating

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depression in the elderly will not remove physical pain, but it will ease suffering considerably. Depression is a persistent feeling of grief that lasts for days, weeks and even years and is accompanied by one of the signs and symbols mentioned above. It can lead to deep discouragement, and to an almost chronic pessimism. Depression is the state that occurs after all solutions and actions have been tried, when there are no more options for a persons’ condition and they surrender to depression and despair.

Risk Factors in Depression Depression has several causes, and one cannot point to a single cause, because there is no such thing. Depression is the result of a combination of states and it usually occurs where there is specific sensitivity. Depression is triggered by the association of several biological, psychological and social factors (Hughes & Stoney 2000). No matter its causes, depression is more than a psychic state. The disease is correlated with changes in the brain functions and is closely linked to unbalance in certain types of chemical substances (neurotransmitters) that carry the signals to the brain and nerves. Etiologically, there is no unique cause triggering depression. Constantin Enăchescu (2004, 385) points out, in this respect, three aspects: -

Somatogenic (to which depression is also associated) Endogenous (the predisposition of a person to “attract” depression because of a depressive structure) Psychogenic (as a response to everyday events—reactive-situational depression).

Life events are environmental factors and social factors (separations, deaths, job changes) which result in depression symptoms (Beekman et al. 2002). Some of the factors involved in depression are (Loo & Loo 2001, 37): -

-

Gender: depression is twice more frequent in women than in men (women differ in emotional organisation and tend to solve emotional conflicts through neurosis, which opens the path to depression; men tend to turn depression into delinquency or alcoholism). Age: classical authors estimate that the incidence of depression increases with age.

12

-

Chapter One

Professional insertion: depression is more frequent in housewives than in employed women, and also depends on the type of job. Socio-economic status: income, accommodation, quality of social relationships.

Physical Causes of Depression -

Hormonal or chemical unbalance (hormonal changes during puberty can lead to depression, and so do hormonal changes after giving birth to a baby or hormonal changes accompanying menopause) Medicines and drugs Old people’s chronic diseases Old people’s melancholic temper Improper nutrition, rest and physical exercise Genetic vulnerability (50% of bipolar depression patients have at least one parent suffering from this disorder, while people whose close relatives suffer from depression are twice more vulnerable [Hart & Hart Weber 2001, 55–56]).

Emotional Causes of Depression -

-

Repressed anger caused by loss of self-esteem and of esteem for one’s partner or beloved ones, loss of fortune, loss of social status, loss of expectations, loss of health and abilities, loss of goals. Extreme fear of death, losing one’s job, failure, an empty home after children’s departure, ageing, loneliness, rejection. The elderly experience now, more than ever, fear of physical impairment, of losing economic safety, of death, of their children’s indifference, of losing children, of losing friends and social contact and, above all, fear of being abandoned (Wolff 1978). Interiorised stress because of moving out (maybe to an asylum for the elderly), material problems, financial obligations, family responsibilities, adult children with problems, or a partner with an illness. Clinical studies suggest that 50 to 75% of visits to a psychiatrist’s practice are motivated by stress. As for the death rate, stress is a risk factor that is more serious than smoking. According to a report of the National Observatory of Drugs, the French are among the greatest consumers of antidepressants and tranquilisers in the world, while also being the greatest consumers of alcohol. Alternatively, in most cases, alcohol consumption is a way to manage stress and depression-related problems. In Western countries, the depression rate

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has increased steadily in the last thirty years, and in the most advanced anti-depressive consumption has doubled in the same period (ServanSchreiber 2005). Lack of coordination between resources, abilities and capabilities, between society’s demands and one’s possibilities of meeting them play a pivotal role in stress. Pathogenic intervention of psychic stress in affective disorders has long been acknowledged. Psychic stress is incriminated as one of the most important factors triggering depressive disorders. Stress and lack of control of stressful situations can lead to depression. There are individual differences in stress response: We ask ourselves if stress has forms specific to each age. Stress contributes substantially to ageing. Despite common belief and the fact that ageing is the most difficult period in one’s life – health declines, disabilities increase, attractiveness of the physical world decreases, financial difficulties occur, social marginalisation and stigmata occur, etc.—old age is not a stressor in itself, it is not a determining factor or, in other words, a predictor of stress. (Prelici 2002, 83)

-

Low self-esteem and wrong direction. Low self-esteem, often associated with depression, reflects a lack of respect for oneself, the persistence of the feeling of inadaptability, of inferiority, as well as the fear of not being wanted. Self-esteem is the nucleus of the concept of the self, meaning that the person feels competent, respected and praised, which has a significant impact on human thought and behaviour. Self-guidance and self-appreciation aim at one’s own ability of controlling one’s own life in relation to others, of accepting the responsibility of one’s own decisions and actions in society, while observing the rights and needs of the others (ibid.). Unfortunately, selfguidance in depressive people is mistaken or absent.

Psycho-social Causes of Depression The psycho-social factors generating depression in the elderly, and supporting the methodological and research parts of this book, are: -

Retirement without being prepared or wishing for it Losses of the partner, adult child, beloved ones (friends, neighbours, acquaintances), health, social status, assets, motivation for living Poverty Loneliness/Institutionalisation.

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Chapter One

High-risk situations are those to which we are highly sensitive. Likewise, a depressive agent is the product or the factor that facilitates or induces depression (Cungi & Note 2007). Depressive states can be triggered by important losses, by chronic diseases, by financial difficulties or by unfavourable changes in one’s life (Boiútean & Grigorescu 2005). Working for somebody’s benefit (e.g. grandparents with grandchildren) is important for both the elderly and the family. Losing one’s job results not only in economic repercussions, but also in a significant number of social and psychological consequences such as lack of self-esteem and identity, lack of structure and goals in life, and less contact with one’s friends and work mates (Bara 2000). All these factors lead to major depressive crises with severe effects, among which is a suicidal disposition. In general, these factors do not act separately—two or three such factors associate and result in depression. Retirement Quite often, retirement is associated with old age, in which the active adult loses their former status. For many, retiring is a psycho-drama, a very stressful event. Therefore, adapting to the retirement period is extremely important in the elderly. The moment of retirement is frequently a depressor in the elderly. It is now that many old people lose their self-esteem, feel useless and misunderstood. Both active women and men perceive retirement as a stressful event in their life, particularly when their professional life comes first and family comes second, and they suddenly lose everything that has been of importance for them. Some authors (Gârleanu-ùoitu 2006) claim that retirement-engendered disorders are more frequent and more intense in men than in women as men are more involved in their professional activities than women, who are also involved in household chores to which they can fully dedicate after retirement. Retiring means, for men, completely changing their status and roles; in general, they lose important statuses and roles, and the loss is more dramatically perceived when professional authority and social role are extremely important. The loss of roles gained with huge efforts during their active life is sudden and prevents them from adapting easily (at an age when the capacity to adapt also decreases), which results in a decrease of prestige and in dependence and depression. Women bear retirement better than men, which can explain their longer lifespan. The crisis of retirement is less brutal as they shift easier from professional activity to

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15

household activities dedicating themselves, to a larger extent than men, to different family matters. Specialists also mention that another important factor impacting one’s attitude toward retirement is the environment, being either urban or rural. In the rural environment, cessation of activity is never complete or sudden. In exchange, very active people from the urban environment that have dedicated themselves, during their entire adult life, exclusively to professional activities, bear retirement with more difficulty and find it harder to adapt to the new situation. Among the measures meant to prevent the post-retirement crisis, we could include a gradual retirement plan over several years during which the person can develop hobbies and interests outside the work place. Before retiring, the person can be prepared through counselling to see the retirement as an opportunity for recreation, encouraging participation in club activities (angling, gardening, volunteering) to be developed later (Wolff 1995). In order to prevent individuals from perceiving retirement as a trauma, we need to prepare them for it in due time. This way, we will be able to avoid many of the negative effects of sudden retirement on the old person’s life. When an old person signs their retirement application, it should not be a stigma, an acknowledgement of their uselessness; on the contrary, it should express the desire of the person to interrupt an activity in order to start a new one. This change of function of activity can be seen not as a trauma, but as a blessing. Unfortunately, many old people experience retirement as some kind of dismissal, of humiliation, turning retirement into a crisis of prestige. Retirement is perceived by some old people as a retirement from social life—they no longer participate in cultural life and stop visiting their neighbours, focusing on just a few aspects of their life such as food, hygiene and rest. Retirement is perceived, by other old people, as a normal stage in life that should be lived properly, and they focus on reading, fine arts, and gardening, activities that they practice with great pleasure and in the company of their pairs. The family can be of great help for the retiring old person (Hepworth et al. 2010). If the latter benefits from emotional care from their family, their psycho-affective state will be good. Likewise, if after retirement the old person is invited to live with one of their married children, they will feel useful again and will enjoy financial assistance, moral support and company (particularly that of his grandchildren). Retirement age is also the age of changes in all major life aspects of family, friends, recreation and religion, and in attitudes toward health

16

Chapter One

issues, economic security, joy of living and happiness. After retirement, there is sometimes a decrease in material resources which results in conditions of poverty. Upon retirement, many old people have to face humiliating, painful material limitations that have not affected their life before. Authorities often forget that a pensioner has worked all their life for a decent, normal pension. They also forget that the elderly also have rights for their work and the right to benefit from social facilities. Retirement is an attribute of the modern era. It was first introduced in Germany (1889), then in Denmark (1891), New Zealand (1908), England (1908) and the U.S.A. (1911). At the beginning, retirement was conceived as a form of social work (1879–1915). Before this time, people worked throughout their entire life. The state pension system in Europe was created by Otto Von Bismarck during 1870–1880 and was called the “iceberg” of the pension system. Bismarck, in nineteenth century Prussia, relied on employee taxation but the taxes were rather insignificant because of the small number of pensioners. Retirement age was therefore established at sixty-five, with a working lifespan of only forty-five years. Since then, the pension system invented by Bismarck has become a major issue in European countries where the number of pensioners is increasingly larger and that of active people increasingly smaller. The private system of pensions appeared against the background of this major issue. In the 1980s in Chile, Jose Pinera, considered the primary expert in private pension systems, tried to change the paradigm of the pension system developed by Bismarck. Pinera started with the question: Why should we take from the employees and give it to the retirees? Why not make savings, as we do to buy a bike or a house, for the pension the individual will have when they decide not to work anymore? He claims that once you let the employee decide by themself how much to save and where and when to retire, you make them free (Pop 2007). Long-term, the passage from the state system of pensions to the private one will free pensioners from state dependency and restore their dignity. There are several types of responses in the elderly to retirement (Gal 2001, 93): -

The balanced type, the most frequent, is a natural acceptance of retirement, sometimes accompanied by resignation The optimistic type, when the old person enjoys retirement and sees a new beginning in it

Depression in the Elderly

-

17

The pessimistic type, when the old person sees retirement as an end, as a catastrophe.

A. M. Guillemard (in Gârleanu-ùoitu 2006, 44–45), describes three types of retirement: -

-

-

The retirement-consumption that can have two forms: one is part of the “mass-consumption” through leisure activities (trips, holidays, shows), the other belongs with the family (time spent with the grandchildren, family reunions, achieving and financing family projects). For some of them, this is also the period when they can discover family dysfunctions or family dissatisfaction that support depression states. The retirement-revendication that emphasises the place occupied by the elderly in society—such a pensioner always feels wronged, identifying many discriminatory situations and also has pro-retirement initiatives. The retirement-participation marks adhesion to society and expresses high consumption of mass-media (radio and TV broadcasts).

Guillemard (ibid.) claims that social determiners of retirement activities are rooted in active life (incomes, relationships, health state, ageing level, instruction level, and other activities beside one’s job). Statistics show a low rate of survival after retiring. We cannot say if it is about depression, privations or purely and simply wearing and organic over-ageing (Dehelean 2001). At the European level, standard retirement ages range between sixty and sixty-five; according to the new directives of the European Union, they plan to establish standard retirement age at sixty-five for both men and women, which can help fight depression. Losses Among the factors most often mentioned that trigger depression is separation from or loss of a close person. F. K. Goodwin & K. R. Jamison (in Denninger, Henderson & Fallis 2002) validated this hypothesis, emphasising the role of event accumulation in life. Old age is the age with most losses, and a beloved family, acquaintances and life partners all reduce the network of relationships. The old person starts to confront more and more with a feeling of loss and fear: “fear of losing someone is, sometimes, more intense than fear of losing oneself” (Dehelean 2001, 18).

18

Chapter One

The most painful of all losses are those of one’s adult child and/or partner, particularly if the affective bond between the two was strong (in such cases, the loss of one’s partner results in the death of the other) (ibid.). Some elderly people lose their house at this age and go to an institution because the person(s) in charge no longer take(s) care of them. This kind of loss results, most often, in a crisis. It is an acute emotional disorder associated with a lack of capacity of facing problems, obvious at physiological, psychological, cognitive, behavioural and relational levels. The loss can be either a real or symbolic one. Loss of health is frequent among the elderly. It is a loss difficult to bear by both themselves and their families. Ageing and old age brig significant changes in the body that play an important role in the lives of old people. Almost all severe, chronic diseases are risk factors in depression in the elderly (Barbier 2003). Statistics show that diseases are more frequent with age. In many situations, diseases are diagnosed in the elderly at advanced stages, after a long evolution. With age, there are also changes in the necessary amount of vitamins. This is why the elderly need to supplement their nutrition with vitamins and minerals to maintain health and improve life quality. Many old people feel they are purposeless; they no longer dream, they no longer develop ideals, getting to focus on physical diseases alone. They are driven to talk, most of the time, about their diseases and suffering. With no more activities on which to focus, their attention goes entirely to their own body which acquires special importance to them. Old people with disabilities and chronic diseases have low levels of physical competence which limits their ability to face environmental demands. Even relationships with loved ones, family and work mates are affected by physiological and psychological changes specific to old age. As a result of hormonal changes the menopause occurs, triggering depression in fifty-year olds. Depressed old people lack the desire to recover, accepting disease, their own destiny, and even justify it as a sort of punishment. Thus, six to twelve months after their first heart failure, 90% of patients become depressed (Avdeev 2005). Depression is specific to the modern world. According to doctors, it is increasingly spread all over Romania, and psychic disorders are steadily increasing in number. Studies show that one in three Romanians will suffer, at some point in time, a psychic disorder. Socio-economic factors make Romanians vulnerable to psychic diseases. Old people are more and more prone to depression because of everyday deprivation. From a medical point of view, old people’s state of health is precarious, requiring numerous primary and specialised medical investigations,

Depression in the Elderly

19

treatments and free-of-charge medicine. The diseases of old people affect the sensorial sphere (sight and hearing disorders), the motor sphere (pareses, rheumatism, joint diseases), the internal organ sphere (cardio-vascular diseases, digestive and nutrition diseases), and psychic disorders. There is an increase in the rate of cardio-vascular, rheumatism and digestive diseases in the elderly. Insufficient or superficial sleep is caused by disease, suffering and premature ageing. An old person needs eight to nine hours of good sleep starting no later than 11 p.m. (Păúcanu 1994) In psycho-somatic diseases, the emotional factors with the greatest impact are stress and suffering, particularly if accompanied by feelings of loneliness. Negative emotions, stress, suffering, anxiety and fear affect the physiological functions of the body, resulting in difficult breathing and frequent heart palpitations, etc. We can say that the psyche impacts the somatic and the somatic impacts the psyche, and the psychosomatic disease largely depends on personality and attitude. Organic diseases are also accompanied by psychic responses (e.g. hyperthyroidism results in irascibility), the same disease differing from person to person. Psychic mechanisms such as imagination, obsession and depression can result in organic suffering. On the other hand, psychic disorders are transposed at the organic level and cause somatic diseases. All diseases have a psychic aspect, and many diseases are triggered by emotional-affective factors. An old person’s attitude toward disease is critical in the triggering or healing of a disease. An optimistic old person has better chances of being cured than a pessimistic one. Psycho-social factors also contribute to both disease incidence and to maintaining it. A normal ageing process affects the entire body of the adult by diminishing or aggravating their health state by decreasing body resistance to effort and aggression from pathogens, and by altering vital functions. Poverty Poverty is perceived by many old people as a heavy burden of old age. Poverty is sometimes considered to be the fourth world, specific to poor elderly people. Old people are one of the most vulnerable groups exposed to poverty risk. Poverty is not a virtue, but a shame, and a very hard one to be carried. But whose shame? The pauper’s shame, of course, and equally the rich as well, and of society on the whole. Some find it difficult to accept and

20

Chapter One

would rather ignore it. However, poverty exists, and even Jesus Christ said: “Bring the homeless poor into the house” (Is. 58:66ff.).

J. van Stralen (1996) defined poverty as the appearance of multiple privations and of the incapacity to overcome crisis situations. A state of poverty does not involve the existence of a single privation; in most cases, it is about a sum of lacks: lack of job, worn out or improper clothing, lack of food or little diversified food, a poor education and the impossibility of resuming it. In addition, there is also a sum of issues a pauper cannot face, such as limited income, debt accumulation, health issues, impossibility of paying for one’s education, feeling of embarrassment or of exclusion from the society, appeal to alcohol, etc. Poverty is usually associated with a change of the living standard from bad to very bad (ibid.). Poverty is a state of permanent lack of resources necessary to support a decent life as acceptable for a given society. Poverty means insufficiency of resources for a normal social life. Poverty is determined by comparing one’s resources with a certain level considered a poverty threshold. Since the focus is on the lack of resources, we refer here, particularly to economic resources as a general, essential source of most everyday life activities. Being a poor old person is to be resourceless. Poverty occurs only when there are no resources to live a normal life from the perspective of both society and old person. Defining poverty is also a matter of duration. Because of life fluctuations, anybody may, for shorter periods (one to several months), not have the income necessary to ensure minimal life standards. Resources accumulated can compensate this temporary lack, while some types of consumption can be postponed. In such a situation, a person cannot be considered poor. Poverty occurs only when the lack of resources lasts longer and cannot be compensated by previous reserves or by postponing consumption. Poverty can be of two types, absolute and relative, but there is no clear boundary between them. The concept of absolute poverty aims at establishing a universal standard—a threshold below which, in any community, a person is considered poor. Absolute poverty usually relies on the idea of subsistence, defined as the lack of means necessary to support human life. The concept of relative poverty is more functional. It focuses on the identification of minimum acceptable conditions in a given socio-cultural context. From this perspective, this concept of poverty is more effective in analysing poverty within communities and allows a more realistic image at a given time. Relative poverty relies on the sociologic concept of relative frustration. Frustration is the effect of blocking the

Depression in the Elderly

21

satisfaction of a need, and it therefore represents the result of comparing individual possibilities with one’s own necessities. As a social being, man always compares himself with others (his consumption compared to the consumption of the others). Relative poverty can be linked to relative frustration, and a man defines himself as poor, or not, in comparison with others. According to UN statistics, 1.4 billion of the 5.3 billion people on earth are poor. Of the 1.4 billion poor people, 1.2 billion live in developing countries. There are two hundred million poor people in developed countries, of which thirty million are in the U.S.A. and one hundred million are in the ex-Soviet Union and Eastern Europe countries. These data concern the situation before the onset of transition in Eastern Europe. One of the costs of transition to the market economy is aggravation of poverty (Constantinescu 2000). At the level of common knowledge the situation of the American poor is less serious than that of an Indian poor, things can be rather different as an American’s poverty can be “uglier” from a human point of view, more degrading and more explosive socially, than an Indian’s (Zamfir & Zamfir 1995, 31). The psychic balance of an old person becomes labile; material difficulties make them tired and increasing deterioration of living conditions turn them into a pauper. The lack of satisfaction of basic needs of nutrition and health, and the rather precarious comfort in ensuring these needs, impact their adaptability to the new living conditions (Puwac 1995). Poverty limits the old person’s freedom and deprives them of dignity. The Universal Declaration of Human Rights, the Declaration on the Right to Development, as well as a series of other instruments of human rights clearly state this. The Vienna Declaration, adopted in 1993 at the World Conference of Human Rights, states that “extreme poverty and social exclusion constitute a violation of human dignity” (Strategia economică pe termen mediu a României 2000). Many old people do not admit they are poor, simply living this way quietly. The direct income of an old person ensures, somehow, prestige, social status, and material independence. Despite the fact that their incomes are not sufficient, old people try and help other people who live in poverty. There are numerous old people that have no source of income (they totally depend on their offspring) and another large number of old people live below the minimum living standards. Old people’s expenses are, generally, for food, medicines and lodging (Mărginean & Socol 1991). The impossibility of buying the necessary medicine because of the shortage of income leads to depression both in the old person and their partner who is incapable of helping their beloved.

22

Chapter One

Loneliness Loneliness has become a “disease” for an increasing number of people, and sociologists have shown that young people are more affected by loneliness than the elderly (Crăciun 2005). It can be defined as a disease when it lasts for an undetermined period and affects an old person against their will. For some old people, loneliness is a refuge, which lets them analyse themselves and everything around them, but the danger lies in chronic loneliness. Chronic loneliness can be very dangerous and can be a symptom of depression, leading to it and, ultimately, suicide. Some old people prefer to be alone because they do not want to communicate with people they have nothing in common with. An old person once said: “I have always had friends, but in my soul I have always been alone.” Loneliness does not occur at a certain age; one can be alone no matter the age. It is not age that engenders loneliness, but one’s state of mind. At old age, a person becomes lonely and the support they get from social services is not enough because social and emotional issues in the elderly are less known than material ones (Brown & Payne 1990). In general, loneliness occurs in old people because their social connections are few rather than because they would not like to have more, because they generally feel isolated. Loneliness in an old person’s life can also occur as a result of repeated failure. Though some of them try to turn loneliness into some kind of virtue, loneliness is still a negative state and results in vulnerability. Some associate loneliness with a loss that makes an individual incapable of acting normally in life situations. After they retire, people tend to isolate themselves. To help an old person escape isolation and loneliness, a social worker needs to help them integrate in a group in which to discover themself and others. Studies show that people who need to socialize and do not are more discontent than people who live with other people, are more exposed to depression and to health issues and have a lower life quality (Lauer & Lauer 2004). This is why we need to carefully select the group in which we try to integrate old people to help them get rid of loneliness. Depression is one of the effects of loneliness. At an old age, depressive states are more and more frequent, and this results in both inner and outer imbalance. In most elderly people, depression is doubled by the fear of death and the nostalgia for happy episodes in their life. These feelings are stronger and stronger after the old person loses their partner, be it a beloved one, a comrade or a pragmatic relationship (DruĠă & DruĠă 2000), or acquaintances of comparable age. Old people that have no children or relatives find it more difficult to adapt psycho-socially. In most cases,

Depression in the Elderly

23

loneliness and isolation makes old people more vulnerable to depression. Most old people prefer the company of other people: they wish to communicate and to help people in a similar situation to get rid of boredom and loneliness. Institutionalisation In many cases, institutionalisation makes old people feel lonely. When somebody chooses or is forced to move to another place or to a care centre, the pressure of the environment increases and the old person is challenged to test their own limits (Codul bunei îngrijiri 2008). If the demands become too difficult they feel overwhelmed and experience physical and emotional imbalance. If the demands are below the old person’s level of adaptation, then the effects can consist in sensorial deprivation, boredom or even dependence. Quite often, the old person moving out has a feeling of exasperation and behaves in a desperate way, recurring to irreversible acts such as suicide. Giving up their habits and the place they have lived their entire life is traumatic because the old person becomes attached to such things. A dwelling is a fundamental need for everybody, but it acquires, in old people, a special meaning. It is not just a comfortable place with affective value, consolidated in time by one’s personal feelings linked to family, friends, and neighbours. A dwelling is part of the old person’s life and they should not separate from it. Loneliness in one’s own dwelling is easier to live with than “uprooting,” and there are frequent cases in which leaving one’s home shortens one’s life, despite high-quality care services (Puwac 1995). Institutionalised old people are more prone to psychiatric disorders and depression in particular. The risk of depression is more increased in institutionalised old people compared to those who live in a community with their own families (we will see later on in this book that this hypothesis is confirmed). Many old people reject hospitalisation and institutionalisation because they fear that it could be their last move, and that they would never return to see their loved ones and their home. At present, institutionalisation of old people is avoided and they tend to be removed them from institutions. Domicile care activity aims at preventing old people from being institutionalised. Brown & Payne (1990, 156) claimed that, in reality, only few old people need full residential care, and most old people need a certain kind of assistance and support from the community. We tend to place our elderly in institutions, hoping that it is better for them, but we do

24

Chapter One

not see (or do not want to see) that many of these institutions are located in old buildings lacking the necessary space to shelter them. Most old people are housed in a completely improper way, and it often happens that two people share the same bed. In many such institutions, there are no trained personnel to provide medical and social assistance and there are no social work programmes to train such staff (Popa et al. 2008). The institutionalisation of old people is still an issue at the national level in Romania, on the one hand, because of the extremely small number of institutions capable of receiving the increasing number of people and, on the other, because of the lack of funds necessary to properly equip these institutions. The pensions of many of these people are ridiculously small and cannot meet basic needs (not to speak of small desires or caprices of the elderly) (Government’s Decision No. 886 from October 5, 2000 regarding the approval of the National grid for the assessment of the needs of older people; Law No. 19 from March 17, 2000 regarding the public pension and other social insurance system consolidated on January 15, 2009). Institutionalized old people claim they are depressed, unhappy and that they cannot adapt, and studies in the field show that they have less vitality, are less active and die sooner than people of the same age who live in communities. It also happens that institutionalised old people are deprived of their own belongings and become the target of verbal and even physical aggression from the institution staff. Another aspect difficult to deal with is violation of intimacy, as many institutions for the elderly do not have separate cabins in the restrooms, the rooms are overpopulated with beds, and old people have to share the same wardrobes and clothes. Counselling the family of the old people plays a pivotal role in avoiding institutionalisation, and is an important step in abandoning the idea. Old people’s families need to be educated to succeed in fighting the myths concerning the elderly. In many cases, the lack of social support from the extended family or from the community results in the loneliness and social isolation in the elderly. Old people always want to interact with the people around them, and this is why the support of the family and of the community is so important. It is only family, community and close friends that can meet the need for a certain meaningful, dignified place that all human beings long for (Brown & Payne 1990). Family is and remains, for the elderly, psychic and material support, and is undoubtedly the most effective antidote to loneliness and abandonment, contributing to their physical, psychic and somatic health. Unfortunately, the present socio-economic, hostile and frustrating conditions make the elderly feel

Depression in the Elderly

25

alone, thus “mutilating” their own affective resources (Mărginean & Socol 1991, 9). If the elderly cannot cope with their own children, separation becomes the main cause of inadaptation to life conditions in the elderly. For most old people, family is the basic vital factor, and this is why family resources should be valorised in the assistance and care of the elderly. The death of one’s partner, the lack of a group of friends, and the feeling of uselessness engendered by retirement can result in depressive states, anxiety and the aggravation of somatic diseases. This is why old people need, more than ever, the support of the family (husband or wife, children, grandchildren, other relatives). In some cases, the lack of a family could be replaced by groups of friends, groups of volunteers or by senior clubs or day centres. The quality of family and inter-human relationships plays a crucial role in the incidence of psycho-somatic diseases. Family and society are pivotal in supporting the elderly and their life quality. The environment on which the elderly rely is the society in its entirety, the community, the neighbourhood, the dwelling and its surroundings. The physical environment of the old person has social and psychological effects on them. The old person tries hard to keep a balance, but it is very difficult because the environment changes continually without care for the individual. Research in the field shows that the church is an important tool of social support, its members benefiting from increased immunity to both somatic diseases and psychic disorders. Researchers note that people taking part in divine services tended to become depressed less often and use less tranquilisers and sedatives. In many cases, numerous researches show that social support protects against life crises-related emotional disorders. The lack of support from the family and community pushes the elderly to isolation and despair, and ultimately to depression. The quality of the affective environment and of social links is a factor of prevention in depression (Barbier 2003). Old people are often not ready and defenceless in the face of modern life, urban complexity and social change, hence their difficulty in adapting. The old person no longer knows what to do, what to think; on the other hand, they have to face not only loneliness or isolation, but also losses (of a partner and/or friends), scarce visits by their children, relocation, and a feeling of uselessness. All this explains why depression is so frequent among the elderly (Barbier 2003). An individual is not in themself vulnerable, but become so because of different factors such as poverty, improper housing, low-quality services, and disadvantaging regulations. Events in the social environment (socio-

26

Chapter One

professional, socio-cultural, relational) impacting the life of an old person have emotional consequences and produce psychological changes or even psychic disorders characteristic of involution. If in their young and adult ages an individual manages to make up a positive image of themself and an intimate relationship with the others, at the third age, when they are between integrity and despair, the old person will place themself inbetween. Integrity supposes that to be aware of the fact that your life has had a purpose, then you accept yourself with all your qualities and defects, and not regret what you have not achieved (Drimer & Matei-Săvulescu 1991; Balaci 1996). Despair results from not accepting one’s own self and leads to frustration, particularly when confronted with the impossibility of changing anything whatsoever and with insufficient time (Gal 2001). Depressive states can be triggered by important losses, chronic diseases, relationship or financial difficulties, or unfavourable changes (Boiútean & Grigorescu 2005). All these factors can lead to the triggering of a major depressive crisis and ultimately, to suicide.

Defining and Perceiving Depression from the Perspective of the Elderly In general, the elderly are too tired and overwhelmed to fight depression. They face difficulties in seeing their circumstances and particularly themselves. Some of them are tempted to see life through a “black filter.” An old person undergoing depression starts to hate themself, feels helpless and hopeless about their near future. The depressive feels there is no more escape for them, no string to cling to, feeling that they are falling and wishing to die. Death is no longer seen with fear but as a solution and even a liberating one. They are not able to fight any longer because there is no will left to do so. -

What the elderly say about themselves: x “I hate myself!” x “I am no good!” x “Nobody loves me!”

-

What the elderly say about their situation: x “I cannot do anything at this age!” x “There is no solution for me!” x “I cannot stand it!”

Depression in the Elderly

-

27

What the elderly say about their future: x “There is no more hope for me!” x “Nothing is going to change!” x “It is too late!” x “There is nothing for me to live for!”

In many cases, the old man’s opinion of themself and of their depression is the result of the attitude of the society toward depression and old age (Hunt 2006). Society has, in general, the following attitudes toward depression: -

Negative, because depression is upsetting Mysterious, because of the nature of the disorder Indifferent, because of the psychic nature of the disorder, in general Helpful, because of the empathy with the patient and of human love Repulsive, because of the diseased and of the diseased Fearful, because of the antisocial attitude of the patient.

The depressive old person may admit their state or may just as well deny it (Enăchescu 2004, 233): -

They wishes to admit their state and to get help They do not admit their state and do not wish to get help They partially admit their state and wish to escape being labelled as psychically diseased They admit their depression and even try to amplify it because they expect to get some personal social, family, affective or other benefits.

The old person confronted with depression is in an exceptional situation, having to deal with the issues characteristic to their age that dramatically change their life. In most cases, the depressed old person perceives their disease as a feeling of alteration of one’s own life, having the feeling they can no longer lead their life the way they did before becoming depressed, but do not know for sure what to do to escape the situation they are in. Freedom and self-control are excluded from the life of a depressed old person because of the disease itself. In some situations, losing one’s capacity of making rational decisions stops the individual’s development. This differentiates psychic disorders from everyday critical issues.

28

Chapter One

Diagnosing and Treating Depression Depression is a sad soul state, whose size, intensity and duration are variable. The border between normal and pathological is sometimes uncertain. (Loo & Loo 2001, 12). After a person turns sixty, diseases and sufferings are more and more resistant, but this does not mean they cannot be diagnosed and treated. Defining normality involves a rather serious work if we take into account the turmoil of society. These changes have been the subject of many psychiatrists because they are supposed to define and to diagnose (Sadock, Alcott Sadock & Ruiz 2009). It is a long time since we have tried to overcome the difficulty of defining normality. This concept, advanced by Offer and Sabshin, takes us back to the thinking of some psychiatrist-philosophers such as Karl Jaspers who claimed that, in the absence of linking the understanding of the patient’s personal world with the penetrating power, intuition and empathy of the investigator, it is impossible to make a real diagnosis of the patient (Friedman 2000). In time, the human has shown that it is a contradictory being, sometimes even paradoxical, and can behave both normally and abnormally. The word “normal” comes from the Latin norma (right angle)—that which does not oscillate to the right or to the left, but is right in the middle: “The normal is a qualifying term implying a value (‘I wish I were normal’). It is also a descriptive term pointing to a mean (‘I wish I were normal as the others, as everybody’)” (Tudose 2002, 19). Anxiety, deviation, disorder and alteration are suggested by the way Romanian language describes psychic disorders through idioms: “there is something wrong about him,” “to be a button short,” “to be crazy,” “to be mad,” “to be nuts,” “to be poor in spirit,” “to be strange,” “to be wrong in the upper story,” “to have a screw loose” etc. These idioms are not perfect synonyms, and they distinguish between “what is still normal,” “what is abnormal,” and “what is pathological.” These idioms are used when a behaviour stops being “normal” and needs an explanation that could be found in the disease. R. Campbell (2009, 447) defines psychically normal people are those people that are in harmony with themselves and with the environment in which they live. They can have deviating health, but it does not affect their judgement, their intellectual capabilities and, over all, their aptitudes of adapting socially and personally in perfect harmony. These people can be considered psychically perfectly normal. The concept of disease can point to a bad subjective experience, to indisposition and handicap, to a change in the welfare of the body and soul, and to performance behaviour and level. When talking about diseases, it should be done objectively, but when talking about a diseased

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29

person, it should be done subjectively, as an individual experience. Psychic disease has turned from a disease reserved to bad-fortuned people (“the fool of the village”) or from a disease reserved to the lucky (“a noble’s disease”), into an endemic disease of the end of the millennium, together with other somatic diseases that affect all social classes and all races (Friedmann 2000). Age is of importance in the evolution of all diseases and particularly in the evolution of a psychic disease. The concept of health designates bodily, psychic and social welfare, an individual’s capacity of performance in role playing and task achieving (Johnson & Schwartz 1987; Kirst-Ashman 2010). Mental health is a component of human life quality. It is society that establishes diagnosis criteria and enforces behaviour assessment standards. The process of assessing one’s personal state in an attempt to diagnose them should consist of the following: -

The history of the person and of their problems The medical examination of the person The examination of the mental state of the person.

Diagnosis is a rather ambiguous term with multiple meanings for many people. Confronted with a disease, we feel powerless until we diagnose it. If not diagnosed properly, the disease risks being improperly treated. Anybody can be diagnosed with “depression” if five of the nine symptoms below are present for two weeks, on an almost daily basis; depressive mood and loss of interest or pleasure must necessarily be present (Diagnostic and Statistical Manual of Mental Disorders): (1) Depressed mood (can be irritable mood in children and adolescents) most of the day, nearly every day, as indicated by subjective account or observation of others. (2) Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by subjective account or observation of others), and apathy most of the time. (3) Significant weight loss or weight gain when not dieting (e.g. more than five percent of body weight in a month), or decrease or increase in appetite nearly every day (in children, consider failure to make expected weight gains). (4) Insomnia or hypersomnia nearly every day. (5) Psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down). (6) Fatigue or loss of energy nearly every day.

30

Chapter One (7) Feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick). (8) Diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). (9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, suicide attempts, or a specific plan for committing suicide.

Depression is rather rarely diagnosed in the elderly. They do not admit it as such or they deny it until they give in and commit suicide without drawing anybody else’s attention. Risk factors leading to depression and then to suicide are often ignored or forgotten. Depression in the elderly can wear two types of masks, which makes diagnosis very difficult: -

The mask of normality and of “legitimate sadness” of the old person The mask of organicity that hides dominant somatic pain, suffering and anxiety (Barbier 2003).

Rehabilitating depressed old people consists in developing a favourable psychological climate meant to re-establish existing mental disorders. Psychiatric rehabilitation is guided by the following principles (Enăchescu 2004, 233): -

-

The conviction that there is a potential for growth and change Focusing psychiatric rehabilitation on the person, not in the disease Focusing intervention on behaviour and social functioning Inducing health and then reducing symptoms Reducing the gap between specialists and beneficiaries to strengthen working partnership Focusing psychiatric rehabilitation services on individual needs allowing the individual to exercise their social roles and participate in the community’s social life Supporting interventions on beneficiary’s involvement in the programme Making hospitalisation the ultimate alternative of intervention Developing supportive communities and networks through rehabilitation programmes Developing adaptation activities as a main goal.

People affected by depression do not always have the energy and the power of judgement to ask for a treatment—this is the task of the family,

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31

friends, professionals and other people the old person is in touch with. The postulate says that “once the cause is known, the remedy is simply to apply; in fact, the treatment consists in supplying services” (Prelici 2002, 62). Depressed people can reject the idea of looking for help, believing that this is a sign of personal weakness or a flaw of character, or that they should be able to overcome this alone. The recovery of patients with psychic disorders should be a social desideratum, a socio-moral duty because mental illness is no longer (at least in theory) shameful, being issues of interest requiring more and more understanding. Treating depression is safe and effective even in people with severe depression. What we should do in the future is to focus on preventing depression. Treating Psychic Diseases In recent decades, psychiatric treatment has changed radically. In the past, psychic patients were hospitalised long-term; at present, they try to avoid hospitalisation and treat patients with depression ambulatorily, at their domicile. Admission to a psychiatric service is done against the patient’s will when they lack the power of discernment, for reasons of personal safety and when they are a hazard to society. At present, many psychic diseases benefit from effective therapy. Depression is a frequent disease (more than 10% of Romania’s population is affected); fortunately, it responds to different available treatments favourably (Cungi & Note 2007, 205). Treating depression is possible in most cases. One of the most common medical issues, depression is also one of the most treatable. Sometimes, it remains untreated because the patient is not properly diagnosed or because it is accepted as part of the ageing process. In general, there are two main options in the treatment of depression: psychotherapy and medication. In psychotherapy, they practice cognitive theory and medication, behavioural therapy (relaxation and desensitisation), family therapy and group psychotherapy. Lately, a combined method has been used of chemotherapy and psychological and social therapies. To show the effectiveness of this method, Weissman et al. (1974) used social workers as social therapists to improve social adaptation of depressed patients and chemo-therapeutic treatment. The British researchers got results above those obtained when the patients were treated only with medicines. Other researchers also agreed that the combined method is more effective than just psychotherapy or medication. After the age of sixty, medicines should be progressively reduced every 10 years to reach, at the age of eighty, a level of only 50% of the medicines administered to a young adult.

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Therapeutic methods most used in psycho-social intervention are individual therapy, behavioural psychotherapy, learning social skills, family therapy, existential therapy, and group therapy. Be it psychotherapy, medication or combined method, depression can be treated and the elderly can lead a normal life. At least half of the depressive episodes in the elderly are recurrent. Continuing the treatment over seven to fifteen months after recovery reduces the risk of recurrence. For a treatment to be successful, a maintenance treatment should make the patient also take into account a balanced diet, avoiding alcohol, getting good sleep, along with social and material support from the family and friends. If there is another disease as well, treatment should be continued for that as well. Richard Bandler, co-founder of neuro-linguistic programming, believes that most depressed subjects have as many happy experiences as anybody else, except for the selective deformation (they only remember the black side of things) or for the minimising of what is positive and amplifying what is negative (Talău et al. 2007). Remedies against Depression Specialists in the field claim that there are a few simple steps an old person needs to make if they want to rid themselves of heavy sadness. Here are a few such steps: -

Regular sleep Balanced diet Regular activities carried out with others Removal of stress and avoidance of extreme fatigue Physical exercise Sunbathing (thirty minutes of sunbathing diminishes depression) Listening to music Keeping the environment clean Avoiding spending too much time in front of the TV Writing thank notes and notes of encouragement to other people Establishing small goals and objectives to accomplish Doing something useful.

Social Work and the Depressed Elderly Social life is increasingly complicated and the world is far from perfect; therefore, solving social problems should be increasingly professional.

Depression in the Elderly

33

There are vulnerable people whose needs are not fulfilled, such as children, elderly and disabled people. Social work should act more intensely to protect these categories of people (Prelici 2001; Sorescu 2005). The goal of social work is to make clients help themselves, to change the client for the better. There has been a long debate over the depressed elderly being treated in the family, in the community of friends or acquaintances or removing them from their families and treating them in special care centres. Intervention and care in the community start from the premise that it is not advisable to hospitalise a client. Sorokin & Zimmerman (1929, 164) noted that the number of psychic patients is larger in the urban environment than in the rural one. They claimed that morbidity is influenced by both geographical and social (relations and institutions), cultural (values and norms), economic, professional, spiritual, and recreational elements. Here are a few differences between life in town and life in the countryside: -

There is more stress in town than in the countryside Family is more involved in activities in town, while in the countryside, families are more united Town-based families have few members, countryside families are more numerous The town environment is not protective, while the countryside environment is more protective and safer.

Statistics made during the last ten years in this respect support all this. There is no healing in severe psychic disease; there is instead improvement or temporary recovery, which asks for permanent assistance. Studies carried out by Weisbord, Test & Stein (1980) pointed out not only the therapeutic advantages of the intervention in the community in clients with psychic disorders, but also economic ones depending on the classical intervention in the clinics. Differentiating form and content, a social worker should identify, together with the client, the problems the latter has and the order they should be approached. A social worker should be aware of the fact that the disease has a negative impact on both the client and their family. We should not forget that the person’s self-identity is maintained through their relations with others. A normal person plays a wide range of roles in their environment daily. However, the more severe the disease becomes, some of the roles are no longer played, and the person finds it more and more difficult to face responsibilities and to meet the expectations of others. An

Chapter One

34

old person diagnosed with depression has problems that can be solved not only through psychiatric intervention but in a wider context in which social care plays a significant role. A depressive patient should be seen as an individual that can be cured, and this influences both the social worker’s attitude and the attitude of the patient’s family and the patient themself. Rehabilitation and social reinsertion of depressed old people is a difficult task for social workers, and this is why they need to involve specialists from other fields if they want their results to be good and longlasting, such as psychiatrists, psycho-therapists, psychologists, counsellors and nurses. Most researches involving social workers in the solution of psychic diseased-people point out the fact that social work can really achieve prevention. It is also necessary that social workers be willing to learn from other professionals and to work together with them. Social workers need to broaden their horizons and to continuously improve their competences. Intervening in favour of a client is a major option, particularly when one has respect for human dignity and helps clients reintegrate into a normal life by remaking the links with their family, friends, neighbours and colleagues. Their presence in a multidisciplinary team is a must as a result of the necessity to reintegrate depressed old people in their family and socio-professional environment. The tasks of a social worker differ depending on the place where they work. If the social worker works in a community, then their intervention is possible at three system levels: -

Old person Old person’s family Old person’s community.

If the social worker is hospitalised, then social work implies identifying psycho-social needs and an attempt to meet them in favour of the beneficiary. While working with a depressed old person, a social worker needs to assess their specific needs in one or several planned meetings and use the assessment to develop an intervention plan, which should focus on the following aspects: -

The possibility of pursuing or resuming something they used to do with pleasure, to avoid boredom The possibility of paying for medicines Gratuity of counselling and/or of therapy

Depression in the Elderly

-

35

Access to information about their depression and how to manage it Involvement in support groups (family, friends and church) to enhance self-esteem and self-confidence.

For effective assistance, besides working with the depressed old person, the social worker will have to intervene and work with the old person’s family as well. One should not ignore the fact that a depressed person can impact the entire family. At family level intervention, a social worker can achieve three roles: -

-

Educator, meaning they supply information on the nature of the disease, its possible evolution, the emotional support the old person needs, and how to prevent recurrence. Mediator, meaning they help to calm the situation when the disorder causes a conflict, minimising the negative effects on the depressed old person; in certain cases, the conflict can be one of the main causes of the depression and, if this is the case, the social worker will have to work with the entire family. Counsellor, meaning they emphasise the importance of a warm, calm climate in the family, helping understand the feelings of fury and fear engendered by the disease; they teach the family how to encourage the depressed old person to escape their condition.

A social worker is a specialist familiarised with the language and the concepts of the medical model, particularly of the psychological model. To supply an effective helping hand, they should be familiar with the theory of the “depressive” language, according to which a depressed client’s language speaks of their bad perception of the self, which makes them feel broken and, therefore, useless (Beck et al. 1987, 143). The emphasis set by a social worker differs essentially from that of their colleagues. For them, disease aetiology and diagnosis are less important than the responses of the depressed old person or the impact on the wider environment. The psychic disease of a depressed person is, for a social worker, less relevant in itself than its psycho-social implications. In their study, Alan Butler & Colin Pritchard (1983) claim that in order to fully assess the situation and provide proper intervention, a social worker needs to take into account the following important coordinating principles since, no matter how classic the symptoms are, a disease depends on the patient and their specific circumstances. Therefore, each time we see a mentally ill person, we see a unique manifestation of the syndrome.

36

Chapter One

The more a person cultivates and dares be themself, the more they get support from society, approval and love from the beloved ones, and so the better their balance, self-confidence and chances to recover.

CHAPTER TWO AGEING, OLD AGE AND THE ELDERLY

Ageing and Old Age Sociologists operate with a number of concepts related, more or less, to old age: -

-

Age set, “a broad age band that defines the social status, roles and patterns of behaviour appropriate for those who belong to them” (Bruce & Yearley 2006, 6). Age(i)ng, “a process of change occurring with the passage of time” (Stuart-Hamilton 2000, 219), “the process by which the human body changes and matures over time, especially the means by which dying cells are not replaced in sufficient numbers to maintain current levels of function; the process by which human behaviour alters with time” (Strickland 2001, 22); “the chronological process of growing older” (Bruce & Yearley 2006, 7). Ageism, “discrimination based on negative stereotypes about the elderly and their capacities” (Bruce & Yearley 2006, 7); “stereotyping, holding prejudicial views or discriminating against individuals or groups based on chronological age” (Trogdon Anderson 2008, 103).

From a sociological point of view, ageing has to do with such issues as the life course, cohort perspectives, filial responsibility, intergenerational relations, intergenerational resource transfer, long term care, long term care facilities, retirement and widowhood (Borgatta & Montgomery 2000, 79–86); demography of ageing, ageing and health policy, theories of ageing and the life course, mental health and well-being, ageing and social policy, ageing and social support, sociology of ageing, ageing and technology, ageing and work performance (Ritzer 2009, 67–106; Ritzer & Ryan 2011, 10–11). Ageing should be seen as the growth process through which we get closer to true maturity. The more a person grows, the more they accumulate experience and wisdom.

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French composer Daniel François Esprit Auber said that: “Aging seems to be the only available way to live a long life,” and an old French proverb says: “On vieillit comme on a vécu” (“One ages as he has lived”). Biological ageing affects not only the outside of a person, it also affects the inside, and the elderly perceive it more from inside than from outside. There are people who consider old age as a state, a feeling, and age as what you feel and not necessarily what you look like; therefore, at sixty-five one may feel younger than a thirty-five year old. The word “gerontology,” coined in English in 1903 from the Greek words geron meaning “old man” and logos meaning “study,” designates the study of the biological, psychological and social aspects of aging. Gerontology is the theoretical basis for geriatrics; the term started to be used in 1950, though it was used for the first time in 1903 by Russian biologist, zoologist and protozoologist Ilya Ilych Mechnikov (Pop 2002). Gerontology was born as an independent science as a result of human curiosity, as people wish to know more about what comes next in their lives. Human curiosity focuses rather on the future than on the past. Gerontology was born to help people better understand ageing. The need to better understand ageing and its issues (depression, in particular, and anxiety) and to better explain it is obvious in a series of books for the “dummies” (Elliott & Smith 2006; Agin & Perkins 2008; Iljon Foreman, Elliott & Smith 2008; Elliott & Smith 2010). Like other sciences, gerontology has several subfields that better define it. Three such subfields are of particular interest from the perspective of this book: biogerontology, psychogerontology and social gerontology (see Table 2-1 below). Table 2-1. Subfields of gerontology Gerontology is the study of the biological, psychological, and social aspects of ageing Social gerontology Psychogerontology Biogerontology is a subfield of is a subfield of is a subfield of gerontology that gerontology that gerontology that focuses on the focuses on the focuses on the psychological aspects social as opposed to physical or the physical or of ageing biological, as biological aspects of opposed to the social ageing aspects, of ageing

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39

Social gerontology, as a subfield of gerontology that focuses on the social aspects of ageing, integrating components of gerontology and sociology (ibid.). Geriatrics (from the Greek words geras meaning “old age” and iatreia “treatment”) is the department of medicine dealing especially with the problems of ageing and diseases of the elderly. The term was introduced by American doctor Ignaz Naasher in 1909. In other words, it is the medicine of the elderly (or the medicine of a group of age [Pop 2002]). In brief, gerontology studies ageing from a bio-psycho-social perspective, while geriatrics studies ageing from a medical perspective only. Gerontological social work is a subfield of social work defined as the process through which old people benefit from social protection measures and professional care aimed at meeting their needs and good social insertion, at increasing life quality and at preventing social marginalisation. It is, therefore, the totality of professional activities allowing the elderly to benefit from assistance in improving their condition (Stanciu 2008). For more and more people, old age corresponds to retirement time. Many old people get depressed after they retire if they perceive it as a kind of social fall or as a handicap. Moreover, they can feel useless, neglected, marginalised and persecuted, which turn them into irritable, pitchy dissatisfied people. Ageing is doubled by a deep feeling of discontent which, if not controlled properly, can result in crises. Discontent is the result of the losses the elderly start to experience; if the old person focuses too much on what they used to be or to have in their youth or adulthood, they risk stopping their personal growth. When an old person focuses only on losses (of health, house, dreams, control, income, independence, beloved ones, hope), then they start to lose their own life. Negative thinking is also a cause of discontent. Such feelings as fear, revolt, bitterness and pride are rooted in negative thinking and bring psychic discomfort into the old person’s life, thus causing involution. Old age is a social construction with personal significance for each person alone. Thus, though it is seen as a state affecting everybody alike, in reality it includes heterogeneous groups of people, some of which consider themselves old, while others consider themselves still young. Age identity is particularly important as it consists of the personal way the individual identifies themself with chronological age, and of how one perceives old age (Rădulescu 1999). One can differentiate chronological age (the actual age) and age identity (the age an individual believes they are, no matter its chronological dimension). In general, age differences impact conduct, social status and even restriction. Some old people

40

Chapter Two

perceive more of their chronological life, while others emphasise functional age and try to ignore chronological age. Chronological age shows exactly how old a person is (how many years have passed since they were born). Chronological age is characterised rather by numbers than by states. It is rather an indicator of quantity than of quality (see Figure 2-1 below). Different comparative studies show that the elderly who feel their state of health is worse than that of other people of their age are more inclined to declare themselves older than their chronological age. Functional age shows how a person sees themself from the perspective of their present state of mind. Functional age is characterised rather by states than by numbers, and is rather an indicator of quality than quality (see Figure 2-2 below). There are many old people that do not feel their chronological age—they are the young-old. In addition, there are young people who do not see their chronological age and behave like old-young. Two of the aspects of functional age are important: positive and negative ones. The positive aspect of functional age resides in the fact that many old people, despite their age, are very well, fit and do not see their age in a dramatic way. They feel young even at eighty, which is extraordinary. There are also old-young who, despite their chronological age, are very mature, experienced, responsible and wise in everything they do. This is the positive aspect of being young-old or old-young. Unfortunately, there is also a negative side of this kind of relation, that being the young-old who behave like children or teenagers, emphasising more rights than duties, refusing to involve themselves in the raising and education of their grandchildren because they are too busy with themselves. The negative aspect of being young-old resides in the fact that some young people also behave like bored old people (bored of their life, profession, family and even of themselves). Fortunately, there are many young-old and old-young (see Figure 2-3 below). There are, in the society we live in, several forms of focus of the elderly on their age. Some of them focus only on the weak points of old age, on its shortcomings, while others focus on the strong points and its benefits. We can, therefore, classify old people from the point of view of their focus on old age strengths, weaknesses, opportunities or threats.

Ageing, Old Age and the Elderly Figure 2-1. Chronological age

Indicator of quantity, not quality

Chronological age

It is a number, not a state

Figure 2-2. Functional age

Indicator of quality, not quantity

Functional age

It is a state, not a number

41

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Chapter Two

Figure 2-3. Positive and negative aspects of functional age

Oldyoung

Young-old

Old

Resource-centred old person. If an old person focuses mainly on managing their own personal and family resources and also on community social service or social networks, they are a resource-centred old person. Result-centred old person. Focusing on intervention objectives and results helps an old person focus not only the hardships of the moment, but on future, on prospective results. Problem-centred old person. If an old person cannot cut off from the present, if they have no hopes for the future, if they are tempted to see only present threats and the negative sides of old age, then they are a problem-centred old person. Unfortunately, in many cases, exaggerated focus on problems does not solve them; on the contrary, it only amplifies them. If an old person sees more of their chronological age than their functional age, they will be tempted to focus more on problems than on resources or results. Assessment-centred old person. If an old person manages to also see the positive side of old age, and manages to understand the benefits of old age, they are an assessment-centred old person. It really matters if the old person takes chronological or functional age into account. More focus on functional age will help them focus on assessment.

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Figure 2-4. Old people’s focus forms from the perspective of a SWOT analysis Resourcecentred old person

Resultcentred old person Assessment -centred old person

Problemcentred old person

Some authors believe “old age signs” increase around the age of fifty, causing deep changes in the individuals’ view of their own ageing. These signs can be grouped into (Rădulescu 2002a, 2002b): -

Physical or psychic signs (consisting in the slowing down of certain functions) Generational signs (e.g. the birth of a grandchild) Death rate signs (death of relatives, friends, and acquaintances).

It is believed that ageing starts at sixty-five, but this is just a convention. Senescence depends less on age than on physical, moral or social condition. Some authors differentiate senility within senescence as a final deterioration period, though senescence in itself is not a disease, but a decline of sensorial, motor and intellectual functions. As childhood, teenage, youth and maturity are normal states, so is old age part of the normal life cycle. Ageing is a normal, physiological process that predisposes more to diseases with a more or less specific pathology. Ageing is a complex biological process that is genetically determined and modelled by the environment. Most scientists claim in almost unanimous agreement that the body and mind develop between twenty and thirty and then between thirty and forty. Between forty and sixty, one consolidates

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Chapter Two

and maintains what they have already achieved, and life after sixty largely depends on the reserves of each individual. When an old person is labelled “old man, old woman,” “grey head,” “faded,” “drooped,” “withered” or “expired,” no matter how strong they are they feel overloaded with this label and, finally, become a victim. To eat or be eaten, this is the law of the jungle. To define or be defined, this is the law of man … fighting for labelling is a matter of life and death. A classical western movie scene shows two men fighting desperately to grab a gun fallen on the ground. The first to touch it will shoot and save his life; the other one is shot and dies. What is at stake there is not a gun, but a label: he who manages to stick it first is the winner, the labelled one is the victim. (Szasz 1975, 89)

Some authors distinguish between “normal” and “pathological” ageing (Gal 2001). “Normal ageing” is defined as a slow, continuous, dynamic process that allows reaching old age with minimal difficulties of adaptability. Ageing has a differentiated, individual character because it is a historical synthesis of what the individual has been in their life. “Pathological ageing” involves a quicker rate of involution, a quick, severe degradation that makes the difference between chronological and functional age. Pathological ageing is characterised by: -

A disease or several diseases that add to age-characteristic deficiencies Precocity of disease(s) Unusual intensity of old age-related signs.

Though healthy ageing is increasingly important for old people, public focus on the scale and costs of medical care, of pension and other services amplifies the negative image of ageing. We need to change this image firstly because it is false—old people can play important roles in society (raise grandchildren, helping their adult children go to work); secondly, because it is discriminatory of people that have been active all their lives and are not paying for their past. Ageing is more and more a social exclusion risk, which can be very dangerous for a people’s mentality (Powell 2001). According to the Commission of the European Communities (2003): Social risks typically cover old age, retirement and age-related dependency, the death of a provider, disability, sickness, maternity, dependent children and unemployment, and, sometimes, the need to care for the frail elderly and disabled or sick relatives. Social protection ensures that these social

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risks do not result in poverty and that the lack of resources does not prevent the access to services that are essential a human life in dignity.

Rich countries have managed to develop numerous services to properly support old people. Research on the psychology of old age focuses mainly on the way we can ease the life of the elderly, thus underlying the need for social work focused on them. The increase in the number of old people correlates with the increase of expenses for health and social work. Diseases result in economic losses and put pressure on the public care system. Specialised services for the elderly, including medical ones, are extremely costly and involve considerable efforts from society. Proverbs from the nineteenth century speak of two kinds of old age: -

“old age in good health,” suggesting self-care ability “Invalid old age,” marked by decadence announcing death (“old people lose everything”).

They say that, at old age, the past is long and the future is short. This is mainly the perception of the old person that starts dreaming and planmaking. This is why it is preferable to make short-term plans at this age because they can bring satisfaction. An important factor in understanding old age-related social problems is old people’s cultural attitude. In a world that valorises youth and economic power, where there is ongoing competition, where many people have lost the joy of living and live in stress and anxiety, old people are often despised and considered a burden. They know, feel, see and hear it and feel unhappy and rejected (Wolff 1995). The cultural factor plays an extremely important role in shaping social attitudes toward the elderly. There is a clear difference in attitude between Eastern (China, India, Israel and Japan) and Western countries, and this marks an old person’s everyday life. In an atmosphere of respect, acceptance and love, old people are happy, serene and friendly, and they rarely suffer from resentment, bitterness, depression, as one can see on the faces of old people from the United States, for instance (ibid.). The pejorative way of seeing and treating an old person (in spite of the fact that, someday, the people in question will end the same way), is a social factor that overlaps other factors and makes the old person’s life unhappy (Dehelean 2001). In our society, most often defined by the dissolution of the extended family, the decrease of the death rate and by the increase of life expectancy, old age is, most often, synonymous with impotence, incapacity, disease, lack of discernment, rigidity combined with

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Chapter Two

conservationism, irritability and dependence; old people are, therefore, considered a burden for the society. It is essential to talk about the negative side of old age in our society. In traditional societies, old people enjoyed prestige (hence the famous council of the elderly, including in Romanian society) as a sign of confidence in their force of finding solutions to the problems of the community, based on experience and skills acquired (Stan 2001). Civil society plays a pivotal role in the way society sees old people and care for them. Old age is both an individual and social problem. Old age in itself is seen as a burden even by old people. It is perceived as a period marked by tragedy; one suddenly realises they are no longer what they used to be, and can no longer do what they could do. There is nothing for them to do, and they have plenty of time that they do not know how to spend. They start to feel useless and senseless and ready to give in to depression if they do not get help or cannot fight it themself. Retirement, separation from one’s children due to their marriage, death of one’s partner are considered to be significant changes and can result in isolation and loneliness. Against this background, feelings such as fear and inner turmoil can lead to personal disorder or depression. Fear of old age, in some people, is synonymous with regret for youth; other people fear death or living in poverty and pain because of the shortcomings specific to old age. This is why old people risk perceiving their past as an empty baggage, heavy and useless. The paradox of our times is that, though life can be prolonged, old age risks becoming precocious because of physical and psychic stress (Gal 2001). There is also, in old people, an ambivalent desire to stay active and to maintain the important role acquired during their lives and, on the other hand, the legitimate desire to rest and disengage socially. Social problems, such as depression, suicide, alcoholism and dementia among old people are the result of their lack of adaptation to the events and imbalances of old age. All this involves numerous tasks and responsibilities for the old person’s family and society. In many cases, the family is not ready for old age. Rich old age without suffering can be reached by preparing for it long before it comes (at least in maturity). A period of preparation could help the different generations empathise with one another. Leo Tolstoy was right when he said that old age is the most precious of ages, the most useful age for you and the others. Old age cannot and should not mean “disease.” In his De senectute (“On Old Age”), Roman philosopher, statesman, lawyer, orator, political theorist, consul and constitutionalist Marcus Tullius Cicero said that old age does not start at a

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precise time—man feels well at this age as long as he can fulfil his duties properly; daring is specific to young age, provision to old age. For some authors, old age represents individual and collective decay. Other authors divide old age into autonomous and dependent (Gârleanuùoitu 2006, 22). Autonomous old age, in its turn, can be divided into two periods: -

Autonomous old age proper, or intermediary age, the age of people aged sixty to seventy and playing an active socio-economic role. Dependent autonomous old age, the age of old people living at their own domiciles, with no outside major support.

In recent years, there has been a shift from the traditional, numerous family made up of several generations, to the nuclear family. Rural exodus resulted in an old village population. An ageing population is more and more a social issue for both its members and social institutions. According to WHO, the ageing of the population is both a great triumph and a great challenge. WHO emphasises that the elderly are a precious resource often ignored that can make a contribution to society. Any country can get older if the governments, international organisations and civil society adopt “active ageing” policies and programmes that improve health, participation and safety of the elderly. In all countries, and particularly in developed countries, support measures for the elderly are a necessity, not a luxury. The term “active ageing” was adopted by WHO in the 1990s, and it is an inclusive message rather than a good health-ageing message. This concept admits the factors that, together with health care, affect the way in which individuals and populations age. Demographics of Ageing Populations Statistics of each European Union member nation concerning ageing populations point out that they represent over 19% of the total populations of these countries (Gârleanu-ùoitu 2006). In a recent study at the level of EU-25, it is mentioned in the Government’s Decision No. 1826 from December 22, 2005 regarding the approval of the National Strategy for the Development of Social Services that the old population increased from 350 million in 1950 to 450 million in 2000. In 2025, they estimate 470 million people, and after 2050, 449 million (see Figure 2-5 below). The number of people aged sixty-five to seventy-nine will increase significantly after 2010, reaching 37% in 2030. The factors considered

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Chapter Two

essential for this ageing trend are represented by the decline of the birth rate during several generations and a decline of the death rate during childhood and teenage years. The structure per ages was influenced by such factors as war, migration or economic crisis, but the main cause is the decreasing death and birth rates. The number of people aged sixty and over worldwide will increase from sic hundred million in 2000 to about two billion in 2050, while the share of people in the third age will increase from 10% in 1998 to 15% in 2025. The greatest and fastest increase will take place in developing countries, where the third age population will quadruple in the next fifty years. The group with the highest increase among third age people is those aged eighty and over. In 2000, there were seventy million people, which is expected to increase five times in the next fifty years. Figure 2-5. Evolution of EU old population (millions of people)

The speedy rate of population ageing in Romania in the last fifteen years makes both demographers and social and economic policy-makers worry (see Figure 2-6 below). Part of the European ageing, Romanian ageing has its own features (Romilă 2004). While, in other countries, it started a century ago, allowing for prospective thinking, in Romania it drew attention only after 1956. A WHO Report of 1998 estimated life expectancy for the Europe of 2025 to be around eighty. In some countries (e.g. France) they estimated life expectancy depending on the type of job starting from the age of sixty.

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Thus, a rate of six years longer than privately-employed people (workers) belongs to liberal professions (with higher education). At the European level, life expectancy is around eighty-one in women and seventy-five in men. Demographers estimate that this difference between women and men will disappear in the near future. According to the Statistic Yearbook for 2002, there were people that could not accept the irreversible loss of one of most important social roles, being husband or wife. “Joining destinies” can be explained by the fear of loneliness, need of family life, involvement, and refusal of giving up roles specific to adulthood. Figure 2-6. Evolution of Romania’s population (thousands of people)

Part of the European ageing, Romanian ageing has its own features (Romilă 2004). While, in other countries, it started a century ago, allowing for prospective thinking, in Romania it drew attention only after 1956. A WHO Report of 1998 estimated life expectancy for the Europe of 2025 to be around eighty. In some countries (e.g. France) they estimated life expectancy depending on the type of job starting from the age of sixty. Thus, a rate of six years longer than privately-employed people (workers) belongs to liberal professions (with higher education). At the European level, life expectancy is around eighty-one in women and seventy-five in men. Demographers estimate that this difference between women and men will disappear in the near future. According to the Statistic Yearbook for 2002, there were people that could not accept the irreversible loss of one of most important social roles, being husband or wife. “Joining destinies”

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can be explained by the fear of loneliness, need of family life, involvement, and refusal of giving up roles specific to adulthood. The survey carried out in Romania in 2002 showed that, of the total widowed people, 78.2% were sixty and over. The incidence of widowers and widows increased in people aged seventy-five and over (37.7%). The share of widowed people is higher in the rural areas while the share of divorced people is higher in the urban areas (Census of Population and Housing 2002). There are also differences between old people of different ethnic minorities. In Romania, the oldest, according to the data of the last census (2011), is the German one, whose people aged sixty and over represent 32.2%. Following this are the Hungarians, whose members aged sixty and over represent 22.4%, smaller than the German share but higher than the national mean. Roma people make up only 5.2% of people aged sixty and over, while Roma children represent 36.3%. The ageing process of the Roma population is the least significant because the birth rate is 2.454 to 1. The pyramid of the population is a demographic instrument showing the age structure of the population of a country at a given time. It consists of two graphs set against each other containing the number of men and women, respectively, per age group. In the ideal pyramid, the greatest basis reflects a fertility level that ensures a harmonious renewal of the population (2.1 children per woman). The median, well-proportioned area shows the existence of a sufficient number of adults contributing to social insurance and pension system. Of the 21.6 million inhabitants (on July 1, 2006), 10.5 million are adults, 6 million are pensioners and 5 million are children (people below eighteen). The narrow basis shows few children are born (about 220,000 compared to the necessary 350,000 to ensure population renewal). The pyramid includes the two million Romanians working legally abroad, as well as illegal workers whose number is unknown. The most pessimistic variant of the demographers show a dramatic decrease and ageing of the population. If fertility is maintained at the same level and the number of old people keeps increasing together with life expectancy, Romania’s population will reach sixteen million. The number of active adults will be so small that the dependence ratio (adults that support vulnerable groups of children and the elderly) will be 1 to 9 (Romania’s Population—Quo Vadis?) Romania’s demographic evolution follows European and world ageing trends and their economic and social consequences. Ageing is predominant among women. The inactive population is 30% more numerous than the active population, and 36% of the households of old people have active

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people (Puwac 1995). Many studies carried out in Europe and America show that, in many cases, the elderly are not properly protected, and cannot protect themselves because they do not know or cannot exercise their rights mainly because of their health. Some authors believe that the death rate after the age of seventy-five has been replaced by a higher percentage of diseased people. Thus, the age of dependence or of multidependence demands more and more support from the society (social and medical needs).

Passage Stages The stages in a person’s life can be compared to the seasons of a temperate continental climate. Ever since the moment of birth, we are ageing and directing towards the Great End. Spring is the season of young adults (aged twenty to forty). This season is characterised mainly by the search for personal accomplishment. These are the years when people are the healthiest and most energetic and when they dream the most. It is now that some manage to establish interpersonal relationships based on confidence while others do not. Summer belongs to medium-age adults (aged forty to sixty-five). This is the season for investing time and resources in supporting others. These are the most beautiful years of creativity and productivity. Some become very altruistic while others feel more and more exhausted and have to face the crises of middle age. Autumn is the season of senior adults (aged sixty-five to eighty). It is now that management and control is transferred to others, and physical decline becomes more and more visible. Some people accept it, while others try to reject it and, ultimately, themselves. Some sociologists call this “late adulthood.” They believe it is one of the most demanding periods in one’s life when there is retirement, death of a partner, amplification of impotence, institutionalisation, and preparation for death; all this asks for change and adaptation because the mind and heart are the same, but the body is not (Hyges, Kroehler & Vander Zanden, in Gârleanu-ùoitu Daniela 2006). Winter is the season of old adults (aged eighty and over). This is the season of dignity and self-respect, but also the season of support from others. Mature people are characterised by wisdom, while others start feeling useless. Nowadays, people turning old are more advantaged than people in the past because they enjoy a better psycho-affective state and better health conditions (at present, diseases can be diagnosed and treated with different medicines); old people also enjoy superior financial safety.

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Findeisen (in Gârleanu-ùoitu 2006) believes old people are now healthier, more and more educated, less needy and more willing to be active. Most people aged sixty-five to seventy-five have the same health as middle-age people. The stages of old age have been classified as follows (ibid.): -

Passage to old age (sixty-five to seventy-five) Middle old age (seventy-five to eighty-five) Great old age (eighty-five and over).

The last life cycle begins after sixty-five. Romanian authors distinguish between four stages of old age (CreĠu, in ùchiopu & Verza 1981, 339): -

-

-

The passage stage (sixty-five to seventy), marked by retirement and narrowing of social relations, is ignored by 75% of the people sixty and over. In general, it is not very challenging. First old age (seventy to eighty) is characterised by a diminution of physical and psychic skills, which makes old people reduce activities and social interaction. People at this age take care of their health state and start admitting limitations. If they do not get seriously ill, this can be a truly serene period. Second old age (eighty to ninety) is characterised by a steady decrease of physical and psychic skills. Health state is worse and worse, and the couple can dissolve because of the death of the partner. There are changes at all levels and it is more and more difficult to face life’s challenges. Great old age (ninety and over).

Old age implies experience and this favours a deeper vision of the world, as the individual has been able to systematise it. It seems that, while biological potential decreases, it is generally replaced by wisdom. The important thing is not how long you live, but how you live (Păúcanu 1994). Old age is also the period when people have to face a crisis of prestige. Each individual is unique in their way and this determines the way they will find their own solutions. A saying goes that one has to live a life to be considered a human living. The irony is that reaching full human status coincides with the end of life (Gal 2001).

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Consequences of Ageing on the Person Passing from one stage or “season” to another brings about changes in everybody’s life. Old age brings significant changes in both professional life and in the relationships with one’s family and friends. These changes require a quick adaptation because it is a very short period. Old age is a multidimensional phenomenon that affects people in different ways. Biological Consequences The endocrine system is largely linked to ageing; it regulates fat deposits, muscle and bone volume, metabolism, body weight and psycho-affective well-being. It decreases oestrogen production in women (menopause) and testosterone production in men (andropause). There is natural damage of the human body: -

Diminution of movement coordination Deterioration of vertical posture Change of general aspect of the skin that loses elasticity Decrease of water level in the body Diminution of joint mobility Loss of calcium that results in changes of carriage, posture and teeth Higher incidence of heart failure Degradation of sight and hearing Decrease of general duration of sleep, particularly of paradoxical sleep that favours information storage and learning, in general Higher incidence of insomnia Decrease of protective skills Disappearance of hair pigment Decrease of energy Diminution of sexual desire.

The first three causes of morbidity in old people are cardio-vascular diseases, associate conditions and rheumatism diseases (Puwac 1995). After the age of sixty-five, the old person needs more medical services than in other periods of life. Psycho-social Consequences From a psychic point of view, decline is directly related to an individual’s anatomic and physiological structure, with genetic resistance and also with

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environmental factors and socio-professional satisfactions. From a psychological point of view, senescence differs from person to person; some can keep their intellectual functions in a good state beyond eighty, while others find it difficult to keep them until they are sixty. Intellectual changes (mental skills) are less obvious than physical (motor responses, fine motor skills) or sensory changes (hearing, visual acuity). Assessment of functional skills in the elderly depends on the type of activity and from individual to individual. For instance, one cannot compare intellectual, creative work with physical work. Unlike physical work, creative work can be done even during great old age. Tolstoy wrote until he was eighty-two, Pablo Picasso painted until he was ninety-two, Michelangelo, Brâncuúi and Verdi reached maximum creativity between seventy and ninety. Creativity in the elderly touches every field of activity. Most people that became old too early have a weak nervous system, and most young old people have a strong personality, a positive attitude toward their lives and self. Old age is the period when the number of functional neurons decreases, resulting in a diminution of the functionality of the central nervous system, hence the decrease of adaptability to changes. Old people are now characterised mainly by emotional disorders (depression, panic, etc.). There is diminution of short-term memory and preservation of long-term memory. Focus also decreases and so does the interest in new activities. Physiological changes bring about a feeling of impotence, which results in major changes in self-image. Among stress events that affect an old person’s life are retirement, institutionalisation, lack of social support from the family or community, poverty and, above all, loss of one’s partner. The old person starts experiencing loneliness (despite the support of the people around them). The old person loses not only their partner, but material benefits as well. If they cannot cope with it, they risk becoming depressed. From a sociological point of view, old age raises three important questions: voluntary or involuntary retirement, cultural attitude toward the elderly and economic insecurity (Wolff 1978). There is also “emotional wilting.” What an old person feels is (Elliott & Smith 2006, 13): -

They not feel like being with anybody They get very nervous when meeting new people They do not feel like talking to anyone They feel overly sensitive when anyone criticizes them in the slightest way They are more irritable with others than usual They worry about saying the wrong thing

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They do not feel connected to anyone They worry about people leaving them They do not feel like going out with anyone anymore They are plagued by visions of people they care about getting hurt They are withdrawn from everyone They feel uptight in crowds, so stays at home They feel numb around people They always feel uncomfortable in the spotlight They feel unworthy of friendship and love Compliments make them feel uneasy.

An old person’s negative behaviour is obvious in that (ibid., 10): -

Things are getting worse and worse for them They worry all the time They think they are worthless They never know what to say No one would miss them if they were dead They are afraid that they’ll get sick They think they are a failure Their thoughts race, and they obsess about things They do not look forward to much of anything They get really nervous around people they do not know Thoughts about past trauma keep rolling through their mind They find it impossible to make decisions They cannot stand it when they are the centre of attention Their life is full of regrets They cannot stand making mistakes They do not see things getting any better in the future They worry about their health all the time They are deeply ashamed of themself They over-prepare for everything.

Isolation is accompanied by depression which becomes a social issue. Depression is not only a consequence; it favours and amplifies the ageing processes. Alcoholism or medicine addictions are rooted in depressive states. Alcoholism is very frequently associated with depression in the elderly (Gal 2001). Constantin Bogdan (1997, 37) considers these changes as materializing in the following:

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-

Decrease of cognitive fluency and performance: x Difficulty in assessing remembrances, in remembering, in evoking recent events, but performance in evoking childhood events (regressive memory). x Difficulty in learning or acquiring new elements and in intellectual operations. x Difficulty in abstracting and analyzing—after sixty, intellectual skills deteriorate in a different way; some resist (comprehension, vocabulary), some deteriorate (mental calculus, memory stabilisation, perceiving similarities, etc.). x Difficulty in orienting in space. x Difficulty in focusing plus fatigue during focusing. x Difficulty in adapting to new situations. x Persisting on recurrent themes.

-

Shift of affectivity toward the depressive pole: x Increase of introversion (the old person is more reserved). x Decrease of affective responsiveness (sorrow and joy vanish quicker). x Decrease of tolerance to frustration (the old person is grumpier and more anxious). x Decrease of emotional and motivational reactivity. x Decrease of censorship of emotional behaviour, emotional ability (changing moods).

-

Strengthening of personality traits depending on the previous level (the person ages as they have lived).

-

Incidence of compensating responses: x Extreme conservationism and resistance to change. x Need to strengthen moral and social value (the old person needs their prestige to be acknowledged; they want everybody to be aware of who they have been, more exactly that they used to be “somebody”). x Authoritarianism. x Excessive attachment to material goods.

Specialists claim gerontological examination should cover three fields; medical, psychiatric and social (Vetel, Papin & Mailland, in Gârleanu-

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ùoitu 2006). They claim this way of assessing an old person’s condition is more adequate since it guides them toward the best intervention service. Literature points out the differences between evolvescence, the period of life during which development consists mainly in physical and pulsation growth, and senescence, seen as the maximum period of organising culture-based experience. Thus, old people face not only quantitative and qualitative psychic and pulsation changes, they also face a “personality restructuring.” More and more gerontologists agree that the ageing process has a socio-psycho-medical dimension. Biological, psychological and social adaptation in the elderly define their capacity of maintaining the benefits of their own lives and of learning to live with the changes in family and society brought about by old age. Adapting to old age implies a good health state, a number of friends, pleasure in work, support, help, feeling of being useful, satisfaction in one’s own family, a feeling of happiness, all of which depend on the person’s previous lifestyle (Alston & Dredley 1973).

Needs, Problems and Fears of the Elderly from the Perspective of Social Work Definition of Terms For a better understanding of the terms, we have chosen to define the concepts of “need,” “problem,” “fear” and “elderly” from a medical perspective (Miller & O’Toole 2003): -

-

-

Need—something that is required or necessary. Basic human needs are those things that are required for complete physical and mental wellbeing. Needs vary greatly in the degree to which they are necessary for survival. For this reason, they are often classified into a hierarchy according to their relative urgency. Those on lower levels must be met before attention can be paid to needs on higher levels. The most widely used classification is called Maslow's hierarchy of needs, devised by Abraham H. Maslow. Problem—something of difficulty or concern. A client p’s in the Omaha system, the second level of the Problem Classification Scheme, representing 40 nursing diagnoses that historically, presently, or potentially adversely affect any aspect of the client’s well-being. Accurate identification of client problems enables the professional to focus nursing interventions. Fear—the unpleasant emotional state consisting of psychological and psycho physiological responses to a real external threat or danger. Fear is a nursing diagnosis accepted by the North American Nursing

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-

Diagnosis Association, who defined it as a response to a perceived threat that is consciously recognized as a danger. Causative factors may include separation from one's support system in a potentially threatening situation such as hospitalization, diagnostic test, or treatment; knowledge deficit or unfamiliarity; language barrier; sensory impairment; and phobic stimulus or phobia. Persons experiencing fear may verbalize increased tension, apprehension, diminished selfassurance, panic, or a jittery feeling. Objective signs include increased alertness; concentration on the source of fear; attack and fight-or-flight behaviours; and evidence of sympathetic nerve stimulation such as cardiovascular excitation, superficial vasoconstriction, and dilation of the pupils. Interventions are aimed at helping the individual to identify effective and ineffective coping behaviours, promote effective coping strategies, and maintain psychological equilibrium Elderly—aged. Frail elderly are individuals over 65 years old who have functional impairments; sometimes used to describe any adult over 75 years old.

The relationship between need, problem and fear in the elderly is shown in Figure 2-7. below. Figure 2-7. Need—Problem—Fear in the elderly

Need

Old person Fear

Problem

On the whole, an old person is disadvantaged because of the low level of physical and material resources or of handicap. The elderly are considered, nowadays, useless. We forget too soon that they have also been young and that we will get old someday. We ignore the future maybe because we live mainly in the present; this is a symptom of selfishness. An old person should not forget that their value lies in spirit and not in the body or psyche (as in youth or adults). A spiritless old person is

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valueless, but an old person is valuable due to their life model and positive impact on their peers. Elderly Needs A person’s need is defined as the feeling of loss or bad mood that pushes a human being to do whatever necessary to fulfil it (Bogdan 1997, 363). In our debate on elderly needs, we need to start from Abraham H. Maslow’s hierarchy of needs (Miller & O’Toole 2003): -

-

-

-

Physiologic Needs … are essential for the maintenance of biological homeostasis and the survival of the individual and the species. They include needs for oxygen, water, food, elimination of wastes, temperature regulation, avoidance of pain, rest and sleep, exercise and sex. Needs for Safety and Security … include needs for protection from physical harm, for order, consistency, and familiarity in one’s surroundings, and for some degree of control over matters concerning oneself. Needs for Love and Belonging … include needs for giving and receiving love and affection and for sexual intimacy, for friendship and companionship, and to identify with a group. Needs for Esteem and Self-Esteem … are the needs that are necessary for a person to have a basic sense of self-respect and self-acceptance and to be self-sufficient. Self-esteem requires an understanding of oneself and one's limitations and the ability to face and cope with stress and painful realities. Persons in whom these needs have been met are relatively free of feelings of inferiority or inadequacy. This level also includes needs for approval and recognition from others. Need for Self-Actualization … is the need to make full use of one’s talents, capabilities, and potential. Self-actualizing persons tend to be dedicated, realistic, autonomous, creative, and open. They are not in conflict with themselves and are motivated by their own values and goals.

If possible, we need to fulfil both needs and wishes of the elderly if we want to avoid psychic illness. Old people need affection, communication, faith and sincerity, acceptance and emotional support. Viorel Prelici (2001, 24) claims that: “Need means what is necessary—both for the person and social system—so that they can function within expected or normal limits. A need is not desire for something, but a lack of something.” Developing policies, programmes or services for the elderly should take into account, besides rights and capabilities, their needs. Meeting somebody’s needs has an impact on both an individual’s life and the quality of their functioning

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as a member of a family or society. Meeting these needs is, thus, not just an individual issue, but a societal one, since the society takes responsibility for the welfare of its members. Not meeting such needs or ignoring them can deepen the suffering and result in dependence and, subsequently, death (Wincott 2011). Social work, a component of the Romanian national system of social protection (Roth-Szamoskozi 2003), consists of social services meant to develop individual or collective capabilities to meet social needs, increase of life quality and promotion of social cohesion and inclusion (Government’s Decision No. 829 from July 31, 2002 regarding the approval of the National plan anti-poverty and for the promotion of social inclusion, Law no. 47 from March 8, 2006 regarding the national system of social work). The same law defines social need as the ensemble of requirements indispensable for everybody to ensure life conditions for proper social integration, but makes no mention to the elderly and their condition (Planul NaĠional Anti-Sărăcie úi Promovare a Incluziunii Sociale 2002). Bradshaw (Concepts of Need and Social Justice) distinguishes four categories of needs: normative, felt, expressed and comparative (see Table 2-2 and Figure 2-8 below). Table 2-2. Categories of needs (after Bradshaw) Type of need Normative need

Felt need

Expressed need (Demanded need) Comparative need

Definition Need that is defined by experts. Normative needs are not absolute and there may be different standards laid down by different experts. Need perceived by an individual. Felt needs are limited by individual perceptions and knowledge of services. Felt needs turned into action. Help seeking.

Examples Vaccinations, a decision by a surgeon that a patient needs an operation

Individuals with similar characteristics to those receiving help.

Compiling an at-risk register of babies in need of specialist treatment based on characteristics which have been associated with handicaps in the past

Having a headache, feeling knee pain

Going to the dentist with toothache

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Need is a necessity, but not a static one. According to Elena Zamfir (2003), necessities evolve and it is the level of aspirations that determines this evolution. The Romanian author classifies human needs from the perspective of life quality. There are: -

Universal needs that lie at the basis of absolute indicators of life quality Evolving universal needs that generate both absolute and relative indicators of life quality Alternative human needs that characterise a life style or another leading to happiness Fake needs that point to an alienated, marginal, pathological lifestyle, generating the illusion of partial satisfaction and leading, ultimately, to failure.

Figure 2-8. Categories of needs

Normative need

Felt need Comparative need

Expressed need

The need for social assistance is a category apart that facilitates: “Minimum resources for a dignified life and a normal social functioning not covered by one’s personal effort or by the components of social security.” (C. Zamfir 1999, 445) Old people sometimes need social assistance because of the lack of financial resources (substandard life, lack of dwelling, lack of access to

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medical services) or the severe limitation of one’s ability to lead a normal life (handicap, health problems, integration problems [family or community], difficulty of establishing relationships, etc.). Material support and social assistance services are the two kinds of support for people in need which are not covered by the social assistance system (C. Zamfir 1999), and this is obvious in the case of Romanian elderly. Law no. 17 from March 6, 2000 regarding the social assistance of the elderly, republished in 2007, suggests the need for assessing the needs of the elderly. According to this law, the needs of the elderly are assessed through social survey based on data concerning the conditions that need special care, the capacity of self-caring, accommodation conditions, and minimum income level to ensure the satisfaction of current needs. Social needs that are not satisfied (depressive affectivity caused by loneliness, social isolation, lack of activities that make somebody feel useful) impact physical and psychic health generating or increasing medical need level (Mărgineanu & Socol 1991). The most heterogeneous population group is that of old people. Their needs differ because of genetic, environmental and living conditions. It is difficult to design an algorithm of the needs of the elderly because it would not fit all these people. Personal features in combination with one’s own experience of life generate a unique combination. This shows that the ratio between the importance of the social and that of personal changes is in favour of the latter (Dallos & McLaughlin 1993). Developing programmes and services for the elderly should take into account the diversity of this group of vulnerable, disfavoured people. The elderly are people with special needs that need help and protection to lead a decent life. Through different programmes, we need to try and change the mentality of people—an old person consumes and is close to their end, which results in discriminating access to medical and social services. International bodies such as the United Nations and the World Health Organisation have established the groups of elderly that are subjected to special health, social and economic risks: people aged eighty-five and over, people that live alone, women (particularly spinsters and widows), institutionalised people, childless people, seriously ill people, disabled people, and couples of which one is seriously ill. A widespread conceptual model is that of Virginia Henderson who categorised nursing activities into 14 components based on human needs (Virginia Henderson’s Need Theory). These components can be grouped as follows:

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-

Physiological components: x Breathe normally x Eat and drink adequately x Eliminate body wastes x Move and maintain desirable postures x Sleep and rest x Select suitable clothes-dress and undress x Maintain body temperature within normal range by adjusting clothing and modifying environment x Keep the body clean and well groomed and protect the integument x Avoid dangers in the environment and avoid injuring others.

-

Psychological aspects of communicating and learning: x Communicate with others in expressing emotions, needs, fears or opinions x Learn, discover or satisfy the curiosity that leads to normal development and health and use the available health facilities.

-

Spiritual and moral component: x Worship according to one’s faith.

-

Components socially oriented to occupation and recreation: x Work in such a way that there is a sense of accomplishment x Play or participate in various forms of recreation.

The needs of a person are multiple and complex and satisfying them aims at producing a welfare state—a state of psychical and physical comfort and, therefore, an increase of the quality of life. The Problem of the Elderly An increasing number of old people face serious problems such as poverty, abuse (physical, emotional, sexual), loneliness, disease, depression, dependence, lack of proper services. In a word, Romanian elderly face discrimination. There are factors generating problems, fears and vulnerabilities in the elderly and these factors should be taken into account in social work for the elderly and in social policies. Some of the problems Romanian elderly are facing are:

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Abandonment. Old people feel abandoned by society, their own children and other relatives. Some old people are abandoned in retirement homes and hospitals. There are three forms of abandonment of old people by those who have moral and material obligations toward them: abandonment proper (the old person is left in hospital, in a retirement home or domicile and is never contacted); semiabandonment (the old person in hospital, at retirement home or at their domicile is seldom visited), and; quasi-abandonment (despite the permanent link with the hospital or retirement home management and some material contribution, there is no affective relationship or moral support whatsoever). One of the main causes of abandonment is the precarious material situation of the family. Abandonment can be prevented by treating the old person with respect, accepting them as unique and valuable. Fortunately, old people enjoy more care within their families than claimed in literature (Puwac 1995). Another cause of abandonment of an old person is total dependence—if relative physical and/or material dependence (which means occasional support from the family) is acceptable, total physical and/or material dependence is hard to accept, which increases the chances for the old person to be institutionalised. Abuse. The causes of abuse are manifold—social stress (as a result of increased poverty rate) determines family violence, and family violence resulting in its dissolution and transfer of aggression to the public sphere, generating child or old person abandonment. Abuse of old people consists of neglecting them and physical and emotional abuse. Romanian sociologist Henri Stahl (1939, 23) spoke about foster parents “depending on their children who had sold their entire fortune depriving them of the bare necessities of life.” In most cases, the abuser is a son or daughter in financial or marital difficulty who drinks and who used to be, in turn, victims of violence. Old people abuse is, in this case, a consequence of the “beaten child” syndrome (Rădulescu 2001). Physical vulnerability and isolation expose old people to all kind of abuse—physical, sexual, emotional, and financial—and neglect from both family and society. British statistics show that half a million old people from the United Kingdom are abused in their own homes (Help the Aged 2004). An old person is a human being and we need to help them, no matter what they have done in their life. We need to valorise old people and benefit from what they did in the past, not blame them for their shortcomings. Belonging to ethnic or racial groups make old age even harder to endure. This is generally not acknowledged by most of the population.

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-

-

-

-

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Dependence results from the need for support, and loss of autonomy. A dependent old person can no longer do what they used to. The term was brought to light by geriatric doctors in 1979, and it replaced other terms such as “handicap” or “impairment.” Dependent old people need their family’s support; unfortunately, fewer and fewer families take on this responsibility, which has been transferred to society. Old people dependence is caused by the lack of material resources and by diseases. Dependence causes fear, uselessness, uncertainty, anxiousness and isolation both self-imposed and family imposed. Isolation can aggravate both physical and psychical state (Gal 2001). Depression is the main factor leading to suicide in the elderly, with both men and women having lost their partners. Suicide caused by depression has higher rates in the elderly than in adults. Disability. When an old person is also disabled, they are even more rejected than any other old person. A disabled person faces several vulnerabilities when turning old, such as natural biological and psychical impairment, aggravation of impairment, acquisition of new impairment because of old age, low income during active life, and loss of helping relatives. False representation (based on stereotypes) on old age. Stereotypes lead to a false image of this stage in life because they emphasise losses more than experience. False images of old age can result in frustration, despair and even suicide (Stănculescu 2008). Lack of public health measures. Being in good health needs good environments, nutrition and labour conditions. Higher and higher air, water and soil pollution affect the quality of the ecological environment. Many people do not have a place of their own, and many of those who own one cannot fully enjoy it because it is old and needs repairs they cannot afford. Poverty. If the old person used to have a small income, then there is a risk of exposure to poverty. Though not in itself a cause of violence, poverty is, together with alcohol and drugs, a favouring condition. Suicide. This is one of the saddest social phenomena, a sign of spiritual decay and great personal and social unhappiness. Rădulescu & Piticariu (1989, 88) mention the following risk factors involved in suicidal behaviour in the elderly: hard living conditions, serious chronic and degenerative diseases, retirement, chronic social-economic deprivation, social isolation and hopelessness, loss of beloved ones. Worldwide, each year there are 850,000 suicides, of which 60% are caused by depression (ibid. 89). Old people are more vulnerable than adult ones; they are alone and they believe there is nothing more left

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for them in the future, which leads them to suicide more easily. Suicide is not, though, synonymous with depression. The kind of depression, the gender of the old person and their age determine it. Suicide is more frequent among isolated people who live in precarious conditions, and who get no, or almost no, support (Loo & Loo 2001). The most important factors affecting life quality in the elderly are health, loneliness, income, dwelling, final care. After retirement, old people visit mainly institutions such as theatres, cinemas, travel agencies, public libraries; several years later, they will also start visiting medical and social institutions as well. Fears of the Elderly Everybody has their doubts, conscious or not, caused by the fear that they will not be able to fulfil all their needs or solve their problems. One of the essential fears in humans, and particularly in the elderly, is the fear of death. Managing to fight this fear largely depends on one’s attitude toward it. Attitude toward Death Man is the only being aware of its own death. Though unconsciously, they thinks of death and particularly with what is beyond it. Perception of death differs from person to person. Some people ignore it, while others accept it. Yet, ignoring or accepting death does not change anything, and the last years in one’s life confront man with the most difficult experiences of their life, sometimes resulting in crises. Some people avoid thinking of death, but they hope their death will come pretty late. Death is the final point of life on earth; it opens the path to a new world, to a new entity called eternity. Nobody can die in our place. We die little by little from the moment we are born, and also each time somebody we love dies. The death of somebody we love is but a rehearsal of our own demise. We live and die on our own, and through all those that have meant something for us. Despite the fact that time goes by he who truly loved will never forget their beloved ones (Munteanu 2004). The best known perspective on individual attitudes toward death is that of Kübler-Ross (1997). Her book, On Death and Dying, discusses for the first time what we call nowadays the Kübler-Ross Model or the Five Stages of Grief—denial, anger, bargaining, depression, and acceptance.

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Old people experience most of these stages in no defined sequence when confronted with the death of a loved person or with their own death. Most people, having reached late old age, are true believers. They believe in God and this gives them hope. At old age, dialogue with the divine is crucial and can materialise in prayer, meditation, fasting and good deeds. All this makes the preparation for death easier. G. W. Allport (in CreĠu 2001) says that if the religious feeling is strong, old people find it easier to face the hardships of old age. The death issue is difficult not only for the old person that will soon face death, but also for the people who will survive somebody’s death. In the last hours and minutes of life, these are the questions that most people ask themselves: -

Do my children love or at least like me? Does my spouse still love me? Do I love myself or at least like myself?

The answers to these questions help us in many cases understand if the person will die happy or unhappy. Death characterises not only old age, but can occur at any age, no matter the spiritual, social or material condition of the person.

CHAPTER THREE DEPRESSED OLD PEOPLE AND THEIR FAMILIES

Depression is an illness, difficult to deal with for both the old person and their family (Cungi & Note 2007). The family members play a pivotal role in the life and evolution of the depressed old person. If they enjoy a mature environment affectively, intellectually and educationally, then they will be able to overcome crisis situations and depression easier. For a depressed person, their family is of great help. The depressed person needs to feel they are taken care of and protected. Their need for encouragement can be fulfilled through gestures, well-chosen words, and facts. Approaching mental illness as a phenomenon that affects both the old person and their family is a reality that cannot be questioned. The depressed old person can no longer argue their own ideas and mentality, and this prevents conflict situations engendered by the generation gap. A depressed old person’s family should be aware of the fact that they have a very low level of self-esteem and that they are no longer confident in themself. This is why the old person needs, more than anybody else, the care and love of their own family. Care and love can help them regain selfconfidence. The members of their family should understand that medicine cannot always remove pain. Care and love supply the emotional support a depressed old person needs. Most often, depression is not admitted by the old person, who puts it all on somatic or existential conditions. As a rule, the old person’s family ignore all this and consider that both claims and demand for support should be blamed on old age (Barbier 2003). The family and relatives of the old person should not ignore that certain emotional disorders, even minimum, can have considerable repercussions. The family of a depressed old person should calm them down and try not to put pressure on them. We should also take into account that family tolerance can erode over time and that there is a risk that the family demands that the depressed old person be hospitalised (removed from the family environment). At this stage, a social worker should intervene and help the family, explain the nature of the illness, its evolution and possible treatments. In general, the family has typical reactions concerning a mental illness:

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Lack of understanding (this is why the social worker needs to explain the mental illness) Increase of tension within the family Culpability Tendency to hide the truth, which leads to isolation and, finally, to loneliness.

The client’s illness aggravates the lack of harmony in a family, resulting in distortions of communication, break ups and even resuscitation of older conflicts. There is a feeling of culpability and frustration among the family mixed with fear caused by the illness. Dmitri Avdeev (2005) claims that family neuroses are increasing in number. Society pulls the alarm signal, and this is why the family should get more help nowadays. Intervention in favour of a client affected by depression should be done from the perspective of their links with real life and mainly with their family. The family, as a primary support group, plays a decisive role in the psychological, social and economic support of any human, in general, and of a depressed old person in particular. The integrative-holistic vision of social work, its intervention strategy according to which an individual in difficulty is seen within the psychosocially significant relationships network, aims at the reinsertion of the depressed person in a genuine life space. They should be seen also from the perspective of their relationships with their family and friends. It is thus that the intervention of the social work act adapts to the ensemble of the realities of the individual’s life as much as possible for the social reinsertion to be doable. These strategies of social work restore the rights of an individual, making possible the satisfaction of his needs, expressions of the human essence, through the restoration of their links with the community. These strategies emphasise the therapeutic potential of the community, of the family and of the group of friends in the recovery of a depressed person’s psychic, social potential.

General Trends of the Family in Contemporary Society The modern family has to face all kind of situations and problems and becomes, in most cases, incapable of resolving its problems alone. Nowadays, some families oppose the principles of school and society. Other families learn to communicate better and better with the exterior and have communication problems within the family. For André Berge (1967, 11) a family is a kind of “cooperative of feelings that help family members

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overcome easier the problems and obstacles of life.” The family is the first instrument of regulation of the relationships between its members and the society. The family is a basic human group that has determining links. Family is our starting point in life; it is also a place of refuge when life is too harsh. Family is, or it should be, a special place, an area of harmony and good understanding. Family is a primary support group with a decisive role in supporting psychologically, socially and economically all its members and particularly depressed family members. Family and the group of friends can play a pivotal role in the recovery of the psychic and social potential of the depressed person. An old person preserves or even develops their personality within the family, and as well as this a child discovers their own personality within the family. Family is the first regulation system of the interactions between a child and their social environment. In Romania, there is still a favourable attitude toward the family. As a group of people, family is characterised by the following: -

Kinship Shared life Feeling-based relationships Shared aspirations and interests Shared history.

The types of relationships within a family are: -

Among husband and wife, as a result of marriage Among ascendants and descendants, as a result of procreation Among descendants—brothers and sisters Among other family members—grandparents and grandchildren, parents-in-law and children-in-law.

Maria Voinea (1993: 5-6) says that … defining the notion “family” raises a few difficulties because of the complex meanings of this fundamental social nucleus, because of the diversity of the relationships between the group members, and because of their virtual implications in the wider social sphere. We need to mention that defining family requires at least two kinds of approaches: sociological and legal. Sociologically, a family, as a specific form of human community, designates a group of people united through marriage, filiation or kinship, which is

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A family is a system: “Family is the system most capable of impacting social life” (Prelici 2001, 85). Family could also be defined largo sensu as: a social group whose members are related through age, marriage or adoption and who live together, cooperate economically and take care of the children or, stricto sensu, as a social group made up of a married couple and its children. (Zamfir & Vlăsceanu 1998, 234) A family is a group with particular features, who live according to certain habits, who observe certain traditions, even unconsciously, who apply certain rules of education – in a word, who create a climate. (Vincent 1997, 179)

Due to the changes of the 1990s, Romanian family structure acquired new forms that include couples with no descendants, monoparental families, divorced people, consensual families and celibacy. Unfortunately, the slogans of our modern society are “seize the day,” “life is short,” “all in one,” “instant,” “disposable” etc. All these “mentalities” redefine the concept of “family.” A nuclear family is no longer made up of a father, mother and children—there can also be a single mother and her children, a single father and his children, maybe a possible “trial marriage” between them, over a certain period, to test feelings and abilities; families with same sex partners, with same sex parents; families with absent parents in which elder brothers raise younger brothers, etc. All these changes in the nuclear family produce serious effects on the lives of their actors. Floare Chipea defines family synthetically as: a form of human community, a primary group with all its characteristics, that differs from other primary groups through a few specific notes: it unites its members through marriage, consanguinity, or adoption relations;

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its members usually live together, making up a single home; they share economic activities; they are related biologically, spiritually and ideologically, preserving and perpetuating the culture of the given society; they support each other emotionally and affectively as husband and wife, mother and son, mother and father, etc.; in state and law conditions, the group founds itself based on rules stipulated in official documents. (Chipea 2001, 24–25)

Only family, community and close friends can fulfil the need to belong to somebody or to a group (Regan 2011) and to have a place full of sense and dignity in life for any human being (Brown & Payne 1990). In many cases, when turning old, a person lives alone and the help they get from social services does not meet this need, because social and emotional problems of the elderly are less-known than material ones. The most important role in fulfilling social, emotional and physical needs of the dependent old person belongs to the family; the state has to create the conditions for the maximisation of the abilities of the people, families, and communities to manage their own problems independently (ibid.). In traditional societies, families and communities respected their elderly; moreover, the elderly played a special role in the life of families and communities. The elderly were counsellors and even leaders and addressed questions related to the hardships of life, holding high authority and prestige positions in the social life. When society was characterised by strong families, old age meant social prestige, experience and wisdom. In such a society, old people were appreciated and their contribution to the spiritual field was appreciated as vital for the community. In modern societies, families and communities have decreased the social importance of old age; moreover, it has become one of the most despised stages of life. Nowadays, more than ever, modern society appreciates and promotes youth and prosperity, and tends to exclude old age and old people. Old people are often considered “second-hand” people. More and more families give up material, affective and moral support for the elderly. Moreover, the modern family tends to nuclearise, separate and fragmentise; children get married and wish to live by themselves, without having other generations around. Iolanda Mitrofan claims that family is the nucleus of human organisation, the molecule or microstructure that reproduces all social functions: reproduction and support for human species biological continuation, production of subsistence means, education and socialisation of newly-born and, subsequently, ensurance of moral and spiritual continuation of society. (Mitrofan 1989, 5)

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The trend to nuclearise and individualise the modern family has deep impacts on the relations between old people and their descendants. Within the institution of the family there are complex changes with multiple social, economic and psychic consequences. Stronger nuclearisation leads to the increase of the number of families, and this increases the number of demands for homes. On the other hand, the appearance of the children makes the parents change their attitude toward old people and this brings about old people revalorisation. Old people become useful; they take care of their grandchildren and contribute to their education so that the children’s parents can go to work. This is beneficial for both the parent and the child, provided that the parent be present in his child’s life and education. The higher the valorisation of the elderly, the more present the abilities and personal experiences of the elderly in the network of social institutions, including at the family level; this is about human wisdom, receptive and mature, valorising an invaluable resource of the society. Modern society undergoes all kind of changes such as speeding up the rhythm of rhythm, reducing time spent with the family, increasing time spent working, all of which contribute to a change of values and even lifestyle. Nevertheless, time has proved that family has a particular ability of adapting. All these changes at societal level affect the elderly the most because it is they who preserve and spiritually “carry on” the world of childhood, teenage and maturity. The problem is that this world corresponds only partially to the stage of old age. The youth should be prepared to accept from the elderly what they can offer – the fruit of a life experience, patience in reaching a goal in life, the capacity of making plans, working and relaxing, and avoid useless vices, as well as efforts to admit the true value of life, to know how to become friends and preserve friendship, how to establish a family life and a harmonious couple rich in accomplishments, and how to accept one’s own handicaps and failures without complaining and without resentments. (Wolff 1978, 44)

The changes in family behaviours are caused by economic, social, cultural and ideological factors. Research carried out in Eastern and Western European countries highlight the main factors having determined the changes in family models (Mihăilescu 1999, 28–36):

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Diminution of the family functions by the society that overtakes them Increase of the degree of employment of women and their wish to promote socially Increase of economic independence of the youth Increase of political, cultural and spiritual diversity Changes of morals and increase of social permissiveness toward new forms of behaviour Borrowing behavioural models from other groups.

For a depressed old person, family is a vital, essential factor; its response and attitude have a significant impact on the old person’s state of health, health quality and lifespan. Disparagement of old age, the sociologists believe, actually means “fear of effects and consequences of old age, fear of illness and death, fear of turning valueless for the relatives because of ageing” (Rădulescu 2002a, 37). Believe it or not, dependent old people, alone or abandoned by their families, are one of the largest groups of clients of social work services; unfortunately, their number is predicted to increase in the near future. Family tends to abandon their elderly because solidarity relationships are disturbed, family hardships, the mentality concerning the family duties toward the elderly, the selfishness of the youth, or the feeling of shame when the elderly are in need. The new generation tends more and more to reject the negative aspects of life such as old age, illness and death. The psychological gap between generations tends to increase due to the emotional relationships of opposition and mutual denial. The economic situation of a family is very important for its welfare, but it is not all. The lack of financial resources is a stress in the family that can lead to frustration. The ingredient that can help reduce tension between family members is effective communication. There are families with low resources whose members stay united and who can overcome crisis states. If there is will to communicate, then family members will manage to overcome their problems. Social life continuously changes; therefore, family also changes. From a solid cell, with beneficial, well delimitated functions, family can turn into an unstable, stress-, unhappiness- and dissatisfaction-generating structure that plays the opposite role it should. The issue of modern family lies between the two poles—integration and disintegration. It is sad that, when the people that should be protected and helped to better communicate—the children and the elderly—become the victims of family disintegration, the situation becomes dramatic.

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Though some of the family duties have a material and moral value, the family tends to transfer them to the state, which decreases tolerance toward the elderly. Abandonment is thus just a step ahead: “Emancipation, democratisation, secularisation, and liberalisation of the family life turned the family from “depositary” of social changes into a “barometer” of social changes” (Mihăilescu 2000, 17). There are frequent cases in which an old person is placed in a state institution. This placement is usually done because of material reasons by the old person’s children, who take away their belongings, pension and home, which is either inhabited by somebody else or rented. They try to hide abandonment, to make it totally ignored, though it is steadily increasing in Romania. When an old person is abandoned they can be found either in hospitals (their children forget to take them back home and the medical staff does not know what to do with them), retirement homes, or their own flat (their children no longer visit or support them). It is ideal to have an old person integrated into a family that functions normally, ensuring both a decent living standard and proper care and treatment. Family solidarity is essential, and is the warranty of the old person’s life. Therefore, placing the old person in the family or as close as possible to it has a favourable impact on their health. Their physical and affective isolation cause or speed up involution. The family that isolates old people commits ingratitude and aggravates their state of health, speeding up regression, ageing and even death. Behavioural models and family members’ relationships make them psychically comfortable and safe, or uncomfortable and unsafe. A modern family is, nowadays, responsible for its members. For Bandina & Mahler, family is: a social group established through marriage, consisting of people who live together, share the same household, are linked through certain natural and biological, psychological, moral, and legal relationships and that are responsible for each other in front of society. (Bandina & Mahler 1970, 36)

Family in Transition After December 1989, Romania has undergone a period of transition. During this period, both family life and marriage have been affected by three kinds of mutations—political, economic, and social—as well as by the effects of job occupation strategies, of building and distributing dwellings, and of policies in the field of education and health.

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Family has not been a passive factor in the midst of transition, though by definition it is a traditional institution that tends to preserve its structure. Despite all this, because of the transition, family has turned into a dynamic social institution. These mutations had to impact this biological, social, economic and affective micro-community. The decrease of the standard of living of the population because of the decrease of the purchasing power, unemployment, the costs of living, the failures in getting a proper dwelling, the decrease of access to culture, and the uncertainties and unbalances of all kinds have all marked the population’s attitudes and mentalities, including family behaviour. The changes at society level also generate dysfunctions at family level, resulting in a series of changes of the traditional models. The marital couple has been increasingly oriented toward its own interests, toward ensuring material and emotional comfort, rather than toward achieving the functions of the institution of the family. In “transition” societies, the life of a pensioner is more dramatic because they cannot face elementary expenses. Sometimes, their life is marked by lack of heating, isolation and malnutrition. Children cannot always help their parents because they also have financial problems. State institutions should involve themselves in this more. At the third age, besides affection, old people also need comfort. December 1989 in Romania has also determined radical changes in all the spheres—economy, society, politics and economics—that are new challenges for the family, its structure and functions, and for family protection by the state. Romanian families have strongly been affected by poverty, by a decrease in incomes, and by the increase of unemployment. This is why specialists believe the Romanian family is under the incidence of shock created by the difficulties of the transitions. As a result of these changes, there are also symptoms of dysfunctional families that are relevant for the family crisis state. Among them, the most important are marital conflict, family violence, child abandonment and abandonment of old people. A phenomenon specific to the communist regime was quasi-forced urbanisation of a considerable amount of the rural population, absorbed as labour force. This phenomenon has had negative impacts on family relationships and structure. The prolonged absence of the father and mother, engaged in exhausting commutes because of the distances to work places, resulted in weakening family relationships, and diminishing communication and intimacy, which favoured first emotional divorce then separation, not always legalised. The process of adapting to the urban lifestyle of rural families has often resulted in:

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During the transition period, fatigue and disorientation impacted the family and pessimism and concern impacted the entire Romania. The period of transition has also had a few beneficial effects on family and society. During the transition period, family has given up duplicitous behaviour (in which one talks freely at home and extremely carefully, or even using a code outside the home), replacing it with sincere debate over serious or controversial social issues. Transition has also led to an increased democratisation of the relationships between parents and children, and between teachers and students. The shift from absolute authority of the parents and teachers to normal, relativized relationships is one of the fundamental features of Romanian transition and globalisation. The shift from a close, censored society to an open, democratic one has opened the road to information and knowledge and access to information, which is a true cultural asset. Among the deficiencies of the transition period, we can identify the fact that family and particularly young people have adopted the Western model according to which what matters is what you have, not what you are—a consumerist behaviour based on “have” instead of “be.” More and more individuals and families are prisoners of the mirage of quick enrichment at any cost and without scruples. Yet, there is also a cultural model—“to have in order to be.” People can no longer draw attention through their inner richness, through what they are, and therefore try to replace the lack of qualities with all kind of ephemeral possessions. Families feel the consequences of the lack of communication because of the high costs that no longer allow them to pay visits to one another, to have a phone, and to use mail and communication services. Families have also given up celebration of birth, baptism, marriage, funeral or relaxation through holidays spent away from home. The transition period has also facilitated cultural models, models of modernisation of family lifestyle, of clothing, and also models of impoverishment through inflation and unemployment. The level of aspirations and expectations of the population has not been properly analysed, which has generated a lot of confusion and disappointment among its members. Unfortunately, our society is increasingly facing abandonment. Parents abandon their children in orphanages and, when they grow up, children

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abandon their parents in asylums. Disengagement from family duties, disparaging of the notions of “family,” “marriage” and “responsibility,” mainly affect the vulnerable members of the families—children and the elderly. These two categories of people lose the certainty of support and care they need and that they are entitled to get day after day. Confronted with this cruel reality and “modern” mentalities, social work tries to militate for disfavoured people and help them overcome crisis situations. Moreover, social work tries to also help their families through different services and programmes. The presence of an old person in a family results in tensions between the spouses and even family unbalance and dissolution. The role of social work is to offer counselling programmes for the spouses to help them overcome this issue. If the old person is also (chronically) ill, they are most often institutionalised. A family member with a mental disease is a cause of family unbalance. Psychic illness has a negative impact on social relationships, and particularly on the family of a mentally ill person’s family. Trends in the Romanian Family If, a century ago, sociologists asked themselves where the family came from, they are asking themselves nowadays where the family goes. Mass media, and most of studies focused on the family, repeat a series of clichés such as family dissolution, family disappearance, family ageing, etc., emphasising the association between family and crisis. The idea of a family crisis appeared at mid-nineteenth century, and the main themes supporting this idea aimed at weakening paternal authority, the spirit of obedience, and state intervention in family life. Starting with the 1980s, the theme of family crisis was replayed in the context of the alarming changes of new family structures—increase of the number of consensual couples, expansion of celibacy, diminution of the number of descendents, and reduction of mean duration of marriages. Despite these pessimistic forecasts that give the family no chance, time has proved that it has a strong power to adapt and represents more than a “basic cell” or “ultimate refuge”—it proved itself to be a true social institution, flexible and resistant to change. People are more and more aware of the fact that having a family means having a lot of satisfactions but, at the same time, a lot of responsibilities. In all European countries, there is a trend favourable to family life, no matter how complex and deep the changes within it. Most people continue to get married, and marriage is still considered a source of personal happiness, despite the high rate of divorce and loneliness that tends to

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characterise more and more people. In Gilles Ferreol’s (1994, 10) opinion, “the wave of change is far from pulling down the building of family.” Though forced to go through different changes in time, the family is still the first institution of moral education and an educational environment by excellence for its younger members: Family is at the same time a guardian of parental morality through pure joy, love and responsibility. Children are a strong impulse for work and saving, a strong obstacle against outer temptations. The presence of children exercises a moral censorship on the parents’ conduct. Due to their wish of making children as happy as possible, parents strive to be good examples and success in all fields. (Mladin 1980, 291)

A true family is not without problems, but can overcome and survive them. In general, the family contributes to equipping its members for the social life outside it. Christian morale asks to take care of our peers as we do for our relatives, to consider old people as our own parents, and children as our own children. The particular importance of the family as a natural social life frame is also underlined by the particular importance Jesus Christ gave it. The most important figures of the Church also owed their ascension to the education from their families. For many of them, family was a model to follow. Each generation leaves behind a material and cultural heritage that belongs to the great thesaurus of mankind. Its specificity is due to the bio-psycho-social features of the generations as well as to science and technology. Unfortunately, the elderly, long ago carriers of this heritage, no longer play this role in our society (Ionescu & Negreanu 2006, 37).

Functions and Duties of the Family in Relation to Depressed Old People Family functioning also depends on the social organisation it reflects. Family as a fundamental sub-system of any social system is supported by the necessity of fulfilling its specific functions “that cannot be transferred to any social unit” (Spânoiu 1974, 193), but need to be fulfilled within it. The significant functions of a family are: Maintaining biological continuity of society, procreating, raising and educating children, maintaining cultural continuity through cultural heritage, transmitting social position to descendents, fulfilling emotional

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and private needs, ensuring safety, preserving personality and social integration through orientation, education and socialisation. (Voinea 1993, 45)

Family is important for a nation’s development due to its functions since human population is not amorphous but is structured into families. Romanian sociologist Henri Stahl made a complex analysis of the family functions and grouped them into two major categories—internal and external functions (Stahl, in Voinea 1993, 45): -

Internal functions contribute to creating a private life regime meant to ensure a climate of security, protection, and affection for all its members: x Biological and sanitary functions, ensuring the fulfilment of sexual needs of the marital couple, procreation and sanitary conditions for the normal biological development of all the family members. x Economic functions, ensuring the incomes for the entire family and organising management based on shared budget. x Family solidarity functions, including support based on love and respect between parents and children, brothers and sisters, old people and sick people. x Pedagogical, educational and moral functions, aiming at ensuring children education and primary socialisation.

-

External functions mainly ensure the proper, natural development, socialisation and social integration of each family member: they are a continuation of the internal functions, and have long-term effects on the family aiming at inserting the adults in the production activity.

The distinction between internal and external functions is relative, because they are not isolated. In addition, they characterise all families. These family functions are very important for depressed old people. Family member quality and their later evolution depend on how these functions are fulfilled. Biological Function of the Family The biological dimension of the family life includes two components: sexual and reproductive. Unlike other animal species, in humans, fulfilling instincts is accompanied by affection, warmth and trust, which ensure a

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certain level of comfort and safety. This function ensures the fulfilment of certain vital needs for both individuals and the society in which they live. In our society, there has been a shift from the extended family to the nuclear family and from a large number of children to very small numbers. In the near future, there will be more and more couples without children. Economic Function of the Family Traditionally, the economic function of a family has three main dimensions: -

Productive, whose main goal is to produce within the house the goods and services the family needs. Professional training of descendants and handing over trades from parents to children. Financial, consisting in the management of a budget to cover the family needs and to save money as a source of future purchase of goods and services.

The economic function of a family has undergone important changes over time. Modern society, based on labour division between its members and on their training, has diminished the traditional components of economic life. Industrialisation, modernisation and social mobility have pushed the individual outside their family, toward enterprises, firms and social services. From an economic point of view, modern society has the following features: -

Families are interested in making as high profit as possible. Young people are willing to undergo training processes, no matter the costs. Young people wish to be trained in a profession with high standards and generate high incomes. A very diversified structure of expenses.

Because of the changes it has undergone, modern society has restructured its economic function and diminished its productive function, preserving the consumption sector.

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Family Solidarity Function The unity of all family members in achieving a shared goal leads to their solidarity, to the achievement of its goals and to a harmonious family life. This family function has a twofold importance: -

It provides emotional safety, trust, support, protection and the possibility of harmoniously developing each family member’s personality. Any deregulation of this function leads to the destruction of the group unity, generates unbalance in other functions, and represents an indicator of family disaggregation.

Family solidarity is a complex function marking all family members and moments. Family solidarity produces effects at three different levels— marital, paternal, and fraternal. In time, family solidarity functions decrease mainly because of social mobility (that makes the difference between work place and residence place) and of physical and affective separation. A family’s elderly members play a crucial role in maintaining this function because they can maintain the family balance through wisdom and expertise acquired over time. Pedagogical, Educational and Moral Function (or the Socialisation Function) of the Family This function aims at ensuring the education and primary socialisation of children. Parents and grandparents play a fundamental role in the life of their children and grandchildren, respectively: “Socialisation is the psychosocial process of transmitting-assimilating attitudes, values, conceptions or behavioural models specific to a group or community in order to socially mould, adapt and integrate an individual” (Zamfir & Vlăsceanu 1998, 546) For some authors, socialisation is a fundamental process through which they transmit cultural heritage, norms and values from one generation to another. Socialisation is achieved through competition of several agents, among which the most significant are family, organisations, pressure groups, social classes, and educational institutions, from pre-school to post-academic and religious institutions (Hill 1973, 98). Family is the main factor moulding and socialising a child, the fundamental frame within which their psychological and social needs are fulfilled. Each family member needs to socialise to feel good and develop normally.

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Basic or primary socialisation is achieved within the family. Within the family, children learn that individuals have interests, desires and habits and that all of them need to take them into account; that resources are limited and they need to share them (food, dwelling, even affection). Because of the changes families have undergone, they tend to increasingly transfer this socialising function to other social institutions such as nursery school, kindergarten or school. To preserve this function of the family (as a main socialising institution), grandparents should get more involved in the raising of their grandchildren. Unlike other social institutions, family socialisation is achieved within a climate of affectivity that facilitates the transmission and acquisition of social values and norms. A normal family should fulfil all its functions. In reality, families achieve these functions in very different ways. Some families can be characterised as functionally rich, while others lack some of them. Through these functions, a family ensures for its members safety, care, protection and material and moral support. A healthy family is defined by the functions it accomplishes, by the feelings of love and respect that unite the spouses and the family members, by their dedication, solidarity, and cohesion. Family environment is satisfactory for an old age if it meets his basic needs and provides an affectionate, protective environment. André Berge believes that: A family environment satisfies a child’s need if it meets his basic needs and provides an affectionate, protective environment, a double condition indispensable for a young being to learn, self-develop, and relate to others, polarise sexually and experience, for the first time, social and sentimental feelings. (Berge 1970, 89)

It is within the family that they build human relationships such as subordination, superordination, complementarity and reciprocity relationships. A family’s educational duties are multiple and complex; supposing a conscious, consequent action of the parents and grandparents. This function aims at integrating its members in social life. Parents and grandparents (involved in the raising of their grandchildren) should have the necessary knowledge to carry out educational activities, should wish to carry out educational activities, be aware of the finality of educational activities, be able to carry out educational activities, and have the necessary time and materials to carry out educational activities. Parents can make up a team with the grandparents to provide their children with the proper education. Complementarity could be beneficial for all family members.

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An individual’s socialisation spans their entire life and provides a chance for social and emotional moulding, of preserving integrity and of social integration. Nowadays families are dissociating. Among divorces, lose morality, child abuse and rebellion, united families are on the verge of extinction and are true exceptions. Yet, there are still enough strong families in everyday life, not just in TV programmes. People can enjoy warm family life if they know how to get it. The family now faces problems it has to solve and overcome, and family balance depends on how they manage to do this. Mattaini, Lowery & Meyer (2002) claim that life problems a family has to deal with are caused by inner pressure resulted from family members growing up, stagnation of family evolution, idiosyncratic problems, and by outer pressure resulting from cultural differences, racist or sexist context, too much tolerance toward abuse, and exchanges between the environment and the family or between family members. To cope with these problems, a family should change in shape and/or structure or redefine the roles and duties of its members. This means that a family is continuously undergoing more or less serious crisis situations. Though there are rumours that the institution of the family is a threatened species, there are still billions of people who believe in it and in its role. For many such people, family is still the first and most important school of human relationships. Family attributions consist of a wide range of roles that each member of the family has to play. The role of a family in which there is a depressed old person is vital. The problem is there are also old people with no family at all; families that refuse to support their elderly for various reasons (they are gone, they inherited nothing, they have resentments that block communication and life in common, etc.); and families that are too poor to take care of the elderly. Family cohesion in the third age is extremely important because, no matter what an old person goes through (illness, suffering, pain, joy), when there is somebody to share it with, everything becomes easy and the problems can be resolved and overcome. Family members should be aware of the fact that, if they isolate the elderly, they will experience isolation, which almost always leads to anxiety and depression. Love helps people overcome isolation and separation and be themself. To love means to give, not to receive, and giving is the highest form of power (Fromm 1956). A family’s unity helps each family member to lead their life well and be able to resolve conflicts through communication and mutual help. Family members are linked through rights and obligations of a moral, legal, economic, religious and social nature.

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Petru IluĠ said that: the problems of Romanian families have increased in number and complexity and they need organised assistance. Defining family issues and demand for assistance and therapy will come from the families themselves, from the communities and at global society level. High-standard families will ask for more specialised assistance than low-standard ones. For the latter kind of families, communities and society will ask rather for assistance. Socio-educational status will be a strong discriminatory variable in social assistance: high-standard families will ask rather for psychosocial assistance than for material and/or sanitary assistance. There will be no correlation between the demand for psychosocial assistance and the intensity of family problems. The frequency, intensity, and kind of demand for assistance will depend on mentality and material status. But the way demands will be dealt with depends on the quality of the experts involved. (IluĠ 1995, 216)

Rural families tend to take care of their elderly more than urban ones. Though Romanian villages face ageing, there are still extended families that take care of their old people. Many old people from the rural area live together with their children and grandchildren, which is of great help for the pensioners of the countryside whose incomes are very low (most of them have a pension as former members of the agricultural production cooperatives, which is less than enough to lead a decent life). We live in a civilised world, or at least we would like to. But nowadays’ family members should not forget that there are also obligations besides rights that they should observe if they want to lead a normal life. Respect is the keyword that helps with most family members’ relationships. The Explanatory Dictionary of the Romanian Language (1998) defines respect as “an attitude or feeling of esteem, consideration toward somebody or something; veneration.” If families treated their elderly with respect, many of their traumas and fears would vanish. Gheorghe Marin wrote about respect: when there is sincerity in it, it values more than other things, even more than love. How many times, in moments of distress, when failure darkened our life, respect from people around us reminded us we are humans, we are esteemed, and the feeling of dignity restored optimism, strength to work and self-confidence? (Marin 1978, 13)

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Respect is a feeling because it speaks of an affective state; some kind of consideration because it expresses appreciation, attitude, because it materialises in gestures and words. True respect is inspired by sympathy and appreciation, while an enforced one is not (ibid., 26). Each person is unique and should be respected; respect means not dominating the other, not using the, even when they feel they could. The Bible itself speaks of children’s duties toward their parents and the elderly. According to the teachings of the Bible, not only parents have duties toward their children. There is, in the Decalogue, a special Commandment regulating the relationship between children and parents: “Honour your father and your mother, so that you may live long in the land the LORD your God is giving you” (Exodus 20:12). Obedience and respect play a key role in the relationships between generations. If family members were aware of these realities and took responsibility for their parents who are incapable of taking care of themselves, society would not have to intervene through social work services to support such people. What happens nowadays is much more serious—parents and, in general, old people, are not only neglected by their children, but even abused and removed from their own houses and thrown out onto the street. This may be called abandonment of human relationships. Children leave their parents, and family members abandon their ascendants. There are two kinds of old people: those who would like to stay with their own families and those who would not, for various reasons (they would not like to become a burden for their families, or they are selfish and don’t want to be disturbed by their grandchildren). A “generational sandwich” is made of adult-children or child-adults. They have to take over both the responsibilities of their parents and the responsibilities of their own children. If this burden is carried only by the couple, it becomes exhausting. In such cases, social work services have to help the family ease the burden in order to avoid abandonment. Elderly involvement and roles in a family life Studies carried out on the elderly show that they help their families a lot, taking over certain chores. Though, at a macro social level, the elderly are no longer active, at the micro social level (family) they continue to be very active and useful, helping to resolve different administrative and household, educational and social services that would otherwise be done by the adults in their families.

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By taking over some of the adults’ roles in the family, the latter can dedicate to self-improvement and take part in economic and social activities. Though not legally employed, old people can contribute to the development of the society they live in feeling useful even at a very old age. Here are some of the roles the elderly can play in their families (see Figure 3-1 below): Figure 3-1. Roles the elderly can play in their families

GRANDPARENT

COUNSELLOR

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VOLUNTEER

PASSIVE PERSON

Grandparent. This is one of the nicest roles an old person can play. It makes an old person feel useful and fulfilled since it allows transferring cultural heritage from one generation to another and, particularly, lots of affectivity. Usually, this role is played by old people that have invested in both a family and a career. For them, retirement is easier to bear and grandchildren in the family makes them feel useful. Raising a grandchild makes an old person younger. If the children live far from the old person, they can feel lonely and isolated and, ultimately, become depressed. This role is important for both old people, and children and grandchildren. Among the causes that have reduced the role of the parents in the professional training of their descendents are: (a) Jobs—parents spend less and less time with their children who are taken to nursery schools and kindergartens from an early age; (b) Job diversification—parents find it more and more difficult to practice the “job of parent”; (c) Large amount and a wide range of knowledge—parents no longer can keep pace with their children. Sociological field research (Cernescu 2003) shows that grandparents take over the task of taking care and monitoring children

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of up to three years of age (46%), accompany children to the kindergarten (23%), and first grade schoolchildren to school (11%). Help from the parents in both child raising and household chores are the main reasons some young adults wish to live together with their parents after getting married. Romanian authors (Drimer & MateiSăvulescu 1991) show that in the traditional family, old people play an essential role in the moulding and education of children. Freed from the daily work responsibilities, they were an available and privileged interlocutor for children who had a lot to gain. There was full complementarity between the child (a hyper receiver) and their free, experienced grandparent (a hyper remitter). Since old people evoke the past, children understand they belong not only to the father-mother couple, but to an entire string of generations. At the affective level grandparents are also superior to parents, who are often too tired, nervous, and concerned with their work. Thus, grandparents become the ideal educators, telling stories, comforting, advising and, most importantly, not punishing. Due to their kind and affective ways, they play a fundamental role in their grandchildrens’ lives, ensuring the transfer of “ethical information” from one generation to another. Counsellor. Old people can counsel their children and grandchildren in matters of family life. The life experience of an old person can help the children overcome difficult situations, particularly when the young couple have them. Volunteer. Many old people choose to involve themselves in different humanitarian activities to help their peers, to feel useful and to do something with their time. Many nongovernmental organisations work with volunteers in different projects and carry out a wide range of activities. Old people are very serious volunteers, and this is why many organisations wish to have pensioners in their volunteer networks because they have a much more flexible programme than employed people. There are, in the United States, many old people involved in charity as volunteers. Volunteering makes old people feel useful, experiment with new actions, get into touch with new people and feel fulfilled. Though they play different roles within their families, many old people are not satisfied with what they do socially. Therefore, they can fulfil their social needs by doing something really necessary socially, being considered a member of the community, using their spare time as satisfactorily as possible, being acknowledged as an individual, acting as a true personality, feeling protected and cared for, activating their intellectual abilities and manual skills, all within communitarian organisations. Developing an environment proper for

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volunteering increases the cultural, social, and economic role of the elderly and allows for old people’s contribution to society in the form of unpaid work. “A society for all ages” is one in which old people have the opportunity to contribute to societal development. Passive Person. Some old people choose to do nothing after they retire. This is motivated by one or several of the following: (a) they are very tired after they have worked hard all their life and wish to enjoy a full rest; (b) they have no grandchildren and do not feel like helping their families; (c) they are selfish and choose not to get involved in helping their families but to focus on themselves and on their spouses (if they are still alive). This is the role of old people who used to be very dedicated to their work and had no time to invest in their families (communicating with their children or partner). This amplifies despair because, after they retire, they lose their job and status and have no family support. Being a passive old person isolates the individual even more, bringing about a lack of communication, estrangement and loneliness, and even an early death. Communication is crucial in a family, and lack of it results in psychic discomfort, tension and dissolution of the family.

To recover balance, an old person should focus on broadening the range of interests, on involving themselves more actively in social life, and taking over the roles mentioned above. According to Charles Swindoll (1994), a good family life is not random but the result of deliberate will, determination and practice. There is no aspect of life more pleasant than tight relationships and feelings of safety within a strong family in a world of loneliness and chaos.

Motivating and Helping Families Support the Elderly In our opinion, one of the best, if not the best model of funding family caregivers is the Swedish one (Johansson 2004). According to that model, the economic support programmes for caregivers were targeted on attendance allowance, caregivers’ allowance and care leave. Johansson mentions (ibid., 34): -

Age restrictions for caregiver’s allowance and care leave Categories of beneficiaries (care recipient for attendance allowance, and caregiver for caregiver’s allowance and care leave) Taxation levels (none for attendance allowance)

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Identity of payer (municipality in attendance allowance and caregiver’s allowance, the National Social Insurance for care leave) Pension credits (none for attendance allowance) Level per month (about 550 Euros as attendance allowance, about 1,560 Euros as caregiver’s allowance, and 0% of the income as care leave) Number of recipients in 2002: 5,542 (attendance allowance), 2,002 (caregiver’s allowance), and 9,432 (care leave).

In brief, there were three programs for economic support available for family caregivers caring for older people in Sweden (ibid., 35): -

-

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Attendance allowance (the first and oldest), an untaxed cash payment that goes to the dependent to be used to pay the family member for their help. Eligibility was usually based on level of dependency or amount of care giving, “measured” in hours of help needed and given per week. Many Swedish municipalities had seventeen hours of care giving per week as the cut-off criteria to receive the allowance. Each municipality had the right do decide whether to provide this program, with their own eligibility criteria and level of payment. There was no federal or state regulation of this. Caregiver’s allowance (actually not an allowance), a municipality reimbursement or salary for the work of the family caregiver. A caregivers’ allowance provided similar social security protection as for the care personnel in the formal services and this income was taxed. The salary amounted to the same as a home help employed by the municipality in their own services. This program was also a matter for the local municipality to decide on (there was no national or federal regulation). The opportunity to be employed as caregiver by the municipality was far from a first-hand suggestion from the municipality, but in certain circumstances (the elderly living in a remote part of the municipality and having a daughter living nearby), this could be a preferable arrangement for all involved. However, it was not possible to receive a caregiver’s salary if you were sixty-five and over. Relatives who took care of an elderly family member in a terminal care situation could receive payment from the National Social Insurance Care leave (enacted in 1989). It was possible for relatives (under sixtyseven) to take time off work, with compensation from social insurance, for up to a total of sixty days per relative. The number of days was referred to the person being cared for. The caregiver and the person

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cared for had to be both registered at the social insurance office (the caregiver had to be under sixty-five), and the care had to take place in Sweden. Payments were payable at full, half or one quarter rate. Starting from January 1, 1998, the level of payment was 80% of income qualifying for sickness benefit. In Romania, the funding of elderly caregivers is acknowledged legally (by higher fora), according to the methodology of applying Law no. 17 from March 6, 2000 regarding the social assistance of the elderly, republished in 2007. This law stipulates that the spouse and relatives caring for elderly can benefit from part-time jobs with funding for the other half of the salary from the local budget, corresponding to the monthly gross salary of a debutant social assistant with medium-level training. Moreover, the period the spouse or relatives care for the elderly is calculated as a full-time length of service. The substantial contribution of the family to the care of its elderly is well known, and therefore the support system should direct toward the family, encouraging it to care for the elderly and not institutionalise them. If the family benefited from proper funding, many placements could be avoided and care results would be better (with the cooperation of the old person whose wish of staying with the family is fulfilled), and costs would be lower due to the larger share of care by non-professionals from the family. The family should be helped to function within normal parameters, and each community should provide temporary housing (day, night, weekend, seasonal) or help families in need. At present, there are no written laws that force families to care the elderly, but there are unwritten laws that make the family the most powerful structure of informal support, remaining the main form of affective, material and physical support, ensuring the elderly a better quality life and a decent old age.

CHAPTER FOUR SOCIAL PROTECTION OF THE ELDERLY IN EUROPE AND ROMANIA: PREVENTING DEPRESSION

Social protection can be defined as the ensemble of policies, measures, institutions and bodies that ensure the support of people in need. Older people living with depression are considered to be people in need. All over Europe there are now older people who need relevant and complex social and health policies to overcome crisis situations. Social protection is a component of the national system of social work. The state and civil society are bound to prevent, limit or eradicate temporary or permanent effects of events considered to be social risks because they can generate marginalization or social exclusion of people in need (Abraham 2000; Abraham, Crăciun & Rizon 2003). Social protection is defined as an ensemble of social actions aimed at preventing, reducing or eradicating the consequences of events considered to be social risks. In some developed countries, the constitution contains special provisions concerning the social protection of the elderly while in other countries no legal regulation stipulates their rights (Cox 2008; Reisman 2009; Chen & Powell 2012). The quick increase in the number of elderly population and the inevitable change in structure of the ageing population arouse interest in two important governmental policy areas: ensuring proper health care and proper economic and social support for the elderly. From an academic and political point of view, the most important issue in ageing demographics is elderly welfare in the context of social and economic changes associated with development. Yet another issue of ageing demographics is defining, identifying, and properly assessing the number of older people in need (United Nations Department of Economic and Social Affairs—Population Division 2009). Very often, the elderly are excluded from decision making as they cannot state their position because of moral, affective, health, economic or administrative reasons. Alternatively, the fundament of a right resides in

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expressing one’s will and observing it. In most cases, older people often do not succeed in making their will properly known. In the decades to come, the European Union and candidate states will also know unprecedented changes in the number and structure of population. Fertility rate is expected to keep below natural replacement rates, and life expectancy is predicted to increase by almost one year every ten. It is difficult to foresee migration but, in the absence of major political changes, it does not seem that the general demographic pattern will be reversed. According to the Eurostat scenario, the most important impact will be not on the size of total population, but on the number of working people (of the people performing service). While this population (aged fifteen to sixty-four) in the European Union will fall to about forty million in the next fifty years, the number of people aged sixty-five and over will increase to about the same level of forty million (Mărginean et al. 2001). As a result, the age dependency rate will double from 24% in 2000 to 49% in 2050 (see Figure 4-1 below). This means that the ratio between working people and older people is 4:1, while in 2040 it will be 2:1. These projections supply an instantaneous aggregate for the entire European Union. More worrying changes are expected in a few countries where the fertility rate has seriously fallen. Politicians should take into account all of these considerable risks (Solbes 2003). Figure 4-1. Forecast of age dependancy rate

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The social protection of the elderly materialises at both social insurance and social work levels, and the trend is to harmonise recommendations of the international and European bodies and progress at the world level. This is a must for Romania since its demographics are similar to most developed and developing countries. The goal of social protection is to reintegrate people in need of normal life by stimulating active forces and increasing their capacity of facing the problems specific to their age. In Romania, the reform of the pension system started by gradually increasing the retirement age, a system very unbalanced by the reduction of the retirement age limit after December 1989 as a measure meant to reduce severe unemployment. Important legal acts meant to ensure social assistance for the elderly have been adopted in Romania: Law no. 17 from March 6, 2000 regarding the social assistance of the elderly, republished in 2007, Law No. 705 from December 18, 2001, regarding the national system of social work, Law No. 47 from March 16, 2006, concerning the national system of social work, Law No. 270 from November 14, 2008, to modify Law No. 17 from March 6, 2000, regarding the social assistance of the elderly, and the establishment of the National Council for the Elderly, a governmental institution with a consultative role and regional representation. According to the new legislative framework in the field of social work in Romania (Law No. 47 from March 16, 2006, concerning the national system of social work), the national system of social work is an ensemble of institutions and measures through which the state, local administration public authorities and civil society ensure the prevention, limitation and eradication of temporary or permanent effects of some risk and crisis situations that can engender the marginalization or social exclusion of people, groups or communities. The structural elements of any public system of social work are in close interdependence. The Romanian system of social work consists of the following (Runcan 2009, 12): -

Social institutions Social services Social benefits Social work legislation Social work system specialists Social work system beneficiaries.

The general goal of the national social work system is to protect people who, because of physical, psychical, economic or social reasons cannot

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fulfil their social needs or develop their own skills and competencies to normally and actively participate in the social life. In Romania, the social work system developed gradually and unevenly. Some domains of social work such as child protection or protection of the challenged have undergone radical and rapid changes compared to social protection of the elderly. Social work services, together with financial contributions, contribute to the accomplishment of the mission of the social work system: preventing, limiting or eradicating temporary or permanent effects of situations that can result in marginalization or exclusion of people. In fact, these services correspond to a modern vision of social work involving people, groups and communities in active need, stimulating them to mobilize resources and resolve the issues they are facing. According to the law of the national system of social work: “social services are the complex ensemble of measures and actions meant to meet the social needs of people, families, groups, or communities, and prevent or surpass difficult, vulnerable or dependence situations, aiming at increasing the quality of life and the promotion of social cohesion” (Law no. 47 from March 8, 2006 regarding the national system of social work). There are several classifications of the social work services. Depending on the type of approach, social work services can be community, primary or specialized. Community services have a general character, provide primary support for the needy, and are supplied at domicile, in the family, or in the community. Specialized services provide a more focused support to resolving particular issues, and are supplied both at domicile and in specialized institutions. An efficient social work system combines these types of services. Another distinction at the level of social work services concerns the place where they are supplied, either in natural environment (family, school, place of work), or specialized institutions, and on a temporary (counselling centres, day centres) or permanent (residential institutions) basis, as stipulated by the law (Law no. 47 from March 8, 2006 regarding the national system of social work, art.12). Depending on the situations addressed, there are emergency social work services and chronic situation social work services available. Social work services have a double function: -

Integrating the person in their environment with proper support Mobilising social resources to resolve social issues.

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Depending on the complexity of the situation, social services specialised for the elderly can be supplied in an integrated system in association with medical services. Social work services have different features from country to country depending on the level of socio-economic development, of political options and on the attitudinal and cultural models of the society. The elderly enjoy social benefits such as spa tickets, low-cost train tickets, and free of charge or low-cost subscriptions for municipal transportation, but they can also benefit from low-income people support such as social aid, heating aid, emergency aid, financial aid and death aid. More and more social policies addressing the depressed elderly focus on promoting deinstitutionalisation and involvement of community and civil society because, on the one hand, the number of institutions of older people care is low and, on the other, the number of older people is increasing in both Romania and Europe. Care of the elderly is an indispensable form of social policy in our society. The first issue to be resolved is to ensure material existence under more or less specific institutionalised forms. Legal social care regulations stipulate both support for the vital necessities (food, accommodation, health) and aid for particular situations, for services (home care for the elderly), for social care placements (see also Doel 2010). All social care measures for the elderly, including institutions specialised in the field, have to inculcate a feeling of social safety in different life circumstances such as the progressive diminution of their strength and capabilities or dependence on others. Numerous surveys (Cernescu 2003) as well as experience lead to acknowledging that older people need accommodation with no home chores but allowing them to organise themselves. Older people wish to live separately yet in a community to be able to enjoy help or to be taken care of, if this is the case. Most specialists consider that the most viable solution is still housing for an old person with their family. At world level, they pay more and more attention to housing programmes that take into account adapting to older people’s needs, building houses that meet them. The main directions in house design are flexibility of areas and rooms to be easily adaptable to later changes, separation of sleeping and cooking areas, and designing flexible areas for large families that are easily dividable into smaller flats (two bathrooms and two cooking areas). Another form of protection of the elderly is older people’s homes. It is true that many older people feel socially discriminated and refuse to be admitted to such institutions. Some of the reasons are that they have to share common areas with people they do not know, and to give up their

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furniture and belongings. The elderly also fear that, once admitted to the home, they will lose independence, identity and, finally, life itself. All these measures and forms of care demonstrate the necessity of restructuring and adapting social work forms, more numerous and diverse ways of aiding older people. Social policies that try to protect depressed older people need to take into account those factors that help the elderly the most: -

Ensuring dignified, safe old age Stimulating self-confidence Acquiring the feeling of usefulness Spending time in the most pleasant ways Improving life style, creating a psycho-social integration framework.

Social Protection of the Elderly in Europe— A Depression-Preventing Factor Ageing ranks among priorities on the European agenda at the beginning of the third Millennium. Old Europe deserves its name not only due to its ancient civilisation but also because of the record of having the oldest population. This justifies the concern of European bodies for this phenomenon and for the ageing demographics. Each state needs to protect the rights and freedoms of older people depending on its economic, social and cultural possibilities. Globalisation has led to a common body of rules for the states and international bodies that ensure a more efficient legal protection for the increasing old population. The Council of Europe promotes actions in favour of the elderly and examines the way in which member nations can protect old generations against poverty, discrimination or dependence (see also Okitikpi & Aymer 2010). Reports on the impact of the social protection systems on old age and poverty suggest some actions concerning the following: -

The pensioners’ active potential The promotion of the best practices concerning old labour force The transition from professional activity to retirement Improving the condition of old women The care and access to care of dependent older people The consolidation of solidarity among generations The integration of older people menaced by isolation, etc.

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It is well-known that mental disorders do not characterise a certain country, and are almost omnipresent and have a significant impact on the person experiencing them, their family, and society on the whole. Mental disorders can lead to handicaps, thus resulting in an economic burden for society. The European Union understands the seriousness of mental disorders and of the risks and has advanced suggestions, pacts and resolutions to its member states to help them harmonise national regulations in the field aiming at increasing quality of life. The health of a person, in general, and the mental health of a person in particular, are key-sources for the European Union in ensuring citizens’ quality of life and evolution in the economic and social sphere of each member-nation, in general, and of each citizen, in particular. The rights and freedoms of the citizens are protected by each state. As for the elderly, each state protects these rights and freedoms depending on its economic, social and cultural conditions. All of these rights and freedoms are protected and materialised in both written and unwritten laws—moral laws that should protect the older people and offer them the chance of living normally. The documents issued by international bodies such as the United Nations Organisation, the World Health Organisation, the Council of Europe, or the European Union show a particular interest in population ageing and the necessity of social protection for the elderly. These documents are an indispensable guide in the development of social policies concerning the elderly (Bălaúa 2003). The European Pact for Mental Health and Well-Being The European Pact for Mental Health and Well-Being is an alarm signal concerning the mental health state of the European Union citizens. The pact was launched within the EU High-Level Conference “Together for Mental Health and Well-Being” held in Brussels, June 12–13, 2008. This pact led the member states to take measures to improve the population’s mental health within a trans-sectoral strategy that goes beyond the medical sector, ensuring a higher level of social protection and mental well-being in education and labour. The participants in the conference recognised the following: -

Mental health is a human right. It enables citizens to enjoy well-being, quality of life and health. It promotes learning, working and participation in society. The level of mental health and well-being in the population is a key resource for the success of the EU as a knowledge-based society and

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economy. It is an important factor for the realisation of the objectives of the Lisbon strategy, on growth and jobs, social cohesion and sustainable development. Mental disorders are on the rise in the EU. Today, almost 50 million citizens (about 11% of the population) are estimated to experience mental disorders, with women and men developing and exhibiting different symptoms. Depression is already the most prevalent health problem in many EU-Member States. Suicide remains a major cause of death. In the EU, there are about 58,000 suicides per year of which 3/4 are committed by men. Eight Member States are amongst the fifteen countries with the highest male suicide rates in the world. Mental disorders and suicide cause immense suffering for individuals, families and communities, and mental disorders are major cause of disability. They put pressure on health, educational, economic, labour market and social welfare systems across the EU. Complementary action and a combined effort at EU-level can help Member States tackle these challenges by promoting good mental health and well-being in the population, strengthening preventive action and self-help, and providing support to people who experience mental health problems and their families, further to the measures which Member States undertake through health and social services and medical care. (The European Pact for Mental Health and Well-Being 2008, 2)

Perhaps the most shocking remark here is that “Depression is already the most prevalent health problem in many EU-Member States.” We might add that it also affects more and more old people. The pact calls for action in the following five priority areas: -

Prevention of depression and suicide Mental health in youth and education Mental health in workplace settings Mental health of older people Combating stigma and social exclusion.

As far as the “mental health of older people” is concerned, the participants in the conference emphasise the following (ibid., 5): The EU-population is ageing. Old age can bring with it certain risk factors for mental health and well-being, such as the loss of social support from families and friends and the emergence of physical or neurodegenerative illness, such as Alzheimer’s disease and other forms of dementia. Suicide

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rates are high in older people. Promoting healthy and active ageing is one of the EU’s key policy objectives. Policy makers and stakeholders are invited to take action on mental health of older people including the following: -

Promote the active participation of older people in community life, including the promotion of their physical activity and educational opportunities; Develop flexible retirement schemes which allow older people to remain at work longer on a full-time or part-time basis; Provide measures to promote mental health and well-being among older people receiving care (medical and/or social) in both community and institutional settings; Take measures to support caregivers.

Though recognising that primary responsibility for action in this area rests with member states, the pact builds on the EU’s potential to inform, promote best practice and encourage actions by member states and stakeholders and help address common challenges and tackle health inequalities. European parliament resolution of February 19, 2009 on mental health The European Parliament Resolution of 19 February 2009 on Mental Health relies on several preparatory actions and documents on mental health: -

the EU high-level conference “Together for Mental Health and WellBeing” established the European Pact for Mental Health and WellBeing. the Commission’s Green Paper on Improving the mental health of the population - Towards a strategy on mental health for the European Union. its resolution of September 6, 2006 on improving the mental health of the population towards a strategy on mental health for the European Union. the declaration of the European Ministerial Conference of the World Health Organisation (WHO) of January 15, 2005 on facing the challenges of mental health in Europe and building solutions. the conclusions of the European Council of June 19–20, 2008, which underlined the importance of closing the gap in health and in life

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expectancy between and within member states and stressed the importance of prevention activities in the field of major chronic noncommunicable diseases. its resolution of January 15, 2008 on the community strategy 2007– 2012 on health and safety at work. the United Nations (UN) Convention on the Rights of Persons with Disabilities. Articles 2, 13 and 152 of the EC Treaty. the Charter of Fundamental Rights of the Union. Rule 45 of its Rules of Procedure. The report of the Committee on the Environment, Public Health and Food Safety.

Based on these actions and documents, the European Parliament identified the main arguments in favour of measures to be taken in the field of mental health in general, and of mental health in older people in particular: -

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mental health and well-being are central to the quality of life of individuals and society and are key factors in the EU’s Lisbon Strategy objectives and the revised strategy on sustainable development; the prevention, early detection, intervention and treatment of mental disorders significantly reduce the personal, financial and social consequences thereof. various EU strategic documents have highlighted the importance of mental health in realising those objectives and the need for practical measures in this respect. the added value of the community’s mental health strategy lies primarily in the field of prevention and the promotion of the human and civil rights of people with mental health problems. mental health problems are widespread in Europe, with one in four people experiencing them at least once in their lives, while many more are indirectly affected; the standard of mental health care varies considerably between different member states, especially between the older and some newer ones. gender-specific aspects should be taken into account when considering the subject of mental health; more women than men suffer from mental disorders and more men than women commit suicide. suicide remains a significant cause of premature death in Europe, with over fifty thousand deaths a year in the EU; in nine out of ten cases, it is preceded by the development of mental disorders, frequently depression; and the rate of suicide and attempted suicide among people

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who are in prison or in detention is higher than among the general population. devising policies to reduce the incidence of depression and suicide goes hand in hand with the protection of human dignity. even though depression constitutes a frequently occurring and serious disorder, measures to combat it often remain inadequate; only a few member states have implemented prevention programmes. there is still a lack of understanding and investment in the promotion of mental health and prevention of disorders and a lack of support for medical research and for people with mental health problems. the financial cost to society of mental ill-health is estimated to be between 3% and 4% of the member states’ gross domestic product (GDP); in 2006 the cost to the EU of mental illness was EUR 436,000 million, and most of that expenditure was made outside the health sector, primarily because of systematic absence from work, incapacity for work and early retirement; estimated costs do not in many cases reflect the additional financial burden of co-morbidity, which is more likely to affect persons with mental health problems. social and economic disparities can increase mental health problems; the rates of mental ill-health are higher among vulnerable and marginalised groups, such as the unemployed, immigrants, prisoners and former prisoners, users of psychotropic substances, persons with disabilities and persons with long-term illnesses; specific actions and appropriate policies are necessary to assist their integration and social inclusion. there are significant disparities between and within the member states in the field of mental health, including with regard to the areas of treatment as well as social integration. persons with mental health problems are more at risk than the rest of the population of developing a physical disease and have a lower likelihood of receiving treatment for these physical diseases. while physical and mental health are of equal importance and there is interaction between them, mental health often remains undiagnosed or underestimated and receives inadequate treatment. in most member states there has been a move away from long-term institutionalised care towards supported living in the community; however, this process has taken place without proper planning and resourcing, without control mechanisms and often with budget cuts, which are threatening to cause re-institutionalisation of thousands of citizens with mental illness. the European Mental Health and Physical Health Platform was set up

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in 2008, gathering high-level representatives from key organisations. the foundations for lifelong mental health are laid during a person’s first few years of life; mental illness is common among young people, in whom early diagnosis and treatment is of the utmost importance. the ageing of the EU’s population entails more frequent occurrence of neurodegenerative disorders. the discrimination and social exclusion experienced by people with mental health problems and their families are the consequences not only of mental disorder but also of the stigma, rejection and social marginalisation they encounter, and are risk factors which impede their search for assistance and treatment. the European Union has designated 2010 as the European Year for Combating Poverty and Social Exclusion. research is producing new data on the medical and social dimensions of mental health; however, there are still significant gaps and consequently care should be taken not to hamper the public or private medical research effort by imposing a series of, often onerous, administrative requirements or excessive restrictions on the use of relevant models for the development of safe and effective medication. learning disabilities (mental handicap) share many of the same characteristics and give rise to the same needs as mental disorders. much improvement is essential in the training of medical professionals who encounter mental illness sufferers, including medical practitioners and members of the judiciary. Mental health disorders are ranked first in terms of human morbidity.

The European Parliament Resolution of February 19, 2009 on Mental Health calls on all member states: -

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to develop an awareness of the importance of good mental health, particularly among healthcare professionals and target groups such as parents, teachers, those providing social and legal services, employers, caregivers and, particularly, the public at large. to improve knowledge about mental health and about the relationship between mental health and the years of healthy life, through establishing mechanisms for the exchange and dissemination of information in a clear, easily accessible and comprehensible manner, in cooperation with the commission and Eurostat. to propose common indicators to improve the comparability of data and facilitate the exchange of best practices and cooperation between the member states to promote mental health.

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to use the funding facilities available under the Seventh Framework Programme for more research in the field of mental health and wellbeing, and the interaction between mental and physical health problems; to explore the funding facilities for mental health initiatives under the European Social Fund and the European Regional Development Fund. to make optimum use of the community and national resources available to promote mental health issues and organise awareness and training programmes for everyone in key positions to promote early diagnosis, immediate intervention and proper management of mental health problems. to conduct and publish a survey of mental illness services and mental health promotion policies across the EU. to adopt UN resolution 46/119 on “the protection of persons with mental illness and the improvement of mental health care” drawn up by the United Nations Commission on Human Rights and adopted by the General Assembly of the United Nations in 1991. to give people with mental health problems the right to equal, full and appropriate access to education, training and employment, in accordance with the principles of lifelong learning, and to ensure that they receive adequate support for their needs. to introduce screening for mental health problems in general health services and for physical health problems in mental health services; furthermore, to establish a comprehensive model of care. to disseminate the results of the thematic conferences to be held in order to implement the goals of the European Pact and to propose a European Action Plan for the Mental Health and Well-Being of Citizens and Medical Research. to keep the proposal for a European Strategy on Mental Health and Wellbeing as its long-term objective. to create up-to-date mental health legislation which is in line with international obligations as regards human rights, equality and the eradication of discrimination, the inviolability of private life, autonomy, bodily integrity, the right to information and participation, and which codifies and enshrines the basic principles, values and objectives of mental health policy. to adopt common European guidelines defining disability in accordance with the provisions of the UN Convention on the Rights of Persons with Disabilities.

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As for the mental health of older people, The European Parliament Resolution of February 19, 2009 on Mental Health: -

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calls on the Member States to adopt appropriate measures to improve and maintain a high quality of life for the elderly and to promote health and active ageing through participation in community life, including the development of flexible retirement schemes. stresses the need to promote research into prevention and care with regard to neurodegenerative disorders and other age-related mental illnesses and for any future commission action or proposal to distinguish between Alzheimer's disease or similar neurodegenerative disorders and other forms of mental illness. encourages the development of an interface between research and policy in the field of mental health and wellbeing. notes the need to assess the co-morbidity of elderly people and the need for the training of healthcare personnel to increase knowledge about the needs of the elderly with mental health problems. calls on the commission and the member states, in the context of the open method of coordination on social protection and integration, to take measures to support caregivers and to develop guidelines for nursing and long-term care in order to help prevent maltreatment of the elderly and to allow them to live with dignity in an appropriate environment.

Social protection of the Elderly in Romania: A Depression-Prevention Factor In its EU accession process, Romania was forced to improve its legislation and institutional regulations regarding both social care for the elderly and mental health of its citizens. Romania’s government was sent, at the end of 2005, a warning letter from the EU asking it to increase its efforts to improve the care of the mentally ill. The EU also sent several reports and recommendations to warn about mental health protection. The government’s social programmes in the field of health rely on the fact that “health care should be a collective social asset accessible to all Romanian citizens, no matter their capacity of payment, while ensuring free, equitable access to health services” (Romania’s Post-Adhesion Strategy). Health indicators of Romania’s population point to a critical situation. Romania ranks, in most indicators, among the lowest in Europe in this regard. According to The National Plan for Anti-Poverty and for the Promotion of Social Inclusion and other documents, the critical health

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state is the result of the combined effect of several factors such as poverty (lack of financial resources, improper food, improper housing, lack of elementary hygiene conditions), lack of social organisation (lack of care for one’s own health state, unhealthy lifestyle, lack of culture and hygiene education), lack of access to medical services, lack of compulsory prevention and treatment services, and lack of medical care systems based on territoriality (National Strategic Report regarding Social Protection and Social Inclusion 2008). Actions at the national level are fewer and more guarded than international ones, and reflect truer concerns for global demographics and its consequences. Yet, it is encouraging that there are also regulations in Romania. Law No. 74 from May 3, 1999 for the ratification of the European Social Charta revised, adopted in Strasbourg on May 3, 1996, commits to promote proper measures for older people, allowing them to remain full members of the society and to have enough resources for a decent life, participate actively in the public, social and cultural life, decide on their own lives, lead an independent life in their habitual environment (if possible), rely on home care services adapted to their needs and, for the institutionalised older people, proper support and care. After Romania joined the European Union, it had to harmonise its regulations in both social work and mental health. Thus, integrating mentally ill people in society has become a priority, and important funds have been allocated for the establishment of fifty community medical assistance centres through the conversion of mental health laboratories. Frame laws regarding the national system of social work, the protection of the older people, and the protection of mentally ill people have undergone deep changes, additions and completions, and some of them have even been republished. Romanian regulations in the field of social work for the older people, of the protection of mental health and of mentally ill people are: -

Law no. 47 from March 8, 2006 regarding the national system of social work Law no. 17 from March 6, 2000 regarding the social assistance of the elderly, republished in 2007 Law No. 487 from July 11, 2002 regarding mental health and protection of mentally ill people, republished in July 17, 2012 Order of the Minister of Health No. 372 from April 10, 2006 regarding the Norms for the Enforcement of the Law No. 487 from July 11, 2002 regarding mental health and protection of mentally ill people, with further changes

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Government’s Decision No. 541 from June 9, 2005 regarding the National Strategy for the Development of the Social Care System for Older People during 2005–2008 Government’s Decision No. 1826 from December 22, 2005 regarding the approval of the National Strategy for the Development of Social Services Government’s Decision No. 1175 from September 29, 2005 regarding the approval of the National Strategy for the Protection, Integration, and Social Inclusion of Persons With Disabilities During 2006–2013 Government’s Decision No. 686 from July 2005 regarding the prevention and control of family violence.

The Ministry of Labour, Family and Social Protection and the Ministry of Health developed action plans to implement these national strategies based on United Nations standard rules regarding civil, political, social and economic rights meant to protect everybody and to increase quality of life in older people from Romania. All these strategies and plans are based on a frame-document titled Romania’s Post-Adhesion Strategy for the period 2007–2013. The chapter “Development of Human Capital,” Public Health section, points out that Romania is willing to continue the reform of the health system in two main directions: focus on the development of the health infrastructure and focus on the increase of the share of preventive health services. The development of health infrastructure ensuring trained personnel aims at improving the national emergency system through building/rehabilitation, equipping specialised establishments and rehabilitating the assistance system for mentally ill people (community mental health centres and psychiatric assistance compartments, mechanisms for the social reintegration and reinsertion of mentally ill people). The increase of the share of preventive health services will be done through the development of community medical assistance and primary medical assistance, through the information and education of the population on how to prevent and diagnose chronic disease with major impacts on the population’s health (Romania’s Post-Adhesion Strategy). The National Strategy for the Development of the Social Care System for Older People during 2005–2008 The National Strategy for the Development of the Social Care System for Older People during 2005–2008 is a political document through which the Romanian Government binds to approach, in a sustainable, participative

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and preventive manner, the policies of social care for institutionalised older people, for older people abandoned by their families, and for older people neglected or abused, homeless, or on the verge of poverty and social exclusion. The strategy meets the need for a national system of social work in Romania, and for the promotion of an integrated system of social work policies that covers the social needs of older people. The Strategy has also taken into account the legislative package concerning the social work system, The Social Programme from December 23, 2003 for the period 2003–2004, The National Plan of Development 2007–2013, the rights, goals and recommendations in the field of social work of the European Union, The Political Declaration and Madrid International Plan of Action on Ageing stated at the second World Assembly on Ageing in Madrid (2002) (Bădescu, Mihăilescu & Zamfir 2002). The principles in Romania’s National Strategy for the Development of the Social Care System for Older People during 2005–2008 are deeply rooted in the principles of the UNESCO’s Universal Declaration on Bioethics and Human Rights: -

Human dignity and human rights Benefit and harm Autonomy and individual responsibility Consent Persons without the capacity to consent Respect for human vulnerability and personal integrity Privacy and confidentiality Equality, justice and equity Non-discrimination and non-stigmatization Respect for cultural diversity and pluralism Solidarity and cooperation Social responsibility and health Sharing of benefits Protecting future generations Protection of the environment, the biosphere and biodiversity (see also ğigmeanu & Keller 2008; Dolgoff, Harrington & Loewenberg 2012).

Both the strategy and the national plan for social action concerning older people emphasise the idea that older people need not only social security, but also support systems, i.e. social and medical services. The strategy and the plan are ways of clarifying and reorganising the social work system for the elderly in accordance with the trends of institutional and administrative

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reform of Romania (Government’s Decision No. 541 from June 9, 2005 regarding the National Strategy for the Development of the Social Care System for Older People during 2005–2008). Law No. 487 from July 11, 2002 regarding mental health and protection of mentally ill people Mental health is a fundamental component of the health of each individual and a major goal of public health policy. Law No. 487 from July 11, 2002 regarding mental health and protection of mentally ill people protects mental health and mentally challenged people in Romania. A mentally ill person is someone with a psychic unbalance, rather than psychically handicapped or alcohol or drug addicted; a mentally handicapped person is one incapable of facing social life because of their psychic disorder. According to art. 6, al. (1) of the Law No. 487 from July 11, 2002, promoting mental health aims at behaviour models and healthy lifestyles which increase resistance to risk factors and to psychic disease. The goal of caring for mentally people is, irrespective of age or social status, to protect and strengthen each mentally ill person’s autonomy (Gormally 1992). Everybody in Romania, including mentally ill people, have rights. Section 3 of the Law No. 487 from July 11, 2002 stipulates these rights that should be observed: -

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The right to the best medical and mental health care services available. The right to be treated humanely and with respect for human dignity, to be protected against any form of economic, sexual or other form of exploitation, against damaging or degrading treatment. The right to indiscrimination based on psychic disorder. The right to exercise all civil, political, economic, social and cultural rights acknowledged in the Universal Declaration of Human Rights and other international conventions and treaties of which Romania is a signatory or a party. The right to live and work within the society, if possible; local public administration, through its competent bodies, ensure the integration or reintegration in professional activities depending on the health, social state and professional-reinsertion capacity of the mentally ill persons. The right to get community care from the perspective of this Law. The right to a private life. The right to communication, particularly with other persons from the care unit.

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The right to send and receive private messages with no censorship at all. The right to be visited by a councillor or by a personal or legal representative and, if possible, by other visitors; the right to mail and communication services, as well as to newspapers, radio, and television. The right to choose their own religion. The right to education. The right to buy or receive everyday life items, entertainment or communication; the right to lead an active life adapted to their social and cultural environment, to encouragements to use these means and to professional readjustment measures meant to ease social reinsertion. The right to be informed, as a patient of a mental institution, in an accessible form and language, on their rights as stipulated by law, together with explanations on how to exercise these rights; The right to a personal or legal representative informed about these rights in case of incapacitation. The right to designate the person to be informed on their behalf as well as the person who will represent their interests in front of the institutions.

According to art. 24 of the Law No. 487 from July 11, 2002, all persons with mental disorders in Romania should benefit from medical assistance and social care and protection of the same quality as those supplied for other categories of ill people, and adapted to their condition. Chapter seven of Law No. 487 from July 11, 2002 presents the financing system for mental health services in Romania. All these services are financed from the health insurance budget and the state budget. Order of the Minister of Health No. 372 from April 10, 2006 regarding the Norms for the Enforcement of the Law No. 487 from July 11, 2002 regarding mental health and protection of mentally ill people, with further changes This regulation brings improvements in the field of mental health in Romania and also some changes and completions. The Order of the Minister of Health No. 372 from April 10, 2006 presents in detail all Romanian institutions habilitated to take concrete measures for the promotion and defence of mental health as well as to prevent and treat psychic disorders:

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The Ministry of Public Health The Ministry of Labour, Family and Social Protection The Ministry of Education, Research and Innovation The Ministry of Administration and Internal Affairs The Ministry of Justice and Public Freedoms The Ministry of Youth and Sport The National Authority for the Protection of Persons with Disabilities The National Authority for the Protection of Child’s Rights.

The plan for the promotion of mental health and for the prevention of psychic diseases is developed by the Ministry of Health in cooperation with the above-mentioned institutions and also with Romanian nongovernmental organisations. What is new in the Order of the Minister of Health No. 372 from April 10, 2006 in the field of mental health in Romania is the functional organisation of the country’s area into geographical areas called “psychiatric sectors.” This new organisation aims at ensuring community psychiatric assistance, increasing service availability and, last but not least, an increase in the quality of services for mentally ill people. According to art. 9 of the Order of the Minister of Health No. 372 from April 10, 2006, the following structures are organised in each psychiatric sector depending on the local needs and features: -

Mental Health Centres Day Stationaries Psychiatry Practices Accommodation centres, with or without legal personality.

The services provided in each psychiatric sector are: -

Ambulatory psychiatric centres Mobile assistance services Day psychiatric services Rehabilitation services Hospital services Home care.

All these services are provided in both urban and rural environments, in each psychiatric sector, by the therapy team made up of psychiatrists, social workers, psychologists, psychiatric assistants, and other categories of personnel.

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Government’s Decision No. 1175 from September 29, 2005 regarding the approval of the National Strategy for the protection, integration, and social inclusion of persons with disabilities during 2006–2013 The National Strategy for the protection, integration, and social inclusion of persons with disabilities during 2006 to 2013 followed by the Action Plan for the Implementation of the Strategy of the Ministry of Health in the field of mental health were a must for Romania because the situation of the mental health system before this was in crisis. The patients with different psychic disorders and those taking care of them were often stigmatised, which would bring them deeper into discouragement, isolation and even despair. The goal of this action plan for mental health is to provide the entire Romanian population with access to at least reasonable quality mental health care. The action plan emphasises that the link between the mental health system and social services is weak and sometimes even counterproductive. We need to focus more on a better cooperation between health services and social services, and between psychiatrists and social workers, because the client should be seen as a whole, as they have not only physical, but also psychic and social needs. The present model is focused on the client, and the specialists of the multidisciplinary teams should make an assessment of the social, psychological and physical needs of each person with depression or other psychic disorder. The Community Centre for Mental Health will play a central role in the reform of the mental health system in Romania. The goal of this community centre is to bring mental health closer to the community, not only in the urban but also in the rural area. It will allow the treatment of more depressed persons at home and not in hospital, which will also result in a decrease of the costs in the health system and an increase of the quality of community services. These centres will function only within a system of mental health and social care and if there is enough protected housing available. It is essential that protected housing functions in the community and that each patient has their own room. The ideal would be that each community centre has fifty places in protected housing. In this system of protected housing, persons with depression or with other psychic disorders get assistance from a psychiatric assistant and from a social worker. The support provided by such a team is essential for persons living in protected housing. Since 2006, there has been a change for the better in both social and mental health fields. The National Progress Report presents the measures

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and the action directions in the field of mental health (National Progress Report—Common Memorandum regarding Social Inclusion 2006): -

They established the National Centre for Mental Health within the National Institute for Research-Development in health They have hired 110 social workers whose mission is to monitor the patients’ rights in psychiatric hospitals They have established ten Community Centres for Mental Health They have allocated funds for the improvement of the conditions in seven hospitals.

The directions of action in the field of mental health in Romania are numerous. Here are the most important ones: -

The mental health system needs to focus on the physical, social and psychic needs of the client For Romania’s population (twenty-one million people) we need 140 psychiatric units (in 2006, there were 38 such hospitals) A therapy team taking care of a person with psychic disorders should be made of psychiatrists, psychiatric assistants, social workers, clinician psychologists and auxiliary personnel Spending for mental health need to increase to 10% of the general budget of the health system.

According to the World Health Organisation, the money spent on mental health is a profitable investment. Romania has started to understand this and, in 2006, the Ministry of Health allocated important funds for the mental health system. The funds allocated for the National Programme of Mental Health increased five times from twenty to one hundred billion RON. This money has been used to establish eight pilot-centres of community mental health and for the partial rehabilitation of six psychiatric hospitals (Peer Review 2006. Evaluation Mission on Mental Health Romania. Draft Report [ref. Peer 21830]). The main task of coordinating the implementation of the reform in the field of mental health at national level belongs to the Intersectoral Committee for Coordination in Mental Health. This committee is a body meant to facilitate and consolidate communication and decisions between the factors involved. It has an executive committee that implements the decisions made. The committee and its executive achieved the action plan for the implementation of the strategy of the Ministry of Health in the field

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of mental health (National Progress Report—Common Memorandum regarding Social Inclusion).

PART TWO

CHAPTER FIVE DEPRESSION IN THE ELDERLY: QUANTITATIVE RESEARCH

The present research aims at analyzing the psycho-social factors generating depression in the older people. The goal of this study is to uncover the intra-personal perspective on the impact of psycho-social factors on depression in the elderly. We have used the survey method, and our research instruments have been the opinion questionnaire on the psycho-social factors that lead to the onset of depression in older people and the Beck Depression Inventory—Short Form (Blanchet et al. 1998; Chelcea 2004). The general hypothesis of the research is that any major negative affective event increases the risk of onset of depression. The working hypothesis is that there are several psycho-social factors generating depression in older people: -

Retirement Losses Poverty Loneliness.

The working hypothesis concepts can be operationalised as follows: -

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Retirement is often associated with old age, when an active adult loses their status and gets another less satisfactory one, i.e. the status of an old person. Retirement is a factor precipitating the onset of depression in older people. This is the time when lots of older people lose selfesteem and feel useless and sometimes misunderstood. Losses (of a partner, of an adult child, of the social status, etc.) accumulate when one gets older. Loss generates crisis in a person’s life and old persons are sometimes unable to overcome it. Poverty is more difficult to bear in older people than in younger people. Older people are one of the most vulnerable groups. Poverty is often seen as a heavy burden, particularly when old, as it generates humiliation and humiliation generates loss of self-esteem.

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Loneliness can be seen as a disease of old age. Unfortunately, an increasing number of old people are marked by this disease. In many cases, it is institutionalisation that makes old people feel lonely. Depression risk increases more in institutionalised older people than in older people living in a community, in their own families. In many cases, the lack of social support from the extended family or from the community makes old people feel lonely and socially isolated.

It is worth mentioning that these psycho-social factors do not usually act separately, and two or three such factors associate and lead to depression in the elderly. The population targeted consists of older people institutionalised in the psychiatric hospitals of Timiúoara and Gătaia (Timiú County, Romania), in the Home for the Elderly of Timiúoara and of older people with families that attend a day centre in Timiúoara. The research sample is made of three lots of older persons: -

The depressed—fifty older persons diagnosed with depression and admitted in the “E. Pamfil” Psychiatric Clinic of Timiúoara and the Psychiatric Hospital of Gătaia. The institutionalised—fifty older persons institutionalised in the Home for the Elderly of Timiúoara. The non-institutionalised—fifty older persons living with their families, or close to them, and attending a day centre of Timiúoara.

In the selection of each lot, we used both inclusion and exclusion criteria (Gerring 2007). Selection criteria for the depressed sample were: -

Inclusion criteria: x To be over fifty-five years old x To be have been diagnosed with depression x To be hospitalised in either the E. Pamfil Psychiatric Clinic of Timiúoara or the Psychiatric Hospital of Gătaia.

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Exclusion criteria: x Not to be over 55 years old x Not to be diagnosed with depression x Not to be hospitalised.

Selection criteria for the institutionalised sample were:

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Inclusion criteria: x To be over fifty-five years old x To be retired x To be institutionalised in the Home for the Elderly in Timiúoara x Not to have been diagnosed with depression.

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Exclusion criteria: x To not be over fifty-five years old x To not be retired x To not be institutionalised in the Home for the Elderly of Timiúoara x To be diagnosed with depression.

Selection criteria for the non-institutionalised sample: -

Inclusion criteria: x To be over fifty-five years old x To be retired x To attend the Day Centre of Timiúoara x To not be diagnosed with depression.

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Exclusion criteria: x To not be over fifty-five years old x To not be retired x To not attend the Day Centre of Timiúoara x To be diagnosed with depression.

Quantitative Research Instruments The instruments used in the quantitative research were: -

The opinion questionnaire on the psycho-social factors that led to the onset of depression in older people was administered to the three lots of older people. The Beck Depression Inventory—Short Form was administered to the three lots of older people. Administration of the inventory was supervised by Dr. Mieta-Gabriela HaĠegan, psychiatrist and manager of the Psychiatric Hospital of Gătaia.

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Research instruments were tested on a lot of older people (ten hospitalised depressed older people, ten institutionalised older people, and ten noninstitutionalised older people attending a day centre). Initially, the opinion questionnaire on the psycho-social factors that lead to the onset of depression in older people had forty items but, after pretesting it, we decided: -

To remove the less relevant items and those difficult to understand for older people—a total of sixteen items—because the forty-item questionnaire was too long to be filled in by older people. To supply a brief, clear definition of depression to make sure everybody understands what it is. To administer a twenty-four item questionnaire.

Data were collected between January 2008 and April 2008.

Processing and Storing Research Data Coded data were stored in an Excel database and kept on our personal computer to ensure confidentiality (O’Leary 2004). Statistical analysis of data was done with an IMB SPSS 16. Graphic presentation was done with Microsoft Office 97. The statistical analysis consisted of two stages: -

A descriptive stage in which we calculated answer frequency in each questionnaire item. A comparative stage in which we calculated answer frequency for each item depending on the lot. We designed contingency tables and the Ȥ² comparison test, considering as significant values of p > 0.05 (probability 95%).

Comparative Analysis of Psycho-Social Factors Leading to the Onset of Depression in the Elderly As mentioned above, the three lots included fifty old people each (see Figure 5-1 below).

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Figure 5-1. The three lots of old people

Age We identified four age groups in our sample: -

Fifty-five to fifty-nine years old—depressed old people represent 64%, institutionalised old people represent 4%, and non-institutionalised old people represent 2%. Sixty to sixty-four years old—non-institutionalised old people represent 22%, depressed old people 18%, and institutionalised old people 14%. Sixty-five to sixty-nine years old—non-institutionalised old people represent 30%, depresssed old people 10%, and institutionalised old people 10%. Seventy to seventy-five years old—institutionalised old people represent 72%, non-institutionalised old people 46%, and depressed old people 8%.

It is important to note, on the one hand, the significant high percentage of depressed old people aged fifty-five to fifty-nine (64%) and, on the other hand, the large share of institutionalised old people (72%) and of noninstitutionalised old people (46%) aged seventy to seventy-five (see Figure 5-2 below).

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Figure 5-2. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on age group

Gender -

Males—depressed elderly males represent 50%, non-institutionalised elderly males 50%, and institutionalised elderly males 24%. Females—institutionalised elderly females represent 76%, depressed elderly females represent 50%, and non-institutionalised elderly females represent 50%.

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Figure 5-3. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on gender

Education We identified six groups depending on the level of education of the old people in our sample: -

Illiterate—institutionalised old people represent 4% and depressed old people represent 2%; no non-institutionalised old person chose this answer. Elementary school—institutionalised old people represent 22%, noninstitutionalised old people 14%, and depressed old people 6%. Grammar school—institutionalised old people represent 52%, noninstitutionalised old people 36%, and depressed old people 18%. High school—depressed old people represent 60%, non-institutionalised old people 14%, institutionalised old people 4%. Post-High school—non-institutionalised old people represent 22% and institutionalised old people 12%. No depressed old person chose this answer. Higher education—non-institutionalised old people represent 14%, depressed old people 14%, and institutionalised old people 6%.

We need to point out, here, the large share of high school graduates among depressed old people (60%), and the shares of grammar school graduates

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among institutionalised old people (52%) and non-institutionalised old people (36%) (see Figure 5-4 below). Figure 5-4. Comparative analysis of depressed, institutionalised, and noninstitutionalised old people depending on the level of education

Occupation -

Active—only depressed old people chose this answer (8%); Retired—institutionalised old people represent 100%, non-institutionalised old people represent 100%, and depressed old people represent 92%.

To note the large share of institutionalised old people (100%), noninstitutionalised old people (100%), and depressed old people (92%) that are retired, compared to the only 8% depressed old people that are still active (see Figure 5-5 below).

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Figure 5-5. Comparative analysis of depressed, institutionalised, and noninstitutionalised old people depending on occupation

Marital Status There are four groups in our sample depending on marital status: -

Married—depressed old people represent 32%, non-institutionalised old people represent 24%, and institutionalised old people represent 12%. Not married—depressed old people represent 18%, institutionalised old people 6%, and non-institutionalised old people 2%. Widowed—non-institutionalised old people represent 64%, institutionalised old people 64%, and depressed old people 30%. Divorced—depressed old people represent 20%, institutionalised old people 18%, and non-institutionalised old people 10%.

We need to point out the high share of widowers among institutionalised and non-institutionalised old people (64% each), and the almost equal shares of depressed old people that are married (32%) and widowed (30%) (see Figure 5-6 below).

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Figure 5-6. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on marital status

Level of Depression There are three levels of depression in our sample of old people: -

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Mild depression—non-institutionalised old people represent 46% (0.51–1.20 on the Beck Depression Inventory), institutionalised old people 4% (0.51–1.20 on the Beck Depression Inventory), and no depressed old people chose this answer. Moderate depression—institutionalised old people represent 62% (1.21–2.00 on the Beck Depression Inventory), non-institutionalised old people 22% (1.21–2.00 on the Beck Depression Inventory), depressed old people 42% (2.01–2.50 on the Beck Depression Inventory). Severe depression—depressed old people represent 58% (score 1.21– 2.00 on the Beck Depression Inventory), institutionalised old people 34% (2.01–2.50 on the Beck Depression Inventory), and no noninstitutionalised old people chose this answer.

It is interesting to note, on the one hand, that 58% of depressed old people suffer from severe depression, compared to only 34% of the institutionalised old people and no non-institutionalised old people. On the other hand, 62% of the institutionalised old people, 42% of the depressed

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people and only 22% of the non-institutionalised old people suffer from moderate depression (see Figure 5-7 below). Figure 5-7. Comparative analysis of depressed, institutionalised and noninstitutionalised old people depending on level of depression

Analysis and Interpretation of Quantitative Data Favourite Pastimes The older people in our sample made the following options about their favourite pastimes: -

Spending time with family—depressed old people represent 46%, noninstitutionalised old people 34%, and institutionalised old people 20%. Meeting my friends/neighbours—non-institutionalised old people represent 46%, institutionalised old people 8%, and depressed old people 4%. Travelling—non-institutionalised old people represent 18%, institutionalised old people 6%, and depressed old people. Staying home alone—depressed old people represent 30%, institutionalised old people 18%. No non-institutionalised old person chose this answer. None—institutionalised old people represent 48%, depressed old people 16%, and non-institutionalised old people 2%.

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It is interesting to note here that spending time with the family is important for 46% of the depressed old people, 34% of the non-institutionalised old people and 20% of the institutionalised people. Meeting friends/neighbours is important only for non-institutionalised old people (46%), while 48% of the institutionalised old people have no favourite pastimes (see Figure 5-8 below). Figure 5-8. Comparative analysis of answers about favourite pastimes

Most Important Wish The old people in our sample were asked to state their most important wish for old age: -

Good health—non-institutionalised old people represent 72%, depressed old people 60%, and institutionalised old people 30%. Money—depressed old people represent 4% and non-institutionalised old people 2%. No institutionalised old person chose this answer. Long life—depressed old people represent 4%, non-institutionalised old people 2%, and institutionalised old people 2%. Good relationships with family and friends—non-institutionalised old people represent 24% and depressed old people 10%. No institutionalised old person chose this answer. Easy death—institutionalised old people represent 68% and depressed old people 22%. No non-institutionalised old person chose this answer.

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Note the significant share of non-institutionalised old people (72%) and of depressed old people (60%) wishing to be in good health compared to the significant share of institutionalised old people wishing to die easily (68%) (see Figure 5-9 below). Figure 5-9. Comparative analysis of answers about most important wishes

Frequency of Depression Episodes The old people in our sample were confronted with depression at three different rates: -

Many times—depressed old people represent 80%, institutionalised old people 56%, and non-institutionalised old people 16%. A few times—non-institutionalised old people represent 60%, institutionalised old people 34%, and depressed old people 16%. Never—non-institutionalised old people represent 24%, institutionalised old people 10%, and depressed old people 2%.

Here, we should note the large share of frequent depression episodes in depressed old people (80%) and institutionalised old people (56%), compared to the large share of non-institutionalised old people who claim to feel depressed only a few times (60%). Depressed old people are the best at identifying depression episodes (see Figure 5-10 below).

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Figure 5-10. Comparative analysis of answers about frequency of depression episodes

Effect of Forced Retirement Forced retirement can give older people three different feelings: -

Freedom—non-institutionalised old people represent 20% and depressed old people 14%. No institutionalised old person chose this answer. Deprivation—non-institutionalised old people represent 22%, institutionalised old people 20%, and depressed old people 8%. Depression—institutionalised old people represent 80%, depressed old people 78%, and non-institutionalised old people 58%.

Institutionalised old people (80%), depressed old people (78%) and noninstitutionalised old people (58%) become depressed through their forced retirement (see Figure 5-11 below).

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Figure 5-11. Comparative analysis of answers about forced retirement effect

Perception of Retirement The old people in our survey had to choose between three different perceptions about retirement: -

A period of rest—non-institutionalised old people represent 62%, depressed old people 30%, and institutionalised old people 12%. A period of deprivation—institutionalised old people represent 44%, non-institutionalised old people 24%, and depressed old people 22%. A burden—depressed old people represent 48%, institutionalised old people 44%, and non-institutionalised old people 14%.

The old people in our survey have different perceptions about retirement— non-institutionalised old people see it as a period of rest (62%), depressed old people see it as a burden (78%), while institutionalised old people see it equally as a period of deprivation and a period of rest (44% each) (see Figure 5-12 below).

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Figure 5-12. Comparative analysis of answers about the perception of retirement

Acceptance of Retirement Three main attitudes towards retirement were discerned in the old people in our survey: -

Await it with joy—non-institutionalised old people represent 12%, depressed old people 10%, and institutionalised old people 6%. Consider it normal—institutionalised old people represent 90%, noninstitutionalised old people 78%, and depressed old people 66%. Cannot accept it—depressed old people represent 24%, noninstitutionalised old people 10%, and institutionalised old people 4%.

Note the large share of institutionalised old people (90%), noninstitutionalised old people (78%), and depressed old people (66%) who consider retirement is something normal in a person’s life (see Figure 5-13 below).

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Figure 5-13. Comparative analysis of answers about acceptance of retirement

Reasons to Remain Active There are three main reasons why older people wish to remain active: -

Material reasons—depressed old people represent 60%, institutionalised old people 58%, and non-institutionalised old people 50%. Social status—non-institutionalised old people represent 24%, institutionalised old people 18%, and depressed old people 18%. Feeling of young—non-institutionalised old people represent 26%, institutionalised old people 24%, and depressed old people 22%.

What is striking here is the similarity between the options of the three lots of old people. Depressed old people (60%), institutionalised old people (58%) and non-institutionalised old people (50%) would like to stay active for material reasons, while the other reasons show almost equal amounts (see Figure 5-14 below).

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Figure 5-14. Comparative analysis of answers for reasons to remain active

Religious Feelings There are three main attitudes about religious feelings: -

I do not believe in God—non-institutionalised old people represent 10%, institutionalised old people 4%, and depressed old people 6%. I sometimes believe in God—depressed old people represent 20%, non-institutionalised old people 16%, and institutionalised old people 4%. I have always believed in God—institutionalised old people represent 92%, non-institutionalised old people 74%, and depressed old people 74%.

What is remarkable here is the large share of believers in God in all three lots of old people in our survey—92% of the institutionalised old people, and 74% of the depressed old people and of the non-institutionalised old people (see Figure 5-15 below).

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Figure 5-15. Comparative analysis of answers about religious feelings

Church Attendance The older people in our survey have three different attitudes about attending church: -

Never—non-institutionalised old people represent 14%, depressed old people 14%, institutionalised old people 4%. Sometimes—institutionalised old people represent 68%, depressed old people 64%, non-institutionalised old people 30%. Every Sunday—non-institutionalised old people represent 56%, institutionalised old people 28%, and depressed old people 22%.

It is important to emphasise that, though believing in God, very few institutionalised old people (28%) and depressed old people (22%) attend church on a regular basis, while non-institutionalised old people do it on a regular basis 56%. On the other hand, 68% of the institutionalised old people, 64% of the depressed old people and 30% of the noninstitutionalised old people attend church sometimes (see Figure 5-16 below).

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Figure 5-16. Comparative analysis of answers about church attendance

Depression Caused by the Loss of the Partner The answer to this question is a close one: -

Yes—non-institutionalised old people represent 90%, institutionalised old people 88%, and depressed old people 80%. No—depressed old people represent 20%, institutionalised old people 12%, and non-institutionalised old people 10%.

Here again, we note that all three lots of old people consider the loss of the partner as a major cause of the onset of depression: 90% of the noninstitutionalised old people 88% of the institutionalised old people, and 80% of the depressed old people (see Figure 5-17 below).

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Figure 5-17. Comparative analysis of answers about the onset of depression as a result of the loss of the partner

Depression Caused by the Loss of an Adult Child The answer to this question is again a close one: -

Yes—institutionalised old people represent 100%, non-institutionalised old people 96%, and depressed old people 96%. No—depressed old people represent 4% and non-institutionalised old people 4%, while no institutionalised old person chose this answer.

There is a remarkable similarity of the answers to this question in all three groups of older people—100% of the institutionalised old people and 96% of the depressed old people and of the non-institutionalised old people consider the loss of an adult child the main cause of depression (see Figure 5-18 below).

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Figure 5-18. Comparative analysis of answers about the onset of depression as a result of the loss of an adult child

Depression Caused by the Loss of Health The answer to this question is again a close one: -

Yes—institutionalised old people represent 98%, depressed old people 96%, and non-institutionalised old people 88%. No—non-institutionalised old people represent 12%, depressed old people 4%, and institutionalised old people 2%.

We point here to the similarity in answers between the three groups of old people—98% of the institutionalised old people, 96% of the depressed old people, and 88% of the non-institutionalised old people consider that the loss of health is the main cause of depression (see Figure 5-19 below).

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Figure 5-19. Comparative analysis of answers about the onset of depression as a result of the loss of health

Onset of Depression—Comparison of Causes Two more Risk factors have been added to the factors mentioned above— loss of social status and loss of motivation for living: -

Loss of partner—institutionalised old people represent 28%, depressed old people 28%, and non-institutionalised old people 10%. Loss of adult child—institutionalised old people represent 54%, noninstitutionalised old people 48%, and depressed old people 42%. Loss of health—non-institutionalised old people represent 28%, depressed old people 26%, and institutionnalised old people 16%. Loss of social status—non-institutionalised old people represent 12%, depressed old people 2%, while institutionalised old people made no choice. Motivation for living—depressed old people represent 2%, institutionalised old people 2%, and non-institutionalised old people 2%.

All three groups of old people made similar choices as far as the impact of different losses is concerned. The loss of an adult child ranks first at 54% of the institutionalised old people, 48% of the non-institutionalised old people and 42% of the depressed old people, followed by the loss of the partner at 28% of the depressed old people and of the institutionalised old

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people, and only 10% of the non-institutionalised people, and by the loss of health at 28% of the non-institutionalised old people, 26% of the depressed old people and 16% of the institutionalised people (see Figure 5-20 below). Figure 5-20. Comparative analysis of answers about the onset of depression as a result of several types of losses

Causes of Discomfort Six causes of discomfort were suggested to our respondents: -

Poverty—non-institutionalised old people represent 14%, depressed old people 12%, and institutionalised old people 6%. Depression—depressed old people represent 50% and institutionalised old people 8%. No non-institutionalised old people chose this answer. Loneliness—non-institutionalised old people represent 40%, institutionalised old people 32%, and depressed old people 18%. Bad health—institutionalised old people represent 54%, noninstitutionalised old people 34%, and depressed old people 18%. Inactivity—non-institutionalised old people represent 6%, no institutionalised old person chose this answer, and no depressed old person chose this answer.

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Alcohol—non-institutionalised old people represent 6%, no institutionalised old person chose this answer, and no depressed old person chose this answer. .

Though objective testing identifies depression in institutionalised old people, they do not perceive depression as a major cause of discomfort (8%), unlike depressed old people (50%). Bad health comes next, with 54% of the institutionalised old people, 34% of the non-institutionalised old people, and 18% of the depressed old people, followed by loneliness with 40% of the non-institutionalised old people, 32% of the institutionalised old people, and 18% of the depressed old people (see Figure 5-21 below). It seems that only unemployment results in high rates of depression (Pierson 2011, 62). Figure 5-21. Comparative analysis of answers about the causes of discomfort

Perception of Poverty Our respondents were asked to choose among three types of perception of poverty: -

A burden—institutionalised old people represent 70%, noninstitutionalised old people 52%, and depressed old people 46%. Deprivation of rights—non-institutionalised old people represent 28%, depressed old people 12%, and institutionalised old people 10%.

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A hopeless condition—depressed old people represent 42%, institutionalised old people 20%, and non-institutionalised old people 20%.

Most old people in our survey see poverty as a burden. Institutionalised old people 70%, non-institutionalised old people 52%, and depressed people 46%. Depressed old people (42%) and institutionalised old people and non-institutionalised old people (20% each) also see it as a helpless condition (see Figure 5-22 below). Figure 5-22. Comparative analysis of answers about the perception of poverty

Causes of Loss of Psychic Balance We asked our respondents to choose among the following causes of loss of psychic balance: -

Material difficulties—depressed old people represent 74%, noninstitutionalised old people 66%, institutionalised old people 50%. Losses—institutionalised old people represent 50%, noninstitutionalised old people 30%, depressed old people 24%. Other causes—non-institutionalised old people represent 4% and depressed old people 2%. Institutionalised old people made no choice whatsoever.

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It is interesting to note that most old people consider they might lose psychic balance because of material difficulties—depressed old people (74%), non-institutionalised old people (66%) and institutionalised old people (50%), or because of different personal losses—institutionalised old people (50%), non-institutionalised old people (30%) and depressed old people (24%) (see Figure 5-23 below). Figure 5-23. Comparative analysis of answers about the causes of the loss of psychic balance

Fear of Poverty Poverty can occur at three different times in life: -

In early adulthood—non-institutionalised old people represent 16%, depressed old people 12%, institutionalised old people 4%. In middle adulthood—depressed old people represent 6%, noninstitutionalised old people 4%, institutionalised old people 2%. In late adulthood—institutionalised old people represent 94%, depressed old people 82%, non-institutionalised old people 80%.

It is not surprising that all three groups of old people consider that poverty occurs almost always in late adulthood—94% of the institutionalised old people, 82% of the depressed old people, and 80% of the noninstitutionalised old people (see Figure 5-24 below).

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Figure 5-24. Comparative analysis of answers about the fear of poverty

Effects of Poverty In this case, the respondents had to choose between the following effects of poverty: -

Depression—depressed old people represent 82%, non-institutionalised old people 82%, and institutionalised old people 76%. Despair—institutionalised old people represent 14%, noninstitutionalised old people 10%, depressed old people 8%. Suicide—institutionalised old people represent 10%, noninstitutionalised old people 8%. No depressed old person chose this answer. Other effects—depressed old people represent 10%. No noninstitutionalised old person and no institutionalised old person chose this answer.

It is extremely important to note, here, that all three groups of respondents consider that the most important effect of poverty is depression—82% of the depressed old people and of the non-institutionalised old people and 76% of the institutionalised old people. Surprisingly, suicide is seen as an effect of poverty only by a few institutionalised old people (10%) and by a few non-institutionalised old people (8%) (see Figure 5-25 below).

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Figure 5-25. Comparative analysis of answers about the effects of poverty

Frequency of suicidal attempts We asked our respondents to choose among the following rates: -

Never—non-institutionalised old people represent 80%, depressed old people 50%, institutionalised old people 42%. A few times—depressed old people represent 20%, institutionalised old people 20%, non-institutionalised old people 18%. Many times—institutionalised old people represent 38%, depressed old people 30%, non-institutionalised old people 2%.

Note, here, the large share of non-institutionalised old people (80%), depressed old people (50%), and institutionalised old people (42%) who have never had suicidal thoughts, and the moderate rate of institutionalised old people (38%) and of depressed old people (30%) who admit having had suicidal thoughts a few times, and the very low rate of suicidal thoughts among non-institutionalised old people (2%) (see Figure 5-26 below).

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Figure 5-26. Comparative analysis of answers about the frequency of suicidal attempts

Causes of Loneliness The respondents were asked to choose among the following four causes of loneliness: -

Scarcity of social contacts—institutionalised old people represent 76%, depressed old people 72%, and non-institutionalised old people 32%. Isolation by the society—institutionalised old people represent 24%, depressed old people 18%, and non-institutionalised old people represent 12%. Retirement—non-institutionalised old people represent 46% and depressed old people 10%. No institutionalised old person chose this answer. Other causes—non-institutionalised old people represent 10%. No depressed old person and no institutionalised old person chose this answer.

In institutionalised old people (76%) and in depressed old people (72%), the main cause of loneliness is scarcity of social contacts, while retirement is seen as the main cause of loneliness in non-institutionalised old people (46%) and in depressed old people (10%) (see Figure 5-27 below).

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Figure 5-27. Comparative analysis of answers about the causes of loneliness

Effects of Loneliness This time, the respondents were asked to make a choice from the possible effects of loneliness: -

Depression—non-institutionalised old people represent 86%, institutionalised old people 80%, and depressed old people 76%. Despair—institutionalised old people represent 12%, depressed old people 8%, non-institutionalised old people 6%. Suicide—institutionalised old people represent 4% and depressed old people 2%. No non-institutionalised old person chose this answer; Other effects—depressed old people represent 14%, noninstitutionalised old people 8%, institutionalised old people 4%.

The answers of the three groups of old people point, not surprisingly at all, to depression as the main effect of loneliness—86% of the noninstitutionalised old people, 80% of the institutionalised old people, and 76% of the depressed old people (see Figure 5-28 below).

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Figure 5-28. Comparative analysis of answers about the effects of loneliness

Feelings about One’s Family The respondents were asked to state their feelings about their families: -

Very content—non-institutionalised old people represent 78%, institutionalised old people 22%, depressed old people 20%. Neither content, nor discontent—depressed old people represent 52%, institutionalised old people 44%, and non-institutionalised old people 10%. I have no family—institutionalised old people represent 34%, depressed old people 28%, and non-institutionalised old people 12%.

We should point here particularly to the large share of depressed old people that have no family (78%), which could explain the onset of depression, and the rather large share of institutionalised old people who have no feelings about their families who institutionalised them (44%) (see Figure 5-29 below).

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Figure 5-29. Comparative analysis of answers about the feelings about one’s family

Effects of the Lack of Social Support from the Family Here again, the respondents were asked to choose among three possible effects of the lack of support from the family of an old person: -

Depression—institutionalised old people represent 88%, depressed old people 86%, and non-institutionalised old people 84%. Suicide—depressed old people represent 4%, non-institutionalised old people 4%, and institutionalised old people 2%. Other effects—non-institutionalised old people represent 12%, institutionalised old people 10%, and depressed old people 10%.

It is not surprising that all three groups of old people consider that the lack of social support from the family leads mainly to depression—88% of the institutionalised old people, 86% of the depressed old people, and 84% of the non-institutionalised old people (see Figure 5-30 below).

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Figure 5-30. Comparative analysis of answers about the effects of the lack of social support from the family

Role of Family Support in Avoiding Depression, Suicide, and Other Negative Effects This time, the respondents were asked to choose among three positive effects of family support in the elderly: -

Avoiding depression—institutionalised old people represent 98%, depressed old people 96%, and non-institutionalised old people 94%. Avoiding suicide—non-institutionalised old people represent 2% and depressed old people 2%. No institutionalised old person chose this answer. Avoiding other bad effects—non-institutionalised old people represent 4%, institutionalised old people 2% and depressed old people 2%.

Here again, family support is seen as the most important factor in avoiding depression in all three groups of old people—98% of the institutionalised old people, 96% of the depressed old people, and 94% of the noninstitutionalised old people (see Figure 5-31 below).

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Figure 5-31. Comparative analysis of answers about the role of family support in avoiding depression, suicide, and other negative effects

The values of the Test Ȥ² and the significance of differences between the three lots of the quantitative research are presented in Table 5-1 and Figure 5-32 below. Figure 5-32. Significance of differences (p) between lots per item

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Table 5-1. Values of the Test Ȥ² and Significance of Differences between the Three Lots of the Quantitative Research

Compared item

Chi square

P

A1 A2 A3 A4 A5 A6 A7 A8 A9 A10 A11 A12 A13 A14 A15 A16 A17 A18 A19 A20 A21 A22 A23 A24 A25 A26 A27 A28 A29 A30

78.53 64.12 43.00 14.79 33.21 11.16 2.94 8.64 20.52 2.32 2.05 4.96 16.28 59.48 14.52 9.70 5.17 11.07 22.38 53.22 6.31 46.41 0.572 1.542 86.75 9.29 61.65 8.21 21.53 100.84