Aging and late-onset disability: addressing workplace accommodation. (Aging and Late-Onset Disability).

It is becoming more common in the U.S. workforce that persons are maintaining employment longer for both personal and financial reasons. Americans over the age of 55 account for 22% of the nation's job growth and represent 18 million persons in the workforce. (U.S. Bureau of the Census, 2000). As the baby-boom generation moves toward retirement age and as health care advances continue, more individuals are choosing to continue to engage in full and part time work activities. The value of work as a source of personal identity and reward, remains a strong component of many aging person's lives. (Szymanski, Ryan, Merz, Trevino & Johnston-Rodriguez, 1996).

As a result of persons remaining in the workforce, the opportunity for greater occurrences of traumatic and disease related disabilities exist. Fortunately, advances in medicine and rehabilitation, have made living and working with a disability a greater possibility. Aging with a disability has been described as one of the most important new developments in rehabilitation. (Rancho Los Amigos National Rehabilitation Center, 2001). The purpose of this article is to identify some of the key issues affecting older persons with late-onset disabilities (post age 55) and to offer some recommendations for rehabilitation professionals to facilitate maximum adjustment to employment and other important life areas.

Psychosocial Adjustment

With aging and the occurrence of later-in-life disabilities, numerous employment and other important life domain issues emerge that can require significant life adjustments. Psychosocial adaptation to disability involves complex interactions between personal, social, and environmental factors for each person (Keany & Glueckauf, 1999). Livneh (2001) recommends viewing adaptation ecologically, and that practitioners use an eclectic approach to teach adaptive coping skills, help client work through perceptions of loss, and assist in modification or removal of environmental barriers. Adjustment to disability for persons with late-onset occurrence can be challenging because of their pre-disability lifestyle and level of functioning. Because of their age and life experiences, such persons have acquired certain stability and predictability factors related to their personal, family, and work life. The occurrence of a disability can potentially disrupt many of the previously manageable aspects of their life such as employment, relationships, and economic independence and lead to feelings of frustration and despair. Their values tend to be more stable and entrenched and can present challenges to adapting to new changes. Successful adjustment requires a level of value examination, a reshaping of values and goals, and implementation of coping strategies (Keany & Glueckauf, 1999). Persons with late-onset disabilities face the dual challenge of adjusting to both their disability and aspects of growing older with the accompanying physical and role changes.

There are certain implications for persons with late-onset disability entering rehabilitation settings. For older persons, independence, effort, accepting pain, and maximizing functional ability are valued often at the expense of comfort and nurturance (Hartke, 1991).

In rehabilitation, goals are often defined by values that constitute quality of life, such as suitable income, independent living arrangement, driving privileges, and job satisfaction. Being able to develop or maintain a positive or high quality of life after a disability is one of the key outcomes in rehabilitation (Kemp, 2000).

Employment

From an employment standpoint, older persons with late-onset disabilities have followed a more traditional career development evolution as described by Super and other theorists (Szymanski, Hershenson, Enright & Ettinger, 1996). In general, their work lives have had elements of choice and some degree of opportunity to move among various employment situations. Many have had stable careers in semi-skilled, skilled, and professional occupations and are actively planning for retirement. In fact, 33% of the workforce over the age of 55 is employed in managerial and professional occupations (U.S. Bureau of the Census, 2000). With the occurrence of a disability after the age of 55, questions regarding ability or lack of ability to remain in employment become important considerations. Financial matters also become significant as adjustment to a reduced level of income is frequently required. The individual may need to explore benefits, such as short and long term disability and Social Security Disability Insurance (SSDI). Future vocational planning with realistic job goals can become a major task for those who desire to continue working. Even consideration of a career change may be a challenge for persons who have remained in one career throughout their employment history, not to mention issues around physical stamina, sensory acuity, and cognitive functioning brought on by the disability or simply the function of age. Some older adults have decided not to pursue competitive employment due to their age and disability and are using vocational programs inappropriately to remain active. Many older persons are not pursuing competitive employment goals, but rather are using vocational programs as a social outlet (Drebing, Losardo,Van Ormer, Krebs, Penk, Nasser, et al, 2002). Alternative programming should be sought for such persons.

Older persons with late-onset disabilities are often faced with significant financial challenges, such as, issues related to health care coverage and concerns regarding retirement planning. If they need to remain in the workforce but are unable to return to their former position or their former employer at pre-disability wages, specialized services related to vocational assessment, job placement, and job accommodations will be necessary. These may well be persons who have not engaged in recent job searches and may be unfamiliar with the labor market and contemporary job seeking skills. In addition, the lack of current experience with today's technology can present significant barriers.

In addition, older persons with late-onset disabilities may be faced with issues of discrimination in the employment process. Rehabilitation counselors and other professionals need to be versed in facets of Title I of the Americans with Disabilities Act (ADA) and the Age Discrimination in Employment Act (ADEA) to assist persons navigating the employment application and hiring process. Dobren (1994) suggests that rehabilitation counselors become ecologically oriented and function as an advocate for client causes, going into the client's environment and helping effect change. This can mean a more active role for the counselor in the employment process, especially in assisting older persons.

Aging parents often need to be cared for by their middle age children. These potential stressors often lead to role changes and alternative living arrangements. Some older adults are grandparents assuming primary care for their grandchildren as well. Such family related concerns can directly impact re-employment planning and may mean accommodations in work schedules, earning levels, and require other family support.

Vocational Assessments

The authors have experienced that frequently, older persons prefer not to discuss their private issues with rehabilitation practitioners and resist the idea of a vocational assessment. Such persons have already sustained a sense of loss and may choose not to have their privacy further invaded even if it means losing much needed benefits. Income and assets tend to be the primary privacy issues. It is imperative that practitioners build a rapport with clients before seeking sensitive information.

Ethical issues and values are an integral part of rehabilitation practice at all times when working with older persons with late-onset disability. Rehabilitation professionals must be sensitive to the values of older persons if they are to be successful in helping them assume their place in the workforce. Some older persons have a different set of work values from younger members of the labor force and will resist seeking assistance from rehabilitation professionals considerably younger than themselves.

A traditional vocational evaluation with aptitude tests and work samples may not be appropriate for older persons with late-onset disabilities. This will be particularly true for persons who have had extensive vocational experiences and come with a professional or highly skilled background. More appropriate and agreeable assessments should be conducted in real work settings in the community. Informational type interviews and exploration of the client's avocations and interests in an informal manner are more useful in shaping vocational goals. Community trial job experiences may be more beneficial than formal testing sessions. Activities that occur in the person's natural environment and protect their sense of personal pride in past achievements are recommended such as situational assessments and an examination of hobbies. Confidentiality must be maintained at all times.

Rehabilitation counselors must be sensitive to the personal needs and wishes of older persons with late-onset disability. Effective empathy allows the counselor to focus on the clients' perspective as it relates to their involvement in the rehabilitation process. Older persons returning to the workplace have already suffered a huge loss; many even view their disability as a death sentence. Rehabilitation counselors must help empower older persons as they work through defining and accepting their role limitations. An environment that fosters empowerment is one that includes Yalom's curative factor, instillation of hope, thus improving quality of life by allowing clients to sustain satisfying careers after the occurrence of a late-onset disability (Corey, 2000).

Workplace Accommodation and Technology

While many older persons are fearful of using assistive technology, (Hodges, 2001) it can play a significant role in helping such persons gain some sense of independence. Hodges (2001) contends that many older persons with late-onset disability resist new advances in technology that would assist them in their homes as well as in the workplace. Specialized training and orientation to technology, including training in aspects of computer operation should be utilized for older persons with late-onset disabilities. There are many assistive devices and accommodations available today for specific impairments, such as, screen readers, ergonomic chairs, augmentative devices, mobility aids, checklists for memory problems, frequent breaks, natural supports, interpreters, drivers, and personal assistants. It is important that the rehabilitation professional provide for technology assessments as part of the placement process. It would be appropriate to consult with a rehabilitation engineer in many situations to make certain that the special aides and accommodations are in place at the work site. Some accommodations may be quite simple, such as more frequent work breaks and a flexible work schedules, while other accommodations may be more complicated and require extensive modifications to the work site. Mobility restrictions that limit a person's movement about the office or factory may require the individual be located instead in one work area.

Job Placement

Those involved with placement of older persons with late-onset disabilities, must have special sensitivities to their unique employment issues. Stamina may very well be a key factor and must be addressed with care by the placement person. Older workers take great pride in their work histories and years of achievement in the workplace. They take particular pride in their durability and dependability. Addressing the issue of stamina needs to be done in a manner consistent with medical information that may place some restrictions on their physical capacities, while highlighting their areas of strength. Workplace accommodations can be used to offset deficits in stamina.

Job developers need to capitalize on the experience of older workers. These workers often bring a maturity, experience, and work ethic to employers that is lacking in younger workers. They can also serve as role models and mentors to younger workers. In addition, older workers tend to work more independently. Job developers can highlight these assets to potential employers, especially when assisting workers to move into new vocational areas. As mentioned previously, older persons with late-onset disabilities may not be proficient with technologies, such as computers. This often becomes an issue during the job search phase, when using the Internet as a placement tool. The job placement specialist should provide tutoring to clients to introduce them to the Internet as a job search tool. Doing so will also provide the additional benefit of gaining computer proficiencies that can aid in the actual performance of future job duties.

Lifestyle adjustments after becoming disabled often presents special challenges for older persons returning to the workforce. Many are forced to enter occupations with less pay and responsibility. For those who enjoyed a stable career with excellent retirement benefits, health care, and pension, the resulting loss can impose devastating psychological and physical limitations. Great care should be exercised in placing older persons in occupations which provide them with the opportunity to achieve an improved sense of worth.

Job developers must be keenly aware that hiring discrimination is an important factor to keep in mind when looking for placement opportunities for persons returning to the workplace after acquiring a disability. The use of tailored resumes becomes an important tool. Using a functional resume will allow older persons to give employers information about their experiences, without allowing them to focus on the age of the candidate.

Hahn (1985a) suggests this lack of desire for employers to hire older persons stems from several stereotypes about disability and persons of age. These stereotypes result from false assumptions that are influential and are magnified over time. These assumptions are based on the myth that a disability is a personal attribute. While a disability is a central part of life and the identity of the person with the disability, it is not solely an attribute but rather it is rooted in the environment. In certain environments such as the workplace, some disabilities are more noticeable than others, while in other instances, they may not be very noticeable. It is not surprising that the stereotypes are so deeply influenced by public policy in this society (Crispell & Gomez, 1988; Handberg, 1989; Higgins, 1980).

Hahn (1985b) contends that the use of ubiquitous questions about disability on application forms, or physical examinations, have been used for many years to facilitate the difficult process of making personnel decisions by screening out individuals who lack the physical attributes that employers deem necessary to perform a job.

Gunther (1987) observes that there is an emphasis on performance-oriented goal attainment where activity, cooperation, and independence are highly valued. These values may reflect the general youth of rehabilitation workers as well as the emphasis by the current health field environment on speed and measurement outcome to justify expenses. Older persons with late-onset disability may require additional time to attain rehabilitation goals. Older persons, who often have their own unique set of values, are seen as uncooperative when they don't concede to the values of younger rehabilitation workers. It is important to be sensitive to the comfort level of older persons with late-onset disability when assigning younger, inexperienced staff. A much wiser choice might be to assign an older, experienced worker to achieve the desired outcome.

Below are two case studies highlighting the unique aspects of working with older persons with late-onset disability.

Case Study #1

At the age of 62, Doris sustained a traumatic brain injury (TBI) as the result of an automobile accident. She was hospitalized for one month and participated in an aggressive rehabilitation program with physical and occupational therapy as well as psychological counseling.

For over twenty-five years she had operated her own small business with several contract employees. Her husband died eight months prior to the accident and she was still grieving his death. She has two grown children.

Significant issues related to her post discharge care were addressed when she moved in with the oldest child with the goal of returning to her home, which she did one year later. She had significant cognitive problems related to her head injury, including difficulties with memory, concentration, decision making, and activity initiation. This created major adjustment issues for both her and her family, given her past mental acuity and problem solving abilities.

Doris was unable to drive and was limited to focusing on activities of daily living for the first year post accident. It was necessary for her to make the decision to sell her business and apply for social security benefits. There were numerous family adjustment issues with her grown children taking a much more active role in her care and readjustment. She had problems understanding the nature of her disability and initially resisted psychological counseling, believing it was an acknowledgment of "craziness." Doris also had to deal with her ongoing issues related to the death of her husband, which compounded her own cognitive adjustment.

However, after several meetings with an experienced and older psychologist, she was able to become less defensive and began to share matters related to the death of her husband, her loss of her worker identity, and family role changes. The psychologist also provided counseling to all family members. In addition, she became more receptive to cognitive techniques through occupational therapy to assist with her memory and concentration problems.

Today, Doris lives at her home and is still not yet cleared to drive, but has a more normal and stable life. She has had more time to spend with her grandchildren due to the termination of her business. Her children have encouraged her to do volunteer work, but have not been able to resolve transportation issues as she lives in a suburban area without public transportation. When she is able to drive again, it is expected that she will seek volunteer work opportunities.

This case is a good example of some of the critical issues of aging and late-onset disability in terms of psychosocial adjustment, changing family roles and vocational impact. Doris is also an example of the benefits of aggressive contemporary medical rehabilitation efforts, which, while able to restore her to a maximum level of cognitive functioning, led to numerous personal and family adjustment issues. She was fortunate to find a rehabilitation professional who was able to assist her and her family in dealing with life changes subsequent to her injury.

Case Study #2

Ginny, at the age of 56 was diagnosed with major depression. Ginny was hospitalized for several weeks and was placed under suicide watch. Ginny was prescribed several psychotropic medications, was stabilized, and subsequently released from the hospital after one month. Ginny began a course of psychological counseling to assist her in returning to a "normal life."

Ginny had difficulty adjusting to life after being diagnosed with mental illness and was unable to function in her previous occupation as a customer service supervisor for a major cable company. As a result of the depression, Ginny began to have interpersonal problems on the job and eventually had to quit and go on medical disability leave. After two years on medical leave, Ginny was still unable to return to work. Ginny had to accept the fact that she would have to apply for social security benefits. Ginny was resistant to applying for benefits, stating she had worked all of her life and she did not want to be dependent on handouts from the government. Ginny reluctantly applied and was granted social security benefits.

Ginny was embarrassed by her encounter with the mental health system and although once vibrant, outgoing, and determined, she isolated herself from her friends, family, and former co-workers. Although Ginny continued taking her medications, she was often tearful, depressed, suicidal, and unable to independently complete activities of daily living. Ginny had difficulty making decisions and exhibited concentration and memory problems. Ginny was eventually referred for vocational rehabilitation services by her therapist.

Ginny received extensive rehabilitation services, including, vocational evaluation, vocational counseling and guidance, job coaching, and job development services, small business owner training, and computer training to aid her in starting a new career.

Ginny was assigned to a middle-aged, female, counselor who had been practicing for many years. The counselor was very empathetic, yet consistent in her quest to empower Ginny. Ginny was allowed to express her feelings of sadness and hopelessness, but was then encouraged by her counselor to move forward with her life. Ginny was not allowed to languish in her sorrow, but rather was encouraged to take action to improve her situation

The combination of age, experience, and style of the counselor proved to be a good match for Ginny as she began to regain control of her life.

Today Ginny is self-employed, operating a small business from her home selling craft items. Ginny works part-time and receives social security benefits. She continues to receive psychological counseling. While Ginny was not able to return to full-time employment in an office setting, she has found happiness at home after her late-onset disability.

This case demonstrates the value of an experienced counselor improving a client's quality of life by giving her the support and time needed to adjust to the realities of her disability.

Summary and Recommendations

Persons who are aging and have late-onset disabilities present unique challenges for successful rehabilitation. Along with the normal developmental issues of growing older, a disability can create major adjustment issues in terms of employment, financial planning, role adaptations, and support systems. As such, the authors suggest several recommendations for enhancing the probability for older persons with late-onset disability to overcome such challenges.

First, it is recommended that rehabilitation professionals should possess a thorough understanding of psychosocial adjustment to disability and aging and appreciate that persons may require advocacy as well as assistance in resolving concerns.

Secondly, effective rehabilitation professionals should exhibit counseling skills emphasizing rapport building and empathy. Capitalizing on older persons' life experiences, resiliency, and determination can facilitate adjustment.

Third, in the area of employment planning, special considerations need to given in terms of assessments, accommodations, technology, and job placement.

Fourth, rehabilitation professionals should make every effort to match experienced staff with older persons as this may yield better outcomes and diminish time needed to establish a working relationship.

Finally, training and sensitizing older persons to computers and technology can facilitate job placement activities as well as help connect them to today's technology in the workplace.

It should be noted that research in the area of aging and late-onset disability is limited and should be encouraged. As the population ages, proven strategies to help older persons lead fulfilling lives will be important to rehabilitation practitioners.

References

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Dobren, A. A. (1994). An ecologically oriented conceptual model of vocational rehabilitation of people with acquired midcareer disabilities. Rehabilitation Counseling Bulletin, 37, 215-228.

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Hartke, R.J. (1991). Psychological aspects of geriatric rehabilitation. Gaithersburg, MD: Aspen.

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Hodges, R. (2001). SPRY Conference focuses on increasing use of Internet among older persons. Retrieved November 3, 2002. Available: http://www.spry.org/new_items/archive_ news_internetuse.html

Keany, K. C., & Glueckauf, R. L. (1999). Disability and value change: An overview and reanalysis of acceptance of loss theory. In R. P. Marinelli & A. E. Dell Orto (Eds.), The psychosocial and social impact of disability (pp. 139-151). New York, NY: Springer.

Kemp, B. (2000). Quality of life while aging with a disability. Retrieved July 25, 2002. Available: http://www.jik.com/ qolkemp.html

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Rancho Los Amigos National Rehabilitation Center (2001). Aging with disability. Retrieved July 25, 2002. Available http://www.ji.com/awdrtcawd.html

Szymanski, E. M., Hershenson, D. B., Enright, M. S., & Ettinger, J. M. (1996). Career development theories, constructs, and research: Implications for people with disabilities In E. M. Szymanski & R. M. Parker (Eds.), Work and disability: Issues and strategies in career development and job placement (pp. 79-126). Austin: PRO-ED.

Szymanski, E. M., Ryan, C., Mertz, M., Trevino, B., & Johnson-Rodriquez, S. (1996). Psychosocial and economic aspects of work: Implications for people with disabilities. In E. M. Szymanski & R. M. Parker (Eds.), Work and disability: Issues and strategies in career development and job placement (pp. 9-38). Austin: PRO-ED.

U. S. Bureau of the Census, (2000). U. S. Census Data. Washington, D.C.

John Finch, 860 Pipestone Drive, Worthington, OH 43235. Email: [e-mail]

John Finch
Mona Robinson

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