Occupational participation at 85 plus: a review of the literature.
This paper focuses on the occupations of people over 85 for two reasons. Firstly, as shown above, this age group will have the highest growth rate. Secondly, it is important to differentiate within the population aged 65 and over. This population covers at least two generations--the oldest people alive today were born in the first decade of the 20th century, whereas those in their 60s were born in the 1940s, and could well be the children of the oldest. It is generally assumed that from around the age of 85, health and capacity for independent living will decline, and that disability and the need for care will increase. If this is the case, then the occupations of this age group will be different to those of people aged 65 to 85. Due to variable use of age bands in the literature, articles were included in this review which referred to people younger than 85 if they also dealt with people 85 plus.
Current policy as outlined in the New Zealand Positive Ageing Strategy (Minister for Senior Citizens, 2001) reinforces the Government's commitment to promote the value and participation of older people in communities. The Health of Older People Strategy (Ministry of Health, NZ, 2002) has identified the need for research into the development and evaluation of interventions to promote the health and well-being of older people as a priority area. Occupational science has demonstrated that engagement in occupation is based on a biological need and contributes to health and survival throughout the life span (Wilcock, 1995; Wood, 1998). In order to promote the health and well-being of people 85 plus through occupational participation, occupational therapists need to be aware of current theories of ageing which relate to occupation, know what the occupations of this age group are, and understand the factors which shape occupational participation.
Theories of occupation and ageing
Broad understandings of the occupations of older people are contained in theories of ageing. Cummings and Henry (1961) argued for a theory of disengagement in which the main task of old age was defined as letting go and withdrawal from work and strenuous recreation. Since then results from a ten year programme of interdisciplinary research which began in the USA in the late 1960s, led to a paradigm shift away from disengagement theory to "successful ageing" (Rowe & Kahn, 1998). Rowe and Kahn defined the task of successful ageing as discovering or rediscovering relationships and activities that provide closeness and meaningfulness for the older person. They identified three characteristics of successful ageing: low risk of disease and disease related disability; high mental and physical functioning; and active engagement with life.
Closely related to successful ageing is "productive ageing" which refers to "behaviours that are inner-directed, personally meaningful and satisfying to the older person, whether or not they can be categorised as paid or volunteer service and regardless of whether others benefit directly from them" (Kaye, Butler, & Webster, 2003, p. 203). This perspective includes concrete contributions made to society by older people as well as older people engaging in activities that can be self-actualising, meaningful and personally satisfying. This theory attempts to debunk the myth that older people are less productive than younger people and in contrast highlights assets, resources, capacities and skills rather than problems, deficiencies and needs.
While the theories of successful and productive ageing highlight positive aspects of older age, they do not address how older people deal with losses experienced or how their environment may support or constrain their occupations. The theory of "selective optimisation with compensation" (Lang, Ricckmann, & Baltes, 2002) developed during the 1990s suggests older people can adapt to functional decline in three ways:
1. By reducing participation in the number of activities, goals or domains of activity they participate in to focus on those that are most important to them;
2. By maximising their resources in a selected domain of functioning where no ageing losses have occurred; and
3. By using new or alternative means to reach a goal or maintain a desired state once losses have occurred (Lang, Ricckmann, & Baltes, 2002).
The ecological model of ageing and adaptation developed by Lawton and colleagues (as cited in Wood, 2005) expands on the previous theories by considering the contextual influences on the occupations of older people. This model suggests that as older people grow less competent, they become more environmentally vulnerable. Within this model the concept of environmental press is proposed as "immediate environments press for, encourage or demand, the expression of some behaviours while discouraging others" (Wood, 2005, p. 123). The fit between the environmental press and the older person's level of functioning is of great importance. If the environmental presses slightly exceed the older person's competency level, new learning and pleasurable experiences are likely to occur. If, however, the environmental presses significantly exceed competency levels, extreme distress can occur. Conversely, if the environmental presses are slightly beneath competency levels, relaxation and maintenance of skills can occur, and if the environmental presses fall significantly beneath competency levels, the result is likely to be boredom and atrophy of skills.
The above theories were selected from many theories of ageing due to their relevance to occupational participation. It is evident that no single theory of ageing is sufficient to fully address its complexities. Apart from disengagement theory, which has been discredited as arbitrary, partial, and potentially oppressive (Hugman, 1999, p. 1), the theories discussed complement each other to describe the opportunities and challenges facing people 85 plus, ways to adapt to declining function, and the effect of contextual influences on their experience of occupation.
Occupations of people plus
In this review, three major international quantitative studies were found which describe what older people do. Horgas, Wilms and Baltes (1998), as part of the Berlin Ageing Study investigated the everyday activities of 516 people aged 70-105 years. In a secondary analysis of data from 1,439 Canadians aged 67 to 95, Menec (2003) investigated the activities participated in within the past week using a 21 item activity checklist. In Sweden, Haggblom-Kronlof and Sonn (2005) interviewed 86 year old persons (n = 205) at home about their interests. The only New Zealand studies identified were the 1998-99 Time Use Survey, a population based survey which involved a crude analysis of time use patterns for people of different ages (Statistics New Zealand & Ministry of Women's Affairs, 2001), and a statistical review of data on people 85 plus derived from national data bases carried out by Davey and Gee (2002).
The findings in common from these three studies were that the most frequent activities of older people were leisure, instrumental activities of daily living and personal maintenance activities. Paid work was the least frequent activity that older people engage in, closely followed by education. When leisure interests were investigated, the most frequently reported activities were watching TV, reading and social activities (Haggblom-Kronlof et al., 2005; Horgas et al., 1998; Menec, 2003).
There was substantial variety in the way older people spent their time. This supports a heterogeneous view of ageing and reflects life-long activity patterns as well as personal preferences (Haggblom-Kronlof & Sonn, 2005; Horgas et al., 1998). This heterogeneity was also evident in the qualitative literature. Carlson, Clark and Young, (1998) listed a number of exemplary elders who showed very high levels of competence and achievements which surpass those of average people in their prime. Ichijirou Araya who successfully climbed Mt. Fuji at 100 years of age, and Thelma Pitt-Turner, a New Zealander, who finished a marathon at age 82 years are examples. In a qualitative study of 80 people aged 8090, living in Sweden and the UK, participants talked about their participation in golf, attending a gym, sculpting, bread-making, surfing the internet, other computer related activities (including emailing, and playing games) and looking after grandchildren (Green, Sixsmith, Dahlin Ivanoff, & Sixsmith, 2005).
In alignment with the models of successful ageing and productive ageing, a number of studies investigated the engagement of older people in productive activities. Davey and Gee (2002) report that in New Zealand, only 5.6% of men and 2.3% of women aged 85 and over participate in paid work, most of them part-time. Horgas et al. (1998) found that participation in paid work decreased with age. Similarly, the 1998-99 Time Use Survey (Statistics New Zealand & Ministry of Women's Affairs, 2001) showed that participation in unpaid work (i.e. household work, caregiving for household members, purchasing goods or services for one's own household, and unpaid work for people outside the home) decreased over the age of 85. Older people aged 74-85 carry out around 4.5 hours unpaid work on average per day, but for those aged 85 plus, this figure drops to around 3.6 hours per day on average. While the literature reviewed indicated a decrease in paid and unpaid work, the evidence above of continued participation in meaningful and satisfying activities suggests that the models of successful and productive ageing are still relevant for people 85 and over.
As well as active occupations, some of the literature raised the importance of more passive occupations such as reflecting, sitting and watching, or connecting with nature (Dahlin-Ivanoff, Haak, Fange, & Iwarsson, 2007; Rowles, 1991). These occupations were closely linked with the environment of the older person. Rowles (1991) carried out an intensive 3 year ethnographic study of 15 residents aged from 62 to 91 in a small community in the Appalachians (USA). One of his findings concerned what he named the 'surveillance zone', or the space immediately beyond the threshold, which assumed increasing importance in many older people's lives as they grew older. For older people who were housebound, this space became the "arena of their lives" (Rowles, 1991, p. 268) and comprised of the space they could see from their window or porch. Many of these people spent long periods of time sitting and watching the outside world from this vantage point, and occasionally interacting with others with a wave or a conversation.
Personal factors pertaining to participation in occupation
What individuals 85 plus do, depends on a number of personal factors including, interests, health, disability, physical and cognitive functioning, gender, marital status and finances.
Nilsson, Lofgren, Fisher, and Bernspang (2006) investigated factors underlying participation in activities of Swedish people 85 plus. They found that the leisure activities people in that age group were most likely to participate in (social activities, cultural activities and TV/video/movies) were also activities of interest. Therefore they were motivated to participate and thus achieved a sense of well-being. These results suggest that people 85 and over, select meaningful activities related to their interests and ability, and this supports both the theory of selective optimisation with compensation (Lang, Ricckmann, & Baltes, 2002) and the model of successful ageing (Carlson, Clark & Young, 1998).
Health, disability, physical and cognitive functioning
Health, disability, physical and cognitive function are closely related to age. Research did not always separate these factors and their effect on activity participation. Being in good health, however, is associated with participation in a wider range of activities than being in poor health and/or experiencing disability (Glass, Mendes de Leon, Marattoli, & Berkman, 1999; Green et al., 2005; Haggblom-Kronlof & Sonn, 2005; Menec, 2003). Similarly lower levels of physical functioning and decreased cognitive functioning were also linked to decreased levels of activity participation (Christensen et al., 1996; Menec, 2003).
For many occupations, there were no significant differences in engagement between men and women. Older people conformed to traditional gender stereotypes in certain occupations, for example, women aged 80 plus were more likely to participate in cooking, baking, housework and art/craft activities than male counterparts (Haggblom-Kronlof & Sonn, 2005; Horgas et al., 1998). In a study with a mean age of 76 years, men were more likely to participate in other domestic activities such as gardening, lawn care, and home maintenance (Stanley, 1995). Another study involving people age 65 plus found that while older men were more likely to engage in fitness activities, older women were more likely to engage in productive activities, which they defined as a combination of instrumental activities of daily living and paid or unpaid work (Glass et al., 1999).
Few of the studies considered marital status. Horgas et al., (1999), however, found that unmarried persons spent more time engaged in instrumental activities of daily living, and less time watching television than others. As a large proportion of unmarried people are widowed women, this finding reflects the gender stereotyping noted above. Davey and Gee (2002) reported that in the 85 plus age group, partnered women recorded more necessary time (self care and sleep), more unpaid work inside and outside the home, and less free time, than both partnered men and unpartnered men and women.
Hugman (1999) suggested that while many older people are increasingly well-off and able to enjoy leisure activities, travel and community life, others remain limited by financial circumstances so that old age is increasingly a divided stage of the life-course. The research was inconclusive on the effect of finances. Two studies found no relationship between finances and occupational participation (Glass et al., 1999; Horgas et al., 1998), while another study found that lack of money was one of seven reasons reported for giving up interests and was linked to fewer interests outside of the home (Haggblom-Kronlof & Sonn, 2005).
Environment and participation in occupation
The environment is the context in which occupational performance takes place and can be defined as having cultural, institutional, physical and social elements (Townsend, 1997).
Currently in New Zealand, Maori, Pacific and Asian people together make up only 3% of the population aged 85 years and over (Davey & Gee, 2002). Nonetheless, these population groups are also ageing. By 2051, it is projected that Maori will make up 13% of the population aged 65 and over (Cunningham et al., 2002). No research was found related to the occupations of older Pacific and Asian people in New Zealand, but limited data was available on the occupations of older Maori. The 1998-99 Time Use Survey (Statistics New Zealand & Ministry of Women's Affairs, 2001) reported that Maori aged 65 plus undertook more unpaid work outside the home than non-Maori, and more specifically, that Maori spent significantly more time on religious, cultural and civic participation than non-Maori. Waldon (2004) interviewed 400 older Maori (45% of the sample were aged 70 years plus) recruited through iwi and Maori community networks. Eighty five percent of respondents indicated they were seen as kaumatua, and 68% were involved in marae activities. Whanau relationships were typically close. Respondents reported reciprocal involvement where older Maori could count on their wider whanau for assistance including financial aid, transport and help when unwell, but that much more often, older Maori offered assistance to their whanau by caring for children, disabled or older whanau members.
What people choose to do at any age is influenced by the sociohistorical context that they live in. The social policy of compulsory retirement at age 60 or 65 was closely related to belief in the disengagement model of ageing. In recent decades, attitudes have shifted away from disengagement theory towards successful and productive ageing, and socially acceptable options available to older people are now more varied. For example, as stated in the New Zealand Positive Ageing Strategy:
Retirement from the paid workforce does not mean that people cease to contribute to society--it provides opportunities for participation in different ways and in a range of roles: as employees, volunteers, family members, neighbours, caregivers, committee and trust members, kaumatua, business mentors and advisors, and members of communities (Minister for Senior Citizens, 2001, p. 10).
In New Zealand, this has been accompanied by structural changes such as abolishing mandatory retirement, and increasing the age of eligibility for public pensions. Another shift has been towards reducing dependence on public pensions and fostering privatised saving for retirement. Over time, these changes are likely to result in an increase in the numbers of older people (including those 85 plus) in paid employment.
In this section, the effects of the organisational structure of living in a long term care institution on the occupations of people 85 plus are discussed. A qualitative study from the UK on people with a mean age of 90 underlined the difference in participation in occupations for residents living in residential care compared to people living at home (Hearle, Prince & Rees, 2005). The narratives of the people living in residential care indicated sterility in their lives when compared to the narratives given by those living in the community: one of the residents in a care setting stated "We just go from one meal to another. I don't do anything, I can't ..." (Hearle et al., 2005, p. 29), whereas a person living at home reported, "I sit and think, and listen to my tapes, talk to my carers and friends, and then I go to the day centre to talk to other people who never see anyone" (Hearle et al., 2005, p. 29).
Hearle et al's. (2005) finding was consistent with an Australian study by French (2002) which used an ethnographic approach to investigate the impact of the organisational culture of a care facility on the residents' participation in occupations. French found that the key task of the facility was "to provide a transitional space for residents to pass from social death to physical death" (French, 2002, p. 30) and that residents seemed to be "processed through a series of procedures administered by various staff including toileting, bathing and medication" (French, 2002, p. 32). In order to prevent falls, residents were often risk deprived, which seemed to reduce their potential to participate in satisfying occupations. French found that compared to the range of occupations reported in the literature for people 85 plus living in the community, people in a residential facility participated in a restricted range of occupations.
In contrast to the findings of French (2002) and Hearle et al. (2005), Van'T Leven and Jonsson (2002) found that for some frail older people in long term care, watching others engaged in activities provided a degree of occupational satisfaction, and they suggested that "being in the atmosphere of doing" was experienced as having the same or very similar quality to the actual doing. Paradoxically, their participants felt that "they did a lot and at the same time they did nothing" (Van'T Leven & Jonsson, 2002, p. 152).
While the studies by French (2002) and Hearle et al. (2005) cannot be generalised due to the limited number of facilities they included, both raised the issue of the potential for occupational deprivation in long term care settings. Hearle et al. (2005) suggested that institutions press on residents in their rigid adherence to routines, and through the lack of opportunity to pursue interests and hobbies. In line with the ecological model of ageing and adaptation, it seems that in some long term care environments, the environmental presses fall significantly beneath competency levels, leading to apathy, high levels of inactivity, and excess disability, where a resident becomes more functionally disabled due to staff performing more care than is actually needed (Aller & Van Ess Coeling, 1995). As Hearle et al. suggested, where this is the case, the ecology of residential homes needs to be examined and changed to empower residents with the acknowledgement of personal choice and to meet their occupational needs.
Facilities that empowered residents and where organisational culture supported residents' participation in occupations were described by Green and Acheson Cooper (2000) in the UK. Green and Acheson Cooper found this depended on management taking a lead in promoting participation. Due to the difficulties of engaging frail residents in activities, the use of informal and nontraditional activities and flexible use of the environment were found to be essential, for example: impromptu dancing, helping in the home, gardening, and fish & chip lunches.
The literature also provided examples of long term care using alternative models to traditional institutional care which were successful in promoting increased levels of participation in occupations of their elderly residents. Bundgaard (2005), and Reimer, Slaughter, Donaldson, Currie, and Eliasziw (2004), reported on small living units in Denmark and Canada respectively, where if residents choose to, and are capable, they are involved in the everyday activities of the unit and eat together with staff. Bundgaard (2005) found that this way of organising meals influenced most of the everyday life in the unit by "shaping a homely place" (p. 94) and provided a place for valued occupations for the residents. Reimer et al. (2004) found that these residents demonstrated fewer declines in their activities of daily living than residents in traditional facilities.
The physical environment includes natural and built surroundings such as buildings, roads, gardens, vehicles for transportation, technology, and weather. Minimal literature was found relating to occupations of people 85 plus and aspects of their physical environment. In the previous discussion on passive occupations, both Rowles (1991) and Dahlin-Ivanoff et al. (2007) mentioned the importance of a window, porch or balcony overlooking a scene of interest for housebound people. Green and Acheson Cooper (2005) identified the nearby location of friendly neighbours, accessible shops, and a "not-too-big-garden" as important for personal wellbeing for people aged 80-89 years. Nilsson, Lofgren, Fisher and Bernspang, (2006) found that people aged 85 plus living in an urban/suburban area were more likely to report participation in cultural activities and hobbies, while those living in rural areas were more likely to report pets, music, watching sport, and fishing, hunting, and shooting.
The social environment refers to patterns of relationships, community, and social groupings (Townsend, 1997). As noted previously, social activities are one of the most frequently reported occupations internationally for people aged 85 plus. In New Zealand, Davey and Gee (2002) found a high frequency of contact with family and close friends (49% had contact every day and 41% once a week). No studies were identified which specifically discussed the effect of the social environment on the occupations of people aged 85 plus.
This paper set out to investigate the occupations of people 85 plus and the effect of personal factors and environmental context on their participation in occupations. A significant body of international research was discussed but data pertinent to New Zealand appears insufficient. The literature reviews indicated a substantial variety in the way people 85 plus spend their time, and the range of occupations carried out. While the proportion of people 85 plus in paid work is small, they continue to participate in a significant amount of unpaid work, especially in the case of Maori. As well as active occupations, for some people in this age group, passive occupations are important. The most significant personal factors affecting occupational participation were a person's interests, health, disability, physical and cognitive functioning. All aspects of the environment were related to occupational participation, although limited literature was found which discussed the effects of the social and physical environment.
Given the lack of detailed research related to the occupations of people 85 plus in New Zealand, there is a need for more New Zealand based research which examines this topic. In particular, it is proposed that occupational participation of people 85 plus living in a range of environments, and how these environments support or constrain their participation, should be investigated. Both quantitative and qualitative research is needed to describe the occupations of people over 85 and to explore the complex relationship between personal factors, environment, and participation.
* There is a large degree of heterogeneity in the occupations of people 85 plus.
* The theories of successful and productive ageing, selective optimisation with compensation, and the ecological model of ageing and adaptation were upheld by the literature and found to complement each other.
* A person's interests, health, disability, physical and cognitive functioning are key factors affecting participation in occupations when aged 85 plus.
* There is a lack of New Zealand research into the occupations of this age group.
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Laura Haslam, B.Sc. (Hons.) Psychology, B.Sc. (Hons.), OT, NZROT
Senior Occupational Therapist
Psychiatric Service for the Elderly
Canterbury District Health Board
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|Title Annotation:||THEORETICAL ARTICLE|
|Publication:||New Zealand Journal of Occupational Therapy|
|Date:||Sep 1, 2008|
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