Resilience in the Elderly
About the Author
Dr. Carol Hoare is Professor of Human Development and Human and Organizational Learning in the Department of Counseling/Human and Organizational Studies at The George Washington University. An alumna of Carlow University and the University of North Carolina at Chapel Hill, she earned her doctorate in Adult Learning and Human Development at The George Washington University. She has served as a university trustee, provided consultation to national and international organizations and, at The George Washington University, has served as department chair, Acting Assistant Dean, and co-director of the University Office for Community Services. She has studied, taught, and published on topics in adult development and learning for twenty-five years and is the author of more than fifty original research articles, paper presentations, book chapters, and invited addresses. Her recent book, Erikson on Development in Adulthood: New Insights from the Unpublished Papers (Oxford University Press, 2002), has received wide-ranging acclaim in the United States and abroad. Her recent edited volume, the Handbook of Adult Development and Learning (Oxford University Press, 2006), is the first publication to show the reciprocal relationship between development and its compatriot, learning, during the adult years.
Carol Hoare, EdD
When an explorer on an unknown river finds the current quickening under his boat, hears a faint but increasing roar, and sees above the farthest treetops a mist of spray, he knows that he is nearing a cataract. Yet if he is bold, if his craft is strong, and if on a prosperous voyage he has already shot other foaming rapids with success he may push blithely into the unknown, confident that he can override all dangers. (Nevins, 1950, p.3)
In this introduction to his two volume history of Abraham Lincoln’s political emergence, Nevins described the spirited mettle and positive outlook of this country at the middle of the nineteenth century. We might use his metaphor to capture the meaning of resilience during adulthood. In this, the craft and its occupant represent physical and psychological readiness, respectively, just as the explorer’s confidence conveys a history of prior success in similar circumstances. The sustaining current indicates a supportive society and relationship network. All of these characteristics are important to resilience.
Definition and Personal Correlates of Resilience
The attribute of resilience has a lengthy history, with its study flourishing in the nineteenth and twentieth centuries. Theories of human adaptation have ranged from natural selection to ego psychology (Masten & Reed, 2002). With respect to the latter, Freud (1928) held that the ability to flourish in the face of calamity is a remarkable human attribute. After Freud’s era, the construct of resilience found its way into theories of motivation and self-efficacy (Masten & Reed, 2002). Recently, resilience has been employed to describe attributes that have been found to support healthy outcomes in children who had been imperiled by environmental hazards or detrimental caregiving circumstances. (Garmezy, 1991; Luthar, Cicchetti, & Becker, 2000; Masten, 2001; Rutter, 1999). Thus, the notions of childhood protection and illness prevention have surrendered to resilience indicators. That is, given that many children will experience trauma, what qualities are seen in resilient children compared to those who are less resilient?
In the last decade the theoretical and research literatures reveal certain common characteristics of the resilience phenomenon. All who write on the topic include the ability to manage trauma such that long term negative consequences are diminished. In this, personal resources and a history of effective coping are paramount. The capacity to “bounce back” after adversity has been emphasized by a number of theorists (e.g., Gucciardi, Jackson, Hodge, Anthony, & Brooke, 2015; Southwick, S., & Watson, 2015). This is the “ability to bend but not break in recovering from threatening challenges” (Southwick & Wilson, 2015, p.21). The American Psychological Association (2010) concurs by defining resilience as the “process of adapting well in the face of adversity, trauma, tragedy, threats or even significant sources of threat.”
Positive adaptation is a clear marker of resilience, yet the literature holds no uniform definition of the resilience phenomenon. Furthermore, resilience is sometimes seen as a process and in other instances as an outcome (Hu, Zhang, & Wang, (2015) Some authors consider resilience a trait or inborn capability (Hu, Zhang, & Wang, 2015), while others hold to a more fluid attribute that comes into play as one equilibrates after the traumas of life (Gucciardi, Jackson, Hodge, Anthony, & Brooke, 2015). A number of authors question whether the resilience phenomenon stands on its own or is the same as positive emotionality (Bonanno, 2004; Robinson , Larson, & Cahill, 2014). Unknown is whether the resilient individual “sustains” or “regains” psychological and physical health after adversity (Masten, 2011). Despite definition variance, however, it is clear that the findings support the belief that resilience is common in healthy adults and is not nearly as rare as was once believed to be the case (Bonanno, 2004; Masten, 2001).
Recently, the theoretical and research literatures on resilience have increased immensely and, in the last decade in particular, resilience has informed the psychosocial literature on adulthood. In adulthood, resilience refers to the ability of adults who have experienced a life altering experience, such as the loss of a loved one or some other personally shattering event, to remain comparatively stable or to return to healthy psychological functioning after the incident. Resilience has been studied with respect to Post Traumatic Stress Disorder (PTSD) and related maladies, largely in young and middle-aged persons.
Unfortunately, the resilience concept has been only sparsely studied with respect to the older years of life. This is unfortunate in that, as common experience and the literature on aging show, the later years include a variety of losses and traumas that challenge and often diminish physical and mental health. Largely due to ageist stereotypes, the expectation often exists that elderly persons have limited resilience, and that they have negative views about themselves, their peers, and their ability to remain in personal control of their existence (Baltes & Baltes, 1990). This bias is countered by a literature providing evidence that most elders are similar to younger persons in their reports of self-efficacy and personal control (Baltes & Baltes, 1990). Baltes and Baltes (1990) claim that alterations in aims, desires, and ambitions may account for this similarity. The older adult revises prior views to account for a new experience of life. Furthermore, the elder’s comparison group often changes, with the senior now comparing the self with persons in like circumstances. This permits the person to find him or herself advantaged when compared with many other elders who are similarly situated.
In the remainder of this article we consider the meaning and characteristics of resilience that are important to the elderly. We first consider data with respect to successful aging and then look to resilience indicators found in the research literature. The article concludes with a section on some interventions that may augment resilience among elders.
In 1987, Rowe and Kahn published an exceptional article that changed the way many developmental theorists and gerontologists think about the aging process. Historically, perspectives about the later years of life had held a decrement mentality. Decline charted elders’ advancing years, and the old were seen as burdens due to physical illness, cognitive loss, isolation, and, often, depression. In their article Rowe and Kahn stated that what we had previously considered normal aging was actually a “gerontology of the usual” (p. 143), and the typical pattern seen was not normal aging but usual aging. Rather, the authors held, we should subscribe to a rendition of successful aging. Successful aging is characterized by maintenance or expansion of intellectual powers and autonomy, and by superior physiological functioning. These lead to enhanced health and ability, and the avoidance or even reversal of functional losses. The authors demonstrated that physical fitness, good nutrition, and normal weight are moderators of the aging process. In the absence of disease cognitive decline is preventable and often countered when elders engage in active cognitive processes or training. On the other hand, typical or usual aging often shows deteriorating cognitive powers, curtailed autonomy, poor physiological functioning, and limited longevity. Hsu and Jones (2012) found that only 29% of their sample clustered in the successful-aging group.
In the psychological realm, Rowe and Kahn showed the positive effects of autonomy, personal control, and good social support, and the negative effects of bereavement and forced geographic relocation. Positive psychosocial factors promote health-enhancing and risk-limiting behaviors, and reduce vulnerability to infections processes and immunological depletion. Adequate social support counters stresses and depression, and is associated with self-reported well-being. Under conditions described as those that promote successful aging, elders show reduced morbidity and mortality.
Related to Rowe and Kahn’s findings, studies have shown that when middle-aged and older adults participate in cognition-promoting exercises such as playing word puzzles, Sudoku, chess, and musical instruments, cognitive decline is forestalled. When such activities typify everyday life, openness to experience and learning are enhanced, cognitive flexibility is maintained, and persons are inclined to engage in additional learning. These findings have been demonstrated by data from the Seattle Longitudinal Study (SLS). In the SLS, Schaie (2005) showed that, for those who continue to learn, who live in resource rich environments, and who do not suffer from cardiovascular or cerebrovascular disorders, cognitive prowess is maintained and expanded into the seventh decade of life (see also Fillit, et al, 2002; Knoops et al., 2004) Schaie (2005) holds that extensive reading, travel, and attendance at cultural and professional meetings decrease cognitive decline significantly (see Lachman, Rosnick, & Rocke, 2009).
Adults who are characterized by limited cognitive undertakings have about 2.5 times the probability of developing dementia compared with those who show extensive cognitive engagement (Hoare, 2011). In studying 500 elders over 75 years of age, extensive cognitive immersion was associated with a decreased risk of dementia over the subsequent two decades. Based on 20 years of longitudinal data, Schooler and Mulato (2001) found that elaborate cognitive activities expanded intellectual performance in the far years of life. Complementing these findings, in studying data from 48,537 online subjects, combined with findings from memory and intelligence tests, Hartshorne and Germine (2015) found considerable heterogeneity in cognitive peaks and declines for various abilities. Although working memory and digit span peaked around 30 years of age, emotion-recognition abilities remained stable between 40 and 60 years of age, and vocabularies crested in the eighth decade of life.
Without using the actual term, many of the authors cited above have described resilience in adulthood. Resilience does not just appear when one needs it most. Rather it is engendered by mentally engaged lifestyles, physical fitness, social support, and a sense of active agency in controlling one’s life.
Finally, although it is beyond the scope of this article, it is important to note that a number of theorists have implicated physiological factors in an individual’s response to stress and coping. For example, in an extensive review of psychobiological markers of resilience and vulnerability, Charney (2004) cited evidence that genetic factors play important roles in one’s behavioral response. He found that brain regions, neural mechanisms, and neurochemicals intersect with traits that are associated with resilience and vulnerability (see also Elliott, Sahakian, & Charney, 2010). Synthesizing macro (societal) and personal (family, individual psychosocial, physiological, cellular) factors in vulnerability and resilience, Szanton, Gill and Thorpe (2010) examined the potential intersection between contextual and physiological factors. The authors contended that under challenging conditions resilience can be linked to neurochemical activity and related cellular functioning.
Psychosocial Resilience in the Elderly
Research that has specifically addressed resilience in older adults is meager and tilts toward examining such qualities among those who can be considered as resilient to begin with, that is, those who are community dwelling (non-institutionalized), have lived into their later years, and can function as research subjects (Thorp & Blazer, 2012). However, several studies are worthy of mention. One study found that mortality rates were reduced by six percent among elders who were more self-accepting, non-isolated, and less anxious than their peers (Shen & Zeng, 2010).Two studies have shown that resilience foreshadows good mental health (Nygren, et al., 2005; Mehta, et al., 2008), and one study found that resilience buffered the effects of poor health (Windle, Woods, & Markland, 2010). Resilience has often been seen under conditions of social support and ample socioeconomic resources (Kwong, Du, & Xu, 2015). However, among minority and immigrant populations, the effects of structural discrimination auger against healthy personal behaviors and adequate resources in education, social services, and health care (Kwong, Du, & Xu, 2015). Thus, resilience should be treated as a multifaceted construct with different cultural, racial, and social class ramifications.
Studies with respect to the harbingers of resilience have found that optimism, strong social networks, self-rated successful aging, emotional health, cognitive success, and the absence of depression foreshadow resilience. Comparing young adults (under 26 years of age) with older adults (over 64 years of age), Gooding, Hurst, Johnson, and Tarrier (2012) found that older adults were more resilient than young adults, particularly with regard to problem solving and the ability to regulate emotions. This should not be surprising since most older adults have had many years of experience in solving problems and controlling their feelings.
Based on their research and literature reviews, Aldwin and Igarashi (2015) found that while the essence of resilience connotes a person’s ability to adapt flexibly, resilience should be thought of as an individual attribute, as a process, and as an end result. These are contingent on resources at the personal (e.g., intellectual) and contextual (e.g., social support) levels. And, in their meta-analysis of 60 studies on resilience and mental health, Hu, Zhang, and Wang (2015) agreed that resilience is both process and outcome in that it mobilizes the ability to grapple with adversity and leads to positive outcomes. In the Hu, Zhang and Wang (2015) study resilience was positively associated with good mental health such as positive affect and life satisfaction. Negative correlations were found for depression, anxiety, and pessimistic affect.
In reading the resilience literature one comes away with a veritable laundry list of factors that are correlated with, and result in, resilience. In part, this is a function of multiple definitions of resilience. Nonetheless, “flourishing under fire” is one positive predictor of positive aging (Ryff & Singer, 2003, p. 15).
Aging adults may or may not have the capacity to improve their own resilience. Thus interventions may be useful in this respect. A wide range of interventions permeate the literature. Here we look to three types that are emphasized by a number of writers on the topic: 1. mindfulness meditation, 2. cognitive reframing, and 3. mastery development.
However, first it is necessary to avoid a scattergun approach. Those who intervene must identify the attributes that are most in need of improvement. In doing so, one must observe and listen carefully to elders. Their descriptions of their own experiences of resilience are fundamental to the work that follows. Elders are the ones who are experts on their own life histories and their knowledge, beliefs, and opinions, conscious or less so, must prefigure any attempt to adjust their behavior. Second, a plan should be developed with the client that extends their positive experiences of resilience (Wagnild & Collins, 2009).
MINDFULNESS MEDITATION: ASSISTS POSITIVE COPING
As is indicated by a number of authors, mindfulness meditation (MM) training has been shown to improve a person’s ability to cope, to enhance a sense of well-being, and to augment positive emotions (Davidson & McEwen, 2012; Kabat-Zinn, 1990; Southwick & Watson, 2015). In MM, the elder practices skills that assist in focusing attention on the current moment, developing acceptance and tolerance, and regulating emotions. (Baer, 2003;Kent & Davis, 2010). Thus, rumination about potential future stresses is avoided and elders learn to reconcile themselves to exigencies that cannot be altered.
COGNITIVE REFRAMING CAN ALTER NEGATIVE PERCEPTIONS
Cognitive reframing or reappraisal is a useful tool that helps persons to alter their perceptions of events such that their negative emotional impact is diminished. Research has shown that those who report using reappraisal tend to be more flexibly adaptive and have better social outcomes. Through training elders can learn the skills of reinterpretation or distancing as they reframe meanings. In reinterpretation, persons psychologically alter the meaning of events, contexts, or outcomes such that more positive effects can be envisaged. In distancing, one alters the perceived closeness of an occurrence by seeing it through the lens of an uninvolved third-person. Distancing tends to show greater long term benefits, although both skills are important to elders.
MASTERY DEVELOPMENT: ENHANCING SENSE OF ACHIEVEMENT
Finally, personal mastery can be developed. In mastery development programs elders develop the skills that enhance self-agency. Elders develop active, positive coping abilities, learn to understand the role of their actions on consequences, and develop abilities in responding effectively to challenges. According to Masten (2011) mastery leads to five key results:
1. improved mastery and ability to cope well,
2. improved relationships with others,
3. enhanced self-awareness and knowledge,
4. movement away from materialism,
5. and, in some, enhanced spirituality.
A number of studies have implicated protective attributes that sustain healthy functioning in spite of trauma, loss, and adversity. These include positive adaptability, a sense of good self-esteem, and an achievement mentality (Bookwala, 2014; Kishida & Elavsky, 2015; Robinson, Larson, & Cahill, 2014). These qualities are also correlated with positive emotions and affect and a feeling of well-being (Robinson, Larson, & Cahill, 2014; Ryff;, 1995). All of these qualities implicate personal hardiness (Robinson, Larson, & Cahill, 2014) and a history of low vulnerability (Bonanno, 2004; Connor & Davidson, 2003).
Resilience is multifaceted and complex. It is wrought by a number of individual psychosocial and physiological attributes and resources, and tends to develop best in the context of a supportive environment. The literature reveals a variety of definitions, a broad array of human characteristics that correlate with resilience, and a host of potential interventions. Research on resilience in the elderly is limited, partly in response to still-prevalent ageist stereotypes. There remains much to be learned from resilient elders themselves, particularly from those who are aging successfully.