J.H.K.C. Psych. (1994) 4, SP2, 39-44

ORIGINAL PAPER

STRESS, COPING AND AGEING

Bernard W.K. Lau

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STRESSES AT OLD AGE

In general, life is characterised by a multiplicity of stresses. People react to these stresses with their own clusters of defense mechanisms or coping skills. As a result, these protective mechanisms· determine the amount of strain an individual experiences and the subsequent likelihood of its expression as psycho-pathology. In particular, old age is marked by the presence of a wide range of stressors. The older person is often subject to biological deterioration, social extrusion, and economic deprivation. The course of events at this period of lifespan is such that these traumas may occur in rapid succession without allowing the person time to regain his balance before confronting the next stressor. Even taken individually, particular stressors will separately dictate an array of coping mechanisms for successful outcomes.

Evans (1984) draws on a number of studies to suggest that adverse life events occur more frequently in old age and that their occurrence causally increases the prevalence of illness in old age. As the elderly population encounters these and other loss events, resolution of life events may be hampered by their relative social status in relation to younger age groups. Dowd (1980) has argued that social exchange between young and older age groups is characterised by an imbalance in the exchange ratio which effectively places the elderly in a double bind, namely, that declining resources in old age entails negotiating from weakness at a time when resources are exchanged for less than they would be for a younger person.

Alternatively, it is still possible that older adults actually encounter fewer stressful events than the young (Lowenthal, Thurber & Chiriboga, 1975; George, 1980; Harris, 1989). But the fact remains: many of the stresses of younger adults' lives have pleasant aspects. Leaving home, getting married, having a baby, buying a house, getting a promotion are all stressful, but they also bring challenge and reward. In contrast, many of the stresses of later adulthood are primarily negative: poor health, reduced income, death of a spouse (Chiriboga & Cutler, 1980). In this line of thought, problems in the life of the aged often are conceptualised as divergences from an optimal state of well-being, whether these divergences are caused by health problems, or by loss of social roles, economic resources, or significant others (Atchley, 1989).

However, it may in fact be the case that the elderly are particularly prone to experience multiple, albeit low prevalence of, life events, which could act synergistically to cause decline in well-being (Fried & Bush, 1988). None the less, even when elderly people might cope better with loss of a spouse or close relatives and friends than do younger counterparts, they undoubtedly exhibit greater vulnerability when confronted with certain life events. Notable among these is residential relocation. This has local relevance when we realise there is a booming industry of old-aged home in Hong Kong owing to mass emigration of younger people in recent years (Cheng, 1993).

WHY MORE VULNERABLE

While the potentially adverse consequences of stress are universal and apply across the lifespan, there are at least several reasons why elderly persons are particularly vulnerable. Firstly, relative to younger contemporalies, they are typically confronted with a multitude of major life events following on the heels of each other. These are all potentially stressful in their own right in that they impose significant demands upon the coping resources available to an individual. Furthermore they do so at a time when the very resources that might facilitate stressful adaptation may themselves be diminished by other recently experienced and/or co-occurring events. Those losses that could enhance the range of coping for older people may also prevent them from employing other coping responses such as the use of social resources.

Secondly, a number of factors cause powerlessness in the elderly. Contextual events that may render a person "helpless" include (1) being assigned a label that connotes inferiority in relation to other persons, (2) engaging in a consensually demeaning task, and (3) no longer engaging in a previously reinforcing, valued task. Elderly persons are the targets of many false labels, myths, and stereotypes (Matteson & McConnell, 1988). Many elderly persons internalise these beliefs imposed by others in their social spheres. When assigned a consensually demeaning task, the elderly individual erroneously infers self- incompetence.

Thirdly, the social network also changes over the life span and is likely to be markedly different in old age in comparison with middle and younger adult years. For example, the elderly are typically separated from their children and face a shrinking support system with the demise of spouse, relatives, and friends. The social network may also have different expectations and generate social pressures for the older persons that are different than those placed on the young or middle-aged (Schulz & Rau, 1985).

Fourthly, since the ageing process involves general reduction in immunological competence (Rollin, 1986a), the older adults' ageing body may magnify the adverse effects of each stress, even though they may not perceive the event as especially stressful. In reality, an ageing immune system can make adults more vulnerable to the physical effects of stress. The strain is exaggerated if they have already suffered from some degenerative disease, such as heart trouble or diabetes. It is pertinent to note that prolonged autonomic arousal will have greater deleterious effects among older people who after stressful experiences, take longer to return to basal homeostatic levels (Birren, 1992).

Undoubtedly, many factors can modify the destructiveness of stress on older adults. Experience with stress in earlier stages of life seems to prepare a person for the losses and stresses of age. Older people whose early lives have been smooth and stress-free often seem unable to cope with stress. Being able to anticipate a stressful event seems to make it less destructive. If a stress is anticipated, older adults often can work it through ahead of time. Then when the event arrives, they may be able to cope effectively.

AGE DIFFERENCES IN COPING

Over the last decades, there have been speculations about age differences in coping following preferred views in various lines, not infrequently amounting to considerable controversy. McCrae (1982) characterised these as regression and growth hypotheses.

On one hand, it is contended that there are some association between age and coping preferences. In this light, age was presumed to be negatively correlated with problem-focused coping and total number of coping responses. Very old (that is, 70s and 80s) individuals utilise fewer coping responses, when faced with stressful situations. Specifically, they tend to use responses aimed at controlling the source of stress itself less often than do younger elderly individuals. This might reflect limited resources among older persons for changing the stressors in their lives. Another possibility is that as individuals age they simply use fewer coping mechanisms more efficiently (Patterson, Smith, Grant, Clopton, Josepha, and Yager, 1990).

Folkman, Lazarus, Pimley, and Novacek (1987) found that, across a range of stressful situations, older respondents used less confrontive coping. They were more likely to rely on cognitive approach {positive reappraisal) and avoidance (distancing and escape-avoidance) coping and less likely to utilise behavioural approach processes such as seeking social support, problem solving, and confrontation. Similar results were reported by Irion and Blanchard-Fields (1987), indicating that older individuals used less confrontive coping in dealing with threat.

Overally speaking, age differences were apparent in all coping strategies in both threat and challenge situations. Younger adults (under age 50) more frequently reported hostile reactions and the use of escapist fantasy than did middle-aged or older adults (McCrae, 1982). In contrast, middle-aged and older respondents endorsed fewer strategies related to hostile reaction, escape avoidance, and self-blame. Older persons tended to use more adaptive coping responses and were less likely to vent frustration on other people than either of the younger groups (Costa, Zonderman & McCrae, 1991; Felton & Revenson, 1987; McCrae, 1989). In particular, Felton and Revenson (1987) reported lower use of emotional expression, self-blame, and informationseeking in their older subjects.

McCrae (1982) also showed that older subjects were less likely than younger subjects to endorse coping styles of blaming (either self or others), and to use humour and cognitive reappraisal to create an optimistic attitude.

Moreover, Folkman and her colleagues (1987) found that older respondents consistently used more passive, intrapersonal, emotion-focused coping responses, whereas younger respondents were more likely to use active, interpersonal, and problem-focused coping.

However, in coping with health problems, older persons tended to use confrontative coping more than any other response. It appears from the research that people who survive to advanced age readily engage in health-protective behaviours and indeed may respond more positively than younger peers to instructions aimed at health promotion (Ory, Abeles & Lipman, 1992).

From another viewpoint, after controlling for types of stress, some reports suggested that there were few age differences in coping. For example, no significant age differences were found for rational action, seeking help, perseverance, isolation of affect, expression of feelings, distraction, intellectual denial, self-blame, social comparison, substitution, drawing strength from adversity, avoidance, withdrawal, active forgetting, or passivity (McCrae, 1982; Lazarus & DeLongis, 1983). In a study of coping with interpersonal conflicts, Quayhagen and Quayhagen (1982) found that older adults used less help seeking and problem solving, but more affectivity (emotional ventilation). They found no differences in existential growth, fantasy, or minimisation of threat.

In the same vein, Felton and Revenson (1987) reported no age differences in the use of cognitive restructuring, wish-fulfilling fantasy, or threat minimisation. Other work of Felton and colleagues (Felton & Revenson, 1984; Felton et al., 1984; Revenson & Felton, 1985) showed that differences in coping responses among patients stressed by chronic disease are related to specific demands of the illness, illness beliefs, and characteristics of the person but not to age. Most patients, young or old, were found to mobilise coping behaviours that were well suited to the stressors and effective in reducing distress. Research with moderately impaired patients with Alzheimer's disease (Kiyak, Montgomery, Borson, & Terri, 1985), a disorder that directly affects the "organ of coping", demonstrates a restriction in the normal range of coping strategies as well as a tendency to use more primitive coping styles such as denying or ignoring the problem. Age per se does not appear to be a factor.

It seems that age-related differences in coping do not closely fit with a regression or with an opposing growth hypothesis. Age differences were likely to be confounded with differences in the types of stress typically encountered by adults of different ages. Overall, it is likely that older individuals are neither more or less mature than younger adults in their use of defense mechanisms.

DEVELOPMENT OF COPING STYLES

Several studies have suggested that coping styles undergo a natural development across the life span. In this connection, one might expect a change in the strength or time course of older persons' reactions, both behavioural and emotional.

Generally speaking, the middle-aged adults appear to be very well aware of the strategies they use in pursuing their long ranged goals. One of the goals of middle age seems to be a reduction of "load" in order to gain or maintain effectiveness, whereby the successful middleaged and older adults become increasingly effective in their careers as a result of the concepts or abstractions they form. They trim the information load by chunking information. By developing a map of major life events, larger units of information can be dealt with to avoid an overload of details. Furthermore, the successful middleaged or older adults would seek to conserve their energies. Unlike young adults, they seem to be subjected to a lesser load by virtue of the "map of life" they have developed and the strategies they have evolved in managing their lives and the attendant stressors.

However, in literature diverse pictures on coping style have been painted. On one hand, the elderly were sometimes portrayed as rigid and unable to adapt. For instance, Pfeiffer ( 1977) articulated a widely held view that older persons are more rigid in their thinking than are younger persons. They are, therefore, prone to the use of primitive mechanisms of coping and defense and more likely to use a limited range of responses, typified by withdrawal, denial and anxiety.

Wedin (1977) speculated about why more primitive cognitive response may be a salient response in stressful situations. Firstly, a more primitively organised response is obviously less complex than the more abstract one. Secondly, it may still have superior anxiety-reducing properties. Thus, such responses may have a misfired adaptive function in stressful circumstances. In states of chronic anxiety, as commonly in later life, the egocentric approach to problem solving dominates. It may serve an adaptive function by simplifying the environment and distorting it in such a way that it looks less threatening.

Those stresses, both internal and external, that assault the elderly individual may in the end precipitate regression in cognitive functioning. In particular, losses of various kinds -- death of a loved one, separation, ill health, threatened body integrity, reduced cerebral and physiological reserve, and environmental deprivation due to retirement and financially reduced circumstances -- constitute the "powerful enemies" that the elderly individual encounters. In this context, later life presents a developmental crisis which can be met in some way by regression to earlier modes of adaptive functioning. Camaron ( 1967) also provided evidence that an ego function dimension is a complicating factor in the elderly. Using the relatively global concept of ego strength, as measured on the Barron Ego Strength scale, he compared young and aged samples and found that the aged generally had lower ego strength than the young.

From a certain angle, the elderly person's withdrawal from the world can be taken as a form of mastery of the external stimuli. In this regard, Neugarten and Guttman (Neugarten & Guttman, 1958; Guttman, 1969) found an age-related movement through successive egomastery styles. Active mastery, instrumental and productive ways of mastering the external world, was found in the men aged 40-60. These men saw the environment as rewarding boldness and risk-taking and saw themselves as possessing energies congruent with the opportunities presented in the outer world. In contrast, 60-year-old men saw the environment as dangerous and complex and the self as conforming and accommodating to outer-world demands. This change was described as a movement from active to passive mastery. After 65, the conformist mode was replaced by magical mastery, which involved projective rather than instrumental revisions of the world and the self . In this later stage, primitive defensive operations, such as projection and denial, seemed to substitute for realistic activity. According to Feifel and Starck (1989), older men prefer resignation to avoidance, whereas middle-aged men do not. Older men may have a shrinking sense of time and thus may want to resolve conflicts and attain closure on important life issues. By the same token, Brandstadter (1992) also suggested that there is a gradual age-related shift from assimilative to accommodative modes of coping.

On the other hand, ageing was seen by others as a process of attaining wisdom, and greater maturity of coping was also hypothesised. In a longitudinal study of male Harvard graduates, Vaillant (1977) described a change in coping strategies as the men reached middle age. His findings suggested that people become better capers as they age and are less inclined than in their younger years to distort reality as a means of controlling the stressfulness of events.

Empirical studies of normal elderly subjects (McCrae & Costa, 1985) showed that the capacity of flexible responses to stress is retained into advanced old age. The majority of older people appear capable of using a wide repertoire of coping styles (Kahana and Kahana, 1982) and can call upon the most appropriate response for a given situation. This can be explained by his greater experience with diverse life events and repeated practice in coping with major stressors. Usually later life is inherently less stressful than earlier states of life cycle as a consequence of repeated exposure to stress (Eysenck, 1983).

Taken together, data from these studies support the conclusion that normal ageing is generally accompanied by more mature coping responses and a greater capacity to tolerate negative affective states without losing resilience in the face of stress. Only in the presence of a significant mental disorder or cognitive impairment should older persons be expected to show diminished effectiveness and breadth of coping responses.

In this light, the comments of McCrae (1984) are apt. He found that the meaning of a stressor to the individual (whether the event was defined as a loss, a threat, or a challenge) consistently and significantly affected the choice of coping mechanisms, regardless of the respondent's age. For example, events identified as losses resulted more often in expressions of feelings or of faith for people of all ages, whereas challenges were met with r11tional action, perseverance, positive thinking, and restraint. These responses were just as likely in older as in young persons coping with similar events. Herein lies a possible explanation for these conflicting findings regarding the influence of age on coping style. The nature of stressful life events changes across the life span; normative stressors in old age differ markedly from normative stressors in youth. It may be these different situations and older persons' appraisals of them, rather than any age-related changes in coping style per se that account for differences reported in samples of different ages (Folkman & Lazarus, 1980; Siegler & George, 1983). In other words, because the situations are different, the same events evoke different arrays of coping responses at different ages. The recent work of Folkman and associates (1987) provides some support for this interpretation. Because older men are more likely to report on health concerns and middle-aged men to focus on work- and family-related problems, some of these age differences may actually be due to differences in focal stressors.

REACTIONS TO ILLNESS

Contrary to popular stereotypes, the elderly are in practice more vigilant with respect to health problems. One hypothesis is that older persons differ in the way they represent diseases. On the other hand, in comparison with younger persons, many elderly people tend to practise more preventive health behaviours and are more likely to adhere to therapeutic regimens (Prohaska, Leventhal, Leventhal & Keller, 1985), because they are more anxious or frightened about the dangers of specific diseases. Even when the elderly may not feel personally vulnerable to illness or like to interpret symptoms as indicators of illness, such increased attentiveness or monitoring of symptoms or a greater readiness to attribute symptoms to deadly diseases would have already resulted in increased vigilance. Naturally, these cognitive factors provide some worry and/or emotional upset about the possibility of illness. As people grow older, they become increasingly motivated to reduce the level and cost of emotional distress and do so by acting ·(seeking care) to define and treat health threats, thereby eliminating any emotional distress created by uncertainty. It is likely that older persons might indeed differ from younger persons in their coping expectations and/or in the appraisals they make of coping outcomes (Ory, Abeles & Lipman, 1992), and actually desire less control over their health care than younger individuals. A number of studies have suggested that today's elderly patients have different expectations of health care professionals and frequently prefer that professionals make decisions for them (e.g. Smith, Woodward, Wallston, Wallston, Rye & Zylstra, 1988; Woodward & Wallston, 1987).

There is growing evidence that contemporary older adults cope with illness in different ways than younger patients. Older adults, particularly those with serious illness, make greater use of minimisation and less use of information seeking and emotional expression in coming to grips with sickness (Felton & Revenson, 1987). Undoubtedly, an individual's age may also influence treatment decisions.

While common sense does recognise that chronic diseases are diseases of ageing (Leventhal, Leventhal & Schaefer, 1992), many people who survive to advanced old age do so with a litany of multiple chronic conditions. Previous experience in coping with chronic illness can lead to better management of the disabling effects of these diseases and less emotion-focused coping. Instrumental strategies useful in managing a chronic illness may be more readily undertaken by an older person who has had time to experience their benefits with other illnesses and has had years of experience with these multiple conditions. Therefore, it is not surprising that age differences in styles of coping with chronic illness have been demonstrated.

In clinical practice, each patient with chronic disease brings to the process his or her own set of biases, values, and expectations, many of which are implicit and not clearly articulated. For the patient, coping is reflected in maintaining a personal balance between the damaging effects of disease on overall well-being and the destructive effects of its management on life satisfaction. From the viewpoint of the physician, coping is reflected in compliance with a medical regimen that has been tested empirically, and impersonally, in groups of patients more or less similar to this one. For the family caregiver, coping is reflected in the patient's capacity to live with the illness with appropriate degrees of dependence and distress, without jeopardising the interpersonal relations between the patient, his or her caregiver, and the physician.

THE CHINESE CASE

Hwang Kwang-kuo (1978) in Taiwan has developed a sophisticated classification of the ways Chinese people respond to interpersonal and psychological problems. Broadly speaking, he identified two basic approaches to life's problems, the active and the persevering. Active approaches include problem analysis, self-assertion, and seeking help from others. Persevering approaches derive from the Confucian traditions of self-control, and include strategies like stopping thought, self-instruction in patience, and non-resistance. Older, lower-class persons are more likely to use persevering approaches and to experience social withdrawal, existential complaints and cognitive disturbance.

He further categorised four different methods used by the Chinese in resolving threats and uncertainties:

1. Self-reliance, in which the individual has the options of (a) relying solely upon his/her personal resources for solving the problem (this involves going through the cognitive process of analysing the situation and devising the solution), (b) enduring the situation even if it may be long term, (c) making endeavours to solve the problem by more hard work, and (d) instilling more self-confidence through the conviction that s/he can solve the problem eventually.
2. Social-reliance, in which s/he will seek the help of others, especially among peer groups.
3. Supernatural powers, in which s/he will seek blessings from supernatural powers, including praying, ancestor worship, or fortune telling.
4. Passive behaviour, which is closely related to the philosophy of Taoism -- the emphasis is on doing nothing, but waiting to let nature take its course.

So the common coping strategies adopted by Taiwanese men were related to cognitive processes, either by the more passive means of learning to live with their problems, or facing the problems and persevering. In this connection, it has been demonstrated that the type of psychopathology Chinese people experience is related to the way they approach life's problems generally. This finding provides further support for the link between cognitive factors and psychiatric symptoms (Bond, 1991).

CONCLUSION

Over the last twenty years or so, most research on stress and coping has focused on younger adults, partly because of the widespread belief that older adults experience fewer life stresses and partly because of the assumption that coping strategies are similar across the lifespan. More recent studies are now able to show that the older persons constitute a different population and deserve a specific study in its own right, although the needs and problems of this sector of population has long been ignored. Again, this may be due to stereotypic effects of ageism and misattribution of problems or pathology to ageing. This has a clinical bearing when symptoms presented by elderly patients to doctors may be explained away simply as effect of ageing without paying due attention to the underlying organic aetiology. The misdiagnosis or even the delay in arriving at the correct diagnosis can often have devastating outcome. It is therefore useful to explore the probably unique psychology of this group of people and to investigate whether cross-cultural or cross-racial differences are present. Thus further research in Chinese communities remains to be desired, whereby the clinical needs of this population can be met sufficiently while at the same time their personal needs will be attended to.

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Bernard W. K. LAU MBBS, MRCPsych, DPM Honorary Consultant Psychiatrist, St. Paul's Hospital; Baptist Hospital; Haven of Hope Hospital. Room 703, Capitol Centre, 5-19 Jardine's Bazaar, Causeway Bay, Hong Kong.