Shrinking Of The World

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Older individuals tend to use less and less of what can be termed the total environment. This gradual restriction often begins when the person leaves the world of work at retirement. A second point at which there is a reduced level of participation in the outside world occurs when the individual experiences the onset of a chronic illness. Further restrictions are put into play as the individual ages and sensory deficits, such as vision or hearing losses, become more intensified. Such physical alterations can at times be sufficiently severe to constitute a need to alter individual lifestyle. A frequent change is to limit outside activities, with a concomitant increased usage of the home environment.

Home environments are utilized at a much higher rate by older persons due to physical constraints, economic difficulties, and even psychological conditions such as fear. The location of the residence of the persons plays an important role in the perception of safety within the environment and the view of the outside environment as being essentially hostile. Such a restriction to the home environment leads to what can be termed a ''basic-needs orientation.'' Requirements for the carrying out of activities of daily living (ADLs) take on increasing importance as the limitations due to senescent changes and disabilities due to disease continue to escalate.

Independence in this shrinking environment continues to be eroded, and there is the necessary enlistment of outside resources. The entrance of other family members, health care personnel, social service agencies, and a host of other assistive groups into the individual's private life means the lessening of decision-making power by the older person. As the individual gradually loses control of his or her personal life due to illness, immobility, or sensory loss, the control of that life is assumed by outside agencies. Such a decrease in control is usually followed by further constrictions of the individual world.

Even when the person continues to reside at home, there is a progressive diminished utilization of all of the home space and features. Such diminished utilization can begin with the individual's not using the basement, attic, garden, or garage. Outdoor activity is reduced and eventually ceases. Particular rooms of the home are no longer utilized, such as the living room, dining room, or spare bedrooms. Should the person have difficulty using stairs, the bedroom may be moved to a first-floor room and use made of a first-floor bath when it exists. Some home modifications may be necessary to achieve such a move. The individual may remain on the second floor if such accommodations to a first level are not possible.

Restrictions of the life space eventually center on ''the areas of survival.'' These areas are the kitchen, the bathroom, and the bedroom. The circle of ex perience also perceptibly narrows, and control slowly, but inexorably, moves away from the individual. As the person continues to age and become more dependent, even possibly bedfast, the locus of control becomes more decidedly assumed by outside agencies. The final area of control, the most personal, is taken over by someone else at the bedside.

The types of activities that usually suffer some restriction generally fall into the categories of instrumental activities of daily living (IADLs) or activities of daily living (ADLs). Although many of these activities are considered routine, their performance reflects upon individual functional capabilities. Problems in the performance of such activities are frequently the basis for a determination as to whether or not the person can live independently and whether institution-alization needs to be considered.

One intervention that can help offset some problems is the development of augmentative technologies that permit persons to perform many of the actions they had been used to carrying out in their own homes. Decreasing abilities to use particular appliances, to utilize the entire living space, or to provide for the accommodation of sensory losses, reduced mobility, and the reduction in physical strength can all be counteracted by modifications of existing homes or the construction of homes that are prosthetic in nature. The conventional home may be a lethal environment for the elderly. Just as environments for special populations, such as children, take into account their special needs, environments for older persons require a careful assessment to determine their suitability.

Furthermore, the functional capability of the individual allows for decision making in terms of how life will be scheduled and structured. Deciding how to spend one's day, or what the daily menu will be, is often regarded as routine and a matter of course. When such decisions must be made in concert with other individuals, or when decisions regarding such issues are determined solely by others, the locus of control has effectively moved away from the individual. When such control includes areas such as dressing, feeding and toileting, the loss of control becomes almost complete.

The situation becomes one that can possibly be best described as Maslow in reverse. In Maslow's pyramid (1968), persons satisfy lower basic needs and move up to the top or pinnacle of the pyramid to reach a personal sense of achievement in intellectual or spiritual arenas. Older persons have spent their lives in striving to reach the top of the pyramid, and many achieve this task successfully. Now that they are at the top of the pyramid and are aged, they must move downwards, backwards, if you will, and this is a negative progression that is not happily attempted. To move down from the pyramid's top means preoccupation with biological and psychological functioning. Furthermore, since such basic needs had once been mastered, there may be anger and frustration at having to attend so exclusively to meeting these needs again, particularly when one's tolerance and ability to cope are waning. This move also constitutes a radical change in self-image, and those intellectual, spiritual, or professional achievements that form part of self-identity pale against the reality of negotiating a steep flight of stairs or opening a food container. For older persons, intellectual, professional, spiritual, aesthetic, and avocational growth seems to have been dismissed, disregarded, or diminished in meaning.

Physical movement also is restricted as the environment shrinks. Contrary to the dictates of human health requirements, older persons become more sedentary and engage in less exercise. Part of this reduced physical activity results from reduced participation in the environment because of physical or environmental barriers. Environmental barriers can include the structure of the home, its layout, and the presence of stairs. Storage spaces and appliances may be difficult to access or use, thus cutting back on the person's activity. Shrinkage of the environment due to the nature of the environment itself means that there is a lack of fit between the person and the environment. Such a lack of consonance means that the person is less stimulated by the environment and finds it to be more of a frustration. Increasingly, drawing away from the environment and curtailing their ability to manipulate the environment to their own best advantage results in persons losing control of their lives and, eventually, of themselves. Both physical and mental deterioration may result, and it is at this juncture that a loss of interest in life may manifest itself. Coupled with such negative views of the self are the feelings of impotence and uselessness. Suicidal ideation becomes a possibility.

The social climate in which many older persons experience aging is often bereft of caring friends and family members. Support groups may not be available due to several factors, including three principal ones: death, distance, and divorce.

The longer a person lives, the greater is the likelihood of the experience of the death of a loved one. Such death experiences may be multiple, and the person begins to feel like ''the last leaf'' and to question the purpose of continued existence. Due to the shrinking of the world, fewer persons are available to fill the gaps left by the dead.

Not only do the elderly suffer from the presence of death, but they are also plagued by distance. They themselves may have moved a number of times during their lifetimes and not have developed lasting friendships. Relatives, due to the mobility of society, may be scattered across the globe. Despite the advertisements of telephone companies, long-distance calling is not an effective substitute. Relationships are maintained only through persistent and ongoing contact, and distance attenuates many once-close relationships.

Divorce effectively divides older persons from potential support groups. Women who are divorced in old age have difficulty in finding new partners. Men are more likely to rebuild personal lives with new partners due to the greater presence of older women and society's sanction of older men's marrying women of much younger ages. A man can have two or three families throughout life, whereas many women are limited to one. The longer life expectancy afforded women continues to exacerbate this problem.

With the presence of multiple families, the obligation to care for an older person becomes more problematic. Divorced parents frequently are estranged from children or have a series of children, both of their own and of their succeeding partners, such that responsibility for the older parent is often muddied. There is much confusion as to with whom the moral responsibility for an aging parent lies. Should it be the daughter who has never lived in the mother's home? A step-granddaughter? The deceased husband's natural daughter who resided with them while attending high school? When children are available, they are faced with responsibilities for several sets of older relatives. These may include one's own parents, parents-in-law, aging aunts and uncles, and older siblings.

Older individuals may also be called upon to repeat their nurturant roles in old age. A not-unusual scenario is that of a woman of 82 who is caring for her son who is 63 and a mother who is 101. The restrictive world in which the older woman lives due to physical health problems and an ineffective environment make the provision of such care even more problematic.

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