41.2 Theories Related to the Older Adult

Psychosocial Development Theory

Erik Erikson, a life-stage theorist, explained the psychosocial development theory, which emphasizes the social nature of human development from infancy through older adulthood. Erikson proposed that personality development takes place throughout the life span. Erikson suggested that how people interact with others affects their sense of self.

Erikson proposed that we are motivated by a need to achieve competence in certain areas of our lives. According to his theory, individuals experience eight stages of development over their life span, during which a conflict or task needs to be resolved. Completing each developmental task results in a sense of competence and a healthy personality, whereas failure to master these tasks leads to feelings of inadequacy. According to Erikson (1963), individuals progress through a predictable series of developmental stages (Table 41.2).

According to Erikson, the late adulthood task relates to ego integrity versus despair. He stated that during older adulthood, individuals reflect on their lives and experience a sense of either satisfaction or failure. People with few regrets and a sense of integrity often feel pride in their accomplishments. People who struggle with this stage may feel as if their life has been wasted. Focusing on how life experiences “would have,” “should have,” and “could have been” can lead to bitterness, depression, and despair.

In nursing practice, Erikson’s theory allows nurses to understand the complex dynamics that shape an individual’s health and wellness path throughout life. Nurses can provide highly individualized care by understanding that personality development continues to evolve and change even in older adulthood. Applying Erikson’s theory in real-life nursing situations may look like this:

• encouraging physical activity based on ability
• connecting individuals with grief support networks
• recommending community groups based on interest
• referring to nutrition services to support healthy eating
• providing continuity of care between medical specialists and support services
• showing respect for clients in older adulthood

Disengagement Theory

The disengagement theory is one of the earliest theories on aging. It was proposed by Elaine Cumming and William Earl Henry in 1961. The disengagement theory suggests that withdrawing from society and social relationships is a natural part of growing old. There are several main points to the theory. First, because everyone expects to die one day, and individuals experience physical and mental decline as they approach death, it is natural to withdraw from individuals and society. Second, as older adults begin to withdraw, they receive less reinforcement to conform to social norms. Therefore, this withdrawal allows greater freedom from the pressure to conform. The theorists described the experience of social withdrawal differently for men and women because traditionally, men focused on work and women focused on marriage and family. The disengagement theory states that when individuals withdraw, they will be unhappy and directionless until they adopt a role to replace their accustomed role compatible with the disengaged state (Cumming & Henry, 1961).

While the disengagement theory served as a springboard for ongoing research into aging, the foundations of the theory imply a negative connotation with aging. Historically, the theory was not well received due to this negative portrayal of older adults within society. Subsequent studies suggested that engagement and activity, rather than disengagement, is the basis by which older adults progress through the aging process. Additionally, some critics of the disengagement theory cite several concepts within the theory that tend to discredit it, including the following ideas:

• Disengagement in older adulthood is universal.
• Disengagement is involuntary.
• Disengagement is inevitable.

These ideas do not fit with the currently accepted cultural beliefs about aging. Adults have vastly different experiences with the aging process depending on social, physical, and emotional factors. Even as Cumming and Henry proposed the disengagement theory, other researchers worked to define aging in a more positive and individualized way. The focus shifted from disengagement to personal and community engagement.

Activity Theory

The social withdrawal that Cumming and Henry recognized (1961), and its notion that older adults need to find replacement roles for those they have lost, is addressed anew in the activity theory. According to the activity theory, activity levels and social involvement are critical to the process of finding replacement roles and keys to happiness (Havighurst, 1961; Havighurst et al., 1968; Neugarten, 1964). According to this theory, the more active and involved an older person is, the happier they will be. Critics of this theory point out that access to social opportunities for activity are not equally available to all. Moreover, not everyone finds fulfillment in the presence of others or participation in community activities. Reformulations of this theory suggest that participation in informal activities, such as hobbies, most affects later life satisfaction (Lemon et al., 1972).

The activity theory is highly adaptable to nursing practice because it considers the whole individual and assumes that engagement and activity improve quality of life. As nurses work to create care plans for older adults in a variety of settings, the activity theory informs specific actions. For example, maintaining physical movement through independent activity of daily living (ADL) or group activities is crucial for patients living in long-term care facilities. For older adults living in the community, nurses can tailor care to include community gatherings, social groups, and fitness activities depending on the individual’s health status. The activity theory inherently focuses on wellness and how individuals can adapt to older age in healthy ways.

Hierarchy of Needs

Abraham Maslow (1943) proposed the hierarchy of needs, a commonly known concept that explains individuals’ wide-ranging physiological and psychological needs throughout their life span. Physiological needs create the foundation for this theory, with other needs developing if physiological needs are met. These needs are often depicted as a pyramid (Figure 41.2).

Figure 41.2 Maslow’s hierarchy of needs remains relevant for older adults as they continue to require basic physiological necessities, seek safety and security, value social connections and belonging, strive for recognition and self-esteem, and pursue personal growth and meaning in their lives, highlighting the enduring importance of these fundamental human needs throughout the aging process. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

At the pyramid’s base are all the physiological needs necessary for survival. Basic requirements for security and safety follow physiological needs. Next, the hierarchy focuses on the need to be loved and have a sense of belonging, and finally, the need to have self-worth and confidence. The top tier of the pyramid is self-actualization, which is a need that essentially equates to achieving one’s full potential, which can only be realized when needs lower on the pyramid have been met. Maslow suggested that self-actualization is an ongoing, lifelong process and that only a small percentage of people achieve self-actualization (Francis & Kritsonis, 2006; Maslow, 1943).

According to Maslow (1943), one must satisfy lower-level needs before addressing those higher in the pyramid. So, for example, if someone is struggling to find enough food to meet their nutritional requirements, it is quite unlikely that they would spend an inordinate amount of time thinking about whether others viewed them as a good person. Instead, their energies would be geared toward finding something to eat. However, it should be pointed out that Maslow’s theory has been criticized for its subjective nature and inability to account for phenomena that occur in the real world (Geller, 1982). Late in life, Maslow proposed a self-transcendence level above self-actualization to represent striving for meaning and purpose beyond the concerns of oneself (Koltko-Rivera, 2006). For example, people sometimes make self-sacrifices to make a political statement or in an attempt to improve the conditions of others. Mohandas K. Gandhi, a world-renowned advocate for independence through nonviolent protest, went on hunger strikes several times to protest a particular situation. People may starve themselves or otherwise put themselves in danger, displaying higher-level motives beyond their own needs.

The vital aspect of Maslow’s hierarchy of needs for nurses is the understanding that older adults may need support in each area of the pyramid throughout the aging process. Table 41.3 lists nursing actions that support the most essential levels of need. Maslow’s hierarchy is not a progressive process but a fluid motion of changing needs. Physiological needs, safety and security, and love and belonging are the most critical and action-based levels where nursing care is administered. However, nurses can also work to maintain self-esteem and the process of self-actualization for each patient. The needs portrayed in the pyramid can develop concurrently. For example, an individual may have a short-term increased physiological need related to an acute illness but still require love, belonging, and safety. Individuals receiving hospice care may require significant nursing care related to physiological needs. However, they may also require from nurses and spiritual leaders significant care focused on self-esteem, security, and belonging at the end of life.

Age Stratification Theory

While we now have an increased awareness of the concept of ageism, the age stratification theory was the first to suggest that members of society might be stratified by age, just as they are stratified by race, class, and gender. Since age serves as a basis of social control, different age groups will have varying access to social resources such as political and economic power. Within societies, behavioral age norms, including norms about roles and appropriate behavior, dictate what members of age cohorts may reasonably do. These norms are specific to each age group, developing from culturally based ideas about how people should “act their age.”

Thanks to amendments to the Age Discrimination in Employment Act (ADEA), which drew attention to how our society is stratified based on age, U.S. workers no longer must retire upon reaching a specified age. As first passed in 1967, the ADEA protected against a broad range of age discrimination and specifically addressed termination of employment due to age, specification of age limits or preferences in advertised positions, and denial of healthcare benefits to those over 65 years old (U.S. Equal Employment Opportunity Commission, n.d.).

Nurses must also know that age stratification rarely explains behaviors and social norms. Factors such as gender, socioeconomic status, geographic location, and other cultural factors may play a role in the stratification of older adults.

Life-Stage Context

The Evolving Role of Grandparenting

According to the American Association of Retired Persons (AARP) (2019), in the last twenty years, the number of adults in the United States who are grandparents has increased from 56 million to over 70 million. The AARP (2019) also suggests that up to 96 percent of adults over age 65 years are grandparents. The grandparenting role varies widely depending on age, culture, proximity to family, and values. Some individuals experience grandparenting in a traditional role of general family support and older adult status. Others have a much more complex grandparent-grandchild relationship. While this is a reciprocal relationship, it is often the choice of the grandparent to determine the extent of interaction and connection they have with their grandchildren. This intergenerational support promotes healthy growth and development for the next generation. AARP (2019) states that up to 10 percent of grandparents live in the same home with their grandchildren.

Due to the broad age range of grandparents, the United States Census Bureau reports that over 3 million grandparents remain in the workforce (Figure 41.3). More than 400,000 of these individuals over 60 years of age are responsible for the care of grandchildren they live with (United States Census Bureau, 2019). In addition, grandparents are core caregivers for many grandchildren while their parents work. Grandparent caregiving may be full time or part time, depending on the family’s needs. Grandparents may step into a caregiving role at different times due to the shortage of caregiver opportunities for young children. In the changing economy, grandparents hold a significant role in early childcare and child-rearing. Regardless of the number of parents in the household, parents now work more hours than throughout history. This requires childcare, and the cost of childcare is steadily increasing. Since early childcare is not a federally required benefit for working families, families are turning to grandparents as a childcare option, particularly those parents with irregular work hours. Because up to 2.7 million children live in a household with grandparents, some of whom work to help raise the children, legislation has been proposed to provide financial and housing assistance (Casey et al., n.d.). One such bill, the Grandfamily Housing Bill, seeks to provide government funds to create stable and affordable housing for families headed by grandparents (Casey et al., n.d.).

Figure 41.3 Over 3 million grandparents are in the labor force. Of those, over 1 million are responsible for most of the basic care of their coresident grandchildren. (credit: “American Community Survey” by United States Census Bureau, Public Domain)

Grandparents as caregivers can be a desirable circumstance for families. A robust intergenerational bond between grandparent and grandchild in healthy family relationships promotes health across these age groups. Strong relationships with grandchildren are also a significant benefit for older adults. This relationship can create rich multigenerational support for older adults. Healthy grandparent-grandchild relationships offer considerable benefits to grandchildren and grandparents, including the following:

• encouraging family values
• providing mentorship
• building self-esteem
• fostering respect
• dispelling fear of aging
• dispelling ideas related to ageism