|Year : 2014 | Volume
| Issue : 1 | Page : 32-37
Perception of old age and self: A comparative study of elderly females living in community and in old age home
Shipra Singh, Nitin B Raut, Alka A Subramanyam, Ravindra Kamath, Charles Pinto, Sunitha Shanker
Department of Psychiatry, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra, India
|Date of Web Publication||29-Sep-2014|
Department of Psychiatry, Topiwala National Medical College and BYL Nair Charitable Hospital, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Aims and Objectives: To study and compare the perception of old age and self in elderly women living in community and in old age homes.
Materials and Methods: By using a cross sectional study design 60 elderly females (30 each from community and old age homes) were assessed using a semi-structured proforma and an interview questionnaire. Data was qualitatively analysed and frequency computation was done.
Results: The elderly women living in community had more of an attitude of 'acceptance' towards old age and 'generativity' was a part of ageing for them. They were found to be more satisfied with life and had better emotional support, whereas elderly in old age home perceived better instrumental support.
Conclusion: Both community living and living in an old age home, have certain positive aspects. From a perspective of future policies and outreach services, it would be interesting to note the same and use best of both the worlds to provide the best for the elder in either setting.
Keywords: Elderly, old age homes, perception of old age, women
|How to cite this article:|
Singh S, Raut NB, Subramanyam AA, Kamath R, Pinto C, Shanker S. Perception of old age and self: A comparative study of elderly females living in community and in old age home
. J Geriatr Ment Health 2014;1:32-7
|How to cite this URL:|
Singh S, Raut NB, Subramanyam AA, Kamath R, Pinto C, Shanker S. Perception of old age and self: A comparative study of elderly females living in community and in old age home
. J Geriatr Ment Health [serial online] 2014 [cited 2019 Nov 15];1:32-7. Available from: http://www.jgmh.org/text.asp?2014/1/1/32/141923
| Introduction|| |
"All my life I've been taught how to die, but no one ever taught me how to grow old"
Ageing is a universal and inevitable phenomenon of life. It refers to a multidimensional process of physical, psychological and social changes. While some dimensions grow and expand over time, others decline. "Old age" refers to a phase of human life known for reduced physical ability, declining mental ability, the gradual giving up of role playing in socio-economic activities, and a shift to a status of economic dependence. Old age is called "dark" not because the light fails to shine but because people refuse to see it. 
According to Erikson, the balance between the contrary dispositions of integrity and despair to achieve wisdom is the task of old age, which also demands disinvolvement with life.  According to him, some of the conflicts between identity and role confusion, first addressed in adolescence, appear again in old age. Kaufman  says that for the old, the source of meaning in their lives is created by comparing their own life experience with cultural expectations, or with possible selves that might have been. She claims that, through the integration of these various realities, old people are able to create an identity for the present, and find a path for whatever remains in the future. Atchley  suggests that the "remembered" self may be re-interpreted by the old individual as one looks back, in order to maintain an "acceptable" self. They judge themselves by comparing themselves with others or with their own construction of their past selves. The term 'ageism' is now often used in this context. It refers to a socially constructed way of thinking about older persons based on negative attitudes and stereotypes about aging and a tendency to structure society based on an assumption that everyone is young, thereby failing to respond appropriately to the real needs of older persons. It is often a cause for individual acts of age discrimination such as in the design and implementation of services, programs and facilities. 
There has been a progressive increase in both the number and proportion of the aged in the world and also in India over time, particularly after 1951. The proportion of population over age 60 years has increased to 7.0% by 2001.  India has thus acquired the label of "an ageing nation" with 7.7% of its population being more than 60 years old. The longer life expectancy and their higher number per 1000 males is showing increase in population of elderly females.  With an increase in the geriatric population and an expected decline in the population of the middle aged, the burden of caregiving is bound to increase and lead to some unforeseen problems, one of them being institutionalization of elderly.
Although Indian society had the traditional informal support systems such as joint family, kin and community but due to modernization and globalization, the capacity of the this support system is slowly weakening and is not in a position to fulfil even the basic needs of the elderly.  The traditional sense of duty and obligation of the younger generation towards their older generation is being eroded - and has led to rapid increase in their institutionalization. 
Presently, there are 1018 geriatric homes in India today.  Out of these, 427 homes are free of cost while 153 geriatric homes are on pay and stay basis, 146 homes have both free as well as pay and stay facilities and detailed information is not available for 292 homes. A total of 371 geriatric homes all over the country are available for the sick and 118 homes are exclusively for women. 
As far as women are concerned, the situation is even worse. Traditionally, a woman, in Indian society, identifies herself with her husband. In fact, dependency, economic as well as social, on father, husband and subsequently on son, low level of education and access to health care, make an elderly female much more vulnerable than her male counterpart. "If men, who were once active in the labour force and had made substantial tangible contribution, are considered as 'burden', then how will women, who always had been invisible contributors, be treated when they are no longer useful?"  To go from living at home, where the daily minutiae of life are under one's own control, to living in a very large building with a hundred or so people whom one has not chosen is really difficult.
The usual thinking is that old age is the negative and final segment of human life and living in an institution would be even worse but awareness and acceptance of the fact that ageing has physiological, psychological and social determinants would make the ageing process acceptable, cheerful perhaps even desirable by making living meaningful. According to the activity theory that explains the relationship between social engagement and psychological well-being, the social role participation is important to achieve positive adjustment in old age. 
Recently, there has been increasing interest in the quality of care in nursing homes and the perception and feelings of the residents. Parfitt  found that elderly people had changed in some way since admission to the old age homes, perceptions of diminished self confidence being the most prominent change. Loss of autonomy has the most impinging impact on the identity of the old person, as it means loss of freedom - an important element of human dignity. However, Slettebo  found that all the informants emphasized the importance of feeling safe and respected. The experience, however, is linked to a feeling of loneliness in most of the case. Prabhavati  found that the elders in old age homes were quite happy as far as the basic necessities were concerned. Institutional care settings for older people are not totally barren domains of solitude and emptiness, as are considered to be. Whilst residents may not always be engaged, they do communicate and they do interact. Their social interactions reveal the older person making sense of the presence of others, interpreting behaviours, and showing an awareness of 'self'. 
"What is it like for an elderly to be a resident in an old age home or for that matter to live with her family?" What are their day to day experiences? What is the extent of support they are receiving? What is the impact on their well-being, self-esteem and moreover, their own self and overall existence?
To find the answer to all these questions, this study was planned in a qualitative fashion, to make the elderly females residing in community and those in old age homes, express their views and experiences in their own words, so as to have a better understanding of their well-being, the motive being able to develop a comprehensive model of elderly care. As Paul Thompson  writes: "Even at the most practical simple level, those concerns and aspects of their lives which are not highly valued by external observers may well be among the most significant".
This study was done with the aim of studying the perception of old age and self in elderly females residing in community and in old age homes, and to compare the two.
| Materials and methods|| |
This was a cross sectional study carried out in the Psychiatry OPD of a tertiary care teaching municipal institute and at 3 different old age homes in Mumbai, after obtaining Institutional Ethics Committee approval and permission from the concerned authorities. A total of 60 elderly females with age of 60 years or more were included in study, 30 from the community (the non affected elderly female relatives of the patients attending the psychiatric OPD) and 30 from the old age homes. Those in old age homes should have stayed there for minimum duration of 6 months. Those having any other present or past psychiatric illness, having uncontrolled medical or surgical disease and not willing to give consent for the study were excluded from the study. A written informed consent was taken from the participants before commencing the study. Interview was conducted by a single interviewer based the semi-structured proforma concerned with the demographic details and the semi-structured questionnaire.
The questionnaire included 9 questions for the elderly women living in old age homes and 8 for those living in community, which are shown in [Table 1].
The responses received for each question were studied 3 different times by 3 different assessors (2 psychiatrists and 1 psychologist) and the themes emerging from these were sorted out. In the next reading, certain broad categories were identified for the previously identified common themes and a more abstract meaning was searched for. Then, frequency computation and descriptive analysis of the data was carried out.
| Result|| |
The demographic details of the sample studied are shown in [Table 2].
For assessing the perception of old age in the two study groups, the responses were grouped under 7 evolving themes. First was Inevitability (i.e. the quality or state of being impossible to avoid or evade the situation (given a chance, the person would like to revert or avoid this stage); then Acceptance (i.e. a person's assent to the reality of a situation, recognizing a process or condition [often a negative or uncomfortable situation] without attempting to change it, protest, or exit); third was Part of life where old age is considered a part of life, similar to the other stages of life and then is the highest stage of Generativity (concept of Erik Erikson), a concern for people besides self and family that usually contribute to the next generation. On the other side, 3 themes were found - Dependence (which refers to the state of relying on or needing someone or something for aid, support, or the like); Loneliness (Loneliness is an unpleasant feeling in which a person feels a strong sense of emptiness, yearning, distress and solitude resulting from inadequate quantity or quality of social relationships), and Worthlessness (a component of low self-esteem, characterized by feelings of uselessness and inability to contribute meaningfully to the well-being of others or to one's environment). The frequency of various themes in both the study groups is shown in [Table 3].
It was found that 'acceptance' for the old age and the phenomena of 'generativity' is seen more in females living in community, that is 53.3 and 26.7% against 30 and 16.7% in those of old age homes, respectively. The other virtues did not show much difference between the two groups. In response to satisfaction with their past lives, it was found that 63.3% females of old age home were satisfied as against 83.3% females living in community. Among the old age home residents, 36.7% females had willingly come to old age homes, while 63.3% had to come against their wish. There was no significant difference in the way the elderly females perceive about their living situation in the two groups. More than half (53.3%) of the females in the community and 50% in old age homes said that they enjoy their current living situation whereas 26.7% and 26.6% just accepted it, in the two groups respectively. Rest of them reported themselves to be unhappy.
On assessing their current experiences with colleagues or family members, it was found that the elderly living in community had more of social interaction (63.3%) than those in old age homes (46.7%) and also found it to be more satisfactory i.e. they had fairly good relation among them, sharing their joys and sorrows, and also their views on various aspects of day to day life, and helping out each other, as against those in old age homes where it was interactive (having communication among themselves but not emotionally bonded) in 30% or mere acceptance (not satisfied, identifying the problem either within oneself or among others, had minimal social engagement, however accepting the situation) in 23.3% females. Interpersonal problems were found to be more in community setting i.e., 46.7% as against 20% in old age homes. Regarding the support perceived by the elderly women, it was found that instrumental support and emotional support in old age home residents was 66.7% and 26.7% whereas in community setting, it was 20% and 80% respectively. Financial support was nearly equal in the two groups [Table 4].
Considering the routine and leisure activities done by elderly females of the two groups, it was evident that in the community, majority (56.7%) spent their time doing household works or talking to family members or others (46.7%). In the old age homes, they spent time in religious gatherings (70%), reading books (40%) and doing daily exercises (33.3%). Some used to watch television, meditate and serve others, who required help. To feel connected to God, worship was done by 86.7% of women in old age homes and 90% in community. One-fifth (20%) women in community and 10% in old age homes found serving others as a means to do so, and the rest had no faith in God. The data suggested that feeling closeness with God gave peace of mind in 83.3% women in community and 76.7% in old age homes. However, 43.3% of old age home residents found it a means to alleviate stress, as against 36.7% women in community. Few of them also reported receiving joy and strength.
In relation to the understanding of human existence, 63.3% of community and 46.7% of old age home residents said that it is basically to perform ones duties well and to take care of one's family; 46.7% of community and 50% of old age home residents found service to be the essence of human existence. A similar proportion in both groups (13.3%) were of the view that they were living just for the sake of living, as they have no other choice, referred here as relinquished. Remaining ones found spirituality to be the ultimate meaning of life.
| Discussion|| |
Our analysis revealed that perceptions of old age followed two broad themes, which we classified as a trend towards 'fatalism' and 'role loss'. Fatalism here refers to the philosophical doctrine that all events are predetermined so that man is powerless to alter his destiny, thereby accepts and submits to this doctrine and lacks actions and efforts to change it, which appears similar to the stages of death/loss, given by Elizabeth Kubler Ross.  On the other hand, is the role loss - as people age; they start losing roles as active parents, employees, and spouses, which leads to feelings of loss of control over life and impaired social contact. The resulting state of dependence and loneliness further leads to worthlessness in older individual. According to Dubey et al., elderly woman living in families had positive attitude towards old age, but simultaneously felt it to be a period of dependency. 
Satisfaction with the past life was seen more in females living in community which can be attributed to the social interaction, expressions of feelings and support from the family. Most of the females in old age homes were staying there unwillingly as majority of them were single or widowed having no one to take care of, who were forced because of various reasons and those facing social compulsions as that of having to live with their daughters, which is not fairly acceptable in Indian society. According to a study done by Sandhu et al. 
in an old age home, only 17% of the people living there were due to their own wish to lead a peaceful and independent life, others due to one or the other compulsions.  Kalavar et al.  cited that most common reasons are childlessness (30%), intergenerational strife (28%) that maximally included inability to get along with daughter-in-law, and inability to live independently after bereavement (12%).
Elderly women had nearly similar perception about their living situation in the two groups which suggests that apart from the effect of surrounding, the external environment, there are some intrinsic factors within oneself like, realization of one's strengths, resilience, gathering support from memories, being close to others and helping and supporting others, that are responsible for how one reacts and adapts to a particular stimulus. Nygren in her study on elderly females found that successful ageing requires inner strength as described in her book Life goes on-living it all, means that this strength makes it possible to live and to be open for everything that life has in store.  Others have also reported similar observations. 
Social interaction in old age homes was found to depend mostly on its structure. One of the three had a relatively fixed routine; residents were made to engage in group activities and were taken for frequent outings. As it was situated in the core of the city, the residents themselves could go out to get their commodities of daily use. However, the second was at the outskirts of the city and had many ill residents. The apparent fit ones mostly engaged themselves in taking care of those who were not well, and because of its location, they were not allowed to go out alone. This might have been the reason for obtaining the results of comparatively lesser social interaction in old age homes.
Interpersonal problems were found to be more in community setting, probably due to the change in the role when the elderly lady of the house hands over the responsibilities to the daughter-in-law, however complete end of the dominance may not be an immediate consequence. Further, since more and more females are joining the work force, there is little time left to take care of elderly at home.
As a contrast, in the old age homes, each one has equal rights and opportunities for everything. Hubbard et al in a similar study found that institutional care setting for older people is not totally an arena of seclusion and emptiness. They also interact and communicate, showing an awareness of self and engaging in meaningful interaction and activities is associated with better morale and life satisfaction. 
Institutional settings are better off in providing instrumental assistance in daily living compared to those at homes, as they are constructed with such a view-point. Due to rising education level and globalization, children are moving to far-off places for job opportunities leaving their old parents behind, and even if they are staying with them, they don't have sufficient time to take care of them in routine activities, as was evidenced by Rawat et al.  However, children or the other associated family members are taking care of the financial needs of their elderly in old age homes as well as in family. Dubey et al.,  in their study reported financial crisis in elderly living in either settings. Institutionalized elderly women felt even more helpless because they had no money to meet their material needs. Emotional support in our study was found to be considerably higher in the community settings due to family support and social interaction, which is similar to what was described by Dubey et al. 
In the community, most of the females were engaged in household chores or interacting with family members whereas in old age homes, they had mostly a predetermined routine of everything, whether it be religious gatherings, reading books, exercises (yoga) or serving their ill friends. Involvement in activities seems to have a positive impact on their thinking and well-being, as has been found by Menac et al.  that social and productive activities gives physical benefits, as seen in their better functioning and greater longevity, whereas activities, such as reading, may have more psychological benefits by providing a sense of engagement with life.
Similar to involvement in physical activity, being spiritual, having a sense of responsibility towards mankind and feeling closeness with God has a positive impact on the psychological well-being, and was considered the essence of human existence by the elderly women. Various researchers have concluded that religious beliefs and practices, and being spiritual have a positive impact on overall well-being. ,,,
| Conclusion|| |
A longitudinal study would have yielded better results. However, we can conclude that the community residents had more acceptance towards old age and were quiet satisfied with their lives as compared to those in old age homes. Also, they were socially interactive and perceived more emotional support; although instrumental care was better provided in institutional settings.
The whole idea is to merge the acceptable points of the two living arrangements so as to have a more comprehensive model for elder care, wherein they can lead a dignified and a meaningful life.
| Acknowledgement|| |
We would like to acknowledge Mr. Shailesh Mishra from Silver Innings Foundation, an NGO working with senior citizens and its networking partners, for his valuable support, and also the management of those old age homes, without the co-operation of which the study would not have been possible.
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[Table 1], [Table 2], [Table 3], [Table 4]