Daniel S. Gardner, PhD, LCSW
New York University
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Alleviating suffering and enhancing quality of
life
Monitoring and managing chronic physical
and mental health conditions, and geriatric
syndromes
Enhancing functional abilities and reducing
frailty (e.g., falls prevention)
Supporting continued autonomy and control
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Multiple losses and transitions
Awareness of passage of time and time left
Facing death and dying
◦ Elders think and talk more about death
◦ Less likely to verbalize fear of dying
◦ Pain and physical discomfort, loss of control,
existential concerns (e.g., the afterlife)
Search for meaning (i.e., spirituality,
transcendence, and “legitimatization of
biography”)
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Interpersonal transitions
◦ Socio-emotional selectivity (Carstensen, )
◦ Dependence on family and friends
◦ Widowhood
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Social construction of aging
◦ Culture values individualism and autonomy, agency
and productivity, youth and beauty
◦ Aging and illness equated with physical “decline”,
dependence, loss of personhood and control
◦ Profound negative impact on elder’s social value
and self-worth
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A major public health issue
◦ Can decrease quality of life and increase decline
◦ Associated with physical, psychological, social and
functional impairment
◦ Increases healthcare utilizations and costs
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Nearly 5 million (15%)* of the 34 million
Americans over 65 suffer from recurring
depressive episodes
Significantly higher among chronically and
progressively ill and frail elders (10-43%)
Depression is not a normal response to aging
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Biomedical risk factors:
◦ Chronic physical illness and pain
◦ Neurological or cognitive deficits
◦ Poor nutrition
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Psychological and social risk factors:
◦ Multiple losses (e.g. loss of loved ones, loss of social
roles, and autonomy)
◦ Adverse life events (e.g. bereavement, retirement, serious
or life-threatening illness)
◦ Social isolation and lack of social support
◦ History of depression or substance abuse
◦ Lack of socioeconomic resources and poverty, societal
oppression and discrimination
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Goal: Early identification and prevention through
intervention
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Often most catastrophic and stressful event in life
Loss of shared past and future, companionship;
social role and connection to social network, sexual
partner, economic security (i.e. for women), and
social status
Short-term impact on physical & mental health:
◦ Health status and perceived health decrease
◦ Mortality and suicide rates increase
◦ Higher rates of anxiety, depression, disorientation,
memory problems, substance abuse
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Development of new roles and identities
Variations due to gender, race/ethnicity, quality of
relationship, social supports, & economic resources
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Increasing burden of care on families
Aging caregivers, competing demands
Negative impact on caregiver’s physical and
emotional well-being
Family decision making:
◦ Advanced care planning
◦ Treatment decisions
◦ Long Term Care and care transitions
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Family conflict, congruence and substituted
judgment
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Changing context of end of life
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Death as the province of old age
Medicalization of illness and dying
Biomedical/technological advances
Ambiguity in the dying process
Health care system barriers
◦ Fragmentation and lack of coordination, shift to
home-based care, rising financial burdens
◦ Shortage of geriatric and palliative care specialists
and skilled providers
◦ Ageist attitudes and beliefs
◦ Valuing curative over palliative care
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Importance of skilled geriatric assessment and
familiarity with geriatric interventions
Interdisciplinary care across continuum of care
Care coordination across settings and
transitions
Use of evidence-based practices and narrative
methods to aid in search for meaning
Increased training and education of next
generation of healthcare professionals in
geriatric and palliative care
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Integrate palliative care in all geriatric care
policies and guidelines
Increase Medicare and Medicaid financing of
community home-based services, mental
health care, hospice and palliative care svces
Develop and pilot demonstration projects
that integrate palliative care with healthcare
of older adults; Fund existing models (e.g.,
PACE) that have been shown to be successful
Fund provider support around advance care
planning
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Identify gaps in research on needs of older
adults and their families at end of life
Increase research into patient unmet needs
and preferences, aging family caregivers,
impact of present policies and programs
Develop and test evidence-based
interventions for elders and family caregivers
around family communication and decision
making, advance care planning, and coping
with depression, dementia, and other
disorders