And then you die…

And then you die…

We've come to the end. There's nothing left to think about but death. A lot of people assume that a typical place to wait for death is in the dreaded nursing home. Nursing homes have a lot of bad connotations: foul odors, boring food, nothing to do except watch TV. Most people don't want to live or die in a nursing home. Fortunately, most people don't live or die there. In this section we look closely at the odds of ending up in a nursing home. Furthermore, for those who do reside in nursing homes, daily life doesn't have to be so dreadful. After learning in the section on myths about the self that aging is not so depressing after all, it shouldn't be surprising that suicide is not a problem across the board for older people. Men over age 80 are at increased risk, but not women. So our mythbusting is more nuanced in this case. In our discussion of this myth we offer some clues as to why suicide might be more of a problem for older men than for older women, but readers may have some ideas of their own about this. Finally, we take on the fear of death and see who the real scaredy cats are.

Myth #35 A majority of older adults end up in nursing homes and stay there till they die

Nursing homes, often known as skilled nursing facilities, are intended for people who need more care than they can typically get at home or even in an assisted living facility, but less care than they would get in a hospital. Services provided in nursing homes generally include not only room and board, but also nursing care, medication management, personal care (assistance with activities of daily living – ADLs – which include bathing, dressing, eating, toileting, and transferring from bed to chair), and social/recreational activities. Some nursing homes feel a bit like hospitals, whereas others are more homelike, with more personal decoration and less of an institutional feel. For residents with cognitive problems, the environment is more restrictive, and access is controlled so that they won't wander outside.

Average nursing home costs in 2012 were $222 per day for a semi-private room – that's $81,030 annually (MetLife Mature Market Institute, 2012). Medicare will cover nursing home costs for a limited period of time following hospitalization. Medicaid will pay these costs on a longer-term basis but only when individuals can demonstrate that they fall below a certain income level and possess only limited assets. Some people purchase expensive long-term care insurance to protect their nest egg from being depleted by these costs.

Assisted living facilities (ALFs) are for those who need help with some ADLs but not round-the-clock nursing supervision. ALFs often have nurses on staff to manage medications and monitor health. Typically, assisted living communities provide housekeeping, laundry, recreation, two or more meals per day, security, transportation, as well as care and medication management and monitoring. Very often residents need more and more help with ADLs as time goes by, and there may be additional charges for help beyond a certain minimum. Monthly costs in 2012 averaged $3,486 for ALFs that provide a middle range of services (MetLife Mature Market Institute, 2012). Medicare doesn't cover any of these costs, though Medicaid might for certain facilities and for people who qualify through means testing (i.e., fall below a certain income and have few assets).

On the face of it, nursing homes seem like a perfectly reasonable choice for those who need the care. Nevertheless, a lot of people fear living in a nursing home more than they fear death. In one survey (Prince Market Research, 2007), 13% of people aged 65 and older identified moving into a nursing home as their greatest fear – and only 3% said that death was what they feared most. Aging in place (staying at home in one's community) is what 89% of these individuals considered most desirable. What people fear they'll find in a nursing home compared to aging in place is the loss of control over their lives. Recall that in Myth #20, “Older adults prefer to be taken care of – they don't want a lot of responsibilities,” we summarized a classic research study (Langer & Rodin, 1976) in which nursing home residents were found to do much better, physically and emotionally, if they were responsible for the care of a plant compared with those who had a similar plant cared for by someone else. Given that finding, imagine how it would feel to have a disability that requires a degree of support, but perhaps not as much support as a nursing home provides. It's possible that many people in this situation fear that placement in a long-term care facility will require them to accept a level of care that's greater than their level of perceived need – greater than would be required by their perceived level of decline. That fear could be what is most stressful and discouraging (Hill, 2005).

Do the majority of people aged 65 and older live in nursing homes? Absolutely not! In 2011, only 3.6% of people aged 65 and older lived in institutional settings. The percentage increases with age, but it never gets anywhere near a majority. It's 1% for people aged 65 to 74, 3% for people aged 75 to 84, and 11% for people aged 85 and older (U.S. Department of Health and Human Services, Administration on Aging, Administration for Community Living, 2012).

Even though at any given moment only a small percentage of the older adult population resides in a nursing home, patients often spend some time in a nursing home after a hospital stay and a fairly large group of older people die there – although not nearly a majority. The Centers for Disease Control and Prevention (CDC, 2008) reports that in 2005, the following percentages of deaths occurred in nursing homes/long-term care facilities: 13% of people aged 65 to 74, 24% of people aged 75 to 84, and 42% of people aged 85 and older. In a study of 1,817 nursing home residents who died between 1992 and 2006 (Kelly et al., 2010), the median length of stay in the nursing home before death was less than six months. However, the individual differences are pretty large. Shorter nursing home stays at the end of life tend to go along with greater access to paid and informal caregiver support. So being male, being married, and having a higher net worth are associated with increased opportunities for care in a person's home environment. Thus, social and demographic factors play a role in how long people stay in nursing homes at the end of life.

Obviously, not everyone who lands in a nursing home dies there. Some go there following a hospital stay for rehabilitation, but then they return home. A fair number of nursing home residents head to a hospital with an acute problem and die there. In fact, more people die in hospitals than in nursing homes: 43% of those aged 65 to 74, 40% of those aged 75 to 84, and 34% of those aged 85 and older (CDC, 2008).

Most people wish to die at home, and more and more people are able to do so. According to the CDC (2011), in 1989, one-sixth of Americans died at home; by 2007, that figure had gone up to one-quarter. Obviously, place of death is related to the care that's available in that location; in 2007, people under age 65 were more likely to die at home (30%) than those 65 and older (24%). However, these statistics vary by culture: non-Hispanic whites were less likely to die while hospitalized and more likely to die in nursing homes than Hispanic or non-Hispanic black, Native American, or Asian or Pacific Islanders, who were more likely to remain at home until they had a need for acute care in a hospital. In a study of a random sample of Medicare beneficiaries who died in 2000, 2005, and 2009, Teno and colleagues (2013) confirmed the CDC data that more persons aged 65 and older were dying at home as time went by.

That takes care of the population statistics on site of death. However, we still haven't gotten to the question of whether individuals are able to die where they wish to die. Fischer, Min, Cervantes, and Kutner (2013) found a low rate of correspondence between hospital patients' preferred and actual site of death. These researchers recruited patients in three hospitals in the Denver area, asking their preferred site of death and then followed up for five years. At the start, 75% stated that they would like to die at home, 10% in the hospital, and 6% in a nursing home. Of those who died during the follow-up period, only 37% died where they stated they would prefer to die.

With so many living in dread of landing in a nursing home, it's not surprising that new models of skilled care are being developed. One example is the “Eden alternative,” which is a new way of conceptualizing nursing home care as envisioned by the physician-director of a nursing home, Dr. William Thomas (Hill, 2005). He calculated that the medical model wasn't the best model for nursing homes, which are called homes, after all. His Eden alternative homes resemble homes, not hospitals. In these facilities, residents aren't forced to accept a greater level of care than they need. The residents and the staff simulate a family-based relationship that emphasizes connectedness. Residents can volunteer in child-care centers if they're up to it, and thus have opportunities to give as well as receive care, and they can have plants and pets. In general, to the extent they are able, residents have a lifestyle more similar to a home environment than a hospital.

In summary, a majority of older people don't end up in nursing homes for extended periods of time and stay until they die. The odds of dying in a nursing home do increase with age, but they've decreased overall in recent years. The fact is, the majority of older people want to die as members of the larger community and not in a care facility. Nevertheless, as of now, the best hope for people who need a lot of care seems to be in the form of innovative residential facilities that feel more like homes and less like the feared nursing home.

Myth #36 Suicide is more common among adolescents and young adults than it is among older adults

Suicide makes news when it becomes a problem for a particular group, such as returning service persons and gay youth. Suicide among very old men isn't part of our national conversation. Yet, these are actually the folks with the highest suicide rate. According to the CDC, the suicide rate in 2010 in the U.S. was 12.43 per 100,000 persons. The breakdown of this figure by age and sex appears in Table 5.1.

Table 5.1 Suicide injury death rates per 100,000, U.S. 2010

Source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online] (2013, July 3).

Age group	Rate for men	Rate for women
15–19	11.70	3.13
20–24	22.23	4.66
25–29	23.12	5.17
30–34	21.85	5.53
35–39	23.62	7.02
40–44	25.60	7.87
45–49	30.11	8.67
50–54	30.71	9.41
55–59	30.02	8.88
60–64	24.88	7.02
65–69	22.98	5.36
70–74	25.28	4.03
75–79	29.91	4.04
80–84	35.65	3.33
85+	47.33	3.27

A quick glance at Table 5.1 shows that the suicide rate is higher for men than it is for women in all age groups. Moreover, there are gender differences when we look at the rate of suicide from the young to the older years. For women, the suicide rate increases slightly through middle age and then declines somewhat. The suicide trajectory is very different for men, whose rate actually reaches a peak in older adulthood (especially in the 80s). The gender difference grows with age, nearly doubling for men over time, but changing much less for women. For the 85 and older age group, the rate is over 14 times higher for men than it is for women.

What about the ratio of attempted suicides to completed suicides? Researchers have found evidence that older people are more likely than younger people to succeed in their suicide attempts. Moscicki et al. (1988) examined suicide attempts in a sample of nearly 20,000 adults aged 18 and older from five different U.S. cities. Respondents completed face-to-face interviews that included a question about whether they had ever attempted suicide. (Obviously, these attempts had not succeeded.) Moscicki et al. found that the lowest prevalence of attempts occurred in the over 65 age group. Yet the oldest people have the highest actual suicide rate. According to Kastenbaum (2006), suicide attempts are “successful” in 1 out of 25 attempts for younger adults, but 1 out of 4 people aged 65 and older who attempt suicide actually complete the act.

Why are suicidal behaviors more lethal among older adults? Conwell, Duberstein, and Caine (2002) note that older adults have less physical resilience (less likely to recover from a botched attempt), experience greater isolation (less likely to be rescued or to be given emotional support if there are warnings), and perhaps are more determined to die. Also, compared to younger age groups, older people are likely to use more violent, and also more effective, methods for committing suicide. For example, Cohen and Eisdorfer (2011) report that in the general population, 57% of suicides involve firearms, but in the older age group that figure rises to 70%.

Kaplan, Huguet, McFarland, and Mandle (2012) used CDC data from 2003 to 2007 on male suicide decedents aged 65 and older from 16 states. It's reasonable to focus on men – recall from the CDC statistics cited at the beginning of this section that the suicide rate for men is much higher than it is for women. In this data base, nearly 80% of the 4,000 men who committed suicide had used a firearm, and the use of firearms as a means to commit suicide increases with age. Those who did use firearms were mostly white, married, veterans, and residents of southern states. Also, firearms were the means used in 90% of suicides that occurred in rural areas, where the availability of firearms tends to be greater. It's probable that men consider firearms to be a masculine way to deal with adversity; it might not be considered masculine to fail at a suicide attempt, and using a gun does ensure against failure in most cases. According to Kaplan et al., those who used firearms, rather than other methods, were significantly less likely to have been diagnosed and/or treated for mental health problems previously or to have had a prior suicide attempt. However, 67.7% of firearm users had physical health problems.

What are the psychological risk factors for older adult suicide? According to Conwell, Van Orden, and Caine (2011), “establishing causation of a complex, multidetermined, rare and dire outcome such as suicide is a daunting task” (p. 452). Because failed attempts aren't very common among older adults, one has to look back after the death to evaluate what might have been going on in the person's life. This is called a psychological autopsy. Conwell and his colleagues examined all of the well-conducted studies based on this method. After summarizing the risk factors, they conclude that the most prominent antecedent of suicide in older adults is psychiatric illness, most often major depression, which is present in up to 97% of cases. Poor physical health and functional impairments are often present, but this is also true of many older adults who don't commit suicide. Nevertheless, the relative risk for suicide increases with the number of acute and chronic illnesses a person has. It's also important to consider the meaning that an illness has for an individual and the impact of the illness with regard to function, pain, and feelings of personal integrity and autonomy. In addition, stressful events often cluster before suicide attempts, but for older adults these events are usually different than they are for young adults. For young and middle-aged adults, typical stressors are problems with relationships, finances, employment, and the law. By contrast, for older people stressors are more likely to be physical illness and losses. Also, there's a high likelihood that community-living older suicide victims live alone, so it may be that social isolation and loneliness add to their stress.

In a study conducted in Spain, Miret and her colleagues (2010) focused on suicidal intent, which is defined as the seriousness or intensity of the wish to commit suicide. Suicidal intent can be measured by such indicators as planning the suicide, taking precautions against intervention, and lack of communication with others about one's emotional situation. These researchers found that the majority of suicide attempts have low or moderate intent, but high intent is a good predictor of “success.” Just as Conwell and his colleagues found with psychological autopsies, Miret et al. note that people with high intent are likely to be single, divorced, or widowed; to have a psychiatric diagnosis, especially depression; and to have experienced recent stressful events. Not surprisingly, older people have higher intent than younger people.

Researchers at the University of Michigan argue that substance abuse disorder (especially alcohol abuse) is the second most common psychiatric disorder after depression to be associated with suicide in the older age group (Blow, Brockmann, & Barry, 2004). Older people are more sensitive to the effects of alcohol than are younger people because of an age-related decrease in the ratio between lean body mass and fat. Also, liver enzymes that metabolize alcohol become less efficient with age, and central nervous system sensitivity to drugs increases with age. Thus, Blow et al. contend that older people might have a problem after consuming fewer drinks than younger people would. Also, they claim that alcohol use and misuse are more prevalent among the suicidal than the nonsuicidal elderly. Too much drinking may well interact with depression, so older people with depression get even more depressed when they drink. That would mean that alcohol could tip an already depressed person into thinking about suicide.

Another factor that might influence someone with depression to yield to thoughts of suicide is the perception of being a burden to loved ones, regardless of whether or not the loved ones actually do feel burdened. Jahn, Cukrowicz, Linton, and Prabhu (2011) studied perceived burdensomeness in a sample of 106 adults aged 60 to 93 recruited from a community health center in Texas. They found that people who were depressed and who also believed themselves to be a burden to others were more likely to entertain thoughts of suicide than those who were depressed but did not also have the perception of burdensomeness.

In summary, to make a determination about the myth that suicide is not a problem in the older population requires that we consider gender. Older women don't seem to be more at risk than women of other ages. However, older men, especially those aged 80 and older, are at notably higher risk for suicide than are people in any other group. In general, for older adults, the warnings (failed suicide attempts) that would alert family or professionals in the community are often not present, and the methods used to complete the act are particularly lethal. As a society, we should be especially watchful of older people (especially men) who are depressed and alone, who have multiple impairments and multiple stressors, who use alcohol in excess, and who feel that they're a burden to other family members. If they have access to firearms, so much the worse. Finally, although we don't often get warnings from potential older suicide victims, we should take very seriously any that we do get.

Myth #37 Older people have the greatest fear of death of any age group – they are the closest to it, so they should know

Given the sharply escalating rate of death in older groups, it seems reasonable to assume (and most people do) that older adults fear death because there's a good probability they'll face it in the near future. In 2010, the following were the death rates by age per 100,000 people: 206.2 deaths in the 25–34 age group, 339.9 deaths in the 35–44 age group, 815.7 deaths in the 45–54 age group, 1,727.5 deaths in the 55–64 age group, 3,868.5 deaths in the 65–74 age group, 9,869.5 deaths in the 75–84 age group, and 13,934.3 deaths in the 85 and older age group (Murphy, Xu, & Kochanek, 2013). But despite their closeness to death, older people don't fear it as much as one might think.

One way to measure fear of death is to ask people how they feel about the end of life. Karl Pillemer (2011) conducted in-depth interviews with 300 older adults from all walks of life and religious backgrounds. He refers to these individuals as experts because they were nominated by organizations or friends for being particularly wise. To learn about the experts' views on death, Pillemer posed the following question: “When people reach your age, they begin to realize that there are more years behind them than in front of them. What are your feelings about the end of life?” (p. 141). In their responses, Pillemer's experts did not express an overpowering fear of death, nor was there any evidence of denial that death would occur. One 90-year-old expert stated firmly that she wasn't afraid to die and had no worries about it, though she did admit that she had had such fears when she was younger. Another expert, aged 94, considered death to be a natural part of life and expressed no fear about it. Yet another expert, aged 87, stated that her fear of death changed as she aged: earlier, she had felt a great deal of anxiety about the idea of dying, but she no longer thought about it much – her main goal now was to do everything she could do in the time she had left. A 73-year-old expert survived a life-threatening illness in his late 50s but was diagnosed recently with an illness that is usually terminal within a short period of time. He claimed to have no fear and felt that a realistic outlook about the imminence of his death made facing it easier.

In summing up the experts' responses, Pillemer concluded they had little worry about death itself. But even though the experts were not fearful about death, they did emphasize the importance of planning so that those left behind would not be burdened with a load of work. For many, planning involved ensuring that their wills were valid and up to date as well as checking that their finances, personal papers, and possessions were in order. Several experts thought “tidying up” possessions was analogous to tying up the loose ends of their lives, and engaging in such end-of-life activities helped them accept the inevitable. Experts beyond the age of 70 expressed a desire to “seize the day” and thought worrying was a waste of whatever time they might have left. Several experts were determined to visit close friends even if it meant distant travel – some actually informed friends that they were choosing to visit them while they were alive, rather than attending their funerals later on. Even so, some of the experts considered funerals a way to celebrate the deceased person's life, hardly a negative view.

Pillemer's experts' views on death are echoed in a study conducted in England. Field (2000) interviewed 28 men and 26 women between the ages of 65 and 80 to determine the validity of the widespread belief that older adults fear death. Of the total sample, only one woman expressed clear fearfulness about death. Eighteen of the 28 men reported that they were not fearful, and an additional seven reported they were no longer fearful (but maybe had been at an earlier time). Of the 26 women, 13 reported they were not fearful and an additional seven were no longer fearful. If anything, rather than fear of death itself, these individuals were more concerned about process of dying, including the possibility of an extended period of pain prior to death. Some were concerned about the effect their death might have on a spouse and therefore hoped they would not die first, leaving a spouse or other family members alone.

Older people tend to be concerned about the place of death and the type of death they will experience more than they are about the fact of death. Lloyd-Williams, Kennedy, Sixsmith, and Sixsmith (2007) interviewed 40 men and women ranging in age from 80 to 89, all of whom lived alone in the community. These individuals were a subsample from a larger study conducted in the U.K. and were selected to be diverse in terms of gender and health but also cognitively able to respond to open-ended questions regarding end-of-life issues. The majority of these individuals felt they had been graced with long lives, and they acknowledged that death was inevitable. They didn't want to become a burden to others should they be afflicted with a long and debilitating illness, and they wanted to have some control over when their lives would end. Some had already made funeral plans and arrangements in order to spare their relatives from any responsibility after their death. Research participants aged 80 and older in the U.S. expressed similar views – their main worry wasn't death but rather how and when death would occur and whether the dying process would be a burden to family members (Gold, 2011).

Overall, then, older adults as a group don't fear death itself. But are there individual differences in this regard? Fry (2003) conducted a survey of 167 women and 121 men from one of three similar mid-sized cities in Alberta, CA. These were predominantly European American individuals ranging in age from 65 to 87. Approximately 164 lived independently in the community, and the rest lived in semi-supervised assisted living settings. Fry found that self-efficacy ratings were significant predictors of fear of death and dying – compared with people with low feelings of self-efficacy, those with high feelings of self-efficacy reported less fear. (Self-efficacy is the belief in one's ability to succeed in a given domain, for example academics or relationships.) Interestingly, the researchers found gender differences in self-efficacy associated with fear of death and dying. For women, strong feelings of self-efficacy in the interpersonal and emotional domains were associated with lower fear of death and dying. Specifically, women who felt they could manage relationships with family, friends, and acquaintances (interpersonal self-efficacy) and felt confident they could remain emotionally balanced during periods of stress (emotional self-efficacy) expressed less fear of death and dying. For men, strong feelings of self-efficacy in the instrumental, organizational, and physical domains were associated with lower fear of death and dying. Specifically, men who felt they could manage instrumental daily needs such as using the phone and arranging transportation, who felt capable of organizing their business and financial affairs, and who had strong convictions about their physical health expressed less fear of death and dying. For men, but more so for women, self-efficacy in the domain of spiritual health – that is, the ability to generate spiritually based faith and inner strength – was associated with lower fear of death and dying.

In addition to feelings of self-efficacy, what other variables could have a bearing on whether, and to what degree, older adults fear death? Several researchers have investigated the role of religious belief, level of education, ethnic background, and type and extent of social support with regard to fear of death (see e.g. Fortner, Neimeyer, & Rybarczyk, 2000; Neimeyer & Fortner, 2006; Wink & Scott, 2005). As yet, there are no definitive answers as to exactly what factors or combination thereof may buffer individuals against the fear of death, but clearly not all older adults are the same.

Cicirelli (2002) interviewed European American and African American adults over the age of 60 and found no differences in their fear of death. Nevertheless, older adults with more physical problems and those living in institutional settings such as nursing homes expressed higher anxiety about death compared with those in who were in better health and living in the community. Perhaps older adults who are dependent upon others feel less in control of their environment and therefore experience more anxiety about death.

Again, despite individual differences, older adults as a group don't express a strong fear of death. But how do they compare with other age groups in this regard? Young adults find it difficult to imagine there might not be a long future stretching out in front of them (Thorson & Powell, 2000). The low rate of death for this age group certainly bodes well for a lengthy future, so it stands to reason they don't think about, much less fear, death. In contrast, middle-aged adults express greater fear of death not only compared to younger adults, but also compared to older adults (Fortner et al., 2000; Kastenbaum, 1999). Why might this be the case when the rate of death is so much higher for older adults than it is for middle-aged adults? First, middle-aged adults have greater caretaking responsibilities than older adults do. They may still have dependent children and many are providing help to the older generation. Middle-aged adults may well be anxious about leaving family members to function on their own. Older adults usually have fewer caregiving responsibilities – their children are probably well along into adulthood and hopefully have fashioned independent lives and are able to fend for themselves. Also, older adults are less likely than middle-aged adults to be assisting with elderly parents – after all, they are now elderly themselves! So any fear of death stemming from concern about leaving behind those who depend on them is justifiably allayed in the older adult age group, whereas such concern is likely at its peak in the middle-aged group. Second, older adults have had more time than middle-aged adults to carry out whatever they planned to do in their lives. Their lesser fear of death may stem from awareness that the future does not hold as many possibilities as it did earlier in their lives. Finally, older adults may express less anxiety about death because they have experienced the death of friends and loved ones with increasing frequency with the passing of time. In some sense, they are socialized to the possibility of death. It is not uncommon for older adults to read the obituaries in local newspapers on a daily basis.

In sum, although older adults are closer to death than any other age group, they don't express much fear of death itself. There are individual differences of course, but in general, their concern lies more with the circumstances of dying – they wish to have some control over the dying process and to die with dignity.