Understanding Theoretical Underpinnings Related to Ageing for an Enhanced Care of Elderly

The enormous increase in geriatric population overtime has created intense need of planning appropriate care for them to improve their quality of life. Considering geriatric population, nurses and health care professionals (HCPs) usually focus on single aspect of wellbeing but it is necessary to focus on their other dimensions of health as well. In consideration to this, the paper goes on describing the process of ageing through a theoretical perspective. Moreover, the paper attempts to highlight problems faced by geriatric population in general with some evidences of research from Pakistan. Furthermore, the paper suggests relevant solutions to these growing issues highlighting the role of HCPs and especially from the perspective of nursing, as they are the common and direct care givers.


Introduction
Due to outstanding efforts of medical health the rise in the population of older adults has become one of the most dramatic demographic variations in the world. World Health Organization (2013) estimates the world's older adult population would increase to more than 2 billion by year 2050. Considering these statistics, as HCPs it is crucial to understand the phenomenon of aging to provide appropriate and holistic care to geriatric population. Mostly, the health care professionals strive for physical wellbeing when geriatric care is considered. But the psychosocial health holds equal importance in welfare of elderly client. Ageing refers to process of becoming old that [1] seconds Rose (1991) defining aging in the seminal book on the evolution of aging as "a continual decline in the age-specific fitness mechanisms of an individual." During this period of life, along with physical changes they experience drastic social and psychological changes which impact their psychosocial health. To understand these changes, it is essential to have brief idea about social, psychological and biological theories of ageing.

Social Theories
The social theories of ageing include Activity Theory and Continuity Theory. They are two most important and currently acceptable theories that describe the social changes in an elderly's life. The Activity Theory describes that the activeness of elderly person supports health. This means that health of elderly individual can improve by increasing social activeness and participation. The counter point to this thinking was that everybody doesn't enjoy social gatherings. Therefore, the recent studies have shown that more satisfaction lies in practicing the hobbies. However, according to the Continuity Theory elderly people may continue their life positively with inner personality and social relationships. As per an example a woman who was a teacher in her young adulthood continues to teach her grandchildren after retirement. This is healthy when the individual is psychologically healthy to implement their decisions but in diseases like Alzheimer's and Dementia people may require proper and specific rehabilitative intervention to have continuity [2]. [3] in his book of Developmental Theories of the Life Cycle gives the concept following psychological theories of ageing.

Psychological Theories
Erick Erikson's Theory: His theory is of psychosocial development which describes that in this stage of life individual experiences the developmental crisis of ego identity versus despair. He highlights that the state of ego identity is achieved when the individual acknowledges its own life as positive productive journey. Erickson emphasizes that this stage is only achieved when previous developmental stages are positively accomplished. Whereas, despair occurs when the individual is not able to positively resolve the age specific crises.
Peck's Theory: He pointed out that Erickson's way of describing the psychological crises in late adulthood is very superficial and does not offer complete description. So, he came up with further divisions of psychological stages in second half of life. He proposed three stages of old age. In his first stage of Ego Differentiation versus Work-Role Preoccupation he described that as the preoccupied role changes, the variation creates crisis in an individual's life. Like a woman after retirement may find it stressing to stay at home and perform house hold chores in routine without going out. According to Peck, the next stage is of Body Transcendence versus Body Preoccupation. In this elderly people experience physical declines. This decline in physicality leads to the development of bodily aches. He further describes that those individuals who value physical functioning would suffer more through this stage as compared to those who value relations and mental wellbeing. The third stage is of Ego Transcendence versus Ego Preoccupation. It is the last stage of peck's distribution. This stage focuses on the behavior which adults develop to make their future generations understand the concepts of life through their experiences to make them live a better life. For example, an elderly in a family share his success stories to the children and grandchildren in a way to make them learn the realities of life.
Fisher's Theory: In contrary to Erickson and Peck's theories of development Fisher gave the concept of Age Independent Stages of Adulthood. In his theory Fisher proposed 5 post-retirement periods of adulthood. The first stage is of Continuity with Middle Age which describes that some individuals continue their life without stress. Considering it as time to enjoy and relax. On the other hand, some individuals may experience distress due to anticipatory fear of low financial conditions and declining health. For example, some elderly couples plan to fulfill their unmet desires after retirement where as some may look for alternatives to continue earning and improve financial sources. The second stage of his distribution is of Early Transition. According to Fisher, this stage results from major changes such as early death of a spouse, deteriorating health status and need to readjust. Here individual's choices may give his old age a new direction.
They can choose alternatives such as part time jobs or a volunteer work to remain engaged in activities rather than spending time alone. In his third stage of Revised Life Style, Fisher describes that now the individual adapts the choices made by him previously and choses an independent life. He emphasizes that adjustments to the previous transition of life are achieved here. These changes are highly individualized, as for instance one individual may prefer social services where as some may join institutes for fulfillment of personal goals. Fisher's fourth stage is of later Transition results primarily from the health related lose. Here the individuals have to depend on others for taking care of them. This stage is also individualized, for example some individuals may take it positively and prefer joining a senior citizen or nursing home for a better quality of life where as some individuals may lose interest in life due to dependence. Fisher named the fifth stage of his theory as Final Period. According to him here the individual becomes adapted to changes of life such as living without spouse or disability.

Biological Theories
Along with psychological and social aspect consideration of biological view is essential. This is because the physical deteriorations ultimately affect the psychosocial health of an individual. Kunlin Jin (2010) supports the concept of two biological theories which are programed theory and error theory. The Programmed Theory suggests that process of aging, follows a biological timetable which has a particular order and regulation that from birth and to death. These all changes are dependent on gene expression. Whereas, the Damage or Error Theory constitutes the wear and tear theory which says that due to long-term use of body it wears off and loses strength i.e. Ages.

Issues Arising for Geriatric Population
In the light of these developmental theories of ageing it can be determined that elderly people usually suffer through many stress provoking social, psychological and biological changes. The fact of physical deterioration with growing age, fear of being dependent on others, fear of not able to live according to one's own wish and fear of decreased income are some of the problems which provokes the development of stress. In addition, [4] highlighted problems such as sensory impairments, bodily weakening, cognitive impairment; fear of death, decreased social interactions and unfulfilled expectations, potentially affects the psychosocial health of clients.
Furthermore [5], highlights that particularly in Pakistan the biggest problem faced by geriatric population is low socioeconomic status after retirement. A study conducted in Peshawar, Pakistan during 2010 showed that from the sample of 60 individuals the 73% participants were dependent on their pensions which were very nominal and not enough for their needs. Moreover, the second most common problem identified was the decline in memory status and physical condition. In the above mention study out of the total 60 individuals 31.66% and 58.33% of individuals reported their mental and physical status (respectively) to be either weak or too weak. The other listed problems were feeling lonely, problems in decision making, problems with relationships and guilt of dependence.

Nurse and HCPs' Role
To address this issue the collaborative efforts of all health care forces are of high importance. Particularly, Nurses among all HCPs are considered as highly influential body of care in geriatrics [6]. This implies a huge responsibility on nursing professionals to plan proper therapeutic activities for elderly people to provide them with problem specific care. The first and foremost need is to increase physical functioning of the individual because as highlighted above physical deterioration and guilt of dependence are amongst most distressing situations of their life. Therefore, to achieve an optimal level of physical wellbeing and decreasing dependence, the provision of awareness about physical exercise is essential [7]. Along with this, the development of community-based health care programs by community health nurse is necessary to promote independence and maintain compliance to such activities. Beside encouraging sense of physical wellbeing, nurses can promote use of relaxation therapies such as music therapy to promote mental wellbeing and reduce stress. According to [8], music therapy can promote cognitive, motor, social and emotion wellbeing in geriatric population.
The other most common problems include hopelessness, loss of interest in activities and social isolation. Here, psychotherapies such as, Cognitive Behavioral Therapy (CBT) and Reminiscence Therapy (RT) could play a vital role. CBT potentially helps in behavioral modifications and changing perception towards negative consequences of life [9]. Whereas, Reminiscence Therapy (RT), follows a group directed approach during which individuals share their pleasant past experiences and talks about positive feelings associated with them [10]. Although, the role of a nurse in these psychotherapies is not very evident but nurse can emphasize the practice of these therapies and provide emotional support for the patients and monitor their everyday progress during these activities.
Moreover, the fact of bodily weakening with the progression of age cannot be denied. Therefore, the positive role of family in geriatric care is indispensable. Here the role of nurse as an educator arises to provide family with appropriate education about the ageing process, behavioral management and the caregiving trajectory (Stuart, 2009). Likewise, providing knowledge to the client himself is very essential to promote self-care ability and sense of independence in them [11][12][13]. Furthermore, it could be inferred from the above-mentioned concept of activity theory that by planning activities of interest in group and individual settings nurses can promote health of client. Lastly, to reduce financial issues vocational skill development activities should be provided to clients. As prevention is always better than remedy so it's necessary for nurses to educate young and middle-aged clients to prepare them for future consequences. Health policies should be developed to promote bio-psychosocial wellbeing in geriatric population from initial stages to prevent negative outcomes [4]. Nurses on a leadership role can promote and inculcate these dimensions in country level policies. Above all, principle of altruism, positive regard, empathy and support should serve as basic guiding attitude for care of geriatric patients.

Conclusion
Older adults go through massive life changes during their later years. Here the need of planning proper care interventions for geriatric populations arises. So, this is an integral responsibility of all HCPs to work collaboratively to reduce problems faced by geriatric population to make their late life positive, productive and healthy.