Introduction and Overview

This chapter is a clinically-oriented discussion of the emotionally colored meanings that aging and declining physical status exert as life stressors in advancing years. Traditional Western and alternative Eastern medical perspectives, notably Ayurveda, are reviewed.

Older age brings numerous successes, healthy achievements, and pragmatic perspectives that enrich a meaningful life. Medical problems, however, challenge this. The aging spine, for example, typically becomes less agile; flexibility and the range of movements previously achieved with ease diminish. Pain and fatigue ensue. Activities of daily living become arduous. People notice these physical limitations in subtle and often disconcerting ways. The subliminal impact of age and physical changes is often insidious, and eventually adds to the burden that real physical limitations impose. As aging progresses and the recognition of progressive restrictions increases, quality-of-life challenges require action.

Aging is an inescapable process of metabolic and functional alterations, all of which have their sequelae. Resilience is more fragile; people take fewer risks and intentionally minimize change. Although everyone can expect the inevitable cast of aging, there is much variability in its effects. Genetic, environmental, traumatic, and lifestyle factors contribute to how health and disease interact. The way a person chooses to live can often influence genetic predispositions and ordinary wear and tear. Achieving and maintaining optimal health includes freedom from pain and its perception as suffering. Impairments in biopsychosocial functioning, especially related to musculoskeletal events, however, become a common challenge. A working knowledge of aging has pragmatic value. Screening for emerging disabilities affords the physician a valuable clinical perspective. When indicated, patients can be referred to specialists who conduct formal assessments of physical and mental function.

Wellness and healthy functioning are noticeably disturbed when decompensations in formerly healthy equilibriums occur. At this point, a physician may make a formal diagnosis. Disease and diagnosis, as such, do not denote “disability.” These say little about their functional impact. Signs and symptoms do reflect that some “impairment” has occurred.¹ Measuring diminished functioning adds to quantifying decompensations from previous baselines. A brief discussion of these concepts follows.

For these reasons, good clinical care requires that perceived impairments be carefully assessed using standardized protocols performed by specialists. Imaging studies are also invaluable. Evaluations must be correlated with the performance of a specific task or the overall performance of a complex range of defined tasks, particularly when a demand for action is required. “Tasks” are complex physical or mental actions having an intended result, for example, reading a book or riding a bicycle. Complex tasks, for example, are those encountered in occupational performance or “work.” These require the participation and coordination of multiple mental and physical systems. Other examples include time spent working at a computer, ability to lift items of a specific weight, walking, taking a shower, or driving a car. “Limitations” in these functions are ordinarily a reflection of an inability to intentionally accomplish these acts. These “impairments” denote derangements in the structure or function of organs or body parts and, to some extent, can be objectively measured. If, however, less defined syndromic symptoms are in excess of hard data measurements, estimated functional capacity can be ascertained by using clinical findings that have multidimensional consistency relative to typical reference populations. When a physician recommends that one or more behavioral tasks be curtailed because of “direct threat,” namely, risk of injury or harm to self or others, a provider “restriction” has been imposed.

After a range of therapeutic interventions and rehabilitative efforts has occurred, a functional capacity test of physical abilities measures the patient’s enduring impairments in ability to perform a defined task or tasks. Limitations in ability are called the “residual functional incapacity”; conversely, defined tasks that a patient is able to perform constitute the “residual functional capacity.” Capacity here denotes real-time ability to perform a task successfully. This is an individual’s current ability to work based on his or her capacity not only to tolerate symptoms but also to anticipate rewards and success.

The concept of “disability” is complex. It denotes an inability to perform or substantial limitations in major life activity spheres: personal, social, and occupational. Disabilities are due to limitations, especially impairments caused by medical and psychiatric conditions (including subjective pain reports) at the level of the whole person, not merely isolated parts or functions. From a functional perspective, “occupational disability” denotes current capacity insufficient to perform one or more material and substantial occupational duties currently demanded and accomplished previously. Last, the term “handicap” denotes an inability measured largely by the socially observable limitations it imposes. Handicap connotes the perception or assumption by an outside observer that the subject or patient suffers from a functional limitation or restriction. The term “handicap” implies that freedom to function in a social context has been lost. In this sense, people with handicaps can benefit from added supports. “Accommodations” that modify or reduce functional demands or barriers are given to them. Opportunities in social contexts, therefore, afford expanded freedom for more activities. In this way, participation restrictions diminish. Intolerance to pain and fatigue are the most frequent reasons patients stop working and claim disability.

Striving for and maintaining a good quality of life or better is a fundamental value for everyone. This encompasses not only developing new strengths both mentally and physically, but also preserving current assets. Efforts in this direction prevent functional limitations and ameliorate disabilities. These include, for example, maintaining upright and stable posture, agile ambulation, and freedom from the limitations and burdens that pain imposes. Routine medical care and available specialized care afford opportunities to benefit from the advances that rational scientific medicine has to offer. The progressive globalization of diverse cultures, moreover, has introduced Eastern systems of wellness and healthcare not previously recognized or even available in the West. One of the inestimable benefits of this expanding diversification is the widening scope of health-enhancing treatment options. The cultural diversity and traditions of both physicians and patients make it wise for the contemporary healthcare provider to be cognizant of medical systems other than those typically regarded as conventional in Western terms. The prudent physician must always distinguish what is merely wishful thinking from what is yet unproven but within the context of realistic discovery and future confirmation.

Among these, Ayurveda – Traditional Indian Medicine – will be introduced both theoretically and as a range of interventions dealing with the management of aging and orthopedic problems. Ayurveda is a novel treatment option or adjunct among more traditional Western modalities. Given such choices, each person has opportunities to choose proactively, while realistically assessing his or her own specific needs and preferences in selecting healthcare. Different approaches may complement one another or be used integratively. In an available framework of rational and diverse treatment options, choices grounded in scientific evidence and trusted traditions may serve as a basis for good, well-rounded clinical care.^2,3

Understanding the Patient’s Perspective

Adequately understanding how patients perceive their distress, and the problems involved in seeking help and choosing helpers, is fundamental to good care. The extent to which a provider appreciates and utilizes this understanding substantially contributes to patient compliance and better outcomes.

When a patient finally recognizes that signs and symptoms, especially pain, fatigue, and diminished functioning, are not transitory and may be progressively worsening, mixtures of distress, ambivalence, curiosity, and denial interact. Anxiety further blurs clear thinking and discrimination. For older patients, conscious fears about more permanent loss of functioning and subtle fears about reduced life span, even death, are present. Anxiety, fear, and inhibitions go hand-in-hand.

Older patients are acutely aware of changes in physical and psychological functioning. Identifying and adequately adapting to these degenerative changes is difficult, since even acclimating to the inevitable, ordinary changes met with in daily life can be trying. Patients often dread the efforts required to undergo a variety of tests, some of which are arduous and time-consuming, and others that are, in fact, painful (for example, discogram). A patient’s insurance may not adequately cover some diagnostic procedures, or even some recommended surgery. This can present not only a financial burden but also an important psychological stressor to older patients whose incomes and earning capacities are limited.

Often, patients talk with family members and friends before deciding to consult a physician. Although many patients are now more knowledgeable about medical illnesses and treatments than in the past, especially because of media exposure and availability of internet data, the personal nature of the problem and its attendant emotional conflicts continue to exert significant cognitive dissonance and avoidance. It is not uncommon for patients to become clinically depressed secondary to the stress and diminished functioning resulting from orthopedic problems. Developing a stooped posture or various degrees of kyphosis, for example, affects one’s physical appearance and adds to lowered self-esteem and withdrawal. Many become progressively isolated and remain homebound. In previous generations, the phrase “shut-in” described such confinement.

These considerations highlight the importance of the initial diagnostic process for the physician. Surgeons need to consider possible referral for further psychiatric assessment and treatment of anxiety and depression. The art and science of medicine, interviewing, and the physician-patient relationship intersect here. In contrast to problems in older patients, an often overlooked issue is the presentation of pain with or without orthopedic injury in the young adult. Behaviors with a high risk for orthopedic injury, such as motorcycle and race car driving, are more common in this population. Previous histories of substance abuse, even current malingering, must be high on one’s clinical index of suspicion to help avoid wrong and puzzling diagnoses, and treatments that appear to fail or seem resistant.

Explicit and subtle factors contribute to a good interview. Attentiveness, composure, active listening, and sensitive responsiveness are fundamental. A recognition of the inevitable anxiety and cognitive strain under which a patient in distress labors should remind the physician to go slowly in questioning, speak clearly, and reiterate important diagnostic questions. Most patients, because of anxiety, have a difficult time hearing and understanding discussions with the doctor. Older patients, in addition, may be less receptive because of the aging process itself. People in pain show irritability and impatience. The physician’s attentiveness to these and other features of the patient’s presentation will facilitate a meaningful yield in accurately assessing signs, symptoms, and history. Listening attentively to what is said and what seems left out is important. Carefully assessing the extent of a patient’s expectations for recovery from pain and limited functioning is important. Written materials outlined by the surgeon before, during, and after a surgical procedure are often useful. When tailored to the specific patient and his or her particular condition, they are seen as believable and help consolidate diagnostic and treatment information, and minimize misunderstanding and error. All aspects of patient-physician contact should facilitate the entire diagnostic and treatment process. Telephone inquiries, waiting rooms, and administrative and nursing personnel can set the stage for a productive interview and more accurate data collection. Tightly managed pre-op assessments also ensure better post-op compliance with rehabilitative recommendations such as adherence to physical therapy.

Last, orthopedic surgery teams tend to have multiple participants. With so many caregivers in the field, the wise chief surgeon intentionally takes the lead and orchestrates, within reason, the specific and overall flow of care, always keeping the needs of the individual patient in mind. Ideally, a designated contact person will be assigned to the patient throughout the process. Patients are aware of this. Compliance and better outcomes result.

Western Perspectives on the Psychology of Aging

Aging denotes the effects of the passage of time on the body as well as its interpretation, as felt in emotional terms. Physical changes and attendant pathology are typically tangible and measureable. Emotional changes are much more subtle. These progressive changes are reflections of the continuing process of crossing “chronological thresholds.” Each person’s life is an autobiography of both change and continuity. A “considered” life has been looked at in a purposeful way. In the process, real opportunities open. One can choose to take an active role rather than merely being passive. Ongoing self-examination, self-exploration, and action are basic tools. Transformations of perspective, if purposely thought out, become essential for successfully traversing the inevitable changes that occur across the lifespan. Creative and lively attitudes bring rewarding results.

Why would a person want to be proactive? This chapter will make it clear that aiming for optimal health and biopsychosocial balance is essential to a sound lifestyle. The motivations for this are grounded in both biology and psychology. Biological survival means adapting to the constantly changing environment in as healthy a way possible. Psychological survival means creating conditions that strive for positive quality of life and result in meaningful satisfaction. Survival presumes intelligence, flexibility, and recognition of novel opportunities for success. This shores up functional viability on all levels, physical and psychological.

A new conceptual paradigm called the biopsychospiritual model⁴ has recently been advanced. This enriched perspective recognizes the integral nature of body, mind, and spirit and includes such considerations as sacredness of life, refinement of consciousness, and the deepening fruitfulness that a proactive life may take over the lifespan. Profound respect for life and a renewed humane outlook underlie this approach. These considerations have pragmatic value. They can result in a sense of self-empowered creativeness that engenders the rational therapeutic optimism so essential to functional generativity across life’s chronological thresholds and challenges.

The passage of time changes both body and mind, often in incompatible ways that can be confusing. The enrichments that adaptive intelligence brings over the years also enable people to more sharply sense their developing medical problems. Biological aging denotes the effects of internal physicochemical changes. Menopause and andropause are well known conditions. “Osteopause”—a decline in robust bone integrity—is also real. These include both decelerations in functioning and the impact of external aggressions such as trauma, disease, sun, wind, ionizing radiation, and extremes of temperature, to name just a few. Psychological aging is affected by perceptions of self and others: a sense of self and self-image, and earlier experiences with others. Viewing and identifying with how parents and grandparents age undeniably shapes one’s self-image. How significant others physically change over time never goes unnoticed. Although our “biological clock” is out of our personal control, our “psychological clock” is, in fact, the timing we create for ourselves. Forced retirement, for example, solely owing to pain and health challenges, some of which may be treatable, repairable, or reversible, is a prime instance of biology colliding with psychology.

After young adulthood, at about age 30, a perceptible decline occurs in the physical self, the body. In middle adulthood, the 40s, one becomes more realistically able to assess both one’s positive assets and those considered less desirable. After 50, noticeable declines in mental flexibility make it more of a challenge to implement change based on one’s recognition of real and subtle limitations. At this time, the ill health of others seems to stand out. The death of a loved one or spouse is not uncommon. After 60, stark awareness of aging and some degree of chronic pain confront most people. This results in less energy, mobility, and stamina. One’s memory tends to decline as well. Stressors become more frequent; adaptation to stressful life events is less resilient in advancing years. Dysphoria and clinical depression, at times, may add to the burden of aging. The National Center for Health Statistics in the United States shows that the suicide rate rises after age 65, especially for the Caucasian male population.

Anxiety accompanies tangible limitations of functioning in the course of aging. Anxiety, often felt as a low-grade sense of malaise, also tends to intensify with age. Irrational fears may develop. Pain and progressive functional limitations exacerbate feelings of harsh loneliness. Many older adults wish to remain in the workforce, and dread the occupational limitations that health challenges impose. Experts in work-related disability research have shown that the beneficial effects of work do outweigh the risks related to work. The far-reaching rewards associated with work are substantially greater than the harmful effects of a long-term lack of meaningful work. Aside from the financial advantages, work enhances self-esteem, structure, and social affiliation.

As aging and the concomitant suffering associated with pain increase, the problem of isolation becomes pronounced. Isolation is not only purely social. More important, the negative effects of isolation derive from subjectively interpreted feelings of withdrawal, disinterest, and anhedonia. These typically provoke subtle feelings of unconscious envy and conscious feelings of jealousy in complicated ways that further exacerbate mental equanimity. Such complex emotions elicit excessive anxiety, which tends to destabilize the mind. Less than optimal thinking processes, poorer decision-making skills, and a hypervigilant state marked by dysphoria result.

Various degrees of emotional contentment, to be sure, also accompany the aging process. The core of the biopsychosocial self has its base in the physical body. The conscious and unconscious sense of this awareness is termed “body image.” Identity, confidence, and mental equanimity are stabilized to the extent that body image is ego-syntonic or pleasurably felt. Self-esteem strengthens. As the body and its functioning naturally decline, however, body image suffers. People then experience various degrees of emotional malaise, discomfort, and unhappiness.

The patient’s physical appearance and perception of being fit, attractive, beautiful, or handsome are intimately involved in the aging process. The attendant decline in functioning makes this more poignantly felt. The aesthetic sense of beauty is based on innate biological and evolutionary programs along with individually-acquired learning. The roots of the perception of attractiveness rest on the perception of symmetry, proportion, and novel complexity. Attractiveness results more from biological characteristics whereas beauty and self-confidence add emotional depth, the psychological dimension. As aging and illness occur, the physical body becomes less symmetrical. Female and male attractiveness appear to diminish. More rigidly fixed postures and their emotionally-laden facial expressions become etched in. Looking in the mirror is a distressing reminder. When others respond to the patient with disdain after noticing a less than attractive appearance, this distress is reinforced. These changes, moreover, signal that something should be done. The patient wonders what can be done to help or correct undesirable changes. Questions about how to repair the burgeoning deterioration that is perceived to be the source of distress come to the fore. The more that physical deterioration can be ameliorated, the more an individual’s sense of being fit is strengthened.

Typically, the decade of the sixties introduces the inevitability of bodily aches and pains, less than optimal posture, and, perhaps, some degree of structural deformity. This stark confrontation with the reality of the physical side of the self spares few. The perception and interpretation of this painful recognition stimulate upset, ambivalence, and emotional discomfort. An individual’s emotional response to pain is felt as suffering. The patient’s description of pain is often inarticulate and requires the sensitive, explorative questioning of the physician. This again attests to the importance of diagnostic interviewing and establishing a positive therapeutic relationship.