Getting Old

Getting Old offers concise advice and practical suggestions for all
readers interested in or worried about ageing, either in themselves
or in someone they care about. With a focus on a positive view of
ageing, it discusses central physical and mental aspects of getting
old, as well as the social and psychological aspects such as choosing
where to live and becoming more oneself.
Rowan Bayne and Carol Parkes take a pragmatic approach to
reviewing what is happening in many aspects of your life as you
age. Essential topics covered include mobility; diet and digestion;
understanding and improving sleep; memory problems and
dementia; being an active participant in consultations about your
own healthcare; attitudes to getting old; romantic relationships
and loneliness; deciding where to live, moving house and choosing
other types of living arrangements; and death and grief. They invite
readers to focus on their own life and experience, to understand who
they are and what they really want now. An important part of self-
understanding is the application of personality theory to changes
associated with getting old, and readers are encouraged to reflect on
what might work for people with their personality characteristics,
and how to improve their stress management, communication and
decision making.
With suggestions for further reading and useful organisations
that offer support, Getting Old offers valuable, affirming guidance
for all those and their relatives going through this life stage, as well
as health, social care and counselling students and professionals.

Rowan Bayne is Emeritus Professor of Psychology and Counselling

at the University of East London. His main expertise is in applied
personality theory, counselling and counsellor training. He has
published 18 books and has run courses on selection interviewing,
personality differences and counselling for several major organisations
such as the BBC, British Rail, the City of London and Warwick
University.

Carol Parkes is a freelance consultant, trainer and coach. She is

a medical doctor who specialised in public health medicine and
epidemiology. In the past, she has been part of national and
international research projects on cancer screening and has many
publications in peer-reviewed journals as well as book chapters. She
later worked in consultant and leadership roles in the NHS for 10
years before embarking on her current freelance career.
Getting Old

A Positive and Practical

Approach

Rowan Bayne and

Carol Parkes
First published 2021
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN
and by Routledge
605 Third Avenue, New York, NY 10158
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2021 Rowan Bayne and Carol Parkes
The right of Rowan Bayne and Carol Parkes to be identified as
authors of this work has been asserted by them in accordance
with sections 77 and 78 of the Copyright, Designs and Patents
Act 1988.
All rights reserved. No part of this book may be reprinted
or reproduced or utilised in any form or by any electronic,
mechanical, or other means, now known or hereafter invented,
including photocopying and recording, or in any information
storage or retrieval system, without permission in writing from
the publishers.
Trademark notice: Product or corporate names may be trademarks
or registered trademarks, and are used only for identification and
explanation without intent to infringe.
British Library Cataloguing-in-Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging-in-Publication Data
A catalog record for this book has been requested

ISBN: 978-1-138-56601-9 (hbk)

ISBN: 978-1-138-56603-3 (pbk)
ISBN: 978-1-315-12331-8 (ebk)

Always seek the guidance of your doctor or other qualified health

professional with any questions you may have regarding your
health or a medical condition. Never disregard the advice of a
medical professional, or delay in seeking it, because of something
you have read in this book.
The information and suggestions in this book are safe and
accurate to the best of the authors’ knowledge. The authors
and publisher do not accept any responsibility for losses that
arise from applying them and we recommend that readers check
their use of them with an appropriately qualified health or other
professional first.

Typeset in Sabon
by Apex CoVantage, LLC
Contents

Acknowledgements viii

Introduction 1

SECTION 1
Physical and mental aspects of getting old 3

1 Mobility 5
Muscles, bones, feet etc 6
Falls and balance 11
Exercise (defined broadly) 12

2 Diet and digestion 15

Diet 15
A healthy weight 18
Losing weight 19
Some problems with bladders and bowels 22

3 Sleep 27
Improving your sleep 27
Snoring 29
Night cramps 29
Sleep disorders 29
REM sleep behaviour disorder 29
Restless legs 30
Sleep apnoea 31
vi Contents

4 Memory problems and dementia 32

Mental abilities and age 32
Forgetfulness and age 34
Dementia 37

5 Looking after your health: patients as active

participants in decisions about their healthcare 42
Consulting a doctor 43
Prescription drugs 45
Health screening 47
Miracle cures – what works? 51

SECTION 2
Social and psychological aspects of getting old 55

6 Attitudes towards getting old 57

Others’ attitudes towards getting old 57
Our own attitude towards getting old 59

7 Being oneself 61
Building a picture of yourself 61
Personality development 67
Personal strivings 73
Identifying strengths 75
Identifying values 77

8 Relationships 82
Online dating 82
Romantic love: Lee’s theory of lovestyles 84
Personality and sexual behaviour 85
Coping with sexual problems 86
Loneliness 86
Pets 90

9 Deciding where to live 93

Moving house 93
Living alone 97
Care homes 101
 Contents vii

10 End of life – death, grief and making plans 105

A good death 105
Making plans for the end of life 108
Loss and grieving 115

11 Additional resources 120

Preference theory and improving communication 120
Preference theory and making decisions 122
Assertiveness skills 123
Managing stress 125
Writing life stories 127
Expressive writing 128

Suggestions for further reading 132

Index 133
Acknowledgements

Rowan would like to thank Katherine Bayne for her calm efficiency
throughout the writing of this book. Carol would like to thank Jan-
nie Mead for her support and encouragement. And we both appre-
ciated the experience and understanding of the Routledge editorial
staff, especially Lucy Kennedy, Helen Pritt and Lottie Mapp.
Introduction

We’ve written this book for general readers who are feeling inter-
ested, worried or shocked about a change or problem in themselves
or in someone they care about which could be related to getting old.
You also want to do something about such changes, and our central
focus is to suggest a variety of practical possibilities for action.
The book is in two main parts. In Section 1, we discuss some core
physical and mental aspects of getting old, for example maintaining
and increasing mobility, improving sleep and digestion, and becom-
ing a more active participant in consultations with health profes-
sionals. In Section 2, we turn to social and psychological aspects of
getting old such as choosing where to live, becoming more oneself
and using the idea of styles of romantic love.
There is a bleak view of the truth about getting old and a posi-
tive one. The bleak view is that as we get old, we get stiffer, more
bent over, more achy, incontinent, falling and forgetting more and
more and believing that life is all downhill from now on. The posi-
tive view is that many older people become stronger through life
experience, for example more able to see problems in perspective
and more assertive in expressing their emotions and wishes, but this
positive view tends to be neglected.
An unusual aspect of the book is its application of personality
theory to some of the changes and problems associated with getting
old. Thus, in some of the exercises we encourage readers to reflect on
what might work for them as a person with their personality traits,
motives, strengths and values. In this respect and others, the book
recognises that there is truth in the positive view of getting old as
well as the bleak one and that there are many practical things we can
do to make the last part of our lives healthier and more enjoyable.
Rowan Bayne and Carol Parkes
Section 1

Physical and mental

aspects
 
of getting old
Chapter 1

Mobility

Think of physical changes associated with getting old. For example,

you may find that becoming less agile and more doddery are promi-
nent and that negative changes like these come to mind most easily.
Moreover, the fact that many of these changes can be slowed or
reversed by physical exercise is not exactly welcome to many of
us. Accordingly, we begin this chapter with some general principles
which attempt to counter this dislike.

1 We define physical exercise very broadly, indeed to mean

all physical movement, ranging from a gentle stretch at one
extreme to an ultra-marathon at the other. Either of these and
anything between can slow or reverse the undesirable physical
changes associated with getting old.
2 Exercise should feel good and not be a strain.
3 If you choose to increase the amount or the intensity of an
exercise, that too should feel good. If it doesn’t, we want you to
stop. Generally, this means gradually increasing its level, speed,
frequency or number.
4 We strongly recommend frequent recovery and rest days. Feeling
very tired and aching muscles are useful warning signs, and we
want you to listen to your body when deciding how much rest to
take, although two recovery days a week may be a helpful general
guide. Moreover, injury is more likely in old age, and recovery
from injury tends to take longer, so it is much better to prevent it in
the first place. It is a myth that lots of pain and effort are required
for most of us to make useful improvements in physical fitness.
5 Maintaining or increasing mobility is central to coping with
physical ageing for several reasons. First, it reduces the chances
of many major illnesses such as heart disease and dementia.
6 Physical and mental aspects of getting old

Second, it improves quality of life, for example making falls less

likely and positive social contact more likely. Third, it can lead
to feeling more alive.

In the rest of this section, we suggest some options for working on

muscles, bones, feet, knees and hips, backs, necks, balance, sitting,
walking and running.

Muscles, bones, feet etc.

Muscles
Muscles tend to weaken after 30 years old and especially after 70.
Moving in any way helps counteract this deterioration, but there
are also some exercises which are particularly effective. We outline
these and hope you will try one or more of them.
The idea here, consistent with the general principles at the start
of this chapter, is to start with an exercise and a level you can do
comfortably. Check with your GP or another appropriately quali-
fied health professional that you’re not being too enthusiastic in
your choice. Ideally, a further safety precaution is for somebody
else to be present who is trained in manual handling, and who is fit,
alert and strong enough to break your fall if needed. Alternatively,
have a sturdy table or worktop in easy grasping distance.

Press-ups: five levels of ease/difficulty

Next we describe several variations of the press-up, ranging from
one for beginners to the excruciatingly hard for almost anyone. We
don’t see the aim as being able to do the excruciatingly difficult
variations! (Cf. general principles 2, 3 and 4).

Level 1 press-up
Stand facing a wall, raise your arms and press your palms against
the wall and then move your chest towards the wall and back. Do
as many press-ups as you can comfortably do and then stop.

Level 2 press-up
Stand next to a sturdy table or worktop, palms on the surface, and
bend your knees, pressing down with your hands. Continue until
 Mobility 7

your arm muscles are tired, counting the number of times you can
bend and straighten.

Level 3 press-up
Kneeling on the floor, lower your chest towards the floor. Do this
once and see how comfortable it feels. If it’s not comfortable, go
back to level 2.

Level 4: the standard press-up

NB: This level is quite enough for most people.
Lie straight on the floor face down, supported only by your
palms (which are placed beneath your shoulders) and by your
toes.
Lower your body, breathing out and keeping your body straight
and your buttocks squeezed together (imagine clenching a sheet of
paper between them).
Lower your chest as close to the floor as is comfortable, breath-
ing out as you do so.
Raise your body using your arms and knees, breathing in as you
do it.
That’s one standard press-up. Aim to increase the number you
do when and if you’re ready, bearing the general principles firmly
in mind.

Advanced press-ups
There are lots of variations, e.g. holding one leg in the air, clapping
hands between press ups, or resting both feet on a bench with your
hands on the floor or ground.

Squats: two levels of ease/difficulty

Like press-ups, squats are a weight-bearing exercise, widely used
and effective. They are more practical for some of us than press-ups.

Level 1: beginners’ squat

Sit on the edge of a firm chair, hands clasped in front of your chest,
and stand. Keep your weight on your heels.
8 Physical and mental aspects of getting old

Sit on the edge of the chair and repeat when and if your body
feels ready.
As before, count the number you feel comfortable with and aim
to increase it and/or your speed.

Level 2: the standard squat

Start standing, with your hands in front, feet shoulder width apart
and squat as if to sit on a chair.
Other exercises for the main muscles include walking and run-
ning (discussed later in this chapter), weight-lifting and going up
steps or stairs.
Also, we suggest eating some protein and carbohydrates in the
hour or so after exercise and remembering to rest and recover.

Bones
Bones tend to become less dense and therefore weaker in old age. The
main causes of this are not enough calcium and vitamin D, so eating
dairy foods and protein, and getting plenty of sunshine, can be help-
ful. Even standing helps maintain calcium levels a little. However,
bone is living tissue and needs stimulating through feedback and, in
particular, impacts of the kind produced by jumping, running and
dancing – but not cycling and swimming, because although good for
cardiovascular health, they are not weight-bearing.

Feet
The health of young feet is often taken for granted. In contrast, old
feet are prone to several problems, for example dry skin forming
corns, thickening toenails (to the extent that they can’t be cut in the
usual way) and fungus infections (which if left untreated become
very unsightly). Such changes can limit mobility, the first making
movement painful, the other two through feeling embarrassed.
Having corns removed by a competent chiropodist is painless
and the results are a pleasure. As a friend said after his first visit (in
his mid-70s): ‘It’s like having two new feet’.
Thick toenails are easily trimmed by a chiropodist. Fungus infec-
tions take much longer because toenails grow slowly and the many
remedies prominent in chemists are, in the experience of one of us
and his chiropodist, not very effective (they may well recommend a
 Mobility 9

liquid medicine). Treatment with a laser is potentially much quicker

but much more expensive, and the evidence for its effectiveness is
unclear so far. Washing socks at 60 degrees and spraying anti-fungal
spray inside shoes are also part of the treatment.
There are some basic exercises for increasing foot core stability –
they focus on a set of muscles that affect many other aspects and
parts of our bodies including backs and posture, but tend to be
neglected. You may like to try the following daily:

Sitting on a firm chair, place your bare feet flat on a towel. Wrig-
gle your toes, then seize the towel with them and scrunch it
towards you. Try for a minute or two twice a day.
Sitting on the floor or a chair, ‘write’ the alphabet with your
toes one foot at a time.

Knees and hips

Pain in knees and hips can be caused in several ways and may be
diagnosed wrongly as just ‘part of getting old’ or as needing surgery
when they don’t. The causes include obesity and muscle imbalance
and overuse, and the treatment options, apart from an operation,
are medication, losing weight and structured exercises supervised by
a physiotherapist. Generally, and obviously, it is best to try simpler
procedures first.
If you do decide to have an operation to replace a joint, we sug-
gest asking your GP which surgeons they and other GPs would go
to for that operation themselves.
Ways of keeping joints healthy are regular exercise (with recov-
ery and rest days), avoiding too much twisting, kneeling or lifting,
and only occasional or no sugary food or drink (because they may
cause inflammation).

Lower backs
For lower back pain, continue with normal activities as far as
possible and vary the position of your body. It is a myth that
the best treatment is bed rest or lying on the floor, although this
was for many years the standard treatment, sometimes for several
months, when the result of just a couple of days in bed is weaker
muscles and bones and a slightly increased risk of dying from a
blood clot.
10 Physical and mental aspects of getting old

The following exercises are worth considering for lower back

pain:

• squats (see earlier in this chapter)

• brisk walking, arms swinging, head up (if it hurts, go more
slowly for a while or stop)
• deep breathing in a relaxed way and using your diaphragm
(rest your hands on your stomach and make it swell with your
breath)
• mindfulness (deep breathing may be the active ingredient)
• whole body exercises, like running, dancing and swimming
• yoga, Pilates and the gym suit some people and not others – too
much twisting and bending for them

Back pain is thus not inevitable with ageing, and we can do sev-
eral things to help prevent it: being active (as discussed later in this
chapter), maintaining a healthy weight (see the section on Diet in
Chapter 2), eating and drinking well (both discussed in Chapter 2)
and choosing a bed that suits you.
There is no such thing as an orthopaedic bed or mattress. Appeal-
ing as the idea may be, it is just a marketing term. A bed needs to be
comfortable for you – e.g. you should not feel that the mattress is
swallowing you, nor should it feel like a board – and it is probably
worth changing a mattress after a few years. We also recommend
the back stretcher developed by Neil Summers, especially after a
warm bath, for a few minutes at a time.
Overall, drugs (including pain killers), surgery and injections are
much more risky ways of treating back pain and are often useless.
The simplest and (as it happens) the cheapest options are the most
generally effective and safe, and most back pain heals itself. For the
latest guidance, see nice.org.uk.

Necks
Neck pain is common and not usually a sign of serious illness,
though it is of course painful and awkward. Possible exercises to
try, very gently, are 1) stretch your neck, stopping if it hurts, by
pointing your nose at the ceiling and moving it from side to side,
2) move your head from side to side, looking over each shoulder
and using your hands to stretch a little further, and 3) put your chin
on your chest. If these exercises don’t work, see a physiotherapist.
 Mobility 11

Falls and balance

Falls are both more likely and more dangerous for older people.
Broken bones can mean months of pain and anxiety, and loss of
mobility and independence.
The risk of falling increases at around 65 years old. This is
because we have far fewer of the nerve cells which specialise in
balance and coordination by then. Moreover, this loss is true for
athletes as well as the general population: general fitness doesn’t
prevent it, but particular exercises like those outlined next do.
Injuries from falls can be reduced and prevented by doing some
of the following:

• press-ups (see earlier in this chapter) to strengthen wrists and

arms, thus absorbing much of the impact of most falls and
making your head less likely to hit the ground
• squats (see earlier in this chapter) to strengthen legs and pre-
vent or reduce falling in the first place

Be especially careful with the following exercises: start them hold-

ing onto, or next to, something sturdy to steady yourself if you lose
your balance – a wall or a table, but not a person.

• Stand on one leg when doing everyday things such as watching

TV. How many seconds can you stand without wobbling? A
much more difficult variation is to close your eyes before you
lift one of your feet, and keep your eyes closed. As before, the
aim is to do this comfortably and without wobbling.

Generally we think it better to compete with yourself, for example

in how long you can stand on one leg, but you may prefer to com-
pete with the average score of others or with a judgement on what
is a ‘good score’ for your age group (or a younger one). For the
standing on one leg exercise with eyes open, 20 or 30 seconds is a
good score for people in their 70s. In marked contrast, young adults
can generally stand on one leg with their eyes closed for 30 seconds
or more.
Some hospitals run clinics on improving balance using these and
other exercises. Also, falls can be made less likely by being a healthy
weight, checking your home for objects that could trip you up, look-
ing after your feet, hearing and eyesight, reviewing your medication
12 Physical and mental aspects of getting old

with a chemist or GP and considering aids such as handrails and

walking sticks.
Pilates, tai chi and yoga are also very effective for improving some
people’s balance, and karate teaches ways of falling more safely.
Anyone concerned about having a higher risk of falling or a recent
fall should speak to their doctor. Health professionals are trained to
take a preventive approach to managing falls, and there are useful
guidelines developed by NICE on this (which are being updated as
new evidence on prevention and treatment of falls has emerged).
A comprehensive assessment of fall risk can be carried out, and
specific treatments or interventions will be recommended. These
focus on associated health problems and also relevant issues in the
home environment.

Exercise (defined broadly)

In this section, we discuss sitting and walking, the latter being a very
beneficial exercise for most of us and the former surprisingly unhealthy
(as has been realised only recently). We also, for those who wish to go
further than walking, describe High Intensity Interval Training (HIIT)
and some ideas about links between personality and choice of exercise.

Sitting
Long periods of sitting contribute to lower back and neck pain,
hips and hamstrings that are too tight, weak core muscles, being
overweight and a greater risk of serious illnesses such as type 2
diabetes, some forms of cancer and strokes. Several causes of such
effects have been identified or proposed, for example, raised blood
pressure, shallow breathing, less breaking down of fat and sugar in
the blood stream and arteries becoming stiffer.
It feels rather eerie to think of all these processes happening as we
do an apparently harmless thing like sitting down. Moreover, they
happen however much exercise you do at other times. Essentially,
we are a lot more healthy when we’re moving enough (and also tak-
ing appropriate amounts of rest and relaxation).
Some options to counter the damaging effects of sitting are:

• two minutes standing for every 20 or so minutes of sitting, but with

care, especially if you have lower back or circulation problems
• two minutes walking during each hour of sitting
 Mobility 13

• breathing more deeply

• squats (again!)
• fidgeting

Overall, gradually integrate more moving and kinds of moving into

your daily life. There are many opportunities to move more and
increase strength and fexibility at the same time. And remember
enjoyment and rest too.

Walking
Walking, either strolling or walking briskly, aids mobility and is
good for several parts of our bodies, especially bones, hearts and,
perhaps surprisingly, brains – both cognitive performance and
mood are positively affected. Walking is also aerobic, generally free
of side effects, easy on hips, ankles and knees, not expensive and
easily integrated into everyday life for most of us.
A mixture of jogging and walking, slow jogging and faster jog-
ging are further options and get closer to a very effective form of
exercise called High Intensity Interval Training (HIIT).

High Intensity Interval Training (HIIT)

In HIIT, ‘high intensity’ is doing something physical, e.g. lifting
weights, walking, running, swimming or cycling for as hard and
long as you comfortably can. ‘Interval’ refers to the recovery time
between each intense period. For example, one person might do three
sprints of 20 seconds each for the Intensity element, with intervals at
a gentle pace and about three minutes long (and perhaps downhill)
between each one. Alternatively, in some research the intervals have
lasted for as long as it takes for the participants’ pulse rates to drop
below 120.
If you decide to try HIIT yourself, please read the following fur-
ther information and advice before doing so and apply the general
principles at the start of this chapter too.
A refinement in some research has been to start with several weeks
of preparation designed especially for those who haven’t exercised
for a while. For example, the participants walk 10 minutes a day
for the first week, gradually increasing over the next four weeks
and then adding brisker walking etc. until ready for HIIT itself. The
participants in some of the studies have been in their 60s and 70s.
14 Physical and mental aspects of getting old

The results of a few weeks of HIIT include, for example, lower

blood pressure and blood glucose, reduced fat, and increased leg
strength and aerobic fitness. Overall, HIIT’s method of shorter,
harder and fewer sessions plus recovery time is very effective. The
striking aspects are just how short the sessions are (and generally
they are for one, two or three sessions a week) and how much effect
they have. The studies have been carried out on many groups of
people, including some with diabetes or recovering from recent
heart attacks.
A specific example of one person’s HIIT is to warm up on an exer-
cise bike for two minutes, then gradually speed up and increase the
resistance on the bike at the same time until he ends this phase with
20 seconds going flat out. He then cycles gently for long enough to
feel ready for another sprint of 20 seconds then another minute or
so of gentle cycling and a final all-out 20 seconds.
However, please note that he has been doing HIIT for some time
and it is very important to ease your way in and also to consult an
appropriate health professional first.
A reaction against ‘pure HIIT’ called Liss may appeal more. Liss
stands for Low Intensity Steady State Cardio and is continuous
exercise at a much slower pace for 30 to 60 minutes. The principle
of gradually increasing the amount applies to Liss too. An attractive
variation for some people is to do HIIT, Liss and rest days, each of
them on different days.

Personality and exercise

Different kinds of exercise seem likely to suit people with different
personalities. Suzanne Brue uses a colour system, and there is a brief
quiz to indicate which colour represents your personality in this
sense at www.the8colors.com. For example, people who are whites
in her model tend to enjoy exercising alone in a calm, familiar and
pleasing setting and letting their minds drift – exercise as a ‘moving
meditation’ – whereas reds tend to want lots of stimulation, variety
and quick responding – exercise as absorbing action. Thus, motives
may be the key to finding the form of exercise which suits you. (See
the section in Chapter 7 on personality development for more on
the personality theory used by Brue.)
Chapter 2

Diet and digestion

Diet
It is no surprise that many people are confused about what consti-
tutes a healthy diet. The ‘official’ advice changes over the decades,
and the truth about what we should and shouldn’t eat is often
debunked as new evidence emerges. It is tempting, therefore, to
give up on listening to advice and just eat whatever you fancy. This
would be a mistake, and it is particularly important to eat as healthy
a diet as possible as we age.
There are two main problems with diet research and advice. The
first is that eating is such a deeply personal thing that we do for
all sorts of reasons, not just hunger. We may do it for emotional
reasons, habit, culture, beliefs, finances, availability, etc. It is there-
fore difficult to do good research on it as people often can’t really
remember what they eat, or miscalculate it – and people don’t like
to be dictated to in order to stick to a certain diet that can be fol-
lowed up on in a research study. It is a lot easier to study rats in
lab cages than it is free-range humans. It was much easier to do
the research on the link between smoking and health than diet and
health because smoking is a much more categorical, concrete thing
to know about and recall or stick to. People can more easily say
whether they have smoked 20 cigarettes a day for the last week
than recall their diet in a retrospective study or stick to a diet regime
in a prospective study.
The second problem is that diet is political. There is big money
to be made from certain components of food, and some countries
rely heavily on the economic proceeds of these. For example, there
is a big business in the USA in producing relatively cheap corn, and
so products of this industry, like high fructose corn syrup (HFCS),
have been pushed into human food. If you add natural human taste
16 Physical and mental aspects of getting old

preferences for, say, sweetness, and a money maker like corn, then
the two combine into a perfect marriage. But it is not necessarily
a healthy union – the human cost can be obesity and other sugar-
related problems.
There are a dazzling number of books and articles on diet, and
it would be a full-time job to read them all. Many have completely
opposing messages. Diet is one area where all sorts of people have
their own theories and advice, and in the age of social media, this
can be very confusing. British doctor Tim Spector spent five years
drawing on his medical, genetics and epidemiological skills to pro-
duce an excellent overview of the science and epidemiology behind
diet (The Diet Myth, published in 2015). He examines not just what
is a healthy diet but also what is it that has made too many people
overweight or obese in recent decades.
He points out that people are different in all sorts of ways and
one size doesn’t necessarily fit all. Studying identical twins is a great
way of teasing out what differences are due to genetics. He found
that 60–70% of differences in responses to diet were genetic, i.e.
contributing to the degree to which people are likely to put on
weight, their food preferences and even their liking for exercise.
He thinks that looking at diet in just its component micronutri-
ent parts (protein, fat, carbohydrates etc.) is far too simple. One of
the largest influences on diet and health never appears on the food
labels. It is trillions of microbes that live in us and in particular
in our guts. We become colonised with bacteria from our mother
when we are born (vaginally) and, despite modern obsessions with
antiseptic ‘cleanliness’, the majority of these bacteria that live in
and on us are friendly and health-giving. The whole community of
microbes (mainly bacteria) in our gut is referred to as our microbi-
ome. It is now thought that decreasing the diversity and amount of
microbiome (from our diet and lifestyle) is a large factor in explain-
ing the current epidemic of obesity. Lack of diversity in our diets
and the high consumption of processed foods that contain mainly
corn, soy, wheat and meat have depleted our microbiome.
It is not just food that affects our microbiome; it is also how much
exercise we do. The fitter we are physically, the fitter our gut micro-
biome is. It has been shown that is better to be fat yet fit rather than
thin and unfit in terms of reducing heart disease and overall mortality.
Antibiotics, though of course useful and sometimes life-saving,
can dramatically reduce the numbers and diversity of good bacteria,
but a healthy diet can restore them quite quickly.
 Diet and digestion 17

So what do we eat as we get older? In terms of what is sensible

for most people (of any age) to eat, there is now reasonably good
evidence from lots of studies that are pulled together into large
meta-analyses. The following are pointers:

1 Avoid processed foods as much as possible. This pretty much

means anything that your great grandparents didn’t eat and any-
thing that wasn’t picked, dug up, harvested or obtained directly
from an animal. Processed foods taste good to a lot of people
because they usually have a carefully calculated combination
of fat, sugar and salt – and many people find this combo irre-
sistible, and our brains can get very accustomed to this heady,
pleasure-giving mix. They are also good for the food industry
as filling food with these can extend their transportation and
distribution times and shelf life.
2 Too much sugar is not good for us, and we should be very
careful how much we are eating without realising it. It is an
ingredient of many things that aren’t that obviously ‘sweet’, like
soups – as well as many processed foods, already mentioned.
When people became scared of fats in foods from the ‘low-fat
movement’ in the 1980s onwards, it allowed the food industry
to up the sugar levels instead to keep things tasting okay. It has
been estimated that our sugar consumption has been increasing
at about 10% each decade since 1990, and we are eating about
20 times more than our great grandparents did. Liquid sugar
can increase sugar consumption considerably, so it is wise to
avoid sugary drinks and be aware that a lot of fruit juices and
smoothies are packed full of sugar. Although twin studies have
shown that having a sweet tooth is about 50% genetic, we still
need to actively work on decreasing our actual sugar consump-
tion and wean ourselves off the high sugar taste.
3 Reduce your intake of red meat, especially processed meats like
sausages, ham and salami. This can help decrease risks of dying
early. Non-processed poultry meat is a healthier option for meat
eaters. There are fewer studies on fish eating, but it is unlikely
to be harmful. Of course, there are other reasons for people to
cut down on meat eating – environmental reasons and wanting
to avoid antibiotics and hormones in some non-organic meats.
4 Increase your consumption of fresh vegetables and fruit –
sticking to the five-portions-a-day recommendation is sensi-
ble. Examples of a portion are a small apple, six medium-size
18 Physical and mental aspects of getting old

strawberries and three heads of broccoli. The Mediterranean-

style diet has been repeatedly shown to be healthy and reduces
the rate of disease (such as heart attacks and stroke) and death
rates. This involves eating a lot of whole grains, legumes and
vegetables, nuts and fruits. The diet uses plenty of olive oil (con-
taining mono-unsaturated fatty acids), which has been shown
to be healthy, demonstrating that earlier decades’ preoccupa-
tion with low-fat diets was misdirected. The diet incorporates
moderate amounts of fish, poultry, yogurt and cheese, but less
red meat and processed meat. Moderate amounts of red wine
can be consumed with meals.
5 If you can keep to low to moderate amounts, then coffee, red
wine and dark chocolate are likely to be okay for most people as
they haven’t been shown to have negative health effects. How-
ever, for some people who find it difficult to restrict their con-
sumption, it may be easier to have none rather than risk bingeing.

A healthy weight
Most people gain weight with age, and it is often seen as a natural
part of getting old. However, it isn’t inevitable, and it is a major
threat to health.
A straightforward, low-tech and sufficiently precise way of mea-
suring healthy and unhealthy amounts of weight is to measure your
waist. This method allows for muscle being heavier than fat, which
can result in people with well-developed muscles being wrongly
rated as overweight. Moreover, fat stored around the waist is the
most dangerous for health: too much fat in this area substantially
increases the risks of several types of cancer, high blood pressure,
osteoarthritis and type 2 diabetes.
To measure your waist, put a tape measure around the middle
of your waist, usually at the navel. Stay comfortably relaxed –
tightening your stomach muscles is cheating! How much you’ve
recently eaten or drunk will make a difference, but great precision
is not needed. A waist measure of more than 32” (81cm) in women
and more than 37” (94cm) in men is usually interpreted as too
much. Another way of interpreting a waist measurement is that it’s
healthy when it’s less than half a person’s height without shoes.
However, for both ways of measuring there’s also a cautionary note
for people who are slim: some of us are slim outside but have hid-
den fat inside. Unfortunately, discovering this requires a scan.
 Diet and digestion 19

Losing weight
You may wish to lose weight. If so, the standard advice used to be to
‘eat less and exercise more’. This advice implies that losing weight is
just a matter of will power and discipline, which is a myth and much
too simple and unfair. As already mentioned, about 70% of our pro-
pensity to put on weight is genetic, and unfortunately, these genes
tend to overlap with genes that make us less inclined to do exercise,
so it is a double whammy. However, that doesn’t mean we have no
influence on our weight, as we are not predestined to be overweight.
It may mean that some people have to work harder at it than oth-
ers and need to be very aware of all the factors that are involved in
becoming overweight. They include diet, the microbiome, exercise,
habits and how we eat, medication, mini-fasting and personality.

Diet
The previous sections on diet gave guidance on what dietary habits
are healthy and more likely to keep you at a healthy weight. Reduc-
ing our consumption of processed food and refined sugar will be a
mainstay in weight reduction. To make it possible to adhere to new
habits, they need to be enjoyable and motivating.

The microbiome
Looking after our microbiome is a vital part of losing weight – we
need to make sure we eat a diverse and varied diet to tend our
microbiome. All of the previous diet pointers will have a positive
effect on the microbiome.

Exercise
It is ironic that eating less can result in feeling less energetic, thus
using less calories, and that lots of exercise can make us hungrier.
Added to this, it has been found that just increasing exercise in
order to lose weight is unlikely to work – the body compensates
and slows its metabolism down in order to stop breaking down
fat. It needs to be a combination of both diet and exercise that does
the trick. Although exercise alone may not be great at shifting the
weight, it is beneficial for all sorts of other reasons. Doing no exer-
cise at all is twice as risky as being obese in terms of dying early.
20 Physical and mental aspects of getting old

The risk of heart disease is higher if you are a person who smokes
and doesn’t eat vegetables than if you are a non-smoking, vegetable-
eating, fit, obese person. Another major good thing about exercise is
that it affects your microbiome – it grows larger and becomes more
diverse, which has many health benefits, as mentioned earlier.

Habits and how we eat

Eating too quickly can cause us to overeat (it takes about 20 min-
utes from starting eating to the brain reacting with sensations of not
being hungry). One of the difficult things about eating sugary food
is that we don’t have a natural ‘that’s enough button’ in our bodies
and we can easily gorge on it. It is much more difficult to do that
with foods containing predominantly fat or protein – we tend to
know that we have had enough and stop more easily.
There are many ways in which we can develop healthier eat-
ing habits that will help us not to overeat or eat the wrong things.
Examples are the oft-quoted ‘don’t go food shopping when you are
hungry’, shopping from a list and not having certain things in the
house if you know you can’t resist them. Actual eating habits are
important, like taking time over meals (like many Mediterranean
people do) and chewing properly.

Medication
A side effect of some medications is to increase appetite and to put
on weight. If your doctor prescribes one of these on an ongoing
basis, it is worth discussing how you will manage your weight at
the same time and plan it pro-actively rather than deal with it later
once the weight is on. A compensatory change in diet and exercise
may be required to keep your weight more stable.

Mini-fasting
There are several variations of mini-fasts, including the widely pub-
licised 5:2 diet, which is five days a week eating whatever you want
and the other two non-consecutive days restricting yourself to 600
calories for a man and 500 for a woman.
A variation is the alternate days diet, which assumes that bod-
ies respond well to routine. In this diet, the ‘fast’ is again relative:
about 500 calories, usually eaten as one meal. The research on this
 Diet and digestion 21

approach shows clearly that health improves and weight reduces.

Another benefit was that participants ‘rediscovered hunger’, felt it
to be quite different from just being hungry, and liked the feeling.
Mini-fasting is very simple and flexible. It combines being gentle
and tough, self-indulgent and disciplined (but not for long). A mini-
fast day can be not eating from, say, after lunch to the same time
the next day or from 5pm to 7 the next morning. On ‘feast’ days,
you can eat anything, though obviously some foods contribute less
to losing weight.
A further benefit is that the mini-fast approach gives your metab-
olism a rest and time for repairs. In this respect, it is like vigorous
exercise: interspersing deliberate stress and recovery periods and
treating both as important.
Check with your GP or other appropriate health professional if
you’re thinking of trying any kind of fast. Two useful general prin-
ciples are to make changes gradually and to monitor your reactions
carefully and preferably with someone else involved too. Other
limitations of fasting are that the long-term effects of the different
variations are not yet known, that side effects like dizziness and
headaches occur in a few people and that it is not recommended for
children, women in pregnancy or for people with eating disorders
or type 1 diabetes.
In addition, the mini-fast approach implies that a number of
established ideas about losing weight are myths, e.g. that eating
breakfast is a useful, even major, part of successfully losing weight,
and that grazing – eating little and often – is healthy, which is a
myth despite its attractive rationale of maintaining a stable blood
sugar level and being a natural way of eating. However, it may be
that grazing suits some people and mini-fasting suits others: back to
trial and error to find out what works for you, but with the added
factor of personality to take into account.

Personality and eating less

The underlying principle and assumption here is that if your strategy
for eating less fits your personality, it will be more likely to work. For
example, a major personality difference is that some people like and
indeed need plans and routine more than they like keeping things
flexible and open, while others have exactly the opposite priority.
Calorie counting is seen as more likely to work with people with the
first personality characteristic. However, we can sometimes benefit
22 Physical and mental aspects of getting old

from adding a little of the approach opposite to our own: mini-fasting

when the mood takes you can work better with some discipline, and
sticking to a plan can work better with some flexibility.
For example, X hated herself for being overweight, and her GP
attributed her non-compliance to numerous standard techniques,
like calorie counting and keeping a diary of what she ate, as an effect
of her core personality and therefore that she was very unlikely to
change. Another GP was more optimistic. He took a more positive
interpretation of X’s personality and saw her as strongly resent-
ing rules and plans and therefore more likely to respond well to a
‘sort of’ diet. This means lots of variety and flexibility, therefore
stocking up with healthy and mainly low-calorie food and enjoy-
ing choosing just before eating while trying to eat a bit less than
usual. It also means not keeping many high-calorie foods within
easy reach, because X and people of her temperament tend to have
poor impulse control (but good mental flexibility).
The different strategies are each more likely to work with people
of one of four personality temperaments (see the sections on per-
sonality and core motives in Chapter 7). The strategies are sum-
marised here. They also suggest which strategies are likely to be
futile or counterproductive for each temperament.
The four temperaments and their implications for losing weight are:

1 Using or developing their natural strength of being in touch with

feeling hungry and with when they are full. Refine this to judging
what exactly it is that they want to eat. Also, make dieting as much
fun as possible, and don’t plan. Focus on the process, not on goals.
2 Planning meals and times. Use their natural strengths of being
strong-willed, organised and task-focused.
3 Liking to know theory and to design their own variations of
diets. Want reasons and evidence.
4 Needing to find a personal meaning for losing weight, such as
doing it for someone else. Will diet when it feels right, and are
likely to diet in bursts.

Some problems with bladders and bowels

Bladders
Bladders become less elastic as we get older. They hold less urine,
and urination becomes more frequent and less efficient with more
 Diet and digestion 23

chance of the bladder not being fully emptied and an increased

chance of leakage and incontinence. Getting up once a night to pee
is regarded as a normal part of getting old, twice is border-line,
while about every three to four hours is a typical healthy frequency
during the day. Drinking less as a self-treatment is very tempting but
a bad idea, because it can lead to dehydration.

Dehydration
Dehydration is not drinking enough fluids to be healthy, which
ironically is sometimes the result of trying to reduce episodes of
incontinence or frequency of urinating, particularly at night. Other
causes are not being able to feel thirsty and not enough fluids being
available. Older people sometimes decrease the amount they drink
until only drinking, say, two cups of tea a day. The possible conse-
quences include increased drowsiness (which can be mistaken for
the normal process of dying described in Chapter 10), headaches,
skin and eye problems, confusion (can be mistaken for dementia),
urinary infections, crystals and kidney failure.
Two indicators that you are drinking enough fluid are the colour
of your urine – ideally colourless or pale yellow – and a moist
mouth. Another is of course feeling thirsty, but some of us have lost
this ability or misinterpret it as tiredness or hunger.
The question of how much fluid is healthy is controversial, with
eight glasses of water a day winning the publicity battle for many
years. At the level of individual needs, several factors such as weight
and amount of sweating are relevant, but generally around one to
two litres a day for men and one to one-and-a-half for women is
probably optimal. However, individual differences in physical and
biochemical characteristics are usually substantial, and we suggest
experimenting to find what suits you. Our bodies are usually adept
at monitoring how much fluid we need.

Incontinence
Both urinary and faecal incontinence can usually be cured or man-
aged, but diagnoses of the causes can be complicated. Common
causes of urinary incontinence are enlarged prostate glands, over-
active bladders, urinary infections, other illnesses such as diabetes
and cysts. Common causes of faecal incontinence are poor mobil-
ity, constipation, diarrhoea, lack of fibre, lack of fluids and certain
drugs.
24 Physical and mental aspects of getting old

Your GP may offer diagnoses and treatments, or you can ask

them to refer you to a continence service or centre. Self-referral is
often available too. There are NHS specialist services in most areas
of the UK. Just put ‘continence service’ plus the nearest town or
county into Google.
Typical help with and treatments of urinary incontinence include
continence pads, penile sheaths, avoiding certain drinks and foods
(because they irritate some bladders; examples are coffee, tea, alco-
hol and curries), exercises for pelvic floors and bladder retraining.
Several drugs are also used, for example to relax relevant muscles.
Some of the procedures and treatments involve a risk-benefits
judgement, and one, vaginal mesh, has been banned by the NHS
because of severe problems with it. Others are completely safe. For
example, one approach to understanding your bladder is to keep a
diary for a few days and nights listing 1) what you drink, how much
and when and 2) how much you urinate and when.
Two exercises for strengthening pelvic floor muscles (summarised
from Marion Shoard’s book How To Handle Later Life) are:
Breathe normally throughout the following two exercises. The
first exercise is to gently but firmly tense the muscles that you’d
use if you wanted to stop urinating and excreting faeces – these are
the pelvic floor muscles. Hold each contraction for as long as you
comfortably can, rest for a few seconds and repeat up to 10 times.
Try to avoid tightening muscles in your abdomen and buttocks. A
second exercise is to tighten the pelvic floor muscles quickly and
then at once let them go. Pause for a second, and repeat until the
muscles are tired.
Some authorities consider pelvic floor exercises to be straight-
forward; others see them as simple ideas but risky if they’re done
incorrectly. We recommend checking your technique with your GP
or continence nurse. Also, a lot of patience may be needed – a few
months of doing the exercises before they have an effect is quite
normal.

Bladder retraining
Retraining your bladder to ‘hold on’ for two hours is a realistic
aim. (Young bladders are typically elastic enough to manage four
hours comfortably.) The training involves a gradual increase in
the length of times between the first sign of wanting to urinate
and doing it – for example, perhaps 10 minutes holding on during
 Diet and digestion 25

the first week, then 15 minutes the next week and so on. Tech-
niques that help in holding on include distraction (sitting on a
firm chair, music, going through the alphabet thinking of first
names which begin with each letter) and contracting your pelvic
floor muscles.

Catheters versus incontinence pads

In her 2017 book How to Handle Later Life, Marion Shoard
argues strongly against the use of urinary catheters in normal
practice. Her main reasons are that catheters are a significant
source of urinary infections (which can be very serious) and that
they can interfere with the ability of bladders to return to func-
tioning normally after treatment. In contrast, incontinence pads
don’t cause infections if they are changed often enough and don’t
interfere with restoring normal functioning. They are also now
available in a wide range of sizes and shapes and can cope well
with much larger quantities of urine than used to be the case.
Shoard quotes from Royal College of Nursing guidelines, which
state: ‘Never catheterise or continue catheter usage for nursing
convenience’.

Bowels
Normal bowel movements vary considerably from one person to
another in frequency – from three times a day to once every three
days – but they should be comfortable to do, fairly firm and not
a strain. You may find the idea of not more than 80% effort as a
desirable maximum useful here.
The best position for bowel movements is described and strongly
recommended by Giulia Enders in her book Gut, the Inside Story of
Our Body’s Most Under-rated Organ. She calls this position ‘squat-
ting while sitting’, and it makes constipation, piles and diverticulitis
less likely by relaxing the relevant muscles and straightening the
part of our digestive system which leads into the anus.
To squat while sitting on a toilet, you lean forward slightly and
either put your feet on a low footstool or achieve the same effect by
raising your heels. A variation recommended by Enders for treating
persistent constipation is the ‘rocking squat’ – sitting on the toilet,
bend your upper body forward, then straighten, and repeat a few
times.
26 Physical and mental aspects of getting old

Constipation
Constipation means straining to pass stools or doing so less fre-
quently than is usual for you without another explanation, e.g. eat-
ing less. A change in frequency that persists may indicate a health
problem.
Drinking more and eating more fibre usually cures constipation:
we recommend increasing the amount of fibre you eat by small
amounts, and slowly! It is possible to experiment too enthusiasti-
cally with, for example, bran, become ‘blocked’, and need to see
your GP. Allow about 36 hours between an increase of fibre and
any effects.
Other sources of high fibre include flaxseed, wholemeal flour and
pulses and fruit and vegetables generally. Michael Mosley in his
book Clever Guts recommends seaweed capsules.
Chapter 3

Sleep

Poor-quality sleep contributes to accidents, bad decisions, illness,

etc. If you’re not sleeping well, you may wish to experiment with
some of the suggestions in this chapter.
As a guideline to a desirable amount of sleep, there is general
agreement that most people need seven to nine hours’ good-quality
sleep a night, but with wide individual variation. Feeling awake
during most of most days is a good sign that you sleep well enough,
and this is the case however much you experience your sleep as
fitful and broken. Conversely, daytime tiredness can be caused by
factors other than not sleeping well.

Improving your sleep

Advice on improving sleep is readily available, e.g. at www.rcpsych.
ac.uk and www.raysahelian.com/sleep. Small changes to diet, bed-
room environment, etc. can be very effective. In this section, we
suggest some other options for improving sleep quality and quan-
tity, some chosen as most likely to work generally, others as more
unusual and not widely known about. The approach is one of trial
and error, testing one change or technique at a time for several days.
They are an eclectic mix of options, some of which work for some
people. If you give them a fair chance and they don’t work, your
GP or other health professionals will have other suggestions, prin-
cipally counselling and medication. Sleeping pills should be taken
for very short periods if at all because of the risk of dependence,
the difficulty for some people of withdrawal and the sleep the pills
induce not being as healthy as natural sleep.
Insomnia is used as a general term for sleep difficulties, and
like others comes in varying degrees of seriousness ranging from
28 Physical and mental aspects of getting old

disabling to quite readily responding to relatively simple treatment.

The following suggestions for improving sleep quality are for you
to consider trying yourself. The first method is a general review or
audit which may lead to specific changes to try out. The others are
examples of such changes.

• Audit all the aspects of your life which may be affecting your
sleep. These may include where you sleep, e.g. how dark it is,
quality of mattress and pillows, how well or not you fit with
someone you sleep with, noise, temperature, how you prepare
(if you do) to go to sleep or to go to bed and so on. Review-
ing these aspects of your life can in itself be a powerful step to
improving your sleep.
• Reduce the amount of caffeine you drink (for some people caf-
feine has no effect at all on sleep, whatever time of day or night
they drink it, while others are very sensitive).
• What do you do in the hour or so before bed? It may be worth
trying a more relaxing routine than your usual, or creating
a routine if you don’t have one at all. Bodies and minds,
or at least some of them, prepare themselves for sleep both
through relaxation and the familiarity of a routine. They like
to know what’s coming. Other minds and bodies thrive on not
knowing.
• People who usually fall asleep easily don’t try to do it; it just
happens (alright for some!). One way of trying to do what they
do is to concentrate on what’s going on in your mind and body:
thoughts, feelings, sensations.
• A variation is trying to stay awake, which may seem paradoxi-
cal or perverse, but makes sense as a distraction from trying to
go to sleep.
• Get more exercise, but note that the time of day you do it may
make a difference.
• Reduce alcohol – it’s a sedative which tends to result in shallow,
fitful sleep.
• Try a writing exercise. There are many possibilities here, the
most effective for people in general being to write a specific and
achievable to-do list for the next day. Do this just before set-
tling down to see if you’ll sleep (but think of it as resting rather
than trying to sleep).
• Dim the house lights for the last hour or so before bed.
 Sleep 29

Snoring
Some of the main causes of snoring are smoking, drinking alco-
hol and being overweight. It is linked to heart disease and strokes
and can affect sleep quality. Other causes include some medications
and old injuries to the nose or jaw. It matters partly because it is
dangerous – see the section on sleep apnoea in this chapter. Effective
treatments follow from the causes and range from lifestyle changes
to surgery by an ENT surgeon.

Night cramps
Night cramps, usually in the legs or feet, are very painful but not
usually a sign of illness. To counter them, you might try sleeping
with your legs slightly raised; doing calf stretches during the day,
before bed and when cramping; doing squats; getting a massage;
and adding more magnesium (dark chocolate is a good source) and
potassium (e.g. bananas) to your diet.

Sleep disorders
Three sleep disorders – sleep apnoea, restless legs syndrome (RLS)
and REM sleep behaviour disorder (RBD) – are discussed next.
Accurate diagnosis of sleep disorders may require an overnight stay
at a specialist clinic which your GP refers you to. Diagnosis is com-
plicated by the same symptoms occurring in different disorders; for
example dream enactments occur in RBD, sleep terrors, Post Trau-
matic Stress Disorder, sleep apnoea, epilepsy and as a side effect of
some drugs or withdrawal from them. These disorders or causes
need different treatments.

REM sleep behaviour disorder

In REM sleep behaviour disorder (RBD), the paralysis which usu-
ally occurs during dreams is partial or absent, so that the dreamer
acts out aspects of their dreams. The movements in dream enact-
ments are typically flailing, kicking and jumping or sometimes div-
ing out of bed. The patient may also talk, shout, scream or wail.
Injury to oneself or a bed partner is quite common before diagnosis
and successful treatment.
30 Physical and mental aspects of getting old

The content of the dreams is quite often characteristic: the patient

is defending themselves or playing a heroic role. The dreams thus
have a threat at their heart and are often vivid and violent. They
are also remembered clearly when the dreamer wakes up and later,
unlike most dreams, which fade quickly.
A preliminary diagnosis of RBD can be made by asking, ‘Have
you ever been told that you act out your dreams?’ or to a bed part-
ner, ‘Have you ever known X to act out a dream, where acting out
means flailing or punching?’ A formal diagnosis of RBD requires an
overnight stay at a sleep clinic, where lack of muscle paralysis and
dreaming states are both monitored. Dream enactment does occur
in some other conditions, for example sleep terrors and PTSD,
which complicates the diagnosis.
There is currently no cure for RBD, but the symptoms can be
managed effectively. First, the bedroom is modified to make it safer.
For example, one or more inflatable mattresses can be deployed on
their sides or flat between the bed and wall(s), and furniture with
sharp edges can be moved away from the bed. Some people use a
sleeping bag.
Second, melatonin or clonazepam tablets are taken shortly before
going to bed. Clonazepam, a drug related to Valium, used to be the
first treatment to try, but debilitating side effects and withdrawal
problems are much more likely with it than with melatonin. Both
medications work, but some patients respond best to one or the
other or, in a few patients, to both simultaneously. Melatonin itself
comes in two forms, standard and slow release (Circadin), and
again each of these is most effective with different patients. Why
they and clonazepam work at all is so far not well understood.
A calm period before sleep is probably helpful. Another non-drug
treatment that is plausible but as far as we know has not been tested
rigorously is ‘lucid dreaming’, when the dreamer controls the con-
tent of their dream, in this case removing or reducing any threat
element.

Restless legs
Restless legs syndrome (RLS) is an intense and overwhelming need
to move your legs because of sensations variously described as tin-
gling, aching, burning, etc. It tends to come on while relaxing and
disappear when moving, but only very briefly, and to be worse at
night. It is much more distressing than the term ‘restless’ sounds and
 Sleep 31

can be very debilitating both in itself and because it disturbs sleep.

It affects 5–10% of the general population and is more common
with age.
The causes of RLS are not well understood but are seen as physi-
cal rather than psychological, with an imbalance of dopamine
(a neurotransmitter) and lesions on the brain stem possible expla-
nations. However, it may be that the same symptoms have different
causes in different people, and a wide variety of causes have been
suggested, e.g. low levels of iron, dehydration, too much exercise,
too little exercise, too much sitting, a side effect of some drugs and
some illnesses.
RLS is generally difficult to treat effectively. Apart from walking
and the treatments which follow from some of the possible causes
listed earlier, sufferers rub, bang and squeeze their legs; stretch their
calves and hamstrings; reduce smoking, coffee and alcohol con-
sumption; apply Pernaton gel; cup their hands over their mouths
and breathe in and out; and apply hot and cold packs. There are
also herbal treatments (which imply circulatory and neurological
causes if they work) and drugs. The drugs currently prescribed tend
to be needed in increasing doses and to have significant side effects.
(See the section on medication in Chapter 5.) Overall, the treat-
ments (alone or combined) do work sometimes, and generally it is
of course a matter of cautious trial and error and balancing poten-
tial risks and benefits.

Sleep apnoea
Sleep apnoea is the result of snoring that restricts breathing so much
that it deprives the snorer of oxygen. He or she stops breathing,
splutters or snorts, moves position, stops breathing again and so on.
The causes include sleeping on one’s back, a blocked nose, being
overweight, smoking, drinking alcohol, an underactive thyroid and
sedatives. The effects include daytime sleepiness and heart disease.
Diagnosis involves monitoring oxygen levels at a sleep clinic or at
home.
Treatments for milder cases follow directly from the cause or
causes for that person, e.g. losing weight or surgery on an injured
nose. More severe cases need a mask that pumps air quite gently
through the nostrils. This is uncomfortable and indeed intolerable
for some people, but can dramatically improve quality of life for the
snorer and other people affected.
Chapter 4

Memory problems and

dementia

In this chapter, we consider how our mental abilities might change

as we age and, in particular, the differences between forgetfulness,
Mild Cognitive Impairment and dementia. We also consider the
two most common types of dementia and support for people with
dementia and their carers.

Mental abilities and age

How do people who are old differ in their mental abilities and
characteristics from the young and middle-aged? Do they tend to
be more forgetful? Slower to learn new skills? Confused? Calmer?
Grumpier? Wiser?
In this section, we first note some of the numerous research find-
ings on such questions and then focus on strategies for coping with
those abilities that are declining, and retaining or improving the oth-
ers. If you compare the findings with your observations of yourself
and others, please bear in mind the following assessment from Patrick
Rabbitt’s 2015 book The Aging Mind, an Owner’s Manual (Profes-
sor Rabbitt’s spelling of ageing and ours are both correct). He wrote,

The more closely we study age changes the better we recognise

how slight they are, how very gradually they progress and how
they can be slowed and ameliorated and what are the best steps
we can take to cope with them.

Please therefore bear in mind that the slight differences in typical

performance between groups of people of different ages conceal
large individual differences and overlaps between the age groups.
Age, in Rabbitt’s expert view, is not a good indicator of ability.
 Memory problems and dementia 33

Finding 1 – intelligence test results peak in the late teens or early

20s, remain constant for five to 10 years then decline slowly,
with a slow acceleration in people’s 40s and 50s, accelerating
more sharply in their late 70s and 80s.

This statement is broadly true but complicated by varying pat-

terns and different aspects of intelligence – for example, in some
people speed of making decisions has a pattern very like that of
general IQ scores, while other people’s scores on this aspect of intel-
ligence remain very similar throughout long lives. Much depends
on how intelligence is defined.

Finding 2 – older people are more likely to forget things like

where their keys, glasses etc. are and why they’ve gone into
another room.

This kind of forgetting is true of many people in other age groups

too, indeed of people in general.

Finding 3 – older people tend to forget words, especially peo-

ple’s names. The particular word or name won’t appear, then
it suddenly does.

As with Finding 2, this is largely part of how memory works

and therefore true of people in general too. The differences between
forgetting in normal ageing, Mild Cognitive Impairment (MCI) and
dementia are discussed in the next section.

Finding 4 – older people can remember as long a list of ran-

dom numbers as younger people can. However, they tend to
remember them less well backwards and to be less able to
remember two sets of numbers when each is presented simul-
taneously to a different ear, when there is an interruption
between memorising and being asked to remember the lists,
or when trying to follow two or more conversations at once
(sometimes called the ‘cocktail party phenomenon’).

Rabbitt comments that old age ‘sharply degrades’ this aspect of

memory, so it is a rare exception to his general evaluation of the
differences as ‘slight’ and may well be familiar.
Findings 5–10 next are all slight differences.
34 Physical and mental aspects of getting old

Finding 5 – older people become less efficient at learning new

things but can still learn.
Finding 6 – older people are more inventive/resourceful about
strategies to help them cope with everyday memory problems.
Finding 7 – older people can remain competent in skills learnt
earlier in life if they have continued to use them.
Finding 8 – older people are less able to distinguish between
unfamiliar faces and between different facial expressions.
Finding 9 – older people report feeling happier.
Finding 10 – older people struggle more to stay alert when try-
ing to do difficult tasks for long periods.

Forgetfulness and age

Forgetting in normal ageing

One of the things we just have to accept as we get older is that we
may not be as mentally quick and agile as we once were. It is very
understandable to jump to conclusions and worry that this must
mean we are getting cognitive impairment or dementia and it could
therefore be downhill all the way. This is not necessarily the case, as
it is probably just normal ageing.
We generally wouldn’t expect to be as physically quick and agile
as we age, so most people cut themselves a bit of slack there and
simply accept it as normal ageing. Somehow the changes in men-
tal capacities can seem a bit more worrying, possibly because of
the fear of dementia and not being able to live an independent life
anymore.
Although the mental changes with normal ageing are a nuisance
and they might irritate you or others, they are not bad enough to
have a serious effect on your day-to-day life. You can still live an
independent life, and you don’t need to rely on others to stop the
gap. Normal ageing changes include the following:

• forgetting things occasionally

• slower reactions, thinking things through and decision making –
for example, not being able to multi-task as well as when we
were younger, being a bit slower to process things or react or
making ill-thought-through decisions sometimes
• communication problems – for example, taking a while to
think of the right word, getting distracted in conversations and
losing the thread sometimes
 Memory problems and dementia 35

• changed energy levels and mood – for example, not having the
energy or desire for some interpersonal meetings, not liking
your routines interfered with, having the odd off-day when you
just can’t be bothered with certain things

All of these things can show up more when we are tired, ill or over-
loaded. This is another reason to prioritise getting ft and healthy
and sleeping well – and to very carefully consider not taking on
more than you can comfortably cope with. Just because we man-
aged many roles and activities when younger doesn’t mean we have
to continue to do this as we get older. The assertive skill of ‘saying
no’, discussed in Chapter 11, can be invaluable here.

Forgetting in Mild Cognitive Impairment (MCI)

This is diagnosed by a doctor if they consider someone to have
more difficulties with their memory, thinking and mental process-
ing than would be expected for someone the same age. So it is more
than normal age-related changes, but it is not as severe as dementia
and is not a form of dementia, although, like dementia, it becomes
more common with age. Most people with MCI are over 70. There
are various tests that doctors can do to help them make this diag-
nosis. It may be caused by some underlying conditions that can be
treated – such as depression, a physical illness like thyroid disease
or infections or problems with hearing and sight. All the lifestyle
changes that reduce the risk of getting dementia (discussed later
in this chapter) will also contribute to reducing the risk of getting
MCI. Someone with MCI is at higher risk (than someone without
MCI) of getting dementia later, but it is by no means inevitable.
There is no specific drug treatment for MCI, but living a health-
ier lifestyle helps cognitive functioning. There may be local support
groups that your doctor can refer you to in order to help you man-
age day-to-day life issues and give support and encouragement for
lifestyle changes. On a practical, daily level, there are many things
that you can do to allow for any cognitive limitations and help you
stay living as independently as possible. These will be things that
keep you on top of daily routines and tasks and reduce some of the
stress and anxiety the condition may cause.
A general strategy for coping with forgetting is to appreciate that
it is an essential part of brains working well. Without it, we would
be quickly overloaded by the huge amount of new information
that we process every day. Instead, our brains select and interpret.
36 Physical and mental aspects of getting old

Moreover, not appreciating this and having recurring stressful

thoughts about getting more forgetful can itself interfere with mem-
ory. Sometimes we make jokes about this, saying, for example, ‘I’m
pretty sure that’s not an early sign of dementia’.
Two other general methods for improving our memories and
other cognitive skills are to sleep well and to check the side effects
of any medications. Then there are more specific ways of cop-
ing, e.g. repeating a new name shortly after being introduced to
the person whose name it is; sticky notes and diaries; having pairs
of glasses in more than one room; mnemonics; visualisation tech-
niques, although some of us lack this ability or have it only weakly;
and a healthy diet.
Psychological attempts at brain training in a general sense have
been ineffective so far, though some of its techniques have been and
are widely used. The idea of a ‘brain gym’ implies that it is just like
physical training and so, it is claimed, develops cognitive abilities and
also resists their decline as we get older. A sceptical position is gener-
ally held by researchers so far: that ‘brain training’ develops only the
ability to do the particular exercises or games practised, that at best
they can be fun to do and that they are unlikely to be harmful.
However, one strategy for improving mental skills is dramati-
cally stronger than any other, much more effective than ‘slight’ in
its effects on both physical and mental health, and inexpensive. This
strategy is aerobic exercise.

Aerobic exercise
Aerobic exercise is regular physical exertion which results in heavy
breathing and raised heart rate for a sustained period. You get
sweaty and breathless, but you can still talk in phrases or sentences.
It can be achieved in a variety of ways, the usual recommendations
being walking, jogging, running, cycling, dancing, swimming, etc.
Aerobic exercise benefits our physical fitness generally, e.g. heart
and lungs, but also, and substantially, our brain health and therefore
memory and other mental abilities.
One question about aerobic exercise is the optimum level of exer-
tion for increasing or maintaining good health. Our position is, as
stated in the five principles at the beginning of Chapter 1, in gen-
eral terms, to compete with yourself at a comfortable and enjoyable
level rather than strive to meet a level which is a guess and at best
an average, for example 10,000 steps and eight glasses of fluid a
 Memory problems and dementia 37

day. However, we realise that for some of us, competing with others
or with a standard set by others is very enjoyable and motivating,
and we suggest that if this is true of you that you also emphasise
self-care in an assertive way (Chapter 11). In particular, we want
you to judge well when you need to rest.
We also recommend checking with your GP or other appropri-
ately qualified health professional that what you propose to do is
likely to be safe and effective for you.

Dementia
The thought of getting dementia is frightening. It is not just the fear of
getting it yourself, but also the concern about a partner or loved one
becoming demented and you taking on the role of carer. These fears are
entirely understandable as it is never what anyone wants in old age –
one’s world can be turned upside down by a diagnosis of dementia.
This is a good reason to become more familiar with dementia
and what can be done to prevent it or manage it.

Risk factors
• The biggest risk factor is age – it is more common over the age
of 65 and the risk of being diagnosed with it increases with
each decade. Although it is estimated that about one in six
people over 80 get it, this still means that five out of six people
don’t, which is the vast majority.
• Overall, more women than men get dementia, and certain
ethnic groups are more at risk – African, Afro-Caribbean and
South Asian people have higher rates than white Europeans.
• Inheriting it is very unlikely – and in these rare cases, it is usu-
ally in people under 65. So just because your parent had it in
old age doesn’t mean you will get it too.
• All the things that affect heart and cardiovascular system health
will also affect your brain health. About one in three cases of
dementia are now thought to be preventable, and risk factors that
can be changed include poor physical health, smoking, obesity, lack
of exercise, high alcohol intake, high blood pressure and diabetes.

Types of dementia
Dementia is a term used to describe a set of symptoms that occur
when brain function is affected by an underlying progressive disease.
38 Physical and mental aspects of getting old

The symptoms can vary in each type of dementia and in each indi-
vidual person, but they generally are to do with:

• memory problems
• thinking and communicating problems
• confusion and disorientation
• changes in personality and mood swings

There are many different types of dementia, but the most common
types are Alzheimer’s disease and vascular dementia. Dementia with
Lewy bodies and frontotemporal dementia are two examples of the
rarer types of dementia. Some people have a mix of types of dementia –
most commonly a mix of Alzheimer’s disease and vascular dementia.

Alzheimer’s disease
This is the most common type in the UK and is associated with a
build-up of protein-based ‘plaques’ and ‘tangles’ in the brain. These
interfere with the proper functioning of nerve cells in the brain and
eventually cause death of some of the cells. In addition, there is dis-
rupted chemical messaging in the brain.
Alzheimer’s disease usually comes on slowly, often with mild
memory loss. This progresses, and other symptoms such as dif-
ficulty with language, confusion and changes in personality or
mood swings can occur. The slow pace allows for years of inter-
esting and productive life, especially with carers who under-
stand the need of the person with dementia for sameness in their
surroundings and routine. This aspect of dementia is vividly
described by Wendy Mitchell in her book Somebody I Used to
Know, and Nicci Gerrard in What Dementia Teaches Us about
Love. Also recommended are not arguing with or correcting the
accuracy of the person with dementia’s statements and instead
focusing on their emotions and topics that interest them, e.g. on
reminiscences stimulated by a photo or piece of music and the
other activities recommended in the section on non-drug treat-
ments later in this chapter.

Vascular dementia
This dementia is due to interrupted blood supply to the brain, which
can cause brain cells to die. Vascular changes can be caused by a
stroke (called post-stroke dementia) or after a series of mini-strokes
(called multi-infarct dementia). Another variant is subcortical
 Memory problems and dementia 39

vascular dementia, which is due to poor blood supply to deep parts

of the brain.
Vascular dementia can come on either suddenly or in stages, and
the symptoms depend on which part of the brain has been dam-
aged. However, common early symptoms are problems with think-
ing and planning and difficulty concentrating. There may also be
changes in mood. Unlike Alzheimer’s disease, memory loss is not
such a common early feature.

Getting a diagnosis of dementia

If you are worried about early signs of dementia in yourself or a
partner, then see your GP. GPs are the first point of call for getting
a diagnosis of dementia and excluding other potential causes of
dementia-like symptoms. Sometimes conditions such as infections,
thyroid disease or depression can affect memory, thinking skills and
behaviour and can look like dementia.
Your GP may refer you on to a memory clinic or another hospi-
tal specialist for further investigations. Getting a correct diagnosis is
important as it then allows you to access the dementia support ser-
vices in your area and get treatment, if applicable, as early as possible.

Treatments
Sadly, there is no known cure, as yet, for dementia. Treatments that
are available are to alleviate symptoms and to slow down the prog-
ress of symptoms.
There are four main approaches:

• drug treatments for the chemical changes in Alzheimer’s disease

(and sometimes other rarer dementias)
• drug treatments for underlying conditions that cause vascu-
lar dementia (such as hypertension, high cholesterol, diabetes,
etc.); the specific dementia drugs for Alzheimer’s disease don’t
work for vascular dementia
• lifestyle changes to try to limit the progression of vascular
dementia (this would be all the things that help the underlying
conditions, for example not smoking, eating a healthy diet and
getting enough exercise)
• non-drug treatments of dementia

There are a number of approaches that help to stimulate your brain

and help improve quality of life for people with dementia.
40 Physical and mental aspects of getting old

Examples are:

• Music, dancing and creative arts – sessions are led by a pro-

fessional either one to one or in groups. Engaging in these
activities can help stimulate the brain and improve mood and
expressiveness. It has been shown that memory for music and
songs can remain relatively unaffected by dementia.
• Cognitive stimulation therapy – this can be a set of different
activities (word puzzles, music, talking about memories or
current affairs, etc.) aimed at stimulating brain function and
improving some dementia symptoms.
• Cognitive rehabilitation – where people with dementia can
work with a professional in order to achieve a particular goal
that would be useful. This could be a practical skill or learning
something new.
• Looking back at your life history and reminiscence activities –
working one to one with someone else on memories from the past
is a useful way of improving memory, mood and general wellbeing.

Prevention – keeping your brain healthy

All the things that we can do to stay generally fit and healthy will
have a positive impact on our brain health and help prevent or delay
dementia.
It is not too late to adopt a healthier lifestyle as we age. This
includes the following general points:

• eating a healthy diet (see the section on diet in Chapter 2)

• maintaining a healthy weight
• not smoking
• moderating alcohol intake
• staying physically active
• keeping up with social activities and friendships – in groups
as well as one to one (this requires concerted, active manage-
ment as we age, as we may not have as many social interactions
available ‘on tap’ as we might have had when we were younger,
perhaps from a job or immediate family).
• doing things that stimulate your brain and use different parts of
your brain – a variety of hobbies and activities that you enjoy
and that keep you engaged and active (learning a language, for
example, can be a great all-round brain stimulator)
 Memory problems and dementia 41

• making sure any underlying health issues you may have are being
actively managed by you and your doctor, especially conditions
like diabetes, high blood pressure and high blood cholesterol

Support for people with dementia and their carers

Most people will have little knowledge of what services are avail-
able for people who are diagnosed with dementia or their carers,
unless they have been directly affected by it already, perhaps when
an elderly parent had dementia.
Seek advice from your GP on what services there are in your area.
These can include:

• Health services – these can include a range of nurses and allied

health professionals who may help with specific needs related
to your physical and mental health.
• Social services – including a range of services from help around
the house and making living arrangements safer and more
dementia friendly to providing places in day centres and sup-
port groups. You would need to contact your local authority
social services to arrange an assessment of your needs. They can
then set up a support plan to address your needs.
• Charities and not-for-profit sector – national organisations
such as Age UK, Dementia UK, Alzheimer’s Society, Carers UK
and Carers Trust can be very helpful sources of information
about dementia and also can signpost you to their local and
national services. These range from dementia advisors, nurses
and support groups to day centres and advocacy services.
• Specific support for carers – it is very important to find out
what advice and support there is in your local area to help you
if you are in a carer’s role. It is easy to gradually take on a carer
role and not realise the rising toll this may have on your mental
and physical health. When the focus is mainly on the person
with dementia, it is easy to lose focus on your own needs. Not
only can your GP be of help and ensure you are on the practice
carer’s register, but they can also advise you of other services
that may assist. Social services, for example, can arrange a car-
er’s assessment to help map out what care and assistance you
may need in your caring role. Many of the charities mentioned
previously have specific support and advice for people in a car-
ing role; for example, Dementia UK Admiral nurses can sup-
port families who are looking after a loved one with dementia.
Chapter 5

Looking after your health

Patients as active participants in
decisions about their healthcare

Our aim in this chapter is to help patients who wish to be more

active in consultations about their health with health profession-
als. This approach is consistent with the 2018 guidance from the
Academy of Medical Royal Colleges on the kinds of information
that should be discussed in consultations. To summarise these, the
Academy uses the acronym BRAN, which stands for Benefits, Risks,
Alternative treatments and the likely consequences if you choose to
do Nothing – the wait and see option.
Taking an active approach requires being assertive with health
professionals, as in these examples from two patients. The first is
about an underlying attitude, which would probably make assertive
behaviour more likely; the second is an example of expressing that
attitude.
First patient: ‘I believe in standing up for myself and asking for
details and a second opinion if it feels like a good idea. I understand
that the staff are very busy, but it’s my health that’s at stake here’.
The second patient put a big card at the head of her hospital bed
that read:

Who are you?

What is your job?
What treatments are you considering for me?
Are there other possibilities?

Each of these examples will appeal more to some people than oth-
ers, but they illustrate the spirit of patients being active participants
in decisions about their health and can clarify how assertive we
ourselves might want to be. Here, two central considerations are
1) the fnal assertive right of those listed in Chapter 11: that we
 Looking after your health 43

have the right not to be assertive, and 2) that the aim is for patients
and health professionals to listen respectfully to each other and
indeed to collaborate. The information in the rest of this chapter is
intended to contribute towards such discussions between patients
and health professionals.
To the same end, the National Institute for Health and Care
Excellence (nice.org.uk) provides detailed guidelines for treat-
ing some illnesses, and health professionals are expected usually
to implement these with the informed agreement of the patient or
their representative. Health professionals may also use their clinical
judgement, but if they don’t follow the NICE guidance may have
to justify their decision to colleagues or professional organisations.
The NICE guidance is available on the internet in two forms: for
the general public and for health professionals. We suggest consult-
ing both forms.
Next we discuss four further aspects of medical treatment,
knowledge of which can contribute to being an active participant
on behalf of ourselves or others: doctor-patient communication,
prescription drugs, health screening and miracle cures.

Consulting a doctor
Years ago, there were older people who were reluctant to ‘bother
the doctor’ and would struggle on, trying to sort out their symp-
toms themselves. It may be difficult to believe this now that many
GP surgeries are bursting at the seams with patient requests to be
seen – and some people have to wait weeks before they can get a
routine appointment.
Most older people have now lived most of their lives with a UK
NHS system in place, so the old potential reticence about seeking
help from a doctor (who had to be paid) has diminished, and there
are higher expectations of what our healthcare system can offer us.
However, going to see a doctor is not necessarily a straightfor-
ward thing – and the following points may be helpful for older
people who need medical help:

1 Some people are still rather reticent about consulting a doctor

for various reasons – not wanting to bother them may be still
partly an issue, but also there may be an element of not wanting
to face up to whatever symptom is bothering them and what it
might really mean to their health and life. The truth is that GPs
44 Physical and mental aspects of getting old

are there to be of help: that’s their job, and they want patients
to come to them with their health worries. Most of them would
rather be consulted earlier when treatment might be easier or
more effective, rather than wait for things to get much more
serious. GPs also understand that a part of their job is helping
people who are the ‘worried well’, who don’t actually have any
serious health issues but need their reassurance nonetheless.
2 After the birth of the internet and the copious information on
health issues that anyone could easily get hold of, some people
would arrive at their doctor’s surgery with an armful of paper,
convinced that they were up to date with the latest information
on what they believed was wrong with them. While it must be
a little frustrating for doctors to be presumed less knowledge-
able on medical matters than their patients, there is a balance
to be had here. It is a good idea to do a bit of homework on
your health concern before seeing your doctor – mainly so you
can understand the area better and think of what questions you
may wish to ask your doctor. It may help to write down all the
questions you have so that you don’t forget to ask when you are
under the spotlight. Doing a bit of homework may also give you
a better idea of the range of healthcare practitioners who deal
with different aspects of care of your condition. Many people,
understandably, have no idea what healthcare services are avail-
able to them until they need them.
3 If you are particularly worried about your situation and think
you won’t be able to take on board what your doctor might
say, or don’t feel you’ll remember to ask enough questions, then
take a friend or relative with you into the consultation room
as an extra pair of ears and eyes. They may help to jot things
down to help you remember and act as some moral support at
an anxious time.
4 If you are referred to a specialist at a hospital, then, again, it
may help to do a bit of homework on understanding that part
of the NHS. All NHS Trusts have websites that explain how
services are delivered, who is in that department and who else
works alongside them. Many services are now grouped into
condition-specific clinical networks where all the relevant
healthcare providers work together to offer a more seamless
service for patients – for example, cancer networks and cardiac
networks.
 Looking after your health 45

5 In some situations, you may want to get a second opinion. It

doesn’t necessarily mean you would need to pay for a private
consultation – you could ask to see someone else in your area
of the NHS. Before doing this, make sure you’ve asked all the
questions you are worried about and that you’re as satisfied
with the first doctor’s answers as seems realistic. Some people
worry about appearing pushy or a nuisance and taking up time,
but it is fine to ensure you’re satisfied with your diagnosis and
care. Don’t assume that going privately will mean better care
than in NHS settings – any doctor should be working to the
latest clinical guidelines.

Prescription drugs
Prescription drugs can save lives but, like screening, diagnostic pro-
cedures and other treatments and operations, they come with risks
as well as benefits.
Part of your doctor’s job is to assess whether the benefits of tak-
ing a prescription drug are likely to outweigh the risks for you.
There are some categories of drugs which can have quite severe
side effects, dependence issues or withdrawal problems. Examples
are opioids (used as pain killers), benzodiazepines and some anti-
depressants. The days of anxious housewives being dependent on
benzodiazepines (like Valium) due to over-zealous prescribing are
fortunately mainly a thing of the past. However, there are still many
patients who put off taking or continuing with antidepressants, for
example, because of intolerable side effects.
Patients who are concerned about the side effects and withdrawal
problems of taking a drug they are prescribed can take some or all
of the following steps:

1 Look up the prescribed drug on MedlinePlus and the NHS

website. The most relevant information to look for is generally
1) how long on average it takes to have the various benefits,
2) the most likely side effects and the most serious, 3) whether
starting with a lower dose than the standard one is feasible –
older people tend to be less able to metabolise drugs, and the
standard dosage is usually based on samples of young, healthy
males, and 4) any problems with dependence and the resulting
difficulties with stopping taking the drug.
46 Physical and mental aspects of getting old

2 Ask your GP about any of the answers you found that you
wonder about, plus the risks of not taking it, and possible inter-
actions with other drugs you are taking, including herbal medi-
cines. Older people tend to take more than one drug at a time,
and indeed five drugs is quite common. This is partly because
some drugs, e.g. statins, are prescribed to millions of people to
try to prevent particular illnesses, and some are treatments for
side effects of others.

A lot of these questions are answered by the leafets enclosed

with prescription drugs. This information is clear but understand-
ably very concise, and by the time you get the leafet you may
already have the drug and may decide not to take it. It will then be
wasted – the NHS spends many millions of pounds a year on sub-
scriptions for people who do not take their prescriptions, a deci-
sion which may be healthier for these patients but is very wasteful
for the NHS.

Safe withdrawal from some prescription drugs

Large numbers of patients are dependent on the antidepressants,
pain killers and benzodiazepines mentioned earlier. Professor
Heather C. Ashton’s Manual, which is available free on her web-
site, benzo.org.uk, is a very clear, practical and authoritative guide
to withdrawing safely from benzodiazepines, e.g. clonazepam and
Valium. It also illustrates the principles of safe withdrawal from
addictive drugs generally. The central element is making very small
reductions at the right pace for the individual patient while treating
withdrawal symptoms like nausea, insomnia and rebound anxiety
if necessary.

Avoiding prescription drugs

Many health conditions are caused by or made worse by our life-
style choices. It makes sense to target the cause of our condition
if at all possible, rather than just treat the symptoms with drugs.
Having a prescription written for symptoms is the quickest route,
but proper advice and support on lifestyle changes can take much
more time and patience, for both the health professional and
the patient. Many of the major disease issues for older people
 Looking after your health 47

have a recognised lifestyle element to them, and this is included

in clinical guidelines for the management of the condition. In
many cases, lifestyle changes are advised to be tried first rather
than going straight to medication. Examples are the prevention
of cardiovascular disease and prevention and treatment of type
2 diabetes.
As an active participant in our health, it is important to recog-
nise the degree of influence we have over our health and healthcare
choices. Actively focusing on our lifestyle and getting the support
needed to make healthy changes can make all the difference, not
just to how we feel each day but to how many drugs we have to
take. It is not a foregone conclusion that older people need to be on
a medley of prescription drugs.

Health screening

The intuitive appeal of screening

It is understandable why people want to be screened. Mainly it is
because they want to be reassured that they don’t have a poten-
tially serious health problem. There’s enough in life to worry
about, and so getting tested or screened can help many people
allay their fears and worries about their health. Intuitively, it
makes sense that if diseases can be picked up early enough, then
they can be more easily treated. This becomes even more pressing
if the person has experience of someone close to them, maybe a
relative or friend, who has had the disease or died of it. All of this
can blinker people to the whole picture of screening, including its
potential downside.
However, it is very important to recognise that screening is a bal-
ancing act: overall, is it likely to produce more benefit than harm?
This is why screening needs to be taken very seriously and why, for
example, the UK NHS set up a robust system for evaluating poten-
tial screening tests and programmes. The UK National Screening
Committee (NSC) is the NHS body that oversees policy on screen-
ing. It ensures that the science and evidence have been thoroughly
assessed before a screening test or programme is recommended for
use on NHS patients.
It publishes on its website a list of conditions for which poten-
tial screening tests or programmes have been assessed. These are
48 Physical and mental aspects of getting old

regularly updated as more evidence or decisions become available.

Current (2020) recommended screening programmes for adults are:

• abdominal aortic aneurysm (AAA) (men over 65)

• bowel cancer (men and women 50–74)
• breast cancer (women over 50)
• cervical cancer (women 25–64)
• diabetic retinopathy (for people with diabetes)

See legacyscreening.phe.org.uk for the latest information on screen-

ing programmes and www.gov.uk/phe/screening-leafets.

Accepted principles for healthcare screening

Screening is a balancing act between the potential benefits it can give
and the potential harms. This is the case for any healthcare interven-
tion, but the difference with screening is that it is healthy, asymptomatic
people who are usually offered it. This makes it even more important
that the benefits outweigh the harms. There are a number of accepted
principles of screening that health professionals should subscribe to:

• Only offer screening if there is proven evidence that, overall,

the benefits of screening outweigh the potential harms. This
means that screening should not be offered if there is evidence
suggesting that screening is not beneficial or there is absence
of known evidence (i.e. either the research is not sufficient yet
or it hasn’t been properly assessed against all the good practice
screening criteria).
• Screening should only be offered if it can fulfil the relevant list of
criteria for a worthwhile screening programme. These are well-
established criteria, accepted by the World Health Organisation.
The NHS National Screening Committee uses an expanded ver-
sion of them to appraise all potential screening programmes.

The potential pitfalls of screening

Not knowing enough about the potential downside of screening

There are two great problems concerning the downside of screen-
ing and testing. The first is that not many people know about the
downside or understand it. The second is that many proponents
 Looking after your health 49

(and sellers) of screening tend to play it down or don’t mention

it much at all – instead they are more interested in the potential
benefits. There is probably a third problem as well – if a patient is
particularly anxious to be reassured about their health, they might
choose to turn a blind eye to potential harms of screening.
The following are examples of issues that need to be considered
before undergoing screening.

How important is the condition being screened for?

There is little point screening for conditions:

• that aren’t really all that significant to one’s health

• that could be more easily prevented in the first place
• where not much is known about the natural history of that
disease (e.g. how rapidly it progresses in most people and how
often it is very serious or fatal)
• where there is no known proven treatment or no agreed treatment

Offering screening for these sorts of conditions or diseases is

likely to be of no real beneft to the patient. It may be wasting
their time and raising false hopes and expectations. There’s little
point offering screening when it is not clear whether it will really
make a difference to their health and when it is not clear how any
disease picked up will be treated. If early diagnosis does not result
in better health outcomes, then really all one is doing is giving
someone a diagnosis to worry about for longer (and possibly sub-
jecting them to a host of investigations and invasive treatments
along the way).

Is the screening test good enough?

• Screening should be avoided if the screening test has not been
properly tested for safety and the screening test is not sufficiently
precise or accurate. Not all screening tests are harmless – it is
possible to have a test that, in itself, is too risky to perform on
otherwise well people.
• The screening test is not very good at detecting the condition
(so produces too many false negative results, i.e. missed cases).
This can lead to false reassurance. As a result of this, people
might stop making an effort to keep up their healthy habits and
50 Physical and mental aspects of getting old

behaviours. They may think they are no longer at risk. Exam-

ples are drinking habits, smoking, exercise and diet. This could
therefore put them at even greater risk of the disease being
screened for.
• The screening test is not very good at sorting out who hasn’t got
the disease (so produces too many false positive results). This
can lead to people having to be referred on for further investi-
gations and diagnostic tests when they are actually disease-free.
Not only does this cause anxiety, but also the investigations and
diagnostic measures can be quite invasive and even have their
own risks and side effects. For example, prostate biopsies might
be required for patients who have a raised PSA test, and there
is a risk involved in this. One of the reasons why it took a long
time for the NHS to decide to run the bowel cancer screening
programme was because of the risk that is involved in carry-
ing out colonoscopies on patients who are FOB (faecal occult
blood) test–positive.

Screening is only worthwhile if it gives a measurable benefit to the

patients screened. The most obvious benefit is if screening stops
people dying from the disease. There is little point picking up dis-
eases early if there is no effective early treatment available that can
make a real difference to that person’s health. If the outcomes for
screen-detected patients are no better than those of patients who
present later on with symptoms, then screening is not worthwhile.
Sometimes the research shows differing benefits for different
age groups or sexes – e.g. abdominal aortic aneurysm screening is
only considered worthwhile for men aged 65 and older – screening
women and people younger than 65 does not give an overall benefit
to patients and may even on balance do them more harm than good.
When patients who are otherwise healthy go for screening tests,
they may end up with a test result or diagnosis that not only
causes them anxiety but can also mean that other things are affected
that they hadn’t even considered. For example, their insurance sta-
tus, employment opportunities and medical fitness to carry out cer-
tain activities (e.g. driving or operating certain machinery) might
be affected if they or their doctor are asked to declare their health
status. This may be considered a worthwhile downside if the overall
results of screening benefit the patient’s health and life, but it would
be a significant drawback that needs considering if there are no
other benefits obtained from screening.
 Looking after your health 51

There is little point picking up potential problems if there are no

agreed ways of investigating them further. There needs to be agree-
ment right along the screening ‘pathway’ about who is going to do
what with screen-positive patients. Otherwise, patients’ anxieties
will be raised that they have a positive result, but then they will not
be investigated and diagnosed in a streamlined and efficient way.

Miracle cures – what works?

The modern digital world is full of information only a few clicks
away. Being able to instantly ‘Google’ the answer to almost any ques-
tion is taken for granted these days. It is easy to see the advantages
of this international storehouse of information, but there are clear
downsides when you are looking for answers to health questions.
It is worth considering the following broad points when trying to
find out if something is all it’s cracked up to be.

Advertising and marketing

Don’t confuse good advertising and promotion with actual product
efficacy. There is an art and science to marketing, and although it is
illegal to sell things on false claims, there are some grey areas where
it comes to health products. Some years ago, there was a crackdown
in the UK on how certain ‘alternative’ products were marketed, and
they were no longer able to make health claims on the packaging
and information leaflets. Many had to label themselves as ‘tradi-
tional treatments’ and were not allowed to make bolder claims of
efficacy on health-related conditions. Despite this, if there is a good
advertising campaign or convincing, appealing packaging, it is easy
to believe that the product must be good.

Beware the source

In pre-internet times, it was perhaps easier to see who or what the
source of information was and make your own assessment. Hav-
ing someone in a pub spouting his latest theory on x, y or z was at
least overt, and many people would take it with a large pinch of
salt. But when everything is in printed format and appears on an
impressive-looking website, it can be more difficult to see through
it so readily. Anyone can set up a website on their PC at the kitchen
table, and say they are an international company and experts in
52 Physical and mental aspects of getting old

whatever they choose. They may have almost no credibility under

scrutiny, but on your computer screen they look as authentic as the
next one. It is wise to check out other sources of information, and
even though there has been a lot of ‘expert bashing’ in recent years,
there is some comfort in listening to more traditional sources of
information, where there is professional regulation and peer scru-
tiny. Sometimes the old saying is helpful – ‘if it sounds too good to
be true, then it probably is’.

Organised systems for reviewing health

information in the UK
In the UK, there are well-established, non-commercial organisations
and bodies whose purpose is to systematically review published lit-
erature on given health subjects. These use tightly run methods that
seek out and sift through a myriad of published information, make
sense of it and report the findings so that they are usable for policy
makers and clinicians. These often involve ‘meta-analysis’, which is
a way of combining the results of individual studies to produce one
statistic. There are strict criteria for what is considered acceptable
data and what is not. The work is done by trained experts in data
review and analysis, overseen by independent panels of experienced
professionals in the relevant fields as well as lay members.
Examples are the National Institute for Health and Care Excel-
lence, NICE (which is a public body funded by the Department of
Health and Social Care), and the Cochrane Library and its Reviews
(which are independently funded and non-commercial). The reviews
often include a health economics view of the subject, as many new
treatments are expensive and the question needs to be addressed – is
this treatment worth it in terms of its cost, relative to its reported
outcomes for patients? Unless a health system has an unlimited
budget, decisions have to be made on which treatments or preven-
tion programmes are the most worthwhile, relative to everything
else that requires funding.
Although these reviews are mainly aimed at professionals, they
are published and accessible to all on the web and in printed for-
mat. Some of the detail will, of course, be beyond the general
understanding of a lay person, but they are usually written in plain
English, and the summaries and recommendations are clear enough
for most people to comprehend.
 Looking after your health 53

Other useful sources of information are the reports of expert

committees on specific health subjects that are produced by the var-
ious Royal Colleges and Faculties for different healthcare profes-
sionals (e.g. the Royal College of Physicians, the Royal College of
Psychiatrists, the Royal College of Nursing). Again, many of these
are accessible on the web to everyone, and summaries and conclu-
sions will be generally understandable by a lay person.

Lack of evidence or evidence of lack?

There is a big difference between these two, and yet they often end
up conflated. Some reviews of the literature are able to show that
there is little or no benefit for certain health treatments or preven-
tive measures. This is based on published data and is a useful finding
that can guide your healthcare decisions. This is evidence of lack (of
effectiveness).
However, there is a wide range of things for which there is simply
lack of sufficient evidence with which to make a decision on effec-
tiveness and outcomes. The reason for this can be because good-
enough research has simply not been done or published. There have
been many discussions in academic circles about the implicit bias
to publish research that has positive results, and so research that
shows that something doesn’t work is considered less interesting or
newsworthy.
Another reason for lack of evidence is that the thing being looked
at is inherently difficult to study – perhaps because it is difficult to
strictly define or standardise treatments or find suitable controls or
dummy treatments to compare it with. This can also cause difficulty
obtaining research grants. A bigger problem is where the treatment
or intervention is working in a different type of paradigm, i.e. one
that is outside the usual biomedical model that most doctors use.
Examples here are research on things that are primarily working on
an energetic level rather than a material level, such as acupuncture
and homeopathy. Interestingly, physicists are scientists who continu-
ally have to review their notions of what is possible and acceptable –
as they expand their knowledge and start to look sub-atomically,
they find that solid matter is no longer relevant and energy, waves
or fields become more appropriate. Traditional western medicine
hasn’t quite kept pace with this ‘physics open-mindedness’ despite
the increasing use of many diagnostic and treatment techniques that
54 Physical and mental aspects of getting old

are almost entirely modern physics–based, like MRI (magnetic reso-

nance imaging) scanning.
This lack-of-evidence issue can therefore leave a type of ‘knowl-
edge vacuum’, and it is easy for people to rush to fill it with their
own theories and claims. It is also easy for others to say that some-
thing is rubbish or quackery, based on prejudice and lack of data.
This leaves the lay person in a difficult position of having to make
their own mind up. Some people are more open to understanding
different, alternative paradigms and are happy to look at older, tra-
ditional healthcare approaches such as acupuncture, Ayurveda or
homeopathy.
Ultimately, it is prudent to take a balanced view and trust your
own judgement based on your own experiences, and only try things
that are unlikely to cause you harm.
Section 2

Social and psychological

aspects of getting old
Chapter 6

Attitudes towards
getting old

Much has been written on this topic, but it is not examined and dis-
cussed as overtly as it should be in everyday life. It largely remains
implicit and often hides in the shadows of assumption and prejudice.
The Equality Act of 2010 in England and Wales has nine strands of
equality, and one of them is age. Although it is illegal to discriminate
against people purely based on their age, it is difficult to enforce
this on a day-to-day basis, especially in multi-factored situations
where you can’t quite put your finger on what is going on. Overt
age discrimination in more formal settings (like job interviews) may
be easier to detect and deal with, but the subtler, everyday experi-
ences of age discrimination and prejudice often fly below the radar.
It is much the same for the other aspects of equality where people
are more likely to be discriminated against, like gender and ethnic-
ity, for example. Of course, for an individual, they are always the
sum of many parts – and it can be difficult to untangle the effects.
The day-to-day experiences of, say, an older, Asian woman of lower
socio-economic class in the UK will no doubt be very different from
those of a middle-aged, white, middle-class man.
One way of looking at this in a personal context is to consider
firstly what seems to be the attitude of others towards getting old
and, secondly, what your own attitude to ageing is.

Others’ attitudes towards getting old

Others’ attitudes are both from your more ‘immediate others’ (the
people you directly live and work with) and the culture and society
you live in. It is difficult to live in a culture that exhibits negative
attitudes towards ageing and not absorb some or all of it. The rea-
son that age is part of the Equality Act is because it is an undeniable,
58 Social and psychological aspects

active area of prejudice and discrimination in our culture. We are

culturally looking at people though ‘age-tinted’ lenses that distort
and diminish the reality. This is an area that is included in studies
in sociology, psychology, politics, economics, marketing, philosophy
and more – asking why, as a society, do we diminish and devalue
people simply based on their age? What’s wrong with getting old?
Like other aspects of life, we often aren’t aware of the degree
of the issue until it actually affects us or someone very close to us.
For example, most people don’t notice the difficulty of accessing a
particular building for someone with limited mobility or in a wheel-
chair. So much of life can be taken for granted – until, sometimes
suddenly, it can’t. Ageing happens gradually, but many people may
remember the first time they noticed an effect of being discrimi-
nated against or just treated differently due to their age.
Sometimes it is simply feeling ‘invisible’. Some older women,
in particular, may remember the first time this happened – either
standing at a busy bar trying to get served or walking down a
street and feeling what it is like to be unnoticed. This can be
particularly strange if, when younger, they had a sense of being
‘attractive’ and responded to. On the other hand, some women
may rather enjoy their newfound invisibility and being left alone
and no longer ‘eyed up’.
If one looks hard enough, there are no doubt many examples of
subtle discrimination against older people in, for example, goods,
services and policies. Caroline Creado-Perez’s excellent book Invisi-
ble Women recently won the prestigious Royal Society science book
award. She describes how much of life is ‘one size fits men’ – and
shows examples of everyday bias against women in many areas of
design and policy. A similar book could be written focusing on age
rather than gender, and it would be interesting to overtly uncover
the implicit everyday bias against older people. Most if it is prob-
ably mainly because the needs of older people are simply not kept
in mind. It is highly unlikely to be a positive effort to exclude, dis-
criminate or show disregard to older people. Examples of ‘everyday
disregard’ are making the assumption that everyone is able to con-
duct their affairs online with access to a computer or smartphone;
not supplying frequent-enough buses for out-of-town locations; or
designing packaging for products with use instructions in a tiny,
pale and therefore illegible font.
Sometimes it is something as basic as language that belies preju-
dice. We, all of us, need to notice and modify our use of ageist
 Attitudes towards getting old 59

language, e.g. ‘you’re moaning like an old woman’, ‘the place was
full of little old ladies’, ‘they were just a bunch of old biddies’, and
so on. These examples also add the familiar gender element too.
It is interesting how languages differ in describing age. In Ital-
ian, for example, one doesn’t ask ‘how old are you?’; they literally
say, ‘how many years do you have?’ The reply is, ‘I have x years’.
Saying ‘I have 70 years’ (ho settante anni) feels less defining than ‘I
am 70’ – it is more of a useful acquisition than an identity. Defin-
ing ourselves simply as a number is reductive; human beings are
so much more than that. Similarly, filling in forms can make one
feel very simply ‘categorised’. Instead of having an occupation and
being asked what it is, older people are often forced into ticking the
box that simply says ‘retired’. A retired what is not required – just
‘retired’.
These things may seem subtle and, arguably, trivial in isolation,
but they all add up to an overall ‘drip, drip, drip’ felt sense that can
be very uncomfortable. This is why it is important for us to look
to more positive examples of ageing and the real-life advantages it
can bring, being more aware of societies and cultures that have a
more respectful and honoured attitude to ‘having years’. It is also
why it is advantageous for us all to find and keep in mind positive
role models for ageing and to make our own inventory of all the
benefits of ageing. How we manage our own personal attitudes to
ageing can make all the difference.

Our own attitude towards getting old

Our own attitude will be a mix of our general, intrinsic beliefs,
assumptions and experiences about getting old plus the conditioned
beliefs and judgements that we absorb from the world around us.
Our environment no doubt shapes our own beliefs, but we do have
some choice in the personal arena. We don’t have to accept the atti-
tudes of others and make them our own. We don’t have to behave
as if they were true.
It may help to put your own beliefs and attitudes under the spot-
light. What do you believe about getting old? The trouble with per-
sonal beliefs is that they feel true, like facts – but the reality is they
may not be. This is both good news and bad news. The good news is
that we can decide if our current beliefs and attitudes are empower-
ing and helpful to our lives or not. If not, then consider what would
be a more empowering and helpful belief to have instead. Who do
60 Social and psychological aspects

we know who has a more helpful belief system than we do – and

how does that work for them? We can work out what we have to
think and feel, and so start to change our beliefs. It is hard work
and requires a lot of support, encouragement and practice, but it is
worth it.
The bad news is that many people can feel unsettled and rather
rattled at the prospect of unpicking beliefs they’ve lived by for a
very long time. This can be especially difficult if you are surrounded
by significant people in your life who feel rather threatened by you
changing. Getting around people who have more empowering atti-
tudes and habits about ageing may not only inspire you, but is likely
to support and encourage your change of attitude too.
The evidence suggests that getting good at anything requires the
triad of 1) opportunity, 2) support and encouragement and 3) prac-
tice, practice, practice. (See Bounce by Matthew Syed for an excel-
lent overview of this.) Sometimes we have to actively stop doing
things that keep us stuck in outdated attitudes. We may need to
be very discerning about what external influences we allow in –
what we read, what we watch, what we listen to, who we mix with.
Importantly, we have to catch ourselves in the moment when we are
doing things that are coming from old belief and attitude systems.
Chapter 7

Being oneself

Who are you and what do you want? People might assume these
questions become redundant as we age, expecting we should know
who we are and what we want by now. We have had so much time
and experience in order to get to know ourselves. However, the ques-
tion remains just as important. Ageing provides us with a golden
opportunity to review everything that went before and decide what
works for us now and who we really are at this point in our life.

Building a picture of yourself

This is perhaps an even better time to decide who we are and live
it in reality rather than just in our idealistic fantasy world. The
‘when  .  .  . then’ strategy of a conditional life in the future time
expires itself as we age. The relevant question becomes: ‘if not now,
then when?’ There is no longer a lifetime’s worth of ‘when’ oppor-
tunities left, and this can focus the mind and, hopefully, spur on
some action.
A lot has been written about mid-life transitions – they are a
more accepted part of life, although often the butt of jokes and
cringe-worthy stereotypes. But what about older people’s transi-
tions and explorations into their own identity? One way of look-
ing at this is by boiling it down to two aspects: knowledge and
action.

Knowledge
It is useful to review what we already know about ourselves and also
to fill in the gaps. The song ‘If You Don’t Know Me by Now’ might
come to mind – and other people who don’t have much appetite
62 Social and psychological aspects

for self-examination and reflection may scoff at the idea of, say, a
70-year-old seriously wondering who they are. Ignore them.
The following is a list of areas to get curious about, find out about
or revisit. Pulling it all together enables you to build an ‘inventory’
of yourself.

Personality
This is covered in detail later in this chapter. Being familiar with
your own personality preferences (in the technical sense of that
term) and the preferences of others helps you understand a host of
things about yourself – how you like to communicate, make deci-
sions, energise yourself, arrange your daily life and so on. Some-
times you can see that you may be wired up very differently from
many other people, and it helps to understand that these are just
normal differences and are not wrong. If you have spent your life
so far feeling like a square peg in a round hole, then now can be
a time to start making more congruent choices and looking for
‘you-shaped’ holes. It is energising to be living life in a way that fits
with your personality. There are always things in life that we don’t
necessarily like or are not our strong suit, and we have to ‘flex’ to
deal with them. What we want to avoid, however, is feeling like we
are so constantly flexed that we are almost permanently bent out
of shape.

Values
This is covered in detail later in this chapter. Being clear about
our personal values helps us to make better, more appropriate
choices in later life – choices that both feel right and make com-
plete sense to us. They also provide a way of checking in from
time to time to see if important things are aligned and as we want
them to be.

Strengths
This is covered in detail later in this chapter. Identifying, appreci-
ating and utilising our strengths can be a great boost and support
as we age. Sometimes we have taken these aspects of ourselves
for granted – so now is a good time to more consciously focus on
them.
 Being oneself 63

Interests/skills/energisers
Take a blank sheet of paper and write down:

• all the things (big or small) that you get a sense of pleasure or
satisfaction from
• all the things that you can get so enjoyably engaged in that you
don’t notice time passing
• all the things you loved doing as a child
• all the things you love doing with other people
• all the things you most enjoy doing alone
• what other people who know you well say are your best attri-
butes and skills
• what sort of television programmes or films you are drawn to
• what books or magazines or online sites you would most like to
read on a long journey
• what topics of conversation you find most energising
• what you can easily turn your hand to
• what you can easily turn your mind to

Home and environment choices

Be curious about what sorts of things you are drawn to. What sort
of colours do you like, how do you like to decorate your living
spaces and what is important to you in your environment? What
type of home would you most like and where? What sort of neigh-
bours and locality do you like?

Clothes choices
What sort of clothes do you feel most comfortable in and what
makes you feel most like you? How we dress as we get older is just
as important as before – if anything, we can have a wider choice as
there is a freedom that comes with age that can liberate us from the
expectations and ‘rules’ to do with dressing. The truth is, most peo-
ple are usually so wrapped up in themselves that they don’t really
notice or care about what you wear. It is a good opportunity to have
a real clear-out and re-assessment of what works for you now. If you
really want to wear purple and a red hat that doesn’t go, then do
it. If you feel more at home in muted colours and little adornment,
then do that. Not everyone wants to look like Iris Apfel or Quentin
64 Social and psychological aspects

Crisp as they age, and there is no rule to say the only way older
people will be noticed is if they are wearing very unconventional,
brightly coloured clothes and accessories.

Attitude to life
What bon mots most appeal to you? If you had to be summed up
in three to five words, what would they be? What would some-
one who knows you well say is your attitude to life? If a Martian
came down, curious about people who live on Earth, and secretly
watched you closely for a week, how would they report back to
their fellow Martians?

Things that stress you/things you loathe

Think about two occasions when you felt really stressed. What was
going on, and how did it affect you? What might it be telling you
about those things in life that you simply don’t like and want to
avoid? Are there certain situations or experiences that you know
you loathe? Why do you think that is? Clearly, there are some things
in life that are worth rising to the challenge about and trying to
overcome or deal with. However, as we age, it is also good to know
when enough is enough and be clear about what you no longer want
to tolerate in your life, given the choice. The good thing is that we
usually do have more choice than we realise.

Relational choices
This is about what sort of relationships you like – how many people,
how close they are and what sort of people you like to have in your
life. It is amusing when so-called celebrities say they are having a small
celebration (e.g. a wedding) and are inviting only 200 of their closest
friends. How anyone can have 200 ‘close’ friends is a puzzle. Prefer-
ences about depth and breadth of friends will no doubt be related to
personality. For some people, all they really want is a significant other
and a handful of close friends; others may like a wider range of friends
and ‘hobby buddies’ plus lots of family members around them.

Physical activity likes

The more you enjoy the way you move your body, the more likely
it is that you will both start moving in those ways and keep it up
 Being oneself 65

over the long term. Having an ‘ideal’ way to stay physically active
advised by others is one thing – actually doing it is another. If the
idea of going to a gym leaves you cold, then it is very unlikely you
will do it on a regular basis. But if you love to walk outdoors or
dance instead, then focus your activities around that. It is easier to
add to or enrich a way you like to use your body to get added health
benefits than to do something you really think you ought to do but
dislike. Some people like to do physical activity alone; others like
the support of doing it in a group. Some like it more formal and
structured; others like it informal and ad hoc. Different body types
may well prefer different types of physical activity – just the same
as professional athletes who can vary enormously. A long-distance
runner and a shot putter are so very different.

Arts and music likes

Music may have been thought about a lot more when we were
teenagers – many of us had our favourite mixed tape which we
spent ages putting together. In many ways, music is far more avail-
able these days with multiple devices and streaming capabilities.
We can draw down all manner of music choices from the internet.
(Ironically, younger people are taking to vinyl with much enthusi-
asm, like a new discovery.) It is easier than ever to experiment and
try out new kinds of music.
If you were able to learn to play a musical instrument, which one
most appeals and why? How much do you currently listen to music
played on that instrument?
Making music with other people is increasingly popular, for
example community choirs for those who like to sing. People often
find that singing or playing with others gives them a sense of con-
nectedness and satisfaction.
For broader arts, what sort of free tickets would you most like to
receive? What sorts of activities would make you want to put a red
ring around an advert, or write it in your diary? Who do you most
enjoy going with – and how much are you happy to go alone?

Science interests
You don’t need a formal education in science in order to have an
interest in it. Which parts of science and the natural world do you
find most fascinating? Where do you think science ends and the
arts begin? Which sort of science and natural world programmes
66 Social and psychological aspects

are you most likely to watch on TV? If you could sit round a dinner
table with five scientists from the past or present, who would they
be? What might you like to ask them?

Spiritual choices
As people age, the bigger questions in life can feel more immediate;
for example, what is it all about, is there a higher power, what will
happen to me when I die? What sort of questions would you most
want to ask and how would you like them to be answered? Who
would you most want to discuss them with?
Belief and doctrine can bring people together or drive them
apart, depending on how they approach it. Being curious about this
helps – openness and respect for difference can make one’s relation-
ship to the spiritual side of life much richer.

Action
One way of exploring this area is using a method first described
by Kurt Lewin, a business psychologist: the forcefield analysis. It
sounds a bit technical, but it is actually a very simple approach to
understand what to do to get what one wants. In this case, what we
want is ‘to be myself’, or a more specific part of being myself, for
example, doing more creative things regularly.
Using this method, we map out everything we can think of that
helps us achieve what we want (the so-called driving forces) and
everything we can think of that is getting in the way of achieving
what we want (the so-called resisting forces).
Examples of categories of driving forces (which are a combina-
tion of personal and external factors) are:

• my own skills/knowledge
• my own empowering beliefs and attitudes
• information I have or can get
• resources I have (e.g. money, space, time)
• people who will help me or will also benefit themselves
• physical abilities and health
• my own motivation

Examples of categories of resisting forces are generally the same as

the driving forces, but the lack of them or the negative version:
 Being oneself 67

• lack of knowledge/skills
• disempowering beliefs and attitudes
• lack of information
• lack of people who will help me
• people who will oppose me or not support me
• lack of specific resources

Method:
1 Get a large sheet of paper, preferably turned landscape. At the
top right-hand corner, draw a circle and write in it what you
specifically want to achieve or be.
Then draw a diagonal line across the page, from top left to bot-
tom right.
2 On the left side of the line, put in all the driving forces each with
an arrow facing towards the circle.
3 On the right side of the line, put in all the resisting forces that
are getting in the way, with arrows facing the other way, away
from the circle.
4 Then consider carefully: what is likely to be the most powerful
resisting force?
What is the first thing you can do to start dealing with that?

Mapping it out this way will help you to see why you may be strug-
gling with certain things that you want to do and be. It enables you
to prioritise and fnd a place to start to constructively take action to
get what you want. Because it is taking account of present realities
in your life (and in your mind), it can help stop the endless day-
dreaming, wishing and hoping – and replace it with some construc-
tive action instead.

Personality development
Our personalities can (and usually do) continue to develop through-
out our lives. In this section, we outline a widely used theory of
personality and personality development: psychological type or
preference theory as proposed by Carl Jung and developed by Isabel
Myers. This theory can help us make peace with ourselves, appreci-
ate people with very different personalities and suggest where and
how we may choose to develop our own personalities.
First, we outline the central idea of preference and its application
to personality development when getting old. Other applications of
68 Social and psychological aspects

preference theory included in this book are in Chapter 2, where we

applied the theory (without naming it) to eating less, in Chapter 8
to sexuality and in Chapter 11 to some difficulties in communica-
tion and strategies for managing or resolving them, managing stress
and making decisions.

The concept of preference

Preferences are certain personality characteristics which each of us
feels are us at our most natural and comfortable, whereas others
feel that the opposite characteristic is most natural for them. For
example, if you prefer Introversion to Extraversion you will, given
normal development and the opportunities, behave introvertedly
most of the time and extravertedly some of the time, and Introver-
sion will feel (and be) more comfortable and natural to you. For
people with a preference for Extraversion, the opposite is the case.
The concept of preference is illustrated well by writing your signa-
ture, first as you usually do and then with your other hand. What is
different about the two actions? Using your preferred hand usually
feels more comfortable, natural and easy while the non-preferred
hand feels awkward, clumsy and child-like. Moreover, while we can
use our non-preferred hand, it takes more concentration and effort
and is therefore more tiring and harder to sustain.
In traditional preference theory, there are eight preferences,
arranged in four opposite pairs, for example Extraversion and
Introversion. The preferences are described in the next section.
Both our preferences and our non-preferences usually develop
throughout our lives, and the theory is optimistic about people in
general developing their preferences most and ‘being themselves’
in this sense. However, some people develop one or more of their
non-preferences most – like a left-handed person taught to be right-
handed – and according to the theory usually don’t ‘feel right’.
When this happens, they can develop their preferences and become
more themselves. This happens to some extent naturally but can
also happen deliberately, as suggested later in this chapter.

Brief descriptions of the eight preferences

in current preference theory
The following descriptions can be used to investigate your own
preferences if you wish. If so, please choose in a provisional way,
 Being oneself 69

behaving like a good detective. Your aim is to isolate your basic

enduring preferences from other influences on your behaviour;
these ‘other influences’ include culture, upbringing, roles, other per-
sonality characteristics, stress, self-image and how developed your
preferences and non-preferences are, hence the need to gather clues
and interpret them carefully and respectfully. This may sound like
a formidable task, but in everyday life people are generally quite
accurate in their judgements of their own preferences and those of
others.
Some of the standard terms for each preference are indicated in
the following, but please note that their names have a particular,
technical meaning, so that, for example, Thinking does not mean
‘without feelings’, and Judging does not mean judgemental.
A summary of the preferences and some general characteristics
associated with them is:

Extraversion – More outgoing and active versus its opposite of

Introversion
Introversion – More reflective and reserved
Sensing – More practical and interested in facts and details ver-
sus its opposite of Intuition
Intuition – More interested in possibilities and overviews
Thinking – More logical and reasoned versus its opposite of
Feeling
Feeling – More agreeable and appreciative
Judging – More planning and coming to conclusions versus its
opposite of Perceiving
Perceiving – More easy-going and flexible

There are many ways of discovering or clarifying your preferences,

including reading descriptions of the combinations of preferences;
asking someone who knows you well to judge the accuracy of your
choices; and observing your comfort with and energy for various
ways of behaving. The results of the free questionnaire and scoring
at Keirsey.com provide a useful clue to preferences.
If you don’t find a good enough best fit between the various clues
and your own or another person’s personality, it may mean that the
theory or parts of it don’t apply to you or that you need more time
to clarify your or their preferences. For example, X saw himself
as preferring Introversion, Intuition, Thinking and Judging, but his
closest friend at the time, who knew him well, said that X really
70 Social and psychological aspects

preferred Feeling and Perceiving. X disagreed and left it there for

over a year.
This error (as it turned out to be) is partly explained by his being
so pleased with the Introvert and Intuition descriptions that he took
it for granted that his other two choices were accurate too. Dur-
ing the year, he observed his behaviour and feelings about them
more carefully and critically. He said to one of his students (who
preferred Judging and who said she thought he didn’t) that his
enjoying marking which TV programmes to watch in the weekly
schedule was a clue for Judging. Her sceptical expression and his
observation that he treated the marked schedule very flexibly were
useful clues for both Feeling (enjoying making decisions about what
he liked) and Perceiving (some planning, but very flexibly).
X also read more about the preferences and saw more people with
various preferences in action, and gradually realised that, although
his Thinking was quite developed, his Feeling was ‘more him’, and
as for Judging, it was not very developed (so far, and nothing like
as much as his Perceiving). How could he ever have misjudged his
personality so much?
This example illustrates some of the complexities of clarify-
ing one’s preferences (and therefore non-preferences). However,
although such judgements should be provisional, they are usually
made – accurately – much more quickly than X made his.
Preference theory is useful for understanding and improving per-
sonality development in later life in two ways. The first applies to
normal development in which our preferences develop first and
much more naturally and easily than our non-preferences, as befits
core characteristics. However, in later life we put more emphasis
on developing our non-preferences (though not developing them as
much as our preferences).
The second, more unusual development path is that some of us
develop one or more of our non-preferences first, because of the
way we were brought up. For example, X, who prefers Feeling, is
brought up to see this preference as not manly and therefore sees
himself as preferring Thinking. He feels uneasy or uncomfortable
about this sometimes. Two main possibilities for him are 1) to con-
tinue to ignore the impulses to express and develop Feeling and
never find his true self in this respect or 2), perhaps through a rela-
tionship or counselling, to notice, value and develop his Feeling. He
will then feel more fulfilled and be more effective.
Some ways of developing each preference and non-preference are:
 Being oneself 71

For Extraversion  Be spontaneous

 Speak to an audience
 Speak to someone you don’t know
For Introversion  Be alone for longer than usual for you
 Listen when you’d rather speak
 Read quietly for longer than usual for you
For Sensing  Observe and keep observing (an exercise prominent
in mindfulness)
 Be very specific about something
 Focus on someone’s actual words and how they speak,
including gestures and changes in tone
For Intuition  Brainstorm
 Give an overview
 Focus on possible underlying meanings of what
someone is saying and not saying
For Thinking  Create a flow chart
 Do a cost-benefit analysis for a decision
 Define something precisely
For Feeling  Clarify your values
 Give a compliment
 Reflect on what matters most to someone you
know well
For Judging  Make a list of things to do, do them and tick each one
off as you finish it
 Resist an impulse
For Perceiving  Act on an impulse
 Re-examine a decision and gather more information
which may be relevant to it
 Relax instead of completing or finishing something

The following steps are an approach to developing your preferences

and non-preferences:

Step one – consider how developed each of your preferences is

in the way outlined earlier, e.g. like a good detective
Step two – consider how developed each of your non-
preferences is
Step three – consider whether you want to develop any of your
preferences or non-preferences further and choose one to
focus on
Step four – choose from the ways of expressing that preference
or non-preference and decide how to behave more in that
way
Step five – observe carefully your experience and evaluate it
72 Social and psychological aspects

Usually, when part of your real self is waiting and ready to be

developed, the process is enjoyable: it feels very right. But occa-
sionally the corresponding non-preference has been so thoroughly
practised and the preference so thoroughly discouraged that it
can be more of a struggle: it can feel squashed and submerged.
This complexity tends to happen in later life when there is more
time for refection and less authentic ways of behaving are more
ingrained.

Identifying core motives

This section describes two approaches to identifying the core motives
in temperament theory and three variations of the Strivings Assess-
ment Questionnaire (SAQ), which is much more focused on indi-
viduality in motivation.

Temperament theory 1
Temperament theory is a variation of preference theory that
suggests that four combinations of some of the preferences are
particularly powerful for understanding behaviour: Sensing plus
Perceiving, Sensing plus Judging, Intuition plus Thinking and
Intuition plus Feeling. The assumption is that one temperament
is dominant in each of us. Linda Berens in her booklet Under-
standing Yourself and Others: An Introduction to Temperament
expressed this idea dramatically. She wrote that blocking it is
like ‘psychological death’, and that people feel ‘light of spirit’
when their core motives are met and ‘drained of energy’ when
they are not.
A version of the motives at the core of each temperament is listed
next. Which is most like the real you? Which next most? And so on.
Alternatively, you may like to try choosing the one least like you
first and then the one you could not live without. The outcome may
be, for example, the combination of Intuition plus Feeling as most
like you, with Sensing plus Judging hardly at all.
Examples of core motives in the four temperaments are:

Sensing plus Perceiving (SP) Solving practical problems quickly,

expediently and with flair; being free
Sensing plus Judging (SJ) Being responsible and useful to a group
or community and planning in detail
 Being oneself 73

Intuition plus Thinking (NT) Designing new theories and mod-

els and analysing intricate problems with precision; being
competent
Intuition plus Feeling (NF) Developing an authentic identity,
helping other people to do the same; harmony and finding
something worth believing in

The following observation by Otto Kroeger and Janet Thuesen in

Type Talk illustrates temperament theory well. They were writing
about the way their guests behave around their swimming pool:

• Our SP guests always grab all the pool toys, head right for the
water and invent a new game.
• The NFs spread on the lounge chairs and talk earnestly about
life and people.
• The NTs dangle their feet in the water, rib each other and cri-
tique the issues and people in their professions.
• And the SJs always, always find some work to do, like hanging
up towels, husking corn, scrubbing the grill or pulling weeds
from the garden.

Temperament theory 2
Another approach to clarifying core motives is to work from the
specific to the general by thinking about one or more of the most
fulfilling or enjoyable projects you’ve ever worked on. Then, con-
sider which if any of the needs associated with the temperaments
fits your chosen projects best.

Personal strivings
Personal strivings are what we typically try to do or want to try to do
in our everyday behaviour. A simple questionnaire is used to explore
them: the Strivings Assessment Questionnaire (SAQ). It asks you to
complete the sentence stem ‘I typically try to . . .’ several times (say
10–15 times). Next, rate each personal striving, for example using a
1- to 6-point scale (where 6 is high) and these three criteria:

• how committed you are to each striving;

• how rewarding you find it; and
• how difficult you find it.
74 Social and psychological aspects

Another criterion, with a hint of Linda Berens’ phrase ‘psycho-

logical death’ when she was discussing the power of core motives in
temperament theory, is to ask, ‘how essential is it for you?’
The aim of the SAQ is to reveal how a person thinks about their
goals and therefore indicate their core motives, clarify them and at
some point perhaps challenge them, e.g. with how well they fit with
developing preferences/non-preferences or whether they are likely
to be achieved or not.
Here is an example of responses to an SAQ:

1 Become more extraverted – less timid with the people I know

2 Not be dominated (bullied?) by H
3 Take more pleasure in everyday small things
4 Eat less chocolate
5 Answer my emails more quickly
6 Re-read all of X’s books
7 Help my sisters more
8 End with my scary counsellor
9 Phone my parents once a week, at least
10 Take more pleasure in everyday things

SAQ 2
Step 1
Very quickly, write 100 statements completing the stem ‘I want . . .’.
Repetition is allowed.

Step 2
Analyse the activity and particularly the 100 statements. Did you
answer freely? Are any wants repeated? Are any surprising? Are any
enlightening? What do they tell you about your motives?

SAQ 3
The final method is another variation of the SAQ and is more elaborate:

Step 1
Write a list of all the things you’d like to have but don’t have at
present – anything at all, including feelings and possessions. No
time limit: take as long as you like to write the list.
 Being oneself 75

Step 2
Prioritise each item on the list as most desired, next most desired
and so on.

Step 3
Explore how each of the top-rated items, say the top five, would
change your life if you achieved it. What difference would it make?

Step 4
What motives seem most prominent? How much do they feel as if
they’re from you? This is a key step for uncovering possible core
motives.

Step 5
Do you still want the items on the list as much as when you rated
them as most desirable, etc.?

Step 6
Choose one item, brainstorm possible ways of moving towards
achieving it and devise an action plan.

Identifying strengths
The concept of strengths has been revived and refreshed by Alex
Linley in his book Average to A+. Realising Strengths in Yourself
and Others. Linley’s carefully expressed definition of a strength
is ‘a pre-existing capacity for a particular way of behaving, think-
ing, or feeling that is authentic and energising to the user, and
enables optimal functioning, development and performance’.
Some key points about this definition are that our strengths are
inside us, either at birth or developed as children; when we use
our strengths, we feel more real, fulfilled and energised; doing
something well isn’t the same as enjoying it, though there is
some overlap; and a very important point: everyone has some
strengths.
Many questions are raised by Linley’s definition: ‘So we can’t be
anything we want to be?’, ‘Some strengths are genetic and some
learned?’, ‘How can I discover what my strengths are?’ and, more
subtly, ‘Is it possible to overuse a strength?’ and ‘Is it true – it’s such
76 Social and psychological aspects

a romantic idea – that our strengths, or some of them, can be hid-

den from us?’
An example of a strength is Lift – improving the mood of others
through being optimistic and encouraging. Another is Bounceback –
using setbacks to achieve more than you expected. Other terms
for strengths are more familiar – e.g. Curiosity, Kindness, Humil-
ity. If your reaction to Lift, Bounceback etc. is to feel inadequate
or despairing, that is not the intended effect of a strengths-based
approach! Rather, the idea is to feel encouraged to look for our
own strengths.
The orthodox approach to identifying our strengths, and often a
good starting point, is to complete a questionnaire. Free question-
naires, scoring and interpretation are available at www.viastrengths.
org and www.authentichappiness.org. New developments will be
reported on the Centre for Applied Positive Psychology (CAPP)
website, www.cappeu.org. A limitation of the questionnaires is that
there may well be many strengths which haven’t been named yet.
Another option is to take part in an Individual Strengths Assess-
ment (ISA), developed at CAPP, with a specialist interviewer or
coach. The underlying method accepts that asking someone or one-
self directly ‘What are your strengths?’ may be too abstract. Rather,
questions like ‘Tell me about a really good day for you’, ‘When do
you feel most alive?’ and ‘What sorts of activities give you the most
energy?’ are asked as part of a conversation. A supplementary and
minor strategy in the ISA is to ask about activities that are weak-
nesses or are draining. The replies are carefully observed for clues,
and the clues noted for later feedback. They may also be followed up
at the time, looking for further evidence for or against a real strength.
Other strategies are to:

• notice what you really look forward to doing

• notice what ‘comes easily’ to you, with the proviso that some
people take one or more of their strengths for granted
• notice what you miss doing
• explore your memories of early childhood and ask others about
you then: what themes and patterns can you identify, and how
are they related to your current experience and behaviour? Lin-
ley uses the concept of a ‘golden seed’ – when someone remarks
on an ability or talent in us and we remember the remark; teach-
ers, relatives and guardians or parents are all likely sources (as
they are of ‘leaden seeds’)
 Being oneself 77

• explore who you admire and why (it may be easier to see some
of your own strengths in someone else)
• ask other people who know you well when you’re most ener-
gised and when you’re at your best
• if you know your preferences, read the descriptions of them for
strengths that are characteristic, and see if they apply to you
and if you want to develop them further

Identifying values
Personal values tend to stay implicit for most people. Few people
actively and overtly set out their values or articulate them to oth-
ers. In contrast, many businesses and organisations have mission
statements and values statements up front on their websites and
documents, in the belief that people need to know what drives them
and what they stand for.
People may be more familiar with the cultural or religious value
system which they are a part of. These may be easier to under-
stand as they are often articulated more and can be seen to be
shared by many people. Personal values, however, are less obvi-
ous, but we all have them as individuals. They are quietly acting
as drivers, motivators or avoiders underneath, often without the
person knowing about it. Sometimes people only know what they
value when it is threatened, walked over or ignored. Generally, we
only get really worked up about something if it is really important
to us.
This is the nub of personal values – they are usually abstract
nouns that describe what really matters for us. For example, for
some people it could be security, obedience and loyalty; for others
adventure, exploration and freedom will be more important. They
are not just superficial, changeable preferences or desires – they are
deeply held ways of being that are centrally important to who we
feel we are as a human. If we had to write our own personal ‘mis-
sion statement’ in life, our values would be central to it.
Although most lists of values are abstract nouns, for some people
it is easier to see something more concrete as a value. For example,
owning a particular house might be a (or the) top core value for
someone who doesn’t want to include it within another value, like
security, escape from ‘normal life’, environmental friendliness, sta-
tus, etc. Generally, though, it is clearer to work through to greater
abstractness.
78 Social and psychological aspects

This may seem a bit philosophical and theoretical to some peo-

ple, but values are very useful to get familiar with in many practical
areas of our lives. Living congruently, in line with what is really
important to us, is a recipe for personal peace and happiness. How-
ever, living in a way that is at odds with our values can spell itchy
discontentment at best and misery at worst.
One of the interesting things about personal values is that they
may surprise others. It can be tempting to make assumptions about
other people’s values, perhaps thinking they will coincide with your
own or the predominant cultural values. This is as potentially fool-
ish as assuming someone else shares the same political views – and
we all know how embarrassing or irritating it is being at a social
event with others who assume you voted the same way they did.
There are three difficult issues that can arise concerning values.
The first, most obviously, is not being aware of them and not
knowing why the choices you are making aren’t working. Something
simply doesn’t feel right, and you can’t quite put your finger on why.
The second is thinking you can just get a grip and get on with
something (that, unbeknownst to you, is not congruent with your
values) and it will all be okay if you just try a bit harder. Obvi-
ously, we all have to do things in life that we may not particularly
like now and again, but it becomes a serious issue if we sign up to
long-term situations that are not congruent with our values. Clarity
about your values makes being assertive (e.g. saying ‘no’) and mak-
ing decisions more straightforward.
The third is when we are in a close relationship with another,
like a spouse, and there are two sets of values to be taken into
consideration in all the important decisions you inevitably have to
make as a couple. Knowing each other’s values can aid important
negotiations, as these can be overtly put on the table and worked
with respectfully.

Clarifying values
There are a number of ways of getting clear about what your values
are and different methods appeal to different people.

Method 1
This looks at important areas of your life and asks questions about
them, looking for the underlying reasons why they are important.
 Being oneself 79

The areas of your life can be:

• relationships
• work
• leisure
• health
• money
• environment
• other areas (such as religion/spirituality)

For each area, ask yourself these questions, and jot down the words
that come up (or ask someone you trust to work with you on this):

• What do I value about .  .  . (e.g. my relationship with my

husband)?
• What is important to me about . . . ?
• What do I get out of . . . ?
• What else does it give me?

Method 2
A direct approach to discovering your core values is first to ask
yourself, ‘What really matters to me?’ and, perhaps separately,
‘What really doesn’t matter to me?’, and to make two lists. Single
words or brief phrases may be most useful. The second step is to
decide which values are your top and bottom priorities, aiming for
five or so in each set. This may not be a quick process, and you may
wish to refine your choices as your awareness deepens, or as you or
your life change. A further perspective is to examine the origins of
each value, as a way of checking its real importance to you.

Method 3
Emotions are good clues to values. For example, if you groan when-
ever Manchester United are mentioned positively, this suggests a
low value for that team or for football in general or for aspects of
English Premier League football. The ‘whenever’ is important: val-
ues are usually defined as enduring beliefs about what matters to
you and what doesn’t matter.
Another useful clue from emotions is to notice your emotional
reaction to things that really upset you. The strong emotions may
80 Social and psychological aspects

be a clue to something that is very important to you being rubbished

or transgressed. This may be a more ‘working it out backwards’
method, but sometimes we only know what is really important to us
when it is taken away or threatened in some way. So, for example,
if someone is very upset by the meanness and tightness of others,
then it may suggest that generosity is an important value to them.

Prioritising values
You may find out you value, say, 10 main things in life. For example,
they could be achievement, security, honesty, dependability, fairness,
respect, commitment, independence, wealth and learning. However,
it is even more useful to know which of those 10 you value the most.
So they need to be prioritised from 1 to 10.
There are different ways of prioritising values. The first is to put
your list on sticky notes in a line and re-order them with the most
important on the top.
Another way is to make forced paired choices, so you consider
each value in relation to each of the others in turn and ask yourself
‘of the two, if I could only keep one, which one would I keep?’
Give a tick to the value that you choose in each comparison, add
the ticks up at the end, and re-order the list of values according to
which gets the most ticks. Lindsay West describes this in more detail
in her book Coaching with Values.

Different types of values in specific situations

There are other situations where it is useful to be explicit about
what we value when making a particular decision, for example
moving house. Most people have a list of moving criteria that
they want to satisfy, regarding where they live and the sort of
home it is.
Take time to really think about what is important to you regard-
ing where you live. It is such a big and expensive decision that you
will want to avoid making a mistake (as far as possible). You can
link this to your general underlying values. It may be something
that is fairly specific, like living in a certain area of the country or
having enough bedrooms to accommodate family gatherings – or
it could be more general, like somewhere where there is peace and
quiet or where there is easy access to nature (because peacefulness
and nature are two of your personal values).
 Being oneself 81

Try and come up with a list of about 10–15 moving home val-
ues/wants. For example, it could include a large garden/within 15
minutes’ drive to a train station to the city/where there is a lively
social and cultural scene within walking distance/old cottage style/
place for parking two cars/a view from the reception room window/
within 30 minutes’ drive to the coast/easy access for friends and
family to visit. See how much your home values and wants cor-
respond with or reflect your personal values. So if you really value
going to live theatre, for example, how will you do that if you live
in a rural area with no theatres within easy reach?
By doing the prioritisation of the home values/wants, you can
clearly see which aspects you might possibly be willing to compro-
mise on in order to achieve the more important values. You will
note that some options you were previously considering become
eliminated as they do not allow your most important values/wants
to be fulfilled. This is particularly important when there is more
than one person making the decision – in this case, two (or more)
sets of values need to be worked on, and you can’t assume that your
lists of values will be the same. Even if they were, once they were
prioritised, the order of importance would most likely be different.
Moving to a home where only the values/wants that appear at the
bottom of your prioritised list get met (and the most important ones
don’t) will probably cause problems in the long run.
Example:

Value no. Home value/want Scoring

1 Large garden √√
2 Within 15 minutes’ drive to a train station serving √√√
the city
3 Lively social and cultural scene within walking √√√√√√√√
distance
4 Old cottage style √
5 Place for parking two cars √√√√
6 View from the reception room window √√√√√√
7 Within 30 minutes’ drive to the coast √√√√√√√√
8 Easy access for friends and family to visit √√
9 Detached house √√√√
10 Quiet road √√√√√√√
Chapter 8

Relationships

In this chapter we look at selected aspects of relationships. We start

with a discussion about online dating, styles of romantic love, per-
sonality and sexual behaviour and coping with sexual problems. We
then turn to the issue of loneliness and what we might be able to do
about it. Finally, we have included a short section on owning pets
as they frequently provide a daily source of relatedness, especially
if we live alone.

Online dating
Online dating is a contemporary solution to the problem of get-
ting enough human interaction. This is most likely to appeal to you
if you want a fling or romantic love (variously defined), but can
on occasion lead to a new acquaintance or friendship. Attitudes
to online dating have changed dramatically, from it being seen as
shameful and desperate to gaining wide acceptance.
Online dating has great potential for good, but there are also risks
and problems. The most positive aspect for many people is the huge
number and variety of people there are to choose from or be cho-
sen by. The risks include security, rejections and becoming unkind –
there are always more ‘candidates’ to assess and reject, and they can
become dehumanised in the eyes of the person rejecting them.
To make good choices of who to meet or invite to meet, it may
be useful to know what qualities in a partner are most important to
you. You may like to try listing your top three. Of course, the more
qualities you list, the less likely you are to find all or most of them
in one person. Also, you may, because of your lovestyle (described
later in this section), see this exercise as pointless or irrelevant to
finding true love.
 Relationships 83

If you also want to increase your chances of being chosen by

people you would choose and not to sabotage your chances if you
meet, we suggest using a recent photo that does you justice but no
more than that, and writing a succinct, specific and accurate profile.
The process of online dating is usually first to exchange a few
messages online or on the phone, then if it seems to be going well,
one of you will suggest meeting. If you both agree to meet, then a
coffee or drink have the advantages of being relatively easy to end
if, for example, the person’s photo is of a much younger them and
that matters to you. On the date itself, we hope you will try to make
a balance between listening – including questions you ask the other
person which relate to something they’ve said and leaving space for
them to speak – and speaking about aspects of yourself.
It may also help to be prepared for – even to expect –
disappointment. Probably the most likely outcome is a mutual
agreement that it was good to meet but not to meet again – quite
liking each other, but no ‘chemistry’. There is a real skill in ending
such meetings well, but it is reported to be not widely used. Instead,
there is ‘ghosting’, which is simply not replying to emails or other
attempts at contact. The alternative and probably often neglected
skill is to be honest with yourself and then with the other person,
respecting their feelings and being ready to deal with a variety of
reactions such as anger, embarrassment, sadness and relief. The sec-
tion on assertiveness skills in Chapter 11 includes some relevant
ideas and details of the skill of saying no.
You may find it helpful to keep a journal or diary after each
meeting. How did you feel before, during and after the meeting?
Excited, flat, drained, interested? Were you particularly happy or
mortified about anything they or you said or did? Are there any
implications for how you are with the next person you meet or
the next time you meet this one? Hopefully your notes will not be
needed for long before you meet somebody who appeals enough (or
more) and who feels the same way about you.
A subtle problem with online dating is that it can seem the only
way to meet a desirable partner when, in fact, relationships still
begin in other ways. Indeed, many romantic relationships do not
start online. Another subtle problem, touched on earlier, is that treat-
ing other people as easily disposable can leave you feeling shallow.
There are numerous and very varied dating websites, and it’s a
matter of researching them online or through asking people who’ve
tried them to find those that are most likely to suit you.
84 Social and psychological aspects

Romantic love: Lee’s theory of lovestyles

John Lee’s ideas about styles of loving can be a helpful perspective on
worries or puzzles about true love. They can also be challenging or
threatening to a particular relationship or to a belief about true love.
Lee suggested five lovestyles plus three main combinations:

Eros: Immediate physical attraction, delight in the other per-

son, intense
Ludus: Playful, free of commitment and deliberately avoids
intensity
Storge: Friendly, companionable and affectionate
Pragma: Practical and realistic, a ‘shopping list’ style – arranged
marriages and some approaches to internet dating
Mania: Feverish, obsessive and jealous, intense
Storgic Eros: Friendly intensity
Ludic Eros: Playful intensity
Storgic Ludus: Friendly playfulness

A major strength of Lee’s model is that each style is true love for
some people. If you are surprised by or recoil from one or more of
them, it’s probably a good clue for your own lovestyle or styles.
Lee’s theory also answers many questions about love, like ‘Does real
love appear suddenly or gradually?’ and ‘Do I really love X?’ So, for
example, part of the answer to whether true love appears suddenly
or gradually is that it depends: in the Eros style, it’s instant, and in
Storge, it’s gradual.
A complicating (but sometimes very welcome) aspect of Lee’s
theory of lovestyles is that while each of us has a preferred style
of love, some people can love different partners in different styles
or the same partner in different styles at different times. For exam-
ple, quite a common pattern is changing, perhaps quite gradually,
within the same relationship, from Eros to Storge, i.e. from intense
to peaceful.
A risky but brave application of Lee’s theory is to discuss your
own and a partner’s lovestyle with them. Lee’s book Lovestyles is
unfortunately out of print, but there are more details on the inter-
net, including a questionnaire. Discussing some or all of the items
of the questionnaire with a partner or potential partner is another
level of analysis – and possibly riskier still – but bear in mind that
Lee found good relationships in all combinations of his lovestyles!
 Relationships 85

Personality and sexual behaviour

The preference theory of personality explains, at least in part, some
major differences in what people find erotic or a turn-off, and it
does so without seeing the differences as unnatural or one of them
as superior to the other. It suggests that some people really are mis-
matched, but it is also true that we vary in how flexible and adapt-
able we can be or want to be.
The preferences for Extraversion etc. can be associated with vari-
ous sexual behaviours which follow directly from the theory:

• people who prefer Extraversion like to talk during sex and to

be direct about their reactions and feelings, while Introverts
don’t talk much or at all during sex
• people who prefer Sensing tend to ‘stay present, stay physical’,
while those who prefer Intuition talk more broadly
• people who prefer Thinking like to work on improving their
skills and techniques, while those who prefer Feeling are more
likely to emphasise romance and being in the mood
• people who prefer Judging like to give notice or have a routine,
and those who prefer Perceiving like to be surprised

You may recognise some of these differences in yourself and oth-

ers and smile. Or you may wish to treat some of them as ways of
developing a preference or non-preference as discussed in Chap-
ter 7. The sexual behaviours listed (and of course others) can also
be discussed with the relevant partner, and sometimes their con-
sistency with personality differences will make blame and confict
less likely. The other person is probably not setting out to disap-
point you!
For example, Z’s partner described the way he kissed her, with an
affectionate but puzzled smile, as ‘like kissing a corpse’. His version
was that he likes gentle kissing and that she kissed like a Labrador
(said warmly but sadly). They had then showed each other how
they especially liked to be kissed and smiled ruefully about the huge
difference, but it seemed like an unmovable gap and perhaps one
that indicated deeper future problems for them as a couple. They
also found that his preferring Introversion and her preferring Extra-
version made their differences a bit easier to accept, and in some
relationships it could potentially have done more, but for them it
was not a solution, and she ended the relationship.
86 Social and psychological aspects

Coping with sexual problems

Many sexual problems can be resolved by discovering what you
do and don’t like sexually and finding someone who shares at least
some of those preferences or is willing to experiment. His or her
full informed consent is vital here and so is honest, clear discus-
sion. Examples of solutions are avoiding penetrative sex, examining
beliefs such as frequency being more important than quality or the
opposite, that sex should always be sensational (as it tends to be in
films), trying different positions, saying a particular word or phrase
or deciding to be celibate.
If good communication between partners doesn’t solve a sexual
problem, modern medical treatments and counselling can be very
effective; see your GP or the College of Sexual and Relationship
Therapists (cosrt.org.uk).

Loneliness
There are some horrible truths about loneliness. It can enter by the
back door, when one is not expecting it, and it can linger in a vague
presence that is quietly life-sapping. It is alarmingly common and it
is not good for health, mental or physical.
Fortunately, there is now increasing awareness of the prevalence
of loneliness and of the negative impact it has on people’s lives. In
the UK, there are a number of initiatives that have been set up to
understand and deal with loneliness. In October 2018, the UK gov-
ernment launched its strategy for tackling loneliness. This followed
on from the campaign work that Jo Cox organised as an MP before
she was murdered. A generally accepted definition of loneliness used
by the Campaign to End Loneliness and the UK government strategy
is ‘a subjective, unwelcome feeling of lack or loss of companionship
arising from a mismatch between the quality and quantity of the
social relationships that we have and those that we want’.
It is recognised that it is not just a straightforward situation of
not having enough social companionship. It is subtly linked to a
range of other factors at the individual, family and society level.
Isolation, health and ageing can play a part, as well as structures
and cultures in society. It has been reported that more individualis-
tic cultures that value independence (such as northern Europe and
North America) are paying a price by experiencing increased loneli-
ness. Cultures that are more inter-dependent (like southern Europe
 Relationships 87

and South America) have denser social networks, where there are
fewer people in an individual’s network but they know each other
better. These cultures tend to experience less loneliness.
The UK Office of National Statistics looked at what factors are
present when people report being lonely – the most common charac-
teristics are being widowed, having poor health, having a long-term
illness or disability, having caring responsibilities and being unem-
ployed. The other most common factor was being aged 16–24, so it
is not just a problem of older people, despite the usual stereotypes.
The government is now looking at ways of defining and collecting
more consistent data on the prevalence of loneliness. Recent sur-
vey estimates from the Office of National Statistics and from the
Campaign to End Loneliness suggest that 5-18% of UK adults feel
lonely often or always. There are an estimated 1,100,000 chronically
lonely people aged 65 and over. Thirty percent of people aged over
80 reported being lonely in 2014–15. About 11% of people over 75
reported having no close friends in 2011–12. This is a serious public
health issue, likened to the seriousness of smoking and obesity.
The effects of frequent or longstanding loneliness on health are
often cited – it is associated with a number of health problems.
These include increased risk of coronary heart disease and stroke,
increased risk of cognitive decline and dementia, increased risk of
depression, low self-esteem and sleep problems. It can also set up
vicious circles whereby loneliness changes our perceptions, expec-
tations and memories of our interactions with others. Looking
through these grey-tinted spectacles, we think others are behaving
in more unfriendly ways than they actually are, and this sets us up
for withdrawal and more loneliness.
An added issue is the stigma associated with loneliness. It is esti-
mated that about a third of people in Britain say they would be
embarrassed to say they felt lonely. This is one of the things the
government strategy wants to change – so that people are more
open to seeing it as a normal phenomenon that may be the result of
a number of factors stacking up and therefore not a character flaw
or weakness. It has been the same story for mental health issues
such as depression and anxiety. It may well help that people in the
public eye are more willing these days to open up about their own
personal experiences of mental health problems without feeling a
sense of embarrassment or shame.
BBC Radio 4 undertook a large loneliness survey in 2018 before
the government strategy was launched. They collaborated with
88 Social and psychological aspects

academics and the Wellcome Collection and invited people to

answer a large number of questions to do with their experience of
loneliness, their health and wellbeing and their beliefs about lone-
liness and how to tackle it. There was a large response – 55,000
people aged between 16 and 99 answered, including 13,000 people
aged over 60. Of course, this is a self-selected sample of people, so
it may not necessarily be representative of the general population.
However, there are some interesting results so far from this very
large sample.
They found the people reporting to be the most lonely had issues
with trusting others, and tended to have lower self-esteem and
higher measures of neuroticism, although they didn’t appear to have
lower social skills. Interestingly, the lonelier people scored higher on
empathy. Being a female carer was associated with a higher risk of
loneliness. These are all associations and not necessarily causal  –
and it is not clear whether loneliness causes the related issue or
whether it is the issue that makes one lonely, or a bit of both in a
feedback cycle.

Managing loneliness
It is a good idea to view loneliness in terms of prevention and treat-
ment, especially as one ages. When one realises how common loneli-
ness is, it is wise to try to prevent it as best one can. It potentially
links into so many factors in our lives, and viewing these with a pre-
ventive hat on must help. For example, when making choices about
where to live, it would be sensible to consciously check for potential
loneliness in the future, especially if there is a sudden change in one’s
circumstances, like a bereavement or illness that causes reduced
mobility. Understandably, it has been found that loneliness is more
likely in places where there is a lower sense of community. (See also
Chapter 9, ‘Deciding where to live’.)
Another preventive measure may be to review one’s own social
and relational ‘resources’. If all of our relational eggs are in just one
or two baskets, then it puts us in a precarious position, especially
as we get older. Research suggests that single people tend to have
wider social networks than married people and they are more used
to having to spread their net more widely. One psychologist lik-
ens this situation to having a ‘relational pension’ – as it is not just
money that needs to be put aside for our old age. We need to plan
for enough social relationships too.
 Relationships 89

For people who are already lonely, there is a world of differ-

ence if this is a more fleeting, temporary feeling or whether it is
long-standing and chronic. Despite the stigma of loneliness, it is a
normal human reaction to feeling socially and relationally ‘hungry’.
Knowing there are things one can do to relieve it and knowing it
won’t last forever can be great comforts. Admitting it to oneself is
the first step towards tackling it – and then looking for helpful ways
of alleviating it.
The top five things to alleviate loneliness suggested by the people
who responded to the Radio 4 questionnaire were:

1 Do activities that distract you or dedicate time to work, studies

or hobbies
2 Join a social club or take up new activities or pastimes
3 Change your thinking to make it more positive
4 Start a conversation with anyone
5 Talk to friends and family about your feelings

These suggestions will appeal to people differently, and some may

not help the chronically lonely. One of the things that lonely people
need to be aware of is how the experience of loneliness can change
how they view others. It can erode trust in others, and it is easy to
misinterpret cues or responses from others, thinking they are more
negative than they really are.
Lonely people can have high expectations for their relationships
with others. It can be helpful to consciously lower these expecta-
tions and learn to be content with different degrees of depth of
relating with different people. Joining a choir, for example, and
hoping to meeting a new best friend may set the expectations too
high. Another perspective might involve viewing one’s social/rela-
tional ‘cake’ as having different ingredients provided by different
people and different situations. It may be asking too much to expect
to get the entire cake made from one or two people in older age,
even if this has been your experience earlier in your life. Changing
one’s attitudes may be easier said than done, and some people may
need support with this.
Personality type will no doubt have an effect. For example,
people with preferences for Extraversion, Sensing and Perceiving
may, in general, find it a lot easier to enjoy meeting different sets of
people for sports or hands-on hobbies. Many Introverted, Intuitive
types may prefer fewer, deeper relationships, and this puts them at a
90 Social and psychological aspects

disadvantage if life events or circumstances lead to a change in their

existing close relationships (bereavement, for example).
Using social media can help, but research is suggesting that people
reporting loneliness tend to have higher relationship expectations
than non-lonely people. People who aren’t lonely use social media
more as an adjunct to their social life – to find out information, for
example, or to connect with people they already know.
In the government strategy on loneliness, there are recommen-
dations for setting up ‘social prescribing’ via GP surgeries, so that
patients who appear to be at risk of or are suffering from lone-
liness can be referred to various community support schemes to
help tackle it. Ultimately the prevention and treatment of loneli-
ness requires a ‘loneliness lens’ to be put in front of all aspects of
society  – housing, employment, education, community facilities,
etc. – to see how both subtle and more overt factors are contribut-
ing to this problem.
For us as individuals, it may help to have our own personal strat-
egy to both prevent loneliness as far as possible and to do everything
we can to alleviate it if it becomes a more long-standing problem.
Seeing it more as a life situational issue to deal with (rather than an
intrinsic personal problem) can help get us into ‘problem-solving
mode’ in order to tackle it more effectively.

Pets
The decision to have a pet is a weighing up of pros and cons and
doing a fair amount of homework. If you already have a pet, there
are a number of issues to consider as you get older.

The good that pets do

There is increasing evidence that pets can have a beneficial effect
on their owners, both physically and psychologically. For example,
stroking a cat or dog can be relaxing, de-stressing and lower blood
pressure and heart rate.
Obvious benefits of more usual domestic pets, like a dog or cat,
are the companionship they give, especially if one lives alone. Hav-
ing another living creature to care for and be responsible for can
give a sense of purpose and belonging. Walking into a home and
being greeted by a friendly animal with a wagging tail is a delight
for many people.
 Relationships 91

Having a dog that needs exercising is a good way of giving struc-

ture to the day and ensuring that you do go out and walk yourself,
all year round. It also makes people more open to others – as people
are far more likely to stop and greet the dog, especially if they have
one themselves.
If moving to a new area, a dog is a great way of meeting new
people. It is a safe way of breaking the ice in a relaxed, unpres-
surised way.

The practicalities

The costs
The costs of pet ownership need a careful estimation. It is not only
the cost of buying a pet, but also the monthly cost of feeding and car-
ing for the animal. The costs of buying popular breeds of dog or cat
have gone up considerably in the last 20 years or so. Even cross-breed
puppies can now cost thousands of pounds, especially the crosses that
have become in vogue, like poodle crosses such as cockerpoos.
Of course, where to buy them needs researching properly, espe-
cially for puppies and kittens, in order to avoid unscrupulous breed-
ers and sellers (who are attracted to this area because of the vast
sums of money that can be made). Advice can be sought from ani-
mal welfare organisations and charities, such as the Kennel Club,
the Cat Society and their breed clubs and societies. Given the num-
ber of cats and dogs in rescue centres, it is most sensible to look
here first. They are likely to ask some serious vetting questions to
assess the suitability of potential new owners and their homes.
Other costs to take into account are for vaccinations and vet
bills, insurance and care services if you go away and need to pay for
boarding or home stays.

Does it suit your lifestyle?

Domestic pets are a big responsibility and a tie. This is especially
important if one doesn’t have a convenient ‘back-up service’ to step
in and look after them. Trips away, if the pet can’t come, require
proper planning to take account of pet care. Cats are somewhat
easier than dogs as they are generally more independent – but they
still need sufficient human interaction and freedom to express their
natural selves.
92 Social and psychological aspects

There is plenty of information online from vets and animal

behaviourists about which breed of dog is suitable for different liv-
ing environments and lifestyles. Never be tempted to buy a cute-
looking small puppy without seriously thinking about what it will
grow into and what its space and exercise needs will be.
As the Dog’s Trust advert says, ‘A dog is for life, not just Christ-
mas’. It is a commitment for 10–18 years, depending on the breed.
In general, smaller breeds and cross-breeds live longer. It is there-
fore possible that the dog or cat will outlive you – and subsequent
provisions for the animal need to be thought through. There are
charities that can help older people who are having difficulty exer-
cising their dogs – like the Cinnamon Trust in the UK. They can
arrange for volunteers to be regular dog walkers.
Another issue is if circumstances change and you need to go into
a care home or other assisted living arrangement. Not all homes
will allow pets, despite their potential health benefits. Giving up a
beloved pet at such a vulnerable stage in one’s life can be a great
wrench.

Bereavement
As pets age, they can become more dependent and their needs can
get more complex. This can make it difficult to arrange care for
them if you need to go away. When the time comes, you can be
faced with the awful decision about euthanasia. It will of course be
a matter of carefully weighing things up, and your vet will help with
this. Ultimately, it is a judgement call for the owner. Not everyone
can understand the depth of grief that an owner can go through
at the loss of their beloved pet, especially if they were their sole
long-term companion at home. Some people say they couldn’t bear
to go through all that again, but with time they are likely to see it
differently. 
Chapter 9

Deciding where to live

In this chapter, we discuss the issues involved in moving house

when you get older. We also focus on two other aspects of living
arrangements – first, living alone and second, moving to a care home.
Of course, there are other options that older people can consider,
such as sheltered accommodation, assisted living and retirement
villages. There is some excellent advice and information on these
options on the Age UK website and its related factsheets. We think
it is wise to start thinking about the whole range of options earlier,
when we still have time to think about and research what our best
choices might be for later on, rather than waiting until we are pushed
into a quick decision due to unforeseen changes in circumstances.

Moving house

Reasons for moving house

Some estate agents remember the ‘4 Ds’ as common reasons for
prospective vendors wanting to move – divorce, death, debt and
downsizing. Current young people would probably laugh at the
concept of downsizing, as current house prices mean that many of
them can’t afford to get on the housing ladder at all or, at best, can
only afford a small studio flat.
For older people, who have benefitted from more favourable
conditions for buying their own homes, there is a lot more choice.
The English Housing Survey in 2017 showed that 74% of people
aged 65 and over owned their own homes outright. This was up
from 56% in 1993. For younger people, the trend is in the opposite
direction, and many of them are still likely to be renting when they
reach retirement age.
94 Social and psychological aspects

For older people, circumstances may push them into making a

move (e.g. the first two of the 4 Ds), but for others they may wish
to rethink their living arrangements to suit them better as they get
older.

Downsizing
With families having grown up and left home, some couples wonder
why they are still living in a family-sized house that requires main-
tenance, heating, cleaning, etc. Despite the comforts of familiarity,
it doesn’t feel quite right. It may also be the case that some people
don’t get any happier or content with living spaces over a certain
size.
If they have children who are really struggling with their living
costs, some orchestrate a downsizing and gift the difference to their
children to either help them get a leg up on that elusive ladder or
just give them a chunk of money to contribute towards their living
and rental costs.

Location
Another reason for moving is that the location doesn’t suit your
needs anymore. Perhaps the main reasons for living there in the first
place are no longer so important, e.g. access to a train station for
commuting or good local schools. The area could be one that’s not,
for example, diverse enough, quiet enough or vibrant enough to suit
your life now. It may be too far away from family and friends. See
also the section later in this chapter on living alone and geographi-
cal location.

Accommodation
What may have been ideal in the past may be less appropriate now.
Three floors and many flights of stairs can be seen as a good way
to keep fit – or else a complete pain – as you age. A good question
to ask is ‘is this making my life easier or not?’ There’s something
quite unsettling about knowing that your living accommodation
is not working for you, and is not supporting you in your daily
life. Rather than struggling with what doesn’t work, think about
what would work better for you now –your ideal accommodation
blueprint.
 Deciding where to live 95

Things to be aware of

The process of moving

Moving house is often very stressful. This may be particularly the
case if it is decades since you last did it. However, the process has
changed over the last 20 years with the introduction of online infor-
mation from estate agents and lettings agents. It saves all the travel-
ling round that we used to do to sign on with agents, not knowing
what they had to offer.
The legal side of it is much the same in the UK as it always was,
although it has been speeded up somewhat due to being able to
email correspondence and forms and many of the searches now
being done online.
It is worth familiarising yourself with the chain of events involved
in moving, and there are books and online guides on this that are
helpful. If selling and buying, it helps if the estate agent has a dedi-
cated ‘sales progressor’ whose job it is to ensure the process is going
smoothly and can liaise with all parties, especially if there is a long
chain involved.
If you need mortgage funds, retirement income–linked mortgages
are available, but the whole mortgage system has tightened up con-
siderably since the recession in 2008. The amount of information
the lending companies require now can feel like an invasion of pri-
vacy for some people who haven’t mortgaged for a long time.

Realistic assessment of costs

People who have done building projects and refurbishments often
say the actual cost is about double your initial ballpark estimate
of time and money. It can be similar with moving house. There are
many non-obvious costs involved, which stack up to make the final
total much more than you might have bargained for. So, at the start,
it is sensible to plan out a realistic itemised estimate of the whole
moving project, including the estate agent’s fees, the legal fees, stamp
duty, surveys, removals and any re-decorating and updating of the
new home. It amounts to a sizeable – and non-returnable – sum.
A major unknown at the start, if you are selling and buying, is
how much you can sell your existing home for and therefore what
you might be able to afford to buy. Reputable estate agents will give
a realistic assessment of this based on your local market conditions
96 Social and psychological aspects

and what similar properties have actually sold for recently. It is

an inexact science though – all a house is worth is what someone
is willing to pay for it at that time. Bringing you on board with
them by doing so-called flattery pricing may look very promising
up front but can waste time and possibly miss good, realistic sales
earlier on.

Avoiding mistakes
No one wants to go through all the costs of moving (time, energy
and financial costs) to find out too late that they haven’t got what
they really wanted. Going through an assessment of needs and pref-
erences is more detailed than just how many bedrooms you want
and how much outside space and whether it is modern or period
style. What is it that you really want and need and don’t want or no
longer need? Think about this now and, say, in 10 years’ time. Some
might say they’ll just move again when they get older or if they get
less fit or mobile. This could be a major undertaking or burden at a
time when you may be much less inclined to do it, plus it is all the
moving costs again – so it worth trying to ‘future proof’ your cur-
rent move as best you can.
Doing an assessment of ‘moving criteria and values’ is useful as
it sets out your blueprint of what you really want and need. See
Chapter 7 on a suggested way to do this. Doing the prioritisation
exercise is important, especially if there are two of you with differ-
ent sets of preferences and needs. It enables you to explicitly discuss
and explore how to get most of your joint priorities met as a team,
rather than two individuals fighting from their corners.

Do you really need to move at all?

Sometimes things aren’t working for you in the accommodation,
but other aspects of where you live, like location, are just fine. It can
be useful to get some advice (perhaps from a professional architect
or designer) who can see the bigger picture on options for staying
put. Aspects that you have assumed cannot be changed may be able
to be altered enough to make it work for you. It may not necessar-
ily be big structural changes that are needed but a rearrangement of
how you use the spaces available.
All of this would need to revolve around what you need now
from your living space. Paying for someone to come up with fresh
 Deciding where to live 97

ideas may be money well spent if it avoids a much larger expendi-

ture on moving house. We may get so entrenched in our habitual
view of our space that it is difficult to see it any other way.

Options for people who are not home owners

High private rental costs and the lack of social housing in the UK
are regular news items and major political issues. Market rates on
rentals are so high in certain areas that it pushes some people into
financial hardship and even homelessness. Although it is recognised
that many young people are in the so-called Generation Rent, where
they have little or no hope of ever buying a home, the problem is
still there for a smaller, but significant, proportion of current older
people.
Recent research by the UK homeless charity Shelter has shown
that a large proportion of older, private renters are spending over
half their income on rent, whereas 30% of income is generally con-
sidered as the maximum that is affordable, especially for people
on lower incomes. This is a political-social issue and needs tack-
ling at that level. For individuals affected (or potentially likely
to be affected later on), it is nonetheless worth thinking of other
ways of easing the problem and doing it as early as possible. It is
understandable that people in this situation may think they have
no choices as they are so constrained by circumstance, but some
out-of-the-box thinking may be of help, including thinking through
some more unusual ways of providing housing.

Living alone
As most people know, the number of older people living alone is
increasing. Data from the Office of National Statistics in UK in
2019 showed that 21% of people 65 and over live alone and 42%
of people over 75 do. Is this a problem and, if so, what can an indi-
vidual do to help themselves?
Humans are, at our core, social animals – it is written into our
DNA as a survival instinct from the earliest times when the odds of
living another day were a lot worse than now. Those who lived and
worked together in groups were more likely to survive. Our DNA
has hardly changed, but in modern life it is clear that individuals
do vary in their desire and capacity to spend time alone and live
alone. Introverts, for example, tend to need and enjoy more time
98 Social and psychological aspects

alone than extraverts do, but there are many exceptions, of course.
There are many people who need a lot of ‘alone time’ but none-
theless want the comfort and advantages of knowing they are not
alone under their roof all day and every day. It can be comforting to
know that someone else is in the next room or that someone will be
around to eat with and when you wake up in the morning.
There are many people who are quite content to live alone and
who lead full and enjoyable lives – so what is it that makes the
difference?
One important aspect is how we ended up living alone, whether
it was something we actively chose or something that was circum-
stantially thrust upon us. For the former, living alone may be fine
for certain periods of time and at certain stages of life. All this can
change, however, and it is likely that living alone at 60 is a very
different ball game than living alone at 80. Our needs and circum-
stances can change, sometimes quite dramatically, and it may be
difficult to predict or even imagine that they will. The change from
an active choice (where there might have been other reasonable
options) to no choice and no obvious alternatives can be shocking.
For the group who have living alone suddenly thrust upon them,
there are more hurdles to jump. Usually, it will be as a result of a
life event, like death of a partner or a divorce. But other things can
happen – I know an elderly, single woman who was suddenly thrust
into living alone when her younger sister, who had lived with her
for many years, rather suddenly got married and left.
This gives two major issues to deal with – bereavement or loss as
well as the sudden plunge into solo living. Living alone for the first
time in decades requires a massive adjustment. Many couples divide
up their activities into who is responsible for what, and it can eas-
ily be taken for granted that ‘I do this’ and ‘you do that’. The ‘you
do that’ responsibilities may be an alien territory to navigate if you
realise you have very little or no experience or knowledge of how
to do it yourself.
Aside from the practical ‘keeping the show on the road’ respon-
sibilities, there are the less overt companionship needs. Assuming
the relationship was reasonably harmonious, the loss of the other
can feel like a complete paradigm shift. There is suddenly no one to
think about and talk to in your immediate environment – no one to
ask or be asked, ‘would you like a cup of tea?’
There is another group who somehow find themselves living
alone without necessarily having chosen it – things just pan out
 Deciding where to live 99

that way. Many of them may have preferred to live with others, but
due to, for example, the breakup of a relationship earlier in life or
lack of suitable partners or co-habitees, they end up living alone.
Other people may mistakenly assume they have actively chosen this
way of living, but they, themselves, have to just get on with it as best
they can, sometimes for decades. The current modern way of living
is not very geared up for this, especially for people who are around
45–65. They don’t quite fit with the younger people who are more
used to house and flat sharing and yet not yet old enough to want
to take on older ‘retirement community’ living arrangements. There
needs to be some middle ground where it becomes more normal
for people to think about a newer way of sharing/communal living.
People who live alone can experience a rather surprising lack of
understanding from their non-solo friends and family. When people
are so used to living with others under the same roof, often for
decades, they have no real notion of what it might be like to be
living alone again, day in and day out, especially as a retired, older
person.
For whatever reason one has ended up living alone, there are
certain factors that need considering to try to make it a more man-
ageable and positive situation:

1 Ensuring you get enough human interaction/companionship in

your day and week
2 Considering carefully where you live and trying to future-proof it
3 Thinking outside the box

Getting enough human interaction

Getting enough human interaction will of course depend on how
much each individual decides is ‘enough’. For those who reckon
they don’t need so much, it is worth being mindful of slipping into
too little interaction, just out of habit, and not quite bothering to
make an effort. People living alone, who don’t have social interac-
tion at home on tap, have to make more effort to go out and find
their interactions, or reach out to people via electronic means. They
may have to learn how to be pro-active in looking out for social
opportunities and get used to making the first move.
There is some debate about what type of human interaction
counts more. In this age of digital connectivity, it is extraordinary
that one can chat to a daughter on the other side of the world via
100 Social and psychological aspects

Skype or some other platform. I know a 90-year-old man who is a

keen user of Facebook and WhatsApp. Clearly, this is so much bet-
ter than not having such facilities, but it is still not the same as being
in the same room as another human being. There are certain subtle
aspects of connectedness that happen much better in the flesh.
If circumstances have changed, for example, retirement from a
busy job, then suddenly the ready-made interactions from work
disappear out of the equation. It may have been a real pleasure to
come home alone after a busy day at work, and it is surprising to
realise how much work contributed to the meeting of our social
needs. Sometimes it helps to get a regular part-time job, and it can
be an adventure to do this in a completely new setting or field. Vol-
unteering is another way to get out and connect with others, but it
does need to be in an area that really does put you in contact with
people – a friend of mine reminded me that working in a charity
shop doesn’t necessarily mean she meets many people, as she spends
most of the time out the back doing admin or organising donations,
and the only person she sees much of is the manager.

Where you live

Living in an old cottage down a single-track lane in the countryside
may be appealing and enjoyable for a fit, older couple or even a person
living alone while they work. All of that can change if circumstances
suddenly change – retirement or bereavement, for example. Living
alone and being geographically isolated can tip the balance into an
unforeseen problem. It can make everything that much more difficult.
Bothering to make an effort to go out to see people (or inviting them
to you) can be a major hurdle. Not many people are keen on driving
15–20 miles round trip to go out on a dark, wet winter evening.
Social isolation can also be considered in terms of who you’d like
to live amongst and what facilities and social opportunities there
are locally. Living in a ‘dormitory’ village or town may simply not
work if there are not enough people like you and not enough activi-
ties to go to that you’d enjoy.

Thinking outside the box

If living alone doesn’t really work for you, it is worth consider-
ing some alternative strategies. It is possible for more unusual
arrangements to be made if people are willing to take a risk and try
 Deciding where to live 101

something new. For example, there are ways of pooling resources

among two or more friends and sharing a living space that could
even be carved up into private and communal areas. Another option
is taking in a lodger if there is enough room or if the existing space
can be re-arranged/extended in some way. All the ‘yes, buts’ to these
solutions would need to be thought through and a strategy devel-
oped for dealing with them as best one can. For example, think of
the legal situation of having a shared bought home – who owns
what and is responsible for what and what to do if one of you wants
to exit the arrangement, etc.
Thinking only in terms of ‘couples/families’ living together ver-
sus ‘solo living’ is very limiting. The current younger generation of
Millennials is already having to change all this out of economic
necessity and the unreachability of rents and mortgages, especially
in large cities.
Of course, there are various communal living retirement home
options. These could be a perfect balance of retaining some inde-
pendence and onsite support and social opportunities. They tend to
be expensive, however, and therefore unaffordable for many people.
If they are in a converted large building (like an old school or con-
vent) or even newly built, the geographical setting needs to be con-
sidered, as it may be too remote. It may then make you dependent
on a car to get out and about as public transport in more remote
areas is often not frequent or there at all. The reality may not be
all the smiles of good-looking older couples seen in the advertise-
ments and brochures. People can behave quite territorially and in
an entitled way when suddenly living together in such close proxim-
ity with shared communal spaces. A couple I know who moved to
a converted school had to do some concerted ‘peace negotiations’
with a prickly, more elderly couple upstairs in order for the curt
‘notes’ left at the communal entrance to stop.
Doing your homework on these options is so important to find
out the realities of daily life and to compare that to what matters
most to you. It is definitely a good idea to bring in an assessment of
your values into any big decisions that need making (see Chapter 7).

Care homes
Generally, it will be some form of crisis or rapid deterioration of
health that causes people to go into a care home. The decision about
whether someone is at a stage to need a care home will mainly be
102 Social and psychological aspects

made by the nearest relatives alongside their doctors, as by that

stage the elderly person may no longer be in a position to make a
reasoned assessment. Frequently the reason that care is needed is
because of cognitive decline or dementia, when it becomes unsafe
to leave someone unattended in their own home for any length of
time. They may be admitted from home or from a hospital stay,
when it is not considered appropriate or safe to discharge them
back home. A physical condition or event (like an infection or a
fall) that needed treatment in a hospital can be the thing that exac-
erbates the decline.
Sometimes, if there is an elderly spouse, they may be simply no
longer able to cope as the main carer and so a care home becomes
the only feasible option. Even with maximum at-home care assis-
tance from social services and community health teams, it is still
difficult to care for someone at home if they really need supervision
24/7. Getting private live-in help or nursing care is not always fea-
sible as it is expensive and there needs to be suitable accommoda-
tion available.
Given that the final decision is often out of your hands, it is a
good idea to think about this before getting to that crisis point or
that level of decline. It is a bit like wills – some people think it is
negative and morbid to think about such things when they are still
well. This may be fine for people who have cooperative and car-
ing families, when they can rely on a partner or one of their adult
children to make a decision in their best interests. For people who
have no children or no partner, it is wise to think through eventuali-
ties and what your preferred strategy would be, early enough to be
discussed with someone you trust.

Which care home to choose

Over the last few decades, most of the provision has moved to the
private sector. The majority of the local authority-run homes have
either closed or been privatised. Care homes have had a bad press –
if there is a horror story about abuse of residents or gross misman-
agement, it tends to hit the headlines. Of course, this is a skewed
picture as it doesn’t report on all the many care homes that manage
to look after vulnerable people in a caring and competent way. It is
both physically and psychologically demanding work and relies on
empathetic and extremely patient staff, many of whom will be paid
relatively little.
 Deciding where to live 103

It is very difficult to make an assessment about a care home if

this arena is new to you and if it is in a geographical area you
are not familiar with. Getting recommendations from other local
families is helpful. Local healthcare providers, like GPs, would be a
useful source of information when choosing a care home, but they
would be unlikely to be able to be drawn on the subject. There are
Care Quality Commission assessments and reports done regularly
on care homes, and these are worth looking at. Ultimately, making
one’s own assessment through visiting the care home in person is
essential.

Funding of care home costs

Anyone who has not been directly involved in a close relative or
friend’s entry into a care home is usually shocked at how much
they cost. Currently, in the UK, the average cost of a residential
care home per week is about £600, which is £31,200 per year.
There are, of course, regional variations in this, with the north
generally cheaper than the south. If the care home also provides
nursing care, then the costs are usually well over £800 per week
(£41,600 pa).
For people seeking support from their local authority, they will
have a care needs assessment done, and if this shows that a care
home place is required, then the individual will be means-tested.
This includes the financial asset of their home, if they own one. In
practice, this means their home will need to be sold in order to fund
care, assuming they were the only one living in it. The individual
has to completely self-fund if they have assets over £23,250. The
council can offer a deferred payment agreement if an individual’s
house has to be sold.
Only when the individual’s funds get down to the nationally indi-
cated threshold will their local council step in to fund their care
home costs. Each local authority agrees a nominated amount that
they will pay towards care costs per week. This sum is often a lot
less than the amount charged to private funders and so begs the
question, where does the shortfall come from? The answer to this is
not clear, but media investigations suggest that the ‘real’ cost of care
homes would be some point in between the cost charged to private
funders and the cost charged to local authorities. What this there-
fore suggests is that the private funders are, in effect, subsidising the
local authority-funded places. In the past, this may have been dealt
104 Social and psychological aspects

with by moving the client into a local authority–run care home but,
as mentioned earlier, most of these have now been privatised.
Another method of funding care is via an immediate needs annu-
ity. By paying a very large premium up front, the company will
undertake to pay all the care home fees until the person dies. These
sums are worked out like any insurance scheme so that the odds are
in favour of the insurance company making money overall (as they
are a business, of course). It also puts the relatives in the difficult
position of trying to make a ‘guesstimate’ of how long the older
person is likely to live.

Getting financial advice

Whichever route is decided to fund care, it is wise to involve a rec-
ommended independent financial advisor as the sums one would be
dealing with are so large and it can be daunting.
If funds are generated from the sale of a home, they need to
be properly managed. With the current paltry rates of interest in
deposit and cash savings accounts, it means that the capital will
shrink relative to inflation. Of course, the alternatives do require
investments in stocks and shares and bonds which are subject to
some uncertainty, even for people who want to invest at the lowest
level of risk.
Making a decision about an immediate needs annuity policy
requires a lot of thought and so it is advisable to get some pro-
fessional advice. If there are no children or legatees of the elderly
person, then it may be an easier decision to make, as no one else is
particularly affected by all or most of the elderly person’s money
being used up. Of course, it is their money to be spent on them, but
some elderly people want to try to safeguard their money as much
as they can so that they can leave some to their family or chosen
beneficiaries after their death.
Chapter 10

End of life – death, grief

and making plans

In this chapter, we take a positive approach to the end of life. First,

we outline the idea of a ‘good death’, as proposed by Kathryn Man-
nix, and then discuss some ways of making good deaths more likely
to happen. Examples are joining a death café, engaging a doula and
referral to a hospice. We also summarise the case for and against
assisted dying. Next we consider additional actions we can take to
make the end of our life more thought out and consistent with our
wishes and values. They are organising a power of attorney, mak-
ing a will, making a living will and planning a funeral. Finally, we
discuss an experience which for many of us happens more often as
we get older: coping with bereavement in ourselves and others.

A good death

Kathryn Mannix’s approach to a ‘good death’

Contemplating and accepting that we will die is part of getting old,
though rarely easy and often avoided, hence the subtitle of Kathryn
Mannix’s 2018 book With the End in Mind: Dying, Death and Wis-
dom in an Age of Denial. Mannix has a lot of relevant experience
as a palliative care consultant in hospices and patients’ homes. She
has encountered thousands of deaths and formed clear ideas about
what normal dying is like and how to describe it in a helpful way to
people who are dying or involved with others who are dying. Her
conclusion is that when we are dying ‘there is usually little to fear
and much to prepare for’. If true, this view is a very comforting one.
In preparing for a death, she matches the pace of the person dying
or involved, e.g. as a relative or carer, and when it feels appropri-
ate, she asks what worries them about dying. Usually she is able
106 Social and psychological aspects

to reassure them. For example, the person may be very afraid of

pain and the effects of being drugged on their mental capacity, and
she describes how modern drugs can remove the pain but leave the
dying person’s mind clear. She tells patients whose pain relief is not
straightforward that enough morphine to control the pain would
also sedate them, and that there is a choice to be made.
Mannix also describes how people normally die: essentially a
peaceful process in which we gradually feel less energetic and more
tired and consequently sleep more. Then gradually, perhaps over a
few weeks we sleep more deeply and in time slip into a coma, becom-
ing unconscious, not just asleep, part of the time. Near the end we’re
often unconscious all the time and our breathing starts to change.
Sometimes it’s deep and slow, sometimes shallow and fast. Then, gen-
tly, it stops.
This natural and peaceful dying is in marked contrast to what
many of us believe dying to be like – great pain, struggling to sur-
vive and deeply sad. This bleaker view of what death is like tends to
reduce the chances of the open, clear communication which is at the
heart of Mannix’s idea of a good death. Far too often, she believes,
we keep people who are dying alive and rush them into intensive
care for a treatment that is aggressive and ignores their wishes. Her
approach emphasises giving the dying person the opportunity to
choose, in a calmer and more aware way, what they will do and
what treatments they will have and not have.

Supporting a good death

Joining a death café

In death cafés, people who usually don’t know each other talk about
any aspect of death and dying that comes up. Apart from feeling
liberating to most people who go, and useful in itself, this is also
practice in talking about death which can make helpful conversa-
tions about death more likely with friends and relatives. Health pro-
fessionals too can struggle to tell patients they are dying, perhaps
because it seems like a failure on their and medicine’s part.

Engaging a doula
Doulas provide physical, emotional and spiritual support to people
who are dying. Their role depends on their client’s wishes and early
 End of life 107

in their time with a client they write a care plan together. Some
doulas charge a fee while others are volunteers. Generally, they are
connected to charities and hospices. Details are available from the
organisation Living Well, Dying Well at lwdwtraining.uk.

Referral to a hospice
Hospices are far from being places where people just go to die. They
offer a wide range of positive and practical activities, from pain
relief and physiotherapy to workshops in painting, singing and yoga
for patients with various terminal illnesses, including heart and lung
disease. Moreover, many of their patients are cared for in their own
homes or as day patients.

Assisted dying: for and against

The following bald statement of the arguments does not make a
distinction between assisted dying for people with a terminal illness
and those who are healthy physically and mentally and are compe-
tent to decide that they want to die. We have tried to be objective
in our statements.
Arguments for assisted dying include:

Assisted dying has been legal in some countries and states, e.g.
the Netherlands, Switzerland, California and Canada for
many years, with safeguards to prevent its abuse. The effec-
tiveness of the safeguards is disputed.
It is a caring and merciful act respecting human dignity and the
right to choose.
Some terminal illnesses can’t be made bearable in palliative
care.
Its availability improves the honesty and clarity of conversa-
tions about death.

Arguments against assisted dying include:

Assisted dying is currently (2021) illegal in the UK.

People with terminal illness (or with disabilities) may feel pres-
sured to kill themselves in order not to be or feel like a burden.
Some people who want to die, e.g. because they are clinically
depressed, change their minds later.
108 Social and psychological aspects

The sanctity of life, as a religious or ethical principle, takes priority.

It’s not needed because patients can legally refuse treatments
that are keeping them alive.

This list of arguments only touches on the complexity of assisted

dying. Moreover, some of them apply to people who are not ill
but who want to die, which is even more contentious than assisted
dying for people who are terminally ill.

Making plans for the end of life

There is something rather sobering about making plans for our own
deterioration or demise. It is an area many of us would rather not
have to think about – we might prefer to bury our heads in the sand
and distract ourselves elsewhere. However, the issues don’t go away.
They may instead have to be dealt with by default legal or medical
processes or by passing the buck to your next of kin.
Most of us want to make sure we have our say in how our lives
are run, especially in significant decisions about the big things in
life. We would not want our thoughts, feelings, preferences and val-
ues ignored when deciding where to live, who to live with, what
work to do or where to go on holiday, for example. So why would
we suddenly not mind what happens to us when we become older
and more vulnerable and are not able to make decisions in the usual
way? The difference is that these latter decisions need to made in
advance at a time when we are best resourced to make them.
Areas where previous planning can be both responsible and help-
ful are:

1 Planning for who will be responsible for your best interests if

you become unwell or lose your mental capacity to make sound
decisions and manage your life.
• Power of attorney
2 Deciding which treatments you would want/not want if you
became seriously unwell or at the end of life and are unable to
make or communicate your decisions at that time.
• Advance decisions/advance statements/living wills
3 Making a will.
4 Planning what sort of funeral you would like.
 End of life 109

Power of attorney
Power of attorney is a legally recognised process whereby you can
set up in advance a plan of who will take over responsibility for
your affairs should you become unable to make the decisions your-
self or manage certain areas of your life.
The idea is to set it up and register it when you still have capac-
ity to decide, so that it is ‘ready in the wings’ to be activated if and
when a time comes when you need it, i.e. when you are no longer
able to look after your own affairs.
It is not about passing power to someone else to run your life
against your will and preferences – it is set up by you, for your best
interests and preferences, with people you trust becoming respon-
sible at a time that you need them to.
There are two main types of power of attorney that can be set
up now:

• a lasting power of attorney (LPA) for financial decisions

• a lasting power of attorney (LPA) for health and care decisions

Before 2007, the LPA for fnancial decisions was called an enduring
power of attorney. There is also a third type – an ordinary power
of attorney, which is set up to cover certain responsibilities for your
fnances should you need it while you are still mentally capable –
for example, if you are temporarily unwell, in a hospital or travel-
ling abroad.

LPA for financial decisions

This covers areas such as managing finances, bank accounts and
investments as well as paying rent, mortgages, bills and selling your
home. It is up to you to decide when you want this to start as
you don’t have to wait till you are lacking mental capacity. Mental
capacity is centred on someone’s ability to understand information
related to a decision, to actually make decisions and communicate
their decisions. It is set out in law in the 2005 Mental Capacity Act,
so there are clear safeguards for making this assessment.
In setting up an LPA, you decide who you want to be your attor-
ney, and there can be more than one. You decide which sorts of
financial decisions you will allow them to make, so it is not all or
nothing. You also decide if you want your attorneys (if you have
110 Social and psychological aspects

more than one) to make all decisions jointly or whether they are
also able to make them on their own (called ‘severally’).
The process in England and Wales is managed by a governmen-
tal executive agency called the Office of the Public Guardian. The
government website (www.gov.uk) has all the information needed
to find out about lasting power of attorney and how to make one,
including downloadable forms. It can be done oneself for a small
registration fee without having to involve a solicitor, although some
people like to take some legal advice about it, particularly if their
financial affairs are complicated. The LPA needs to also have the
signature of a certificate provider who confirms that you under-
stand what you are signing and are not in any way under pressure.
This can be someone you know well (but not a family member), or
else a professional like a doctor or solicitor. Once registered, the
LPA will officially sit with the Office of the Public Guardian until
it is needed to be used.

LPA for health and care decisions

This is set up in a similar way as the LPA for finances, except it is
to appoint an attorney who can make decisions on more general
aspects of your life, such as what medical care you have, where you
live, what you eat, who you should have social contact with, etc. It
also covers decisions about life-saving treatments.
This LPA can only be activated into use if you lose mental capac-
ity. Regarding a health decision that can be covered by an advanced
decision, if there is a similar decision set out in the LPA (e.g. a
wish to refuse life-saving treatments in certain circumstances), then
whichever was signed the most recently takes precedence. There-
fore, the attorney has to stick to the wishes that are set out in a
more recently signed advanced decision.

The situation of losing capacity before setting up a power

of attorney
If you became unable to look after your own affairs and can’t make
decisions due to a lack of mental capacity, then there is a safety
net, but it is a long-winded and more complicated one. Without a
registered LPA, then the Court of Protection in England and Wales
may become involved. There is an application process for the Court
of Protection for whoever it is who needs to make decisions on
 End of life 111

your behalf. The court would decide if they are appropriate to be

appointed as a deputy to make decisions for you on either prop-
erty and finances or personal welfare issues, or both. The role of a
deputy is similar to that of an attorney, and they have to do every-
thing that is in your own best interests. The main issue here is that
you are not the person who chooses your deputy, and the process
of appointing one can take a long time and be a lot more expensive
than agreeing to an LPA.
In the worst-case scenario where there is no one to step in and
make decisions on your behalf (i.e. if there is no family member
or friend to offer), then an independent mental capacity advocate
(IMCA) must be instructed to protect your rights. This system for
advocacy was set up under the Mental Capacity Act.

The ReSPECT form

ReSPECT stands for Recommended Summary Plan for Emergency
Care and Treatment. It is a further option for recording how you
would like and not like to be treated in a health emergency if you
can’t express your wishes at the time. The form is completed in dis-
cussion with your GP. Details can be obtained from your GP surgery
or at www.respectprocess.org.uk.

Advanced decisions, advanced statements

and living wills
The terminology can be a bit confusing here. An advanced decision
is also known as an advanced decision to refuse treatment and is
known more colloquially as a ‘living will’. It is a legally binding
document that sets out your decisions about what you do and don’t
want to happen treatment-wise should you become unable to make
or convey decisions at the time.
An advanced statement is a list of your more general preferences
about day-to-day living should you become incapable of deciding
at the time. It is not legally binding, but it should be taken into
account by people who are acting in your best interests.

Advanced decisions
The advantage of making an official advanced decision is that you
can set out all your preferences about what healthcare you do or
112 Social and psychological aspects

don’t want and under what circumstances you would like to be kept
alive. It is set up when you are able to make decisions and must be
signed by a witness if you decide you do not want life-saving treat-
ment. Planning in this way is taking serious responsibility for decid-
ing what is right for you – everyone is different and there is nothing
right or wrong about one’s preferences. It is an effective and legally
binding process, whereas casually saying things like ‘if ever I get like
that, I want you to shoot me’ (as one of our relatives used to say) is
neither helpful nor legal.
An advanced decision needs to be specific about which treat-
ments you are refusing and under what circumstances. To make it
easier to write, there are suggested formats for writing one on char-
ity websites such as Compassion in Dying (www.compassionindy
ing.org.uk). Once it is done, it is not written in stone, as you can
change your mind at any time and re-write a new one. Of course,
you would need to let the relevant people know about it and where
to find it written down, such as family members, your doctor or
healthcare workers. It is a good idea to ask your doctor to keep a
copy in your medical records.
There are various types of life-sustaining treatment that you are
able to refuse, such as ventilation (if you can’t breathe by yourself),
antibiotics or cardiopulmonary resuscitation (CPR, if your heart
stops). However, there are certain basic nursing care elements that
cannot be refused in an advanced decision, such as pain relief, food
and drink and basic nursing to keep people warm and comfortable.
It is not possible to demand certain treatments that healthcare staff
do not think are clinically appropriate. As the current law stands
in the UK, it is not legal to ask for euthanasia or to have someone
assist you in taking your own life, so this cannot be part of an
advanced decision.

Advanced statement
An advanced statement gives you the opportunity to put down in
writing your more general lifestyle preferences, should you become
unable to communicate these at a later date. It can cover day-to-day
preferences such as what type of food and drink you like, clothes
you like to wear, music, entertainment, bathing, who you would
like to visit you, etc. It is a good place to write down any religious
or spiritual beliefs you have and how you would like them to be
honoured.
 End of life 113

Although this is not legally binding, it does give your family and
carers useful information about how you would like to live and be
treated. It is also helpful to let your attorneys have this information
if you have set up an LPA for health and care decisions as it allows
them to make decisions for you that are consistent with your previ-
ous wishes.

Making a will
It is estimated that about a half of adults in the UK do not have
a will – or do have one that is no longer valid. That means that
they have no say over what happens to their estate if they die, and
it would therefore be allocated or divided up according to strict
intestacy rules.
This could present significant issues for people who are left
behind, especially if they are not recognised in the intestacy rules,
for example, a partner you live with or common law spouse, when
you are neither married nor in a civil partnership, even if you have
children together.
The process of making of a will is surprisingly easy and not too
expensive. It can be done by a lawyer who can explain the techni-
calities and do the proper wording of the will and ensure that it is
signed and witnessed in the correct way. It is easy to find local law
firms that specialise in wills and probate and book an appointment.
There are other ways to do it not involving a lawyer. There are
professional will writers (who would need to be a member of the
Institute of Professional Will Writers), or there are some charities
which will draft wills for free. Some banks will help you write a
will, but you would need to check how much they charge for this
service. It is also possible to write your own will, but it is important
that it is done in the correct way with the required signatures, oth-
erwise it may not be valid – so simply writing a list of your wishes
on a piece of paper and signing it will not suffice.
It may not be the process that is getting in the way of people mak-
ing a will, but uncertainty about the contents. Who do you leave
it to? This can be a minefield for some people as their head may
be saying one thing and their heart another. There may be fears of
upsetting or offending people, and there may be a list of ‘shoulds’
and ‘oughts’ that you are grappling with. However, it is your life and
your estate and you can do what you like with it. No one is obli-
gated to leave it to their closest family, for example – it could be left
114 Social and psychological aspects

to a whole mix of different people or charities of your choice. Mak-

ing these difficult decisions is sadly part of adult life, and it is best
thought through calmly and with enough time to consider it well.
Another part of the process is to decide who you would like
to be your executor(s). These are people who are responsible for
ensuring that your wishes in your will are carried out properly. This
involves their time and effort, so it is best to seek their agreement
first. Another aspect of this is to think about how old they are in
relation to you, as you would need to work out the likelihood of
you dying before they do.
There is a list of criteria that need to be met to ensure a will is
valid. It is worth being aware of these, especially if you are doing a
DIY will. People have to have mental capacity to sign their will, so
it is too late to make a will after the loss of mental capacity, such as
that caused by dementia. Another way to invalidate a previous will
is by getting married or entering a civil partnership – in this case
you would need to write another one. It is as well to do the same if
you divorce or separate.

Planning a funeral
Perhaps the legacy of black and sombre Victorian funerals is stuck in
the minds of many people and makes them a topic to avoid thinking
about. However, there’s a rather heartening sign in a local funeral
director’s window – ‘Funerals, like birds, are all different and can be
full of colour and song’.
What happens after you die is something that is worth think-
ing about in advance. One might debate who funerals are actually
for – the deceased person or their families and friends left behind?
Whichever way one looks at it, it is most likely that the remaining
family and friends and other mourners would like to know that you
had preferences about how your passing might be marked. Assum-
ing you have left some money, then it is usually your estate that will
pay for the funeral and any related gathering, so it reasonable to
make some preferences about it known in advance and even have
it planned.
If you decide on a funeral, you can plan it in great detail, e.g.
to create a mood which is more celebratory than sombre or vice
versa. Or you can leave that decision completely to others. Funeral
companies are much more flexible than they used to be. Consider
for example the options of burial, cremation, direct cremation and
 End of life 115

promession, or burial in a biodegradable box in a wood coffin ver-

sus a top-of-the-range solid oak coffin in a crypt. Promession uses
liquid nitrogen to freeze-dry a dead body and then vibrates it so
hard that it explodes into particles. The particles are then dried and
mixed with soil.
Contrary to what a lot of people believe, one doesn’t have to
have a funeral at all. There is no legal requirement to do so. Some
people dislike funerals so much that they request that one doesn’t
take place when they die. Some relatives feel the same and may
make that decision themselves when their family member dies.
Direct cremations are becoming increasingly popular – they are a
lot cheaper to arrange and involve the funeral directors taking the
coffin themselves to a crematorium for cremation. There is no ser-
vice, and no one else attends. The ashes can be dealt with according
to the family’s wishes, including being collected by the family later
so that they can have their own ashes ceremony at an appropriate
place of their choosing.
It is also possible to arrange a DIY funeral without a funeral
director, but there will still be fees for burial or cremation – more
information on this is available via your local Council. It would
require a lot of planning if you are not using any of the services of a
funeral director. The official death registration processes would still
have to be done, including the fees for this.
Regarding costs, many people are aware of how expensive even a
fairly modest funeral is – often several thousand pounds. Some peo-
ple plan for this by setting up a funeral payment plan in advance.
One can compare prices of different funeral directors, and elements
of the funeral can be made cheaper or more expensive depending
on your choices for type of coffin, flowers, ceremonies, etc. Burials
are generally more expensive than cremations. Instead of a religious
ceremony, it can be led by friends and relatives themselves or by
employing a non-denominational celebrant who will lead the cer-
emony according to your choices.

Loss and grieving

Types of loss
As we age, the chances of experiencing loss increase. Although we
might automatically think this about losing a loved one, possibly a
partner, family member or friend, there are other types of loss that
116 Social and psychological aspects

surface with age. Not all are about significant people dying; some
are situational (like loss of work, health, status, familiar environ-
ment), and some are more abstract, such as loss of choice, or loss
of opportunity. Just because it is a less obvious loss doesn’t mean
it is not significant. There is no official list of ‘valid losses’ in life –
everyone is different and sometimes a major loss for one person
would be less significant for another. For example, some people are
bemused by the depth of grief that a friend is experiencing after
their beloved companion dog has died.

How we respond to loss

Our response to significant loss is grief. It is well known that many
western cultures are uncomfortable about dealing with loss and
grief. This can make the whole process that much more difficult for
individuals who are grieving.
Elizabeth Kubler-Ross is a well-known author on this subject. She
initially wrote about the five stages of death and dying, and many
people are familiar with these: denial, anger, bargaining, depression
and acceptance. She subsequently applied the same stages to loss
and grief. She was dedicated to helping people understand what is
happening to them at such a vulnerable time and to help others to
support them as best they can. Her model is helpful, and it makes
a lot of sense. For those of us who have been through a significant
loss, we can look back and see variations on the themes of these five
stages that happened to us. We can even more easily see it happen-
ing to others going through grief.
Kubler-Ross was keen to remove the misunderstandings about
her ‘stages’ – and emphasised that there are many subtle ways in
which any of the five stages can manifest for an individual. Also,
they were not fixed milestones of a process of grieving that people
predictably and neatly went through – they could occur in different
orders, and some people rotate back and forth through different
stages of grief in shorter or longer timescales. She wanted to point
out human individuality, and not everyone adheres to strict models.
We can’t monitor someone’s progress through sequential stages to
see if they are doing it ‘right’ or ‘on time’.
It is understandable, in our culture, that people who feel uncom-
fortable around loss and grief might want to compartmentalise
grief into a neat package of controllable stages. It is an attempt
to intellectualise and operationalise a potentially bewildering and
 End of life 117

devastating human experience. In a way, it is a cultural rendition

of denial. This was not how Kubler-Ross intended her work to be
understood. She wanted the culture to become more aware of the
needs of the dying and the needs of the grieving.
So for us as individuals, what is useful is to appreciate the many
varied responses to loss and to be understanding and accepting of
them. It is worth becoming more aware of what might happen to us
in grief, not just to have some self-compassion but also compassion
for others.
Death and dying, grief and grieving are often hidden away behind
closed curtains and doors, and behind cheerful, brave faces. We
need to be more open-minded and open-hearted about it, however
uncomfortable that feels. What a gift it is to be with someone whose
world just fell through the floor, and hold a supportive space with
them without the usual placating epithets (‘you must be strong’;
‘you’re so brave’; ‘X or Y wouldn’t want to see you so upset’, etc.).

Dealing with loss and grief

There are many helpful books and articles relating personal stories
of how people have dealt with the most egregious of personal losses.
Although reading about other people’s grief at a time when you are
going through your own may seem like the last thing you might
want to consider, sometimes it is comforting to know that you are
not alone in this. Each person gets through it in their own way, in
their own time, and there is no ‘how-to’ guide that works for all.
However, the following general points may be helpful.

Getting appropriate support

For overt losses, like the death of a loved one, there be a flurry of
offers of help and support straight away, but these may dwindle
over time. People usually want to be helpful, but getting the bal-
ance right is difficult to gauge. It is fine to ask for more or specific
help from friends and family – or to ask them (kindly) to back off a
bit and give you some space, if you need that. Don’t underestimate
the usefulness of professional support if that feels appropriate, as
there are many therapists and counsellors who specialise in loss and
bereavement.
For non-overt and potential losses, like anticipatory grief or more
abstract losses, then it can be more difficult for other people to
118 Social and psychological aspects

really understand what’s going on for you. It is difficult enough for

you to know what is happening – so getting professional help may
be particularly helpful so you can feel supported and understood.

Self-compassion
There has been a lot of thinking about the concept of self-compassion
in the last 15 years or so. Kristen Neff’s book, ‘Self Compassion’ has
a helpful approach to it and sees it as a mix of three strands:

• Self-kindness. It helps to fully appreciate how very tough this

situation is and cut yourself a lot of slack. Purposely focus on
what acts of self-kindness you can do for yourself – little things
as well as the more substantial.
• Mindfulness. This is about acceptance and awareness of what is
happening to you in each moment rather than over-identifying
with it, denying it or running from it. Feelings come and they
pass through, if you don’t block them or grab onto them too
much. There are many useful guides to mindfulness available
these days, despite the concept not being at all new. Take from
them what you find helpful.
• Common humanity. It changes our focus when we realise loss
and grief are a common human experience – we are all vulner-
able creatures on this planet, and awful things can happen to
any one of us. No one is immune. We don’t feel so separate or
singled out when we realise we are all in this together and most
of the difference is generally just timing and luck.

Anticipatory grief
Anticipatory grief is particularly difficult as the loss hasn’t hap-
pened yet but feels like it is hovering around the next corner. When
you (or a loved one) are given a serious diagnosis with a poor prog-
nosis or great uncertainty, then it is understandable that you will
conjure up various awful potential outcomes. This imagined hor-
rendous future can completely take over your life. It is important
to keep things more balanced and purposely train yourself to also
focus on the here and now – what is okay now, what is working,
what we do have in the present moment. It is easier said than done,
but as Michel de Montaigne, the French Renaissance philosopher,
once said, ‘My life has been full of terrible misfortunes, most of
which never happened’.
 End of life 119

For anticipatory grief as well as situational and abstract losses,

it can help to remember the three concentric circles about focus of
control. In the outer circle, there are all the things we are concerned
about; the middle circle contains that part that we have some influ-
ence over; and the inner circle contains the smaller portion that
we also have control over. When we shift our focus to our circle of
control and circle of influence, we feel we have more agency and
feel less like a victim.

It takes time
We all know that time is a great healer, but having the patience and
fortitude to stick it out is so hard. However, eventually things do
get a little easier, no matter how unlikely that feels when we are in
the thick of it. Over the course of time, some sort of acceptance will
happen, even though we may be very changed by the experience of
loss. For many people, it can also bring a new sense of meaning to
our lives and our own sense of humanity.
Chapter 11

Additional resources

In this chapter, we first return to the personality theory referred to

in earlier chapters and in particular its application to improving
communication and decision making. Then we outline several more
techniques and skills for managing some of the changes and prob-
lems associated with getting old: assertiveness, managing stress,
writing life stories and expressive writing.

Preference theory and improving

communication
One particularly useful application of preference theory is to
understand and improve how we communicate with each other.
People with different personality preferences tend to communicate
in a way consistent with their preferences. It is not just the focus of
the content of what we say; it is also the style in which we say it.
This means that the more similar we are in terms of preferences, the
easier it tends to be to for each person to be heard and understood.
The reverse is also true – the more different we are, the more there
are likely to be very different styles of communication which can
result in misunderstandings and frustrations, especially if we are
not aware of what is going on. There is no right or wrong in terms
of communication – we just need to be more open to accepting the
diversity of styles and become more flexible in our approach with
people who are very different from us.
People with each pair of preferences tend to find the following
differences a problem:

• between people who prefer Extraversion and those who prefer

Introversion: need to talk versus need to be alone
 Additional resources 121

• between people who prefer Sensing and those who prefer Intu-
ition: focus on details and realism versus focus on general pic-
ture, links and speculation
• between people who prefer Thinking and those who prefer
Feeling: being seen as unsympathetic and critical versus being
seen as illogical and too agreeable
• between people who prefer Judging and those who prefer Per-
ceiving: controlling and planning versus flexible and very open
to change

Some strategies for managing (and preventing) communication

problems between people with opposite preferences follow directly
from the likely diffculties:

• people who prefer Extraversion with those who prefer Intro-

version: allow time for privacy and to reflect
• people who prefer Introversion with those who prefer Extra-
version: explain need for time alone, allow for the other per-
son’s need to talk in order to clarify
• people who prefer Sensing with those who prefer Intuition: give
the overall picture or purpose first, with relevant details later
• people who prefer Intuition with those who prefer Sensing: say
a particular idea is speculative before saying what it is; include
some detail
• people who prefer Thinking with those who prefer Feeling:
include effects on people; begin with points of agreement
• people who prefer Feeling with those who prefer Thinking:
include reasons and consequences; be concise
• people who prefer Judging with those who prefer Perceiving:
allow for lots of flexibility in plans, style of working, etc. and
for the other person’s need not to be or feel controlled
• people who prefer Perceiving with those who prefer Judging:
allow for some planning and structure and for the other per-
son’s need to control and decide

A closely related approach to communication is the four tempera-

ments model, which we introduced in Chapter 7. Some implications
of the four temperaments model for improving communication are:

• SPs (people who prefer both Sensing and Perceiving) need

action, so if they see a practical problem that they want to do
122 Social and psychological aspects

something about, stand aside! They also hate feeling trapped,

so offer options and avoid pressurising.
• SJs (both Sensing and Judging) need tradition and structure,
so are decisive and orderly, specific and detailed. They tend to
focus on a task until it’s finished and to dislike distractions.
Otto Kroeger advised ‘hit and run’ when you want to suggest
a change of plan to someone who prefers Sensing and Judging:
speak concisely and leave quickly.
• NTs (both Intuition and Thinking) criticise to improve some-
thing or someone, and to analyse them, so they like debating,
solving problems impersonally and using complicated theories.
Therefore, offer (well-reasoned) criticism, be prepared to have
your competence tested, and try not to take criticism person-
ally. Indeed, it may well be a compliment: your idea or behav-
iour is worth bothering with.
• NFs (both Intuition and Feeling) need to develop themselves as
people and to help others to do the same. They provide and thrive
on encouragement, warmth and approval, and they tend to take
criticism personally. Their approach is naturally collaborative.

Preference theory and making decisions

Preference theory assumes that we make our best decisions using
both Thinking and Feeling, but giving the most weight to the one we
prefer. Thus people who prefer Feeling can use their non-preference
for Thinking to list points for and against, then their preference for
Feeling to say which of the points matter most, then Feeling again
to make the decision. Conversely, people who prefer Thinking are
likely to find the analytic listing of points and arguments most natu-
ral, but can also include their emotional reactions to each point,
then come back to their Thinking again to make the decision.
Another framework for making decisions based on the theory is
to use four preferences:

Sensing: what are the relevant facts and details?

Intuition: what are the possible ways, however speculative and
unlikely, of interpreting these facts? And are any models or
theories relevant?
Thinking: what are the consequences of each choice, short- and
long-term? What are the arguments? What’s logical?
Feeling: what are the probable effects on each person involved?
What are the priorities here? Which do I like most?
 Additional resources 123

The theory implies putting the most effort into the stages associated
with our non-preferences (because they are likely to be less devel-
oped) and applying our preferences last (because they are likely to
be more trustworthy).

Assertiveness skills
Assertiveness can be defined as respecting your own rights and the
rights of other people. It can be defined in terms of those rights (e.g.
those listed in the next section) and as skills, e.g. saying no, making
requests, giving and receiving compliments and giving and receiving
criticism.
If you want to try being more assertive, we suggest looking out
first for times when you are not assertive and regret it. For example,
you might observe one or more of the following:

• you said yes or behaved in a way that ‘said’ yes when you’d
rather have said no
• you didn’t ask someone for something when you’d rather you
had asked
• you rejected a compliment when you actually liked it and
believed it was genuine
• you didn’t give someone a genuine compliment when you
wanted to

Take one of these exchanges, for example the time you’d rather
have said no, and analyse it:

1 Write down what you’d rather have said, ideally finding a key
phrase. (You may wish to change this key phrase later as a result
of the other steps.)
2 Consider the possible costs of saying no.
3 Consider the possible benefits of saying no.
4 With this person in that situation, which are more important to
you: the benefits or the costs?

It can be very clarifying to rehearse the likely interaction with a mir-

ror, recording device, friend or group (carefully chosen!) for practis-
ing the assertive skills of everyone in it.
Next, if your ideas about the likely benefits exceed the costs, con-
sider actually saying no to that person the next time the oppor-
tunity arises, using your key phrase. The word ‘no’ itself can be
124 Social and psychological aspects

particularly powerful too. Another option is to create the opportu-

nity to be assertive: ‘You asked me yesterday to help you with X and
I’ve thought hard . . .’ or ‘Earlier you asked me to do X for you and
I said I would. I’ve thought about it and changed my mind’. There
are many other variations, which will depend on the particular situ-
ation where you want to say no and also on the relationship with
the person you are saying no to. Anne Dickson’s book A Woman in
Your Own Right (which applies just as well to men) includes many
excellent examples of the skills in action.
Another way that assertiveness can be used is to analyse a prob-
lem from the perspective of a list of assertive rights such as the
one given later. The usual way assertive rights are described is for
oneself only, but the format here, devised by Meg Bond in her book
Stress and Self-awareness. A guide for nurses, conveys in a very
clear way that assertiveness is about respect for the same rights in
other people too.
Deciding whether you agree or not with each assertive right may
also clarify your values. An exercise you may wish to try is to con-
sider each pair of rights in turn. How easy or difficult do you find it
to accept this right as generally true for first other people and then
yourself? The rights can be particularly helpful when you are upset
or angry to realise that your reaction is or may be out of proportion
to the event apparently causing it.

Assertive rights for oneself and others

1 I have the right to be treated with respect, and others have the
right to be treated with respect.
2 I have the right to express my thoughts, opinions and values,
and others have the right to express their thoughts, opinions
and values.
3 I have the right to express my feelings, and others have the right
to express their feelings.
4 I have the right to say ‘no’ without feeling guilty, and others
have the right to say ‘no’ without feeling guilty.
5 I have the right to be successful, and others have the right to be
successful.
6 I have the right to make mistakes, and others have the right to
make mistakes.
7 I have the right to change my mind, and others have the right to
change their minds.
 Additional resources 125

8 I have the right to say that I don’t understand, and others have
the right to say they don’t understand.
9 I have the right to ask for what I want, and others have the right
to ask for what they want.
10 I have the right to decide for myself whether or not I am respon-
sible for another person’s problems, and others have the right
to decide for themselves whether or not they are responsible for
another person’s problems.
11 I have the right to choose not to assert myself, and others have
the right to choose not to assert themselves.

Managing stress
Some signs of too much stress are:

• on thoughts and emotions: difficulty concentrating, being anx-

ious, irritable or bored, low mood
• on the body: tight throat, aches, dry mouth, tics, frequent
urination
• on behaviour: accidents, drug misuse, criticising, sleep difficulties

It’s important to note that some of these signs of stress may be

caused by illness and may therefore need medical attention. More-
over, another sign, unfortunately, is ignoring such signs. Ideally,
we would notice them early and take action to reduce or remove
them, but being stressed is itself distracting. The advantages of early
action are obvious: less energy wasted and less damage done. Work-
ing out the source(s) of stress, internal and external, may also be
more feasible.

Preference theory and stress

The theory of personality preferences introduced in Chapter 7 states
that the activities and circumstances which are enjoyable for peo-
ple with some preferences are stressful for those with the opposite
preferences.

Extraversion – not much happening; not enough contact with

people (even though most do need some time on their own)
Introversion – not enough time for reflection or for oneself
Sensing – vagueness and abstract theory
126 Social and psychological aspects

Intuition – routine, repetitive and detailed activities

Thinking – lack of logic, intense emotions
Feeling – conflict and criticism, discourtesy
Judging – lack of plans, and changes of plan
Perceiving – restrictions on autonomy, few or no options

Coping with stress

A three-stage model of coping with stress is:

Stage 1: Monitor your signs of too much or too little stimula-

tion, especially early warnings
Stage 2: Choose one or more coping strategies
Stage 3: Try them out, monitoring the effects

Choosing one or more coping strategies is currently a matter of

personal experiment, although some strategies work well for most
people and are therefore more likely to be worth trying. They
include exercise (Chapter 1), sleep (Chapter 3), expressive writing
(this chapter) and relaxation.

Physical relaxation
Physical relaxation is a direct way of coping with stress, both imme-
diately and preventively, and instructions/guidelines are widely
available. Two 10-minute sessions of progressive relaxation a day
seem to have a beneficial and cumulative effect. However, some-
times attempting to relax is itself stressful. Several factors can make
a difference: e.g. some people prefer a well-lit room, others a dark
one; some respond best to several two- or three-minute sessions,
and so on. Moreover, someone can try too hard to relax or may be
afraid of losing control of certain images or emotions. Relaxation
can also be boring and therefore stressful.
A simple relaxation technique from yoga is to:

1 Make yourself comfortable. Take two or three deep breaths

through your nose. Then place one of your index fingers on the
point between your eyebrows, with the thumb on one nostril,
middle finger on the other.
2 Closing your left nostril, breathe in slowly and deeply through
the right.
 Additional resources 127

3 Closing your right nostril, breathe out slowly through the left.
4 Keeping the right nostril closed, breathe in through the left.
5 Closing the left nostril, breathe out through the right.

You can breathe in to (say) a count of three, hold for two, out to
six – but ideally, fnd your own rhythm. A further refnement of the
instructions is that when you’ve breathed out, pause and wait until
you want to breathe in – until it ‘feels right’.

Writing life stories

Many people find it helpful to explore their life stories. They dis-
cover something surprising and useful and make more sense of their
life and of themselves. Others have no interest, sometimes because
their lives feel too traumatic and are best left alone.
The process of exploring and analysing life stories can be emo-
tional. If you become ‘caught up’ or stuck in an emotion, distraction
techniques like counting backwards in sevens from (say) 300, or
breathing slowly and deeply, can be effective for regaining enough
composure to continue reflecting and analysing, or to stop.
A simple approach to writing a life story is to just write, say, three
pages. You might also try writing in the third person, from the per-
spective of someone who knows you well. Another option is to use
a structure, e.g. chronological, places you’ve lived, life events you
see as pivotal or close relationships.

The life story interview

Dan McAdams developed a more elaborate system: the life story
interview, in which the interviewee (who can be the same person as
the interviewer) is asked first to think about their life as if it were a
book with chapters, and then to identify each chapter and outline its
contents, like a plot summary. Next, she or he is asked to describe
eight key scenes from their story, each depicting one of the following
events: a high point, a low point, a turning point, earliest memory,
important childhood episode, important adolescent episode, impor-
tant adult episode and one other important episode.
There are five further stages in the full life story interview. Briefly,
they are describing the biggest challenge faced by the interviewee
and how they met it; the character with the most positive effect on
their life and the one with the most negative effect; an account of
128 Social and psychological aspects

where the story is going, for example main goals, dreams and fears;
questions on values and religious and political beliefs; and, finally,
identifying a single integrative theme.
At each stage, the interviewer can vary in how probing they are
and in their use of theory to guide their questions. In analysing
your answers, the key question is ‘what does this aspect say about
who I am and who I might be?’ For example, a theme might be that
you have been faced with many obstacles but have resiliently over-
come them, and you might choose to continue in your life with this
theme, or refine it, add to it or reject it.
Exploring life stories can stimulate feelings of nostalgia which
can be seen as pointless or detrimental. However, nostalgia can
have positive effects such as strengthening our sense of identity and
reminding us of how we have coped with a problem before. Curi-
ously, such effects quite often occur a few days after reminiscing
rather than immediately.
Reflecting in a nostalgic way may lead to you feeling guilty about
things you did (or failed to do) many years before. In turn, you may
feel you should atone in some way. Before you act, please consider
the idea that your good actions may outweigh those you feel guilty
about and thus make the case for action less compelling.
In addition, please also consider who the action is for. A way
of doing this is to apply assertive rights (see earlier in this chap-
ter) to both yourself and anyone else you are inclined to involve.
For example, ‘I have the right to make mistakes’ and ‘Others have
the right to make mistakes’ or ‘I have the right to be treated with
respect’ and ‘Others have the right to be treated with respect’. Does
your possible action treat the other(s) with respect? Might they
have forgotten about what you did or didn’t do or not want to be
reminded?

Expressive writing
Expressive writing is an effective way of managing stress and
improving health for many people. Generally, it has beneficial effects
through increasing a sense of perspective, calmness and control, and
clarifying emotions, thoughts, wishes and values, which in turn tend
to lead to better decisions and actions. Moreover, it is inexpensive,
portable and private and has a low risk of negative effects.
The following method is based on the extensive research on
expressive writing. There are four steps:
 Additional resources 129

Step one is to write freely about a preoccupation, problem, question

or event. The research on the effects of doing this has been on a wide
range of topics from traumatic events like being in an earthquake to
positive ones like new and good things in your life. Decisions, reac-
tions to a news item or a memory are other possibilities – anything
that you find puzzling, troubling or interesting.
Write for yourself alone, and aim to write for at least 15 minutes.
A variation for step one is ‘freewriting’. This is writing without
stopping, censoring or editing (you can shred it later) about what-
ever comes to mind, either generally or about a particular topic.
Put grammar, spelling and punctuation aside. Write anything, but
keep writing. Write for at least 15 minutes, including things like ‘I’m
stuck’ or ‘this is silly’.
Freewriting comes easily to some people and for others develops
with practice or doesn’t suit them. If you’re writing using a com-
puter, you may feel freer not looking at the screen.
Step two is to analyse what you’ve written. In freewriting particu-
larly, you’ll probably find some repetition and lots of uninteresting
stuff but also some useful and sometimes surprising bits. Underline
those. You’re writing and analysing to clarify and discover what
you mean, feel, value, think and want. The following questions can
be useful as prompts:

1 What emotions/feelings/thoughts that may be useful have you

written down? Are you reminded of others?
2 What actually happened (specifically)?
3 How might other people have reacted in your position?
4 How would you like to have reacted?

Step two is meant to be very different in ‘feel’ from step one:

thoughtful, considered and detached rather than spontaneous and
free. Being kind to yourself about what you’ve written is a helpful
idea for some people.
Step three is to write a list of possible actions to take about the
problem or issue you’ve written about. These can range from the
practical and easily achievable to the fanciful and wildly unlikely to
happen. They can include a change of attitude on your part as well
as things you might say or do.
Step four is to consider the arguments for and against each pos-
sible action. For example, is it legal? What are the likely effects on
others and on you, short-term and long-term?
130 Social and psychological aspects

Or you could apply the steps of writing freely and analysing to

the actions or discuss them with someone you trust. It can be par-
ticularly useful if this person is significantly different in personality
from you, e.g. someone more logical, if you tend to focus more on
how you and others feel or vice versa.

Risks of expressive writing

A risk of expressive writing in some people’s view is that it is self-
indulgent and can lead to ‘wallowing in misery’ and your mood
spiralling down. The four steps are designed to counter this: being
stuck and the opposite risk of premature action are both countered.
Further, someone else may read what you’ve written and react
badly. Solutions include writing PRIVATE at the top, putting it in a
locked drawer or shredding it.
You may feel worse after expressive writing. There is something
about putting things into words, spoken or written, which can have
this effect, especially short-term. However, the positive and longer-
term effects of writing in this way are significant: for example,
greater clarity and better health, as shown by fewer visits to a health
centre in the six months after doing it, and lower levels of stress
hormones. Thus it is a matter of balancing risks against benefits.

An example of freewriting with commentary

Step one (abbreviated): write freely

My hamstring hurts again. That’s 3 ½ months of several times of
apparent recovery and then not right again. This happens every few
days. Feel despairing, very fed up and old. I’ve been disciplined and
patient (for me) and it seemed fine. Will it ever be right again? Have
I damaged it so that keeping fit, well what counts as fit at my age,
is impossible?

Step two: analysis

Note: If you used the technique of freewriting in step one, it’s
probably best to underline the potentially useful bits before doing
step two.
I do feel despairing at times but even if it’s a serious injury people
recover from much worse and I know that, just forget it sometimes.
 Additional resources 131

So I’m being overdramatic and catastrophizing and this is very

familiar where injuries are concerned.
This injury is uncomfortable rather than painful. On the other
hand the repetitive slight injuries may be cumulatively damaging.
Also, I’m very lucky to have played football for nearly all my life
with only occasional minor injuries so even if this is the end of my
football it’s been good.

Step three: possible actions

1 Try a different physio? Ideally I’d go to see Paul.
2 Let go of playing football.
3 Ask my GP (a rugby player) to recommend a physio.
4 Be even more gradual in how I build up to full recovery.
5 Buy an exercise ball to sit on.
6 Look up lower back injuries and treatments because I’d forgot-
ten that they can lead to discomfort away from the back.
7 I do slouch and sprawl a lot (what are sofas for?) so posture and
back stretcher.
8 It may be significant that while I can do lots of press-ups I’m
weak at lunges. Core muscles?
9 Similarly, it may be as simple as that I’ve been doing too many
lunges and squats; I do tend (to put it kindly) to do appealing
new things too enthusiastically.
10 Operation?

Step four (abbreviated): decide which actions to do and how

and when
Action 2 is still too soon and premature to explore it, and 1 and 3
are for if the others don’t work. Actions 4 and 8 need patience so
are difficult, but vital, I suspect, and 10 is silly and impatient. The
rest I’ll do, gently, starting today. Discipline! But do them with TV
or music.
Suggestions for further reading

Rowan Bayne (2013) The Counsellor’s Guide to Personality: Understand-

ing Preferences, Motives and Life Stories. Palgrave Macmillan.
Linda Berens (2000) Understanding Yourself and Others: An Introduction
to Temperament.: Telos Publications.
Patrizia Collard (2014) The Little Book of Mindfulness, 10 minutes a day
to less stress, more peace. Gaia Books.
Rangan Chatterjee (2018) The Four Pillar Plan: How to Relax, Eat, Move
and Sleep Your Way to a Longer, Healthier Life. Penguin.
Anne Dickson (2012) A Woman in Your Own Right: Assertiveness and
You. Quartet.
Alex Linley (2008) Average to A+. Realising Strengths in Yourself and Oth-
ers.: CAPP Press.
Muir Gray (2015) Sod 70! The Guide to Living Well. Bloomsbury.
Phil Hammond (2015) Staying Alive: How to Get the Best from the NHS.
Quercus.
Otto Kroeger & Janet M. Thuesen (1988) Type Talk. Delacorte Press.
Elisabeth Kubler-Ross & David Kessler (2014) On Grief and Grieving.
Simon & Schuster.
Kathryn Mannix (2017) With the End in Mind: How to Live and Die Well.
William Collins.
Michael Mosley (2018) The Fast 800: How to Combine Rapid Weight
Loss and Intermittent Fasting for Long Term Health. Short Books.
Marion Shoard (2017) How to Handle Later Life. Amaranth Books Ltd.,
2nd ed.
Tim Spector (2015) The Diet Myth. Weidenfeld & Nicolson.
Index

5:2 diet 20 dehydration 23; incontinence

23–4; retraining 24–5
abstract loss 116, 117–18, 119 Bond, Meg 124
advanced decisions 111–12 bones 8
advanced statement 111, 112–13 bowel movement 25; constipation
advertising of health products 51 26; incontinence 23; position 25
aerobic exercise 36–7 brain training 36
age discrimination 57–8 brisk walking 10, 13
ageing, beliefs about 59–60 Brue, Suzanne 14
Age UK 41, 93
alternate days diet 20–1 caffeine 28
Alzheimer’s Society 41 calorie counting 21
antibiotics 16 Campaign to End Loneliness 86
anticipatory grief 118–19 care homes 101–2; choosing
antidepressants 45, 46 102–3; costs, funding of 103–4;
Ashton, Heather C. 46 financial advice 104; see also
assertiveness skills 123–5 living alone
assertive rights 124–5, 128 Care Quality Commission 103
assisted dying 107–8 carers for people with dementia 41
attitudes to life 64 Carers Trust 41
attitudes towards ageing 57; Carers UK 41
everyday disregard 58; language catheters 25
58–9; of others 57–9; and Cat Society 91
personal beliefs 59–60; positive Centre for Applied Positive
role models 59 Psychology (CAPP) 76
clinical networks, condition-
back pain 9–10 specific 44
back stretcher 10 clonazepam, for REM sleep
balance 11–12 behaviour disorder 30
benzodiazepines 45, 46 clothes choices 63–4
bereavement 92 cocktail party phenomenon 33
Berens, Linda 72, 73 coffee 18
bladder 22–3; catheters versus cognitive rehabilitation, for
incontinence pads 25; dementia 40
134 Index

cognitive stimulation therapy, for eating 15; grazing 21; habits 20;
dementia 40 and personality 21–2; see also
College of Sexual and Relationship diet
Therapists 86 emotions, and values 79–80
communal living retirement homes Enders, Giulia 25
101 end of life: advanced decisions
communication 34, 120–2 111–12; advanced statement
community, sense of 88 111, 112–13; funerals 114–15;
Compassion in Dying 112 good death 105–8; loss and grief
constipation 25, 26 115–19; making plans for 108–15;
corns, foot 8 power of attorney 109–11; will
Court of Protection 110–11 113–14
Cox, Jo 86 enduring power of attorney 109
Creado-Perez, Caroline 58 Equality Act (2010) 57
creative arts, for dementia 40 Eros 84
evidence: of lack 53; lack of 53–4
dancing, for dementia 40 exercise(s) 5, 12; aerobic 36–7;
dark chocolate 18 bones 8; fall prevention and
dating, online 82–3 balance 11; foot 9; High
death: five stages of dying 116; Intensity Interval Training (HIIT)
good death 105–8; see also end 13–14; intensity of 5; for losing
of life; grief; loss weight 19–20; lower back pain
death cafés 106 10; Low Intensity Steady State
decision making: healthcare, Cardio 14; and microbiome 16,
patients as active participants in 20; muscle 6–8; neck pain 10;
42–54; and power of attorney and personality 14; press-ups
109–10; and preferences 122–3 6–7, 11; recovery and rest days
deep breathing 10 5; and sleep 28; squats 7–8, 10,
dehydration 23 11; for strengthening pelvic floor
dementia 37, 102; Alzheimer’s muscles 24; walking 12, 13
disease 38; diagnosis of 39; expressive writing 128; freewriting
prevention of 40–1; risk factors 129, 130–1; risks of 130; steps
37; support for people with 129–30
dementia and carers 41; symptoms extraversion (personality
of 38; treatments for 39–40; types preference) 68, 69, 71, 85, 89,
of 37–8; vascular 38–9 120, 121
Dementia UK 41
Dickson, Anne 124 faecal incontinence 23
diet 15–18; 5:2 diet 20; alternate falls 11–12
days diet 20–1; Mediterranean- false negatives 49–50
style 18; mini-fasting 20–1; false positives 50
political dimension of 15–16; fasting 20–1
research/advice, problems in feeling (personality preference) 69,
15–16; and weight 19 70, 71, 85, 121, 122
direct cremation 115 feet 8–9
doctor consultation 43–5 fibre 26
doulas 106–7 financial decisions, lasting power
downsizing 93, 94 of attorney for 109–10
dreams 29–30 forcefield analysis 66–7
 Index 135

forgetfulness 33; aerobic exercise of costs 95–6; reasons for 93–4;

36–7; in Mild Cognitive values 80–1, 96
Impairment 35–6; in normal human interaction, and living
ageing 34–5; see also dementia alone 99–100
freewriting 129, 130–1
fruits 17–18 immediate needs annuity 104
funerals 114–15 implicit bias 53
incontinence 23–5
genetics, and diet 16 incontinence pads 25
Gerrard, Nicci 38 independent mental capacity
ghosting 83 advocate (IMCA) 111
‘golden seed’ 76 individualistic cultures, and
good death 105; assisted dying loneliness 86
107–8; death cafés 106; doulas Individual Strengths Assessment
106–7; hospices 107; Mannix’s (ISA) 76
approach to 105–6 injury(ies) 5, 11
grazing 21 insomnia 27–8
grief 116, 117; anticipatory 118–19; intelligence 33
dealing with 117–19; getting inter-dependent cultures, and
appropriate support 117–18; loneliness 86–7
and time 119 introversion (personality
preference) 68, 69, 70, 71, 85,
healthcare decision making, 89, 97–8, 120, 121
patients as active participants in intuition (personality preference)
42–3; doctor consultation 43–5; 69, 70, 71, 85, 89, 121, 122
health information 51–4; health intuition plus feeling (NF) 73, 122
screening 47–51; prescription intuition plus thinking (NT) 73, 122
drugs 45–7 isolation, and living alone 100
health information: advertising
and marketing 51; expert jogging 13
committees, reports of 53; lack judging (personality preference) 69,
of evidence/evidence of lack 70, 71, 85, 121
53–4; organised systems for Jung, Carl 67
reviewing 52–3; source of 51–2
health services for people with Kennel Club 91
dementia 41 knees 9
heart disease 20 knowledge about self 61–2; art
High Intensity Interval Training and music likes 65; attitudes to
(HIIT) 13–14 life 64; clothes choices 63–4;
hips 9 home and environment choices
home choices 63 63; interests/skills/energisers 63;
hospices 107 personality 62; physical activity
house, moving 93; accommodation likes 64–5; relationships 64;
94; alternatives 96–7; assessment science interests 65–6; spiritual
of needs/preferences 96; avoiding choices 66; strengths 62;
mistakes 96; downsizing 94; stressful/loathsome situations 64;
location 94; options for people values 62
who are not home owners 97; Kroeger, Otto 73, 122
process 95; realistic assessment Kubler-Ross, Elizabeth 116, 117
136 Index

lack: of evidence 53–4; evidence McAdams, Dan 127

of 53 medications 20, 30; see also
language, ageist 58–9 prescription drugs
lasting power of attorney (LPA) Mediterranean-style diet 18
109; for financial decisions MedlinePlus 45
109–10; for health and care melatonin, for REM sleep
decisions 110 behaviour disorder 30
Lee, John 84 memory see forgetfulness
Lewin, Kurt 66 mental abilities 32–4; see also
life stories: interview 127–8; forgetfulness
writing 127–8 Mental Capacity Act (2005) 109, 111
lifestyle: changes 29, 35, 39, mental health 87
46–7; preferences, and advanced microbiome 16, 19
statement 112–13; suitability of Mild Cognitive Impairment (MCI),
pets with 91–2 forgetting in 35–6
Linley, Alex 75, 76 Millennials 101
living alone 97–9; alternative mindfulness 10, 118
strategies for 100–1; choice of mini-fasting 20–1
98; and geographical location Mitchell, Wendy 38
100; and human interaction mobility 5; bones 8; exercise
99–100; as a result of 12–14; falls and balance 11–12;
circumstances 98–9; see also feet 8–9; knees and hips 9; lower
care homes back 9–10; muscles 6–8; neck
Living Well, Dying Well 107 10; see also exercise(s)
living will see advanced decisions Montaigne, Michel de 118
location, house 94 mortgages 95
loneliness 86–8; and cultural Mosley, Michael 26
differences 86–7; definition motivation: core motives,
of 86; effects on health 87; identification of 72–3; personal
management of 88–90; strivings 73–5
prevalence of 87; stigma moving see house, moving
associated with 87 multi-infarct dementia 38
loss: abstract 116, 117–18, 119; muscles 6–8
anticipatory grief 118–19; music 40, 65
dealing with 117–19; getting Myers, Isabel 67
appropriate support 117–18;
and living alone 98; of pets 92; National Health Service (NHS) 24,
response to 116; self-compassion 43, 44, 45, 46, 47, 50
118; situational 116, 119; types National Institute for Health and
of 115–16 Care Excellence (NICE) 43, 52
lovestyles 84 neck pain 10
lower back pain 9–10 Neff, Kristen 118
Low Intensity Steady State Cardio night cramps 29
(Liss) 14 non-preferences 70–2, 123
lucid dreaming 30 nostalgia, and life stories 128
Ludus 84
obesity 16
Mania 84 Office of the Public Guardian 110
Mannix, Kathryn 105–6 olive oil 18
marketing of health products 51 online dating 82–3
 Index 137

opioids 45 red wine 18

ordinary power of attorney 109 relational pension 88
relationships 64, 82; coping with
pelvic floor muscles, exercises for sexual problems 86; loneliness
strengthening 24 86–90; online dating 82–3;
perceiving (personality preference) personality and sexual behaviour
69, 70, 71, 85, 89, 121 85; pets 90–2; romantic love 84
personality 62; and communication REM sleep behaviour disorder
120; development 67–73; and (RBD) 29–30
eating 21–2; and exercise 14; rental costs 97
identification of core motives ReSPECT (Recommended
72–3; and losing weight 21–2; Summary Plan for Emergency
and preferences 68–72; and Care and Treatment) form 111
relationships 85, 89–90; see also restless legs syndrome (RLS) 30–1
preferences ‘rocking squat’ position 25
personal strivings 73–5 romantic love 84
personal values see values
pets 90; benefits of 90–1; loss, and science interests 65–6
bereavement 92; ownership, screening, health: accepted
costs of 91; suitability with principles for 48; downside of
lifestyle 91–2 48–9; and false reassurance
physical activity 64–5; see also 49–50; importance of medical
exercise(s) conditions 49; intuitive appeal of
physical relaxation 126–7 47–8; potential pitfalls of 48–51;
Pilates 10, 12 tests 49–51
post-stroke dementia 38 second opinion 45
power of attorney 109; LPA for self-compassion 118
financial decisions 109–10; LPA self-kindness 118
for health and care decisions sensing (personality preference) 69,
110; ReSPECT form 111; 71, 85, 89, 121, 122
situation of losing capacity sensing plus judging (SJ) 72, 73,
before setting up 110–11 122
Pragma 84 sensing plus perceiving (SP) 72, 73,
preferences 68–72, 85; and 121–2
decision making 122–3; and sexual behaviour 85
improving communication sexual problems, coping with 86
120–2; and stress 125–6 Shoard, Marion 25
prescription drugs 45–6; avoiding sitting 12–13
46–7; safe withdrawal from 46 situational loss 116, 119
press-ups 6–7, 11 sleep 27; auditing life aspects that
processed foods 17, 19 affect 28; improvement 27–8;
processed meats 17 night cramps 29; snoring 29
promession 115 sleep disorders 29; REM sleep
psychological death 72, 73 behaviour disorder 29–30;
restless legs syndrome 30–1;
questionnaires, for identification of sleep apnoea 31
strengths 76 sleeping pills 27
snoring 29
Rabbitt, Patrick 32–3 social isolation 100
red meat 17 social media 90
138 Index

social networks 87, 88 UK National Screening Committee

social prescribing 90 (NSC) 47, 48
social services for people with urinary catheters 25
dementia and carers 41 urinary incontinence 23–5
Spector, Tim 16
spiritual choices 66 vaginal mesh 24
squats 7–8, 10, 11 values 62; clarification of 78–80;
‘squatting while sitting’ position 25 identification of 77–81; issues
standing 8, 12 concerning 78; prioritisation of
standing on one leg exercise 11 80, 81; in specific situations 80–1
stigma associated with loneliness 87 vegetables 17–18
Storge 84 volunteering 100
strengths 62; definition of 75;
identification of 75–7 waist measurement 18
stress: coping with 126; physical walking 12, 13
relaxation 126–7; and weight: and eating habits 20; and
preferences 125–6; signs of 125 exercise 19–20; gain 18; healthy
stressful/loathsome situations 64 18; losing 19–22; and medications
Strivings Assessment Questionnaire 20; and microbiome 19; mini-
(SAQ) 72, 73–5 fasting 20–1; see also eating
subcortical vascular dementia 38–9 Wellcome Collection 88
sugar 17, 19 West, Lindsay 80
Summers, Neil 10 will 113–14
women, bias against 58
tai chi 12 World Health Organisation 48
temperament theory 72–3, 121–2 writing 28; expressive 128–31;
thinking (personality preference) freewriting 129, 130–1; life
69, 70, 71, 85, 121, 122 stories 127–8
Thuesen, Janet 73
toenails 8 yoga 10, 12, 126–7