Fourteen older adults were interviewed (eight women and six men). Their age varied from 65 to 101 years old. Because we strived for maximum diversity, we included one respondent who was slightly younger (less than one-year difference), but who has severe mobility problems. This person met all the other selection criteria. All participants indicated they had chronic health problems which impacts their functioning. The number of indicated problems varied from one to three. (Table 1)
The analysis of what the older adult experienced is represented in three themes: their perceived level of activity and participation, their perceived health, and the factors they perceive as influencing their activity level and their participation.
Perceived level of activity and participation
The ‘activity and participation’ theme was categorized into five subthemes: Basic Activities of Daily Living (BADL), Instrumental Activities of Daily Living (IADL), productivity, leisure activity and mobility.
Eleven respondents indicated being able to handle BADL on their own. All respondents indicated perceiving limitations regarding IADL, productivity, leisure activity and mobility.
Regarding BADL, three respondents indicated requiring assistance with dressing and undressing. The extent of help required varied, from completely dependent to needing help closing small zippers. About half the respondents (eight) said they had problems climbing stairs.
All older adults mentioned IADL problems. Nearly all respondents reported being able to prepare small snacks. Doing laundry, cleaning, running errands and working in the yard were most problematic. Three respondents reported performing only a few IADL activities. These respondents were older than 90 years old and two of them had profound visual impairment. The remaining limitations were mostly about strength, flexibility, endurance and balance. Strength refers to both a global reduction in strength as well as specific strength loss in the hand region. The reduction of flexibility was mostly on the level of the hands and wrists. Visual impairments greatly limited being active in the field of IADL.
“In the kitchen, it’s my wife who does everything. I can’t do anything because I can’t see it I can’t feed the animals anymore either, my wife does that. My wife does the yard. To go outside I take my walking-frame, but last Sunday I took my cane. I should have used my walking frame.” (91-year old man with visual impairment and mobility issues)
One respondent had a part-time paid job. Two respondents gave informal care to or did chores for family members and friends, which varied from having a fixed schedule to sporadic services. One respondent wanted to be more productive, but saw no opportunities.
All respondents (n = 14) reported that the variety of pastime activities available to them had been reduced. This varied between a slight to a great reduction. The decrease included both outdoor activities as well as individual indoor activities, for example not being able to read a book.
All respondents reported a decrease in mobility. Six of the respondents used an ambulatory aid. All respondents had a decreased ability to travel long distances. Two respondents communicated being able to ride a bicycle but only with a bicycle adjusted to their needs. Five respondents still drove a car. Three respondents still went on holidays. One respondent traveled as he used to in the past. One respondent made large voyages, but only with a group. The third respondent indicated only travelling when it is comfortable. For example he preferred to pay more for comfortable transportation.
“The large walks have been left behind. Up until about four years ago, those still went fine, despite my back. And cycling, mostly up and down, I don’t like going straightforward all the time. It seems like it’s more exhausting if I don’t have variation.’ (75-year old man with lower back-pain)
Most of the older adults (n = 11) indicated being in good health, independent of the number of health issues they have, and the degree of the limitations they experienced. Three people rated their health more poorly. Two of these have severe mobility limitations. Both respondents wanted to stay active, despite their limitations. Nobody said their health was bad.
‘I’m generally good, it’s just my walking that’s less good, but otherwise I’m healthy. I never have exacerbations. I’m happy with what I can still do.’ (78-year old person using a walking aid)
Factors older adults perceive as influencing their activity level and their participation
Categories that are mentioned as extrinsic factors that influence functioning are: assistive devices, the dwelling and living environment, professional and informal support and medication. These factors can be both facilitating as well as inhibiting.
The most used assistive devices pertained to mobility (n = 8). Kitchen devices are less often used (n = 2). Five respondents go outside with a walker or a rollator. One respondent utilized a cane outdoors. Two older adults used a stair-elevator. Three older adults were advised to use a cane, but refused to do so because of perceived stigma. The respondents stated that aids can facilitate one aspect of functioning, but also bring about new limitations in other areas. For example, a walking aid facilitates walking, but causes issues when trying to transport things or perform certain other actions while walking. Sometimes, specific kitchen devices were used for household tasks that require hand-strength, for example a bottle-opener with an elongated handle.
All respondents reported that their dwelling and living environments were adapted for them to function optimally. In two of the nine houses with more than one floor, a stair lift was installed. Two other older adults did not use the upper floors anymore, but did not find their home not adapted to their needs. All older adults who lived in an apartment made use of the elevator present in the building. One respondent recently moved to assisted living and said this facilitated mobility. The majority of the older adults indicated that the neighborhood was not suitably adjusted to moving around safely. Stairs, the type of terrain and support points in the neighborhood were indicated as important determinants for mobility.
The help from professional services were perceived as facilitating, but with certain limitations. The limitations had to do with frequency and time. For example, certain types of services were not provided on weekends. The professional services consisted of help at home or respite care. Examples of services at home are library at home, the garden service, meals on wheels and home care. Examples of respite care are day-care centers and a short stay. The respondents generally perceived informal assistance by family and neighbors as facilitating. The respondents also mentioned disadvantages. Informal caregivers, just like professionals, are not always available. Informal caregivers have their own needs and worries and that can interfere with the provided informal care.
‘Especially strength in my hands, that’s what I perceive. When I need to turn the key, then I need to do that twice and twist, or if I need to open a jar, then I give it to the neighbor boy.’ (87-year old lady living alone)
Taking medication is perceived as normal. Older adults indicate that medication is not enough to alleviate all pain or discomforts, for example rheumatic pains. Despite optimal medication-intake, they still experience limitations. They also indicate that for certain afflictions, no suitable medication solutions are available yet.
Perspectives on determinants of functioning, social participation and health
Characteristics of both attitude, social influence and self-effectiveness and the applied coping strategy determine the intention of whether or not to perform an activity or to achieve participation.
The attitude of the older adult towards their—possibly reduced—functioning was determined by one or more of the following categories: significance, necessity, wellbeing, conviction and desire for autonomy.
The care for a pet, a partner, a friend, a grandchild, their property and self-care were meaningful actions that motivated the older adult to remain active. Things that the older adult did not perceive as meaningful, did not motivate them to be active or to participate socially.
‘… I have trouble talking to other people, having a conversation, that’s just not me … my mother was like that as well. Everyone knew she didn’t do chatting’ (one hundred and one-year old woman living alone)
Activities that normally are not performed by older adults because of bodily limitations, were still performed in extraordinary situations. Enjoying things you do was often mentioned in the frame of ‘doing things together’ and doing things that lie within the sphere of interests, like hobbies. Both increased their feeling of wellbeing.
Being convinced that a certain way of behaving contributed to better physical or mental health, or a certain mental attitude can lead to being active or to healthier active behavior.
‘I often tell myself exercise in the morning, every day. But some do nothing, I wonder how people with back pain can stay still for hours and don’t take on an ergonomic position.’ (Seventy five-year old cohabitating man)
The desire for autonomy was the greatest motivation to staying active. All older adults expressed the wish to maximally maintain their privacy.
‘Get up, washing my intimates and my face, I’ve already washed my intimates when the nurses come to shower me. I want to wash my intimates myself.’ (one hundred and one-year old woman living alone)
The perceived social pressure and support that motivated being active or that influenced the frequency of participation, mainly consisted of the non-professional environment, more specifically the children and peers (friends and acquaintances). The most important peer for this was the partner. Perceived social pressure and support was seldom coupled to the professional environment.
Traditions and religious activities were situations that older adults experienced as social norms and motivated them to active behavior. Weekly church services and leaving the house for family events were the most common examples. The importance the older adult placed on their (self) image was a self-enforced norm, but it was often strengthened by a societal norm.
‘I refuse to wear a hearing aid. I think it’s a sign of old age…. My wife does everything in our household. Every two weeks the work woman comes. Everything else we do ourselves… I don’t like that someone would think, I’m here with pensioners who neglect everything around them…’ (Ninety two-year old cohabitating man.)
Active behavior that was performed through mirroring was limited to peers. Active peers in the immediate environment motivated others to active behavior.
‘I think it’s because you’re still in your regular environment. You see people doing things and think ‘I can do that too’ and you do it too. Because should I get into a pensioner’s home it’ll be over quickly.’ (eighty-seven-year old cohabitating women)
The belief in the self-effectiveness of the older adult was a determining factor of whether they came to activities and participated. The decision of whether to be active was determined by the balance between the effort and the result the effort provided. Most older adults could estimate how much effort they needed to exert to complete a certain action and how long they could maintain this.
‘Running I’ve thought of that, but why should I do that? I can walk just as well.’ (seventy-six-year old man living alone)
Eleven respondents adjusted their actions according to their insight into their own effectivity, but this was not the case for all older adults. Three older adults exceeded the limits of their comfort zone to still be able to perform certain actions.
‘When I wake up I think ‘I hope I don’t have pain today for a change’. Rheumatism, that sometimes takes two hours. And I think like ‘If I didn’t have pain I might miss it’… The laundry doesn’t go as fluidly as it used to, where it used to take an hour I now take an hour and a half. It’s the same with cleaning.’ (seventy-seven-year-old woman living alone)
Older adults used various coping strategies. Problem-focused coping strategies are often employed. Emotion-focused and appraisal-focused coping strategies are noted less often.
Older adults that employ problem-oriented coping strategies have a positive attitude, were more determined or that over the course of their life they had learned to solve problems on their own. To keep the stress under control older adults dealt with the problem actively. They looked for ergonomic solutions like sitting down whilst ironing, performing an action in phases, purchase multiple walking aids to utilize at various locations, or they purchased ergonomic products. Looking for social support with a partner, the neighbors or someone from the wider environment, such as the cashier, was often employed. Aside from that, older adults would anticipate possible issues like staying within the boundaries of back problems or working slower.
An emotion-focused coping strategy that was employed is seeking diversion, for example thinking of the grandchildren and meditation, like reading a prayer.
An appraisal-focused coping strategy that came to the fore as a comforting thought was humor.
‘Relativize through humor… we try and agree with each other as much as possible. What’s changed is that instead of softly whispering to each other we now have to yell at each other.’ (ninety-one-year-old cohabitating man)