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Phebe Tucker, MD
Ping Zheng, MD, PhD; Andreas Maercker, MD, PhD
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What does 'resilience' include for older adults?
SPECIAL REPORT: EXPLORING RESILIENCY
In psychiatry and psychology, resilience is identified as an individual’s positive adaptation to life tasks under stressful and adverse social situations, or positive growth that mediates rates of recovery after disruptions.1-4 The concept describes dynamic coping capacity related to risk factors (eg, stressful life events such as disease, loss of social support, financial hardship).5 Psychological resilience can be influenced by the interaction of internal factors (eg, cognitive capacity, personality, physical health) and external resources (eg, social status, financial stability).6 These can be leveraged—along with biological, psychological, social, and environmental protective and promotive factors—to shift an individual along the path from adversity and disruption to adaptation, recovery, wellness, and even growth.7,8
We define “resilience” as the ability to recover from disruptions, in contrast to either preventing disruptions or allowing them to be deterministic.9 This definition is consistent with the National Academies of Science (NAS) definition of resilience in the face of natural disasters,10 a framework that can be applied to resilience for aging adults with applications to psychiatry.3 The critical functions for aging adults in a resilience analysis might include the ability to live independently, or to engage meaningfully in certain activities. In a psychiatric context, these critical functions can be defined by both patients and clinicians, rather than only by researchers who may not fully capture what individuals deem important.11 For psychiatric health in older adults, resilience includes acceptance that disruptions will arise over time and produce negative impacts, as well as that the effects of adversity do not have to be permanent or deterministic of future life experiences.
Phebe Tucker, MD
Ping Zheng, MD, PhD; Andreas Maercker, MD, PhD
Aspects of Resilience
Resilience, as envisioned by the NAS, is composed of 4 separate phases: preparing for a disruption, absorbing a disruption by decreasing certain critical functions (such as rationing food, water, energy, and communication during a disaster), recovery, and finally, if possible, adaptation to improve critical functions. For older adults, these phases occur within an expected decline due to the normal aging process, and resilience theory aims at recovery that fits a patient’s specific aging trajectory. A patient’s decline can be accelerated by disruptions such as the death of a partner, serious accident, or a pandemic.
Among aging individuals, mental health and illness adversity may be long-term chronic, episodic, or acute, and it may require consideration of the life course. For instance, some individuals struggle with depression or bipolar disorder over many years, whereas others may face life crises, such as dementia or suicidal ideation, that arise during later life. Additionally, we can identify 2 contrasting generic resilience and aging trajectories: (1) declines in physiological and psychological resilience due to normal aging; and (2) increases in resilience due to social learning and successful coping strategies. The unique contexts of aging are incorporated into the resilience process (Figure 1).12
The resilience matrix, originally conceived by Linkov et al13 and based on system capabilities from Alberts and Hays,14 can be applied to an individual (in conjunction with a clinician) to help develop their psychiatric resilience. The resilience matrix emphasizes 4 domains of critical functions that can help a patient identify and articulate aspirations and interventions within a resilience context (Figure 2).13,14 In the case of psychiatric evaluation, the domains also could be characterized in 4 ways (Table).
Building Resilience Together
To apply these components of psychiatric resilience and aging, the clinician will need to work with each individual patient to determine the critical function(s) most important for their recovery. Such critical components might include identity and self-image development to enhance meaning in life, relationships with family members, and the ability and desire to live independently. Clinicians can structure resilience-oriented treatment using the aforementioned matrix to prioritize critical functions before or during disruptions in order to manage the absorption, recovery, and adaption process.
For clinicians to operationalize the resilience matrix, they must differentiate resilience-by-design and resilience-by-intervention.15 The former assumes that a system can internally reconfigure to adjust and recover following a disruption, while the latter relies on external resources.
In the case of clinicians, this resilience matrix can help frame the external support (resilience-by-intervention) that a clinician might offer their patients. In addition to supporting patients after disruptions, the resilience matrix framework can provide avenues for patients to build internal resilience (resilience-by-design) for the future, or to mobilize existing internal resilience. A clinician focused on a particular patient can tailor resilience strategies that capitalize on the patient’s unique strengths and circumstances, which for older adults, compared with young individuals, include considerable experiential contexts and learning. Similar to designing resilient systems in engineering, psychiatrists can develop strategies to enhance individuals’ mental health. Ensuring overall mental health through the use of relevant medications and treatments approximates resilience-by-intervention in broader governance (like stockpiling resources in the case of crises).
Disruptions can take many forms for patients, and a resilience-oriented treatment plan is not predicated on predicting which disruptions will arise. For clinicians, the preparation phase should establish a relationship with the patient that is characterized by trust. This relationship, and other preparation areas that can be identified in collaboration with the patient, constitute a suite of potential resilience systems that can be leveraged and enhanced before a disruption occurs. Protective factors might include a propensity to set conditions for rest, meditation, relaxation, restoration, and social engagement; development of mastery and self-confidence; practicing positive behaviors such as cultivating and maintaining loving, supportive relationships; and problem-solving ability.16 These constitute a patient’s resilience-by-design: meaning the internally embedded perspectives, learned coping strategies, reflexes, and management strategies that enable patients to face crises productively as they arise.
Building a patient’s resilience-by-design in the preparation phase provides the patient with the appropriate tools or learned perspectives to apply when a disruption occurs, thereby initiating the absorption process. Absorption is the process of encountering the disruption and subsequent loss of critical function, which can vary in magnitude according to resilient resources available. Such resources include collaborative work with the clinician, who can evaluate the components of the resilience matrix and identify elements or skills that may need clinical direction. The clinician can help the patient identify when the switch is made from absorption to recovery and guide the patient to the tools best suited for each stage. These resilience-by-interventions rely on the clinician’s understanding of the patient’s needs and goals, and existing foundational resources, and the clinician’s ability to supplement any resources that are missing or depleted.
Finally, adaptation asks the patient to use the disruption as an opportunity to reevaluate and potentially change habits or behaviors that were either previously deficient or have become untenable under new circumstances. This phase of resilience invites the patient to reimagine ways to support their critical functions, which should either ensure the return to the patient’s original trajectory or, possibly, their return to an improved trajectory, if they have embraced the opportunity to evaluate and carefully optimize beliefs and behaviors.
This resilience matrix framework can be empowering to older adults. At a population and public health level, the coronavirus pandemic has revealed that older adults may be better positioned to cope with stressful situations, such as social isolation, than their younger counterparts.17-19 The reasons for this are numerous, and they likely include the confluence of more resources, previous learned experiences, and fewer responsibilities. Regardless of the reasons, the results of these studies provide a counterpoint to the idea that elderly patients are frail and helpless.
Ultimately, degradation to death remains an inevitability, but resilience can be part of the tool kit to prolong life and, equally important, to prolong the period when quality of life can be maximized. Some study results suggest that increasing psychiatric resilience could be comparable in importance with decreasing physical disability in terms of ensuring successful aging.20 A resilience framework, structured by the resilience matrix, can help clinicians support patients prior to and during disruptions to their lives, whether those disruptions are anticipated or not.
Dr Linkov is the senior science and technology manager of the US Army Engineer Research and Development Center (ERDC) and an adjunct professor at Carnegie Mellon University. He is responsible for ERDC’s project portfolio in the areas of crises management and resilience. He has published widely on environmental and technology policy, and on risk and resilience analytics, including 25 books and more than 400 peer-reviewed papers and book chapters. Ms Galaitsi works with the Risk and Decision Science team within the US Army Corps Engineer Research and Development Center. Her research topics include the public health response during the 2020-2021 coronavirus pandemic, governance of synthetic biology, stakeholder engagement in water resources management, automated algorithms and artificial intelligence, and resilience applications in fields like gerontology, team behavior, and value chain analysis. Ms Klasa is a PhD candidate in health services organization and policy at the University of Michigan’s School of Public Health, Department of Health Management and Policy. She uses mixed methods to explore the intersection of health policy, risk/resilience, and politics, drawing from cross-disciplinary training in nursing, health care management, public health, economics, and political science. Dr Wister is director of the Gerontology Research Centre and a professor in the Department of Gerontology at Simon Fraser University. His work has been published often on topics such as baby boomer health dynamics; population aging and population health; resilience and aging; social isolation; and environmental adaptation among older adults. His most recent book, Resilience and Aging: Emerging Science and Future Possibilities, co-edited with Theodore D. Cosco, was published in 2021 by Springer.
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