Old Age Social Construction

“Old age is a social construction. Discuss this statement and how it relates to health care for people with dementia in Australia. Support your argument with recent Australian data and at least one sociological concept or theory”

Dementia is a condition associated with cognitive decline, that, whilst not a natural part of ageing, often affects older people (65+ years) as they age. However, old age is a socially constructed concept, wherein theories such as medicalization, stigma, and intersectionality majorly impact the epidemiological data. According to the Australian Bureau of Statistics (ABS), dementia is one of the top three leading causes of death. This is likely due to the medicalization of dementia, which does not consider it a normal

ageing process. It views aging as a risk factor, and primes physicians to believe that “people can be explained and predicted” (Biernacki, 2008), and forget that human behaviour must not always follow rules of physical cause and effect. That said, dementia often goes undiagnosed, with barriers including the lack of knowledge and reluctance of general practitioners (GP) to diagnose, and the tendency of patients and their carers to avoid medical help. These barriers can be attributable to the stigmatisation of the condition. This is increasingly alarming due to the rising mortality rate. Furthermore, those affected by dementia appear to predominantly reside in major cities. However, the intersectional identities held by rural residents suggests that this data may be skewed, as they face restrictions that lead to lack of diagnosis and management by rural GPs and hospitals.

Epidemiology
In 2015, there was an estimated 342,800 Australians with dementia, compared to 46.8 million globally (Australian Institute of Health and Welfare, 2012; Prince et al, 2015). Whilst dementia is not an inevitable part of ageing, it becomes increasingly common with age. This is evident in Figure 1, wherein the percentage of people with dementia increases as age increases, with those aged 85 and over being most affected (41.1%). Furthermore, the number of Australians with dementia is projected to rise by 39% by 2020, the largest ever growth rate.

Figure 1: Estimated number of Australians with dementia by age and sex, 2011 (Australian Institute of Health and Welfare, 2012)

That said, prevalence is often determined by the number of people diagnosed with, or reporting the condition.

However, as dementia is frequently unrecognised and/or undiagnosed until it’s latter stages, these approaches are ineffective. For dementia, there is often a significant gap between when symptoms are first identified, and when help is first sought from a health professional; a further gap proceeds before the condition is diagnosed. A New South Wales study reported that there was an approximated 23 months between when symptoms were initially noticed, and the first health professional consultation, proceeded by another estimated 37 months before a concrete diagnosis. This vastly contrasts with the data from a six-country European survey for Alzheimer’s disease, where the gap until the first physician consultation was 11 months, and the average time from symptom recognition to a diagnosis was 20 months. This gap has been suggested to be due to an interplay of factors that create barriers to diagnosis at the mild stage. They included aspects relating to the primary health care providers, where lack of knowledge and/or time to identify and diagnose dementia, limited access to specialists for diagnosis confirmation, and challenges in communicating the diagnosis were concerns. Another barrier was the inability to identify dementia’s early symptoms, and delay to seek help by the patients and careers were also barriers. Furthermore, systemic factors such as financial

restriction for health care providers in delivering diagnostic tests were barriers.

This is alarming, as studies have reported that the risk of death is increased for people with dementia, compared to those without. Whilst the risk of death rises with increasing severity of dementia, even for those with mild dementia, the risk is higher than for those without it. Displayed in Figure 2, dementia ranked as the third overall leading cause of death in 2010. However, it is also evident that the burden of disease was greater for women than for men, with dementia ranking as the third, compared to sixth leading cause of death respectively.

Figure 2: Leading causes of death, by sex, 2010 (Australian Institute of Health and Welfare, 2012)

Furthermore, dementia accounted for 20,645 of deaths in Australia in 2010, representing 14.4% of all deaths that year (Australian Institute of Health and Welfare, 2012). This pattern continued with dementia remaining in Australia’s top three leading causes of death in 2015, and being the only one with an increasing mortality rate (Australian Bureau of Statistics, 2016). Mentioned previously, dementia becomes more prevalent with age, and as such, dementia related deaths increase with age (Figure 3).

Figure 3: Age-specific rate of deaths with an underlying cause of dementia, by sex, 2010 (Australian Institute of Health and Welfare, 2012)

Figure 3 shows a constantly increase trend for mortality rates due to dementia, with the highest observed for those aged 95 and over.

Furthermore, the 2009 SDAC reported that 69% of people with dementia lived in major cities, 22% in inner regional areas, and 9% in other areas (i.e. outer regional, remote, or very remote) (Figure 4) (Australian Institute of Health and Welfare, 2012).

Figure 4: People with dementia, by remoteness and residency, 2009 (per cent) (Australian Institute of Health and Welfare, 2012)

Sociology
Kimberlé Crenshaw and Patricia Collins’ theory of intersectionality views race, class, gender, ethnicity, sexuality, nationality, ability, Indigeneity, geography, and age, as mutually constructing phenomena that structures complex social inequalities (Hankivsky, 2014; Collins, 2000). Collins stresses that no homogenous standpoint exists for an individual, however, a collective standpoint for a group of individuals does exist, “one characterised by the tensions that accrue to different responses to common challenges” (Collins, 2000). Essentially, intersectionality refers to individuals who can experience multiple forms of discrimination when their identities overlap several minority classes (Collins, 2000).

Stigma is a social process that can refer to an “enacted, perceived, or anticipated social judgement” (Weiss et al., 2006).

It is conceptualised by Erving Goffman (1963) as “the situation of the individual who is disqualified from full social acceptance”, and refers to “the attitudes we normals have towards a person with a stigma, and the actions we take in regard to him” (Goffman, 1963). He identified three distinct types of stigma, the first being individual stigmata, which referred to physical irregularities; the second, deviant individuals, which denoted “blemishes of individual character…weak will…passions, treacherous and rigid beliefs, and dishonesty” (Goffman, 1963); and tribal identities, which included condemned conditions of sex, race, religion, and nationality. As a result of these, stigmatised individuals become excluded, blamed, or belittled by society for the characteristics they possess (Weis et al., 2006), and attain what Goffman (1963) terms a “spoiled

identity”.

Coined by Dr Ivan Illich, medicalization is the process in which nonmedical issues become defined and treated as medical issues. A human problem becomes medicalized when it can be “defined in medical terms, described using medical language, understood through the adoption of a medical framework, or ‘treated’ with a medical intervention” (Conrad, 2008). Hence, in medicalization, an entity that is considered as a disease or illness is not necessarily a medical issue; instead, it needs to become defined as one (Conrad, 2008).