How relationships help us to age well

Declining fertility rates and increased life expectancy have led to a demographic shift towards an ageing population. In the UK, the proportion of people aged 65 and over is projected to increase from 17 per cent in 2010 to 24 per cent in 2051 (Office for National Statistics, 2012). As our population ages, the concept of successful ageing becomes increasingly important and there is an academic and political emphasis on promoting positive states of health in later life.

Some propose that ageing 'successfully' involves the maintenance of physical and cognitive function, the absence of disease, and a sustained involvement in productive activities (Rowe & Kahn, 1997). Another, perhaps less restrictive, view of successful ageing is the ability to effectively adapt to and compensate for functional losses (Baltes & Baltes, 1990). Researchers have attempted to understand what exactly determines successful ageing (e.g. Depp & Jeste, 2006) and, while older adults' health is influenced by a wide range of factors, both social networks and social engagement have been highlighted as being fundamental (Phelan et al., 2004).

Social relationships in later life

Social relationships have been defined and measured in a variety of ways but are most often understood in terms of social networks, social support and social participation (Holt-Lunstad et al., 2010). Broadly, social networks are the structural character of social relationships such as the number of contacts we have or how often we spend time with those people. Social support is a transactional process and our relationships provide a platform for the exchange of emotional and practical support. Finally, social engagement relates to the frequency and quality of formal (e.g. religious participation, meeting attendance and volunteer obligations) and informal (e.g. telephone contact and socialising with friends) activities with members of our social network.

Research shows that there is an age-related reduction in overall social network size and levels of social engagement. Increasing age may be associated with smaller social networks which are contacted less frequently (Ajrouch et al., 2005), and this seems to be particularly true for older men (Cornwell et al., 2008). More specifically, high numbers of non-kin relationships have been found to be less common among older adults and, instead, older adults' social networks are mainly made up of family members (Pahl & Pevalin, 2005). On the other hand, older adults may have higher-quality relationships within that smaller social network and be more involved in their community compared with younger adults (Carstensen, 1992). Research shows that older adults typically have greater contact with neighbours and are more likely to volunteer and attend religious services, though this is dependent on physical health (Cornwell et al., 2008).

Family, and particularly spouses and adult children, are a central source of support to older adults (Waite & Gallagher, 2000). Marital status has not been identified as an independent predictor in studies focused on successful ageing (e.g. Depp & Jeste, 2006), but, on the whole, research demonstrates that marriage has a protective effect on physical (Waite & Gallagher, 2000) and psychological well-being (Schwarzbach et al., 2014). Moreover, social networks and levels of social engagement, which themselves are associated with health, vary by marital status. Marriage is often regarded as a fundamental basis for support and integrates people into wider social networks (Waite & Gallagher, 2000). However, it has also been suggested that couples' networks shrink to a more family-centred network over time and, in considering friendship choice across the life course, Pahl and Pevalin (2005) found that the recently married were more likely to move from nominating a non-relative as their closest friend to having a family member as their closest friend. At the same time, marriage has a protective effect on health and evidence demonstrates that older never-married adults have poorer physical health and increased risk of mortality (Waite & Gallagher, 2000). It is likely that this is a consequence of the lack of support provided by a spouse and perhaps the absence of the associated social network.

Turning to social networks, Fiori et al. (2006) found five distinct network typologies among older Americans that differentially affect health: non family restricted, characterised by low likelihood of being married and very few or no children; non friends, characterised by very low frequency of contact with friends; family, where people had high levels of contact with family members; friends, where people had frequent levels of contact with friends; and diverse, where contact was fairly even across friends and family. Older adults who were embedded in diverse networks that included relationships with friends had higher levels of morale compared with those who were in family-based networks. Moreover, size matters! Cable et al. (2013) found that friendship network size was longitudinally related to psychological health, even after previous psychological health was taken into account.

So evidence suggests that, generally, the more varied your social network, the happier and healthier you will be. This tells us that intimate friends are very important for older adults, especially in the absence of strong family relationships. Often, family relationships can have a negative impact on health, but this is less typical of friendships. Friendships are the relationships we choose and, thus, may allow greater feelings of autonomy and facilitate integration into broader social networks and the wider community.

Despite this, the number of friends decreases with age (Ajrouch et al., 2005). Why should this be case? A simple explanation may be that the network is reduced as people out-survive their friends. Several other theories have also been proposed to explain this pattern. First, Cumming and Henry's (1961) early theoretical perspective, social disengagement, suggested that older adults actively withdraw from their network and reduce their number of friends, perhaps as a result of declining physical health or loss of roles through retirement, for example.

Socioemotional selectivity theory (Carstensen, 1992) offers an alternative view: as we age, we become more selective and strengthen emotional ties, dissolving peripheral relationships and creating a smaller number of high-quality relationships. This occurs as the salience of emotional exchanges increases with age while informational functions of relationships become less important. Kahn and Antonucci's (1980) social convoy model describes patterns of changing social relationships as people age. It holds that the personal (e.g. age, gender) and situational factors (e.g. roles, values, culture), and how these change over time, influence quantity and quality of social relationships. The model suggests that our 'convoy' of relationships changes as we age, and it highlights the increasing importance of emotional quality, rather than only the quantity of social contacts in older age.

Social relationships and health

How do our relationships help us to age well? It is difficult to unpick the relative effects of social network, social support and social engagement since the terms are often used interchangeably (Schwarzbach et al., 2014). However, despite the lack of clarity in definitions, there is a wealth of literature suggesting that how many people we have around us, the support that we give and receive, and how often we see them impacts on our physical and psychological health. Social relationships provide a platform for the exchange of support and opportunities for social interaction, and research demonstrates their independent influence on mortality, heart attack survival, cognitive decline, depression and anxiety (Umberson & Montez, 2010). Holt-Lunstad et al. (2010) conducted a meta-analysis across 147 independent studies focusing on the association between social relationships and mortality and found that people with adequate social relationships (including both functional and structural aspects) have a 50 per cent lower mortality risk compared with those who report poor social relationships.

Focusing on psychological health, support, relationship quality and presence of confidants emerge as significant predictors of depression in older adults (Schwarzbach et al., 2014). These effects of social relationships on health may also vary by gender, though the interactions are more complex (Cable et al., 2013). Clearly, our relationships have some protective effect on both our physical and psychological well-being and the supportive resources promote successful ageing, where 'success' is tied to health.

Two general theoretical processes through which social relationships may influence health have been proposed (see Figure 1). First, social support may have a moderating effect on health, that is, it is mainly effective when high stress is encountered, buffering the negative effects of stressors on heath. This may work in either of two ways. First, people may not recognise a situation as stressful if they have high levels of support, or alternatively, the levels of support may modify the response after the initial appraisal. Rosengren et al. (2004) found that the association between an accumulation of critical life changes and subsequent heart attack was moderated by the quality of social support in middle-aged men. The alternative view is that social support directly benefits psychological well-being and health, regardless of the degree of stress. Either those with high levels of support may feel a sense of belonging accompanied by high self-esteem (Fiori et al., 2006) or, instead, social relationships may encourage or model healthier behaviours, such as eating breakfast and even wearing a seatbelt (Waite & Gallagher, 2000).

Social relationships also offer an opportunity to provide support to others, which can be beneficial to older adults' well-being, perhaps as a result of the increased feelings of independence and usefulness it allows (Thomas, 2010). Piferi and Lawler (2006) found that giving support was related to lower blood pressure and arterial pressure. Moreover, those participants who reported giving support were also more likely to report receiving support, greater feelings of self-efficacy, higher levels of self-esteem and lower levels of depression and distress. It is worth noting that there is a fine balance between providing too little or too much support to others, since providing too much can also lower well-being (Thomas, 2010).

It seems that if we are embedded in a varied network of social relationships where there are opportunities to give and receive support and engage in social activities, we'll be happy and healthy. Is that the full story? Whilst giving and receiving support from family and friends has a beneficial effect on our health as we age, there is also an argument that the receipt of excessive support, particularly from adult children, may in fact reduce psychological well-being and feelings of competence (Reinhardt et al., 2006). According to Thomas (2010), the negative psychological impact of receiving support may be a consequence of identity disruption. For example, an older man must now rely on his daughter to take him to complete his weekly shop, when the norm throughout his life had been for him to provide support to her. This reduces his feelings of competence and, moreover, alters his role as 'father'.

Relationship quality is also important, and may have a greater impact on well-being than structural characteristics of our social networks (Fiori et al., 2006). Reduced well-being may occur when relationships are strained, and there is evidence that these negative social interactions are more strongly associated with psychological well-being than are positive social interactions, especially for those who are more stressed to start with (Ingersoll-Dayton et al., 1997). Reciprocity, the bi-directional giving and receiving of support, also appears to be important for receiving the health benefits of social relationships. Non-reciprocity is associated with poorer self-rated health, trouble sleeping, and higher risks of depressive symptoms (e.g. von dem Knesebeck & Siegrist, 2003).

Widowhood in later life

As we have demonstrated, social relationships and their supportive resources are important for health and help to facilitate successful ageing. The social convoy model (Kahn & Antonucci, 1980) demonstrates that events such as marriage, divorce, retirement and bereavement can affect composition of the social network, the availability of support and levels of social engagement. In our own research, we have explored the impact of spousal bereavement. How does widowhood shape older adults' social relationships and how might this influence successful ageing?

The social support inherent in a marriage offers physical and psychological health benefits, but spousal bereavement removes a primary source of support – the spouse. The widowed report lower levels of psychological health compared with their married counterparts and report higher levels of mood and anxiety disorders (e.g. Schwarzbach et al., 2014), and older widowed adults may be more likely to experience loneliness, compared with younger bereaved spouses (Carr et al., 2006). Research demonstrates that psychological reactions to spousal bereavement are acute and the negative impact typically resolves over time (Wilcox et al., 2003). Spousal bereavement also has a negative impact on physical health, including increased number of health problems, changes in weight, smoking behaviour and inactivity (e.g. Wilcox et al., 2003).

We hear anecdotal accounts of people dying from 'broken hearts' after the death of their spouse, and research demonstrates that widowed adults do have a higher mortality risk compared with married people, especially in the immediate period following bereavement (Stroebe et al., 2007). Moreover, spousal bereavement typically has a negative impact on access to social support and causes significant changes in the wider social network (Pahl & Pevalin, 2005). The bereaved must learn to socialise as a single person, and may face the loss of relationships with other married couples as well as losing links with their shared friends. The social network then evolves over time, with the duration of widowhood positively related to the likelihood of forming new friendships and for some, new romantic relationships (Wilcox et al., 2003).

Why should widowhood cause changes in social relationships? One explanation is that older widowed adults experience a change in identity following the loss of their spouse, which influences who they want to spend time with, and how. As part of a large-scale qualitative study of bereavement, one of us (Bennett, 2010a), interviewed 66 older British widows using a grounded theory approach. One of the important themes to emerge from this study was changes in identity. In the interviews women spoke about the way their identities had changed as a consequence of their widowhood. The women reported an augmented identity. That is, women described not having an identity as a widow alone, but having an identity as a widow whilst retaining their identity as a wife. A sample quote was 'You can't spend years with someone and just cast them aside'. Looking at identity in 60 widowers from the same study, Bennett found that men were more likely to discuss these issues with implicit reference to hegemonic masculinity, that is, the culturally bound expectations of how men should behave. Brannon's (1976) four masculine roles provided a useful framework to think about widow(er)hood and masculinity (Bennett, 2007). These roles are 'the sturdy oak', 'the big wheel', 'no sissy stuff' and 'give 'em hell'. The first three were common amongst the widowers. Men demonstrated how they took care of their families, how they took control, and how they overcame their emotions following the deaths of their wives. They might say 'I really kept these things – perhaps wrongly – pretty well to myself, and it was only when I started going to counselling…', or 'You've got to make a move, make that first step back on the road to normality'.

There is sufficient research to conclude that the death of a husband or wife has a significant negative impact on health. It is, therefore, important to consider factors that promote better health. Stroebe et al. (2007) considered why people are affected by bereavement in different ways. Situational risk factors (e.g. cause and circumstances of death, pre-bereavement caregiving), interpersonal risk factors (e.g. material resources, social support) and personal risk factors (e.g. age, gender, personality) were all found to predict adjustment after bereavement (see also Bennett & Soulsby, 2012). Access to adequate support following the death of a spouse may protect against the negative consequences of bereavement (e.g. Carr et al., 2006).

A clearer understanding of why a supportive social network can promote well-being, and why a dense support network offers better adjustment over time, may help us to promote 'resilience' in relation to older adults. In our research with widowers we identified three groups of resilient widowers (Bennett, 2010b). The first group demonstrated resilience in bereavement, with stable levels of psychological well-being over time. In the second group, the men experienced lowered levels of well-being when their wife died but, over time, were able to return to the same level of well-being as before their loss. The men in the third group achieved resilience through a turning point. The narratives revealed that these men drew on combinations of factors to cope following spousal bereavement, including psychological resources, societal factors and, important to this paper, their social relationships.

Conclusions

As people live longer, there is an increasing interest in understanding and promoting health in later life. We hold that social relationships play a key role in maintaining older adults' health, likely through the opportunities they provide for support exchanges, social engagement and sense of worth. This is recognised by older adults themselves, who endorse social relationships and social activities as being important for ageing well (Phelan et al., 2004). A clearer understanding of the meaning of social relationships to older adults and the ways in which we maintain our social network as we age is vital to promoting successful ageing and promoting health in later life.

- Laura Soulsby is a Lecturer in Psychology at the University of Liverpool L.K.Soulsby @liverpool.ac.uk

- Kate Bennett is a Reader in Psychology at the University of Liverpool K.M.Bennett@ liverpool.ac.uk

References

Ajrouch, K.J., Blandon, A.Y. & Antonucci, T.C. (2005). Social networks among men and women. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 60, S311–S317.
Baltes, P.B. & Baltes, M.M. (1990). Psychological perspectives on successful aging. In P.B. Baltes & M.M. Baltes (Eds.) Successful aging: Perspectives from the behavioral sciences (pp.1–34). New York: Cambridge University Press.
Bennett, K.M. (2007). 'No sissy stuff': Towards a theory of masculinity and emotional expression in older widowed men. Journal of Aging Studies, 21, 347–356.
Bennett, K.M. (2010a). 'You can't spend years with someone and just cast them aside': Augmented identity in older British widows. Journal of Women & Aging, 22, 204–217.
Bennett, K.M. (2010b). How to achieve resilience as an older widower: Turning points or gradual change? Ageing and Society, 30, 369–382.
Bennett, K.M. & Soulsby, L.K. (2012). Wellbeing in bereavement and widowhood. Illness, Crisis & Loss, 20(4), 321–337.
Brannon, R. (1976). The male sex role – and what it's done for us lately. In R. Brannon & D. Davids (Eds.) The forty-nine percent majority (pp.1–40). Reading, MA: Addison-Wesley.
Cable, N., Bartley, M., Chandola, T. & Sacker, A. (2013). Friends are equally important to men and women, but family matters more for men's well-being. Journal of Epidemiology & Community Health, 67, 166–171.
Carr, D., Ness, R.M. & Wortman, C.B. (2006). Spousal bereavement in late life. New York: Springer.
Carstensen, L.L. (1992). Social and emotional patterns in adulthood. Psychology and Aging, 7, 331–338.
Cornwell, B., Laumann, E.O. & Schumm, L.P. (2008). The social connectedness of older adults. American Sociological Review, 73, 185–203.
Cumming, E. & Henry, W. (1961). Growing old. New York: Basic Books.
Depp, C.A. & Jeste, D.V. (2006) Definitions and predictors of successful ageing. American Journal of Geriatric Psychiatry, 14, 6–20.
Fiori, K.L., Antonucci, T.C. & Cortina, K.S. (2006). Social network typologies and mental health among older adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 61, 25–32.
Holt-Lunstad, J., Smith, T.B. & Layton, J.B. (2010). Social relationships and mortality risk. PLoS Medicine, 7(7), e1000316.
Ingersoll-Dayton, B., Morgan, D. & Antonucci, T. (1997). The effects of positive and negative social exchanges on aging adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 52, 190–199.
Kahn, R.L. & Antonucci, T.C. (1980). Convoys over the life course: Attachment, roles, and social support. In P.B. Baltes & O.G. Brim (Eds.) Life-span development and behavior (pp.254–283). New York: Academic Press.
Office for National Statistics (2012). Pension trends. Chapter 2: Population change. Retrieved 15 January 2014 from tinyurl.com/nqhqcax  
Pahl, R. & Pevalin, D.J. (2005). Between family and friends: A longitudinal study of friendship choice. British Journal of Sociology, 56, 433–450.
Phelan, E.A., Anderson, L.A., La Croix, A.Z. & Larson, E.B. (2004). Older adults' views of 'successful aging'. Journal of the American Geriatrics Society, 52, 211–216.
Piferi, R.L. & Lawler, K.A. (2006). Social support and ambulatory blood pressure. International Journal of Psychophysiology, 62, 328–336.
Reinhardt, J.P., Boerner, K. & Horowitz, A. (2006). Good to have but not to use: Differential impact of perceived and received support on well-being. Journal of Social and Personal Relationships, 23, 117–129.
Rosengren, A., Hawken, S., Ounpuu, S., et al. (2004). Association of psychosocial risk factors with risk of acute myocardial infarction in 11119 cases and 13648 controls from 52 countries (the INTERHEART study). The Lancet, 364, 953–962.
Rowe, J. & Kahn, R. (1997). Successful ageing. The Gerontologist, 37, 433–440.
Schwarzbach, M., Luppa, M., Forstmeier, S. et al. (2014). Social relations and depression in late life: A systematic review. International Journal of Geriatric Psychiatry, 29, 1–21.
Stroebe, M., Schut, H. & Stroebe, W. (2007). Health outcomes of bereavement. The Lancet, 370, 8–14.
Thomas, P.A. (2010). Is it better to give or to receive? Social support and the well-being of older adults. Journals of Gerontology Series B: Psychological Sciences and Social Sciences, 65, 351–357.
Umberson, D. & Montez, J.K. (2010). Social relationships and health. Journal of Health and Social Behavior, 51, S54–S66.
von dem Knesebeck, O. & Siegrist, J. (2003). Reported nonreciprocity of social exchange and depressive symptoms. Journal of Psychosomatic Research, 55, 209–214.
Waite, L.J. & Gallagher, M. (2000). The case for marriage. New York: Doubleday.
Wilcox, S., Evenson, K.R., Aragaki, A., et al. (2003). The effects of widowhood on physical and mental health, health behaviors, and health outcome