Resilience in older adults can be defined as the ability to ‘bounce back’ and recover physical and/or psychological health in the face of adversity. [1,2] Despite extensive searches, no systematic reviews addressing resilience in older adults in a palliative care context were retrieved and this remains an area where research is required. Of the literature reviewed exploring resilience in older adults , two systematic reviews were retrieved, [1,2] and a literature review in development of a concept analysis,  were drawn on in the synthesis of this topic.
Overall the quality of the evidence is low, with poor reporting on methodology and quality of the studies being reviewed. [1,3] Only one paper was of adequate quality based on the reported design  though the research question was of least relevance. In general, the published research is not specific to a palliative or an aged care context and suggests significant opportunity for future research.
Resilience is a response to adversity. Initial exposure to adversity is the key to activating this dynamic process,  and the level of resilience someone might demonstrate is determined by how successful the individual is at coping with adversity. In the case of ageing and palliative care a number of stressors can impact resilience of both the individual and their family, such as symptoms of illness and health decline, social isolation, loss of independence, psychological suffering, managing grief and ultimately preparing for, and coping with, bereavement. 
Van Kessel at al. [1,4] studied resilience in older people. To measure resilience, they note the common use of a 25-item Resilience Scale based on five themes: equanimity, self-reliance, existential aloneness, perseverance and meaningfulness. While it is acknowledged that adversity can build resilience, the said adversities appear to be ongoing life experiences rather than specific events. The review also discusses a second key construct of ‘ability’, or the ability to cope with adversity, which appears dependent on other elements such as personality, skills to adapt and look to the future, as well as environmental factors like resources, access to care and social support.  The authors propose that, in this context, managers of residential aged care facilities (RACFs) could use a framework of resilience to evaluate aspects of care and resource allocation e.g. internet access, caregiving etc.  Similar approaches to build resilience could also be considered in community aged care.
In the review by Hicks et al.  ‘resilient ageing’ is posed as a new concept different to other healthy or positive ageing concepts, in that it can be applied in the health promotion of all older people including those who may be frail or have a life limiting illness.  Core attributes of resilient ageing are considered to be ‘coping’, ‘hardiness’ and ‘self-concept’,  further supporting the similar construct of ‘ability’ discussed in the 2013 study by van Kessel. 
The theme of coping as described by Hicks et al.  could also include terms such as adaptation and attitude change and is regarded as a process of cognitive and behavioural efforts to manage psychological stress. In the literature the theme of coping is often associated with ‘loss’, adjustment to new living arrangements (e.g. RACF) and changes in physical and mental health status. Specific coping strategies for situations that cannot be changed, such as in the case of palliative care, were more often emotion-focussed.  Common protective factors of coping include inner-strength, optimism, flexibility, global wellbeing, social support, community support, problem solving skills and leading to heightened adaptation.
While similar to resilience, hardiness is described as a personality trait; such as in people that can manage high levels of stress without succumbing to illness possess hardiness.  In the literature, populations that had experienced some form of marginalization were more likely to demonstrate hardiness. Protective factors of hardiness include social support, prior life experience of hardship, maintenance of a positive attitude, and having a strong faith.
Self-concept is another personality trait but in the literature has been said to be comprised of as many as ten different traits. Although no one definition for self-concept is offered in the review by Hicks et al.,  it is said to be related to self-worth and the ability to adjust oneself to cope and preserve self-esteem. Self-concept is greatly protected by maintenance of positive identity, personal development, interpersonal control, social integration, and well-being.
Overall protective factors of resilient ageing appear to be life experience and social support, however these have the potential to change depending on the person and the context, which may lead to inconsistencies in coping, hardiness and self-concept.  In the review, 40% of the literature found quality of life to be the main outcome of resilient ageing and is consistent with the focus of palliative care.
Implications for policy and practice
Health professionals often have significant interaction with older adults in times of adversity, specifically in a palliative care context, and are in a position to influence a person’s resilience. Enhancing social support systems, feelings of self-worth and identity can assist in coping strategies for the individual and therefore enhance resilience.  There are implications for the development of policy to address the need for access to adequate health care, services and resources required to survive adversity associated with the diagnosis of a life-limiting illness. These resources can positively shape life experiences and coping with adversity. 
Individuals who have previously experienced adversity and have ‘bounced back’ are likely to demonstrate resilience in their approach to a life-limiting illness. However, in knowing that social support, access to adequate healthcare resources and support and maintenance of self-concept are all promoters of resilience, it may be that healthcare models could build on this framework to support people and their family in palliative care.
- Factors affecting resilience in older adults in residential aged care across the continuum of the palliative care journey
- The role of social networks and community supports in enabling the resilience of older people living in the community at the end of their life.
- The relationship of resilience to death literacy, death-coping and hope in palliative care
Page created 15 June 2017