Centenarians: 31.4% expressed willingness to live longer, 30.6% did not, & 38% presented no clear positioning; annoyance, uselessness, loss of meaning, disconnection, & loneliness were common justifications for reluctance

To Live or Die: What to Wish at 100 Years and Older. Lia Araújo et al. Front. Psychol., September 10 2021. https://doi.org/10.3389/fpsyg.2021.726621

Abstract: Previous research has shown that will to live is a strong predictor for survival among older people, irrespective of age, gender, and comorbidities. However, research on whether life at age 100 is perceived as worth living is limited. The available literature has presented evidence for good levels of positive attitudes and life satisfaction at such an advanced age, but it has also suggested that a longing for death is common. This study aimed to add to the existing data on this matter by exploring centenarians' will to live and the associated factors. The sample comprised 121 centenarians (mean age, 101 years; SD, 1.63 years), 19 (15.7%) of whom were males, from two centenarian studies (PT100). Answers to open questions were analyzed to identify the centenarians' will to live and the reasons behind it. Three groups were created (willing to live longer, not willing to live longer, no clear positioning) and further analyzed in terms of sociodemographic characteristics, health status, social functioning, and well-being. Of the total sample, 31.4% expressed willingness to live longer, 30.6% did not, and 38% presented no clear positioning. The presence of the Catholic religion (God) was referred for centenarians in all three groups. Annoyance, uselessness, loss of meaning, disconnection, and loneliness were the most common justifications for being reluctant to live longer. Positive valuation of life and good self-rated health, followed by having a confidant and reduced pain frequency, were the factors associated with being willing to live longer. The results of the study contribute to the understanding of the psychological functioning of individuals with exceptional longevity, particularly concerning the factors behind willingness to live at such an advanced age.

Discussion

Centenarians are an elite group, significantly exceeding the average life expectancy. This study explored the will to live and associated factors in a sample of these long-lived individuals by considering both quantitative indicators and qualitative data. The number of participants willing and unwilling to live longer was similar (31%) but lower than those without clear positioning (38%). Compared with the findings of studies of preferred life expectancy that also considered a non-response group, this was a very high percentage. For instance, in a study of 1,631 younger and middle-aged adults, Bowen and Skirbekk (2017) found that 15.9% of the sample did not clarify their preferred life expectancy. However, due to the lack of studies similar to the present one, whether the greater percentage was related to the centenarians' characteristics or the methodology of the study cannot be determined. Nevertheless, this group may have represented a stoic mindset in which individuals express a valuation of life per se and “as it comes” with discomfort or unwillingness to reflect about lifetime extension (Lang and Rupprecht, 2019).

Still, the qualitative exploration of this group's answers showed that almost everyone justified their lack of answer/positioning by mentioning God, stating that their remaining time to live was a matter that was not in “their hands” (i.e., one they could not control). This follows the idea that a sense of control through the sacred may come when life seems out of control (Wong et al., 2014). Although a sense of control is recognized as an important source of human life-strength, individuals who accept that declining control over environment comes with aging and focus on their ability to control their own internal states and behaviors demonstrate a more successful adjustment to aging (Hyer et al., 2011). Indeed, this group presented a satisfaction with life score very close to the group reporting willingness to live longer.

Regarding the reference to God, which was also present in the other two groups, religion and spirituality play an important role in the lives of older adults, as they help older people find meaning in later life (Frankl, 1963; Atchley, 2009; Wong et al., 2018) and are thus associated with how long one desires to live (Lang and Rupprecht, 2019). Different studies focusing on the centenarian population have confirmed the positive impact of religion and spirituality in well-being, which may be even more significant since this age group may fail to derive basic resources (Bishop, 2011). Archert et al. (2005) found that religiosity was one of the major themes that emerged from a qualitative analysis about adaptation and coping in the lives of centenarians; when asked about the most important thing in their lives, 58% of the respondents mentioned church and/or God. Interestingly, a female centenarian shared a sentence very similar to one of the participants in the present study, arguing that the future is held in God's hands (Archert et al., 2005). Furthermore, Manning et al. (2012) found that centenarians place considerable importance on divine support in their lives. This study found an interconnectedness of spirituality with religion for centenarians; in other words, these two constructs overlap. Through a phenomenological examination of life-satisfaction and compensatory strategies in Jewish-Canadian centenarians, Milevsky (2021) found that compensatory, cultural, and religious processes were imbued into several of the themes, such as “Maintaining connections with family, friends, and God” (p. 101) and “Remaining positive and kind” (p. 104). It is expected to have an intrinsic need to have hope that goes beyond this life and have faith either in something or in someone, which can be religiously oriented or without any religiosity (Saarelainen et al., 2020). But the huge presence of religion in centenarians' discourses found in the present study may echo the importance of church and military in shaping the lives of this older Portuguese generation (Birmingham, 2003), as well as the overall impact of religious beliefs, practices, and culture (Boerner et al., 2019).

The quantitative results of the present study revealed the significant contribution of health (pain frequency and SRH), social functioning (friends as confidants), and well-being (positive valuation of life). These findings confirmed that will to live is the summation of individuals' biopsychosociospiritual dimensions (Bornet et al., 2021) and depends on both external (e.g., social networks) and intra-personal factors (e.g., health and self-perceptions; Lawton et al., 1999). No sociodemographic variable was found to be relevant, which agreed with the findings of a scope review on will to live conducted by Bornet et al. (2021). Positive VOL had the strongest significant association with will to live, which was expected. Despite the great importance being attributed to variables like physical and health functionality in longevity and quality of life (Rowe and Kahn, 1997), some studies have emphasized the importance of psychological functioning and well-being, especially for very old individuals. For instance, a comparison of components in the World Health Organization's (WHO) active aging model by age group (< 75 years vs. ≥ 75 years) revealed the major relevance of the psychological component to the older age group (Paúl et al., 2017). Likewise, the operationalization of the successful aging model (Rowe and Kahn, 1997) in centenarians revealed the importance of subjective appraisals and psychological variables (Araújo et al., 2016).

The fact that the number of health conditions and levels of fatigue and functional capacity presented no significant association with will to live in this study supported the argument that individuals with problems related to physical health and functioning may be able to maintain subjective well-being. This agreed with the paradox of well-being, i.e., reporting experiences of positive psychological functioning despite decline in physical health, as the evidence of resilience in old age (Wiesmann and Hannich, 2014). Interestingly, pain and SRH, the two health factors with a significant impact on will to live, have also been associated with resilience in centenarians (Amaral et al., 2020). Gu and Feng (2018) argued that higher resilience could yield a greater protection for SRH and life satisfaction among centenarians compared with younger elderly groups. Thus, resilience may also be associated with will to live, as identified in younger groups (Bornet et al., 2021). This was supported by the qualitative analysis; aspects related to health, such as dependency, sense of burden, and fear of suffering, were referred to less than uselessness, annoyance, and loss of meaning by centenarians who were unwilling to live longer.

In advanced age, some aspects of purpose in life are more difficult to fulfill, such as having goals for the far future or feeling useful (Pinquart, 2002). This study found that these variables continue to be very important, specifically for (un)willingness to live. Conversely, will to live has strong, direct effects on well-being, including life and aging satisfaction (Jopp et al., 2017). The large influence of positive VOL on will to live meets Lawton et al.'s (1999) assumptions (i.e., years of desired life are mediated by VOL) in an age group in which this issue was not studied. Both existential beliefs and perceived control were higher in the group willing to live longer—that is, they represented important aspects for centenarians' reason for living, even under difficult conditions of functional impairment and disease. This confirmed that a “possible mechanism for the potency of VOL as a determinant of Years of Desired Life is the ability of people to adjust their standards for what is acceptable in everyday life in accord with changes in both their personal characteristics and the circumstances under which they live” (Lawton et al., 2001, p. 25).

Social factors also seem to have a contribution to will to live (Bornet et al., 2021), being an important source of meaning in life among older people (Saarelainen et al., 2020). Social relationships and support may be particularly important for centenarians (Boerner et al., 2016). The loss of friends and relatives that is typical in these long-lived individuals can make social contacts even more significant by reducing opportunities for (intra- and intergenerational) relationships (Randall et al., 2010). In the present study, the only social variable significantly associated with will to live was the number of friends as confidants. Thus, support—rather than size—may be the most significant aspect of social networks. Previous studies of the oldest old have shown the importance of having a close friend for independence (Pin et al., 2005) and well-being (Johnson and Barer, 1997). Indeed, maintaining a confidant is suggested as a strategy that centenarians use to compensate for losses and increase well-being (Araújo and Ribeiro, 2012). From the qualitative data, (social) disconnection and loneliness emerged as an important motive for losing will to live, as was also the case of feeling like a burden.

This last reason, which is typically referred to in studies on will to live (Bornet et al., 2021) since its related to the high burden of taking care of a person in the end of life, shows the need to acknowledge those who are supporting centenarians. The few studies that investigated will to live and end of life issues in centenarian's caregivers and offspring indicated concerns of family members that they'd become a burden for caregivers and would face the unavailability of family support if they became centenarians (Brandão et al., 2019). The fact that caregivers value this aspect so much, reinforces their potential burdens and needs. If being willing to live at 100 years old depends on the availability of social support, more must be invested in these caregiving offspring who are confronted with their own advanced age and the burdens of their parents' very old age (Eggert et al., 2020).

Despite the richness of this study's findings, some limitations should be considered. The cross-sectional design of the study prevented the ability to determine the direction of the relationships between variables, which could be of particular interest in this topic since willingness to live could be a predictor of well-being. Furthermore, those who shared their opinion (i.e., mostly individuals with mild or no cognitive impairment) represented only a part of the original sample, so these findings should not be generalized to the centenarian population.