Exploring Self-Compassion in Older Adults: a systematic review

The present study sought to synthesize available evidence on the role of selfcompassion in elders aged 60 or above and its potential implications during the process of aging. A systematic review was conducted in order to search for empirical scientific articles with quantitative, qualitative, or mixed methods with a focus on selfcompassion in samples with elders aged 60 years or more. Searches were carried out in the Psycinfo, Scopus, Pubmed, Embase and Cochrane databases, without limit of time. After the application of including and excluding criteria, 11 articles were considered eligible for this review, with all presenting good methodological quality. Self-compassion was found to be a promising skill that can promote healthy psychosocial aging, enabling a better adjustment to changes associated with aging. Such results contribute to the development of new mental health intervention protocols, especially in the field of psychogerontology. There is a need for more longitudinal research and investment in the development of specific interventions for this age group.

connected with others in moments of suffering (Neff & Germer, 2013). When faced with feelings of ineptness or failure, self-compassionate individuals tend to offer themselves warm and judgement-free understanding rather than minimizing their pain or reprehending themselves with self-criticism. This process also involves recognizing that common human experience includes being imperfect, committing mistakes and facing life difficulties (Neff, Kirkpatrick, & Rude, 2007). Thus, self-compassion involves a relative predominance of three positive qualities -mindfulness, self-kindness and common humanity -compared to their opposites: overidentification, self-criticism and feelings of isolation.
Even though self-compassion is still a relatively new concept in scientific literature, a growing body of research has shown its potential as a modifiable skill (Neff & Germer, 2013), which is associated with mental health indicators, such as an increased subjective well-being, better behavioral regulation, health indicators and symptom reduction (Brach, 2003), with the potential to provide an adaptive protection against the development of psychopathologies (Zessin, Dickhäuser, & Garbade, 2015). Furthermore, self-compassion is positively associated with psychological well-being (Brown et al., 2018;Zessin et al., 2015) and negatively associated with depression, anxiety and stress (Brown et al., 2018;MacBeth & Gumley, 2012) throughout the human life cycle. Such benefits, along with evidence suggesting that self-compassion is a skill that can be taught (Neff & Germer, 2013), indicate that self-compassion is a tool that can facilitate coping and successful aging. Self-compassion has also been associated with one's ability to manage adversities and make necessary changes in life (Neff, 2011), both particularly relevant for the challenges faced in aging. Still, research investigating this concept in elders is scarce (Homan, 2016;Moore et al., 2009). Therefore, the current literature review sought to synthesize available evidence on the role of self-compassion in elders aged 60 years or more and its possible effects during the aging process. In doing so, this entirety. Two were excluded for utilizing control groups with samples that were not exclusively composed of elders aged 60 years or more and one was excluded for not presenting results related to self-compassion. Full-text articles assessed for eligibility (n = 14) Full-text articles excluded, with reasons (n = 3) Studies included in qualitative synthesis (n = 11) Studies included in quantitative synthesis (metaanalysis) (n = 0) Exploring Self-Compassion in Older Adults: a systematic review __________________________________________________________________________________________ 338 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021

Analysis of methodological quality
The CCAT's mean total score for the articles analyzed in this review was 83,63% (scope in between 63%-95%). While there were no studies with low methodological quality, none of their final scores reached a quality level of 100%. Such outcomes must be interpreted with caution, since the total score represents the sum of eight distinct evaluations on different parts of each article. Thus, it is possible for an article to have obtained the maximum score on one area of evaluation and a low score on another, which may have affected the final result.

Self-compassion in samples with elders
In general, there is an agreement that self-compassion is not only an existing, but also an important variable in samples with elders. However, it behaves in distinct forms in the analyzed articles. For example, in a cross-sectional exploratory study, selfcompassion presented a moderately high mean in the aforementioned sample (Phillips & Ferguson, 2013). In a randomized clinical trial with mixed methods, though, selfcompassion presented a regular range in the quantitative analysis of both the experimental and control groups, as well as in relation to evaluation periods. However, the authors selected ten participants from their experimental sample to participate in a qualitative interview that approached self-compassion. In the qualitative data, selfcompassion was found to be quite present among participants, suggesting their perception of its importance (Moss et al., 2015). When measured one year after volunteer work in an experimental group and a control group, self-compassion was found to be lower in the control group while maintained in the experimental group (Hsiao et al., 2020), demonstrating the variable's continuous character over time when encouraged by stimuli.
Not all articles performed correlational analyses between sociodemographic variables and self-compassion. Among the studies that did, there is no unanimity across Exploring Self-Compassion in Older Adults: a systematic review __________________________________________________________________________________________ 342 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 their data. In a study conducted by Kim and Ko (2018), participants' age was found to be significantly correlated with the negative component of self-compassion, but not with its total score. In Phillips and Ferguson (2013), on the other hand, no significant correlation was found between age and self-compassion. In Bratt and Fagerström's (2019) research, where they sought to conduct the validation and factorial analysis of a brief scale in a sample with elder Koreans, there was no correlation between age and the scale's total score. However, increased age was associated with lower scores on its "selfcriticism" factor and higher scores on its "common humanity" factor. Moreover, once the sample was stratified by age, the scale presented greater internal consistency within individuals aged between 66 and 71 years which comprised the sample's youngest group. In the only qualitative study in this review, the authors assessed that the older women from their interviewed sample were the ones who reported greater resistance to the concept of self-compassion (Bennet, Clarke, Kowalski, & Crocker, 2017). Such discrepancy among the presented results suggests the need of an evaluation of the samples' specificities beyond chronological age.
In relation to gender, there was no agreement among the few studies that made such association. In one article, women presented a lower self-compassion score than men (Bratt & Fagerström, 2019). In the same study, higher scores in the "self-judgement," "isolation," "mindfulness" and "overidentification" factors were negatively correlated with the male sex. Kim and Ko (2018) stated that men scored higher than women in the negative components of the self-compassion scale, even though the difference was statistically insignificant. In yet another study, no significant correlation was found with biological sex, but women did score significantly higher than men in the "common humanity" factor (Phillips & Ferguson, 2013).
It is important to note that seven of the studies evaluated in this review presented a greater number of women in their samples. Additionally, it is worth noting that the study conducted by Bennet and colleagues (2017) was the only one to report  Clínicos, v. 14, n. 1, jan./abr. 2021 participants' sexual orientation in its sociodemographic data. Moreover, even though Smith (2015) also described participants' average income in her sociodemographic results, Herriot, Wrosch, and Gouin, (2018) were the only ones to report that selfcompassion was positively correlated with elders' economic status.
In their first study, the authors used the version of the Self-Compassion Scale with 26 items. In their second study, the authors created a 12-item scale based on the previous one, as the 26-item version was found to be difficult for elders to understand. The authors stated that, after the completion of this study, which has not yet been published, a short form of the scale composed of 12 items was made available in another publication by the authors of the original scale. Allen et al. (2012) pointed out that both the version created by them for this study and the one created by the authors of the original scale presented low reliability when compared with younger samples.
Other studies disagreed on the reliability of the brief scale. Smith (2015) found low alphas in two of its subscales (Self-Compassion: .76; and Common Humanity: .55) and mentioned the use of the short form in her limitations. The author suggested that future studies that aim to include these subscales in their analyses utilize the 26-item version. Through their work, Bratt and Fagerström (2019) sought to evaluate the internal consistency and validity of the short form in a randomized sample of Swedish elders, using confirmatory factor analysis with one 6 factor and one 2 factor model. In their results, the authors suggest psychometric issues with the use of the brief scale since it presented an internal consistency of >.70 only in the group of younger participants aged Exploring Self-Compassion in Older Adults: a systematic review __________________________________________________________________________________________ 344 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 between 66 and 71 years old. The six factor analysis model did not present acceptable internal consistency in the total scale and any subscale except for self-criticism. In the two factor analysis model, only the negative self-compassion component presented good internal consistency, both in the overall sample and in the younger group. On the other hand, Herriot et al. (2018) stated that the brief scale presented an internal consistency of .80 in their study. Thus, there is a need for more analyses of both reliability and internal consistency of the short form of the Self-Compassion Scale in different samples with elders.

Variables associated with self-compassion
Self-compassion is associated with different dependent variables, and has been tested with different models to evaluate its interaction as a mediator and predictor variable. Furthermore, self-compassion has been positively associated with overall wellbeing (Allen et al., 2012), life satisfaction (Allen et al., 2012;Kim & Ko, 2018), social functioning, successful aging (Allen et al., 2012), life meaning (Phillips & Ferguson, 2013), happiness (Smith, 2015), self-acceptance, personal growth, life purpose, positive relationships and domain of one's environment (Homan, 2018).
Two studies stratified the tool for evaluating self-compassion in two factors, with those being its positive and negative components. In their analyses, Kim and Ko (2018) found the negative component of self-compassion to be significantly correlated with depression, anxiety, sleep disorders, life satisfaction and quality of life related to health. Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 self-compassion. Upon the conduction of regression analyses, high levels of selfcompassion were found to predict high levels of life meaning and ego integrity. Only self-compassion's positive factor predicted the variable positive affect. These results suggest that elders with higher levels of self-compassion will also have greater chances of experiencing higher levels of well-being.
Variables related to physical well-being were substantially explored in the research of Allen et al. (2012), which consisted of two studies. The findings of study 1 found self-compassion to be an important mediator of the relation between perception of greater pain and overall well-being, as individuals with higher levels of both pain and self-compassion reported greater well-being. Moreover, participants who reported less overall health but high scores of self-compassion presented a greater well-being than participants with low self-compassion. The poorer their health, the more selfcompassion was found to be related with the maintenance of their well-being. Low mobility has been associated with lower life satisfaction in elders with lower levels of self-compassion, and has been related with lower well-being, with the latter being higher when self-compassion scores were lower. In study 2, self-compassion presented a significant interaction with walking difficulties and willingness to use a walker, as well as with walking difficulties and openness to accept another individual's assistance as physical support. Self-compassion was also negatively associated with how much an individual will resist the need of assistance for walking, and predicted the frequency with which participants asked others to repeat information.
Self-compassion was found to be negatively correlated with depression (Allen et al., 2012;Smith, 2015). Lower depression indices, along with lower sleep disorders scores and greater life satisfaction have been found to predict the positive component of selfcompassion in regression models. Some of the negative component's predictors included higher scores of depression, anxiety, sleep disorders, and lower life satisfaction (Kim & Ko, 2018). Lower self-compassion and poorer health predicted a greater Exploring Self-Compassion in Older Adults: a systematic review __________________________________________________________________________________________ 346 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 depression score. Moreover, high levels of stress predicted lower happiness in individuals with lower self-compassion, and the relation between elders' health and happiness was moderated by self-compassion (Smith, 2015). In general, most studies found correlations between self-compassion and positive variables.
The only study that included a biological variable was conducted by Herriot et al. (2018), and involved the measurement of diurnal cortisol in a sample of elders, which was then correlated with stressor experiences and self-compassion. Their results found higher levels of cortisol to be negatively associated with self-compassion and observed in participants who reported greater physical problems, intense regret and greater functional incapacity, along with low self-compassion. Self-compassion predicted lower levels of cortisol in participants who reported greater functional incapacity and in those with intense regret.
Allen and Leary (2014) explored the association between self-compassion and changes derived from aging. In order to do so, they stratified their sample in three groups in their analyses. The first group was supposed to report a positive change, the second group was supposed to report a negative change, and the third group was supposed to report a neutral change, without the need of it being positive or negative.
Self-compassion was associated with the positive outlook, thoughts about aging and changes associated with aging, and predicted self-compassionate cognitions towards the described event and changes associated with aging. Self-compassion also predicted participants' tendency to deal with the described event by being kind to themselves.
It is worth noting that, in two studies, self-compassion was not part of the general objective, but rather utilized as an associative variable or secondary objective. In their study, Bennet et al. (2017) aimed to explore how physically active women between 65 and 94 years old perceived and experienced their bodies after aging. Self-compassion emerged as a secondary objective in order to understand the perceptions of its function for managing body changes. In Moss et al. (2015), the authors' objective was to test the Allana Almeida Moraes, Carolina Villanova Quiroga, Luisa Raquel Bridi Dacroce, Irani Iracema de Lima Argimon __________________________________________________________________________________________ 347 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 viability and effectiveness of the adaptation of a program based in mindfulness for stress reduction in a sample of elders from a community. In this study, self-compassion was used to evaluate secondary results, being associated with the tools of analyses of variables relevant to healthy aging. Thus, it is clear that self-compassion has already won its place in studies with distinct objectives, emerging as a mediator variable for healthy outcomes in aging.

Discussion
Self-compassion has been associated with one's ability to manage adversities and make necessary changes in life (Neff, 2011), both particularly relevant for aging challenges. For Gilbert and Proctor (2006) a better understanding of their older members, since spiritual care must be faced in a Exploring Self-Compassion in Older Adults: a systematic review __________________________________________________________________________________________ 348 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 holistic manner. While it is usually provided by spiritual or pastoral carers, all healthcare professionals have an important role to perform regarding this type of care (Lepherd et al., 2019).
In regards to the utilized research designs, we observed a variety of models and result measures, with most of the studies being exploratory, even though few of them explored correlational analyses between dependent and sociodemographic variables. At the same time, studies involving randomized samples, which would have promoted greater precision on the impact of self-compassion, were scarce. While searching for this review's articles, we frequently found studies that did not perform separate analyses for age subgroups, making it difficult to determine if the evaluation tools are indeed reliable to illustrate older individuals' point of view. Although such findings may provide important information for the overall population, they may not represent specific needs of the elderly.
It is also important to mention the low incidence of intervention studies. In this review, we only found one study with a randomized clinical trial on the adaptation of an intervention with a sample of elders (Moss et al., 2015), and its emphasis was not even on self-compassion, which was used as a variable associated with secondary outcomes. Considering the amount of changes and losses that occur during aging's normal process, it is important to develop interventions that can assist elders in obtaining efficient strategies for a better adaptation to their environment and its changes.
This relates to the concept of successful aging, in which the elder continues to have an active life despite the usual decline associated with aging. By developing, maintaining or improving their abilities, the elders can also improve their health and quality of life (Perez-Blasco, Sales, Melendez, & Mayodormo, 2016). If it is presumed that the foundation for successful aging is one's ability to adapt to changes, interventions involving self-compassion can promote an emotionally positive attitude which will ultimately provide protection against the negative consequences of self-criticism, Allana Almeida Moraes, Carolina Villanova Quiroga, Luisa Raquel Bridi Dacroce, Irani Iracema de Lima Argimon __________________________________________________________________________________________ 349 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 isolation and rumination (Neff, 2003). Thus, self-compassion constitutes a valuable tool for working with elders (Neff & Germer, 2013), since it provides benefits for their mental health and coping of stressful events in old age (Allen & Leary, 2014). It is also important to emphasize that interventions that are effective for young adults may not be generalizable for older adults due to the life experiences of both groups being mostly different.
Furthermore, we must highlight the low number of studies that opted to conduct a follow up with their samples, depriving themselves from analyzing the long-term effects of their interventions. Longitudinal studies and follow ups could be valuable for providing evidence for the efficacy of interventions on this theme. It is presumed that this also relates to challenges found in research involving elders and the idiosyncrasies of this age group. Barriers such as aging, illnesses, deaths and more typical situations make research with this population peculiar, and involve some obstacles that may be little attractive to the scientific community in terms of research continuity.
As for construct evaluation tools, we identified a need for more analyses on the reliability and consistency of the short form of the Self-Compassion Scale in different samples with elders. We also identified that need with the Self-Compassion Scale, which is the main available tool to evaluate self-compassion, and thus must have its factorial structure determined to be valid and replicable for different populations (Neff, Whittaker & Karl, 2017). Additionally, comprehension factors must also be taken into account, as such materials include reverse items which can lead to confusion in the interpretation of such questions by elders.
In the present review, most studies were found to correlate self-compassion with positive variables. Such data are confirmed by other studies with samples focused on other age groups. Indeed, self-compassion seems to reinforce positive states, so much so that in a recent meta-analysis (Zessin et al., 2015) it has been associated with feelings of satisfaction, happiness, wisdom, optimism, gratitude, curiosity, creativity and positive Exploring Self-Compassion in Older Adults: a systematic review __________________________________________________________________________________________ 350 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 affect. In other studies, it was found to be associated with positive psychological strengths, such as happiness, wisdom, curiosity, personal initiative and emotional intelligence (Heffernan, Griffin, McNulty & Fitzpatrick, 2010;Hollis-Walker & Colosimo, 2011;Neff, Kirkpatrick & Rude, 2007). Some authors have proposed that selfcompassion could be a source of positive aging, given the positive associations found between self-compassion and positive affect, meaning of life and psychological wellbeing, also known as eudaimonic well-being (Keyes, Shmotkin & Ryff, 2002).
Moreover, self-compassion has been associated with a positive tone, positively influencing thoughts and changes related to aging, with it predicting cognitions of selfcompassion towards those changes (Allen & Leary, 2014). This reinforces how important self-compassion is as a source of eudaimonic happiness (which involves finding purpose and meaning of life instead of seeking pleasure and avoiding pain). It is also an important inner resource that helps individuals find hope and inner strength when faced with the challenges of life (Neff & Knox, 2017). In this regard, Neff et al. (2005) suggested that emotional regulation is a defining characteristic of self-compassion. By serving as a protective factor (Van Dam, Sheppard, Forsyth, & Earleywine, 2011), it has a cushioning effect that can be attributed to self-compassionate cognitive strategies represented by a positive cognitive restructuring (Allen & Leary, 2014), which contributes to a higher level of subjective well-being (Neff, Kirkpatrick & Rude, 2007).
Being able to regulate one's emotions and facing adversities have been associated with successful aging, subjective well-being and life satisfaction. Subjective well-being is considered a protective factor against adverse conditions, regardless of whether they are biological or social (Ryff, Friedman, Morozink & Tsenkova, 2012). It involves balancing positive and negative affects that result in life satisfaction.
Aside from correlations with psychological well-being, some studies also report positive associations between self-compassion and physical health, pain levels and sleep quality. This may be related to the fact that self-compassion is a promising and  Clínicos, v. 14, n. 1, jan./abr. 2021 modifiable candidate that can potentially contribute to positive attitudes toward aging (Bryant et al., 2014;Miche, Elsasser, Schilling & Wahl, 2014). Elders with positive attitudes toward aging were found to live up to 7.5 years more than those with negative attitudes (Levy, Slade, Kunkel & Kasl, 2002). Positive attitudes are also associated with reduced cardiac events (Levy, Zonderman, Slade & Ferrucci, 2009), better development of healthy behaviors (Levy & Myers, 2004) and greater well-being among older adults (Bryant et al., 2012). An attitude is defined as a belief that has an evaluative component (Bryant et al., 2012). Attitudes regarding one's personal experience with aging are believed to become salient from midlife, initiated by physicals signs of aging, role transitions, menopause, possible health issues and the loss of one's parents that can lead individuals to question their own mortality (Wurm, Tomasik & Tesch-Romer, 2010).
Negative attitudes, consistent with negative stereotypes of aging, can produce a selffulfilling prophecy, leading individuals to become less active, having less trust and having less meaning of life (Levy & Myers, 2004;Wurm et al., 2010). Identifying modifiable factors that might contribute to the formation of positive attitudes during midlife can be particularly useful for the development of interventions as a way to promote healthy aging.
Results also found self-compassion to be associated with reduced symptoms of depression and anxiety, highlighting evidence on how it may reduce the emotional burden of late life health issues. Thus, self-compassion can be particularly relevant for the well-being of those who face health issues common in adult life. In a meta-analysis, a great size effect was found when examining the relationship between self-compassion and psychopathology in 20 studies, with greater self-compassion being linked to lower indices of depression, anxiety and stress (Macbeth & Gumley, 2012). Even when older adults are not yet going through negative changes in life, self-compassion can play an important role in how they prepare for the future, since aging can be a stressful imminent event for those approaching this stage of life (Sneed, & Whitbourne, 2001).
Exploring Self-Compassion in Older Adults: a systematic review __________________________________________________________________________________________ 352 Contextos Clínicos, v. 14, n. 1, jan./abr. 2021 It is known that depressed elders have greater difficulty with emotion regulation (Larcom & Isaacowitz, 2009). In this sense, self-compassion can be seen as an extremely useful strategy for emotion regulation, with a cushioning effect on psychopathology development (Castilho & Gouveia, 2011). Still, more empirical research on the benefits of self-compassion as a tool to increase emotional well-being is needed. Since the high density of geriatric depression and anxiety constitute a serious public health issue, it is necessary that treatment and prevention options are more thoroughly investigated and then adequately implemented.

Limitations
Given the dissonances found mainly in regards to how self-compassion presents itself in aging, we suggest the conduction of the results' meta-analysis in order to confirm the hypotheses presented above. Moreover, this review utilized a measure of methodological quality with numerical analysis. It would be interesting to also utilize a measure of methodological quality with a qualitative evaluation, since in the analyzed instrument all parts of the articles receive an equal grade. The sum of such grades may be high, but cases can occur in which one area will receive a low grade and this will not be reflected in the final result.

Conclusion
This review presented preliminary evidence for self-compassion being a promising skill that can promote a healthy mental, social, and physical aging. It may even explain why some individuals experience a better adjustment to aging (Brown et al., 2018). Moreover, the benefits assigned to this construct are accompanied by evidence that self-compassion is a skill that can be taught (Neff & Germer, 2013), associated with one's ability to manage adversities and carry out necessary changes in life (Neff, 2011).  Clínicos, v. 14, n. 1, jan./abr. 2021 In general, it must be noted that scientific production in this area is scarce and lacks expressive growth. Nevertheless, we found studies with empirical proposals associating self-compassion with a series of essential predictors of successful aging, indicating this to be a promising area for future research. Important gaps were identified in this literature review, such as scarcity in research aimed to investigate the potential of interventions based on self-compassion to increase elders' well-being in community and clinical contexts. More longitudinal studies that explore heterogeneous samples of elders and sociocultural particularities are also needed. Finally, more emphasis should be given to the importance of investing in randomized clinical trials in order to obtain results that can be better generalized.