Old age

Old age comprises "the later part of life; the period of life after youth and middle age . . ., usually with reference to deterioration".[8] At what age old age begins cannot be universally defined because it differs according to the context. The United Nations has agreed that 65+ years may be usually denoted as old age[9] and this is the first attempt at an international definition of old age. However, for its study of old age in Africa, the World Health Organization (WHO) set 55 as the beginning of old age. At the same time, the WHO recognized that the developing world often defines old age, not by years, but by new roles, loss of previous roles, or inability to make active contributions to society.[10]

Most developed Western countries set the age of 60 to 65 for retirement. Being 60–65 years old is usually a requirement for becoming eligible for senior social programs.[11] However, various countries and societies consider the onset of old age as anywhere from the mid-40s to the 70s.[12] The definitions of old age continue to change, especially as life expectancy in developed countries has risen to beyond 80 years old.[13] In October 2016, a paper published in the science journal Nature presented the conclusion that the maximum human lifespan is an average age of 115, with an absolute upper limit of 125 years.[14] However, the authors' methods and conclusions drew criticism from the scientific community, who concluded that the study was flawed.[15]

Gerontologists have recognized the very different conditions that people experience as they grow older within the years defined as old age. In developed countries, most people in their 60s and early 70s are still fit, active, and able to care for themselves.[16]^:607 However, after 75, they will become increasingly frail, a condition marked by serious mental and physical debilitation.[17]

Therefore, rather than lumping together all people who have been defined as old, some gerontologists have recognized the diversity of old age by defining sub-groups. One study distinguishes the young old (60 to 69), the middle old (70 to 79), and the very old (80+).[18] Another study's sub-grouping is young-old (65 to 74), middle-old (75–84), and oldest-old (85+).[19] A third sub-grouping is "young old" (65–74), "old" (74–84), and "old-old" (85+).[20] Describing sub-groups in the 65+ population enables a more accurate portrayal of significant life changes.[21]^:4

Two British scholars, Paul Higgs and Chris Gilleard, have added a "fourth age" sub-group. In British English, the "third age" is "the period in life of active retirement, following middle age".[22] Higgs and Gilleard describe the fourth age as "an arena of inactive, unhealthy, unproductive, and ultimately unsuccessful ageing".[23]

Key Concepts in Social Gerontology lists four dimensions: chronological, biological, psychological, and social.[24]^:12–3 Wattis and Curran add a fifth dimension: developmental.[25] Chronological age may differ considerably from a person's functional age. The distinguishing marks of old age normally occur in all five senses at different times and different rates for different persons.[26] In addition to chronological age, people can be considered old because of the other dimensions of old age. For example, people may be considered old when they become grandparents or when they begin to do less or different work in retirement.[9]

Senior citizen is a common euphemism for an old person used in American English, and sometimes in British English. It implies that the person being referred to is retired.[27][28][29][30] This in turn usually implies that the person is over the retirement age, which varies according to country. Synonyms include old age pensioner or pensioner in British English, and retiree and senior in American English. Some dictionaries describe widespread use of "senior citizen" for people over the age of 65.[31]

When defined in an official context, senior citizen is often used for legal or policy-related reasons in determining who is eligible for certain benefits available to the age group.

It is used in general usage instead of traditional terms such as old person, old-age pensioner, or elderly as a courtesy and to signify continuing relevance of and respect for this population group as "citizens" of society, of senior rank.[32]

The term was apparently coined in 1938 during a political campaign.[33] Famed caricaturist Al Hirschfeld claimed on several occasion that his father Isaac Hirschfeld invented the term 'senior citizen'.[34][35][36] It has come into widespread use in recent decades in legislation, commerce, and common speech. Especially in less formal contexts, it is often abbreviated as "senior(s)", which is also used as an adjective.

In commerce, some businesses offer customers of a certain age a "senior discount". The age at which these discounts are available varies between 55, 60, 62 or 65, and other criteria may also apply. Sometimes a special "senior discount card" or other proof of age needs to be obtained and produced to show entitlement.

The age which qualifies for senior citizen status varies widely. In governmental contexts, it is usually associated with an age at which pensions or medical benefits for the elderly become available. In commercial contexts, where it may serve as a marketing device to attract customers, the age is often significantly lower.[37]

In the United States, the standard retirement age is currently 66 (gradually increasing to 67).[38]

In Canada, the OAS (Old Age Security) pension is available at 65 (the Conservative government of Stephen Harper had planned to gradually increase the age of eligibility to 67, starting in the years 2023–2029, although the Liberal government of Justin Trudeau is considering leaving it at 65),[39] and the CPP (Canada Pension Plan) as early as age 60.

The AARP allows couples in which one spouse has reached the age of 50 to join, regardless of the age of the other spouse.

Physical marks of old age include the following:

• Bone and joint. Old bones are marked by "thinning and shrinkage". This might result in a loss of height (about two inches (5 cm) by age 80), a stooping posture in many people, and a greater susceptibility to bone and joint diseases such as osteoarthritis and osteoporosis.[46][47][48]
• Chronic diseases. Some older persons have at least one chronic condition and many have multiple conditions. In 2007–2009, the most frequently occurring conditions among older persons in the United States were uncontrolled hypertension (34%), diagnosed arthritis (50%), and heart disease (32%).[49]
• Chronic mucus hypersecretion (CMH) "defined as coughing and bringing up sputum . . . is a common respiratory symptom in elderly persons."[50]
• Dental problems. May have less saliva and less ability for oral hygiene in old age which increases the chance of tooth decay and infection.[51]
• Digestive system. About 40% of the time, old age is marked by digestive disorders such as difficulty in swallowing, inability to eat enough and to absorb nutrition, constipation and bleeding.
• Essential tremor (ET) is an uncontrollable shaking in a part of the upper body. It is more common in the elderly and symptoms worsen with age.[52]
• Eyesight. Presbyopia can occur by age 50 and it hinders reading especially of small print in low lighting. Speed with which an individual reads and the ability to locate objects may also be impaired.[53] By age 80, more than half of all Americans either have a cataract or have had cataract surgery.[54][55][56]
• Falls. Old age spells risk for injury from falls that might not cause injury to a younger person.[57] Every year, about one-third of those 65 years old and over half of those 80 years old fall.[58] Falls are the leading cause of injury and death for old people.[59]
• Gait change. Some aspects of gait normally change with old age. Gait velocity slows after age 70. Double stance time (i.e., time with both feet on the ground) also increases with age. Because of gait change, old people sometimes appear to be walking on ice.[60]
• Hair usually becomes grayer and also might become thinner.[61][62] As a rule of thumb, around age 50, about 50% of Europeans have 50% grey hair.[63] Many men are affected by balding, and women enter menopause.
• Hearing. By age 75 and older, 48% of men and 37% of women encounter impairments in hearing. Of the 26.7 million people over age 50 with a hearing impairment, only one in seven uses a hearing aid.[53] In the 70–79 age range, the incidence of partial hearing loss affecting communication rises to 65%, predominantly among low-income males.[64]
• Hearts can become less efficient in old age with a resulting loss of stamina. In addition, atherosclerosis can constrict blood flow.[61][65]
• Immune function. Less efficient immune function (Immunosenescence) is a mark of old age.[66]
• Lungs might expand less well; thus, they provide less oxygen.[46][67]
• Mobility impairment or loss. "Impairment in mobility affects 14% of those between 65 and 74, but half of those over 85."[68] Loss of mobility is common in old people. This inability to get around has serious "social, psychological, and physical consequences".[69]
• Pain afflicts old people at least 25% of the time, increasing with age up to 80% for those in nursing homes.[70] Most pains are rheumatological or malignant.[71]
• Sexuality remains important throughout the lifespan and the sexual expression of "typical, healthy older persons is a relatively neglected topic of research".[72] Sexual attitudes and identity are established in early adulthood and change minimally over the course of a lifetime.[73] However, sexual drive in both men and women may decrease as they age.[74] That said, there is a growing body of research on people's sexual behaviours and desires in later life that challenges the "asexual" image of older adults. People aged 75–102 continue to experience sensuality and sexual pleasure.[75] Other known sexual behaviours in older age groups include sexual thoughts, fantasies and erotic dreams,[76] masturbation, oral sex, vaginal and anal intercourse.[72]
• Skin loses elasticity, becomes drier, and more lined and wrinkled.[61]
• Wounds and injuries take longer to heal.
• Wounds and injuries are more likely to leave permanent scars.
• Sleep trouble holds a chronic prevalence of over 50% in old age and results in daytime sleepiness.[77] In a study of 9,000 persons with a mean age of 74, only 12% reported no sleep complaints.[78] By age 65, deep sleep goes down to about 5%.[79]
• Taste buds diminish so that by age 80 taste buds are down to 50% of normal. Food becomes less appealing and nutrition can suffer.[46][47]
• Over the age of 85, thirst perception decreases, such that 41% of the elderly drink insufficiently.[80]
• Urinary incontinence is often found in old age.[81]
• Voice. In old age, vocal cords weaken and vibrate more slowly. This results in a weakened, breathy voice that is sometimes called an "old person's voice".[82]

Mental marks of old age include the following:

• Adaptable describes most people in their old age. Despite the stressfulness of old age, they are described as "agreeable" and "accepting". However, old age dependence induces feelings of incompetence and worthlessness in a minority.[16]^:608–9
• Caution marks old age. This antipathy toward "risk-taking" stems from the fact that old people have less to gain and more to lose by taking risks than younger people.[41]^:112,116
• Depressed mood.[83] According to Cox, Abramson, Devine, and Hollon (2012), old age is a risk factor for depression caused by prejudice (i.e., "deprejudice"). When people are prejudiced against the elderly and then become old themselves, their anti-elderly prejudice turns inward, causing depression. "People with more negative age stereotypes will likely have higher rates of depression as they get older."[84] Old age depression results in the over-65 population having the highest suicide rate.[16]^:610
• Fear of crime in old age, especially among the frail, sometimes weighs more heavily than concerns about finances or health and restricts what they do. The fear persists in spite of the fact that old people are victims of crime less often than younger people.[16]^:617
• Increasing fear of health loss.
• Mental disorders afflict about 15% of people aged 60+ according to estimates by the World Health Organization.[85] Another survey taken in 15 countries reported that mental disorders of adults interfered with their daily activities more than physical problems.[16]^:610
• Reduced mental and cognitive ability may afflict old age.[86][87]Memory loss is common in old age due to the decrease in speed of information being encoded, stored, and retrieved. It takes more time to learn the same amount of new information.[88] Dementia is a general term for memory loss and other intellectual abilities serious enough to interfere with daily life. Its prevalence increases in old age from about 10% at age 65 to about 50% over age 85.[89] Alzheimer's disease accounts for 50 to 80 percent of dementia cases. Demented behavior can include wandering, physical aggression, verbal outbursts, depression, and psychosis.[90]
• Set in one's ways describes a mind set of old age.[91] A study of over 400 distinguished men and women in old age found a "preference for the routine".[92] Explanations include old age's toll on the "fluid intelligence" and the "more deeply entrenched" ways of the old.[41]^:116

Many books by middle-age writers depict their perceptions of old people.[93] One writer notices the change in his parents: they move slowly, they have lost strength, they repeat stories, their minds wander, and they fret.[94] Another writer sees her aged parents and is bewildered: they refuse to follow her advice, they are obsessed with the past, they avoid risk, they live at a "glacial pace".[95]

Other writers treat the perceptions of middle-age people regarding their own old age. In her The Denial of Aging, Dr. Muriel R. Gillick, a baby boomer, accuses her contemporaries of believing that by proper exercise and diet they can avoid the scourges of old age and proceed from middle age to death.[96] Studies find that many people in the 55–75 range can postpone morbidity by practicing healthy lifestyles. These discourses take part in a general idea of successful ageing. However, at about age 80, all people experience similar morbidity.[97] Even with healthy lifestyles, most 85+ people will undergo extended "frailty and disability".[89]

Early old age is a pleasant time; children are grown, retirement from work, time to pursue interests.[16]^:603 Many people are also willing to get involved in community and activist organizations to promote their well-being. In contrast, perceptions of old age by writers 80+ years old (old age in the real meaning of the term[98]) tend to be negative.

Georges Minois writes that the first man to talk about his old age was an Egyptian scribe who lived 4,500 years ago. The scribe addressed God with a prayer of lament:[99]^:14

O Sovereign my Lord! Oldness has come; old age has descended. Feebleness has arrived; dotage is here anew. The heart sleeps wearily every day.
The eyes are weak, the ears are deaf, the strength is disappearing because of weariness of the heart and the mouth is silent and cannot speak.
The heart is forgetful and cannot recall yesterday. The bone suffers old age. Good is become evil. All taste is gone. What old age does to men is evil in every respect.[99]^:14–5

Minois comments that the scribe's "cry shows that nothing has changed in the drama of decrepitude between the age of the Pharaoh and the atomic age" and "expresses all the anguish of old people in the past and the present".[99]^:14

Lillian Rubin, active in her 80s as an author, sociologist, and psychotherapist, opens her book 60 on Up: The Truth about Aging in America with "getting old sucks. It always has, it always will." Dr. Rubin contrasts the "real old age" with the "rosy pictures" painted by middle-age writers.[100]

Writing at the age of 87, Mary C. Morrison describes the heroism required by old age: to live through the disintegration of one's own body or that of someone you love. Morrison concludes, "old age is not for the fainthearted."[101] In the book Life Beyond 85 Years, the 150 interviewees had to cope with physical and mental debilitation and with losses of loved ones. One interviewee described living in old age as "pure hell".[102]^{:7–8, 208}

Based on his survey of old age in history, Georges Minois concludes that "it is clear that always and everywhere youth has been preferred to old age." In Western thought, "old age is an evil, an infirmity and a dreary time of preparation for death." Furthermore, death is often preferred over "decrepitude, because death means deliverance".[99]^:303

"The problem of the ambiguity of old age has . . . been with us since the stage of primitive society; it was both the source of wisdom and of infirmity, experience and decrepitude, of prestige and suffering."[99]^:11

In the Classical period of Greek and Roman cultures, old age was denigrated as a time of "decline and decrepitude".[103]^:6–7 "Beauty and strength" were esteemed and old age was viewed as defiling and ugly. Old age was reckoned as one of the unanswerable "great mysteries" along with evil, pain, and suffering. "Decrepitude, which shrivels heroes, seemed worse than death."[99]^:43

The Medieval and Renaissance periods depicted old age as "cruel or weak".[103]^:7

Historical periods reveal a mixed picture of the "position and status" of old people, but there has never been a "golden age of aging".[103]^:6 Studies have disproved the popular belief that in the past old people were venerated by society and cared for by their families.[104]^:1 Veneration for and antagonism toward the aged have coexisted in complex relationships throughout history.[105] "Old people were respected or despised, honoured or put to death according to circumstance."[99]^:11

In ancient times, although some strong and healthy people lived until they were over 70 most died before they were 50. The general understanding is that those who lived into their 40s were treated with respect and awe. In contrast, those who were frail were seen as a burden and ignored or in extreme cases killed.[103]^:6[106] People were defined as "old" because of their inability to perform useful tasks rather than their years.[104]^:6

"The Olympians did not like old people." Their youth rebelled against the old, driving them off or killing them.[99]^:44

Although he was skeptical of the gods, Aristotle concurred in the dislike of old people. In his Ethics, he wrote that "old people are miserly; they do not acknowledge disinterested friendship; only seeking for what can satisfy their selfish needs."[99]^:60

The 16th-century Utopians, Thomas More and Antonio de Guevara, allowed no decrepit old people in their fictional lands.[99]^{:277–8, 280}

For Thomas More, on the island of Utopia, when people are so old as to have "out-lived themselves" and are terminally ill, in pain, and a burden to everyone, the priests exhort them about choosing to die. The priests assure them that "they shall be happy after death." If they choose to die, they end their lives by starvation or by taking opium.[107]

Antonio de Guevara's utopian nation "had a custom, not to live longer than sixty five years". At that age, they practiced self-immolation. Rather than condemn the practice, Bishop Guevara called it a "golden world" in which people "have overcome the natural appetite to desire to live".[108]

In the Modern period, the "cultural status" of old people has declined in many cultures.[103]^:7 Joan Erikson observed that "aged individuals are often ostracized, neglected, and overlooked; elders are seen no longer as bearers of wisdom but as embodiments of shame."[109]^:114

Research on age-related attitudes consistently finds that negative attitudes exceed positive attitudes toward old people because of their looks and behavior.[110] In his study Aging and Old Age, Posner discovers "resentment and disdain of older people" in American society.[41]^:320

Harvard University's implicit-association test measures implicit "attitudes and beliefs" about Young vis a vis Old.[111] Blind Spot: Hidden Biases of Good People, a book about the test, reports that 80% of Americans have an "automatic preference for the young over old" and that attitude is true worldwide. The young are "consistent in their negative attitude" toward the old.[112] Ageism documents that Americans generally have "little tolerance for older persons and very few reservations about harboring negative attitudes" about them.[113]

Despite its prevalence, ageism is seldom the subject of public discourse.[24]^:23

In 2014, a documentary film called The Age of Love used humor and poignant adventures of 30 seniors who attend a speed dating event for 70- to 90-year-olds, and discovered how the search for romance changes; or does not change; from a childhood sweetheart to older age.[114]

Simone de Beauvoir wrote that "there is one form of experience that belongs only to those that are old – that of old age itself."[115] Nevertheless, simulations of old age attempt to help younger people gain some understanding.

Texas A&M University offers a plan for an "Aging Simulation" workshop.[116] The workshop is adapted from Sensitizing People to the Processes of Aging.[117] Some of the simulations follow:

• Sight: Wearing swimmer's goggles with black paper pasted to lens with only a small hole to simulate tunnel vision,
• Hearing: Use ear plugs to dull the sound of people talking.
• Touch: Wearing thick gloves, button a shirt or buckle a belt.
• Dexterity: With tape around several fingers, unscrew a jar lid.
• Mobility and Balance: Carry packages in one hand while using a walker.

The Macklin Intergenerational Institute conducts Xtreme Aging workshops, as depicted in The New York Times.[118] A condensed version was presented on NBC's Today Show and is available online.[119] One exercise was to lay out 3 sets of 5 slips of paper. On set #1, write your 5 most enjoyed activities; on set #2, write your 5 most valued possessions; on set #3, write your 5 most loved people. Then "lose" them one by one, trying to feel each loss, until you have lost them all as happens in old age.

Three unique markers of frailty have been proposed: (a) loss of any notion of invincibility, (b) loss of ability to do things essential to one's care, and (c) loss of possibility for a subsequent life stage.[130]

Old age survivors on-average deteriorate from agility in their 65–80s to a period of frailty preceding death. This deterioration is gradual for some and precipitous for others. Frailty is marked by an array of chronic physical and mental problems which means that frailty is not treatable as a specific disease. These problems coupled with increased dependency in the basic activities of daily living (ADLs) required for personal care add emotional problems: depression and anxiety.[131] In sum, frailty has been depicted as a group of "complex issues," distinct but "causally interconnected," that often include "comorbid diseases",[132] progressive weakness, stress, exhaustion, and depression.[122]^:25–6

Johnson and Barer did a pioneering study of Life Beyond 85 Years by interviews over a six-year period. In talking with 85-year-olds and older, they found some popular conceptions about old age to be erroneous. Such erroneous conceptions include (1) people in old age have at least one family member for support, (2) old age well-being requires social activity, and (3) "successful adaptation" to age-related changes demands a continuity of self-concept. In their interviews, Johnson and Barer found that 24% of the 85+ had no face-to-face family relationships; many have outlived their families. Second, that contrary to popular notions, the interviews revealed that the reduced activity and socializing of the over-85s does not harm their well-being; they "welcome increased detachment". Third, rather than a continuity of self-concept, as the interviewees faced new situations they changed their "cognitive and emotional processes" and reconstituted their "self–representation".[102]^:5–6

The hand of an elderly person

Women at the On Lok Senior Health Services day care program in San Francisco, late 1970s.

Frail people require a high level of care. Medical advances have made it possible to "postpone death" for years. This added time costs many frail people "prolonged sickness, dependence, pain, and suffering".[122]^:9

According to a study by the Agency for Healthcare Research and Quality (AHRQ), the rate of emergency department visits was consistently highest among patients ages 85 years and older in 2006–2011 in the United States.[133] Additionally, patients aged 65+ had the highest percentage of hospital stays for adults with multiple chronic conditions but the second highest percentage of hospital costs in 2003–2014.[134]

These final years are also costly in economic terms.[135]^{:17–8, 92} One out of every four Medicare dollars is spent on the frail in their last year of life . . . in attempts to postpone death.[136]

Medical treatments in the final days are not only economically costly, they are often unnecessary, even harmful.[136] Nortin Hadler, M.D. warns against the tendency to medicalize and overtreat the frail.[137] In her Choosing Medical Care in Old Age, Michael R. Gillick M.D. argues that appropriate medical treatment for the frail is not the same as for the robust. The frail are vulnerable to "being tipped over" by any physical stress put on the system such as medical interventions.[126]^{:116, 189}

In addition to everyday care, frail elderly people and others with disabilities are particularly vulnerable during natural disasters.[138] They may be unable or unwilling to evacuate to avoid a hurricane or wildfire.[138]

Old age, death, and frailty are linked because approximately half the deaths in old age are preceded by months or years of frailty.[122]^{:3, 19}

Older Adults' Views on Death is based on interviews with 109 people in the 70–90 age range, with a mean age of 80.7. Almost 20% of the people wanted to use whatever treatment that might postpone death. About the same number said that, given a terminal illness, they would choose assisted suicide. Roughly half chose doing nothing except live day by day until death comes naturally without medical or other intervention designed to prolong life. This choice was coupled with a desire to receive palliative care if needed.[21]^{:6–7, 9, 12, 32}

About half of older adults suffer multimorbidity, that is, they have three or more chronic conditions.[139] Medical advances have made it possible to "postpone death," but in many cases this postponement adds "prolonged sickness, dependence, pain, and suffering," a time that is costly in social, psychological, and economic terms.[135]^{:18, 72}

The longitudinal interviews of 150 age 85+ people summarized in Life Beyond 85 Years found "progressive terminal decline" in the year prior to death: constant fatigue, much sleep, detachment from people, things, and activities, simplified lives. Most of the interviewees did not fear death; some would welcome it. One person said, "Living this long is pure hell." However, nearly everyone feared a long process of dying. Some wanted to die in their sleep; others wanted to die "on their feet".[102]^:202–7

The study of Older Adults' Views on Death found that the more frail people were, the more "pain, suffering, and struggles" they were enduring, the more likely they were to "accept and welcome" death as a release from their misery. Their fear about the process of dying was that it would prolong their distress. Besides being a release from misery, some saw death as a way to reunion with departed loved ones. Others saw death as a way to free their caretakers from the burden of their care.[21]^{:55, 270, 276}

An elderly Somali woman

An elderly woman walks down a road

Social theories, or concepts,[156] propose explanations for the distinctive relationships between old people and their societies.

One of the theories is the disengagement theory proposed in 1961. This theory proposes that in old age a mutual disengagement between people and their society occurs in anticipation of death. By becoming disengaged from work and family responsibilities, according to this concept, people are enabled to enjoy their old age without stress. This theory has been subjected to the criticism that old age disengagement is neither natural, inevitable, nor beneficial.[157] Furthermore, disengaging from social ties in old age is not across the board: unsatisfactory ties are dropped and satisfying ones kept.[16]^:613

In opposition to the disengagement theory, the activity theory of old age argues that disengagement in old age occurs not by desire, but by the barriers to social engagement imposed by society. This theory has been faulted for not factoring in psychological changes that occur in old age as shown by reduced activity, even when available. It has also been found that happiness in old age is not proportional to activity.[16]^:614

According to the continuity theory, in spite of the inevitable differences imposed by their old age, most people try to maintain continuity in personhood, activities, and relationships with their younger days.[16]^:614

Socioemotional selectivity theory also depicts how people maintain continuity in old age. The focus of this theory is continuity sustained by social networks, albeit networks narrowed by choice and by circumstances. The choice is for more harmonious relationships. The circumstances are loss of relationships by death and distance.[16]^:614–5