58 The Process of Aging

Biological Changes

Each person experiences age-related changes based on many factors. Biological factors such as molecular and cellular changes are called primary aging, while aging that occurs due to controllable factors such as lack of physical exercise and poor diet is called secondary aging (Whitbourne and Whitbourne 2010).

Most people begin to see signs of aging after fifty years old, when they notice the physical markers of age. Skin becomes thinner, drier, and less elastic. Wrinkles form. Hair begins to thin and gray. Men prone to balding start losing hair. The difficulty or relative ease with which people adapt to these changes is dependent in part on the meaning given to aging by their particular culture. A culture that values youthfulness and beauty above all else leads to a negative perception of growing old. Conversely, a culture that reveres the elderly for their life experience and wisdom contributes to a more positive perception of what it means to grow old.

The effects of aging can feel daunting, and sometimes the fear of physical changes (like declining energy, food sensitivity, and loss of hearing and vision) is more challenging to deal with than the changes themselves. The way people perceive physical aging is largely dependent on how they were socialized. If people can accept the changes in their bodies as a natural process of aging, the changes will not seem as frightening.

According to the federal Administration on Aging (2011), in 2009 fewer people over sixty-five years old assessed their health as “excellent” or “very good” (41.6 percent) compared to those aged eighteen to sixty-four (64.4 percent). Evaluating data from the National Center for Health Statistics and the U.S. Bureau of Labor Statistics, the Administration on Aging found that from 2006 to 2008, the most frequently reported health issues for those over sixty-five years old included arthritis (50 percent), hypertension (38 percent), heart disease (32 percent), and cancer (22 percent). About 27 percent of people age sixty and older are considered obese by current medical standards. Parker and Thorslund (2006) found that while the trend is toward steady improvement in most disability measures, there is a concomitant increase in functional impairments (disability) and chronic diseases. At the same time, medical advances have reduced some of the disabling effects of those diseases (Crimmins 2004).

Some impacts of aging are gender-specific. Some of the disadvantages aging women face arise from long-standing social gender roles. For example, Social Security favors men over women, inasmuch as women do not earn Social Security benefits for the unpaid labor they perform (usually at home) as an extension of their gender roles. In the healthcare field, elderly female patients are more likely than elderly men to see their healthcare concerns trivialized (Sharp 1995) and are more likely to have their health issues labeled psychosomatic (Munch 2004). Another female-specific aspect of aging is that mass-media outlets often depict elderly females in terms of negative stereotypes and as less successful than older men (Bazzini and Mclntosh I997).

For men, the process of aging—and society’s response to and support of the experience—may be quite different. The gradual decrease in male sexual performance that occurs as a result of primary aging is medicalized and constructed as needing treatment (Marshall and Katz 2002) so that a man may maintain a sense of youthful masculinity. On the other hand, aging men have fewer opportunities to assert their masculine identities in the company of other men (for example, through sports participation) (Drummond 1998). And some social scientists have observed that the aging male body is depicted in the Western world as genderless (Spector-Mersel 2006).

Social and Psychological Changes

Male or female, growing older means confronting the psychological issues that come with entering the last phase of life. Young people moving into adulthood take on new roles and responsibilities as their lives expand, but an opposite arc can be observed in old age. What are the hallmarks of social and psychological change?

Retirement—the withdrawal from paid work at a certain age—is a relatively recent idea. Up until the late nineteenth century, people worked about sixty hours a week until they were physically incapable of continuing. Following the American Civil War, veterans receiving pensions were able to withdraw from the workforce, and the number of working older men began declining. A second large decline in the number of working men began in the post-World War II era, probably due to the availability of Social Security, and a third large decline in the 1960s and 1970s was probably due to the social support offered by Medicare and the increase in Social Security benefits (Munnell 2011).

In the twenty-first century, most people hope that at some point they will be able to stop working and enjoy the fruits of their labor. But do we look forward to this time or fear it? When people retire from familiar work routines, some easily seek new hobbies, interests, and forms of recreation. Many find new groups and explore new activities, but others may find it more difficult to adapt to new routines and loss of social roles, losing their sense of self-worth in the process.

Each phase of life has challenges that come with the potential for fear. Erik H. Erikson (1902–1994), in his view of socialization, broke the typical life span into eight phases. Each phase presents a particular challenge that must be overcome. In the final stage, old age, the challenge is to embrace integrity over despair. Some people are unable to successfully overcome the challenge. They may have to confront regrets, such as being disappointed in their children’s lives or perhaps their own. They may have to accept that they will never reach certain career goals. Or they must come to terms with what their career success has cost them, such as time with their family or declining personal health. Others, however, are able to achieve a strong sense of integrity and are able to embrace the new phase in life. When that happens, there is tremendous potential for creativity. They can learn new skills, practice new activities, and peacefully prepare for the end of life.

For some, overcoming despair might entail remarriage after the death of a spouse. A study conducted by Kate Davidson (2002) reviewed demographic data that asserted men were more likely to remarry after the death of a spouse and suggested that widows (the surviving female spouse of a deceased male partner) and widowers (the surviving male spouse of a deceased female partner) experience their postmarital lives differently. Many surviving women enjoyed a new sense of freedom, since they were living alone for the first time. On the other hand, for surviving men, there was a greater sense of having lost something, because they were now deprived of a constant source of care as well as the focus of their emotional life.

Aging and Sexuality

It is no secret that people in the United States are squeamish about the subject of sex. And when the subject is the sexuality of elderly people? No one wants to think about it or even talk about it. That fact is part of what makes 1971’s Harold and Maude so provocative. In this cult favorite film, Harold, an alienated young man, meets and falls in love with Maude, a seventy-nine-year-old woman. What is so telling about the film is the reaction of his family, priest, and psychologist, who exhibit disgust and horror at such a match.

Although it is difficult to have an open, public national dialogue about aging and sexuality, the reality is that our sexual selves do not disappear after age sixty-five. People continue to enjoy sex—and not always safe sex—well into their later years. In fact, some research suggests that as many as one in five new cases of AIDS occurs in adults over sixty-five years old (Hillman 2011).

In some ways, old age may be a time to enjoy sex more, not less. For women, the elder years can bring a sense of relief as the fear of an unwanted pregnancy is removed and the children are grown and taking care of themselves. However, while we have expanded the number of psycho-pharmaceuticals to address sexual dysfunction in men, it was not until very recently that the medical field acknowledged the existence of female sexual dysfunctions (Bryant 2004).

Death and Dying

For most of human history, the standard of living was significantly lower than it is now. Humans struggled to survive with few amenities and very limited medical technology. The risk of death due to disease or accident was high in any life stage, and life expectancy was low. As people began to live longer, death became associated with old age.

For many teenagers and young adults, losing a grandparent or another older relative can be the first loss of a loved one they experience. It may be their first encounter with grief, a psychological, emotional, and social response to the feelings of loss that accompanies death or a similar event.

People tend to perceive death, their own and that of others, based on the values of their culture. While some may look upon death as the natural conclusion to a long, fruitful life, others may find the prospect of dying frightening to contemplate. People tend to have strong resistance to the idea of their own death, and strong emotional reactions of loss to the death of loved ones. Viewing death as a loss, as opposed to a natural or tranquil transition, is often considered normal in the United States.

What may be surprising is how few studies were conducted on death and dying prior to the 1960s. Death and dying were fields that had received little attention until a psychologist named Elisabeth Kübler-Ross began observing people who were in the process of dying. As Kübler-Ross witnessed people’s transition toward death, she found some common threads in their experiences. She observed that the process had five distinct stages: denial, anger, bargaining, depression, and acceptance. She published her findings in a 1969 book called On Death and Dying. The book remains a classic on the topic today.

Kübler-Ross found that a person’s first reaction to the prospect of dying is denial: this is characterized by the person’s not wanting to believe he or she is dying, with common thoughts such as “I feel fine” or “This is not really happening to me.” The second stage is anger, when loss of life is seen as unfair and unjust. A person then resorts to the third stage, bargaining: trying to negotiate with a higher power to postpone the inevitable by reforming or changing the way he or she lives. The fourth stage, psychological depression, allows for resignation as the situation begins to seem hopeless. In the final stage, a person adjusts to the idea of death and reaches acceptance. At this point, the person can face death honestly, by regarding it as a natural and inevitable part of life and can make the most of their remaining time.

The work of Kübler-Ross was eye-opening when it was introduced. It broke new ground and opened the doors for sociologists, social workers, health practitioners, and therapists to study death and help those who were facing death. Kübler-Ross’s work is generally considered a major contribution to thanatology: the systematic study of death and dying.

Of special interests to thanatologists is the concept of “dying with dignity.” Modern medicine includes advanced medical technology that may prolong life without a parallel improvement to the quality of life one may have. In some cases, people may not want to continue living when they are in constant pain and no longer enjoying life. Should patients have the right to choose to die with dignity? Dr. Jack Kevorkian was a staunch advocate for physician-assisted suicide: the voluntary or physician-assisted use of lethal medication provided by a medical doctor to end one’s life. This right to have a doctor help a patient die with dignity is controversial. In the United States, Oregon was the first state to pass a law allowing physician-assisted suicides. In 1997, Oregon instituted the Death with Dignity Act, which required the presence of two physicians for a legal assisted suicide. This law was successfully challenged by U.S. Attorney General John Ashcroft in 2001, but the appeals process ultimately upheld the Oregon law. As of 2019, seven states and the District of Columbia have passed similar laws allowing physician assisted suicide.

The controversy surrounding death with dignity laws is emblematic of the way our society tries to separate itself from death. Health institutions have built facilities to comfortably house those who are terminally ill. This is seen as a compassionate act, helping relieve the surviving family members of the burden of caring for the dying relative. But studies almost universally show that people prefer to die in their own homes (Lloyd, White, and Sutton 2011). Is it our social responsibility to care for elderly relatives up until their death? How do we balance the responsibility for caring for an elderly relative with our other responsibilities and obligations? As our society grows older, and as new medical technology can prolong life even further, the answers to these questions will develop and change.

The changing concept of hospice is an indicator of our society’s changing view of death. Hospice is a type of healthcare that treats terminally ill people when “cure-oriented treatments” are no longer an option (Hospice Foundation of America 2012b). Hospice doctors, nurses, and therapists receive special training in the care of the dying. The focus is not on getting better or curing the illness, but on passing out of this life in comfort and peace. Hospice centers exist as a place where people can go to die in comfort, and increasingly, hospice services encourage at-home care so that someone has the comfort of dying in a familiar environment, surrounded by family (Hospice Foundation of America 2012a). While many of us would probably prefer to avoid thinking of the end of our lives, it may be possible to take comfort in the idea that when we do approach death in a hospice setting, it is in a familiar, relatively controlled place.