Life expectancy of Americans is at a record high of 77.6 years. Women still outlive men, but the gap is narrowing. As a group, the elderly are the most rapidly growing sector of the U.S. population. Around 25 million Americans are over 65. Since 1900, Americans have gained 30 more years of life. Advances in health care, medications, and medical devices play a major part in contributing to this longevity.¹ Many older adults now live active lives and are not necessarily sick old people. Incidentally, nurses’ contact with both ill and healthy elderly patients will continue to expand. Understanding the complexities of each elderly patient is crucial to providing good nursing care. An  in-depth understanding will foster nurse-patient relationships that benefit the patient and bring satisfaction  to the nurse.

Part 1 of this two-part series focuses on the expected challenges of growing old. It includes a discussion of successful aging, focusing on emotional growth and the adaptation to bodily changes that come with age. Part 2 addresses psychiatric and cognitive illnesses and how they are experienced and treated in later life.

Chronological age vs. biological age

Chronological age is the measurement of the amount of time that has passed. It is the number used to designate years lived — the number we use when completing forms. In contrast, biological age, also called functional age, denotes the changes that occur in the body in time, not because of time. Biological age is not merely the number of years lived. It varies per individual, and it is determined by genetic, metabolic, biochemical, behavioral, as well as evolutionary factors. In many ways biological age is a more meaningful measurement than chronological age. Since biological changes in the body occur at different rates for different people, a person’s biological age is likely to be different from his or her chronological age. Much variability exists in biological age among elderly persons. Consider that two 75-year-olds can appear much different in age when compared to two 25 year olds. Sixty-five is the chronological age most widely used to denote the start of old age in the United States. In America 65 became the chronological age for retirement. However, when considering biological age, many 65-year-olds do not appear elderly and may not be ready to give up a career or job. This rather arbitrary age used as a marker for the start of geriatrics is an example of the limitations of chronological age. Nonetheless, chronological age is not likely to give way to biological age in the near future since there is no scientific calculation for biological age, and even if available, the use of biological age could pose ethical dilemmas such as the potential for discrimination against those whose biological age is older than their chronological age.²

Psychological growth

The older individual who has mastered the psychological challenges of earlier life can potentially continue to grow psychologically into later adulthood. When the hardships encountered throughout the earlier stages of life are accepted and dealt with, a sense of inner peace and authenticity potentially develops. The term ego integrity is used to denote the successful mastery of later life. The older person who has developed ego integrity generally claims “no regrets” about the way things have gone in his or her life. Inner calm allows these individuals to more comfortably accept the inevitably approaching end of life.³

Conversely, despair is dominant for the older person who harbors regret about his or her past. These people are likely to be fearful and anxious that death will come before a meaningful life can be experienced.³

When ego integrity prevails over despair, the outcome is wisdom.³ Wisdom is an abstract concept that is not easy to define. It is distinct from cognitive abilities, which are measured by standardized intelligence tests. Conceptualized as an especially well-developed form of common sense, wisdom cannot be taught. It comes from experience, insight, and having lived an examined life. People who are wise can discern truth and exercise good judgment. Problems that require wisdom for resolution typically involve multiple and unclear answers. Examples include making decisions about a career path, dealing with issues of mortality, and solving conflicts within families. People observed to have high levels of wisdom are adept at regulating their mood states. They still get angry, irritable, or depressed but are able to manage these states without shutting down or becoming overwhelmed by their emotions.⁴

Wisdom researchers have identified five components of wisdom.⁴ First, wisdom includes a general understanding of human nature. This is the possession of factual information about how people tend to respond, feel, and behave. The second component of wisdom is knowledge about dealing with life problems and being able to evaluate things in depth. Third, wisdom includes the ability to understand and appreciate the impact of the context that surrounds a situation. The fourth component deals with the possession of tolerance for individual and cultural differences. The fifth and final aspect of wisdom includes knowledge about handling uncertainty. The wise person has tolerance for ambiguity and a realization that “things inevitably get in the way” in decision making.⁴

Older people who score high in these wisdom attributes tend to perceive the past in a generally optimistic light. They have learned from their life experiences, from which they have acquired the ability to make sound decisions.⁴

The value of relationships

Social contact and connection with others is an essential human function that has direct and indirect effects on health and emotional well-being. Relationships serve as buffers against stress. Numerous studies have shown that stress negatively affects one’s immune system. This is of particular importance for the elderly because age brings on vulnerability to errors in immune response.⁵ Research also tells us that strong social relationships promote recovery from certain illnesses.⁶ Findings point to the direct impact that interpersonal connectedness has on physical and emotional health. In one study of elderly men, those who experienced emotional support and companionship were at lower risk for developing heart disease.⁶ Another investigation found people who had strong relationships to be at lower risk of dying after a myocardial infarction than those who lacked supportive relations. Death rates are higher among people who are socially isolated. The sheer number of relationships is not as important a factor as the quality of the relationship. The presence of a family member, for example, does not automatically imply a meaningful relationship.

Extensive research on gender differences suggests that the nature of relationships differs for men and women.⁵ Women tend to have more intimate connections. They benefit from having more positive feelings toward relationships. However, women also tend be negatively impacted by some relationships because their emotional investment in others’ concerns can lead to increased conflict and stress. For this reason, relationships for men sometimes can provide greater protection from stress.⁵ Fulfilling informal and formal human connections can both be healthful. Formal contacts that provide support may include a member of the clergy, a housekeeper, a visiting nurse, or a psychotherapist. Informal relations are family members and casual contacts, perhaps the grocery store clerk. For some elderly, close neighbors are a crucial source of informal support. Studies indicate that pets are a source of relational support. Elderly pet owners have been shown to be less depressed, better able to tolerate social isolation, and more active than those without pets.⁷

Relationship loss is common in late adulthood. Parents are deceased, and siblings and contemporaries begin to die. The opportunity for expression of sadness is critical for emotional healing; however, depression is not a normal state for the elderly.⁸ Consider Jane, who at 92 lives in a retirement home. She has no living siblings, has one remaining son out of three children, and has outlived two husbands. Notwithstanding these losses, she has a handful of meaningful friendships, is involved in her church, and is well-liked by the staff members.

Researchers who followed subjects from adolescence to old age in a large-scale qualitative study of adult development discovered valuable information about relationships and aging. Positive relationships at any age were found to correlate to satisfaction in old age. A satisfying marriage at age 50 predicted positive aging at 80. Contentment in later life was the outcome for subjects who had the ability to express gratitude and forgiveness in relationships. Overall, researchers determined that loving relationships promote personal growth and emotional healing.⁸ Successful aging also involves learning to play and be creative after retirement. This ability to adapt to situational and physical changes helps explain why some people age more successfully than others. Much of the difference between young and older groups is due to cohort effects. A cohort effect is the particular impact of a group bonded by a common life experience. For instance, those now in the 80th decade of life have the common experience of being children during the depression and adolescents during wartime, events that inevitably shaped who they are. Cohort groups are socialized into certain beliefs, attitudes, and abilities based on the time in history in which they live. Cohort refers to membership in a group as defined by a person’s birth year. These factors remain stable as the cohort ages. Twenty years from now, a cohort of elderly Americans will be different from the current group because of different historical experiences. For instance, older people 20 years from now will have more formal education than today’s cohort of elderly.⁸ The way healthcare providers interact with patients and conduct patient teaching will need to be modified for each new cohort.

Sexuality in later life

Elderly couples may have inaccurate assumptions about aging and sex. Nurses can sensitively present factual information to patients about the effects of aging, illness, and medications on sexual functioning. The likelihood of sexual activity during later life is related to how sexually active a person was during his or her younger years. Given an available partner, a person who was sexually active in younger years is likely to remain active into late adulthood. Men who have been sexually active generally can engage in some sort of sexual activity well into their 70s or 80s.⁹

Erectile dysfunction is the inability to produce an erection that is sufficient for intercourse. In order to have an erection, the man must be in a responsive state of mind and have normal hormone functioning, including adequate testosterone levels and penile blood supply. Most erectile problems are the result of illnesses that are more common among the elderly or medications taken to treat those illnesses. Hypertension, elevated cholesterol, diabetes, coronary artery disease, smoking, alcohol abuse, and medications (especially those used to treat hypertension and depression) all contribute to erectile dysfunction. Surgeries such as a radical prostatectomy also may cause erectile problems.⁹ Aging itself is not to blame. About 44% of men age 40 to 70 have partial or complete erectile dysfunction. Sildenafil citrate (Viagra) and other erectile dysfunction medications work for more than half of men who use them.⁹ Perhaps due to humiliation, shame, or the belief that there is no help, a man may not seek medical attention for sexual problems.

As a man enters late adulthood, more stimulation is needed for arousal. Erections occur less frequently but last longer. Ejaculations are delayed and less forceful, and unlike earlier in life, do not occur repeatedly. Semen volume is decreased, and sperm counts are lowered.⁹ Nurses can provide valuable information to older men and their partners about these often overlooked or minimized facts about male sexual functioning in later life.

Physiologically, women are able to be sexually active as long as they live. A woman who enjoyed sex in younger years is likely to want to continue.⁹ The major problem is often the lack of a partner. Women who had orgasms in their younger years will likely be able to do so well into their 80s or later.⁸ Sex, however, will be different later in life than it was during earlier periods. Orgasms tend to be shorter, and muscle contractions are fewer in number. With age, women may take longer to become sexually aroused. Decreased ovarian estrogen production after menopause is likely to create vaginal dryness, leading to painful intercourse. Older women may need information about lubricants to ameliorate this problem. Some aging women feel self-conscious about their appearance. As a woman ages, weight gain is common, as are changes in body shape due to redistribution of adipose tissue around the abdominal area.⁹ The nurse can be instrumental in respectfully helping the older woman who never had sex education learn about her body.

Referral to counseling may benefit some men and women. It offers the opportunity for discussion about feelings related to normal body changes and can help the individual feel more comfortable with and knowledgeable about his or her physical self. Do not think that because a couple is older, they are not interested in being sexual. Couples’ counseling or sex therapy may be helpful for some elderly couples. Sex therapy involves helping couples to communicate, explore sexual concerns and needs, and expand their sexual activities. Therapy may assist long-time elderly partners in exploring nonintercourse avenues of sexual expression. Gynecologists or urologists may refer to sex therapists, or patients can contact the American Association of Sexual Educators, Counselors and Therapists www.aasect.org.⁹

Sexual functioning in both sexes is likely to be enhanced by physical fitness. Partners who are in good physical condition are more likely to enjoy sex. They possess the energy requirements for intercourse. Pain from conditions such as arthritis or back ailments also can make sex less desirable.⁹

Cognitive changes

Cognition refers to the mental process by which knowledge is acquired. It involves perception, reasoning, attention, memory, and language. With age, some cognitive abilities remain intact or may even improve while others slowly decline. Overall, changes occur in a slow and gradual trajectory.¹⁰ Information on cognitive changes presented here is based on studies of averages from groups of elderly people. There is much variability among older people with regard to the degree of decline and specific area of functioning. A particular elderly person may function similarly to someone decades younger.¹⁰

Cognitive decline is believed to be related to functional and structural changes in the brain. As one ages, the brain atrophies. The number of neurons and the number of dendrites on each cell decrease. Cellular demyelination also occurs. These changes slow message transmission between cells. Dead nerve cells collect in brain tissue, causing plaques and tangles. Despite this picture of a seemingly deteriorating brain, sparing any illnesses, the majority of cognitive ability is retained as we age.¹⁰

Cognitive ability is commonly divided into two general areas: verbal and performance. Performance skills involve manipulation of objects. They tend to decline at a more rapid rate than verbal skills. Verbal abilities deal with language and remain relatively intact with age.¹⁰

The speed at which a person processes information gradually slows over the life span. Comprehension and production of speech becomes slightly slower over time. In some cases, diminished visual acuity and decreased auditory sensitivity may account for slowed processing.¹⁰

On tests that require complex functions, the elderly do not do as well as younger people. The elderly perform better when they are dealing with familiar tasks compared to new ones. When their ability is measured in everyday tasks, the elderly do better than in the laboratory. In some cases, older adults outperform younger adults when assessed in terms of everyday, real-world functioning.¹¹

Generally, attentional abilities decline with advancing age. Attention involves the complex mental processes of focusing, selecting, dividing, sustaining, and inhibiting. Driving a motor vehicle is a task requiring complex attention. Divided attention is required to drive the vehicle, monitor the dashboard, look at the road and road signs, and be aware of changes in engine sounds. Intersections can be particularly taxing on attentional abilities. Older adults typically do well on simple tasks requiring attention but show decreased ability when attentional tasks are complex—when attention is required to more than one source of information. For this reason and other considerations such as poor eyesight, many older adults run into difficulty driving, and some states require mandatory driver tests for individuals over age 70. However, cognitive changes vary considerably among older adults and many individuals in their seventh decade are safe drivers.¹²

Memory types

Memory is the ability to register, retain, and recall a wide range of information such as thoughts, sensations, experiences, and knowledge. Some aspects of memory remain relatively intact with age, whereas others decline.¹⁰ Short-term memory consists of two components called primary and working memory. Primary memory involves holding small amounts of information for a short time, such as remembering a new phone number long enough to write it down. Primary memory remains relatively intact with age. By contrast, working memory, which requires briefly holding and manipulating information, declines.¹⁰ For instance, this ability is required to repeat digits in reverse (e.g., 4, 9, 7 backward is 7, 9, 4).

Semantic memory is knowledge of facts and meanings of words. This type of memory does not require a reference to time. Generally, decline in semantic memory is negligible.¹⁰ The type of memory that deals with remembering how to perform a motor skill, such as riding a bicycle, is called procedural memory. Overall, decline in this area is minimal.¹⁰ Long-term, or episodic, memory is a unique form of recall because it deals with acquiring and retrieving information from a particular place at a certain time. Remembering what you had for breakfast today or what you did on your 21st birthday are examples of episodic memory. Episodic memory peaks in young adulthood, so it is not uncommon for the elderly to remember information from that period of their lives. Also, memories of experiences that have emotional impact, such as a wedding or what a person was doing when he or she learned of tragic news, are recalled more easily than those that are mundane. This phenomena of memory is called flashbulb memory.¹³

Long-term memory declines slowly over time.⁹ Memory problems associated with aging are likely due to difficulty with both encoding (registering the message into memory) and retrieval. Older adults are generally less precise in encoding new information, and retrieval is slowed.¹⁰ Overall, cognitive decline in the elderly is subtle and more evident in laboratory tests, in which the limits are tested beyond what is typically required for everyday functioning. Humans are remarkable in their ability to adapt and compensate for deficits. Evidence shows that cognitive training can conserve and improve memory, concentration, and problem solving.¹⁴ In the largest study of its kind, independent adults aged 65 to 94 who had no cognitive problems received training for two hours a week for five weeks on tasks related to everyday living. The intervention resulted in improvement in memory, concentration, and problem-solving skills. These findings hold the promise that training applied to specific tasks such as using medication and managing finances may benefit older adults.¹⁴ Doing crossword puzzles, reading, and playing chess are all cognitive activities that stimulate communication between brain cells that are involved in memory and cognition. Cognitive exercises should target tasks that are not done routinely. This will ensure that parts of the brain that aren’t regularly used get a workout.¹³

Good health habits can potentially reduce the risk of developing illnesses that cause cognitive impairment. There is scientific evidence that people who engage in regular exercise have a lower risk for Alzheimer’s disease.¹³ Encourage patients to stop smoking no matter what age they are. Provide patient education about a healthy balanced diet that includes sources of antioxidants and nutrients that protect against age-related deterioration and diseases.¹³ Adequate sleep is also vital for health. Educate patients that approximately eight hours of sleep is required, not optional, for maintaining cognitive functioning. Although insomnia becomes more common with age, due mostly to diseases that interfere with sleep, it is a misperception that less sleep is required later in life.¹⁵ Physical activity during the day promotes a good night’s sleep. Regular physical exercise that includes strength and balance exercises contributes to both emotional and physical health. Exercises that improve lower body strength and balance reduce the risk of falls. For exercises to help the elderly increase strength and improve balance go to http://nihseniorhealth.gov/exercise/balanceexercises/03.html.

Remind patients that simple life choices such as adequate sleep, exercise, activity, and diet starting at any age can potentially increase longevity and quality of life.