As human beings grow older, they go through different phases or stages of life. It is helpful to understand aging in the context of these phases. A life course is the period from birth to death, including a sequence of predictable life events such as physical maturation. Each phase comes with different responsibilities and expectations, which of course vary by individual and culture. Children love to play and learn, looking forward to becoming preteens. As preteens begin to test their independence, they are eager to become teenagers. Teenagers anticipate the promises and challenges of adulthood. Adults become focused on creating families, building careers, and experiencing the world as independent people. Finally, many adults look forward to old age as a wonderful time to enjoy life without as much pressure from work and family life. In old age, grandparenthood can provide many of the joys of parenthood without all the hard work that parenthood entails. And as work responsibilities abate, old age may be a time to explore hobbies and activities that there was no time for earlier in life. But for other people, old age is not a phase that they look forward to. Some people fear old age and do anything to “avoid” it by seeking medical and cosmetic fixes for the natural effects of age. These differing views on the life course are the result of the cultural values and norms into which people are socialized, but in most cultures, age is a master status influencing self-concept, as well as social roles and interactions.

Through the phases of the life course, dependence and independence levels change. At birth, newborns are dependent on caregivers for everything. As babies become toddlers and toddlers become adolescents and then teenagers, they assert their independence more and more. Gradually, children come to be considered adults, responsible for their own lives, although the point at which this occurs is widely varied among individuals, families, and cultures.

As Riley (1978) notes, aging is a lifelong process and entails maturation and change on physical, psychological, and social levels. Age, much like race, class, and gender, is a hierarchy in which some categories are more highly valued than others. For example, while many children look forward to gaining independence, Packer and Chasteen (2006) suggest that even in children, age prejudice leads to a negative view of aging. This, in turn, can lead to a widespread segregation between the old and the young at the institutional, societal, and cultural levels (Hagestad and Uhlenberg 2006).

Disease, injury, and other stress factors harm cells throughout our bodies. Ideally, the damaged cells are cleared by our immune systems through a process called apoptosis. But as we age, our bodies are no longer as effective at removing dysfunctional cells, and this can contribute to a weakened immune system and other less efficient biological processes.

An increasing number of researchers are exploring whether learning to harness a cellular state known as senescence — during which damaged cells resist removal by apoptosis, linger, and harm neighboring normal cells — might hold the key to revitalizing aging tissues and increasing healthy, active years of life.

What is cellular senescence?

Senescent cells are unique in that they eventually stop multiplying but don’t die off when they should. They instead remain and continue to release chemicals that can trigger inflammation. Like the one moldy piece of fruit that corrupts the entire bowl, a relatively small number of senescent cells can persist and spread inflammation that can damage neighboring cells.

However, not all senescent cells are bad. The molecules and compounds expressed by senescent cells (known as the senescent secretome) play important roles across the lifespan, including in embryonic development, childbirth, and wound healing.

How cellular senescence affects the body

The number of senescent cells in a person’s body increases with age. As the aging immune system becomes less efficient, senescent cells accumulate and taint healthy cells. This can affect a person’s ability to withstand stress or illness; recuperate from injuries; and learn new things, since senescent cells in the brain can degrade cognitive functions.

As a result, cellular senescence has been connected to a multitude of age-related conditions, including cancer, diabetes, osteoporosis, cardiovascular disease, stroke, Alzheimer’s disease and related dementias, and osteoarthritis. It has also been linked to declines in eyesight, mobility, and thinking ability. Investigations are underway to see if senescent skin cells may contribute to sagging and wrinkling, and if senescent cells might also be connected to the cytokine storm of inflammation that makes COVID-19 so deadly for older adults.

A scientific curiosity

Cellular senescence has been on scientists’ radar since the early 1960s when Leonard Hayflick, Ph.D., and his colleague Paul Moorhead, Ph.D., overturned the long-held scientific consensus that human cell samples could replicate endlessly in lab cultures. Hayflick and Moorhead showed that there was a limit on the number of division cycles, after which cells entered senescence.

For long after that finding, senescence was believed to be just an odd side effect of laboratory cell culture environments. It was poorly understood and studied by only a few research teams, but in the past 20 years, there has been a spike in interest. Today, it is a still young but promising scientific discipline that has sparked more NIH research as well as private industry support for studies to discover and develop drugs that might give Mother Nature a boost in clearing out senescent cells.

A pioneering pursuit to extend health span

Jim Kirkland, M.D., Ph.D., of the Mayo Clinic, and his former colleague Jan van Deursen, Ph.D., were pioneers of the senescence renaissance. For nearly two decades, Kirkland has studied ways to remove senescent cells. A clinical geriatrician, Kirkland often says he grew tired of prescribing the latest innovations in wheelchairs, walkers, or incontinence control. Instead, he wanted to learn if it was possible to slow down or partially reverse the fundamental aging processes in humans that lead to common health issues as we age.

Kirkland and his team currently focus primarily on a cocktail of two drugs: dasatinib (D), a drug commonly used in leukemia chemotherapy; and quercetin (Q), a pigment found in strawberries, grapes, tomatoes, red wine, onions, and other fruits and vegetables that has natural anti-inflammatory properties. When administered together, D&Q function as senolytics, i.e., drugs that clear out senescent cells.

In 2019 Kirkland and colleagues conducted a very small pilot study of D&Q in 14 volunteers who had idiopathic pulmonary fibrosis (IPF), a fatal, tough-to-treat, and debilitating lung disease. The results showed that the senolytic combination improved physical function in participants, demonstrating the feasibility of testing D&Q for this condition in larger controlled clinical trials. In subsequent small clinical trials, the Mayo Clinic team found that D&Q also cleared senescent cells in research participants with diabetic kidney disease.

In mouse models of IPF, D&Q was shown to clear senescent lung cells, reduce inflammation, and extend health span (the years of life free of major disease and disability), but not longevity. Researchers are currently exploring the potential of senolytics for osteoporosis, glaucoma, macular degeneration, diabetic neuropathy, and other age-related conditions.

Kirkland’s lab has shown that middle-aged mice given a variety of senolytics had delayed onset of several age-related ailments compared to untreated peers. Older mice given D&Q were faster, stronger, and spryer than control groups, and the positive effects lasted until the final months of their natural lifespans. Other studies showed that older mice given D&Q had a 36% longer average lifespan than untreated peers.

Kirkland’s team has also tested the opposite approach, by injecting healthy young or middle-aged mice with a customized senescent cell type. This intervention caused rapid deterioration in their mobility, speed, and strength, and big jumps in frailty rates. What’s more, these negative effects lingered long after the transplanted senescent cells had died off.

A long way to go before safe human use

While these studies pose exciting scientific and medical questions, Kirkland is adamant in underscoring the huge gap between mice and humans. He regularly urges people not to take senolytics or similar supplements or drugs outside of a clinical trial because they have not been confirmed as safe.

“We haven't so far seen serious or severe adverse events in clinical trials with some of these agents, but it doesn't mean they won't happen,” said Kirkland. “They could take a long time to develop, and anything that sounds too good to be true in mouse or cell culture models usually is. We need many more long-term studies and human trials.”

Kirkland, his Mayo colleague Tamar Tchkonia, Ph.D.; and Stefan Tullius, M.D., Ph.D., of Harvard University Medical School, are also looking at other potential benefits of taming senescence to rejuvenate older tissues. One such project is exploring whether treating kidneys or livers from older organ donors with senolytics prior to transplant could help repair the damage accumulated over time and with age. If true, this could make older organs more viable and safer for transplantation, and thus reduce waitlists.

Kirkland emphasized that there are many connections between senescence and age-related conditions, making the field ripe for future discoveries.

Growing interest nationwide

NIA-supported scientists working at NIH and throughout our nation continue to explore the mechanisms that regulate the intersection of senescence, inflammation, aging, and disease. Chronic inflammation seems to be a key to how senescence can turn from helpful to harmful. Healthy tissues normally have a limited type of senescence that suppresses abnormal cell growth that could lead to cancer. But when the healthy cell environment is disrupted by injury or age-related inflammation, this can trigger a loss of control of the body’s natural regulation of senescent cells, which may be linked to the development of cancer and other diseases.

Two top experts in the burgeoning field and frequent collaborators with Kirkland are University of Minnesota researchers Laura Niedernhofer, M.D., Ph.D., and Paul Robbins, Ph.D. Niedernhofer came to senescence from a background in DNA damage and repair.

“Senescence is fascinating to me because a damaged senescent cell can in turn cause damage in healthy cells,” she said, stating further that normal senescence can be helpful, as in wound healing, and that senescence itself is a potent tumor suppressor mechanism.

“Picture a wound on your arm. There is growing evidence that senescent cells may be critical for calling in immune cells to help heal that. But it's just a temporary thing to close that wound and then the signal should go away. The problem comes when you're not able to clear those senescent cells. They are great at spurring the immune system to action, but when your immune system falters as you get older, you get these chronic senescent cells.”

Robbins quipped about the inevitable rise in senescence as we age.

Senescence science collaboration across NIH

NIH-wide interest in how cellular senescence factors into multiple diseases and conditions is growing as well. The NIH Cellular Senescence Network (SenNet), organized by NIA and the National Cancer Institute, is an NIH Common Fund initiative to coordinate the exploration, identification, and cataloging of differences in senescent cells throughout the body. The network also supports research collaboration and data sharing that could lead to future therapeutics. Through SenNet, researchers aim to create a four-dimensional atlas of senescent cells involved in healthy human aging to find and characterize healthy and unhealthy senescent cells. This could inform investigations into how future senolytic therapies can be customized to only target harmful senescence.

Robbins, Niedernhofer, and their colleagues are energized by the future possibilities.

“Before you go in for surgery, you might want to clear your bad senescent cells to help you recover faster,” Robbins said. “Cancer radiation or chemotherapy treatment at a young age has been shown to drive senescence and aging, so there's a whole group of cancer survivors that may be very appropriate for this sort of treatment.”

Niedernhofer added that the senescence field has exploded since she and others described the first senolytic compounds in 2015.

Sorting out good senescence from bad

Other NIA-funded researchers, like Judy Campisi, Ph.D., of the Buck Institute, see senolytics as a potential routine treatment of the future that could help older adults stave off age-related illness and frailty longer, similar to a dental check-up. In the San Francisco Bay area where she lives, multiple public and private research institutions are looking into future medical applications for senolytics.

Campisi began her career focused on how senescence affected cancer. Eventually, she expanded her research into how it contributes to aging and age-related disease.

“We made a mouse model which allowed us to eliminate senescent cells throughout the lifespan, and it improved a lot of age-related diseases in mice,” she said. “Now the question is, could this happen in humans using senolytics? Well, it does in human cells and in certain human tissues.”

Campisi and her collaborators continue to investigate various aspects and mechanisms of senescence, including how it impacts osteoarthritis and sarcopenia (loss of muscle mass later in life that can lead to disability, frailty, and fall risk) and if senolytic treatments can help reduce the harmful side effects of chemotherapy and HIV/AIDS drugs.

Campisi concedes there are still many unanswered questions.

“We know there are good things senescent cells do in healing, tissue repair, embryonic development, and childbirth. But how are the good guys different from the bad guys? And is there a way we kill the bad guys and not the good guys? We honestly don't know that yet.”

Mapping senescence targets across the body

Myriam Gorospe, Ph.D., and her colleagues in NIA’s in-house labs are examining whether senolytics could tamp down harmful senescence in lab and mice models of Alzheimer’s disease linked to problems with thinking and cognition. They are hoping to map and manipulate senescence-related proteins that are involved with the buildup of beta-amyloid plaques and neuroinflammation, hallmarks of Alzheimer’s disease.

Gorospe’s lab is pursuing the quest for biomarkers — measurable substances in the body that indicate the presence of disease — to better pinpoint and target senescent cells in different types of tissue. Her team also works with senomorphics, a different category of drugs that don’t eliminate senescent cells, but instead repress their harmful secretions. They study senescence’s impact on aging body tissues like the lungs and muscles, and its role in conditions like arteriosclerosis and Alzheimer’s-related neurological decline.

Scientists are just beginning to take a closer look at the role senescence plays in one of the most serious public health crises in recent history, the COVID-19 global pandemic.

“Some of the biomarkers on the membrane of senescent cells function as receptors for the SARS-CoV viruses, so they're critical in understanding the acute pathology of COVID-19 infection,” said Gorospe.

Lessons learned from the pandemic could yield useful knowledge as the scientific community moves forward to someday testing if human use of senomorphics or senolytic treatments could help extend healthy lifespan and ward off disease.

Cautious optimism, support for a young science

In August 2019, NIA convened a workshop attended by academic, industry, and public health scientists to study if it was possible to safely repurpose some drugs or dietary supplements for their senolytic or senomorphic effects to treat or prevent age-related conditions. NIA and the broader NIH offer growing funding opportunities in the field through SenNet and other efforts. Currently, NIA supports a growing portfolio of extramural senescence research, coordinated by program officers including Viviana Perez Montes, Ph.D.

Perez Montes and her NIA colleagues agree the potential for harnessing senescence is vast but echo the cautions of Kirkland that this field is still very young, with a lot of work yet to be done, including building a common research infrastructure and safety standards for human studies.

Above all, it’s important to manage expectations for the public and the medical community that any safe potential health benefits from manipulating senescence will be years if not decades in the future.

“We have to remember that senolytics are going to kill senescent cells and we believe that some of those senescence functions could be beneficial,” said Perez Montes. “If you kill and eliminate cells that are not going to be replaced, we don’t know yet the biological and physiological consequences of this elimination, so we need to be extremely careful in future translational and clinical studies because we're still in the very early stages.”

In the early 1900s, a New York physician named Dr. Ignatz Nascher coined the term geriatrics, a medical specialty that focuses on the elderly. He created the word by combining two Greek words: geron (old man) and iatrikos (medical treatment). Nascher based his work on what he observed as a young medical student, when he saw many acutely ill elderly people who were diagnosed simply as “being old.” There was nothing medicine could do, his professors declared, about the syndrome of “old age.”

Nascher refused to accept this dismissive view, seeing it as medical neglect. He believed it was a doctor’s duty to prolong life and relieve suffering whenever possible. In 1914, he published his views in his book Geriatrics: The Diseases of Old Age and Their Treatment (Clarfield 1990). Nascher saw the practice of caring for the elderly as separate from the practice of caring for the young, just as pediatrics (caring for children) is different from caring for grown adults (Clarfield 1990).

Nascher had high hopes for his pioneering work. He wanted to treat the aging, especially those who were poor and had no one to care for them. Many of the elderly poor were sent to live in “almshouses,” or public old-age homes (Cole 1993). Conditions were often terrible in these almshouses, where the aging were often sent and just forgotten.

As hard as it might be to believe today, Nascher’s approach was once considered unique. At the time of his death, in 1944, he was disappointed that the field of geriatrics had not made greater strides. In what ways are the elderly better off today than they were before Nascher’s ideas gained acceptance?

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).

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.

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).

Aging “Out:” LGBT Seniors

How do different groups in our society experience the aging process? Are there any experiences that are universal, or do different populations have different experiences? An emerging field of study looks at how lesbian, gay, bisexual, and transgender (LGBT) people experience the aging process and how their experience differs from that of other groups or the dominant group. This issue is expanding with the aging of the baby boom generation; not only will aging boomers represent a huge bump in the general elderly population but also the number of LGBT seniors is expected to double by 2030 (Fredriksen-Goldsen et al. 2011).

A recent study titled The Aging and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults finds that LGBT older adults have higher rates of disability and depression than their heterosexual peers. They are also less likely to have a support system that might provide elder care: a partner and supportive children (Fredriksen-Goldsen et al. 2011). Even for those LGBT seniors who are partnered, some states do not recognize a legal relationship between two people of the same sex, which reduces their legal protection and financial options.

As they transition to assisted-living facilities, LGBT people have the added burden of “disclosure management:” the way they share their sexual and relationship identity. In one case study, a seventy-eight-year-old lesbian lived alone in a long-term care facility. She had been in a long-term relationship of thirty-two years and had been visibly active in the gay community earlier in her life. However, in the long-term care setting, she was much quieter about her sexual orientation. She “selectively disclosed” her sexual identity, feeling safer with anonymity and silence (Jenkins et al. 2010). A study from the National Senior Citizens Law Center reports that only 22 percent of LGBT older adults expect they could be open about their sexual orientation or gender identity in a long-term care facility. Even more telling is the finding that only 16 percent of non-LGBT older adults expected that LGBT people could be open with facility staff (National Senior Citizens Law Center 2011).

Same-sex marriage—a civil rights battleground that is being fought in many states—can have major implications for the way the LGBT community ages. With marriage comes the legal and financial protection afforded to opposite-sex couples, as well as less fear of exposure and a reduction in the need to “retreat to the closet” (Jenkins et al. 2010). Changes in this area are coming slowly, and in the meantime, advocates have many policy recommendations for how to improve the aging process for LGBT individuals. These recommendations include increasing federal research on LGBT elders, increasing (and enforcing existing) laws against discrimination, and amending the federal Family and Medical Leave Act to cover LGBT caregivers (Grant 2009).

Aging comes with many challenges. The loss of independence is one potential part of the process, as are diminished physical ability and age discrimination. The term senescence refers to the aging process, including biological, emotional, intellectual, social, and spiritual changes. This section discusses some of the challenges we encounter during this process.

As already observed, many older adults remain highly self-sufficient. Others require more care. Because the elderly typically no longer hold jobs, finances can be a challenge. And due to cultural misconceptions, older people can be targets of ridicule and stereotypes. The elderly face many challenges in later life, but they do not have to enter old age without dignity.

Poverty

For many people in the United States, growing older once meant living with less income. In 1960, almost 35 percent of the elderly existed on poverty-level incomes. A generation ago, the nation’s oldest populations had the highest risk of living in poverty.

At the start of the twenty-first century, the older population was putting an end to that trend. Among people over sixty-five years old, the poverty rate fell from 30 percent in 1967 to 9.7 percent in 2008, well below the national average of 13.2 percent (U.S. Census Bureau 2009). However, given the subsequent recession, which severely reduced the retirement savings of many while taxing public support systems, how are the elderly affected? According to the Kaiser Commission on Medicaid and the Uninsured, the national poverty rate among the elderly had risen to 14 percent by 2010 (Urban Institute and Kaiser Commission 2010).

Before the recession hit, what had changed to cause a reduction in poverty among the elderly? What social patterns contributed to the shift? For several decades, a greater number of women joined the workforce. More married couples earned double incomes during their working years and saved more money for their retirement. Private employers and governments began offering better retirement programs. By 1990, senior citizens reported earning 36 percent more income on average than they did in 1980; that was five times the rate of increase for people under age thirty-five (U.S. Census Bureau 2009).

In addition, many people were gaining access to better healthcare. New trends encouraged people to live more healthful lifestyles by placing an emphasis on exercise and nutrition. There was also greater access to information about the health risks of behaviors such as cigarette smoking, alcohol consumption, and drug use. Because they were healthier, many older people continue to work past the typical retirement age and provide more opportunity to save for retirement. Will these patterns return once the recession ends? Sociologists will be watching to see. In the meantime, they are realizing the immediate impact of the recession on elderly poverty.

During the recession, older people lost some of the financial advantages that they’d gained in the 1980s and 1990s. From October 2007 to October 2009 the values of retirement accounts for people over age fifty lost 18 percent of their value. The sharp decline in the stock market also forced many to delay their retirement (Administration on Aging 2009).

Ageism

Driving to the grocery store, Peter, twenty-three years old, got stuck behind a car on a four-lane main artery through his city’s business district. The speed limit was thirty-five miles per hour, and while most drivers sped along at forty to forty-five mph, the driver in front of him was going the minimum speed. Peter tapped on his horn. He tailgated the driver. Finally, Peter had a chance to pass the car. He glanced over. Sure enough, Peter thought, a gray-haired old man guilty of “DWE,” driving while elderly.

At the grocery store, Peter waited in the checkout line behind an older woman. She paid for her groceries, lifted her bags of food into her cart, and toddled toward the exit. Peter, guessing her to be about eighty years old, was reminded of his grandmother. He paid for his groceries and caught up with her.

“Can I help you with your cart?” he asked.

“No, thank you. I can get it myself,” she said and marched off toward her car.

Peter’s responses to both older people, the driver and the shopper, were prejudiced. In both cases, he made unfair assumptions. He assumed the driver drove cautiously simply because the man was a senior citizen, and he assumed the shopper needed help carrying her groceries just because she was an older woman.

Responses like Peter’s toward older people are fairly common. He didn’t intend to treat people differently based on personal or cultural biases, but he did. Ageism is discrimination (when someone acts on a prejudice) based on age. Dr. Robert Butler coined the term in 1968, noting that ageism exists in all cultures (Brownell). Ageist attitudes and biases based on stereotypes reduce elderly people to inferior or limited positions.

Ageism can vary in severity. Peter’s attitudes are probably seen as fairly mild, but relating to the elderly in ways that are patronizing can be offensive. When ageism is reflected in the workplace, in healthcare, and in assisted-living facilities, the effects of discrimination can be more severe. Ageism can make older people fear losing a job, feel dismissed by a doctor, or feel a lack of power and control in their daily living situations.

In early societies, the elderly were respected and revered. Many preindustrial societies observed gerontocracy, a type of social structure wherein the power is held by a society’s oldest members. In some countries today, the elderly still have influence and power and their vast knowledge is respected. Reverence for the elderly is still a part of some cultures, but it has changed in many places because of social factors.

In many modern nations, however, industrialization contributed to the diminished social standing of the elderly. Today wealth, power, and prestige are also held by those in younger age brackets. The average age of corporate executives was fifty-nine years old in 1980. In 2008, the average age had lowered to fifty-four years old (Stuart 2008). Some older members of the workforce felt threatened by this trend and grew concerned that younger employees in higher level positions would push them out of the job market. Rapid advancements in technology and media have required new skill sets that older members of the workforce are less likely to have.

Changes happened not only in the workplace but also at home. In agrarian societies, a married couple cared for their aging parents. The oldest members of the family contributed to the household by doing chores, cooking, and helping with child care. As economies shifted from agrarian to industrial, younger generations moved to cities to work in factories. The elderly began to be seen as an expensive burden. They did not have the strength and stamina to work outside the home. What began during industrialization, a trend toward older people living apart from their grown children, has become commonplace.

Mistreatment and Abuse

Mistreatment and abuse of the elderly is a major social problem. As expected, with the biology of aging, the elderly sometimes become physically frail. This frailty renders them dependent on others for care—sometimes for small needs like household tasks, and sometimes for assistance with basic functions like eating and toileting. Unlike a child, who also is dependent on another for care, an elder is an adult with a lifetime of experience, knowledge, and opinions—a more fully developed person. This makes the care-providing situation more complex.

Elder abuse occurs when a caretaker intentionally deprives an older person of care or harms the person in his or her charge. Caregivers may be family members, relatives, friends, health professionals, or employees of senior housing or nursing care. The elderly may be subject to many different types of abuse.

In a 2009 study on the topic led by Dr. Ron Acierno, the team of researchers identified five major categories of elder abuse: 1) physical abuse, such as hitting or shaking, 2) sexual abuse, including rape and coerced nudity, 3) psychological or emotional abuse, such as verbal harassment or humiliation, 4) neglect or failure to provide adequate care, and 5) financial abuse or exploitation (Acierno 2010).

The National Center on Elder Abuse (NCEA), a division of the U.S. Administration on Aging, also identifies abandonment and self-neglect as types of abuse. Table below shows some of the signs and symptoms that the NCEA encourages people to notice.

Signs of Elder Abuse The National Center on Elder Abuse encourages people to watch for these signs of mistreatment. (Chart courtesy of National Center on Elder Abuse)

How prevalent is elder abuse? Two recent U.S. studies found that roughly one in ten elderly people surveyed had suffered at least one form of elder abuse. Some social researchers believe elder abuse is underreported and that the number may be higher. The risk of abuse also increases in people with health issues such as dementia (Kohn and Verhoek-Oftedahl 2011). Older women were found to be victims of verbal abuse more often than their male counterparts.

In Acierno’s study, which included a sample of 5,777 respondents age sixty and older, 5.2 percent of respondents reported financial abuse, 5.1 percent said they’d been neglected, and 4.6 endured emotional abuse (Acierno 2010). The prevalence of physical and sexual abuse was lower at 1.6 and 0.6 percent, respectively (Acierno 2010).

Other studies have focused on the caregivers to the elderly in an attempt to discover the causes of elder abuse. Researchers identified factors that increased the likelihood of caregivers perpetrating abuse against those in their care. Those factors include inexperience, having other demands such as jobs (for those who weren’t professionally employed as caregivers), caring for children, living full-time with the dependent elder, and experiencing high stress, isolation, and lack of support (Kohn and Verhoek-Oftedahl 2011).

A history of depression in the caregiver was also found to increase the likelihood of elder abuse. Neglect was more likely when care was provided by paid caregivers. Many of the caregivers who physically abused elders were themselves abused—in many cases, when they were children. Family members with some sort of dependency on the elder in their care were more likely to physically abuse that elder. For example, an adult child caring for an elderly parent while at the same time depending on some form of income from that parent, is considered more likely to perpetrate physical abuse (Kohn and Verhoek-Oftedahl 2011).

A survey in Florida found that 60.1 percent of caregivers reported verbal aggression as a style of conflict resolution. Paid caregivers in nursing homes were at a high risk of becoming abusive if they had low job satisfaction, treated the elderly like children, or felt burnt out (Kohn and Verhoek-Oftedahl 2011). Caregivers who tended to be verbally abusive were found to have had less training, lower education, and higher likelihood of depression or other psychiatric disorders. Based on the results of these studies, many housing facilities for seniors have increased their screening procedures for caregiver applicants.

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.