An Introduction to Gerontology, 1st Edition

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AN INTRODUCTION TO

Gerontology
Edited by
Ian Stuart-Hamilton
CAMBRIDGE UNIVERSITY PRESS
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c Cambridge University Press 2011

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permission of Cambridge University Press.

First published 2011

Printed in the United Kingdom at the University Press, Cambridge

A catalogue record for this publication is available from the British Library

Library of Congress Cataloguing in Publication data

An introduction to gerontology / edited by Ian Stuart-Hamilton.
p. cm.
Includes bibliographical references and index.
ISBN 978-0-521-51330-2
1. Gerontology. I. Stuart-Hamilton, Ian. II. Title.
HQ1061.I5558 2011
305.26 – dc22 2011003321

ISBN 978-0-521-51330-2 Hardback

ISBN 978-0-521-73495-0 Paperback

Cambridge University Press has no responsibility for the persistence or

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 Contents

List of figures page vii

List of tables viii
List of contributors x

1 Introduction 1
Ian Stuart-Hamilton

2 The biology of ageing: a primer 21

João Pedro de Magalhães

3 Fostering resilience, promoting health and preventing

disease in older adults 48
Sharon Ostwald and Carmel Dyer

4 Ageing and health: managing co-morbidities and functional

disability in older people 87
Carmel Dyer and Sharon Ostwald

5 Social care and older people 126

Raymond Ngan

6 Cognitive processes and ageing 159

Paul Verhaeghen

7 The psychology of atypical ageing 194

Bob Woods

8 Sociological perspectives on ageing 226

Kate Davidson
vi Contents

9 Retirement 251
Lynn McDonald

10 Sexuality and ageing 283

Rebecca Flyckt and Sheryl A. Kingsberg

11 Policies on ageing 317

Suzanne Wait

12 Cross-cultural differences in ageing 340

Sandra Torres

13 Technology and ageing 363

Anthea Tinker

14 Literary portrayals of ageing 389

Diana Wallace

15 Palliative care for older adults 416

Lynn O’Neill and Sean Morrison

16 Conclusions 430
Ian Stuart-Hamilton

Index 438
 Figures

2.1 Prevalence of selected chronic conditions as a function of age.

Values are expressed in percentage for the US population
(2002–03 data set). page 23
2.2 Mortality rates as a function of age. Values are expressed in
deaths per 100,000 people, plotted on a logarithmic scale, for
the 2002 US population. 23
3.1 Projections of disabled population aged 65+ years based on
actual disability figures for 1982–96 in the USA. 53
3.2 Prevalence of risk factors and health behaviours varies by
disability status among older adults aged 65 or older. 57
3.3 Determinants of active ageing. 62
3.4 Percentage of adults 60 years of age and over meeting the
dietary recommendations for the Healthy Eating Index
components: USA, 1999–2002. 67
3.5 Force-field analysis of restraining and driving factors that
influence an older spousal caregiver’s decision to engage in
health-promoting behaviours. 75
5.1 Differences between the formal and informal care sectors. 130
5.2 Types of informal social support. 131
5.3 The caring dilemma. 137
5.4 A tiered model of service provision. 140
5.5 Social health and social capital. 142
5.6 The Personal Wellbeing Index (PWI) and subjective well-being. 145
5.7 Personal Wellbeing Index: all domains must contribute unique
variance. 145
5.8 Pathways of interweaving formal and informal care. 150
6.1 Distribution of autobiographical memories over the lifespan. 172
6.2 Longitudinal changes in volume in the frontal cortex. 179
8.1 Life expectancy from birth 1986–2008, UK. 229
10.1 Cross-section of the penis. 288
13.1 Gerontechnology impact matrix. 365
 Tables

1.1 Life expectancy of individuals born in 1400, 1841, 1981 and

2009 in the UK page 7
2.1 Diversity of mammalian life histories obtained from the AnAge
database 26
2.2 Genes associated with ageing and/or longevity per model
organism 31
3.1 Recommendations for screening and preventive care based on
functional level and life expectancy 59
3.2 Recommendations for food-based dietary guidelines that
recognize the interactions between food and health within a
social and cultural context 70
4.1 Overview of the comprehensive geriatric assessment 90
4.2 Selected depression-screening approaches 93
4.3 Triggers for IADL 94
4.4 Types of dementia 97
4.5 Methods of treatment for dementia-associated behavioural
problems 105
4.6 Forensic markers 114
8.1 Population projections by legal marital status 2007–31
(percentages) 230
10.1 Changes in female sexual physiology with ageing 291
10.2 Medical conditions known to be related to sexual dysfunction 293
10.3 Medications known to have sexual side effects 295
11.1 Objectives arising from the recommendations for action from
the Madrid International Plan of Action on Ageing, 2002 320
13.1 Percentage of total population aged 60 and over in 2006 and
projections for 2050 367
13.2 Percentage of population aged 80 and over as a percentage of
all aged 60 and over in 2006 and projections for 2050 368
 List of tables ix

13.3 Potential support ratio in 2006 and projections for 2050 369
13.4 Where people aged 65 and over live 375
13.5 Percentages of people aged 65 and over unable to manage
certain tasks without help, 1998–9 379
15.1 Tenets of palliative care 418
Contributors

Kate Davidson, University of Surrey

Carmel Dyer, University of Texas at Houston

Rebecca Flyckt, University Hospitals of Cleveland, Case Medical Center;

MacDonald Women’s Hospital, Cleveland

Sheryl A. Kingsberg, University Hospitals of Cleveland, Case Medical Center;

MacDonald Women’s Hospital, Cleveland
João Pedro de Magalhães, University of Liverpool

Lynn McDonald, University of Toronto

Sean Morrison, Mount Sinai School of Medicine, New York

Raymond Ngan, City University of Hong Kong

Lynn O’Neill, Mount Sinai School of Medicine, New York

Sharon Ostwald, University of Texas at Houston

Ian Stuart-Hamilton, University of Glamorgan

Anthea Tinker, King’s College London

Sandra Torres, University of Uppsala

Paul Verhaeghen, Georgia Institute of Technology

Suzanne Wait, University College London

Diana Wallace, University of Glamorgan

Bob Woods, Bangor University
1 Introduction
IAN STUART-HAMILTON

OVERVIEW
..........................................................
This chapter introduces some general concepts of ageing. First,
it presents different views of what ‘ageing’ is and when ‘old age’
begins. Second, it examines changes in life expectancy and the
proportion of the population that is old. Third, it considers attitudes
to ageing. The final section outlines the structure of the rest of the
book and its rationale.
..........................................................

Different views of later life

Gerontology is the study of old age and ageing. Although everyone
has an intuitive sense of what ‘old age’ and ‘ageing’ are, providing a
watertight objective definition is surprisingly difficult. Ageing could be
said simply to be the process of growing older. However, pedantically
speaking, we are all ageing from the moment of conception: do we
really wish to say that children are ‘ageing’? Hence, ageing is more
sensibly described as change within old age or change that affects
older people. It can thus include processes that started in earlier life
but only manifest themselves in old age (e.g. a cardiovascular problem
that appears in a person’s sixties resulting from a poor lifestyle choice
in that person’s twenties). However, this begs the question of how
to define ‘old age’. At first the issue seems a simple one. Putting
the niceties of political correctness to one side for a moment, it is
intuitively obvious that most people in their seventies and teens look
2 Ian Stuart-Hamilton

radically different and this is reflected in measures of fitness and health. Arguing
for a distinction between older and younger people is thus reasonable. However,
this raises a problem: namely, when do we decide that ‘old age’ begins? If we
want a single ‘threshold age’ that marks the transition to becoming ‘elderly’, then
this inevitably creates problems of inclusion and exclusion. For example, suppose
we choose 70 years of age as marking the onset of old age. A high proportion
of people aged 70 and older have the stereotypical characteristics of being ‘old’,
but not all do. And there are many people younger than 70 who have ‘elderly’
characteristics. If we choose an onset age younger than 70, we are likely to include
more people who lack many elderly characteristics, while choosing an older onset
age will lessen this problem but increase the risk of overlooking individuals who
became ‘old’ many years earlier.
This type of problem is sometimes likened to grading the colours of the rainbow.
It is obvious that a rainbow contains bands of red, orange, yellow, green, blue,
indigo and violet. It is equally obvious that when examined closely, these bands are
not distinct but merge one into another. For example, there is no clear demarcation
line between red and orange; instead, the red gradually changes into orange.
At what point on the rainbow do we say that anything to one side is red and
anything to the other is orange? The simple fact is that any demarcation line is
essentially arbitrary; we have no really objective means of justifying the boundary,
but for the sake of simplicity, a boundary is nonetheless created. This leads some
commentators to argue that because a demarcation line is arbitrary, the entire
categorization into distinct groups is wrong. However, this misses the point that
although the boundaries between groups might be blurred, the groups are clear
enough. Hence, even if the boundary between red and orange in a rainbow might
be artificially created, nobody denies that there are distinct bands of red and
orange. In a similar manner, although any threshold age marking off old age from
younger ages may be arbitrary, it would be foolish in the extreme and serve no
practical purpose to deny significant differences between older and younger adults
in many respects. However, to return to the original question – how do we decide
on what the threshold age is?
It would be possible to spend many pages of increasingly navel-gazing discus-
sion over how to decide on a value for the threshold age. However, this would
serve to do little other than obfuscate the issue. Falling on custom and practice, we
can state that old age is defined as the final segment of the lifespan, and for those
who must have a number to attach to this, it is further defined as beginning at
around 60 years of age. Different gerontologists have different threshold ages for
the onset, but 60 is a reasonable compromise figure. In fact, it has been accepted
by the mainstream literature for nearly 200 years. The nineteenth-century Belgian
statistician Adolphe Quetelet wrote a book called Sur l’homme et le développement
de ses facultés, ou, Essai de physique sociale (Quetelet, 1836; the English translation
 Introduction 3

has the more succinct title Treatise on Man). This was the first appreciable statisti-
cal study of human characteristics, and was hugely influential. Of especial interest
here is that Quetelet defined the onset of old age as being at 60. This was because
in his view, from ‘sixty to sixty-five years of age viability loses much of its energy,
that is to say, the probability of life then becomes very small’ (Quetelet, p. 178).
Once this threshold age had been thus decreed, later researchers tended to take this
as an established fact and hence nearly all research from the 1840s onwards has
tended to see old age as beginning at around the age of 60 (Mullan, 2002). This
in turn influenced the concept of ‘pensionable age’: it is salient to remember that
state pensions and the concept of retirement age are largely the invention of the
late nineteenth century. Prior to this time, although ‘old age’ was identified (e.g.
by exemption from payment of certain types of tax), the idea of there being an
age after which one was occupied in nothing but leisure activities and ‘growing
old’ would for nearly everybody have been an alien concept (Thane, 2000).
Thus, the concept of old age beginning at 60 (or thereabouts) might be seen as a
nineteenth-century invention. Is this for the good or the bad? It is perfectly possible
to argue that by having a threshold age, we lose sight of the fact that ageing is part
of a continuum. We don’t become ‘old’ overnight when we reach 60 – what we are
in later life, is, as shall be seen in many of the later chapters, to a significant degree
a product of what we were when younger. Similarly, having a boundary that states
‘on this side you’re young, on that side you’re old’ oversimplifies things and tends
to label people as stereotypically old at the expense of their individuality. This in
turn can lead to bad policy decisions (see Mullan, 2002). However, this is not the
fault of having a threshold age per se. In addition, Quetelet was certainly wrong
in arguing that the early sixties were a time of major decay – a quick perusal of
Chapters 2 through 4 should establish that. Again, it can be questioned why the
threshold age has remained so static since Quetelet’s day – is what was considered
‘old’ in the early nineteenth century really the same as today? This leads some
sociologists to question whether maintaining the threshold age is really in the
interests of various authority groups (e.g. politicians) who can manipulate the
concept of age categories and what is expected of each age group for their own
purposes (e.g. Bourdelais, 1998). But nonetheless, it is useful, if only for pragmatic
reasons, to have a threshold age. Provided this is employed loosely and individual
variability is borne in mind, it is a useful conceptual tool. And since the established
practice is to use the age of 60 (or thereabouts), this will be used here to maintain
parity with earlier studies.
Having examined the bare-bones definitions of ageing and old age, we need
to turn to general attitudes towards ageing. Do we see it primarily as positive or
negative? Is it something that we wish to alter or are we satisfied to leave it as it
is and simply act as neutral observers? For many researchers, it has been almost
overwhelmingly tempting to see gerontology’s subject matter purely in terms of
4 Ian Stuart-Hamilton

decay, as in Peter Medawar’s definition of ageing as the accumulation of changes

that increase the probability of death (Medawar, 1952). More pithily making the
same point, the character of Mr Bernstein in Citizen Kane describes old age as
‘the only disease . . . that you don’t look forward to being cured of’ (Mankiewicz
and Welles, 1941). Again, there are numerous examples in art and fiction of old
age treated as a punishment. For example, anyone taking a guided tour of the
Accademia in Venice is likely to be told the (possibly apocryphal) story behind
the painting of Giorgione’s La Vecchia (‘The Old Woman’), an imposing portrait
of an elderly woman in simple garb with wrinkled skin, thinning hair and signs
of having suffered a stroke (and possibly dementia) clutching a scrap of paper on
which is written col tempo (‘with age’). Supposedly the painting was done as a
riposte to a young woman who had spurned Giorgione’s advances – in revenge he
painted her as she would appear in extreme old age.
From this perspective, old age is a punishment, a time of waiting for inevitable
death, the only uncertainty being when it will occur. This is in marked contrast
to another, much older, set of views of ageing as a reward. For example, the
antediluvian ageing myth argues that in the distant past people were rewarded for
their great virtue by being given extremely long lifespans (cf. some of the early
persons mentioned in the Bible, culminating in Methuselah, who lived to the tender
age of 969 years). In contrast, the Hyperborean ageing myth states that there is a
distant land where people live to very old age because of their virtuous lives. To
some readers this may conjure thoughts of Shangri-La, a lamasery in the Himalayas
containing improbably ancient monks, featured in the novel Lost Horizon (Hilton,
1933). A rather older legend is that of Prester John, whom Middle Ages Europe
believed to be ruler of a distant Christian kingdom somewhere in Asia (or Africa –
medieval knowledge was often sketchy on this point). He, too, supposedly lived
an exceedingly long life, and his kingdom was a Christian paradise on Earth.
A further myth is that of the fountain of youth, where imbibing at a magical
spring or fountain or eating a special foodstuff confers long life, rejuvenation
and/or immortality. We see this in numerous myths, from the apples tended by the
goddess Idunn that kept the Norse gods immortal and healthy, through to such
modern candy floss as Star Trek: Insurrection. Strictly speaking, Shangri-La also
belongs in this category, since it is the food and water that hold the life-lengthening
properties, not the place itself (Weil, 2005).
Although these myths are undeniably false, they indicate a deeply held wish of
humankind to live long lives since they have been perpetuated across millennia
and many very different cultures. How do we square this with the rather gloomier
views of ageing as a time of waiting for inevitable death? If we take a closer look at
the pro-ageing myths we can see that in fact they want old age, but not old age at
any price. This is neatly illustrated by the ancient Greek myth of Tithonus, whose
lover, Eos (goddess of the dawn), asked the gods for immortality without adding
 Introduction 5

the caveat of wanting eternal youth as well. The gods, with their characteristically
twisted sense of humour, duly gave Tithonus eternal life in that he was allowed
to age for all eternity. This was seen as a dreadful fate and neatly illustrates
that the wish for long life is for a long physically and mentally active life, not
extreme old age just for the sake of it. The point is further amplified by Ovid’s tale
of Philemon and Baucis, a married couple who showed hospitality to Zeus and
Hermes disguised as peasants when other members of their village had shunned
them. As a reward, while the gods destroyed the rest of the village, Philemon and
Baucis were spared and their humble home transformed into a temple. Of interest
is that when Philemon and Baucis were granted long lives by the gods, they added
a request that when one of them died, the other would die as well. So not only was
a long active life seen as desirable, but also one free of grief for loss of a partner.
Thus, at the root of the various views of ageing is a clear message – give us long
life, but without paying the price of suffering. This concept is more neatly expressed
by Dewey’s paradox of ageing. John Dewey, a philosopher and psychologist, wrote
in the introduction to a colleague’s textbook that ‘we are . . . in the unpleasant and
illogical condition of extolling maturity and depreciating age’ (Dewey, 1939, p. iv).
While the textbook has been forgotten, this phrase has remained a touchstone for
the curious doublethink attitude we possess to ageing and old age. On the one hand
it is a reward to be enjoyed, but if anything goes wrong, then it is a punishment.
Gerontology thus finds itself in a position of providing two sorts of answer –
what the process of ageing is and how to make it as enjoyable as possible (what
might be termed the ‘explain’ and ‘improve’ goals). First, let us consider providing
factual information on what old age and ageing actually are. Into this category fall
topics such as what happens to the ageing body, what policy decisions have been
made about the welfare of older adults, and what artistic portrayals have been made
of ageing and old age. These are not mere exercises in cataloguing – many models
of ageing have generated vigorous debates and the area is far from theoretically
dull. It also has a practical purpose, since measures of the incidence of disability in
later life and similar are essential if adequate governmental planning for welfare
provision is to be made in advance of an increasingly older adult population. The
second type of answer concerns how we can alleviate the problems of later life
so that it conforms as far as possible to the ideal of a pain and trouble-free old
age. As noted in Chapter 2, many people fear that gerontologists simply want to
prolong life at the expense of comfort and dignity. This is often called the Tithonus
myth and nothing could be further from the truth. Gerontology is not and never
has been about prolonging life at all costs.
So far in this chapter we have examined contrasting views of what ageing
and old age are, and seen that the study of these topics is multidisciplinary and
needs to be. But this does not necessarily explain why these studies are important.
At a time of economic stringency, why should there be an imperative to study
6 Ian Stuart-Hamilton

gerontology? The argument that it will help us to understand ourselves, while

philosophically sound, is unlikely to impress those holding research funds debating
whether funding the study of ageing really is more important than, for example,
training more engineers or nurses. And the simple truth is that until recent times,
gerontology was an academic backwater. Older people formed a minor proportion
of the population, there were adequate funds to provide state pensions, and medical
and nursing care largely consisted of palliative measures since, because older
people by definition were going to die soon, there was little point in investing
great energy into finding remedies for many of their ills. But all this was before
the so-called greying population. Older people now form a significant proportion
of the population, they are a potent economic force, and they are living longer,
necessitating serious thinking about pension provision and methods of care for a
group of people who can in the main expect to live for 20 years after their official
retirement age. Gerontologists need to be heard because they are dealing with a
significant part of the population. Not only that, but also they are dealing with a
part of the lifespan that a majority of us can expect to experience, rather than the
minority of a few decades ago. To explain this argument, we will need to examine
population statistics.

Population trends
Let us begin by examining life expectancy. This is generally defined as the average
time a person can expect to live. Let us start by examining what this figure
means in industrialized countries with developed economies. According to the UK
Office for National Statistics (www.statistics.gov.uk, accessed 29 June 2009), the
life expectancy for a British boy born in 2009 is 78.3 years, and for a baby girl is
82.1 years. Women live longer than men and the reasons for this are explored in
Chapter 3 (although there are suggestions the gender gap is narrowing, for which
see Chapter 8). A quick perusal of the Organization for Economic Co-operation and
Development (OECD) website (www.oecd.org/topicstatsportal) will reveal a similar
figure for any other industrialized country. Life expectancy figures were lower in
the historical past, as illustrated in Table 1.1.
In the interests of balance, it should be noted that prior to modern records, it is
impossible to find totally reliable population data, but through various ingenious
techniques it is possible to make a good approximation of life expectancy figures
(see Acsadi and Nemeskeri, 1970) and it is these that are used here. But even
allowing for measurement error, what becomes immediately apparent on looking
at Table 1.1 is the vast gulf in life expectancy figures between then and now. For
example, life expectancy at birth has more than doubled since 1400, and even in
1841, life expectancy was 38 years less than it is today. This increase in expectancy