Life expectancy of people in the U.S. is at a record high of 77.9 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. About 25 million people in the U.S. are 65 years old and older. Since 1900, people in the U.S. have gained 30 more years of life. Advances in healthcare, medications, and medical devices play a major part in this longevity.¹ Many older adults now live active lives and are not necessarily sick old people. Incidentally, physical therapists’ (PT) contact with both ill and healthy elderly patients will continue to expand. Understanding the complexities of each elderly patient is crucial to good care. An in-depth understanding will foster patient relationships that benefit the patient and bring satisfaction to the PT.
 
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 lived. It is the number that designates years lived — the number we use when we are asked for the number of our birthdays. 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 by person and is determined by behavioral, biochemical, genetic, metabolic, as well as evolutionary factors. In many ways biological age is a more meaningful measurement. 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. Unlike other periods in life, much variability exists in biological age among the elderly. 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 and is the chronological age for retirement in the United States. However, 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 person 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 denotes the successful mastery of later life. The older person who has developed ego integrity generally claims no regrets about his or her life. Inner calm allows these people to accept comfortably their 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, the outcome is wisdom.³ Wisdom is an abstract concept that is not easy to define. It is distinct from cognitive abilities that 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 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 decisions about a career path, issues of mortality, and conflicts within families. People observed to have high levels of wisdom are adept at regulating their mood states. They still can become angry, irritable, or depressed, but they manage these states without shutting down or becoming overwhelmed by their emotions.⁴
 
Five components of wisdom have been identified by those who study it.⁴ One component 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 is an in-depth knowledge of how to deal with and evaluate life problems. Third, wisdom includes the ability to understand and appreciate the effect of the context that surrounds a situation. The fourth component deals with the possession of tolerance for people and cultural differences. The fifth and final aspect of wisdom includes knowing how to handle uncertainty. The wise person has tolerance for ambiguity and a realization that things inevitably impede decision making.⁴
 
Older people who score high in these wisdom attributes tend to perceive the past in an 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 show 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 effect that interpersonal connectedness has on physical and emotional health. In one study of elderly men, those with emotional support and companionship were at lower risk for heart disease. Another investigation found people who had strong relationships to be at lower risk of dying after a myocardial infarction than those with no supportive relations.⁶ The sheer number of relationships is not as important a factor as the quality of the relationship. For example, the presence of a family member does not automatically imply a meaningful relationship.⁵
 
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 more positive feelings toward relationships. However, women also tend to be negatively affected 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 PT, 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 are less depressed, better able to tolerate social isolation, and more active than those without pets.⁷
 
Relationship loss is common in late adulthood. Parents die and siblings and contemporaries begin to die. The opportunity to express sadness is critical for emotional healing; however, depression is not a normal state for the elderly.⁸ Consider 92-year-old Jane who 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 correlated 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 because of cohort effects. A cohort effect is the particular effect of a group bonded by a common life experience. For instance, those now in the eighth decade of life have the common experience of childhood during the depression and adolescence during wartime, events that inevitably shaped them. 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. In 20 years, a cohort of elderly people in the U.S. will be different from the present group because of different historical experiences. For example, in 20 years, the elderly 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. Physical therapists 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 relates 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. Sometimes external constraints prevent the elderly man or woman from sexual activity. In assisted-living facilities, the need for privacy is often overlooked. Well-meaning staff members who work with these clients may be in denial about the need for sexual intimacy for some in the latter stages of life. The idea of sexually expressive residents may create discomfort. As a result, sexual behavior in this setting often becomes viewed as inappropriate.
 
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. For a man to have an erection, he 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 common among the elderly or the medications that treat them. Hypertension, elevated cholesterol, diabetes, coronary artery disease, smoking, alcohol abuse, and medications (especially those that 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 from 40 to 70 years old have some level of erectile dysfunction. Sildenafil citrate (Viagra) and other erectile dysfunction medications work in more than 50% of men.⁹
 
As a man enters late adulthood, more stimulation is needed for arousal. Erections occur less frequently but last longer. Ejaculations are delayed, less forceful and, unlike earlier in life, do not occur repeatedly. Semen volume is decreased, and sperm counts are lowered.⁹ Physical therapists 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 have them well into their 80s or later.⁸ Sex, however, will be different later in life. 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 because of redistribution of adipose tissue around the abdominal area.⁹ The PT 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 people know and feel more comfortable about their physical selves. 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 Sexuality Educators, Counselors & Therapists.⁹
 
Sexual functioning 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 attention, language, memory, perception, and reasoning. 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 in this module is based on studies of averages from groups of the elderly. There is much variability among older people for the degree of decline and specific area of functioning. One elderly person may function similarly to someone decades younger.¹⁰
 
Cognitive decline relates 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 decreases. 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 during the life span. Comprehension and speech becomes slightly slower. 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 deal 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
 
In general, attentional abilities decline with advancing age. Attention involves the complex mental processes of dividing, focusing, inhibiting, selecting, and sustaining. 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 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 find it difficult to drive a car. Many states require eyesight examinations and written mandatory driver tests for people older than age 70. However, driving skills are often not re-tested. In fact, a road test is typically a one-time event, usually at age 16. The age-related declines in attention and reaction time, particularly after age 85 suggest the need for objective skills retesting later in life.¹²

Memory Types
 
Memory is the ability to register, retain, and recall a wide range of information, such as experiences, knowledge, sensations, and thoughts. Some aspects of memory remain relatively intact with age while others decline.¹⁰ Short-term memory consists of two components: primary and working. 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. Decline in semantic memory is usually 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 time in their lives. Also, memories of experiences that have an emotional effect, such as a wedding or what a person was doing when he or she learned of tragic news, are recalled more easily than mundane memories. This phenomena of memory is called flashbulb memory.¹³
 
Long-term memory declines slowly.⁹ Memory problems associated with aging are likely because of 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 typical requirements for everyday functioning. Humans are remarkable in their ability to adapt and compensate for deficits. Evidence shows that cognitive training can conserve and improve concentration, memory, and problem solving.¹⁴ In the largest study of its kind, independent adults from 65 to 94 years old with no cognitive problems received training for two hours a week for five weeks on tasks that relate to everyday living. The intervention resulted in improvement in concentration, memory, 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.¹⁵ 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 focus on non-routine tasks. This focus will ensure that parts of the brain that aren’t regularly used will have a workout.^13,14
 
Good health habits can potentially reduce the risk of 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 about eight hours of sleep is required, not optional, to maintain cognitive functioning. Although insomnia becomes more common with age, mostly from diseases that interfere with sleep, it is a misperception that less sleep is required later in life.¹⁶ 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. A description of exercises that help the elderly increase strength and improve balance are available on the NIH Senior Health Web site.
 
Remind patients that simple life choices like adequate sleep, exercise, activity, and diet begun at any age can potentially increase longevity and quality of life.
 
Important Considerations^10,11,13

• Don’t blame confusion on getting old. It is a reflection of some disease process. Refer the patient for evaluation.
• The elderly are not asexual. Sexual complaints are because of health or psychological problems, not aging.
• Refer the patient for a physical examination. Refer the depressed patient for evaluation and treatment. (Depression is not a normal part of aginAssist patient and primary caregiver in adapting strategies to compensate for cognitive decline. Consider use of checklists and medication administration boxes.
• Keep in mind that it may take longer for elderly patients to learn to operate medical and computerized equipment (performance skill). Slowness does not mean inability or unwillingness.
• Develop treatment and teaching plans for each patient. (Remember there are differences in cognitive decline for each patient.)
• Speak slowly.
• Give simple rather than complex commands.
• Educate about and encourage appropriate exercise and activity, preferably activities that involve interaction with others.
• Educate about the benefits of social connections. Explore possibilities for both informal and formal relations.

Gannett Education guarantees this educational activity is free from bias.