Journal of Gerontological Nursing

AGING: Birth of an Individual

John Lantz

Abstract

Twentieth-century health care has reached a level of enlightenment never attained before. Consequently, a life expectancy of 71 to 74 now prevails in modern civilized countries. In the United States, for example, the population of aged persons has risen from four percent in 1900 to nine percent today-35 percent of those over 65 being more than 75 years of age.1

This shift in populat ion age distribution has created a problem since normal and abnormal aging are largely indistinguishable by present day methods of measurement. Those who are involved in the delivery of health care are not only concerned with medically diagnosed conditions, but also with assisting the individual with the maintenance of health, the promotion of wellness, and the prevention of illness and disability. A major challenge for the health care worker is to develop an assessment of the older person considering the capabilities and resources.2

It would be fallacious to say an aged person is the same as he was when he was younger because numerous changes occur in a person's body, as well as in his world, as he ages. Actually, as people age throughout life, they become increasingly more unique and individual. This individuality is most apparent when people are "freed" from very restrictive life tasks as rearing children and earning a living. If we are to have a true picture of the aged person's functional capacity, several factors must be taken into account.

The factors to be considered in the assessment of mature adults may be broken down into three major categories: biological, psychological, and sociological. It is important to remember in this breakdown that all three categories are of equal importance and value. All three are interwoven and interrelated. They join together to make the mature individual a unique and "holistic" person, someone who many times is equal to more than the sum of these parts.

The biological aspect includes those observable changes which occur, more or less consistently, from individual to individual, with advancing time. Although no theory exists for why these changes occur, it is believed the process is related to the following theories:

A. The genetic basis for aging in terms óf:

1. Cessation of growth and the failure to replace cells as I hey are destroyed or "die off."

2. Gradual failure of production of a juvenescent or growth substance.

3. Increasing production of an aging factor or hormone.

4. Depletion of essential cell or tissue components necessary for the maintenance of normal structure and function or errors in the function of cellular components.

5. Accumulation within cells or tissue of substances which may be chemically or mechanically harmful.

These are events which can be termed genetically programmed; that is, they may occur progressively and inexorably as time progresses in the life of the organism, more or less independently of the environment.

B. The extrinsic or envionmental factors which may contribute to or accelerate aging, such as:

1. Disease in its broadest sense including bacterial, fungal, animal parasite, and viral infections.

2. Physical trauma or injury including mechanical, chemical, and thermal changes.

3. Radiation effects of a cumulative and dramatic nature.

4. The adverse influences of other animals, in the case of man, his interaction with other human beings.3

The biological changes which occur are most often multiple and variations frequently occur within one individual. This makes it necessary for the health care worker to consider each organ system and those changes and alterations which may occur.

Changes in the structural integrity of the client are the first which might be noticed. These changes occur basically because of a decrease…

Twentieth-century health care has reached a level of enlightenment never attained before. Consequently, a life expectancy of 71 to 74 now prevails in modern civilized countries. In the United States, for example, the population of aged persons has risen from four percent in 1900 to nine percent today-35 percent of those over 65 being more than 75 years of age.1

This shift in populat ion age distribution has created a problem since normal and abnormal aging are largely indistinguishable by present day methods of measurement. Those who are involved in the delivery of health care are not only concerned with medically diagnosed conditions, but also with assisting the individual with the maintenance of health, the promotion of wellness, and the prevention of illness and disability. A major challenge for the health care worker is to develop an assessment of the older person considering the capabilities and resources.2

It would be fallacious to say an aged person is the same as he was when he was younger because numerous changes occur in a person's body, as well as in his world, as he ages. Actually, as people age throughout life, they become increasingly more unique and individual. This individuality is most apparent when people are "freed" from very restrictive life tasks as rearing children and earning a living. If we are to have a true picture of the aged person's functional capacity, several factors must be taken into account.

The factors to be considered in the assessment of mature adults may be broken down into three major categories: biological, psychological, and sociological. It is important to remember in this breakdown that all three categories are of equal importance and value. All three are interwoven and interrelated. They join together to make the mature individual a unique and "holistic" person, someone who many times is equal to more than the sum of these parts.

The biological aspect includes those observable changes which occur, more or less consistently, from individual to individual, with advancing time. Although no theory exists for why these changes occur, it is believed the process is related to the following theories:

A. The genetic basis for aging in terms óf:

1. Cessation of growth and the failure to replace cells as I hey are destroyed or "die off."

2. Gradual failure of production of a juvenescent or growth substance.

3. Increasing production of an aging factor or hormone.

4. Depletion of essential cell or tissue components necessary for the maintenance of normal structure and function or errors in the function of cellular components.

5. Accumulation within cells or tissue of substances which may be chemically or mechanically harmful.

These are events which can be termed genetically programmed; that is, they may occur progressively and inexorably as time progresses in the life of the organism, more or less independently of the environment.

B. The extrinsic or envionmental factors which may contribute to or accelerate aging, such as:

1. Disease in its broadest sense including bacterial, fungal, animal parasite, and viral infections.

2. Physical trauma or injury including mechanical, chemical, and thermal changes.

3. Radiation effects of a cumulative and dramatic nature.

4. The adverse influences of other animals, in the case of man, his interaction with other human beings.3

The biological changes which occur are most often multiple and variations frequently occur within one individual. This makes it necessary for the health care worker to consider each organ system and those changes and alterations which may occur.

Changes in the structural integrity of the client are the first which might be noticed. These changes occur basically because of a decrease in the elasticity of tissues and a diminished ability to function. In addition to these changes a replacement of the contractile fibers in the muscles occurs. These add together in the aged client and contribute to a loss of strength and endurance all of which alter the structural integrity of the individual.

One major problem that develops due to these changes is osteoporosis which occurs in approximately 25 percent of all white postmenopausal females in the United States. Generalized involvement of the entire skeleton can occur with a loss of normal cortical thickness and an increased porosity in the normally compact bone. This change in structural integrity may develop to the point where the skeleton no longer provides adequate support. This absence of the normal quantity of bone is important to assess for it causes 75 percent of the fractures that occur, especially those of the upper femur.

These skeletal changes arc very important but other related alterations are also relevant. The client experiences weakening of the skeletal muscles, a calcification of ligaments and a degeneration of the joints. One will note stiffness and a decrease in the speed of movement. Thinning of the intervertebral discs may occur which can cause the client to be shorter than his previous height and to have shoulders which stoop. These alterations can interfere with his balance.

Alterations in integrity of structure relate directly to motor performance. Decrease in physical activity, motor ability, perception, and judgment occur. There is a decline in strength and a slowing of responses. The individual is unable to have the capacity for continuous exertion.

Another important area for consideration in relation to structural integrity is skin turgor and intactness. The individual in later maturity most often experiences a loss of subcutaneous tissue, a deterioriation of collagen fibers of the underlying supportive tissue of the skin, dryness and a decreased elasticity of his skin. These alterations give the skin a wrinkled and flaccid appearance and predispose to breakdown and impairment in healing.

A similar loss in the elasticity of large arteries occurs. This has been related to the change in characteristics of collagen as well as calcification of the elastin in the arterial walls. General cardiovascular as well as pulmonary changes occur due to these alterations. A decrease in the capacity of gaseous exchange occurs as well as a decrease in mechanical efficiency. These alterations in adequate aeration may also alter the maintenance of normal fluid and electrolyte balance.

Circulatory stasis is very common, and caution must be taken to guard against pooling of blood in the pelvis or extremities. For the mature client this means an avoidance of prolonged sitting. A physical adaptive response that may occur to solve some of the changes is hypertension, a common and normal response for the adult in later maturity.

Cardiac alteration is to be considered in this decrease in circulation. The heart alterations include an increase in fat deposit with the valves becoming rigid and thick and a loss of cellular integrity. These changes decrease cardiac output.

The lungs experience a similar decrease in function with a decrease in breathing capacity, vital capacity, and inspiratory reserve volume. This decline in respiratory function makes it necessary for the elderly individual to breathe longer and harder. Tiredness-is a common problem related to these changes.

Since a general decrease in blood circulation occurs, a decrease of approximately 50 percent of the normal blood flow through the kidneys occurs which alters the total urinary function. Nephrons of the kidney die; 64 percent become nonfunctional. This alteration causes a decrease in the reabsorptive and excretory ability of the kidneys. The kidneys are now less able to concentrate urine and prevent dehydration if fluid intake is decreased. Consideration must also be given to foreign substances which are excreted by the kidneys, i.e., medications. This client may experience an overdose with a dose which is considered normal to others.

In addition to the alterations of excretion, alterations of absorption occur. The gastrointestinal tract has a decrease in enzyme secretion, nutrient and drug absorption, and has slower peristalsis and elimination. These are normal adaptive responses but without proper assessment may lead to a poor nutritional state. This absorption alteration necessitates an increase in the amounts of vitamins and trace elements ingested.

A decrease in trace elements like zinc alters the individual's ability to taste. Food many times becomes less appealing to the individual. Aging also brings about a loss of taste buds. By age 75 the average person has lost 64 percent of his taste buds. It has been commonly believed the aging person prefers bland unseasoned foods. He, in fact, many times prefers highly seasoned foods because more seasoning is required for him to taste the foods.

His sense of smell is also markedly reduced. This makes a considerable difference in a person's pleasure to eat. It also has implications for safety because a person with impaired smell would not be aware of a gas leak, a fire, or spoiled foods.

It is well recognized that an aged person's sense of touch is also less acute. This must be considered in relation to his safety. A loss of subcutaneous tissue, which has a cushioning effect, makes him more prone to pressure damage. He is also less likely to experience pain when a pathologic condition exists. Older people, without apparent awareness, not uncommonly suffer fractures, bruises, burns, or other damage to the body which should have medical attention.

"Less frequently recognized as a problem is the fact that aged people receive less tactile stimulation than younger persons. They, like people of all ages, need and enjoy tactile stimulation."4 They are less likely to receive this stimulation because their physical appearance does not invite touching. Also the attitude of society does not encourage this type of physical contact.

Loss of contact with society also occurs with other sensory loss. This sensory loss interferes with the information gathering function as well as information interpreting function. One way in which man gathers information is by hearing. One's hearing ability changes throughout his lifetime. Our ability to hear high tones decreases from childhood on, and the change is clearly apparent by age 50. After age 65 this impairment accelerates. The ability to hear low tones decreases only slightly throughout man's life span.

As one approaches an individual in later maturity one has the tendency to raise his voice. Instead of helping, that makes it harder for the individual to hear. It is better to speak in a normal tone of voice and at a slower rate. An effort should be made to enunciate each word clearly, but not to exaggerate one's speech. The individual in later maturity generally tends to hear male voices better than female voices because the male's tone of voice usually has a lower tone.

Another consideration must be given when talking to the elderly with hearing difficulty. In our language consonants are in the high frequency range, while vowels are in the low range. If one would write a sentence and remove the c's, f's, s's, th's, and p's, the result would be a disjointed murmur or rumble.

Hearing loss called presbycosis is associated with aging and is due to physiological change. These changes include a degeneration of the auditory nerve fibers, thickening of the eardrum, and a decreased production of cerumen. The incidence of this process occurs in two men out of every ten and one woman out of ten over 75 years of age. Assessment of hearing loss is vital since communication with the individual is a key process of a total individualized assessment.

To further individualize the assessment one must recognize how an individual perceives the world about him. Man perceives his world largely by sight. For the individual in later maturity visual acuity is reduced because of damage to the transparent part of the eyes and a decreased ability for the eye to accommodate to light. Peripheral vision is also decreased. This deficiency can be largely compensated for by turning the head to see things at the periphery. Another change in vision is decreased color perception. Similar colors meld together and are indistinguishable. Use of color schemes with contrasting shades like reds and yellows are more easily seen than greerts and blues. Adaptation to darkness also deteriorates. This can cause problems in dark hallways and at dusk when driving. Some of the disorientation seen in the elderly may be caused by these alterations in vision. If the aged are unable to distinguish colors or objects, landmarks may not be readily distinguished.

In addition to disorientation, sensory changes also reduce alertness. For this reason one will find the elderly person closely monitoring his movements and moving in a slower fashion. A loss in the ability to perceive movement of body parts occurs. A possible cause for these slowed and altered sensory responses is the alteration which occurs in the central nervous system.

In the central nervous system, the effects of aging are more noticeable and apparent. This alteration is seemingly due to a decrease in the electrical activity of the nerve fibers. It contributes to difficulty in fine movement and a loss of a sense of balance. Memory loss for recent events as well as difficulty in choosing from several alternatives may be related to this decrease in electrical activity in the central nervous system. This is a valuable area to consider in one's total assessment of the individual in later maturity.

It is also important to recognize in the assessment that the physiological changes vary from cell to cell and that they occur in different persons in various degrees. It is also important to assess how the individual adapts to these changes and that the decrement may not result in decreased functional ability. "Since the interests and needs of a person change, a decrease in a specific biologic ability such as physical strength may be of no consequence to him. Knowledge of the various changes that usually occur with aging will facilitate assessment of a person's functional capacity and will enable the health care worker to help the aged person maximize his potential in illness and in health."4

Maximum potential in illness and in health is also related to the psychological parameters of the individual in later maturity. Erikson describes the eight stages of man, and states the developmental task in the later mature years as ego integrity versus despair. A complex set of factors combines to make the attainment of this task difficult for the elderly person. Ego integrity is the coming together of all previous phases of the life cycle. Without this the person feels a sense of despair and self-disgust. The individual wishes he would have another chance to redo his life. He may become hypercritical of others and may project his own self-disgust, inadequacy, and anger on to others.5

The image others have of the aged individual is of great importance in helping the aged individual assume a self-image. Our society provides the individual with no clear image of what growing old means. Thus an individual in later maturity has difficulty establishing a self-image and for this reason he may be inhibited in exploring a new role. A person's self-image is influenced by his sense of the meaning of aging and his sense of the meaning of life. This is also influenced by the roles which he has occupied at various stages on the life continuum.

These roles also influence how an individual will behave and react. This influence helps to develop the individual's personality and a type of control over his behavior. It is important to recognize that the personality is not a fixed system completed in childhood. Personality becomes more unique as one increases his life experiences. "Personality, though not the only factor causing differences in the aging process, is an important factor in determining how successfully one ages and how one goes about it."6 One study suggests that there are different but equally successful patterns of good adjustment to aging. In this study those who adjusted well to aging were those who were relatively stable throughout their life. Those who were not able to make adequately successful adjustments were those who were bitter over having failed to achieve their goals in life and blamed others. These individuals tended to look back with disappointment and failure.6

A major consideration must also be given to depression which occurs in an individual with these concerns. He may be depressed due to a real or fancied fact, one either present or past. This depression may lead to a constant reference to morbid or melancholy subjects meant for lost objects. Preoccupation with inner-self and bodily function may also occur. Chronic fatigue may be present in a fashion of escape from reality and one's self. It is important for the health care worker to encourage and support this individual. He needs to maintain his sense of responsibility, achievement and recognition as a worth-while person.

To be a worthwhile person is a difficult task for the individual in later maturity. He must adjust to a loss of life enjoyment, a loss of feelings of self-confidence, a loss of usefulness, and a loss of general zest. This level of his adjustment must be assessed with one area of major adjustment being that of retirement. Our society is a goal-oriented, productive-oriented society and basic retirement does not fit. This mandatory life-style alteration not only poses problems of self-image but also places a financial burden on the individual. With a longer life span and with earlier retirement, these persons face a prolonged period during which the cost of living increases and income remains fixed. Assessment of the individual's source of income is vital for it many times influences the seeking of health care.

One major question arises from these alterations in self-worth and self-image. What should the health care worker and society do so that man may still be man in his final years? They must treat and assess man as valuable in himself with only one aspect being his productivity. It is also important for all to avoid considering old age as a problem. Instead, society should begin by considering old age as a symptom of the problem of society as a whole.

Much consideration must be given by the health care worker to society's view of the individual in later maturity. Society's predisposing attitudes are many times conveyed to the individual and thus influence his seeking service and the kind of service he receives. An excellent example of this would be learning. "It was once supposed that intelligence reached a peak in the teens and thereafter declined steadily and with an increasing rate. Current evidence to the contrary suggests that at least some people improve in ability into middle age and perhaps beyond."7 The only real differences to assess in learning are the motivation, time, and teaching techniques. All of these areas should be considered on an individual basis in a teacher-learner situation.

To learn one must think logically. It is important to assess this because deterioration in the organizing function of the brain can occur with the individual in later maturity. This may lead to some failure in logical thinking. The individual who is pressed to solve a difficult problem may retreat into discussion of extraneous material rather than provide logical inferences from the evidence. This problem-solving orientation should be assessed and the health care worker should consider the individual's ability to generate a hypothesis and his ability to check out the facts.

In assessing the individual's ability, one should not infer that all individuals in later maturity are rigid, illogical, and forgetful. There are tremendous differences in individuals in the rate of deterioration, if any deterioration occurs at all. Many times the deterioration that occurs is totally related to the stress placed upon him by society's influences. These influences and the social parameters consider man's roles in his family, at work and in his community, as well as his interests and activities.

Society basically has graded these roles or behavior patterns so that all persons are seen as either young or old. For the individual in later maturity, it is the first stage of life with a systematic status loss for an entire group. Basically all previous periods of life have been marked by steady social growth with gains in competence, responsibility, authority, privilege, rewards, and prestige.8 The aged individual is confronted with role loss and he is not prepared for this defeat and loss of status.

With this role loss the individual is confronted with the problem that society does not specify an aged role. Therefore, there cannot be role failures for there are no roles. "They are simply bored, but not quite to death!"8

The individual is concerned with his future. He is concerned about his health, the health of his spouse, his finances, and how to fill up his days. In a sense, he wonders what is to become of him. He has for many years assumed responsibility for his own caretaking. Now before him is the fear of inevitable hospitalization, long-term care and providing for him. These concerns, although not clearly valid, do exist and therefore must be assessed.

Another notion that must be considered is loneliness. Loneliness is an absence of meaningful integration with individuals or groups of individuals. It is a conscious feeling of being excluded from the system, and because of this exclusion one receives no opportunities and rewards from the group. Most health care workers who are involved with the later maturity individual perceive this as his major problem. This is not true. Approximately 70 percent of the aged in the United States live with others. In recent surveys 75 percent of the aged population said they are not often alone and 86 percent said they have seen one or more relatives during the previous week.9 What feeling then does exist with the elderly population which looks so much like the destitute feeling of loneliness?

The feeling more prevalent than loneliness in later maturity population is that of isolation. Many of the elderly are confronted with a separation from familiar surroundings, objects, and persons. They also feel isolated because of danger to life and health and concern for isolation related to the unknown-death. Isolation is identified by the physical limitation method, limitations on range of motor activity and restrictions of quantity and variety of sensory experience. As this isolation increases the individual withdraws, has difficulty maintaining contact with reality and has a decrease in rational thinking. Assessment of this individual's identity will help him become an active and worthwhile being in himself.

Self-identity is of great importance. One other aspect in self-identity is a sexual identity. This identity does not exist in a vacuum. Man needs a continuous feedback and reinforcement that he is a sexual being and that his gender is specific. For man in any stage of life this is important whether it be pink or blue ribbons for an infant or a compliment for a woman or a pretty face to a man. Sexual identity is important and this would include sexual intercourse. It is known that frequency of intercourse declines from a peak in the early twenties. However, individuals in their nineties may continue to engage in orgasm. This is important to consider, for although only approximately 38 percent of the women are married, approximately 77 percent of the men are married.

Since the family unit many times remains somewhat intact, it is important to consider income maintenance and work for the individual in later maturity. If one considers that the average man spends half of his lifetime in the work force and only a quarter to be educated and a quarter in retirement, then the importance of work can be seen. Much concern and resentment has been expressed by the individual in later maturity about the low incomes received in retirement, but this is only a small problem. If those retirement incomes were adequate, it would still take about two years to adjust to this alteration in life style.

The assessment process should be one that considers what the individual is capable of doing and one which will help him to be a participant. The health care worker must know not only the individual's disabilities but also his functional capabilities. It is important to remember that:

Old age is something chat happens to everybody, and if we are wise enough and unselfish enough and effective enough, then we ran make those years a time in which to live, not just to linger.

1966 Robert F. Kennedy

References

  • 1. Homberger F, Bonner CD: Medical Care and Rehabilitation of the Aged and Chronically III. Boston, Little, Brown and Co, 1964, ρ 99.
  • 2. Storz RR: Role of a professional nurse in a health maintenance program. Nurs Clin Ν Amer VII (2):20. 1972.
  • 3. Storz RR: Working with older people: a guide to practice. Vol II, Biological. Psychological, and Sociological Aspects of Aging. Rockville, U.S. Department of HEW Public Health Service, ρ 2.
  • 4. Hay ter J: Biologic changes of aging. Nurs Forum XIII 3:299, 189, 1974.
  • 5. Erikson EH: Childhood and Society, 2nd ed. New York, WW Norton Co. Inc. 1963, pp 268-269.
  • 6. Giblin EC {ed): Symposium on assessment as part of the nursing process, Nurs Clin Ν Amer VI (I):116, 1971.
  • 7. Charles DC: Outstanding characteristics of older patients. Amer J Nurs LXI (11):82, 1961.
  • 8. Rosow I: The social contact of the aging self. Gerontologist Spring:82-83, 1973.
  • 9. Rosenberg: Age, poverty and isolation from friends in the urban working class. J Geront 537, 1968.

10.3928/0098-9134-19770701-07

Sign up to receive

Journal E-contents