Loss in late life

Old age can be seen as a succession of losses, gradual or sudden.¹ Stopping work means a loss of the working role, of the companionship of fellow workers, and of a full, structured day; it means a reduction in income—and, for those who live with someone, less time apart. Some people feel much diminished by retirement, hardly know what to do with themselves, and suffer a loss of status. Most developed societies do little to enhance the image of the “senior citizen,” who is liable to be patronised, marginalised, or simply ignored and is seen as a problem for an overburdened welfare state.

There is a view, though, that successful ageing means compensating for some losses by making the best of change. So, the strains of having to commute, living for the job, and struggling to keep up are also lost; some pensions are at least adequate; there are concessions that make life a little cheaper for the over 60s. Having more time to oneself, for hobbies and interests, and to spend with partner are often regarded as benefits. Though it is usually a sudden event, retirement is (unless there is unheralded redundancy) expected and there is time to prepare for it.

Summary points

• In old age comes a succession of losses: dementia occurs in 20% of those over 80; loss of sexual enjoyment is common but not inevitable; half of octogenarians live alone

• Depression in elderly people is often unrecognised; it is often caused by loss and, in turn, causes further losses

• Preparation for retirement, health checks for the elderly, continued access to education, and the use of “at risk” registers can mitigate some of the problems of old age

• The rationing and limitation of social support for the elderly is not justified

Many types of loss

Sensory loss afflicts most people as they age. Presbyopia is readily remedied by glasses, presbyacusis less readily (or perhaps less acceptably) by hearing aids. These are very gradual processes, usually accepted without distress, though blindness or severe deafness is a different matter. Some memory loss may be normal with ageing; speed seems to be affected more than secondary memory, and verbal IQ is very well preserved.² “Benign” memory impairment³ presents no serious problems, apart from the fear of dementia—which is, unfortunately, realised in a fifth of people over 80.⁴

It is not often acknowledged, except as a rueful and ribald joke, that loss of sexual enjoyment is common and distressing, and not an inevitable part of ageing.⁵ Hormone replacement therapy and prostaglandins may do much to restore sexual function and enjoyment, but some older people are too shy to seek help, fearing that they should be “past it” and may be regarded as ridiculous or as “a dirty old man” (or woman).

The risk of serious health problems—stroke, myocardial infarction, heart failure, falls and fractures, arthritis, obstructive airways disease, cancer—increases with ageing,⁶ though many old people are spared serious infirmity until a short final illness. Those who are less fortunate suffer loss of comfort, mobility, and life expectancy. There is a risk of being widowed, especially for women, which represents a major loss after 40 years or more of being together.

Secondary to health problems (which make it difficult to get out and about), to reduced means (for transport and entertainment), and to the dying off of friends and family is isolation, which may be accompanied by loneliness. In Britain, about half of people 80 and over live alone,⁷ and the extended family is stretched very thin by distance and relatively small numbers of children. Another secondary consequence of ill health, and most painful of all for many, is loss of independence.

Since long term care has become ever more arbitrarily and capriciously available from the NHS, old people who own property fear loss of estate. The desire to pass on the fruits of labour, success, sound investment, or good fortune to one’s family is fundamental, and the power to do so may increase an older person’s self esteem. Thus the costs of continuing care add to the problems of infirmity.

Reduced life expectancy is related to age and sickness. Through life a sense of immortality gives place to the shocking awareness of inevitable death, rapidly replaced (except in time of war, epidemic, or other crisis) by a feeling that it is a long time off or by denial. Birthdays like the 40th or 50th may precipitate fears of finality and an anxious review of achievements and ebbing potential. But still denial is a powerful buffer. Old people make long term plans and refer to peers as “old” but not themselves.

A new concern, as euthanasia becomes less theoretical and more real (as already in Holland and recently in the Northern Territory of Australia⁸,⁹), may be overlong survival, where life draws on without quality and the burden of infirmity falls on the family. While euthanasia may seem a boon to some, it could be felt to be a duty by others—to stop being a drag on the family’s emotional and financial resources.

Loss and depression

With so many vicissitudes it might be expected that the morbidity for depression in late life would be high. The evidence, however, is inconsistent and contradictory. While suicide rates peak in old age (for women in their late 60s, men around 80¹⁰) rates of depression are lower in older than in younger people. The epidemiological catchment area study in the United States found a prevalence of 2-3% in people over 65—a fifth of the rate in young adults.¹¹ Using a different instrument to diagnose depression, a survey of psychiatric disorder in general hospital inpatients aged over 16 in Oxford found that depression was least common in people over 70.¹² Younger people might be more open, older more guarded. Older people tend to somatise their emotional complaints, and these symptoms might erroneously be attributed to organic disease. Dementia might remove from consideration people who would otherwise have been recognised as depressed, or the researchers might have happened on an unusually contented cohort.

Rates of depressive disorders as high as 17% have been recorded in London,¹³ and these accord with rates elsewhere in the United Kingdom found by using instruments specially designed for older respondents—the geriatric mental state examination¹⁴ and its computerised form AGECAT,¹⁵ and the SELF-CARE D.¹⁶ Although the syndrome of depressive illness in late life is fairly common, the symptoms are far more so.¹⁷

Depression in old age is often undiagnosed and untreated

Why might depression be less common in older people? Depression carries a high mortality, so sufferers may not survive into old age. Today’s oldest people are hardy survivors of poverty, large families, two world wars, and the pre-antibiotic, pre-welfare state era, and they tend therefore to be resilient. Possibly such benefits as central heating, television, allowances and entitlements, taken for granted by younger people, are appreciated by those who are older and once lacked them, and this offsets some of the losses; not having to work, for example, can be a great relief.

The likelihood, though, is that depression is more common in late life, but is frequently unrecognised. The evidence includes the high suicide rate, already mentioned. Barraclough’s classic study of suicide in elderly people on the south coast of England showed that most were likely to have had depressive illness, had attended their general practitioners weeks before the act, and were being treated with tranquillisers, hypnotics, analgesics, and laxatives but not antidepressants.¹⁸ The evidence also includes the increasing rate of first admissions for depressive illness to psychiatric units in England and Wales (though it is more marked in women, from middle life the rate increases in both sexes with every decade, falling off only in those over 85)¹⁹; and the apparent failure of doctors to recognise depression in older people.²⁰ This lack of recognition may be due to lack of education, motivation (“drugs are likely to be toxic, counselling is hard to come by, and anyway it’s hard to teach old dogs new tricks”) or the somewhat ageist assumption that to be depressed in old age is both normal and justified.

The use of an “at risk” register and screening for depression may be good uses of finite resources

Depressive illness in late life often follows a major adverse life event, like bereavement or acute life threatening illness, but the association may not always be that the loss precedes the depression: depression may cause loss. Depressed people do not care to take care of themselves and may become ill, have accidents, and die from self neglect as well as deliberate self harm.

What to do about it?

Marriage “till death us do part” was easier to honour when it usually meant 10-15 years rather than, as now, 40-50 years, as the high divorce rates in the more developed (and more aged) societies indicate. Shortage of housing is aggravated by the need of divorcees for two dwellings. A small consolation for high levels of unemployment is that, long before retirement age, many people have been prepared for not working and managing on reduced means. Others may benefit from preparation for retirement classes, and workshops are now provided by most large companies, trades unions, and professional bodies.²¹

“The comfortable state of widowhood is the only hope which keeps up a wife’s spirits” (Mrs Peachum in The Beggar’s Opera)

Health education not to smoke, to eat and drink moderately, to watch weight, and to take exercise may reduce ill health later in life. Health checks, either at set times (like the 75th birthday) or opportunistically (“as you’re here, Mr Jones, tell me how you’re enjoying your retirement while I check your blood pressure”) are a good opportunity for health education. An “at risk” register may be a good use of finite resources for older people who have undergone recent life events—a recent move, illness, or bereavement, or who are known to have chronic infirmity or are living alone.²² Screening for depression with, say, the geriatric depression scale²³ or BASDEC²⁴ is a good start to secondary prevention. A positive approach to the treatment of depression in old age is needed: perceiving the mood disorder underlying somatic complaints; using antidepressants with confidence, in sufficient dosage, and for long enough; and recognising the entitlement and likely efficacy of counselling for bereavement and marital problems and in the context of established depression. The consensus statement by the colleges of general practitioners and psychiatrists in 1995 was a good beginning.²⁵

Further education is available in many daytime and evening classes and the University of the Third Age. Societies in which the fitter elders help their less able peers and seniors need not be a Utopian dream. Many retired people would and do like to “justify themselves by good works.”

“Do not go gentle into that good night/Rage, rage against the dying of the light” (Dylan Thomas)

Finally, despair at the demographic time bomb, when there will be supposedly too many pensioners for the remaining workers to provide for them, may have led governments into premature, panicky withdrawal of services. In the United Kingdom, the Community Care Act aimed to contain the costs of residential care, subsidised by social security, by transferring responsibility to local government. The consequence has been rigorous means testing, the expectation that people who have the means will contribute in part or wholly to their care, and, as budgets run short, rationing of care to those with greatest need. However, the “doomsday scenario” may be fallacious: though there will be a substantial percentage increase in octogenarians in the next 20 years or so, the increase in actual numbers will be small.²⁶

The greatest cause of distress, dementia, may not necessarily prove to be intrinsic to aging. Donepezil can now provide temporary respite for 50-60% of people with early Alzheimer’s disease,²⁷ and it is not too fanciful to expect the pace of research into the dementias to yield more lasting remedies that will offset the morbidity associated with an ageing population.

Figure.

Old people suffer a succession of losses