Old Age, Who Cares

Everyone cares about old age, or at least everyone should. Old age is everyone’s problem; it is the ultimate destination of the vast majority of us and affects us all as individuals and as members of society. It is a problem not only because of the biological factors that make older people more likely to become unwell and the economic factors that are the result of a changing population dynamic but because of the simple fact that there is a large group in society (older people, the elderly, the aged) that is the victim of thinly veiled prejudice from all quarters. Ageism is defined as "prejudice or discrimination on the grounds of a person's age” and can include prejudice or discrimination directed towards people of any age. The specific problem of the treatment of older people is more usefully termed gerontophobia and is defined "a fear of growing old or a hatred or fear of the elderly” (1) this definition shows the Janus face that this problem presents with elements of i) fear of ageing, and ii) a sense of hostility towards the older generation. To understand this problem it is important to investigate both elements of this dichotomy; fear and contempt, which combine and develop until older people are pushed to the fringes of society and their poor treatment becomes normalised. This normalization is the wider problem of gerontophobia. 


 Thoughts and fears of our own mortality strike relatively early. While still shielded by youth and by caregivers we are confronted by the death of a much-loved pet, grandparent or someone else close to us. Questions are raised: What does ‘dead’ mean? Why do people die? Will Mum die? Will I die? Death changes from an abstract concept that robs us of Fluffy (the hamster) to a certainty that will affect us, and all of those we love. This arousal of awareness can be sudden and surprising or, if younger, more insidious; as though we have just become aware of an awkward hooded figure, clad in black that was in the room all along; wondering what to do with his scythe. It is the presence of death in our lives, coupled with our self-protective instincts that lead us to fear the end of life. The end of life, it appears, is the end of everything. Ageing is by the same token something that triggers fear; it is the outward sign of the inevitable.

On a gravestone in a Suffolk churchyard is the simple epitaph; Life’s work well done. And we are all aware that this is exactly what death should be about. There are those tragic deaths of course; talk of people struck down in their prime, with ‘so much left to give”, but really, we accept (and hope that in our own case) death is an ending of something good, a full stop to a well-written sentence. Metaphors of resting in peace, and life’s work well done suggest that life is for achievement, and the end of a useful life is the end of life. So those people who have lived beyond their productive years have, by extension of that argument, forfeited their place in useful society. Their continuing existence beyond ‘usefulness’ becomes a cause for contempt towards older people, as they become a drain on society.

In the 1989 book Age Wave (2), describing the ageing population in the USA towards the end of the twentieth century, Ken Dychtwald, a gerontologist and psychologist explored gerontophobia and described it in terms of seven markers:

·  If young is good, then old is bad

·  If the young have it all, the old are losing it

·  If the young are creative, the old are dull

·  If the young are beautiful then the old are unattractive

·  If the young are stimulating, then the old are boring

·  If the young are full of passion, then the old are beyond caring

·  If the children are tomorrow, the old represent yesterday

His markers neatly underline the feeling of an increasingly youth driven society towards older people. It is true that the problem seems increasingly severe; a view often expressed by the general public and newspaper columnists is that a culture characterised by a lack of respect for older people is a new phenomenon, this however is not the case. Literature suggests that a positive view of youth contrasted with a negative view of old age has been expectated for hundreds, if not thousands of years. If it is accepted that the central characteristic of gerontophobia is a fairly organic progression of fear and contempt then this seems logical.

Shakespeare observed, famously in As You Like It the “seventh age of man” as “second childishness, and mere oblivion” (3). In Hamlet, he observes that “old men have grey beards, that their faces are wrinkled, their eyes purging thick amber and plum-tree gum and that they have a plentiful lack of wit, together with most weak hams”(4). Modern literature of course continues the trend of broad generalisations when it comes to older people. In John Steinbeck’s The Grapes of Wrath: “Grandpa was still the titular head [of the family], but he no longer ruled. His position was honorary and a matter of custom. But he did have the right of first comment, no matter how silly his old mind might be”(5).

For the most interesting literary comments on old age that demonstrate older people are rarely been viewed as valuable members of society it is worth looking to Plato. In the opening words of Book I of The Republic written in 360BC Plato examined older people. The patriarch: Cephalus tells the philosopher (styled on Plato’s teacher) Socrates about his old age:

“… I cannot eat, I cannot drink; the pleasures of youth and love are fled away: there was a good time once, but now that is gone, and life is no longer life.  Some complain of the slights which are put upon them by relations, and they will tell you sadly of how many evils their old age is the cause.”(6)

Plato’s description is one of older people disappointed at the lack of respect afforded them by their families. The dialogue concludes that respect is earned not because of advancing years but because of the sum of a person’s achievements, their attitude and behavior. Cephalus himself, though an important man; is indulged rather than liked, and is not invited to take part in the dialogue on justice and society that makes up the bulk of the work. The roman philosopher and orator Cicero (who studied at the Academy Plato founded in Athens some 300 years before) observed that Cephalus, an old man, would have been out of place in such a philosophical discussion, “which he could neither have understood nor taken part in” (From Jowett’s introduction to The Republic (6)).

Plato observes that the poor treatment experienced by older people, and their nature to complain about said treatment “are to be attributed to the same cause, which is not old age, but men's characters and tempers” (6). This brings to light an interesting anomaly in a culture where gerontophobia is considered normal. This anomaly is the favoured position that certain older people can hold in society. The most interesting example here is the figure of the elder statesman, typified by Winston Churchill, who came to power at the age of 65 to lead the UK through the second world war. Where older people are seen as leaders, or particularly active or successful it is more likely that the public will identify with their more youthful characteristics and they will not be associated with old-age with its connotations of weakness and senility (7).

Though the dynamic of our population is changing, as diseases that kill people in their fifties and sixties become easier to treat and the percentage of older people increases, older people in society have been a significant group in society throughout history (8). Age at death is determined largely by our genetic makeup, maximum age therefore can be thought of as a relative constant; with developments in medicine serving to increase the percentage of the population who live to that age. In terms of illness being more common in older people, Hippocrates listed common diseases of ageing in great detail (9) and he is rightly honoured as a great observer, who learned from a great many older patients. Aristotle formulated a theory of ageing which explained it as a loss of heat as unscientific as this now sounds nobody really examined ageing in greater detail or wrote anything better in the 2000 years that followed (10). The common view among physicians until the 17^th century was that ageing was largely an irreversible process of decay and increasing illness (7). Francis Bacon was one of the greatest (and loudest) opponents to this point of view, he proposed that ageing was not necessarily a homogenous process within a population (or across different populations), he suggested an epidemiological investigation of the different effects of ageing on different populations and of the different lifestyles on longevity (8).

It was eventually the work of Ignatz Nascher (who coined the term Geriatrics in 1909) in the USA that sparked scientific and sociological research into the process of ageing (11).  The medical side of geriatrics developed in the UK with the founding of the NHS in 1948 though geriatrics (as a medical specialty) was first born through the work of Marjory Warren, a physician at the West Middlesex hospital who was confronted with an influx of 714 older patients when that institution merged with an adjacent county workhouse in 1935. While reviewing the older patients from the workhouse wards, Dr Warren was able to discharge a great many, by ensuring they would receive proper care and the use of appropriate equipment (such as mobility aids) outside of an institution. She observed a great many differences in disease states in the large group of older people under her care when compared to younger patients as was able to adapt and modify the wards to their advantage (12). In landmark papers in 1943 (13) and 1946 (14) she called for dedicated geriatric departments in hospitals, specialist doctors to staff those departments and for medical students to be trained specifically in the diagnosis, treatment and care of older people. The Medical Society for the Care of the Elderly (later the British Geriatrics Society) was founded in 1947 and the first consultants in geriatrics were appointed shortly after the founding of the NHS (15). Geriatrics today is, sadly, characterized by a lack of funding and a poor image. A report on old age and health care from the Wirral hospital NHS trust published in 2003 suggests that gerontophobia is widespread within the health service, underlining negative attitudes (both held and displayed) towards older people, poor care environment, insufficient workforce capacity in geriatrics, inequalities in access to healthcare and inadequacies of essential nursing care as the particular problems with the care of older people (16).

If there can be any conclusion from this exploration of old age, then it must be that gerontophobia is a real, widespread problem that has become normalized and so has pervaded everyday life since the dawn of culture. It is worth note that gerontophobia is one of the most unusual of all forms of prejudice in that it discriminates against a group of people that the vast majority of society will end up in. Gerontophobia is perhaps most concerning in the provision of medical care where paediatric wards that employ clowns and play specialists, and ensure the healthcare of the young is holistic and discharge-focused can exist in the same building as drab geriatric wards where wheelchairs, televisions and any form of activity are in short supply (16). While gerontophobia in all its forms will never be eradicated from society it must be addressed and challenged unreservedly particularly in the healthcare setting, surely with the ultimate aim of stamping it out entirely.

An original Entry for the 2008 Joy and David Long (Essay) Prize in Medicine.

1. Balaram P, 2004. Gerontophobia, Ageing and Retirement. Current Science 87 (9) 1163-1164.
2. Dychtwald K, Flower J 1989. The Age Wave: How The Most Important Trend Of Our Time Can Change Your Future. 1^st Ed. 1989. Bantam (New York).

3. William Shakespeare c1599. As You Like It. Popular Classics Ed. 1994. Penguin Books (London).

4. William Shakespeare c.1601. Hamlet. New Penguin Classics Ed. 1980. Penguin Books (London).

5. John Steinbeck 1939. The Grapes Of Wrath. Penguin Classics Ed. 2000. Penguin Books (London).

6. Plato 360BC, Transl. and Intr. Jowett B 1871. The Republic. Barnes and Noble Classics Ed. 2004. Barnes and Noble (New York).

7. Thane P 2006. Images of Older People. Wellcome Focus (On Ageing) 01.09.2006. Available Online: http://www.wellcome.ac.uk/assets/WTX033829.pdf Accessed: 29.01.2008.

8. Bacon F c.1623, Ed. Vickers B 2002. Francis Bacon: The Major Works. Oxford World Classics Ed. 2002. Oxford University Press (Oxford).

9. Hippocrates c.420BC, Transl. Chadwick J, Mann WN 1950. The Medical Works of Hippocrates: A New Translation from the Original Greek Made Especially for English Readers. 1^st Ed. 1950. Blackwell (Oxford).

10. Evans JG 1997. Geriatric Medicine: A Brief History. British Medical Journal 315: 1075-1077.

11. Achenbaum WA 1995. Crossing frontiers. Gerontology emerges as a science. 1^st Ed. 1995. Cambridge University Press (Cambridge).

12. Kong TK 2000. Dr. Marjory Warren: The Mother of Geriatrics. Journal of the Hong Kong Geriatrics Society 10 (2) 102-105.

13. Warren MW 1943. Care of Chronic Sick. A Case for Treating Chronic Sick in Blocks in a General Hospital. British Medical Journal 2: 822-823.

14. Warren MW 1946. Care of the chronic aged sick. Lancet 2:841-843.

15. Barton A, Mulley G 2003. History of the Development of Geriatric Medicine in the UK. Postgraduate Medical Journal 79:229-234.

16. Davey B, Ross F 2003. Exploring Staff Views of Old Age and Health Care in The Wirral Hospital NHS Trust. King’s College London Nursing Research Unit: 01.11.2003. Available Online: www.kcl.ac.uk/content/1/c6/01/94/98/WirralReport.pdf Accessed: 30.01.2008.