How old is very old?

The American Geriatric Society and the World Health Organization define the oldest-old as individuals aged over 80 years, while the British Geriatrics Society uses 85 years as a threshold. In recent publications, the cut off was fixed at 85 or 90 years and over [1,2,3].

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Four themes were identified after analysis. The major theme was the description of “the stage of very old age”. This was the stage described by the participants as the next stage of aging after old age. This stage was not based on age as in the literature but was defined when a participant acknowledged a progressive and uncontrollable decline. The other themes identified were the progressive disengagement from activities during the transition to very old age; the progressive exclusion from the surrounding environment and the resignation of the older people; and finally, the fear of the last stage of life. To construct their perceptions of aging, and the transition from old age to very old age, participants confronted their actual perception of their situation, with the stage they expected to be in considering their life course and the surrounding world. We described those four themes and linked them to one another to suggest a theory to answer our research question.

Disengagement in their activities during the transition to very old age

Participants progressively adapted to their experience of aging. They gradually reduced their level of activity: shorter driving distances, lower frequency and duration of activities, more local travel destinations. In some cases, a total elimination of activities was described. These changes took place more or less abruptly depending on the circumstances. The intrinsic factors influencing this disengagement were: physical condition (reduced vision or hearing, reduced mobility and physical strength, illness) or psychological condition (loss of vital impulse). Extrinsic factors were also found: children restricting their parents’ activities due to concern for their safety, death of contemporaries, modification of the couple’s balance when their spouse died or their health deteriorated (illness necessitating regular care). The loss of a spouse was identified as a major factor that influenced negatively several parts of their fragile daily balance, from loss of vital impulse and sadness, to difficulty in maintaining daily activities previously done by the spouse (shopping, cooking, management of personal finances, etc.). When changes in the participant’s situation were unpredictable, the changes seemed imposed. For example, participants did not feel the same way if they stopped driving after a stroke (unpredictable change) versus if they decided to stop driving because they felt gradually less confident. “I used to love reading and painting, but now... I still read a bit with a magnifying glass, but painting, museums and all that, I don’t see well enough, so, hum, my life has narrowed a bit” Mrs. D. Even if this disengagement was regretted, it seemed to be chosen to reduce risks and conserve the energy needed to maintain important activities giving meaning to life. Participants progressively agreed to delegate more tiring tasks and chose to prioritize decisional autonomy over organizational autonomy. At the opposite, we identified certain slowing factors of this disengagement, especially extrinsic factors. Aging participants were grateful for help from family members, as long as relationships remained balanced. The couple was considered as a solid and faithful support system, but its disappearance could bring about a destabilizing change. A network of professional caregivers could also allow to maintain contact and support. The continuation of social relationships and shared activities gave meaning to life. Regarding intrinsic factors, a preserved health status gave a solid basis to maintain activities. “I have everything I need! I could not wish for better. I have my children nearby, my grand-children are adorable and come to visit me, it is enough”. Mrs. L.

The stage of very old age: acknowledging a progressive and uncontrollable decline

“It came progressively, but I find that it happens quickly now. Mrs. L. Before the stage of very old age, old age appeared as a slow, progressive and often unconscious process. It wasn’t felt to match official age, although some key ages were recognized “The 90 years threshold” Mrs. D. It seems difficult to be aware of the process. The participants did not know whether to define themselves as old. This insidious evolution was regretted as it could not be prevented. “No, getting old I can’t say, I don’t think I became aware of it! That’s what’s bad about it!” Mr. B. Age progression was perceived as bringing incapacities and disabilities. Then, the stage of very old age was identified when the effects of biological aging affected lifestyle, and it became difficult or impossible to maintain activities. At this stage aging was keenly felt. The shift to very old age, identified after analysis, was not based on age. The shift occurred when older people became aware of the irreversibility of aging. This awareness led to an absence of project-making for the near future. It was felt as increased susceptibility to fatigue, lowering of physical or cognitive abilities, slowing motor skills, heightened anxiety. “Oh it was, it took place progressively, I don’t know, one year, two years that I can’t do what I did before. Before I was doing the garden, I was helping, now I can’t anymore” Mrs. D.

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When the capacities of aging subjects diminished and they needed to be assisted for common activities (shopping, preparation of meals, hygiene, mobility etc.), dependency appeared and could be a revealing factor of very old age. Loss of autonomy for transport and in particular the abandonment of driving seemed a decisive step, as persons were deprived of a freedom of action. “After all we have everything, all around us. We have the, we go to buy apricots in such a place, you used to go to small villages, so if you don’t have the car you can’t go anymore. So that’s why he doesn’t want to go there anymore” Mrs. T. In this case, an important wish was to keep a hold on the management of their house with the bare necessities to live in their own place as long as possible.

A progressive exclusion from the surrounding environment and resignation

“I think from a certain point in time you should know how to be invisible or at least very discrete” Mr. LB Advancing age was accompanied by a limitation of social relationships due to the loss of one’s contemporaries who passed away or drifted away. “In the village too, the elderly go either to the cemetery or to the retirement home” Mrs. D. The social network of contemporaries in the neighborhood could be replaced little by little by a younger generation, not in tune with the older one, reinforcing the feeling of isolation. With restricted mobility, the home often became the center around which socializing was organized. To keep social links, some attempted to build relationships with their younger neighbors, others forced themselves to move further to meet people. Home carers could be expected to play the role of a social connection. Radio or television allowed to keep a contact with the changing exterior world. “So, well I’m happy, I speak with them for two hours, they don’t do much, they don’t have much know-how either” Mrs. C. An inversion of family dynamics was reported. The participants progressively lost their decisional autonomy while their children decided for them, sometimes imposing a restriction of their activities. Recognizing the family network as essential during the aging process, they accepted a submissive position, tried to become invisible and avoided being a burden for their children to preserve this relationship. “My children conspired to make me understand that it was time that I gave up my freedom” Mrs. L. In time, relationships could loosen, excluding the older people who felt they were becoming less important. Distance from family members increased the feeling of isolation. “The isn’t much else besides New Year and Christmas... and a few small family occasions, which are always interesting but one feels a bigger and bigger distance” Mr. LB. In the absence of descendants, loneliness was even more marked in very old age. The consciousness of the end of a family line could be painful. « Alone! Alone alone it’s despairing, despairing… Being alone, being alone… Not even the telephone, the telephone doesn’t ring, nothing. » Mrs. C. A feeling of indifference and negligence of society towards older people was experienced. The feeling of being useless, of becoming a weight, or even a danger, was expressed, and could bring the subjects to want to withdraw. Older people considered that today’s society was adapted to the younger generation and not to them. This place apart from the rest of society could be difficult to accept. “Young people don’t care” Mr. L.

The feared last stage

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“THE question, question without answer: WHERE, WHEN, HOW? [...] I’m scared about how it will happen, that is, for example to be frank, of suffering: will it be calm, serene? Or will it be in illness, in suffering, in short how it will unfold” Mrs. D. Age progression and diminishing individual capacities placed the subject in a situation of fear and incertitude towards the future. The future seemed narrowed down and the time remaining to live unknown. The participants expressed a certain fatality towards the future, projecting a constant and uncontrollable worsening of their situation (worsening of dependency, suffering illness, loss of activities and so on). “I think the future is the home stretch and it’s the one with the most hurdles and it’s the one that can end up with bad news” Mr. R. The evolution towards dependency was associated with the fear of becoming a weight or a burden for close ones, and the risk of institutionalization. Participants adopted a guarded position towards the future, perceiving that at this age, the situation can shift rapidly. “So, what can you do? Tomorrow I’m going to do my shopping and I wonder every time if it isn’t the last time, because...” Mrs. C. The question of death took a larger place. Death was described like an inevitable and uncontrollable phase towards which people were getting nearer as they aged. Death was often perceived as the next stage in life and appeared imminent. Progressive loss of their contemporaries reinforced the inexorability of death and reminded participants that their turn was getting nearer. “One runs, one flies towards what will take place finally” Mr. R. By realizing their finitude, individuals could come to feel that they were running out of time, leading them to give up certain obligations. Projects were culled until they disappeared completely. The future was perceived as a close continuation of the present, until it disappeared completely. «Well, I have the project to continue I don’t know how, but I don’t make big projects at the moment. I live day by day” Mr. LB. Some could find hope in religion, putting their future in the hands of God. “Make the most of the present moment. Little things, family life, family meals, a sunny day when one is walking with family or friends, et cetera. All these things of daily life live them intensely. Because it’s the present that counts for us, not the future, the present” Mrs. D. Towards a theory of the shift from old age to very old age The results described above led us to attempt to theorize the shift to very old age (Fig. 1). This attempt to theorize illustrates the links between the themes described above. Fig. 1 Theorization of the step to very old age Full size image In our study, the progression towards the stage defined as very old age was described as insidious. It could be precipitated by certain factors such as becoming incapacitated, health issues, falls, dependency, isolation, widowhood. At the opposite, being in a relationship, having a family and/or social network, the involvement of health care professionals, were identified as slowing factors of the insidious progression to very old age. The shift towards very old age, as defined after analysis of participants’ interviews, took place when one became conscious of the irreversibility of aging. Capacities to adapt seemed overwhelmed. Aging became synonymous with uncontrollable decline. In this downward spiral, the future narrowed, became uncertain. The relationship with time changed, and projects lost their place. At this stage, participants preferred to live day by day, made the most of the present moment.

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