The Art of Aging

by Sherwin B Nuland

  For women, some degree of thinning of the vaginal wall is inevitable, as is variable loss of the vagina’s length, width, and elasticity, as well as lessened lubrication, especially during sexual activity. Such changes may make intercourse difficult, uncomfortable, and sometimes painful, even when a bit of bleeding is not caused by local injury during thrusting. The labia lose firmness as they age, the fatty mound over the pubis (classically called the mons veneris, the mound of love) flattens, and the pubic hair becomes sparser. The entire appearance of the field of lovemaking for females has thus become altered.

  For men, an erection is slower to begin and to reach its peak. From the instant or two previously required to make itself evident, the time extends to increasing numbers of minutes, and in a significant percentage approaches infinity, in the sense that all the waiting or manual stimulation in the world has no effect; impotence has reared its flaccid head. The erection of the aging penis often does not become as hard, as large, or as long-lasting as it once was. Orgasms, when they occur, are usually less explosive, take a longer time to come forth, and require far more time to repeat themselves, sometimes measurable in days or weeks. As for fertility, some men have fathered children in their nineties, but most have become sterile by the time they are seventy-five.

  Authors seem to shy away from saying anything about the appearance of aging male genitals, but one need not have done thousands of physical exams in a long career of surgery—it is necessary only to spend the most minimum time in the locker rooms of athletic clubs—to verify that an older penis usually appears somewhat droopier and perhaps a bit smaller than the fuller, younger ones nearby. Its companion testicles hang lower than they did years ago, because of loss of turgor in the skin muscle of the scrotum, a muscle called the dartos. As in the female, the pubic hair is less dense and has lost some of its curl. Altogether, the elderly male sexual apparatus does not present the image of bursting virility that was once its hallmark.

  Desire and what some sex manuals unfortunately call “performance” for both men and women result from a complex of physiological, sensory, and emotional factors that must act in delicately balanced concert if satisfaction is to be achieved. It stands to reason that the neurological, vascular, hormonal, and other physical aspects of this mix will be less efficient with age, as is the coordination required to make everything function with the perfection of timing so necessary to the desired result. In such a situation, inhibiting psychological factors take on a significance at least as great as they did in youth, when a certain animal automaticity of response may have helped to overcome them.

  Older women worry about being unattractive because of wrinkles or sagging flesh, and they may be concerned about the possibility of sexual discomfort or unresponsiveness. Older men are more likely to distress themselves with fears of insufficient libido or of impotence. Both partners bring an entire lifetime of attitudes toward and experience with sexuality that influences their approach to lovemaking. When they are married or in some other form of long-term relationship, these matters may be eased, but hardly always. Men and women, whether straight or gay, are not infrequently inhibited in new sexual relationships by an assortment of factors that stand in the way of fulfillment. In general, the patterns of late-life sexuality reflect the patterns of the decades that preceded them.

  There is no way to know what is sexually “normal” at any time of life, and the older years are more resistant to the word’s definition than any others. Even more than is true of the effects of aging on all other functions and structures of the body, the variability in sexual activity, ability, and satisfaction is enormous. Some few men and women are as active as they were at much younger ages, and many others are far less so but nevertheless quite satisfied with what is possible for them, though it may involve methods short of actual coitus, such as cuddling and mutual masturbation. Still others are without sexual activity at all, because of attitudes about aging, lack of appropriate partners, loss of desire, medical problems of various sorts, choice based on social constraints, or any of an assortment of other factors. The ultimate question about the sexuality of older men and women is whether they are content with what they have. And here perhaps the authors who deny the existence of problems deserve more consideration than I at first gave them. The problems, as always in the eye of the beholder, do exist for many of the elderly, but useful solutions are available for some of them. For the others and for the entire spectrum of sexual relationships among older men and women, we might turn to Shakespeare for the most appropriate response, when he has Hamlet say, “There is nothing either good or bad, but thinking makes it so.”

  When the participants feel discontented with their sexual life, it is almost always because it is not of the quality or quantity they might wish for. Especially because most of the very real problems associated with the sexuality of aging individuals has been found to be physical—and not emotional, as was previously thought—such men and women should be encouraged to seek medical help, because so many of their difficulties are now being treated with increasing success.

  Just as is the situation for sexuality and the physical elements involved—as well as the heart, parathyroids, ovaries, and testicles—all other glands and organs lose elements of function as they become older, and they do so in a variety of ways. The thyroid, for example, tends to slow its function of regulating the rate of metabolism—but not very much. The incidence of levels of thyroid activity in the elderly so low as to be of consequence is less than 10 percent. The insulin-secreting cells of the pancreas, on the other hand, are more likely to cause trouble. The resultant diabetes often goes unrecognized and undiagnosed in elderly people, and therefore untreated.

  The two major sensory organs, the eye and ear, likewise vary considerably among individuals as they age. Predictably, decreased flexibility in the lens of the eye results in loss of ability to accommodate and focus for near vision, explaining the frequency of bifocals on the noses of people beginning at about age forty-five. In addition, adaptation to dark becomes more difficult, which, when combined with an increased sensitivity to glare, makes many older men and women prefer to not drive at night. The problems with glare are the reason that elders are more often than younger people likely to be seen wearing tinted glasses indoors. Even relatively minor manifestations of decreased accommodation and ability in adapting to dark make the possibility of stumbling greater. Should there be any significant degree of the opacification of the lens so common in people on their way to a cataract, the tendency to lose one’s footing or to fall is obviously more pronounced. Though cataract is the most common of the serious visual impairments to which they are prone, the elderly also have a higher incidence of glaucoma, macular degeneration, and diabetic pathology of the retina.

  The tendency toward the development of cataracts is increased among smokers, diabetics, men and women with a history of long exposure to sunlight, and those who have required cortisone-like compounds for extensive periods, but other than the general process of protein fibers conglomerating into cross-links, not much is known about the biochemical basis for the development of cataracts. They are so common that surgery to correct them is the most frequent of the major operations covered by Medicare.

  In reference to what is “the most common,” it will surprise no one who has ever had to raise his voice while speaking with an elderly uncle that the most common of all chronic health issues among men over sixty-five is significant hearing loss; though somewhat less frequent among women, it is nevertheless a problem hardly restricted to the aging male. Lifelong exposure to noise worsens a difficulty that is due primarily to degeneration in the auditory nerve and in the cochlea, the snail-shaped inner ear structure that contains the essential organs of hearing. But here, too, variations among individuals can be enormous, especially since the decibel level in which people live and work varies so widely. Incidentally, another of the reasons not to smoke is the increased likelihood of hearing loss that occurs in the later years among
those who do.

  By now, there have appeared in this chapter enough warnings about the dangers of smoking that they may have become tedious. Nevertheless, be prepared for another one, which I can best illustrate by describing the most useful method I have ever discovered to influence my patients to quit cigarettes. Early in my surgical practice, I began to notice that there was a particular clue that was virtually foolproof in identifying a heavy smoker immediately on greeting her in the consulting room, and it was as plain as the nose on her face. I have chosen “her” rather than “him” to describe the phenomenon because this particular bit of evidence is more noticeable in women, and somewhat less obvious in men. I refer here to a specific pattern and distribution of very fine wrinkling that gradually merges into a greater degree of coarseness as the years of not kicking the habit go on and on. The hair-thin lines appear first in the skin at the corners of the mouth, and then advance with time to involve the area below the nostrils and laterally on the cheeks, as well as the corners of the eyes—the so-called crow’s-feet. The more delicate the skin over any particular location, the more wrinkling occurs. Barely noticeable in their early years—which are usually the late thirties or early forties—these lines progress over perhaps a decade until it is impossible not to be aware of them once their significance is known. They look quite different from the usual subtle aging changes that begin to make their appearance at this age, and become even more obviously different as time passes. By the fifties, the skin of a moderate to heavy smoker’s face has taken on features that are unmistakable, and looks more weather-beaten and older than her non-smoking sister’s. Simply stated, the face of a middle-aged smoker looks older than the face of an abstainer.

  Every experienced physician knows that fear of cancer, emphysema, or any of the other serious problems that a smoker’s flesh is heir to convinces few relatively young people to give up cigarettes. And so it became my custom, immediately after the introductory smile and greeting, to ask suspect new patients a single brief question: “Why do you smoke so much?” When my suspicions proved correct, which was almost always, the response was in most cases an alarmed glance and some variant of “How can you tell?” Though I have no statistics, I do know that I started far more smokers—particularly women—on the road to abstinence by this appeal to vanity than I ever succeeded in doing by invoking the specter of disease.

  Some years after initially making this observation, I began to find reports in medical literature confirming it, and suggesting reasons why the wrinkling occurs. Apparently, the tiny arteries supplying the skin of the face are particularly susceptible to the narrowing effects of nicotine, both acutely with the spasm caused by each cigarette and chronically with the gradual buildup of obstructing material on the arteries’ lining, which effectively obliterates them. The cumulative result is loss of blood supply, most manifest in the finer parts of the skin. A smoker at sixty looks like an abstainer at seventy.

  Though smoking does worsen almost all of them, other aging changes in the skin—which, by the way, is our largest organ—are less under our control. The one exception is the ultraviolet irradiation of the sun, about which most of us can do a great deal. Unlike chronological aging, which is directly proportional to time, so-called photoaging is more related to level of skin pigment and degree of exposure. And it is also unlike chronological aging in the appearance that results from it. The appearance of chronological aging tends to be skin that is pale, smooth, and finely wrinkled, whereas the appearance of photoaging is more commonly skin that is coarsely wrinkled, darker in color, and often disfigured by spidery superficial blood vessels and brownish blotches as well as occasional superficial thickenings, some of which are in fact premalignant lesions. Since the fundamental molecular changes for both conditions have been shown to share certain characteristics, it behooves all of us, and particularly those with light-colored skin, to avoid direct sunlight as much as possible, and at appropriate times to take advantage of the various highly effective sunscreens now available.

  The skin is in a sense the show window of our years, and we tend to watch with dismay as it becomes wrinkled, lax, and less resilient with time. The wrinkling occurs because collagen, the protein fiber that maintains firmness, is gradually lost; the same is true of elastin, the protein responsible for flexibility and, as its name implies, elasticity. Other compounds with the forbidding name of glycosaminoglycans keep the skin moist and supple by binding with water. Because all of these materials dwindle with time, the skin becomes dryer, thinner, and less buoyant, as does its underlying layer of fatty tissue, whose function is to protect the skin by a cushioning effect. Skin loses its former ability to recoil, an effect abetted by the same process of cross-linking among adjacent protein strands that promotes cataract formation in the eye and loss of elasticity in arteries. The number of nerve endings, sweat glands, microscopic feeding blood vessels, and pigment cells decreases. Accordingly, the skin is more prone to injury and delayed healing, factors that make the skin of the very elderly prone to sores, ulceration, and infection. These effects are most pronounced in body areas where the surface is thinnest, such as the face, hands, ankles, and tops of the feet. The scanter fatty layer, lessened circulation, and smaller number of sweat glands compromise the skin’s function of stabilizing body temperature, so the elderly are particularly prone to heatstroke, the effects of cold, and other manifestations of suboptimal surrounding conditions. Even healthy people beyond age sixty should be aware of such matters, and take account of them in tending to their general well-being—and their show window. But certain caveats are in order at any age beyond youth. Among them is that cigarettes and sunshine may cause cancer only in certain unlucky individuals, but we can be sure that their effects on all of us are universal: By prematurely aging the skin, they not only compromise our attempts to appear younger, but make us look older than we are.

  Unlike in organs such as the skin, aging changes in the kidney are relatively independent of anything we can do to lessen or accelerate them. The kidneys are yet another example of structures that continue to perform quite well in the great majority of people so long as they are not subjected to inordinate challenge. Among other manifestations of their loss of reserve capacity is a lessened tolerance to the intake of excessive salt or water. In all, approximately 20 percent of the elderly have some significant degree of kidney impairment, but only in one-quarter to one-half of these (amounting to 5 to 10 percent of the entire elderly population) is it marked. In other individuals, the normative aging changes—decreased kidney weight, scarring of the filtering units, and a lowering of blood flow to an eventual level of about half of what it was in young adulthood—have little effect on ordinary functioning unless hypertension, diabetes, or some other chronic or acute disease is present. Such illnesses decrease kidney function, and so may the pharmaceutical agents used to treat them.

  The aspect of the urinary tract that does tend to let some people—though far from the majority—down is the ability to control and pass urine. Because the aging bladder loses some distensibility, its capacity lessens and urination is more frequent. The situation is not helped by the onset of varying degrees of discoordination between the bladder muscle that pushes urine out and the finely tuned shutter mechanism that helps to keep it in, which must relax at precisely the right instant if all is to go well. A complicating factor may derive from the muscular and fibrous structures of the pelvic floor, which aid in the suspension of the bladder. These sometimes weaken with age, particularly in women who have had several children. This may lead to the annoyance called stress incontinence, perhaps best exemplified by the fortyish mother of three who, on being told a particularly funny story, is said to have laughed and laughed until she felt a little run-down. The muscular and fibrous weakening adds to the tendency toward major problems with incontinence that are experienced by certain of the elderly, particularly those who are somewhat debilitated. Incontinence and retention may contribute to infection, which in turn is an aggravating
factor to both problems, as are mental confusion, certain medications, and an enlarged prostate.

  Enlargement of the prostate is caused by aging changes in the complex relationship between the sex hormones and the cellular and fibrous components of the gland. Because the greatest resultant proliferation of cells occurs in the region around the urethra, some degree of hindrance of the urinary stream occurs in many men. The symptoms, which occur in approximately 30 percent of men, vary from occasional difficulty in beginning to void, all the way to complete obstruction, which requires some sort of medical intervention.

  Unlike the kidneys, the aging gastrointestinal tract is likely to become the source of symptoms of various kinds, though here, too, there is great variability among individuals. Acid reflux, constipation, diverticulitis, gallstones, swallowing abnormalities, susceptibility to bacterial gastroenteritis, decreased sphincter reliability, hemorrhoids—all of these are far more likely to plague the old than the young. But some of these changes are not, strictly speaking, due to age. Instead, they are caused—or at least abetted—by the generally sedentary patterns into which older people too commonly lapse. Many allow themselves to become far less mobile than they once were, to ingest fewer liquids and dietary fiber, and to take more questionably necessary medications, which may worsen any propensities to gastrointestinal problems. Of course, older people’s increased frequency of comorbid disease also worsens such propensities. The solution to some, but obviously not all, of these problems is often found in the greater activity that is the product of not thinking of oneself as over the hill.