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Identity in the fourth age: perseverance,

adaptation and maintaining dignity

LIZ LLOYD, MICHAEL CALNAN, AILSA CAMERON, JANE SEYMOUR and

RANDALL SMITH

Ageing and Society / Volume 34 / Issue 01 / January 2014, pp 1 - 19

DOI: 10.1017/S0144686X12000761, Published online: 06 August 2012

Link to this article: http://journals.cambridge.org/abstract_S0144686X12000761

How to cite this article:

LIZ LLOYD, MICHAEL CALNAN, AILSA CAMERON, JANE SEYMOUR and
RANDALL SMITH (2014). Identity in the fourth age: perseverance, adaptation and
maintaining dignity. Ageing and Society, 34, pp 1-19 doi:10.1017/
S0144686X12000761

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Ageing & Society , , –. f Cambridge University Press  
doi:./SX

Identity in the fourth age: perseverance,

adaptation and maintaining dignity
LIZ LLOYD*, MICHAEL CALNAN†, AILSA CAMERON*,
JANE SEYMOUR‡ and RANDALL SMITH*

ABSTRACT
The fourth age remains a poorly understood phenomenon and there is a lack of
understanding of the perceptions of those who might be considered to be living in it.
This article draws on findings from a study of dignity in later life which examined the
day-to-day experiences of participants who were in need of support and care because
of failing health. It discusses their accounts of the changes to their sense of self
and their identity that came about as a result of their ageing and health problems
and looks also at the ways in which the support and care they received helped to shape
their adjustment to those changes. The accounts given by participants reveal a great
deal about the physical, mental and emotional effort entailed in maintaining a
sense of self and highlight the essential role played by social relationships in
the maintenance of identity. These findings are analysed by reference to emerging
theories of the fourth age.

KEY WORDS – fourth age, identity, dignity, perseverance, relational autonomy,

adaptation.

Introduction

Within social gerontology the differentiation of third and fourth ages

represents an achievement in overcoming the stereotyping of old age as a
period of decline and dependency. The agency and choice of third-agers
contrasts with the loss of agency, associated with the fourth age, which until
recently has been paid less attention by gerontologists. This article seeks to
add to an understanding of the fourth age through an analysis of findings
from an empirical research project by reference to emergent theoretical
models. The idea of successful ageing, associated with the third age, is open

* School for Policy Studies, University of Bristol, Bristol, UK.

† School of Social Policy, Sociology and Social Research, Michael Calnan, University
of Kent, Canterbury, UK.
‡ Sue Ryder Care Centre for the Study of Supportive, Palliative and End of Life Care,
University of Nottingham, Nottingham, UK.

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  Liz Lloyd et al.

to criticism for a failure to acknowledge its inevitable end. In Twigg’s

view (), optimistic accounts of the third age that have emerged have
been made possible only by projecting into a dark fourth age all the
problems and difficulties associated with ageing, while Gilleard and Higgs
() referred to the fourth age as the ‘bitter fruit’ of the victory of the
third age over association with old-age decline. It is timely, therefore, to pay
attention to the ways in which the fourth age is understood in terms of old-
age identity. The article traces key theoretical ideas concerning the fourth
age, discusses data from a study of dignity in later life and considers how
the data can contribute to a fuller understanding of older people’s identity in
the fourth age.

Theorising the fourth age

For Gilleard and Higgs, far from being a stage of the lifecourse that follows
sequentially from the third age, it is it is when others determine that an
individual is no longer able to manage their everyday lives that they become
subjects of the fourth age. They developed the metaphor of the black hole to
describe how the fourth age exerts a gravitational pull and generates an event
horizon – a point beyond which there is no return and in which the absence of
light renders it unknowable. Through this dramatic metaphor, Gilleard
and Higgs emphasise the fear of institutionalisation, of ‘passing beyond
the possibility of agency, human intimacy or social exchange’ (: ). It
is within the power of others – professionals and carers – to determine when
an individual has lost the capacity for self-care and management of everyday
life and thus makes the transition over the event horizon into the fourth
age. In contrast, longitudinal research in Finland by Heikkinnen ()
identified how older people described their own perception of having
crossed a boundary into old age. Participants referred to this boundary as
defined by their chronological age ( appeared to be an important marker)
in combination with deterioration in functional health, senses, memory and
mobility as well as bereavement. Heikinnen referred to the markers of
functional limitations (canes, walkers, wheelchairs) as a prelude to the end
of life and regarded these as marking a separation between how older people
see themselves and how others see them. Coleman and O’Hanlan ()
argued that positive meanings are needed for the last stage of life for the sake
of older people but also, more broadly, to overcome the contemporary
cultural failure to engage with conditions of physical decline and the end of
life. However, Gilleard and Higgs maintained that such attempts have proved
futile and that the fourth age is better understood as a ‘social imaginary’, a
place that is ‘stripped of the social and cultural capital that is most valued’
(: ).

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 Identity in the fourth age 

Twigg called for a wider perspective that highlights the diversity of

people’s experiences and that will ‘wrestle the account of old age out of
the hands of experts’ (: ). However, Gilleard and Higgs ()
questioned whether the fourth age can be properly understood from
personal experience, because it is impossible to separate what occurs within
it from what is projected into it, since it is framed by the institutional
structures associated with modernity. The view that the fourth age is shaped
by the institutional practices of welfare also draws attention to the influence
of demographic trends and the contemporary concentration of morbidity
and mortality in the oldest age groups (Lloyd ; Vincent ).
Concerns about rising levels of demand from higher numbers of people
living to very old age has resulted in greater restrictions on eligibility for
help and support from health and care services in most welfare systems. The
perception of older people as burdensome is reinforced by such develop-
ments and adds to the pressure on older people not to be seen as having lost
their capacity for self-reliance.
The concept of the ‘arc of acquiescence’ developed by Higgs and Rees-
Jones () describes metaphorically the trajectory of ageing, tracing
the process of gradual withdrawal from successful body maintenance and
acceptance of bodily limits. Higgs and Rees-Jones () drew on
Bourdieu’s observations about the process of social ageing as ‘nothing
other than the slow renunciation or disinvestment (socially assisted and
encouraged) which leads agents to adjust their aspirations to their objective
chances, to espouse their condition, become what they are and make do with
what they have’ (: –). In popular discourse this might be described
as ‘growing old gracefully’, which sees dignity in acceptance of the material
reality of bodily ageing. Within gerontology, the terms ‘renunciation’,
‘disinvestment’, ‘withdrawal’ and ‘adjustment’ are contentious, calling to
mind the much-rebuked disengagement theories proposed by Cumming
and Henry (). However, they also denote a degree of choice and
control over decisions and behaviour. If, as Higgs and Rees-Jones ()
argue, it is the loss of agency over the body that characterises the fourth age,
the process of renunciation requires careful analysis.

The end of life: social and biological death

Discussion of the fourth age often concerns the contrast between third and
fourth age. A focus on mortality generates a shift of perspective. In Twigg’s
view it is the closeness of the fourth age to death that provides one reason
why this period lacks meaning and is understood simply as a period of
decline, since death in modern secular societies is without meaning. Lawton
() referred to the extended period of ‘liminality’ experienced by older

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  Liz Lloyd et al.

people in contemporary Western societies – a form of social death that is

experienced prior to physical death. The characteristics of a social death
need to be understood by reference to the meaning of social life in any
cultural context. In contemporary Western cultures the high value placed on
individual autonomy and independence inevitably exacerbates the impact
of the loss of these. Hence, Lloyd described the conditions of dependency
experienced by older people in the period prior to death as ‘an abyss into
which each of us must avoid falling’ (: ), which also points to the
moral obligation placed on individuals to maintain a self-sufficient existence.
Lloyd () drew on Bauman’s observation that dependency on one’s
mortal body is the ultimate dependency, the ultimate limit of autonomy and
the reason why, in the end, the battle for mastery over the body cannot be
won (Bauman ). From this perspective, the fourth age needs to be
understood by reference to the relationship between social and biological
death.
Lawton () pointed to a sense of existential fatigue, associated with the
loss of a sense of self, which was evident among her research participants in
the period of decline prior to death. She described how participants often
divested themselves of possessions and argued that this behaviour emerged
from a decline in their ability to act in embodied ways. There was a marked
contrast between this behaviour and what had become an expectation on
dying people to live until they die through a heroic battle against impending
death. The existential fatigue Lawton observed was characterised by hospice
staff as ‘apathy’ or ‘withdrawal’ and was considered to be a problem. Such
heroic ideas about dying, which hold that the end of life can mark an
integration of the self, have largely been developed in the context of cancer
care where a terminal diagnosis enables the agentic individual to exert
control over the conditions of their dying. With long-term and complex
health conditions, older people frequently do not fit this ideal (Gott et al.
).

Identity, autonomy and dignity

The typification of the fourth age in terms of decline and dependency
suggests that older people would be likely to have their dignity, in the sense
of their identity and autonomy, threatened both collectively as citizens
and individually in everyday interactions (Nordenfelt ; Woolhead et al.
). However, the characteristic of the fourth age, at least according to
Higgs and Rees-Jones (), is the loss of agency over the body and more
crucially in terms of the implications for identity, the impact of cognitive
decline. It is claimed that when the body fails, the ageing experience
becomes more manifest as caring for oneself becomes problematic. Thus the

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 Identity in the fourth age 

concept of dignity is closely associated with the fourth age and with death
itself because the potential for loss of dignity at this time is strong (Nordenfelt
; Tadd and Calnan ). The combined effects of ageing, illness and
disability characteristic of the fourth age change irreversibly a customary
way of life and call into question one’s sense of self. Dignity is central to
understanding older people’s accounts of such changes in their circum-
stances and the effects these have on their identity.
The dignity of identity was described by Nordenfelt () as the dignity
that ‘we attach to ourselves as integrated and autonomous persons, with
a history and a future’ and with relationships to other human beings
(: ). For Wainwright and Gallagher (), the tying of the dignity of
identity to autonomy and bodily integrity is problematic, since it would mean
that changes associated with ageing will inevitably lead to a loss of dignity.
In response, Nordenfelt () argues that his conceptualisation of the
dignity of identity is underpinned by the more fundamental concept of
Menschenwurde, or the dignity of human value. Menschenwurde, according to
Nordenfelt, relates to the dignity of being human and pertains to all human
beings to the same extent. The basis for it derives from the core human
capacities of consciousness and self-consciousness, self-determination and
autonomy. However, the idea of human value as contingent on these core
capacities raises questions about how dignity can be sustained when they are
lost. If, as Gilleard and Higgs () argue, the fourth age is characterised by
a loss of agency and shaped by institutional practices, it would follow that
dignity in the fourth age becomes dependent on the behaviour of those who
assume responsibility for older people.
Nordenfelt’s typology is also open to criticism from an ethics of care
perspective (Held ) in which the self is understood as relational rather
than as individualistic. Within the ethics of care, it is argued that the ideal
of the human being as autonomous, conscious and self-determining allows
no room for the conditions of dependency that all human beings experience
at different stages of the lifecourse, infancy and dying providing the
clearest examples. The key point in the ethics of care is that conditions
of dependency should not be understood as an aberration but as integral
to human life. As a consequence of this cultural rejection of human
dependency, it is argued, the giving and receiving of care has been excluded
from public life and confined to the private sphere, in which the norms of
citizenship are attenuated or cease to apply entirely. From this perspective,
that ‘the battle for mastery over the body cannot be won’ (Bauman )
is a social not merely an individual or professional concern. Relational
autonomy holds that it is through engaging in relationships with others that
identities are formed. Changes in identity across the lifecourse need to be
understood as inextricably linked with changes in intimate and wider social

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  Liz Lloyd et al.

relationships. In old age, this includes increasing relationships with

professionals and carers.
Certainly, evidence from recent studies (Woolhead et al. ) suggests
that it is in contact with health and welfare services where dignity, identity
and independence are most threatened, thus lending support to Gilleard
and Higgs’ view that institutional practice shape the conditions of the fourth
age. However, institutional practices are capable of being manipulated and
changed. There is also evidence (Baldock ; Lawton ; Twigg )
that older people manage to negotiate and maintain a fragile sense of self in
the face of increasing illness and disability and struggle to be seen as having
lost their autonomy. Higgs and Rees-Jones () suggested that the impact
of individualisation and consumerism within health and social care generate
points of conflict in the relationship between the public, on the one hand,
and health-care systems on the other. They depict three, which are likely to
affect the transition from third to fourth age: first, pursuing claims and
questioning institutional discretion and rationing; second, becoming more
resistant to decisions by outside parties to move them into formal categories
of the fourth age; and third, becoming more vulnerable to exploitation and
abuse within welfare markets because of their compromised autonomy.

Maintaining dignity in later life: an empirical study

This section outlines selected findings from a recently completed study in
the New Dynamics of Ageing Programme: ‘Maintaining Dignity in Later Life’
(ESRC RES---). This study examined the experiences of a group
of  people aged  and over (with one exception aged ). All had health
problems that had generated varying degrees of need for support and
care. The overarching aim of the project was ‘to identify factors perceived to
promote or undermine a sense of dignity in older people in need of support
and care’. The research focused on four questions:

. What do participants’ accounts of their everyday life and relationships tell

us about dignity?
. What factors are perceived to support or undermine a sense of dignity?
. How do they manage the transition from self-reliance to dependence
when circumstances change?
. How do they see the future?
These questions are central to developing an understanding of changed
identities in the fourth age, since they focus on the conditions that
challenged participants’ independence and self-reliance and placed them
in a position of increased dependency on others. Moreover, because of their

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 Identity in the fourth age 

T A B L E . Participant characteristics

N
Men 
Women 
Aged – 
Aged – 
Aged  + 
Home owner 
Married/living with partner 
Widowed 
Divorced 
Single 
Have children alive 
Left elementary school at age / 
Additional training/school 
University educated 
Total number of participants 

health problems they faced increasing bodily decline and loss of indepe-
ndence as they faced death at a near but uncertain time. Through a longi-
tudinal qualitative methodology, participants’ accounts of their lives and
their experiences of care were explored. This provided a means by which we
could examine how participants’ changing circumstances generated changes
in their sense of self and identity. Ethical approval was obtained through
the Frenchay NHS local research ethics committee (LREC). Participants had
the capacity to consent to be interviewed throughout the study.

The participants
The  participants (Table ) were based in Bristol () and Nottingham
(). During the course of the study six participants died.
All but one woman of South Asian origin were White British. All
had been employed previously, or had run their own business, occu-
pations including mining, factory work, fire-fighting, skilled engineering,
clerical work and the law. Twenty-eight of the participants were recruited
from three general practitioner (GP) surgeries and six from a day centre.

Methods
In-depth interviews focused on day-to-day events and decisions, participants’
recollections of the past and their thoughts about the future. With some
exceptions (such when a death occurred) each participant was interviewed
in depth four times between May  and December  and was
contacted by telephone from time to time between interviews. Nine

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  Liz Lloyd et al.

participants were visited on a fifth occasion because there were particular

events or decisions occurring that we wanted to capture. Participants were
invited to nominate a supporter for the duration of the study and most of
these were spouses or partners. The longitudinal qualitative methodology
enabled us to adopt a relatively unstructured approach to interviewing, to
raise sensitive topics at appropriate times and to enable participants to raise
issues of importance to them. This was particularly valuable in relation to
talking to participants about their thoughts about the future and their
preparations for the end of life.
Data analysis was informed by the approach outlined by Spencer, Ritchie
and O’Connor (). Interview transcriptions were analysed throughout
the fieldwork process to identify emergent themes. After field work was
completed all transcripts were re-read and conceptual themes developed. It
should be emphasised that although the topic of dignity was introduced in
the first interview, it became evident that the most productive way to explore
the concept was indirectly rather than directly. For example, the interview
data that focused on participants’ increasing need for help and their
perceptions of their loss of self-reliance were analysed by reference to the
concept of the dignity of identity.
In the following discussion of findings, pseudonyms are used and
participants’ ages at the outset of the study are given in brackets.

Dealing with ageing and changed health

During the course of the study the circumstances of every participant
changed in ways that posed a challenge to their identity. All participants’
health changed for the worse, overall, although there were also examples of
recovery and remission within the overall picture. Twelve had serious falls
that required hospital treatment and seven had new diagnoses of serious
illnesses such as cancer and heart and kidney failure. Some who were
seriously ill at the outset had periods of relative stability whilst others
experienced complications or developed new and troubling symptoms
(including paralysis, bleeding and severe pain) that were not diagnosed
satisfactorily. Eight participants gave accounts of improvements in health as
a result of treatment or changed circumstances. One broke his shoulder in
a fall on the ice but through exercise recovered his ability to drive. Two came
off medication after reviews and found that their health improved as a result.
Another had poor health overall and felt she was ‘going downhill slowly’ but
described the effect of her cataract removal as ‘amazing’, as it meant she
could watch the cricket.
Five participants moved to a care home or to more sheltered housing as a
result of poorer functional health and failing mobility. Most faced decisions

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 Identity in the fourth age 

such as whether or not to have surgery on hips, knees and ankles or to use
walking sticks, Zimmer frames or electric wheelchairs. One participant used
an electric wheelchair so that he could continue to do his supermarket
shopping but hated having to ask for help to get items from the higher
shelves. He was unable to use the wheelchair to go to the post office because
other customers complained about the space it took up. How participants
made adjustments to their daily round thus depended on their view of
themselves, how they should present themselves in public places and how
others behaved towards them as well as how easy it was to get around the built
environment.
Several participants were faced with decisions about medical treatment
and whilst the majority opted to go ahead with it, others refused. Some took
the view that the treatment entailed more trouble than the disease itself
while others felt that as they were approaching the end of their time further
treatment was pointless. Three decided against chemotherapy for that
reason, while another said he would prefer to die of a heart attack than
live for a longer period with Parkinson’s disease and so refused heart
medication.
Maintaining a focus on participants’ perceptions of their experiences over
the course of the study also shed light on the significance of changes and
decisions that might at a superficial level appear relatively unimportant
but which evidently affected their sense of self. For example, seven out of
 participants who were drivers at the start of the study had to give up
because of failing eyesight or worries about safety. Others described the
loss of cherished long-standing activities, including theatre-going, garden-
ing, knitting, walking and dancing. The sense of identification with these
activities was sometimes carried over into newly adapted ways of living. For
example, one described himself as ‘a walker’ who would like to be fit enough
still to be walking around the coast-path of Britain but who instead used his
Nordic walking poles for support on his daily walk around the park. On the
whole, though, it was a sense of loss that came across most strongly.
Close relationships changed significantly for several participants and
worries and concerns about families featured strongly. Examples included
when a son or daughter was bereaved or divorced or faced a serious health
problem, when their relationship with their son or daughter was strained or
when a grandchild stopped visiting them. One participant separated from
her husband. Eight participants were bereaved of close family members
or friends. One participant died shortly after his wife’s admission to a
care home. At times the deaths of friends served as a sharp reminder of
impending mortality. Referring to the death of a neighbour, Daniel ()
described how he was thinking of ‘somebody sitting in a very big high
chair . . . with a shortlist, ticking us off’.

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  Liz Lloyd et al.

Participants’ accounts often encapsulated a sense of precariousness

about the present and great uncertainty about the future. As Doreen ()
expressed it:
Well . . . I’d be quite happy if we could stay as we are, but . . . I mean as things go,
I mean I realise uh . . . what’s happened in the last five years has sort of uh . . . there’s
quite a bit changed for us – had to change. And in the next five, I don’t know what will
happen, or the next one or two really.
This sense of precariousness was reflected in participants’ language, which
was peppered with expressions such as ‘any more’ (as in ‘I can’t manage the
garden any more’) and ‘still’ (as in ‘I can still cook my own food’ or ‘I’ve still
got my marbles’). The term ‘still’ was generally used about their continuing
physical abilities but was also used in reference to relationships, beliefs,
desires and preferences. An associated term ‘as long as’ links what they are
still able to do with what this means for the future, including, crucially
whether or not they can remain living in their own home. The term ‘as long
as’ conveys a great deal about participants’ own health and capacities but also
their relationships and their resources. For example, some managed
everyday things as long as they were part of a couple and this led them to
ponder what would happen when one of them died. Terms used about the
future were often quite non-specific: ‘when the time comes’, was a common
phrase, as in ‘when the time comes we would have to get help’. Participants
quite frequently would touch wood when talking about the future or
describing the effort that went into still being able to do something. The
concept of the ‘social imaginary’ is highly relevant here, as some participants
were reluctant to elaborate on their thoughts about ‘when the time comes’.
Fatalistic attitudes were not universal, however: some participants had given
quite a lot of thought to whether it would be preferable for self or spouse to
die first and had discussed the advantages and disadvantages of different
possible scenarios. Others had discussed with their sons and daughters
whether or not they wished to be resuscitated, although only a small minority
had committed their wishes to writing officially.
The precariousness of participants’ lives was also reflected in the way in
which they talked about the onset of health problems. Most regarded their
illness as representing a step-change in their age identity and they often
expressed surprise about how their lives had changed so completely.
Funnily enough, I didn’t think about [ageing] a lot until the stroke happened.
(Graham, )
It’s a complete reversal of my life. (Andrew, )
I feel like a fish out of water. (Lena, )
I was fine until I was about  and then everything fell apart, you know. (Howard, )

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 Identity in the fourth age 

Most referred to ageing as something that had happened to them, had come
upon them from outside and for which nothing could have prepared them,
so reinforcing their sense of precariousness:
Getting older: it’s just sort of sprung on us isn’t it. (Doreen, )
You turn around and . . . gosh I’m  – how did it happen? (May, )
[Referring to his knee problems] That’s when I knew old age was upon me and no
two ways about it. (Brian, )

Comments about ageing were almost entirely negative, with only one
exception, when a participant commented that in old age ‘you can do what
you like’ (Frederick, ). At the time Frederick also said that he did not really
feel old anyway, although comparing himself with his older neighbour made
him anxious about the future. Functional health was the dominant theme in
discussions about old age with several commenting that ageing did not
bother them as long as they could ‘get about’. Several expressed a strong
desire to face up to old age with determination and willpower and a belief in
exercising mind over matter. ‘Not letting it beat me’ was one expression, ‘it’
being an abstract way of describing how sickness posed a threat to one’s way
of life and to life itself. For some, being determined (as opposed to giving
up) was an important affirmation of individuals’ will to live and their sense of
moral identity.
Participants’ views were not always consistent but taken as a whole
reflected a sense of turbulence and instability. At times they differentiated
between desire and realism, describing a reluctant and growing awareness
that their wish to continue life as they wanted to was unrealistic and they
had to be sensible. Bourdieu’s observation about adjusting aspirations to
objective chances is highly relevant to this phenomenon and the accounts
given by our participants reveal how complex and demanding a task this is.
I suppose we’re independent to the point of being daft about it . . . The
things I could do I know I can’t now. We’ve just had this house painted because
it’s no good getting the ladders out. I can’t run up and down ladders now. (Peter, )
I know I’ve done the right thing [moving to a care home] but there’s still that little
‘I wish I wish’, you know. (Brenda, )
These examples illustrate the imperative to adapt to changing circumstances
over which, ultimately, participants would have no control. Being sensible
was a way of accepting the inevitable but this was not the same as giving in
to illness. Edward () said, ‘I don’t sit in a chair all day and stay there, you
know’. Despite his serious illness and his need to use a motorised wheelchair,
he did not identify himself with the ‘old dears’ – mainly women – at the club
where he played the dance records, although he saw himself as ‘hampered’
by his tendency to fall.

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  Liz Lloyd et al.

The bodily effects of ageing

Participants described the effect of illness on their bodily appearance and
how this made them feel. Examples include having to wear bandages, not
being able to wear shoes, facial swelling, rashes and sweating as well as
concerns about body odours associated with incontinence. There were also
effects on personal relationships, including for one the effect of a colostomy
on his sex life, for another his inability to bring his wife a cup of tea because
of tremors and one couple the need to sleep in separate rooms because
of disturbed nights. All participants referred to their loss of strength and
energy – typically described as ‘slowing down’ – and to the need to adapt
the timing of their everyday activities accordingly in order to maintain self-
reliance and independence.
All participants were health-conscious in the classic sense of preventing
illness. None smoked, although most had in the past. Their close attention to
diet and exercise was much as might be expected in any age group although
for some it was the onset of illness that had encouraged this closer attention.
All participants described the things they did to keep ‘with it’ and mentally
alert, including word puzzles, jigsaws and reading.
Participants monitored their health carefully, attending clinics for tests
of blood, urinary and faecal samples as well as blood pressure, vision and
hearing tests. These were regular occurrences for some and part of the
process of diagnosis for others. Participants also monitored their medication
and there were several examples of decisions to stop medication because of
its side-effects. Information to support decisions was obtained from doctors
but also from friends and family, the internet or in one case from contact
with the pharmaceutical company. Of the  participants alive at the end of
the study  had refused, changed or stopped prescribed medication and
a further five had discussed with their doctors their wish to change. These
decisions were sometimes relevant to participants’ sense of self. As Margaret
() said, ‘I’ve never been a pill-taker’. Participants also managed the
functional limitations arising from their illness in ways that required
ingenuity and skill. Examples included stoma care, management of
continence problems, limb massage, eye drops, ear drops, mouthwashes
and injections. There were also new activities to be learnt arising from
impaired memory, including the use of medication organisers, notepads and
pre-set dialling on telephones.
In addition there were changes related to what Archer (), drawing
on Merleau-Ponty (), referred to as the ‘habitual body’. This term
describes those activities associated with a deeply ingrained memory,
which differs from cognitive thought and which is lost through illness and
incapacity. The descriptions participants gave of the loss of balance, their

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 Identity in the fourth age 

failing abilities to hear and see what is going on around them as well as
the changes in their bodies as a result of colostomies, mastectomies or
hernia can all be understood as disruptions to the habitual body. There were
numerous instances of re-learning everyday habitual activities, including
standing up from a sitting position, using the lavatory, walking up and down
stairs, bending over to pick things up from the floor, lifting the arms to hang
the washing and stirring a cup of tea.

Asking for help

Participants’ views on whether or not to get help varied in terms of whom
they turned to, for what reason and in what circumstances. Having to ask
for help was regarded by most as wholly out of character. Four expressed a
strong preference not to have any help at all and when they did receive help
they did not always perceive it as such. Andrew () paid for a driver when he
became unable to drive his own car but still maintained that he ‘managed
everything’ himself. Frederick () changed his view about asking for help
during the icy winter of , when he realised for the first time that
neighbours were willing to lend him a hand, which gave him more
confidence about asking for help more generally.
Most participants placed conditions on being helped whilst others were
more relaxed because the help they received improved their quality of life.
Most resisted asking for help for as long as possible, seeing virtue in self-
reliance and independence. One participant, indignant about the idea that
she could sit and watch someone else doing ‘her work’, sacked the cleaner
that had been employed by her daughter following knee surgery. Some
opted for technological solutions, such as on-line shopping, talking
microwave ovens and adaptations to the home in order to retain their self-
reliance for as long as possible.
Participants’ choice of where they turned for help highlighted differences
between them. Whilst some dreaded becoming dependent on their
families others dreaded the thought of having strangers in the house. For
the majority ( of the ), a mixture of family and paid help was the
usual pattern. The manner in which help was given was very important, as
came over clearly in participants’ accounts but again, personal
preferences highlighted differences. One man hated it when people
helped him to his feet when he fell while others appreciated the kindness
of strangers in similar situations. Paradoxically, help from families was often
described not as help at all but as protecting participants’ independence. For
example, when a wife helped her husband out of bed so that he was ready
for the care workers, this was described as ‘helping him to keep a bit of
independence’.

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  Liz Lloyd et al.

A typical pattern was that help was accepted for particular activities,
generally the heavy jobs, such as shopping, gardening and decorating.
The prospect of being helped with personal care and of strangers seeing
their naked bodies was unimaginable for some and when the topic of
dignity was raised in the interviews it was often this that participants talked
about. Reflecting an awareness of the impact of institutional practices,
Adrian (), said: ‘They don’t think about it but you think about it’. Andrew
() declared at the outset that when he reached the point of needing
personal care he would carry out his planned suicide. On the other
hand, Harry () described how it was not as bad as he had thought it
would be and that the care workers were so kind and thoughtful that he
and his wife grew very fond of them. Others described how they would
accept help in particular circumstances for ‘a proper reason’, as one
expressed it, highlighting the moral nature of such decisions. Bouts of
illness, broken limbs or post-operative weakness provided acceptable
circumstances for asking for help and there was no guilt attached to
receiving it. ‘I had no choice’ was a sentiment commonly expressed in such
circumstances.
Reciprocity was also an important element in participants’ accounts of
help and support. Some – both men and women – were or had recently
been carers to their spouses, involved in all aspects of care, including
bathing and food preparation. The majority talked in more general ways
about what they were able to give their families and friends, which
included advice, financial help and accommodation. Typically, those who
gave up driving gave their car to a family member who in turn would
give them a lift when needed. Decisions about whether or not to give up
the family home and move to sheltered housing or a care home also
took into account the emotional and financial needs of sons and
daughters.

Relationships with families and friends

For most, help received from families and friends meant a great deal more
than merely practical assistance. Participants’ descriptions of their close
relationships conveyed the importance of the sense of security and
protection they provided. Some referred to the family members and friends
that could be relied upon to act on their behalf, such as when the time came
for decisions about whether or not to go ahead with medical treatment.
Families and friends were also a valued source of support in making
decisions about when help was absolutely necessary or what constituted a
proper reason for help. Usually this entailed family members pushing
participants towards receiving help sooner than they wanted to. Bearing in

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 Identity in the fourth age 

mind the conflict described above between ‘being sensible’ and being
independent ‘to the point of being daft about it’, the role of families can be
understood as a kind of foil or a sounding board that enables the individual
to settle on an acceptable solution to problems associated with illness or
disability. Families thus play a central role in maintaining agency and a sense
of self through the process of change and adaptation. Families and friends
could also often be relied upon to know and understand a participant’s
needs and at times this could smooth the difficulties or embarrassment
associated with loss of capacity in public situations, such as the need to use a
lavatory or to have food cut up in a restaurant.
The accounts of participants’ positive relationships with families and
friends stand in stark contrast to the negative accounts of the small minority
who were isolated, estranged from family or whose family relationships were
unhappy. Strained or lost family relationships exacerbated feelings of
precariousness and vulnerability. For example, Dorothy () left her
husband to go into sheltered housing for the sake of her health. Jonathan
() became depressed at his growing dependence on his wife and anxious
about his loss of power in the relationship because he knew he was in a
position where she could bully him, while May () felt she had to guard her
tongue in case her son stopped visiting as he had before. The unhappy family
relationships that came to light in the study were without exception a
continuation of problems earlier in life, such as estrangements from sons,
daughters and grandchildren caused by divorces or rows over money. On
occasion, when reflecting on how things had gone wrong, these participants
were emotionally overwhelmed by regret or a continuing sense of injustice.
Brian () was discharged from hospital into a care home when it was
decided that this was in his best interests because he was unable to care for
himself and there was no-one who could provide the kind of care he needed
at home. He complained bitterly about this decision, describing how he was
all alone ‘fighting a battle with very poor ammunition’. He died within weeks
of this move, describing his life as ‘pointless’. He harboured the vain hope
that the right person would turn up who could be his housekeeper and
enable him to leave the care home.

Health care
The argument that biomedicine has come to define the fourth age, as
argued by Twigg (), was borne out by this research, but perhaps in
more complex ways than is sometimes acknowledged. Arguably, it was their
engagement with treatment, health maintenance and the management of
illness that helped to maintain their agency and provided shape and
direction to their everyday lives. Most participants said they were happy on

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  Liz Lloyd et al.

the whole with their experiences of the health system. However, they also
described the demanding levels of activity entailed in visits to GP surgeries or
hospital outpatient departments. Visits to hospitals often meant long bus
trips or expensive taxi rides. Only a small minority had access to hospital or
community transport. Hospital appointments went wrong fairly frequently,
medical notes were lost and transport arrived after the time of appointments.
In one extreme case a participant was kept waiting for five hours in a waiting
room because the receptionist failed to log her attendance. In all, 
participants gave specific examples of unacceptable treatment, which at
times dealt a severe blow to their self-esteem. For example, James () was
laughed at when he raised questions about the effect of proposed
medication on his sex life while Frederick () was told by an eye specialist
that he was ‘not very bright’ when he became confused in his description of
his eye problems.

Conclusions

This study highlights the problems associated with trying to pin down the
features that are characteristics of the fourth age. The physical, mental and
emotional labour demanded of participants to enable them to manage the
changes in their lives was immense. The term used by some, which
encapsulates what was described by most, was ‘perseverance’, a term that
arguably lies somewhere between resistance and acquiescence (Gilleard and
Higgs ). The term persistence conveys participants’ engagement in a
continuous reflexive process between mind and body, a process that was
punctuated by episodes of change in individual health and abilities
and which occurred within familial, social and cultural contexts as well as
by reference to earlier lifecourse experiences. All were conscious that
decline was inevitable but they had not given up on the exercise of will and
self-determination. The decisions they made to maintain their health, to
manage their illness and to get help were carefully and thoughtfully made.
The need to accept the realities of life, to be sensible and make the most of
what they had was recognised but adjusting to the inevitable did not
necessarily lead to a loss of control. Hence there was a continuation of
individual identity, even in their recognition of how dramatically their lives
had changed. Adaptation was essential to survival and could only be achieved
through perseverance.
Gilleard and Higgs () considered it impossible to understand the
fourth age in terms of individual experience. This study lends support to the
view that the fourth age cannot be defined by reference to specific
characteristics, such as the combination of chronological age and declining

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 Identity in the fourth age 

health. Examination of their accounts of their day-to-day experiences

highlights participants’ continuing agency in maintaining their sense of self
and their dignity of identity, including in situations that posed a serious
threat to it. Thus, it was certainly not the case that a loss of agency, in the
sense of increasing subjection to the will of professionals, could be traced
over the period of the research. It is important to note that all participants
retained mental capacity throughout the study and this probably goes
some way to explaining how they retained a sense of self and a degree of
control over their lives, despite the episodes of poor treatment most had
experienced. Brian’s experience of being obliged to accept a move to a care
home was unique and even in these circumstances he did not lose his sense
of identity. He was acutely conscious that his life had been stripped of social
and cultural capital, as described by Gilleard and Higgs ().
The question of the role of professionals and carers in determining
when participants had crossed the event horizon is highly complex and
the differences between professionals, as described by participants, were
striking. Some doctors offered treatment beyond the point when partici-
pants had expected it and participants were thus able to exercise choice. In
contrast, the blatantly ageist attitudes of others highlighted participants’
vulnerability to the abuse of power. However, the indignation expressed by
participants suggests that while such encounters shook their sense of self and
personal dignity they did not destroy it.
The depiction of the fourth age as a dark and unknowable place (Gilleard
and Higgs ) was reflected in the vague and fatalistic expressions
participants made about the future and the concept of an event horizon was
evident in the use of terms such as ‘still’ and ‘as long as’. Arguably,
participants’ perseverance was necessary to keep themselves on the right side
of the event horizon and from being sucked into the black hole. These
expressions might also be interpreted as a deliberate decision to ‘shelve’
concerns about the future in order to maintain their capacity for day-to-day
perseverance. Even when compromises were made or decisions about
accommodating their functional decline were taken these were seen as
having the effect of maintaining their identity and dignity. Within
participants’ references to their functional abilities in temporal terms
(such as ‘still’ or ‘as long as’) there was recognition that at some stage in the
future the capacities that gave their lives shape and meaning would be lost.
Within participants’ accounts of perseverance were hints and suggestions
that a process of existential fatigue was beginning. The weariness and
exhaustion that many talked about was frequently expressed in general not
specific terms. As Jonathan () expressed it: ‘I’ve still got my life about me
but the flame is getting less’. As in Lawton’s () study discussed above,
there were several examples of participants making decisions and divesting

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  Liz Lloyd et al.

themselves of possessions, which could be understood as marking a shift in

their identity as they prepared for the end of life. Although their dying
trajectories might not conform to the script of a heroic death, they were in
control of their decisions and actions.
The differences between professionals also highlight how the circum-
stances of social death described by Lawton () are socially constructed
and capable of modification. This raises the question of whether, as Gilleard
and Higgs () argued, attempts at overcoming cultural failure to engage
with conditions of physical decline at the end of life are futile. The findings
from this study lend considerable support to the concept of relational
autonomy. The changes to existing relationships, the loss of old friends and
spouses as well as the increasing contact with doctors, community nurses and
care staff highlighted the fluctuating nature of identity. Participants’
relationships were about a great deal more than support and help with the
daily round and the maintenance of dignity through respectful and attentive
interactions. They were the means by which participants were able to
maintain their capacity for autonomous decision-making. It was through
their current relationships that they could see a way of continuing to be
themselves and to maintain social life in the context of bodily decline.

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Accepted  June ; first published online  August 

Address for correspondence :

Liz Lloyd, School for Policy Studies,
University of Bristol,  Priory Road,
Bristol BS TZ, UK.

E-mail: Liz.lloyd@bristol.ac.uk

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