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DEMOGRAPHICS AND PSYCHOLOGICAL IMPLICATIONS FOR THE AGING POPULATION
ANALYSIS AND TREATMENT OF THE AGING FACE
0733-8635/97 $0.00
+ 20
DEMOGRAPHICS AND PSYCHOLOGICAL IMPLICATIONS FOR THE AGING POPULATION Albert M. Kligman, MD, PhD, and Carol Koblenzer, MD
These are unprecedented times in human history. We are in the midst of an epidemic of aging, known as the graying of America. People over 65 account for approximately 12% of the American population, a figure that is expected to double in about 30 years. By that time, half the population will be over 50. Currently, people over 85 make up the fastest growing segment. At the beginning of the century life expectancy was approximately 50 years. Most women did not survive beyond menopause. Today, life expectancy for middle-class white women is approximately 75 years, which means that at least 25 years of their life-span will be postmenopausal. This impressive extension of the life-span is not quite the blessing one might suppose. Men, for various reasons, do not live as long as women, falling short by approximately 8 years, a gap that is actually increasing as longevity in women steadily increases while in men it decreases. This means that at advanced ages, women spend their last years without male peers. These changing demographics will have profound, some think catastrophic, social, political, and economic consequences. Geriatric textbooks focus on age-associated chronic disorders such as arthritis, heart disease, and cancer while giving short shrift to skin. The former are life-threatening or disabling conditions, whereas no one dies of old
skin. We are well packaged in our integument till the very end. There remains in medicine a widespread pejorative view that most skin disorders are nothing more than cosmetic impediments, minor disfigurements, and blemishes that are merely nuisances. This negative outlook is not only insensitive, it is misguided and wrong. We need to look at skin aging in an entirely different light, with special emphasis on the psychological distresses caused by deterioration in appearance. PSYCHOLOGY OF AGING SKIN
Skin is more than a protective shield against external assaults, an impermeable bag that prevents leakage of vital fluids into the environment. Skin is also an important organ of emotional expression, what may be called the social skin in contrast to the biologic skin. Strong feelings are quickly and vividly displayed on the surface. With rage, shame, fear, and hostility, the skin variously blanches, blushes, sweats, and bristles. Moreover, visible skin disorders are viewed differently by society than diseases that make up the domain of internal medicine. Individuals with heart disease or cancer receive sympathy and understanding. By contrast, skin disorders often cause revulsion and aversive behaviors, leaving the afflicted one
From the Department of Dermatology, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania
DERMATOLOGIC CLINICS VOLUME 15 * NUMBER 4 OCTOBER 1997
549
550
KLIGMAN & KOBLENZER
humiliated, rejected, and compromised in all interpersonal relationships.1z,19, Dermatologists are aware that patients have fears and anxieties far out of proportion to the severity of the disease. This applies with equal force to disorders in which there is no deep pathology except for abnormal hyperpigmentation or hypopigmentation, in short, merely a change in appearance with no apparent health conseq u e n c e ~Nonetheless, .~~ people with widespread loss of pigment, e.g., vitiligo and albinism, suffer social discriminations that lessen self-esteem and the confidence to meet life's daily problems.15,28 SKIN DISORDERS AND AGING
National surveys have shown that the prevalence of skin diseases, relatively low in infancy, increases steadily throughout life.lS Most persons over 65 have two or more skin disorders that are worthy of medical attention. These are common conditions that include neoplastic growths, seborrheic dermatitis, fungal infections, a variety of autoimmune diseases, and other ailments. This standard list of afflictions generally neglects an exceedingly important aspect of aging, namely deteriorations in appearance that do not end life but that can certainly spoil it. These losses in youthful beauty can be dismissed as cosmetic defects that the aged should be glad to tolerate in exchange for long life. This attitude makes many other people shy away from seeking professional help for correcting various age-associated defects in appearance. Many misconceptions plague our efforts to educate the public and gerontologists that appearance counts heavily in human interactions. Like all organs, aging skin suffers progressive physiologic decrements; it sweats less, makes less sebum, is cooler owing to loss of small vessels, is paler owing to loss of pigment, heals less quickly, and turns over more slowly. Clinically the skin becomes thin and loose; it no longer fits, behaving like a wornout garment. It becomes dry, scaly, and rough. Not only is it not nice to look at it, it also is not nice to touch and hence becomes untouchable. These changes are discomforting and remind the elderly of the burdens of becoming old. Some of these changes can be counteracted by topical skin care products and sensible behaviors for avoiding environmental stresses.
Turning now to the face, the center of the cosmetic universe, appearance losses are much more t r a ~ m a t i z i n gThe . ~ ~ conventional picture of the aged face is a portrait of conventional unattractiveness with its sags and bags, wrinkles and creases, hanging jowls, sallowness, dyspigmentations, dry, rough feel, benign and not so benign neoplasms, telangiectasia, and other changes. These changes are mainly due to excessive exposure to sunlight in early life and are largely preventable.z1They do not simply reflect the passage of time (intrinsic aging) but are a result of chronic photodamage, a process now termed photoaging. Regardless, medical interventions are now available that can substantially correct all these imperfections and give a boost to self-esteem. THE PSYCHOLOGY OF APPEARANCE
Social scientists, more than physicians, have generated an abundant literature whose many themes can be reduced to a simple, compelling concept: "The Good is BeautifU1."8 The gist of a multitude of studies is that the attractive enjoy many advantages over the ~nattractive.~ A noted surgeon has starkly stated that "Beauty may be skin deep but ugliness is bone deep." The enormous importance placed on good looks in a youth-oriented culture cannot be overstated. Puritanical stereotypes "that what counts is not the cover but the contents" is a mythical ideal that is not consonant with contemporary reality. Appearance counts in all walks of life, from the cradle to the grave. Since childhood, we all were taught that the good and beautiful fairy-tale princess invariably won the noble and handsome prince, with whom she lived in prosperity and happiness, loved by all, while the evil and ugly villains reaped their just desserts. At a practical level, those who are perceived as attractive reap personal, educational, occupational, and social rewards.l6 Less attractive individuals, on the other hand, are disadvantaged and have many obstacles to overcome. Although one may not perceive one's social and physical attributes quite as objectively as others perceive them, the outward presentation is important because interpersonal behavior is reciprocal. The attractive individual
DEMOGRAPHICS AND PSYCHOLOGICAL IMPLICATIONS FOR THE AGING POPULATION
elicits positive responses. These responses reinforce positive attributes, and in turn lead to even greater positive behaviors and consequently enhanced capabilities. The opposite is true for those less well endowed.6 Beginning in infancy, the cute baby has the advantage. The positive reciprocal relationship with the primary caregiver is essential for future psychological adjustment and good mental health.= Homely babies receive less a t t e n t i ~ n .l~7 , School teachers give better grades and greater recognition to attractive children, whereas those who are less attractive are less popular among their peers and receive more punishment.' In adult life, people are more eager to please the attractive person and to do his or her bidding, while at a personal level, he or she is judged happier, smarter, more successful, socially adept and warm, and capable of greater intimacy and sexual fulfillment.' Similarly, other studies suggest that physical unattractiveness is a risk factor for psychiatric disease.*The unattractive are more likely to end up in mental institutions, where they receive less attention from the professional caregivers and fewer visits by family and friends.l0 The same trends hold true in the workplace, where those judged attractive can command better jobs with higher salaries and more rapid promotions.6 We showed neutral observers photos of older women who had aged well, looking younger than their chronologic age, along with photos of older unattractive women who had aged poorly. The panelists were intensively interviewed with regard to the psychological differences. Not surprisingly, the attractive group was perceived as exhibiting many positive attributes. They were in fact healthier, more cheerful, better adjusted, more satisfied with their lives, and more active s0cia1ly.l~The benefits of aging well and retaining an attractive appearance have even greater significance from a medical standpoint. In a famous longitudinal study in which older persons were evaluated annually for 24 age-related functions, the most attractive 15% had better functional scores on 15 of 24 physiologic parameters than the most unattractive 15%. The most attractive 15% were healthier and they even lived longer? It is astonishing how well physical appearance correlates so well with physical health. IMPACT OF AGING
Ageism is the term used to characterize negative attitudes and behaviors toward the el-
551
derly. It is a common view of the young that aged people are unattractive, sexually undesirable, and often intellectually impaired, helpless, and incapable of self-determinati~n.~~ As the skin ages, it becomes, if untended, unpleasant both to touch and to look at. Each morning the mirror reinforces this stereotype. This visual assault on an already impoverished self-esteem contributes to the development of common conditions among the elderly, namely pessimism and depression. Feeling useless, frivolous, or extravagant, medical intervention is not sought and the ravages of advancing years are accepted with resentful resignation by those aging unsucce~sfully.~ No attempt is made to enhance appearance. Consequently, physical health is neglected, and sexuality tends to be deemphasized. These negative feelings may cause the individual to turn inward, away from the world. Minor physical complaints assume major significance, and the individual, viewing himself or herself as old, sick, and lonely, lives accordingly, a condition that feeds on itself, because of the reciprocal responses that it g e n e r a t e ~ . ~ ~ Things are different for the person whose early emotional experience was positive. This person will have modified the environment to his or her advantage throughout life. Positive self-esteem will have permitted failures and adversities to be accepted, integrated, and used for growth. Flexibility of personality will have allowed the individual to capitalize on assets and find new avenues for fulfillment as the years pass. Aging, then, will be successful. Changing social circumstances will be interpreted as opportunity for growth, rather than loss; and feeling young and healthy, this person will strive to look young, accepting with grace the immutable, but seeking aids that are available to maintain the appearance and the cultural Overwhelmingly, physical attractiveness brings advantages throughout life. We found that when elderly women are taught to improve their physical appearance through appropriate use of cosmetics (makeovers), there are significant gains in self-image, self-esteem, confidence, and the sense of physical ~ell-being,'~ changes that have the potential to reverse the downward spiral of negative social interactions. It would seem evident, then, that the medical community would do well to give attention to this aspect of gerontology. It would also seem evident that it is
552
KLIGMAN & KOBLENZER
shortsighted and counterproductive for thirdparty payers to disallow reimbursement for simple procedures such as the removal of unsightly facial blemishes that so readily improve physical appearance, with all that that implies. A second drain on financial and medical resources is the delay in accurate diagnosis and treatment of the psychocutaneous disorders. These include conditions commonly associated with depression, such as idiopathic pruritus, chronic urticaria, and neurotic excoriations. They also include monosymptomatic hypochondriasis in its many forms, which in most cases reflects a distortion of the body image of varying degrees of severity.”, 22 RECOMMENDATIONS Specialists in cosmetic dermatology have an incredible array of procedures that can go a long way toward restoring the face to a more youthful appearance. Physicians must make a concerted effort to educate govemmental agencies, the medical establishment, and the patient population about what is available and the importance of optimizing physical appearance for physical and emotional health, as one way of compressing the duration of terminal morbidity and reducing the cost of health care. Many older patients, either because of rather stringent puritanical values or a personal sense of unworthiness, feel the previously mentioned goals to be vain or frivolous. It is our job to help these patients improve their sense of self-worth. There are many programs for helping the aged with their medical and social problems. We need to raise the consciousness of health professionals and politicians with regard to the psychological support that cosmetic interventions can provide for improving the quality of life for the elderly. No one has stated the case more elegantly and forcefully than Robert Kastenbaum.2O He says:
. . . throughout one’s life, the skin is involved in life-sustaining processes. People tend to resist intimate contact with the elderly, causing them to feel rejected with less motivation to take care of themselves. Whatever makes an elderly person appear less attractive can have an unfavorable effect upon his/her opportunities to make use of society’s life-support systems, psychiatrists, physicians, etc.
Whatever makes an elderly person more attractive to others has the effect of safeguarding well-being and life itself. Improved care of the skin would increase self and social acceptance. Thus, an educational program enlisting the expertise of public health specialists, gerontologists and specialists in the cosmetic arts and sciences would be appropriate from the early school years on.
Cosmetic concerns about fading physical attractiveness are not trivial, frivolous, or an unrealistic expression of vanity. Good appearance promotes healthy living. We must continue research to improve cosmetic options for the enhancement of the physical appearance of the aged. References 1. Adams G R Attractiveness through the ages: Implication of facial attractiveness over the life cycle. In Graham JA, Kligman AM (eds): The Psychology of Cosmetic Treatments. New York, Praeger, 1985, pp 133-151 2. Archer R, Cash TF: Physical attractiveness and maladjustment among psychiatric in-patients. J Soc Clin Psychol 3:170-180, 1985 3. Baltes PB, Baltes M M Psychological perspectives on successful aging. In Baltes PB, Baltes MM (eds): Successful Aging. Cambridge, Cambridge University Press, 1990, pp 1-34 4. Borkan GA, Norris AH: Assessment of biologic age using a profile of physical parameters. J Gerontol 35:177, 1980 5. Cash T The psychology of physical appearances. Aesthetics, attributes and images. In Cash TF, Pruzinsky T (eds): Body Images: Development, Deviance and Change. New York, Guilford, 1990, pp 51-79 6. Cash TF, Kilcullen R The eye of the beholder: Susceptibiliw to sexism and beauwism in evaluation of managerial applicants. J Appl- SOCPsychol 15:591605, 1985 7. Dion K K Physical attractiveness and evaluation of children’s transgressions. J Personal SOCPsychol 24207-213, 1972 8. Dion K, Berscheid E, Walster E: What is beautiful is good. J Personal Soc Psychol 24285-290, 1972 9. Elder GH, Nguyen TV, Caspi A: Linking family hardship to children’s lives. Child Devel56361-375, 1985 10. Farina A, Fischer E, Sherman S, et al: Physical attractiveness and mental illness. J Abnorm Psychol 86:510, 1977 11. Fries JF: Medical perspectives upon successful aging. In Baltes PB, Baltes MM (eds): Successful Aging. Cambridge, Cambridge University Press, 1990, pp 35-49 12. Ginsburg IH, Link BG: Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 205363, 1989 13. Graham JA, Kligman AM: Cosmetic therapy for the elderly. J SOCCosmet Chem 35:133, 1984 14. Graham J, Kligman AM: Physical attractiveness, cosmetic use and self-perception in the elderly. Int J Cosmetic Sci 785, 1985 15. Haffei C, Fossati A, Rinaldi F, et al: Personality disor-
DEMOGRAPHICS AND PSYCHOLOGICAL IMPLICATIONS FOR THE AGING POPULATION
16.
17. 18.
19. 20.
21. 22.
ders and psychopathologic symptoms in patients with androgenic alopecia. Arch Dermatol 130:868872, 1994 Hatfield E: Physical attractiveness in social interaction. In Graham JA, Kligman AM (eds): The Psychology of Cosmetic Treatments. New York, Praeger, 1985, pp 77-112 Hildebrandt KA, Fitzgerald HE: The infant’s physical attractiveness. Its effect on bonding and attachment. Infant Ment Health J 43-12, 1983 Johnson MLT, Robert J: Relevance of dermatologic disease among persons 1-74 years of age. Vital Health Statistics of the National Center for Health Statistics, No. 4, Bethesda, MD, 1977 Jowett S, Ryan T Skin disease and handicap: An analysis of the impact of skin conditions. SOCSci Med 20:425-429, 1985 Kastenbaum R On the significance of skin in human aging and survival. Psychobiologic observations. Columbia Point Campus, University of Massachusetts, 1974 Kligman AM: Early destructive effect of sunlight on human skin. JAMA 210:2377, 1969 Koblenzer CS: Psychiatric syndromes of interest to the dermatologist. Int J Dermatol 32232-88, 1993
553
23. Koblenzer CS: Psychologic aspects of aging and the skin. Clin Dermatol 171-177, 1996 24. Koblenzer CS, Bostron P: Chronic cutaneous dysesthesia syndrome. J Am Acad Dermatol 30:37-374, 1994 25. Mahler M, Pine F, Bergman A: The Psychological Birth of the Human Infant. New York, Basic Books, 1975, pp 4 1 4 4 26. Morgan M, McCreddy R, Simpson J, et a1 Dermatology quality of life scales-A measure of the impact of skin diseases. Br J Dermatol 136:202-206, 1997 27. Parrish JA, Gilchrest BA, Fitzpatrick TB: Between You and Me. Boston, Little, Brown, 1980 28. Porter JR, Hill-Beuf A: Racial variation in reaction to physical stigma: A study of degree of disturbance by vitiligo, among black and white patients. J Health SOCBehav 32:192-204, 1991 29. Porter J, Beuf A, Nordland J, et al: Personal responses of patients with vitiligo. Arch Dermatol 114:138, 1978 30. Weiss SJ: Parental touching: Correlates of a child’s body concept and body sentiment. In Barnard VE, Brazelton TB (eds): Touch The Foundation of Experience. Madison, CT, Int University Press, 1990, pp 425459
Address reprint requests to Albert M. Kligman, MD, PhD Department of Dermatology University of Pennsylvania School of Medicine 205-CRB 415 Curie Boulevard Philadelphia, PA 19104
0733-8635/97 $0.00
+ 20
DEMOGRAPHICS AND PSYCHOLOGICAL IMPLICATIONS FOR THE AGING POPULATION Albert M. Kligman, MD, PhD, and Carol Koblenzer, MD
These are unprecedented times in human history. We are in the midst of an epidemic of aging, known as the graying of America. People over 65 account for approximately 12% of the American population, a figure that is expected to double in about 30 years. By that time, half the population will be over 50. Currently, people over 85 make up the fastest growing segment. At the beginning of the century life expectancy was approximately 50 years. Most women did not survive beyond menopause. Today, life expectancy for middle-class white women is approximately 75 years, which means that at least 25 years of their life-span will be postmenopausal. This impressive extension of the life-span is not quite the blessing one might suppose. Men, for various reasons, do not live as long as women, falling short by approximately 8 years, a gap that is actually increasing as longevity in women steadily increases while in men it decreases. This means that at advanced ages, women spend their last years without male peers. These changing demographics will have profound, some think catastrophic, social, political, and economic consequences. Geriatric textbooks focus on age-associated chronic disorders such as arthritis, heart disease, and cancer while giving short shrift to skin. The former are life-threatening or disabling conditions, whereas no one dies of old
skin. We are well packaged in our integument till the very end. There remains in medicine a widespread pejorative view that most skin disorders are nothing more than cosmetic impediments, minor disfigurements, and blemishes that are merely nuisances. This negative outlook is not only insensitive, it is misguided and wrong. We need to look at skin aging in an entirely different light, with special emphasis on the psychological distresses caused by deterioration in appearance. PSYCHOLOGY OF AGING SKIN
Skin is more than a protective shield against external assaults, an impermeable bag that prevents leakage of vital fluids into the environment. Skin is also an important organ of emotional expression, what may be called the social skin in contrast to the biologic skin. Strong feelings are quickly and vividly displayed on the surface. With rage, shame, fear, and hostility, the skin variously blanches, blushes, sweats, and bristles. Moreover, visible skin disorders are viewed differently by society than diseases that make up the domain of internal medicine. Individuals with heart disease or cancer receive sympathy and understanding. By contrast, skin disorders often cause revulsion and aversive behaviors, leaving the afflicted one
From the Department of Dermatology, University of Pennsylvania, School of Medicine, Philadelphia, Pennsylvania
DERMATOLOGIC CLINICS VOLUME 15 * NUMBER 4 OCTOBER 1997
549
550
KLIGMAN & KOBLENZER
humiliated, rejected, and compromised in all interpersonal relationships.1z,19, Dermatologists are aware that patients have fears and anxieties far out of proportion to the severity of the disease. This applies with equal force to disorders in which there is no deep pathology except for abnormal hyperpigmentation or hypopigmentation, in short, merely a change in appearance with no apparent health conseq u e n c e ~Nonetheless, .~~ people with widespread loss of pigment, e.g., vitiligo and albinism, suffer social discriminations that lessen self-esteem and the confidence to meet life's daily problems.15,28 SKIN DISORDERS AND AGING
National surveys have shown that the prevalence of skin diseases, relatively low in infancy, increases steadily throughout life.lS Most persons over 65 have two or more skin disorders that are worthy of medical attention. These are common conditions that include neoplastic growths, seborrheic dermatitis, fungal infections, a variety of autoimmune diseases, and other ailments. This standard list of afflictions generally neglects an exceedingly important aspect of aging, namely deteriorations in appearance that do not end life but that can certainly spoil it. These losses in youthful beauty can be dismissed as cosmetic defects that the aged should be glad to tolerate in exchange for long life. This attitude makes many other people shy away from seeking professional help for correcting various age-associated defects in appearance. Many misconceptions plague our efforts to educate the public and gerontologists that appearance counts heavily in human interactions. Like all organs, aging skin suffers progressive physiologic decrements; it sweats less, makes less sebum, is cooler owing to loss of small vessels, is paler owing to loss of pigment, heals less quickly, and turns over more slowly. Clinically the skin becomes thin and loose; it no longer fits, behaving like a wornout garment. It becomes dry, scaly, and rough. Not only is it not nice to look at it, it also is not nice to touch and hence becomes untouchable. These changes are discomforting and remind the elderly of the burdens of becoming old. Some of these changes can be counteracted by topical skin care products and sensible behaviors for avoiding environmental stresses.
Turning now to the face, the center of the cosmetic universe, appearance losses are much more t r a ~ m a t i z i n gThe . ~ ~ conventional picture of the aged face is a portrait of conventional unattractiveness with its sags and bags, wrinkles and creases, hanging jowls, sallowness, dyspigmentations, dry, rough feel, benign and not so benign neoplasms, telangiectasia, and other changes. These changes are mainly due to excessive exposure to sunlight in early life and are largely preventable.z1They do not simply reflect the passage of time (intrinsic aging) but are a result of chronic photodamage, a process now termed photoaging. Regardless, medical interventions are now available that can substantially correct all these imperfections and give a boost to self-esteem. THE PSYCHOLOGY OF APPEARANCE
Social scientists, more than physicians, have generated an abundant literature whose many themes can be reduced to a simple, compelling concept: "The Good is BeautifU1."8 The gist of a multitude of studies is that the attractive enjoy many advantages over the ~nattractive.~ A noted surgeon has starkly stated that "Beauty may be skin deep but ugliness is bone deep." The enormous importance placed on good looks in a youth-oriented culture cannot be overstated. Puritanical stereotypes "that what counts is not the cover but the contents" is a mythical ideal that is not consonant with contemporary reality. Appearance counts in all walks of life, from the cradle to the grave. Since childhood, we all were taught that the good and beautiful fairy-tale princess invariably won the noble and handsome prince, with whom she lived in prosperity and happiness, loved by all, while the evil and ugly villains reaped their just desserts. At a practical level, those who are perceived as attractive reap personal, educational, occupational, and social rewards.l6 Less attractive individuals, on the other hand, are disadvantaged and have many obstacles to overcome. Although one may not perceive one's social and physical attributes quite as objectively as others perceive them, the outward presentation is important because interpersonal behavior is reciprocal. The attractive individual
DEMOGRAPHICS AND PSYCHOLOGICAL IMPLICATIONS FOR THE AGING POPULATION
elicits positive responses. These responses reinforce positive attributes, and in turn lead to even greater positive behaviors and consequently enhanced capabilities. The opposite is true for those less well endowed.6 Beginning in infancy, the cute baby has the advantage. The positive reciprocal relationship with the primary caregiver is essential for future psychological adjustment and good mental health.= Homely babies receive less a t t e n t i ~ n .l~7 , School teachers give better grades and greater recognition to attractive children, whereas those who are less attractive are less popular among their peers and receive more punishment.' In adult life, people are more eager to please the attractive person and to do his or her bidding, while at a personal level, he or she is judged happier, smarter, more successful, socially adept and warm, and capable of greater intimacy and sexual fulfillment.' Similarly, other studies suggest that physical unattractiveness is a risk factor for psychiatric disease.*The unattractive are more likely to end up in mental institutions, where they receive less attention from the professional caregivers and fewer visits by family and friends.l0 The same trends hold true in the workplace, where those judged attractive can command better jobs with higher salaries and more rapid promotions.6 We showed neutral observers photos of older women who had aged well, looking younger than their chronologic age, along with photos of older unattractive women who had aged poorly. The panelists were intensively interviewed with regard to the psychological differences. Not surprisingly, the attractive group was perceived as exhibiting many positive attributes. They were in fact healthier, more cheerful, better adjusted, more satisfied with their lives, and more active s0cia1ly.l~The benefits of aging well and retaining an attractive appearance have even greater significance from a medical standpoint. In a famous longitudinal study in which older persons were evaluated annually for 24 age-related functions, the most attractive 15% had better functional scores on 15 of 24 physiologic parameters than the most unattractive 15%. The most attractive 15% were healthier and they even lived longer? It is astonishing how well physical appearance correlates so well with physical health. IMPACT OF AGING
Ageism is the term used to characterize negative attitudes and behaviors toward the el-
551
derly. It is a common view of the young that aged people are unattractive, sexually undesirable, and often intellectually impaired, helpless, and incapable of self-determinati~n.~~ As the skin ages, it becomes, if untended, unpleasant both to touch and to look at. Each morning the mirror reinforces this stereotype. This visual assault on an already impoverished self-esteem contributes to the development of common conditions among the elderly, namely pessimism and depression. Feeling useless, frivolous, or extravagant, medical intervention is not sought and the ravages of advancing years are accepted with resentful resignation by those aging unsucce~sfully.~ No attempt is made to enhance appearance. Consequently, physical health is neglected, and sexuality tends to be deemphasized. These negative feelings may cause the individual to turn inward, away from the world. Minor physical complaints assume major significance, and the individual, viewing himself or herself as old, sick, and lonely, lives accordingly, a condition that feeds on itself, because of the reciprocal responses that it g e n e r a t e ~ . ~ ~ Things are different for the person whose early emotional experience was positive. This person will have modified the environment to his or her advantage throughout life. Positive self-esteem will have permitted failures and adversities to be accepted, integrated, and used for growth. Flexibility of personality will have allowed the individual to capitalize on assets and find new avenues for fulfillment as the years pass. Aging, then, will be successful. Changing social circumstances will be interpreted as opportunity for growth, rather than loss; and feeling young and healthy, this person will strive to look young, accepting with grace the immutable, but seeking aids that are available to maintain the appearance and the cultural Overwhelmingly, physical attractiveness brings advantages throughout life. We found that when elderly women are taught to improve their physical appearance through appropriate use of cosmetics (makeovers), there are significant gains in self-image, self-esteem, confidence, and the sense of physical ~ell-being,'~ changes that have the potential to reverse the downward spiral of negative social interactions. It would seem evident, then, that the medical community would do well to give attention to this aspect of gerontology. It would also seem evident that it is
552
KLIGMAN & KOBLENZER
shortsighted and counterproductive for thirdparty payers to disallow reimbursement for simple procedures such as the removal of unsightly facial blemishes that so readily improve physical appearance, with all that that implies. A second drain on financial and medical resources is the delay in accurate diagnosis and treatment of the psychocutaneous disorders. These include conditions commonly associated with depression, such as idiopathic pruritus, chronic urticaria, and neurotic excoriations. They also include monosymptomatic hypochondriasis in its many forms, which in most cases reflects a distortion of the body image of varying degrees of severity.”, 22 RECOMMENDATIONS Specialists in cosmetic dermatology have an incredible array of procedures that can go a long way toward restoring the face to a more youthful appearance. Physicians must make a concerted effort to educate govemmental agencies, the medical establishment, and the patient population about what is available and the importance of optimizing physical appearance for physical and emotional health, as one way of compressing the duration of terminal morbidity and reducing the cost of health care. Many older patients, either because of rather stringent puritanical values or a personal sense of unworthiness, feel the previously mentioned goals to be vain or frivolous. It is our job to help these patients improve their sense of self-worth. There are many programs for helping the aged with their medical and social problems. We need to raise the consciousness of health professionals and politicians with regard to the psychological support that cosmetic interventions can provide for improving the quality of life for the elderly. No one has stated the case more elegantly and forcefully than Robert Kastenbaum.2O He says:
. . . throughout one’s life, the skin is involved in life-sustaining processes. People tend to resist intimate contact with the elderly, causing them to feel rejected with less motivation to take care of themselves. Whatever makes an elderly person appear less attractive can have an unfavorable effect upon his/her opportunities to make use of society’s life-support systems, psychiatrists, physicians, etc.
Whatever makes an elderly person more attractive to others has the effect of safeguarding well-being and life itself. Improved care of the skin would increase self and social acceptance. Thus, an educational program enlisting the expertise of public health specialists, gerontologists and specialists in the cosmetic arts and sciences would be appropriate from the early school years on.
Cosmetic concerns about fading physical attractiveness are not trivial, frivolous, or an unrealistic expression of vanity. Good appearance promotes healthy living. We must continue research to improve cosmetic options for the enhancement of the physical appearance of the aged. References 1. Adams G R Attractiveness through the ages: Implication of facial attractiveness over the life cycle. In Graham JA, Kligman AM (eds): The Psychology of Cosmetic Treatments. New York, Praeger, 1985, pp 133-151 2. Archer R, Cash TF: Physical attractiveness and maladjustment among psychiatric in-patients. J Soc Clin Psychol 3:170-180, 1985 3. Baltes PB, Baltes M M Psychological perspectives on successful aging. In Baltes PB, Baltes MM (eds): Successful Aging. Cambridge, Cambridge University Press, 1990, pp 1-34 4. Borkan GA, Norris AH: Assessment of biologic age using a profile of physical parameters. J Gerontol 35:177, 1980 5. Cash T The psychology of physical appearances. Aesthetics, attributes and images. In Cash TF, Pruzinsky T (eds): Body Images: Development, Deviance and Change. New York, Guilford, 1990, pp 51-79 6. Cash TF, Kilcullen R The eye of the beholder: Susceptibiliw to sexism and beauwism in evaluation of managerial applicants. J Appl- SOCPsychol 15:591605, 1985 7. Dion K K Physical attractiveness and evaluation of children’s transgressions. J Personal SOCPsychol 24207-213, 1972 8. Dion K, Berscheid E, Walster E: What is beautiful is good. J Personal Soc Psychol 24285-290, 1972 9. Elder GH, Nguyen TV, Caspi A: Linking family hardship to children’s lives. Child Devel56361-375, 1985 10. Farina A, Fischer E, Sherman S, et al: Physical attractiveness and mental illness. J Abnorm Psychol 86:510, 1977 11. Fries JF: Medical perspectives upon successful aging. In Baltes PB, Baltes MM (eds): Successful Aging. Cambridge, Cambridge University Press, 1990, pp 35-49 12. Ginsburg IH, Link BG: Feelings of stigmatization in patients with psoriasis. J Am Acad Dermatol 205363, 1989 13. Graham JA, Kligman AM: Cosmetic therapy for the elderly. J SOCCosmet Chem 35:133, 1984 14. Graham J, Kligman AM: Physical attractiveness, cosmetic use and self-perception in the elderly. Int J Cosmetic Sci 785, 1985 15. Haffei C, Fossati A, Rinaldi F, et al: Personality disor-
DEMOGRAPHICS AND PSYCHOLOGICAL IMPLICATIONS FOR THE AGING POPULATION
16.
17. 18.
19. 20.
21. 22.
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Address reprint requests to Albert M. Kligman, MD, PhD Department of Dermatology University of Pennsylvania School of Medicine 205-CRB 415 Curie Boulevard Philadelphia, PA 19104