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Over ninetyWe are ambivalent about advanced age. Admiration

for those approaching their century as outstandingexamples of triumph over adversity may be temperedby thoughts of old age as a time of decline anddependence; a dwindling of opportunities; a period ofdespondency and inevitable death. We fear frailty andpoverty, incontinence, immobility, and intellectualimpairment.

In developed countries, the very old are the fastestgrowing group in the population. For example, in1981, there were almost 150 000 people over the age of90 in England and Wales; at the millenium, there willbe twice that number. Until now we have known verylittle about the lives of the 90s: who they are, wherethey live, what they do, how they see themselves, thestate of their health, and the support they need. Astudy1 of 200 very old people living in eight provincialEnglish towns is an important contribution to

understanding of our oldest elders.Who survives to a great age? A high proportion of

such people have a family history of longevity, arefrom the middle classes, and avoided the severeinfectious diseases of childhood. Very old womenoutnumber their male counterparts by four to one.The over-90s cite moderation as the main reason for

living so long: although 50% of them enjoy alcohol,very few drink heavily and only a tiny proportionof old men still smoke. No surprises here, perhaps,but those who proselytise about the evils of animalfats might ponder the observation that 81 % of peopleover 90 enjoy meat every day and over 67% eatbutter.

Half of all those over 90 still live at home, two-fifthsliving alone, and their houses are usually in goodorder. Nearly half of them go outside every day,although very few use public transport. A third ofthose living at home share the house with their

children, and families provide most home care.

Informal carers are committed and are happy to go onproviding help and support; most cope well, but some

feel overburdened and resent the restrictions imposedon them by their filial duties. The other half live incommunal establishments-most in residentialhomes and some in nursing homes or long-stayhospital wards (by contrast, only 4% of those aged75-84 are in institutional care). These establishmentsare usually of a reasonable or high standard and thepositive and caring attitudes of the staff are muchappreciated by the residents. However, some homesare criticised for staff shortages and lack of humanity;inflexibility, lack of autonomy, and poor ambiencereceive unfavourable comments.At first sight, the physical health of nonagenarians

appears to be remarkably good. Nearly half of themhave not been to hospital for the past 5 years and mostof the remainder have only attended once over thatperiod. Just a third have regular contact with theirfamily doctor and only half of those living alonereceive any help from district nurses, health visitors,or social services. Over 90% of those living at homeare fully continent; two-thirds never have troublesleeping; only two-fifths take analgesics.Nevertheless, most have at least one chronic disorder,usually deafness, impaired vision, or joint pains, eachof which affected half the population sample. Infunctional terms, the daily living activities that provedmost troublesome were cutting toe nails, preparingmeals, and bathing. The presence of chronic illnessand disability does not inevitably mean that people canno longer enjoy an active life: old people are usuallyadept at adjusting to these disadvantages and are notnecessarily handicapped by them.What is it like to be very old? Over 70% report that

they are in good spirits, never feel lonely, and are freefrom worries. Most lead lives of dignity andcontentment. Personal relationships provide the mainsource of happiness and there is frequent contact withfamilies. Only 3 % either have no relatives or never seethem. Even when people wake to a new morning forthe 35 000th time they usually look forward to afulfilling day. Most obtain solace from their spiritualbeliefs and contemplate death with serenity.Politicians and planners need not be unduly alarmedby exaggerated predictions of a rising tide of totallydependent people who threaten to overwhelm thehealth services. Social services are right to emphasisecommunity care because most old people want to be athome. However, we should recognise that most care inthe community is provided by relatives, not

professionals, and that those carers who are

overburdened need more recognition, support, andrelief. If we are serious about the quality of life of ourmore dependent oldest citizens, we should see whatcan be done to improve the staffing levels, attitudes,and ambience of homes and hospitals for the elderly.Medical researchers might direct more of their

energies to the common visual, auditory, andrheumatological problems afflicting the very old.1. Bury M, Holme A. Life after ninety. London: Routledge, 1991. £35.

ISBN 0-415041651.