Category Adult Development and Aging

What Is Successful Aging?

What does it mean to age successfully? Take some time to think about this question for yourself. Develop a thorough list of everything it would take for you to say that you
will have aged successfully when the time comes. Then ask this question to several people of different ages and backgrounds. Compare their answers. Do the criteria
differ as a function of age or background characteristics? Discuss your findings with others in your class to see whether your results were typical.

Concept Checks

1. What are the most important issues to consider in health promotion and quality of life for older adults?

2. What are the key aspects of a life-span model for maintaining and enhancing competence?

3. What are the major elements in health promotion and disease prevention programs? What are the four types of prevention?

4. What are the key aspects of staying fit and eating right in late life?

14.2 Successful Aging

LEARNING OBJECTIVES • What is successful aging?

M

arie Chen just celebrated her 100th birthday.

During the daylong festivities, many people asked her whether she believed she had a good life and had, in a sense, aged successfully. She answered everyone the same way, telling them that she had her health, enough money to live on, and her family. What more could she want?

Marie gives every sign of having aged very well. She’s 100 years old, with a loving family, good enough health to live in the community, and enough income to pay her bills. But is there more to it than that? Before you read what researchers have to say about aging successfully, complete the exercise in the Discovering Development feature.

Everyone hopes that his or her later years are ones filled with good health, continued high cognitive
and physical competence, and engagement with life. So important and universal are these beliefs that Rowe and Kahn (1998) considered them to be the foundation on which successful aging is built:

The absence of disease and disability makes it easier to maintain mental and physical function. And maintenance of mental and physical function in turn enables (but does not guarantee) active engagement with life.

It is the combination of all three—avoidance of disease and disability, maintenance of cog­nitive and physical function, and sustained engagement with life—that represents the concept of successful aging most fully. (p. 39)

Research participants agree. An extensive study of people’s own definitions of successful aging con­ducted in Canada showed substantial agreement between participants’ definitions and Rowe and Kahn’s three dimensions (Tate et al., 2003). This three-part view of successful aging has become the central theoretical paradigm in gerontology and geriatrics. Rowe and Kahn’s work was grounded in the 10-year, $ 10-million MacArthur Foundation Study of Successful Aging. On this point, Scheidt, Humphreys, and Yorgason (1999) noted that “at least a hundred studies have shown the efficacy of modifications to environmental and lifestyle factors for increasing the likelihood that older individuals might achieve success under this triarchic defini­tion. So what’s not to like?” (p. 277).

546 CHAPTER 14

Vaillant (2002) proposed a similar model of suc­cessful aging which has six criteria rather than three. He proposes three criteria related to health:

• No physical disability at age 75 as rated by a physician

• Good subjective physical health (i. e., no problems with instrumental activities of daily living)

• Length of undisabled life

Vaillant’s other three criteria relate to social engage­ment and productive activity:

• Good mental health

• Objective social support

• Self-rated life satisfaction in eight domains: marriage, income-producing work, children, friendships and social contacts, hobbies, community service activities, religion, and recreation/sports

What is important in Vaillant’s model is not only what predicts long life but also what does not. Interestingly, having had long-lived ancestors was important only up to age 60 but not beyond. Stress – related diseases before age 50 were not predictive. Childhood factors that were important predictors of health at midlife did not predict health in late life. Thus Vaillant’s research emphasizes that late life has many unique aspects and may not relate to variables that predict health at earlier points in life.

A related view of successful aging is one we encountered several times throughout the book: the selection, optimization, and compensation (SOC) model (Baltes et al., 2006). Recall that in this model selection refers to developing and choosing goals, optimization to the application and refinement of goal-relevant means or actions, and compensation to substitution of means when previous ones are no longer available. The SOC model can be applied to the proactive strategies of life management. From this perspective, it is adaptive (i. e., a sign of success­ful aging) to set clear goals, to acquire and invest means into pursuing these goals, and to persist despite setbacks or losses. So the point here, in con­trast to a coping strategy, which would emphasize a more passive approach, is that taking positive action to find substitute ways of doing things is adaptive (Freund & Baltes, 2002).

Taking a broad view to defining successful aging permits researchers to establish what is associated with it. Studies indicate that aging successfully is more likely when people have higher levels of edu­cation, household income, and personal income (Soong-Nang, Choi, & Kim, 2008).

The increased emphasis on successful aging raises important questions about the quality of life for older adults. For example, researchers have not focused much attention on the issue of whether one can outlive one’s expected longevity, that is, how long you think you will live. For example, if you think you will not live past age 75, perhaps because no one in your family ever has, you may map out your life based on this assumption. But what do you do when you celebrate your 76 th birthday? The birthday wasn’t planned, and you may feel confused as to what you should be doing with yourself.

Rowe and Kahn’s view of successful aging also ass­umes certain things to be true: that people have the resources to live a healthy life, have access to health care, live in a safe environment, have had life experi­ences that support individual decision making, and so forth (Holstein & Minkler, 2003). Not all older adults’ lives meet these assumptions (Soong-Nang et al., 2008). For example, poverty, widowhood, and differential social expectations based on gender influ­ence whether a person will be able to exert individual control and decisions over health.

Successful aging is a subjective experience that each person decides individually.

Successful Aging 547

There is another, more serious concern with Rowe and Kahn’s model. By equating health and successful aging, they imply that older people who have health problems have not aged successfully (Holstein & Minkler, 2003). By suggesting that people who have disabilities or health limitations signify failure, or at best “usual” aging, the message that only the fit and vigorous are successful is a negative one. It can also inadvertently reinforce the antiaging stereotype for physical beauty as well as a stereotype for the “active older adult.”

Holstein and Minkler (2003) point out that we should return to an ancient question: What is the good life—for the whole of life—and what does it take to live a good old age? When she was in her late 60s, the late poet May Sarton (1997) wrote this about the imminence of death: “[P]reparing to die we shed our leaves, without regret, so that the essential person may be alive and well at the end” (p. 230).

Sarton’s view may remind you of another, related perspective. Erikson (1982) talked about success­ful aging as ego integrity, a point made by some researchers as well (Chang et al., 2008). Successful aging may be the ability to pull one’s life together from many perspectives into a coherent whole and to be satisfied with it. From this perspective, suc­cessful aging is assessed more from the older adult’s vantage point than from any other (Bowling, 2007). In this sense, older adults may say that they are aging successfully while others, especially those who adopt a medical model, would not say that about them. But who is to say which perspective is “correct”?

In this book, you have seen a snapshot of what adult development and aging are like today. You have learned about their complexities, myths, and realities. But more than anything else, you have seen what we really know about the pioneers who have blazed the trail ahead of us.

In a short time, it will be your turn to lead the journey. The decisions you make will have an enor­mous impact on those who will be old: your par­ents, grandparents, and the people who taught you. The decisions will not be easy ones. But you have an advantage that the pioneers did not. You have the collected knowledge of gerontologists to help. With a continued concerted effort, you will be able to address the problems and meet the challenges that lie ahead. Then, when you yourself are old, you will be able to look back on your life and say, “I lived long—and I prospered.”

548 CHAPTER 14

[1]A digital rectal exam should be done at the same time as sigmoidoscopy, colonoscopy, or double-contrast barium enema. People who are at moderate or high risk for colorectal cancer should talk with a doctor about a different testing schedule. Adapted from the American Cancer Society (2008d).

Lifestyle Factors

Most attention in health promotion and disease prevention programs is on tackling a handful of behaviors that have tremendous payoff, such as keep­ing fit and eating properly. In turn, these programs educate adults about good health care practices and help identify conditions such as hypertension, high cholesterol levels, and elevated blood sugar levels, which, if left untreated, can cause atherosclerosis, heart disease, strokes, diabetes mellitus, and other serious conditions.

Exercise. Ever since the ancient Greeks, physi­cians and researchers have known that exercise significantly slows the aging process. Indeed, evi­dence suggests that a program of regular exer­cise, in conjunction with a healthy lifestyle, can slow the physiological aging process (Aldwin & Gilmer, 2004). Being sedentary is hazardous to your health.

Adults benefit from aerobic exercise, which places moderate stress on the heart by maintaining a pulse rate between 60% and 90% of the person’s maximum heart rate. You can calculate your maximum heart rate by subtracting your age from 220. Thus, if you are 40 years old, your target range would be 108-162 beats per minute. The minimum time nec­essary for aerobic exercise to be of benefit depends on its intensity; at low heart rates, sessions may need to last an hour, whereas at high heart rates, 15 minutes may suffice. Examples of aerobic exer­cise include jogging, step aerobics, swimming, and cross-country skiing.

What happens when a person exercises aer­obically (besides becoming tired and sweaty)? Physiologically, adults of all ages show improved cardiovascular functioning and maximum oxygen consumption; lower blood pressure; and better strength, endurance, flexibility, and coordination (Mayo Clinic, 2008c). Psychologically, people who exercise aerobically report lower levels of stress, bet­ter moods, and better cognitive functioning (Mayo Clinic, 2008c).

The best way to gain the benefits of aerobic exer­cise is to maintain physical fitness throughout the life span, beginning at least in middle age. The ben­efits of various forms of exercise are numerous, and include lowering the risk of cardiovascular disease, osteoporosis (if the exercise is weight bearing), and a host of other conditions. The Mayo Clinic’s Fitness

Successful Aging 543

Center provides an excellent place to start. In plan­ning an exercise program, three points should be remembered. First, check with a physician before beginning an aerobic exercise program. Second, bear in mind that moderation is important. Third, just because you intend to exercise doesn’t mean you will; you must take the necessary steps to turn your intention into action (Schwarzer, 2008).

Nutrition. How many times did your parents tell you to eat your vegetables? Or perhaps they said, “You are what you eat" Most people have disagreements with parents about food while growing up, but as adults they realize that those lima beans and other despised foods their parents urged them to eat really are healthy. Experts agree that nutrition directly affects one’s mental, emotional, and physical func­tioning (Mayo Clinic, 2008c). For example, diet has been linked to cancer, cardiovascular disease, dia­betes, anemia, and digestive disorders. Nutritional requirements and eating habits change across the life span. This change is due mainly to differences in metabolism, or how much energy the body needs. Body metabolism and the digestive process slow down with age (Janssen, 2005).

Every five years the U. S. Department of Agricul­ture publishes dietary guidelines based on current

544 CHAPTER 14
research. In its Dietary Guidelines for Americans 2005 (U. S. Department of Agriculture, 2005), the USDA recommends that we eat a variety of nutri­ent-dense foods and beverages across the basic food groups. Most important, we should choose foods that limit the intake of saturated and trans fats, cholesterol, added sugars, salt, and alcohol. The USDA recommends that women of child­bearing age consume more iron-rich foods. For a more personal guide to good nutrition, check out the USDA MyPyramid website at http://www. mypyramid. gov/.

Did you ever worry as you were eating a triple­dip cone of premium ice cream that you really should be eating fat-free frozen yogurt instead? If so, you are among the people who have taken to heart (literally) the link between diet and cardio­vascular disease. The American Heart Association (2007b) makes it clear that foods high in saturated fat (such as our beloved ice cream) should be replaced with foods low in fat (such as fat-free frozen yogurt). (The American Heart Association provides a website at http://www. deliciousdeci- sions.org with recipes and alternatives for a heart – healthy diet.)

The main goal of these recommendations is to lower your level of cholesterol because high
cholesterol is one risk factor for cardiovascular disease. There is an important difference between two different types of cholesterol, which are defined by their effect on blood flow. Lipoproteins are fatty chemicals attached to proteins carried in the blood. Low-density lipoproteins (LDLs) cause fatty depos­its to accumulate in arteries, impeding blood flow, whereas high-density lipoproteins (HDLs) help keep arteries clear and break down LDLs. It is not so much the overall cholesterol number but the ratio of LDLs to HDLs that matters most in cholesterol screening. High levels of LDLs are a risk factor in cardiovascular disease, and high levels of HDLs are considered a protective factor. Reducing LDL levels is effective in diminishing the risk of cardiovascular disease in adults of all ages; in healthy adults, a high level of LDL (over 160 mg/dL) indicates a higher risk for cardiovascular disease (American Heart Association, 2007b). In contrast, higher levels of HDL are good (in healthy adults, levels at least above 40 mg/dL for men and 50 mg/dL for women). LDL levels can be lowered and HDL levels can be raised through various interventions such as exer­cise and a high-fiber diet. Weight control is also an important component.

Numerous medications exist for treating choles­terol problems. The most popular of these drugs are from a family of medications called statins (e. g., Lipitor, Crestor). These medications lower LDL and moderately increase HDL. Because of poten­tial side effects on liver functioning, patients taking cholesterol-lowering medications should be moni­tored on a regular basis.

Obesity is a growing health problem related to diet. One good way to assess your own status is to compute your body mass index. Body mass index (BMI) is a ratio of body weight and height and is related to total body fat. You can compute BMI as follows:

BMI = w/h2

where w = weight in kilograms (or weight in pounds divided by 2.2), and h = height in meters (or inches divided by 39.37).

The National Institutes of Health and the American Heart Association (see http://www. americanheart. org/presenter. jhtml? identifier=3048134 for a conve­nient calculator) define healthy weight as having a BMI of less than 25. However, this calculation may overestimate body fat in very muscular people and underestimate body fat in those who appear of nor­mal weight but have little muscle mass.

BMI is related to the risk of serious medical conditions and mortality: the higher one’s BMI, the higher one’s risk (Centers for Disease Control and Prevention, 2007b). Figure 14.4 shows the increased risk for several diseases and mortality associated with increased BMI. Based on these estimates, you may want to lower your BMI if it’s above 25. But be careful—lowering your BMI too much may not be healthy either. Very low BMIs may indicate malnutrition, which is also related to increased mortality.

Disease Risk * Relative to Normal weight and waist Circumference

BMI

Obesity

Men 102 cm (40 in) or less

Men > 102 cm (40 in)

(Kg/m2))

Class

Women 88 cm (35 in) or less

Women > 88 cm (35 in)

Underweight

< 18.5

Normal

18.5-24.9

Overweight

25.0-29.9

Increased

High

Obesity

30.0-34.9

I

High

High

35.9-39.9

II

Very High

Very High

Extreme obesity

40.0 +

III

Extremely High

Extremely High

Figure 14.4 Classification of overweight and obesity by BMI, waist circumference, and associated disease risks.

Source: Centers for Disease Control and Prevention (2007b)

Successful Aging 545

Health Promotion and Disease Prevention

By now you’re probably wondering how to promote successful aging. You may not be surprised to learn that there is no set of steps or magic potion you can take to guarantee that you will age optimally. But research is showing that there are some steps you can take to maximize your chances (Guralnik,

Table 14.1

Preventive Strategies for Maximizing
Successful Aging

Adopt a healthy lifestyle. Make it part of your daily routine.

Stay active cognitively. Keep an optimistic outlook and maintain your interest in things.

Maintain a social network and stay engaged with others.

Maintain good economic habits to avoid financial dependency.

2008). As you can see in Table 14.1, most of them are not complex. But they do capture the results of applying the model for maintaining and enhancing competence we examined at the beginning of the section. The key strategies are sound health habits; good habits of thought, including an optimistic outlook and interest in things; a social network; and sound economic habits.

These simple steps are difficult in practice, of course. Nevertheless, they will help maximize the chances of aging successfully. Setting up this favor­able outcome is important. Because of the demo­graphic shifts in the population, health care costs for older adults in most developed countries are expected to skyrocket during the first half of the 21st century. Minimizing this increase is key.

To support these changes, the U. S. Department of Health and Human Services created a national initiative to improve the health of all Americans through a coordinated and comprehensive empha­sis on prevention. Updated every 10 years, the current version of this effort, the Healthy People ini­tiative, sets targets for a healthier population based on three broad goals: increase the length of healthy life, reduce health disparities among Americans, and achieve access to preventive services for all. (You can find the latest version of the initiative at http://www. healthypeople. gov.)

Although significant gains have been made in ear­lier versions of the initiative, they were not universal. Many members of ethnic minority groups and the poor still have not seen significant improvements in their lives. With this in mind, there has been a shift from a focus that included only prevention to one that also includes optimum health practices.

The U. S. government allocates funds appro­priated by the Older Americans Act through the Administration on Aging (AoA) to help support programs specifically aimed at improving the health of older adults. These funds support a wide vari­ety of programs, including health risk assessments and screenings, nutrition screening and education, physical fitness, health promotion programs on chronic disabling conditions, home injury control services, counseling regarding social services, and follow-up health services.

One goal of these low-cost programs is to address the lack of awareness many people have about their own chronic health problems; for example, the AoA estimates that half of those with diabetes mellitus, more than half with hypertension, and 70% of those with high cholesterol levels are unaware that they have serious conditions. Health promotion and dis­ease prevention programs such as those sponsored by the AoA could reduce the cost of treating the diseases through earlier diagnosis and better pre­vention education.

Issues in Prevention. In Chapter 4, we saw that Verb – rugge and Jette’s (1994) theoretical model offers a comprehensive account of disability resulting from chronic conditions and provides much guidance for research. Another benefit of the model is that it also provides insight into ways to intervene so that disability can be prevented or its progress slowed. Prevention efforts can be implemented in many ways, from providing flu vaccines to providing transportation to cultural events so that otherwise homebound people can enjoy these activities.

Traditionally, three types of prevention have been discussed: primary, secondary, and tertiary; more recently, the concept of quaternary prevention has
been added (Verbrugge, 1994). A brief summary is presented in Table 14.2. Primary prevention is any intervention that prevents a disease or condition from occurring. Examples of primary prevention include immunizing against illnesses such as polio and influenza or controlling risk factors such as serum cholesterol levels and cigarette smoking in healthy people.

Secondary prevention is instituted early after a condition has begun (but may not yet have been diagnosed) and before significant impairments have occurred. Examples of secondary intervention include cancer and cardiovascular disease screen­ing and routine medical testing for other condi­tions. These steps help reduce the severity of the condition and may even reduce mortality from it. In terms of the main pathway in Verbrugge and Jette’s (1994) model, secondary prevention occurs between pathology and impairments.

Tertiary prevention involves efforts to avoid the development of complications or secondary chronic conditions, manage the pain associated with the pri­mary chronic condition, and sustain life through medical intervention. Some chronic conditions have a high risk of creating additional medical problems; for example, being bedridden as a result of a chronic

disease often is associated with getting pneumo­nia. Tertiary prevention involves taking steps such as sitting the person up in bed to lower the risk of contracting additional diseases. In terms of the model, tertiary interventions are aimed at minimiz­ing functional limitations and disability.

Historically, tertiary prevention efforts have not focused on functioning but rather on avoid­ing additional medical problems and sustaining life (Verbrugge, 1994). Consequently, the notion of quaternary prevention has been developed to address functional issues. Quaternary prevention is efforts specifically aimed at improving the functional capacities of people who have chronic conditions. Like tertiary prevention, quaternary prevention focuses on the functional limitations and disability com­ponents of the model. Some examples of quater­nary prevention are cognitive interventions to help people with Alzheimer’s disease remember things and occupational therapy to help people maintain their independence.

Although most efforts with older adults to date have focused on primary prevention, increasing attention is being paid to secondary prevention through screening for early diagnosis of diseases such as cancer and cardiovascular disease (see Chapters 2 and 3). Few systematic studies of the benefits and outcomes of tertiary and quaternary prevention efforts have been done with older adult participants. However, the number of such pro­grams being conducted in local senior centers and other settings attractive to older adults is increas­ing steadily, with the focus of many of them on nutrition and exercise (Coulston & Boushey, 2008). The stakes are high. Because tertiary and quater­nary prevention programs are aimed at maintaining functional abilities and minimizing disability, they can be effective, lower-cost alternatives for address­ing the needs of older adults with chronic condi­tions. They can also address concerns about quality of life (Michel et al., 2008).

A Framework for Maintaining and Enhancing Competence

Although most older adults are not as computer literate as Jack, the man introduced in the vignette, increasing numbers of older adults are discover­ing that computers can be a major asset. Many take advantage of the growing resources available on the Web, including sites dedicated specifically to older adults. E-mail enables people of all ages to stay in touch with friends and family, and the growing success of e-commerce makes it easier for people with limited time or mobility to purchase goods and services. Computers are already used in many health devices and are likely to become ubiq­uitous in the home environment of older adults in the relatively near future (Lesnoff-Caravaglia,

(2009) ).

The use of computers is one way in which tech­nology can be used to enhance the competence of older adults. In this section, we consider the general topic of how to maintain and enhance com­petence through a variety of interventions. How to grow old successfully is a topic of increasing concern in view of the demographic changes we considered earlier.

The life-span perspective we considered in Chapter 1 is an excellent starting point for under­standing how to maintain and enhance people’s competence. In this perspective, the changes that occur with age result from multiple biological, psychological, sociocultural, and life-cycle forces. Mastering tasks of daily living and more complex tasks (such as personal finances) contributes to a person’s overall sense of competence even if the

540 CHAPTER 14 person has dementia (Mayo, 2008). How can this sense be optimized for successful aging?

The answer lies in applying three key adap­tive mechanisms for aging: selection, optimization, and compensation (SOC) (Baltes et al., 2006). This framework helps address what Bieman-Copland, Ryan, and Cassano (1998) call the “social facilitation of the nonuse of competence”: the phenomenon of older people intentionally or unintentionally failing to perform up to their true level of ability because of social stereotypes that operate to limit what older adults are expected to do. Instead of behaving at their true ability level, older adults behave in ways they believe typical or characteristic of their age group (Heckhausen & Lang, 1996). This phenom­enon is the basis for the communication patterns we considered earlier in this chapter.

A key issue in the powerful role of stereotypes is to differentiate usual or typical aging from suc­cessful aging (Guralnik, 2008). Successful aging involves avoiding disease, being engaged with life, and maintaining high cognitive and physical func­tioning. Successful aging is subjective. It is reached when a person achieves his or her desired goals with dignity and as independently as possible (Bieman – Copland et al., 1998; Guralnik, 2008; Mayo, 2008; Schulz & Heckhausen, 1996).

The life-span perspective can be used to create a formal model for successful aging. Heckhausen (Heckhausen & Lang, 1996; Schulz & Heckhausen, 1996) developed a life-span theory of control by applying core assumptions that recognize aging as a complex process that involves increasing spe­cialization and is influenced by factors unrelated to age. The basic premises of successful aging include keeping a balance between the various gains and losses that occur over time and mini­mizing the influence of factors unrelated to aging. In short, these premises involve paying attention to both internal and external factors impinging on the person. The antecedents include all the changes that happen to a person. The mechanisms in the model are the selection, optimization, and compensation processes that shape the course of development. Finally, the outcomes of the model denote that enhanced competence, quality of life,
and future adaptation are the visible signs of suc­cessful aging.

Using the SOC model, various types of interven­tions can be created to help people age successfully. In general, such interventions focus on the indi­vidual or aspects of tasks and the physical and social environment that emphasize competence (Allaire & Willis, 2006; Bieman-Copland et al., 1998). When designing interventions aimed primarily at the per­son, it is important to understand the target per­son’s goals (rather than the goals of the researcher). For example, in teaching older adults how to use automatic teller machines (ATMs), it is essential to understand the kinds of concerns and fears older adults have and to ensure that the training program addresses them (Rogers et al., 1997).

Performance on tests of everyday competence predicts longer term outcomes (Allaire & Willis,

2006) . Careful monitoring of competence can be an early indicator of problems, and appropriate interventions should be undertaken as soon as possible.

Health Promotion and Quality of Life

Even though changing unhealthy habits such as smoking and poor diet are difficult, chronic diseases such as arthritis make exercise challenging, and terminal disease makes it tough to see the benefits of changing one’s habits, the fact remains that such changes typically increase functional capability. Current models of behavioral change are complex and include not only behavioral, but also motiva­tional, cognitive, and social components (Aldwin & Gilmer, 2004). Two that are the focus of most research are the self-efficacy model, which empha­sizes the role of goal setting and personal beliefs in the degree to which one influences the outcome, and the self-regulation model, which focuses on the person’s motivation for change.

There is surprisingly little research on health promotion programs designed specifically for older adults (Aldwin & Gilmer, 2004). However, a few trends are apparent. First, although exercise is key to health, because older adults are more prone to injury, exercise programs for older adults need to take such issues into account. Second, health edu­cation programs are effective in minimizing the effects of emotional stress. Third, health screen­ing programs are effective in identifying serious

chronic disease that can limit the quality of life. Each of these areas within health promotion is successful only if ethnic differences are taken into account in designing the programs (Landrine & Klonoff, 2001).

One’s state of health influences one’s quality of life, that is, one’s well-being and life satisfaction. Quality of life includes interpersonal relationships and social support, physical and mental health, environmental comfort, and many psychological constructs such as locus of control, emotions, usefulness, personal­ity, and meaning in life (Kaplan & Erickson, 2000). It is usually divided into environmental, physical, social, and psychological domains of well-being. Personal evaluation of these dimensions is criti­cal to understanding how people view their situa­tions. For example, although half of the people in Strawbridge, Wallhagen, and Cohen’s (2002) study did not meet certain objective criteria for successful aging, they nevertheless defined themselves as suc­cessful and as having a good quality of life.

In short, quality of life is a person’s subjective assessment or value judgment of his or her own life (Aldwin & Gilmer, 2004). This subjective judgment may or may not correspond to the evaluation of others. And even though self – and other-perceived quality of life may diminish in late life, it may not seem like a loss for the older person. For example, an older woman who has difficulty walking may feel happy to simply be alive, whereas another who is in objective good health may feel useless. Quality of

For most people, doing what you enjoy enhances quality of life.

life is best studied from the point of view of the person.

Still, when the level of medical intervention increases as people grow more frail, medical pro­fessionals must be concerned about the trade-off between extending life at all costs and the quality of that life (Michel, Newton, & Kirkwood, 2008). This debate will continue, and will benefit from informed discussions of various options at the end of life, as described in Chapter 13.

Saving Social Security

Few political issues have been around as long and are as politically sensitive as the issues relating to making Social Security fiscally sound for the long term. The basic issues have been well known for decades: the baby-boom generation and the following smaller workforce will greatly stretch the current system, and the present method for raising and distributing revenues cannot be sustained (Social Security Administration, 2008).

Because Social Security is based on current workers paying a tax to support current retirees, the looming funding problems depend critically on the worker-to-retiree ratio. As you can see in Figure 14.3, this ratio has declined precipitously since Social Security began and will continue to do so, placing an increasing financial burden on workers to provide the level of benefits that people have come to expect. Due
to this declining ratio, if the current tax rate of 12.4% each on workers and employers is maintained, payments will exceed income from payroll taxes by 2017, will exceed all sources of revenue including interest on the available surplus (the trust fund) by 2027, and will be bankrupt by 2041 (Social Security Administration, 2008).

So it’s little wonder that young adults have little faith that Social Security will be there for them.

What steps can be taken to keep Social Security sound in the long term? In 2005, President Bush made a concerted effort to incorporate reports from many special commissions established to study the problem (including one he set up in 2001), economists, and researchers who have all proposed changes in the current operation of Social Security. Among the changes proposed over the years are these:

• Privatization: Various proposals have been made for allowing or requiring workers to invest at least part of their money in personal retirement accounts managed by either the federal government or private investment companies.

A variation would take trust funds and invest them in private-sector equity markets. Another option would be

for people to be allowed to create personal accounts with a portion of the funds paid in payroll taxes.

• Means-test benefits: This proposal would reduce or

eliminate benefits to people with high incomes.

• Increase the number of years used to compute the benefit: Currently, benefits are based on one’s history of contributions over a 35-year period. This proposal would increase that to 38 or 40 years.

• Increase the retirement age: The age of eligibility for full Social Security benefits is increasing slowly from age 65 in 2000 to age 67 in 2027. Various proposals to speed up the increase, to increase the age to 70, or to connect age at which a person becomes fully eligible to average longevity statistics have been made.

• Adjust cost-of-living increases downward: Some proposals have been made to lower the increases given to beneficiaries as a result of increases in cost of living.

• Increase the payroll tax rate: One direct way to address the coming funding shortfall is to increase revenues through a higher tax rate.

• Increase the earnings cap for payroll tax purposes: This

proposal would either raise or remove the cap on income subject to the Social Security payroll tax ($102,000 in 2008).

• Make across-the-board reductions in Social Security pension benefits: A reduction in benefits of 3% to 5% would resolve most of the funding problem.

None of these proposals has universal support, and many would significantly disadvantage people, especially minorities and older widows, who depend almost entirely on Social Security for their retirement income (Gonyea & Hooyman, 2005; Syihula & Estes, 2007).

Solving the funding problems facing Social Security will be increasingly important in the next few years. Remember, the first baby boomers became eligible for reduced retirement benefits in 2008. Will it be there for you?

Given the political difficulties inherent in tackling the issue, and the lack of perfect solutions, it is likely that Social Security will remain a major controversy over the next several years.

Concept Checks

1. What major demographic and social policy changes will likely occur by 2030?

2. What are the major issues that confront Social Security?

3. What is Medicare?

14.1 Health Issues and Quality of Life

LEARNING OBJECTIVES • What are the key issues in health promotion and quality of life?

• What are the major strategies for maintaining and enhancing competence?

• What are the primary considerations in designing health promotion and disease prevention programs?

• What are the principal lifestyle factors that influence competence?

J

ack had heard about the many things that were available on the Web, but like many older adults he was a little reluctant to use a computer. He thought that was best left to the grandchildren. But after he purchased his first home computer at age 68, he

began surfing. He never stopped. Now at age 73, he’s a veteran with a wide array of bookmarked sites, especially those relating to health issues. He also com­municates by e-mail, and he designed the community newsletter using his word-processing program.

Jack is like many older adults—better educated and more technologically sophisticated than their predecessors. The coming demographic changes in the United States and the rest of the world in the aging population present a challenge for improv­ing the kind of lives older adults live. For this reason, promoting healthy lifestyles is seen as one of the top health care priorities of the 21st century (Lunenfeld, 2008). Remaining healthy is important for decelerating the rate of aging (Aldwin & Gilmer,

2004) . Promoting healthy lifestyles is important in all settings, including nursing homes (Thompson & Oliver, 2008).

Social Security and Medicare

Without doubt, the 20th and the beginning of the 21st centuries saw a dramatic improvement in the everyday lives of older adults in industrialized
countries. The increase in the number of older adults and their gain in political power, coupled with increased numbers of social programs address­ing issues specifically involving older adults, created unprecedented gains for the average older person (Crown, 2001). As you can see in Figure 14.1, the economic well-being of the majority of older adults has never been better than it is currently. In 1959, roughly 35% of older adults were below the federal poverty line compared to only about 9.4% in 2006 (AgingStats. gov, 2008a).

Whether this downward trend in poverty rates will continue remains to be seen. The baby boom­ers, the largest generation in American history to become eligible for such government programs as Social Security and Medicare, will also be extraor­dinarily expensive due to two factors: their low per­sonal savings rate and the projected costs of chronic disease (Samuelson, 2007).

The Political Landscape. Beginning in the 1970s, older adults began to be portrayed as scapegoats in the political debates concerning government resources.

Part of the reason was due to the tremendous growth in the amount and proportion of federal dol­lars expended on benefits to them, such as through the increase of benefits paid from Social Security during the 1970s (Crown, 2001). At that time, older adults were also portrayed as highly politi­cally active, fiscally conservative, and selfish (Fairlie, 1988; Gibbs, 1988; Smith, 1992). The health care reform debate of the early 1990s focused attention on the spiraling costs of care for older adults that were projected to bankrupt the federal budget if left uncontrolled (Binstock, 1999). Consequently, older adults emerged as the source of most of the United States’ fiscal problems.

It was in this context that the U. S. Congress began making substantive changes in the benefits for older adults on the grounds of intergenera­tional fairness. The argument was that the United States must treat all generations fairly and cannot provide differential benefits to any one generation (Binstock, 1994). Beginning in 1983, Congress has made several changes in Social Security, Medicare, the Older Americans Act, and other programs and policies. Some of these changes reduced benefits to wealthy older adults, whereas others provided targeted benefits for poor older adults (Binstock, 1999).

The aging of the baby-boom generation presents very difficult and expensive problems (Congressional Budget Office, 2008). In fiscal year 2009, federal spending on Social Security and Medicare alone was expected to top $1.1 trillion. As you can see in Figure 14.2, if spending patterns do not change, by 2030 (when most of the baby boomers will have reached old age) expenditures for Social Security and Medicare alone are projected to consume roughly 13% of the gross domestic product (GDP) of the United States. Without major reforms in these programs, such growth will force extremely difficult choices regarding how to pay for them.

Clearly, the political and social issues concerning benefits to older adults are quite complex. Driven by the eligibility of the first baby boomers for reduced Social Security benefits in 2008 and their eligibility for Medicare in 2011, the next decade will see increased urgency for action in confronting the issues. There are no easy solutions, and it will be essential to discuss all aspects of the prob­lem. Let’s look more closely at Social Security and Medicare.

Social Security. Social Security had its beginnings in 1935 as an initiative by President Franklin Roosevelt to “frame a law which will give some measure of

protection to the average citizen and to his fam­ily against the loss of a job and against poverty – ridden old age" Thus Social Security was originally intended to provide a supplement to savings and other means of financial support.

Over the years, revisions to the original law have changed Social Security so that it now represents the primary source of financial support after retire­ment for most U. S. citizens, and the only source for many (Henrikson, 2007; Kingson & Williamson, 2001). Since the 1970s, however, increasing num­bers of workers have been included in employer – sponsored pension plans such as 401(k), 403(b), and 457 plans, mutual funds, as well as various types of individual retirement accounts (IRAs) (U. S. Department of Labor, 2005). This inclusion of various retirement plans, especially savings options, may permit more future retirees to use Social Security as the supplemental financial source it was intended to be, thereby shifting retirement financial planning responsibility to the individual (Henrikson, 2007).

The primary challenge facing Social Security is the aging of the very large baby-boom generation and the much smaller generation that follows. That’s why Nancy, the woman we met in the vignette, and other young adults are concerned. Because Social Security is funded by payroll taxes, the amount of money each worker must pay depends to a large extent on the ratio of the number of people paying Social Security taxes to the number of people col­lecting benefits. By 2030, this ratio will drop nearly in half; that is, by the time baby boomers have largely retired, there will be nearly twice as many people collecting Social Security per worker paying into the system as there is today (Social Security Administration, 2008). Various plans have been proposed since the early 1970s to address this issue, and several U. S. presidents have made it a major agenda item (including President George W. Bush in 2005), but Congress has not yet taken the actions necessary to ensure the long-term financial stability of Social Security (Social Security Administration,

2008) . As discussed in the Current Controversies feature, the suggestions for doing this present dif­ficult choices for politicians.

Medicare. Roughly 40 million U. S. citizens depend on Medicare for their medical insurance. To be eligible, a person must meet one of the following criteria: be over age 65, be disabled, or have permanent kidney failure. Medicare consists of three parts (Medicare. gov, 2008a): Part A, which covers inpatient hospi­tal services, skilled nursing facilities, home health services, and hospice care; Part B, which covers the cost of physician services, outpatient hospital ser­vices, medical equipment and supplies, and other health services and supplies; and Part D, which pro­vides some coverage for prescription medications. Expenses relating to most long-term care needs are funded by Medicaid, another major health care pro­gram funded by the U. S. government and aimed at people who are poor. Out-of-pocket expenses asso­ciated with co-payments and other charges are often paid by supplemental insurance policies, sometimes referred to as “Medigap” policies (Medicare. gov, 2008b).

Like Social Security, Medicare is funded by a payroll tax. So the funding problems facing Medicare are very similar to those facing Social Security and are grounded in the aging of the baby – boom generation. In addition, Medicare costs have increased dramatically due to more general rapid cost increases in health care.

Due to these rapid increases and the specter of the baby-boom generation, cost containment remains a major concern. In 2008, President Bush and the con­tenders to replace him all cited rapidly rising health care costs as a major economic problem facing the United States. But unlike Social Security, Medicare is a government program that has been subjected to significant cuts in expenditures, typically through reduced payouts to health care providers. Whether this practice will continue is unclear, especially when baby boomers find out that their health care cover­age could be significantly reduced.

Taken together, the challenges facing society con­cerning older adults’ financial security and health will continue to be major political issues throughout the first few decades of the 21st century. There are no easy answers, but open discussion of the various arguments will be essential for creating the optimal solution.

536 CHAPTER 14

CURRENT

CONTROVERSIES

Demographic Trends and Social Policy

LEARNING OBJECTIVES

• What key demographic changes will occur by 2030?

• What are the challenges facing Social Security and Medicare?

N

ancy, a 35-year-old new employee at a mar­keting and public relations firm, was flipping through the company’s benefits package. When it came to the retirement plan, she commented to the human resources person, “I guess I better pay atten­tion. I don’t think Social Security will be there for me when the time comes.”

Nancy isn’t alone. Many younger adults in the United States do not believe that Social Security or other government programs will be in existence by the time they get old enough to qualify for them. Demographic and financial trends support this pes­simistic view. As we will see, the baby-boom gen­eration, coupled with structural problems in Social Security and Medicare, give young adults good reasons to be concerned.

Demographic Trends: 2030

In Chapter 1, we noted several trends in the popula­tion of the United States and the rest of the world during the upcoming century. These trends are not likely to change in the foreseeable future. Changes in the composition of the older adult population contribute to potentially critical issues that will emerge over the next few decades. One especially important area concerns the potential for intergen­erational conflict.

Because the resources and roles in a society are never divided equally among different age groups, the potential for conflict always exists. One well – known intergenerational conflict is that between adolescents and their parents. Less well known is the potential for conflict between middle-aged and older adults. This type of conflict has not t raditionally been a source of serious problems in society, for several reasons: Older adults made up a small proportion of the population, family ties between adult children and their parents worked against conflict, and middle-aged people were hesi­tant to withdraw support from programs for older adults. Despite these potent forces protecting against conflict, the situation is changing. For example, the controversy over the rate of growth of Medicare and Social Security that has created heated political debates about social support programs and health care in the late 1990s and 2000s would have been unthinkable just a few years earlier.

To see more clearly how these changing demo­graphics will have an enormous effect on society at large and on the programs that target older adults, let us project forward to the year 2030, when the last of the baby boomers will have reached age 65. Between now and 2030, the following changes will have set in:

• The proportion of older adults in the United States will have nearly doubled.

• Older adults will be much more politically sophisticated and organized. They will be better educated and will be familiar with life in a highly complex society in which one must learn to deal with bureaucracies. And they will be proficient users of the Internet and technology in general.

• Older adults will expect to keep their more affluent lifestyle, Social Security benefits, health care benefits, and other benefits accrued throughout their adult life. A comfortable retirement will be viewed as a right, not a privilege.

• The ratio of workers to retirees will fall from its current level of roughly over 3:1 to 2:1. This means that to maintain the level of benefits in programs such as Social Security, the working members

of society will have to pay significantly higher taxes than workers do now. This is because Social Security is a pay-as-you-go system in which the money collected from workers today is used to pay current retirees. Contrary to popular belief, Social Security is not a savings plan. Whether policymakers will make the necessary changes to maintain benefits that citizens came to view as entitlements remains to be seen.

• The increase in divorce that has occurred over the past few decades may result in a lowered sense of obligation on the part of middle-aged adults toward parents who were not involved in their upbringing

Successful Aging 533

or who the adult child feels disrespected the other parent. Should this lowered sense of obligation result, it is likely that fewer older adults will have family members available to care for them, placing a significantly greater burden on society for care.

• The rapid increase in the number of ethnic minority older adults compared to white older adults will force a reconsideration of issues such as discrimination and access to health care, goods, and services, as well as provide a much richer and broader understanding of the aging process.

No one knows for certain what society will be like by 2030. However, the changes we have noted in demographic trends suggest a need for taking action now. Two areas facing the most challenge are Social Security and Medicare. Let’s take a look at these to understand why they face trouble.

Successful Aging

14.1 DEMOGRAPHIC TRENDS AND SOCIAL POLICY

Demographic Trends: 2030 • Social Security and Medicare • Current Controversies: Saving Social Security

14.2 HEALTH ISSUES AND QUALITY OF LIFE

Health Promotion and Quality of Life • A Framework for Maintaining and Enhancing Competence • Health Promotion and Disease Prevention • Lifestyle Factors

14.3 SUCCESSFUL AGING

Discovering Development: What Is Successful Aging?

Summary • Review Questions • Integrating Concepts in Development • Key Terms • Resources

WELCOME TO THE LOOK DOWN THE ROAD. IN THIS EPILOGUE, WE TAKE A

different perspective on aging. Based on what we know now about older adults and the process of aging, we look to our own future. We consider what society must do to keep the social programs we have come to rely on. We consider what each of us can do to keep ourselves in the best health possible in order to delay or even prevent some of the negative aspects of aging. And we also look around the corner and ahead a few decades. Technical advances will make commonplace what is only science fiction today. For example, it is likely that we will be able to get our annual physical examination remotely, be in classes or meetings led by someone’s holographic projection because they are actually in another place, and remember fondly those days when you had to spend lots of time downloading movies because the connection speeds were so slow. Our daily lives will likely have vastly different elements from those they have right now. Life undoubtedly will be more complicated. But people are still likely to experience firsthand many of the things discussed in this book: marriage, children, career changes, relocation, personal development, physical and cognitive changes, the loss of friends and loved ones, and so on.

For now, though, we must be content with working with what we do and do not know. Throughout this book we have made predictions about this future and guessed how older people may fare. Some of these predictions are not so happy; for example, as many people live to a very old age, there will be more need for long-term care. Whether we will be able to provide the care for them is very much in doubt. Other aspects of the future may be more positive; for instance, as many people live to very old age there will be a much larger pool of older workers to balance the labor force. These predictions represent our best guess about what life will be like in the next few decades, based on what we know now and what is likely to happen if we continue the way we are going.

The purpose of this epilogue is to pull together several crucial issues facing gerontologists as we move through the 21st century and to illustrate how we can set the best stage for our own aging. This survey will not be exhaustive; rather, we will focus on two things: points that have been singled out for special concern, and areas where major advances may have a dramatic impact on our own development.

532 CHAPTER 14