help on writing - Nursing
Students will select any one article provided. The article is to be summarized on no more than 2 sides / pages and should include the following information:
Research design (What they did)
Research Method (How they did it)
Method of analysis (how they analysed)
Key theories of principles of gerontology (The Background)
Key findings
Implications (how does it impact the real world?)
Limitations
Reflection on the quality of research and contribution to academic knowledge and applicability.
Fiona Crawford, NH, Phil Hanlon, Jill Muirie, and DO, who all
contributed equally to the thinking that inspired this article.
Funding: None.
Competing interests: None declared.
1 Obesity: preventing and managing the global epidemic. Report of a
WHO consultation. World Health Organization Technical Report Series
2000;894:1-253.
2 Storing up problems: the medical case for a slimmer nation. London: Royal
College of Physicians of London, Royal College of Paediatrics and Child
Health, and Faculty of Public Health, 2004.
3 Egger G, Swinburn B. An “ecological” approach to the obesity pandemic.
BMJ 1997;315:477-80.
4 Department of Health. Choosing health: making healthier choices easier. Lon-
don: Stationery Office, 2004.
5 Asp N-G, Björntorp P, Britton M, Carlsson P, Kjellström T, Marcus C, et al.
Obesity — problems and interventions. Stockholm: Statens beredning för
medicinsk utvärdering (The Swedish Council on Technology Assessment
in Health Care), 2002.
6 Ebbeling C, Pawlak D, Ludwig D. Childhood obesity: public-health crisis,
common sense cure. Lancet 2002;360:473-82.
7 Department for Transport. Transport statistics bulletin: national travel survey
2002. London: Stationery Office, 2004.
8 Peters J, Wyatt H, Donahoo W, Hill J. From instinct to intellect: the chal-
lenge of maintaining healthy weight in the modern world. Obes Rev
2002;3:69-74.
9 Swinburn B, Egger G. The runaway weight gain train: too many accelera-
tors, not enough brakes. BMJ 2004;329:736-9.
10 Day J. Scottish schools ban food adverts. Guardian 2003;24 Dec.
http://media.guardian.co.uk/advertising/story/0,,1112620,00.html
(accessed 27 Jan 2004).
11 Neroth P. Fat of the land. Lancet 2004;364:651-3.
12 World Health Organization. Diet, nutrition and the prevention of chronic dis-
eases. Report of a joint WHO/FAO expert consultation. Geneva: WHO,
2003.
13 Cable News Network. Transcript of President Bush’s address to a joint
session of Congress on Thursday night, Sept 20, 2001. http://
www.cnn.com/2001/US/09/20/gen.bush.transcript (accessed 27 Jan
2004).
14 Hamilton C. Growth fetish. London: Pluto, 2004.
15 Department for Transport. It’s no joke. www.cyclesense.net (accessed 10
Jun 2005).
16 Lean M. Prognosis in obesity. BMJ 2005;330:1339-40.
17 Ellaway A, Macintyre S. “5-a-day” may be harder to achieve in more
deprived areas. J Epidemiol Community Health 2004;58:892.
18 Ellaway A, Macintyre S. Play areas for children. J Epidemiol Community
Health 2003;57:315.
(Accepted 14 October 2005)
What is successful ageing and who should define it?
Ann Bowling, Paul Dieppe
A definition of successful ageing needs to include elements that matter to elderly people
The substantial increases in life expectancy at birth
achieved over the previous century, combined with
medical advances, escalating health and social care costs,
and higher expectations for older age, have led to inter-
national interest in how to promote a healthier old age
and how to age “successfully.” Changing patterns of
illness in old age, with morbidity being compressed into
fewer years and effective interventions to reduce disabil-
ity and health risks in later life, make the goal of ageing
successfully more realistic. Debate continues about
whether disability has been postponed,1 although the
Berlin ageing study2 and the US MacArthur study of
ageing3 showed that greater longevity has resulted in
fewer, not more, years of disability.
A forward looking policy for older age would be a
programme to promote successful ageing from
middle age onwards, rather than simply aiming to
support elderly people with chronic conditions. But
what is successful ageing? And who should define it?
Methods
We discuss existing models of the constituents of
successful ageing from the social, psychological, and
medical sciences. We undertook a systematic literature
review, searching PubMed, PsycINFO, and SocioFile (all
years) for “successful ageing.” We included 170 papers
presenting reviews or overviews of the topic, data from
cross sectional and longitudinal surveys, and qualitative
studies (full list available on request, but the main ones
are listed here2–22). We also included lay definitions
elicited from our own recent survey of successful ageing.
What is successful ageing?
The main themes emerging from the theoretical litera-
ture reflected psychosocial or biomedical approaches,
or combinations of these (see box). There was some
overlap with lay views; although the latter were more
comprehensive and multidimensional.
Biomedical theories
Biomedical theories define successful ageing largely in
terms of the optimisation of life expectancy while mini-
mising physical and mental deterioration and disability.
They focus on: the absence of chronic disease and of risk
Decline and fall? Goya’s Les Vieilles (“Time of the Old Women”)
M
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Thoughts for today
Department of
Primary Care and
Population
Sciences, University
College London,
London NW3 2PF
Ann Bowling
professor of health
services research
Medical Research
Council Health
Services Research
Collaboration,
Department of
Social Medicine,
University of
Bristol, Bristol BS8
2PR
Paul Dieppe
director
Correspondence to:
A Bowling
[email protected]
BMJ 2005;331:1548–51
1548 BMJ VOLUME 331 24-31 DECEMBER 2005 bmj.com
factors for disease; good health; and high levels of inde-
pendent physical functioning, performance, mobility,
and cognitive functioning. The MacArthur studies of
successful ageing, based on a three site longitudinal
study of elderly US adults living in the community in
1988,3 8 are the most well known and widely published
biomedical studies of successful ageing.
The division of people into “diseased” and “normal”
fails to recognise the large heterogeneity within these
groups. To overcome this, Rowe and Kahn distinguished
between “usual ageing” (normal decline in physical,
social, and cognitive functioning with age, heightened by
extrinsic factors) and “successful ageing” in which func-
tional loss is minimised (little or no age related
decrement in physiological and cognitive functioning,
with extrinsic factors playing a neutral or positive role).3
They confirmed the three components of successful
ageing as absence or avoidance of disease and risk
factors for disease, maintenance of physical and
cognitive functioning, and active engagement with life
(including maintenance of autonomy and social
support). Some investigators have broadened the model
to include more psychosocial elements,4 although
attempts to build interdisciplinary models are still rare.
Rowe and Kahn’s model is the most widely used
approach, but it fails to address the implications of the
fact that a disease-free older age is unrealistic for most
people. Moreover, it has been reported that, although
half of elderly people can be categorised as having
aged successfully in terms of their own criteria, fewer
than a fifth can be so categorised with this traditional
medical model.9
Psychosocial approaches
While the biomedical model emphasises absence of
disease and the maintenance of physical and mental
functioning as the keys to ageing successfully, socio-
psychological models emphasise life satisfaction, social
participation and functioning, and psychological
resources, including personal growth.
Satisfaction with one’s past and present life has
been the most commonly proposed definition of
successful ageing, and is also the most commonly
investigated.15 Its components include zest, resolution
and fortitude, happiness, relationships between desired
and achieved goals, self concept, morale, mood, and
overall wellbeing. Continued social functioning is
another commonly proposed domain of successful
ageing. It encompasses high levels of ability in social
role functioning, positive interactions or relationships
with others, social integration, and reciprocal participa-
tion in society.16
Suggested psychological resources for successful
ageing include a positive outlook and self worth, self
efficacy or sense of control over life, autonomy and
independence, and effective coping and adaptive strat-
egies in the face of changing circumstances. For exam-
ple, when some activities are curtailed (say, because of
ill health) strategies need to be activated to find new
activities and to maximise one’s reserves.17 Successful
ageing is seen as a dynamic process, as the outcome of
one’s development over the life course,18 and as the
ability to grow and learn by using past experiences to
cope with present circumstances while maintaining a
realistic sense of self.
Lay views
There are a few investigations into older people’s views
of what is successful ageing.19 Their definitions include
mental, psychological, physical, and social health; func-
tioning and resources; life satisfaction; having a sense
of purpose; financial security; learning new things;
accomplishments; physical appearance; productivity;
contribution to life; sense of humour; and spirituality.
The box lists several lay definitions that are not
captured adequately by theoretical models.
We also conducted a national, random population
survey of perceptions of successful ageing among 854
people aged 50 or more, living at home in Britain; this
was part of an Office for National Statistics omnibus
survey (analyses ongoing). Of these people, 75\% (631)
rated themselves as ageing successfully “Very well” or
“Well” (as opposed to “Alright,” “Not well” or “Not very
well”). The most commonly mentioned definition of
successful ageing, in response to open ended question-
ing, was having good health and functioning, but these
were rarely mentioned in isolation, and most people
mentioned more than one definition (see figure). Typi-
cal comments were:
“[Successful ageing is to] go out a lot and enjoy life, take it
day by day, and enjoy what you can . . . Have good
health—that’s more important than anything else. Keep
active—while your legs are moving get out on them.”
“[It’s] good health. Well, if you’re fit and able to do more . . .
active . . . you . . . contribute to society and get actively
involved.”
“It’s your outlook on life to start with. I think I have been an
active person. It’s your whole outlook. Do you make an
effort to keep fit? I don’t think about getting old. I just don’t
feel old and act accordingly.”
Main constituents of successful ageing
Theoretical definitions
• Life expectancy
• Life satisfaction and wellbeing (includes happiness
and contentment)
• Mental and psychological health, cognitive function
• Personal growth, learning new things
• Physical health and functioning, independent
functioning
• Psychological characteristics and resources,
including perceived autonomy, control, independence,
adaptability, coping, self esteem, positive outlook,
goals, sense of self
• Social, community, leisure activities, integration and
participation
• Social networks, support, participation, activity
Additional lay definitions
• Accomplishments
• Enjoyment of diet
• Financial security
• Neighbourhood
• Physical appearance
• Productivity and contribution to life
• Sense of humour
• Sense of purpose
• Spirituality
Thoughts for today
1549BMJ VOLUME 331 24-31 DECEMBER 2005 bmj.com
Less commonly, successful ageing was defined in
terms of social capital, as retiring in a safe
neighbourhood, and with good community facilities.
Policy implications
Several policy implications become evident from a
broader interpretation of the concept of successful
ageing. Biomedical research has developed to include
the investigation of biological pathways to unsuccessful
ageing (impaired mental and physical functioning,
including immunological and genetic markers),
although the current policy focus is on disease preven-
tion and health promotion for achieving successful
ageing. Most behavioural actions for successful ageing
continue to promote health related behaviours and
engagement in cognitively stimulating activities.
Indeed, on the basis of the Landmark Harvard study of
adult development, Vaillant argued that successful age-
ing is less dependent upon genetic predisposition than
previously thought.4
If high social functioning, for example, is accepted
as part of ageing successfully, the implication is that
people need encouragement to build up their social
activities and networks from a young age, and the pro-
vision of enabling community facilities is needed. This
is given impetus by research indicating that many
domains of successful ageing are inter-related, and that
having multiple social activities and relationships is
associated with life satisfaction and better health and
functioning, autonomy, and survival.4 20
Psychosocial models have also culminated in the
positive psychology movement, with its proponents of
the benefits of learnt optimism.23 It has been postulated
that people can learn to see “a bottle half full” instead
of “a bottle half empty” and that having a happy
outlook is a skill that can be cultivated. But, irrespective
of the likelihood of genetic influences, getting people
to “cheer up” is not always easy in real life.
With greater recognition that older people are not
a homogeneous group, health professionals need
more balanced, interdisciplinary perspectives of older
age. People’s low expectations of ageing are associated
with their placing less importance on seeking health
care.21 Clinicians need to be aware of their patients’ val-
ues and expectations of ageing in order to enhance
mutual understanding of their health goals and priori-
ties,19 and to consider interventions that will optimise
their chances of “ageing successfully” in their terms.
However, interventions need to target potentially
vulnerable groups early on, as several longitudinal
datasets have shown that variables measured in middle
age predict outcomes in old age.4 Consistent with this
are longitudinal data showing that adaptation to old
age is related to experiences of stressful events, and is
also associated with social class.24
Conclusions
Most concepts of successful ageing are used uncriti-
cally and tend to reflect the academic discipline of the
investigator. Many authors have also confused constitu-
ents with precursors. While the biomedical models
emphasised absence of disease and good physical and
mental functioning as successful ageing, sociopsycho-
logical models emphasised life satisfaction, social func-
tioning and participation, or psychological resources.
Lay views of successful ageing are important for testing
the validity of existing models and measures, if they are
to have any relevance to the population they are
applied to. There is little point in developing policy
goals if elderly people do not regard them as relevant.
Most health care provided in the developed world
goes to those aged 65 years or above. The medical
model is so dominant that few health professionals are
aware of psychosocial ageing. The result is a focus on
the burden of old age, the decline and failure of the
body. This negative perspective inevitably dominates
consultations between doctors and patients. However,
there is ample evidence that many elderly people
regard themselves as happy and well, even in the pres-
ence of disease or disability. Doctors should be aware
that many elderly people consider themselves to have
aged successfully, whereas classifications based on
traditional medical models do not. This review led us to
a paper by Callahan et al,22 who suggested that we need
to examine our assumptions and adopt humility of
perspective. Health professionals need to respect the
values and attitudes of each elderly person who asks
for help, rather than imposing our medical model on
to their lives.
In conclusion, the achievement of successful ageing
in terms of all the criteria presented here is unrealistic
for most people. But successful ageing needs to be
viewed, not only multidimensionally, but as an ideal
state to be aimed for, and the concept itself should be
placed on a continuum of achievement rather than
subject to simplistic normative assessments of success
or failure. Given the enormous body of ongoing
research on the topic, it would be unhelpful to
abandon the term altogether; the adoption of a
broader perspective will have relevance for elderly
people themselves.
We thank Sandra Short, Ian O’Sullivan and the Office for
National Statistics (ONS) staff who carried out the original
Omnibus Survey data analysis and collection. They hold no
responsibility for the further analysis and interpretation of
them. Material from the ONS Omnibus Survey, made available
through ONS, has been used with the permission of the
controller of the Stationery Office. The dataset will be held on
the data archive at the University of Essex.
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Most common definitions of successful ageing given by 854 people
aged ≥50 in Britain
Thoughts for today
1550 BMJ VOLUME 331 24-31 DECEMBER 2005 bmj.com
Contributors: AB undertook the systematic review and analyses
and is guarantor for the study. AB and PD wrote this article col-
laboratively.
Funding: None.
Competing interests: None declared.
Ethical approval: Not required.
1 Mor V. The compression of morbidity hypothesis: a review of research
and prospects for the future. J Am Geriatr Soc 2005;53:S308-9.
2 Baltes PB, Mayer KV, eds. The Berlin ageing study. Cambridge: Cambridge
University Press, 1999.
3 Rowe JW, Kahn RL. Successful aging. New York: Pantheon Books, 1998.
4 Vaillant GE. Aging well: surprising guideposts to a happier life from the Land-
mark Harvard study of adult development. Boston: Little Brown, 2002.
5 Roos NP, Havens B. Predictors of successful aging: a twelve year study of
Manitoba elderly. Am J Public Health 1991;81:63-8.
6 Crosnoe R, Elder GH. Successful adaptation in the later years: a life
course approach to aging. Soc Psychol Q 2002;65:309-28.
7 Andrews G, Clark M, Luszcz M. Successful aging in the Australian longi-
tudinal study of aging: applying the MacArthur model cross-nationally. J
Soc Issues 2002;58:749-65.
8 Seeman TE, Charpentier PA, Berkman LF, Tinetti ME, Guralnik JM,
Albert M, et al. Predicting changes in physical performance in a
high-functioning elderly cohort. MacArthur studies of successful aging. J
Gerontol 1994;49:M97-108.
9 Strawbridge WJ, Wallhagen MI, Cohen RD. Successful aging and
well-being. Self-rated compared with Rowe and Kahn. Gerontologist
2002;42:727-33.
10 Vaillant GE, Mukamal K. Successful aging. Am J Psychiatry 2001;158:
839-47.
11 Von Faber M. Successful aging in the oldest old: who can be characterised
as successfully aged? Arch Intern Med 2001;161:2694-700.
12 Grundy E, Bowling A. Enhancing the quality of extended life years. Iden-
tification of the oldest old with a very good and very poor quality of life.
Aging Ment Health 1999;3:199-212.
13 Palmore E. Predictors of successful aging. Gerontologist 1979;19:427-31.
14 Williams RH, Wirths CG. Lives through the years: styles of life and successful
aging. New York: Atherton Press, 1965.
15 Havighurst RJ. Successful aging. In: Williams RH, Tibbits C, Donahue W,
eds. Processes of aging. New York: Atherton Press, 1963:299-320.
16 Havighurst RL, Neugarten B, Tobin SS. Disengagement and patterns of
aging. In: Neugarten BL, ed. Middle age and aging: a reader in social psychol-
ogy. Chicago: University of Chicago Press, 1968:161-72.
17 Baltes PB, Baltes MM. Successful aging: perspectives from the behavioral
sciences. New York: Cambridge University Press, 1990.
18 Ryff CD. Beyond Ponce de Leon and life satisfaction: new directions in
quest of successful aging. Int J Behav Dev 1989;12:35-55.
19 Phelan EA, Anderson LA, Lacroix AZ, Larson EB. Older adults’ views of
“successful aging”—how do they compare with researchers’ definitions? J
Am Geriatr Soc 2004;52:211-6.
20 Menec VH. The relation between everyday activities and successful aging:
a 6-year longitudinal study. J Gerontol B Psychol Sci Soc Sci 2003;58:S74-82.
21 Sarkisian CA, Hays RD, Mangione CM. Do older adults expect to age
successfully? The associations between expectations regarding aging and
beliefs regarding healthcare seeking among older adults. J Am Geriatr Soc
2002;50:1837-43.
22 Callahan CM, McHorney CA, Mulrow CD. Successful aging and the
humility of perspective. Ann Intern Med 2003;139:389-90.
23 Seligman M. Authentic happiness: using the new potential for lasting fulfilment.
New York: Free Press, 2004.
24 Caspi A, Elden GH. Life satisfaction in old age: linking social psychology
and history. Psychol Aging 1986;1:18-26.
(Accepted 9 October 2005)
Slow tracking for BMJ papers
Christopher Martyn
An editor argues against the current enthusiasm for fast tracking pages
It seems that it all started with the Lancet.1 In 1997 it
offered to publish selected manuscripts within four
weeks of submission. They claimed that their motive
was to get important data into the public health arena
as quickly as possible, citing worrying (worrying!)
instances that they and other journals had experienced
of “delays in the publication of important data with
major public-health messages.” Each week’s delay, they
asserted, is “another week during which the research
findings can leak out, perhaps in distorted form, via the
mass media. Without the full paper, those health-care
workers who advise the public are not privy to the
caveats and interpretations made by the authors of the
study.”
Convinced? Well, JAMA was, and a year or two later
it offered much the same thing.2 It dubbed the process
EXPRESS (Expedited Peer Review and Editorial
System for Science) presumably to give the impression
that it was JAMA’s idea in the first place. Any number of
other journals tagged along, and authors can now
request fast track from the International Journal of Social
Psychiatry, Neuropsychological Rehabilitation, the Euro-
pean Journal of Developmental Psychology, the Journal of
Molecular Endocrinology, and the Journal of Occupational
and Environmental Medicine, to name but a few. There
was even a time when the Quarterly Journal of Medicine
offered to fast track papers.
The BMJ has always been doubtful. As an editorial
in 1999 pointed out: “It usually takes years to do a
study and then years for change to happen: why rush
around to reduce the time to publication by months?”3
But, in the end, we came around, signalling our half
heartedness with the obscure—we reckoned ironic—
icon of a bike with oval wheels. At least we were honest
about the reasons: “We hope it will attract researchers
with high quality studies to submit them to the BMJ,
and we hope it will serve readers by helping us to
attract better papers.”
Evolutionary biologists will understand what’s
going on here.4 In a complex and changing system, a
species needs to continue to develop just to maintain
its fitness relative to other species. If a mutation allows
antelopes to run faster, cheetahs must evolve or starve.
But it’s not only in arms races between predators and
prey that this principle operates. It also happens when
there is competition for limited resources. Trees in a
forest compete for sunlight. If one tree grows taller, it
captures sunlight that would otherwise have reached
neighbouring trees. They are then forced to grow taller
to avoid being overshadowed. Overall, the effect of
competition is that trees become taller. But note the
downside: there’s still the same amount of sunlight. It’s
just that trees have to work harder to get their share.
It’s the same with journals. To prosper they must
attract the best papers—a limited resource. If one jour-
nal makes itself more attractive to authors by speeding
up its processes, others are constrained to follow. But
the process engenders no increase in the number of
good papers. Who benefits? Certainly not the
journals—they’ve had to expend more editorial energy
on publishing the same number of papers. The
authors? Probably not, because the best papers were
usually published fairly promptly anyway. Readers?
Again, and for the same reason, probably not. It’s hard
Because the author
was so slow in
delivering his
manuscript, it had
to be fast tracked to
get into this issue
Thoughts for today
BMJ, London
WC1H 9JR
Christopher Martyn
associate editor
[email protected]
BMJ 2005;331:1551–2
1551BMJ VOLUME 331 24-31 DECEMBER 2005 bmj.com
43© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved.
For permissions, please e-mail: [email protected]
Examining Rowe and Kahn’s Concept of
Successful Aging: Importance of Taking a Life
Course Perspective
James D. Stowe, MS*,1,2 and Teresa M. Cooney, PhD3
1Department of Human Development and Family Studies, University of Missouri, Columbia. 2Frank
L. Mitchell Jr., MD Trauma Center, University of Missouri Hospital, Columbia. 3Department of Sociology,
University of Colorado Denver.
*Address correspondence to James Stowe, MS, Department of Human Development and Family Studies, University of
Missouri, 314 Gentry Hall, Columbia, MO 65211. E-mail: [email protected]
Received January 10 2014; Accepted April 23 2014.
Decision Editor: Helen Q. Kivnick, PhD
Purpose of the Study: This article critiques Rowe and Kahn’s conceptualization of suc-
cessful aging using tenets of the life course perspective.
Design and Methods: A review and synthesis of the literature on successful aging and
studies that use a life course perspective.
Results: We draw on life course principles that view development as a dynamic life-
long process, embedded in historical time and place, and influenced by the web of rela-
tionships individuals are linked to, as well as more distal social structural factors. This
discussion questions the relatively static nature of Rowe and Kahn’s successful aging
model, its emphasis on personal control over one’s later-life outcomes, and neglect of
historical and cultural context, social relationships, and structural forces in influencing
later-life functioning.
Implications: Caution in using the model in its current formulation is needed, and we
promote thinking about how successful aging can better align with micro- and mac-
rolevel issues through utilization of a life course perspective.
Key words: Successful aging, Life course perspective, Theory, Positive aging, Life span
Our goal is to summarize and advance a critique of
John Rowe and Robert Kahn’s (1987, 1997, 1998)
conceptualization of successful aging (SA) from a life course
perspective (Elder, Johnson, & Crosnoe, 2003). Introduced
Abstract
Special Issue:
Successful Aging
The Gerontologist, 2015, Vol. 55, No. 1, 43–50
doi:10.1093/geront/gnu055
Research Article
Special Issue: Successful Aging
Advance Access publication June 6, 2014
Downloaded from https://academic.oup.com/gerontologist/article-abstract/55/1/43/573784
by guest
on 10 February 2018
mailto:[email protected]?subject=
over 20 years ago, Rowe and Kahn’s model remains influ-
ential and widely cited despite criticism from the academic
community. Opportunities to improve Rowe and Kahn’s
model through application of life course principles provide
the impetus for this article. Although some may feel—after
considering the model’s shortcomings—that it no longer
has utility, the popularity of the model in the mainstream
literature and extensive use in scientific inquiry warrants
modification over disposal. Few conceptualizations of posi-
tive aging have spurred such energetic academic inquiry
and debate. The model’s development over time holds value
and represents the process by which science is improved.
Therefore, we encourage cautious use of the model in its
current formulation and attempt to promote revisions to
the SA construct and model as a means of promoting their
utility for policy and practice.
Rowe and Kahn’s model (1997), which is arguably the
best known and widely applied model of SA (Dillaway &
Byrnes, 2009), views “better than average” aging as a combi-
nation of three components: avoiding disease and disability,
high cognitive and physical function, and engagement with
life. Their formulation aimed to eclipse prior thinking about
disengagement and unavoidable senescence by focusing on
activity and function (Johnson & Mutchler, 2014). Moreover,
the model solidified a major turning point in gerontology
and offered ample opportunities for funding programs that
viewed elders as able, valuable societal members who bene-
fited from engaged lives (see Everard, Lack, & Heinrich 2000
for an example of how the model provided a framework for
program development). Their conceptualization of SA also
views decline and functional loss as modifiable although
largely through an individual’s own actions. Literature on SA,
particularly Rowe and Kahn’s conceptualization, is prolific
and thousands of articles cite or utilize this model.
One problem with Rowe and Kahn’s model, however,
is its sole focus on late adulthood as a point to make a
static assessment of an individual’s “successful aging.”
Thus, it fails to capture developmental processes and
trajectories of continuity and change in function over
time. A life course perspective, in contrast, is a dynamic
perspective that considers development, history, and the
importance of relationships over time. In application, a
life course perspective combats the static “snapshot” cre-
ated by Rowe and Kahn’s conceptualization and offers
an enhanced opportunity to understand SA as a devel-
opmental process. In this way, a life course perspective
acts in concert with Rowe and Kahn’s model, especially
with regard to the formulation of research questions
and methodologies that may help counter the model’s
weaknesses.
Several aspects of a life course perspective (Elder et al.,
2003) make it a valuable tool for evaluating this popular
model of SA. First, a life course perspective views aging as
lifelong and thus facilitates understanding of late-life “out-
comes” and the development of effective prevention and
intervention approaches (see Berkman, Ertel, & Glymour,
2011). Moreover, a long view of aging, with an emphasis
on process and change over time, highlights the potential
for growth and adaptation across the entire life span. A life
course perspective points to the importance of context—
historical, cultural, and social—for development and aging
(Dannefer, 2012) and provides a more nuanced perspective
of how social forces and individual agency interact to shape
aging outcomes. We argue that Rowe and Kahn’s conceptu-
alization relies too heavily upon individual agency.
Additionally, Rowe and Kahn’s model describes physical
function as a major characteristic of SA. A life course per-
spective broadens this conceptualization by acknowledging
that diverse experiences may lead to varying interpretations
of success, both individually and culturally.
Finally, a life course perspective focuses on linked lives.
This concept highlights that, as social beings, individuals’
lives and life progress are influenced by significant others
and their life progress. Recognition of such interconnected-
ness strengthens dialogue on SA.
Successful Aging: Then and Now
Havighurst (1963) was part of early discussions of the
concept of SA and distinguished two views of this phe-
nomenon. An “outer” behavioral view focused on enact-
ment of various social roles, whereas an “inner” subjective
view emphasized life adjustment or satisfaction. Avoiding
a behaviorally based conceptualization that aligned with
either disengagement theory or activity theory—competing
perspectives on aging during his time—Havighurst favored
the latter approach. This individualized, subjective view
of SA emphasized developmental continuity. Havighurst
argued that the specific lifestyle favored by particular older
adults depended on the lifestyles they had established ear-
lier in adulthood. Havighurst (1963) concluded that “Inner
satisfaction can be usefully defined and measured as a crite-
rion of successful aging” (p. 311).
This discussion of SA foreshadowed a view of aging
that recognizes consistency in adults’ behavioral prefer-
ences and lifestyles across the life span (Maddox, 1968),
an idea later formalized in Atchley’s (1989) Continuity
Theory of Aging. We highlight these ideas because a life
course perspective is necessary in discussions of continu-
ity, and processes promoting continuity across adulthood
have been articulated by life course scholars (see Caspi
& Roberts, 2001). Additionally, Havighurst’s conception
rejects the “outer” view of SA assessed by narrow, behavio-
ral measures like the engagement component of Rowe and
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Kahn’s model. How the long view of aging challenges the
health and functioning components of Rowe and Kahn’s
SA model is considered next.
Aging as a Lifelong, Intergenerational Process
A life course perspective views aging as a life-span phe-
nomenon and recognizes developmental influences that are
launched prior to birth. Among these early influences are
genetics, which Rowe and Kahn (1987) also acknowledge as
important to aging outcomes. Additionally, environmental
conditions and risks (e.g., poverty) are transmitted across
generations in a family and ultimately affect development
and aging (Ferraro, Pylypiv Shippee, & Schafer, 2009).
Consideration of such factors is critical to understanding
late-life outcomes, developmental potential, and the effec-
tiveness of interventions targeted at negative outcomes.
The pathways and processes through which early experi-
ences affect late-life outcomes are articulated in three distinct
life course models (Berkman, 2009; Berkman et al., 2011;
Hendricks, 2012). Early events or conditions may affect
aging directly over time if they occur during a highly sensitive
or critical period of development. The timing of exposure or
the event may yield powerful consequences for subsequent
development, illustrated by principle of timing of Elder and
colleagues (2003), and may affect the efficacy of later inter-
ventions (Berkman, 2009). Other life situations contribute
to risks that build over time and gain influence in shaping
later outcomes. Cumulative exposure operates differently
from processes noted in the first, sensitive period model,
but it also leads to outcomes that are deeply embedded in
individuals’ lived experience and not easily modified. Finally,
early conditions and events may influence later outcomes
indirectly by shaping intermediate life situations, conditions,
and roles that subsequently affect later-life outcomes. Unlike
developmental consequences resulting from the two process
models described previously, adult outcomes resulting from
this type of “social trajectory model” (Berkman, 2009) may
be resolved by altering the intermediate situations that create
proximal risk (Berkman et al., 2011).
These models challenge Rowe and Kahn’s assertions that
many of the risk factors for SA are potentially modifiable
(Rowe & Kahn, 1997) and that individual agency is central
to achieving SA (Kahn, 2002). Indeed, Kahn (2002) claimed
that a goal in offering the SA model was “that research on
successful aging and its biopsychosocial determinants would
encourage people to make lifestyle choices that would maxi-
mize their own likelihood of aging well, that is maintaining
a high quality of life in old age” (p. 726).
Rowe and Kahn’s emphasis on personal agency was wel-
come in the late 20th century as conventional wisdom about
aging had long been characterized by notions of inevitable
and irreversible loss and decline. Historic overview of these
developments notes how perspectives like the SA model
could have promoted more positive views of older adults
and aging (Dillaway & Byrnes, 2009). Yet, by stressing
personal control and individual agency in old age—at the
neglect of early influences and long-term disease and disa-
bility processes—Rowe and Kahn’s model creates problems
similar to the one-sided view of aging that they attempted
to eliminate. A life course perspective offers a more bal-
anced view of aging by recognizing substantial continuity
in developmental processes and patterns over time while
accounting for personal agency and change within the con-
text of structural constraints (what Settersten 2003, p. 30,
calls “agency within structure”).
Several life course studies demonstrate how adult health
is significantly shaped by childhood vulnerability or risk
exposure. The Dutch Famine Birth Cohort Study revealed
that exposure to inadequate maternal nutrition during
World War II heightened the risk of coronary artery dis-
ease in adulthood among cohorts born during that period
(Painter et al., 2006). Similarly, Brandt, Deindl, and Hank’s
(2012) multination analysis indicated that economic dis-
advantage in childhood significantly predicted SA classi-
fications in adulthood (using criteria like those of Rowe
and Kahn). These classifications differed from those pre-
dicted by respondents’ current socioeconomic status alone.
Additionally, Schafer and Ferraro (2012) assessed the
impact of childhood influences (e.g., parental abuse) and
concurrent adult factors (e.g., smoking) on “disease free”
status in old age. These two sets of influences were of com-
parable strength in predicting this late-life criterion.
Despite ample evidence for continuity in health func-
tion and health-related behaviors across the life span (Lee
et al., 2010; McCambridge, McAlaney, & Rowe, 2011),
research showing modified health risk in conjunction
with behavior change also exists (Cox, 2006; Critchley
& Capewell, 2003). For example, Pruchno, Hahn, and
Wilson-Genderson (2012) compared current and former
smokers to determine whether smoking cessation and its
timing affected adults’ SA classifications. Smoking cessa-
tion did increase former smokers’ chances of a SA clas-
sification relative to current smokers, but only if they
quit smoking before age 30. The impact of cumulative
exposure also was evident, with “pack-years” of smoking
reducing the likelihood of SA. Applying a life course lens
thus challenges the reversibility of broad SA classifications
like that of Rowe and Kahn. Although personal agency
and behavioral change may alter single health indicators,
the extent to which they can reverse one’s overall SA clas-
sification in the Rowe and Kahn model is unknown.
Identifying effective interventions for various late-life
conditions is also difficult without employing a long-term
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view of aging. For conditions shaped directly by early expo-
sure during critical periods, or via cumulative exposure initi-
ated by early events and conditions, it is unrealistic to assume
that lifestyle changes can reverse the problem. Berkman and
colleagues (2011) argue, “…most of our interventions to
improve the health of older populations come too late in the
evolution of disease and disabling processes” (p. 338). Thus,
Rowe and Kahn’s (1997) vision of SA may be unattainable
for many due to early events and circumstances beyond one’s
control in later life. Constraints operating at the macrolevel
rather than the microlevel are addressed later.
Linked Lives: Expanding the Social
Component of Successful Aging
A life course perspective’s emphasis on the interdepend-
ence of individuals’ lives improves upon Rowe and
Kahn’s (1997) focus on individual decisions and actions
in determining aging outcomes. As discussed, family cir-
cumstances, relationships, and events represent powerful
influences on early development, with potentially long-
term consequences (Brandt et al., 2012; Ferraro et al.,
2009; Schafer & Ferraro, 2012; Shaw & Krause, 2002).
The influence of social contacts for development and
aging likely broadens as individuals enter adulthood and
social worlds expand.
Christakis and colleagues documented the significant role
of social connections in health-related behaviors (e.g., eat-
ing, smoking, and sexual risk taking) (Christakis & Fowler,
2009) and health outcomes (Elwert & Christakis, 2008).
They found that social network influences extend up to three
degrees (i.e., from friends of friends of friends) and that some
health conditions are influenced more by friends than by
closer relations such as spouses (Christakis & Fowler, 2009).
Yet, the significance of marital ties for adult well-being is
firmly established. Among young (Kiecolt-Glaser & Newton,
2001) and older couples (Bookwala, 2005), marital interac-
tions are known to influence health status, physical symp-
toms, and chronic conditions (Bookwala, 2005). Spouses also
affect each other’s social engagement. Curl, Proulx, Stowe,
and Cooney (in press) found that if one’s spouse ceased driv-
ing, then paid employment and volunteering decreased, even
after controlling for one’s own driving status and health.
Spousal similarity also illustrates the interdepend-
ent nature of development. Substantial congruence exists
in married partners’ physical and social functioning (Ko,
Berg, Butner, Uchino, & Smith, 2007), cognitive perfor-
mance (Gruber-Baldini, Schaie, & Willis, 1995; Ko et al.,
2007), and risk for specific chronic diseases (Hippisley-
Cox, Coupland, Pringle, Crown, & Hammersley, 2002).
Such similarity may result from assortative mating (Buss,
1984) as well as the conditions that couples cocreate and
share over their lives (Caspi, Herbener, & Ozer, 1992).
Clearly, considering SA a product of individual action and
processes alone is problematic.
The life course perspective’s emphasis on linked lives also
highlights opportunities for aging interventions involving
family and other social relationships. Although Berkman and
colleagues (2011) cite several studies in which efforts to alter
features of one’s social networks (e.g., network integration)
as a means of health intervention were unsuccessful, more
effective solutions may result from utilizing established social
connections for health interventions. For example, evidence
shows that when one partner is enrolled in a weight reduction
program, chances of weight loss for the nonenrolled spouse
increase as well (Gorin et al., 2008). Thus, it is inadequate to
view individuals as solely responsible for health or develop-
mental problems; likewise, it is restrictive to limit interven-
tion efforts to the individual with the targeted problems.
Successful Aging and Historical Time
Historical time is central to a life course perspective, as it
describes development as embedded in sociohistorical con-
ditions that change over time. To date, this idea has been
neglected in discussions of SA. An exception is work by
Dillaway and Byrnes (2009) that analyzed the historical
and sociopolitical context when Rowe and Kahn’s model
emerged. Neglect of historical time is critical because it puts
theorists at risk of formulating and promoting definitions
and operationalizations of SA that are historically bound
and may quickly become inappropriate. If the SA construct
is to guide health policy and programming, the impact of
historical time on aging must be considered.
Though several studies document historical shifts in
mortality (Crimmins & Beltran-Sanchez, 2011), disability,
and health (Seeman, Merkin, Crimmins, & Karlamangla,
2010), we know of only one study that considers cross-
time changes in levels of SA. Using a definition of SA model
akin to Rowe and Kahn’s model, McLaughlin, Connell,
Heeringa, Li, and Roberts (2010) reported a noticeable
drop in rates of SA from 1998 to 2004 using the U.S. Health
and Retirement Study. The odds of older adults meeting the
“successful” classification declined 25\% over this period
due largely to increased rates of chronic disease and physi-
cal impairment. This finding is disconcerting because of
public health problems such as obesity in the United States
and related warnings about chronic cardiovascular prob-
lems and other obesity-related diseases.
Age stereotypes also arise out of existing sociohistorical
conditions. A 2009 report by Levy, Zonderman, Slade, and
Ferrucci noted effects of age stereotypes on cardiovascular
health in later life. They found that holding negative age ste-
reotypes prior to older adulthood predicted cardiovascular
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episodes later in life, whereas possessing positive age ste-
reotypes provided future protection against such events. In
addition to shaping stereotypes, historical conditions influ-
ence the mechanisms through which stereotypes are per-
petuated, as is the case with social media technology today
(Levy, Chung, Bedford, & Navrazhina, 2014).
Heterogeneity in development is another issue empha-
sized in a life course perspective. Although Rowe and
Kahn’s model allows for varying degrees of SA as defined
by the model’s three main components, it overlooks hetero-
geneity resulting from self-rated, subjective success in aging
(Romo et al., 2013). This issue of heterogeneity in aging
experiences also is tied to historical time. For example,
diversity among U.S. elders and their aging experiences is
epitomized by the Hispanic and Latino populations, which
will continue to grow in proportion and significance within
the aging population (Hilton, Gonzalez, Saleh, Maitoza, &
Anngela-Cole, 2012). Health inequalities may contribute
negatively to the aging experiences of these groups (Villa,
Wallace, Bagdasaryan, & Aranda, 2012). As increasingly
diverse perceptions and experiences characterize the aging
population, we must avoid marginalizing differences and
formulate dynamic, inclusive conceptualizations of SA.
Importance of Place
Beyond standing the test of time, useful models of SA will
recognize cultural variation and acknowledge potential cul-
tural bias. A life course perspective emphasizes the impor-
tance of place in human development and aging. Although
Rowe and Kahn’s (1987) early writing referred to cultural
differences in various health factors, their model inad-
equately accounts for them.
Cultural differences may exist in how individuals view their
health, what they consider important in life, and meanings
of “success.” Hung, Kempen, and DeVries’s (2010) review of
34 “healthy aging” found that personal, family, and spiritual
domains of life were mentioned more in lay than academic
reports of healthy aging, and family ties and financial stabil-
ity played a unique role in Eastern cultures. Such variations
reflect the salience of the family collective in Eastern cultures
and their emphasis on interdependence rather than independ-
ence in aging. The value of offspring and importance of fam-
ily engagement, specifically over “social” engagement, are
additional themes in Eastern conceptualizations.
Recent Western conceptualizations of “harmonious
aging” represent attempts to acknowledge global differ-
ences and accommodate a broader set of values in defin-
ing SA (Liang & Luo, 2012). Although not explicit, these
authors rely on tenets of a life course perspective to elucidate
harmonious aging, acknowledging contextual influences on
individuals’ interpretations and achievement of balance in
later life. Notably, North American views of social engage-
ment depend more on physical function (which is needed
to provide practical support) and that engagement and pro-
ductivity are defined in capitalist terms in Rowe and Kahn’s
SA model (Dillaway & Byrnes, 2009).
Attention to place also highlights elements at the mac-
rolevel that influence aging outcomes. Hank (2011) and
colleagues (Brandt et al., 2012) considered the role of coun-
try-level income inequality in rates of SA in 14 European
countries. Using a conceptualization of SA similar to that
of Rowe and Kahn, Hank (2011) documented dramati-
cally higher rates of SA in Northern European (e.g., 21\%
in Denmark) than Southern European (3.1\% in Spain) and
Eastern European (1.6\% in Poland) countries, which mir-
rored cross-national differences in income inequality and
welfare state provisions. In their later study, Brandt and
colleagues (2012) found that country-level differences in
SA associated with income inequality remain significant
even after accounting for individual-level predictors of
SA. Thus, societal level policies that contribute to income
inequality affect SA rates at the macrolevel, regardless of
individuals’ personal characteristics and lifestyles.
Other cultural variations such as physiological factors
(e.g., bone structure) may explain cross-national variabil-
ity in the disability component of SA (Santos-Eggimann,
Cuénoud, Spagnoli, & Junod, 2009), and variable employ-
ment and retirement policies across countries may affect
rates of productive engagement—a component of SA
(Hank, 2011). These distal structural factors shape the
more proximal settings in which individuals live and the
experiences they encounter.
The Role of Social Structure in Successful
Aging
Though life course scholars have yet to fully define the
components of social structure, the socially constructed
categories of race, gender, and social class are key influ-
ences on aging, as are institutional structures and policies
that regulate behavior and provide resources when indi-
viduals encounter risks across the life course (Leisering &
Schumann, 2003; Zagel, 2013). Strengthened by a grow-
ing body of empirical findings (e.g., Brandt et al., 2012;
Schafer & Ferraro, 2012), substantial criticism (Dillaway
& Byrnes, 2009) has been directed at Rowe and Kahn’s
model for its neglect of social structure influences and over-
emphasis on personal action in aging outcomes. By over-
stating the role of personal causation in both the causes
and potential resolution of some health problems, Rowe
and Kahn’s model neglects social inequalities that interfere
with SA. In Riley’s terms (1998), it also “fails to develop
adequately the social structural opportunities necessary for
realizing success” (p. 151).
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Though Rowe and Kahn (1997) move beyond a solely
ontogenetic view of development by emphasizing external
and lifestyle factors in their model, their discussion does
not look beyond personal lifestyle and microlevel environ-
mental influences. Thus, macrostructural factors, such as
one’s status/position in society, are overlooked although
they can shape one’s immediate environment and access
to health resources (e.g., good medical care or nutri-
tious food) (Holstein & Minkler, 2003). Consequently,
sharp social class disparities exist in disease prevalence,
frailty, and other health indicators (Crimmins, Kim, &
Vasunilashorn, 2010).
The cross-national studies on income inequality (Brandt
et al., 2012; Hank, 2011) discussed previously offer con-
vincing evidence that SA outcomes are not accessible to all.
At the individual level, structural characteristics like edu-
cational attainment consistently predict SA classifications
(Hank, 2011; McLaughlin et al., 2010; Pruchno, Wilson-
Genderson, Rose, & Cartwright, 2010; Santos-Eggimann
et al., 2009), as do race (McLaughlin et al., 2010), finan-
cial adequacy (Hank, 2011), and gender (Hank, 2011;
McLaughlin et al., 2010; Pruchno et al., 2010; Santos-
Eggimann et al., 2009). Evidence that structural factors
affect aging does not negate the role of human agency,
but it reminds us that agency is restricted by socially con-
structed opportunities and constraints.
Institutional forces as an aspect of the macroenviron-
ment and social structure that shape individuals’ lives also
are not adequately addressed in Rowe and Kahn’s model.
Riley (1998) was among the first to point out their neglect
of institutional influences, such as the workplace, com-
munities, and schools, on the aging process. She argued
that the chances of enhancing one’s health and well-being
depended heavily on structural opportunities and that
interventions aimed at personal change require structural
interventions. In rebuttal, Kahn (2002) noted that their
model emphasized “what individuals themselves can do
to use, maintain, and perhaps even improve what they
have—their physical and mental capacities” (p. 726),
whereas Riley focused on what societies can do via insti-
tutional and structural interventions. His point, however,
overlooks the interplay of microlevel context, mesolevel …
© The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved.
For permissions, please e-mail: [email protected]
Successful Aging and Its Discontents:
A Systematic Review of the Social Gerontology
Literature
Marty Martinson, DrPH*,1 and Clara Berridge, MSW2
1Department of Health Education, San Francisco State University, California. 2School of Social Welfare,
University of California, Berkeley.
*Address correspondence to Marty Martinson, DrPH, Department of Health Education, San Francisco State University, 1600
Holloway Avenue, HSS Building, Room 326, San Francisco, CA 94132. E-mail: [email protected]
Received January 10 2014; Accepted March 28 2014.
Decision Editor: Rachel Pruchno, PhD
Purpose of the Study: The purpose of this study was to analyze the range of critiques
of successful aging models and the suggestions for improvement as expressed in the
social gerontology literature.
Design and Methods: We conducted a systematic literature review using the follow-
ing criteria: journal articles retrieved in the Abstracts in Social Gerontology, published
1987–2013, successful aging/ageing in the title or text (n = 453), a critique of successful
aging models as a key component of the article. Sixty-seven articles met the criteria.
Qualitative methods were used to identify key themes and inductively configure mean-
ings across the range of critiques.
Results: The critiques and remedies fell into 4 categories. The Add and Stir group sug-
gested a multidimensional expansion of successful aging criteria and offered an array
of additions. The Missing Voices group advocated for adding older adults’ subjective
meanings of successful aging to established objective measures. The Hard Hitting
Critiques group called for more just and inclusive frameworks that embrace diversity,
avoid stigma and discrimination, and intervene at structural contexts of aging. The New
Frames and Names group presented alternative ideal models often grounded in Eastern
philosophies.
Implications: The vast array of criteria that gerontologists collectively offered to expand
Rowe and Kahn’s original successful model is symptomatic of the problem that a
Special Issue:
Successful Aging
The Gerontologist, 2015, Vol. 55, No. 1, 58–69
doi:10.1093/geront/gnu037
Research Article
Special Issue: Successful Aging
Advance Access publication May 9, 2014
58
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mailto:[email protected]?subject=
normative model is by definition exclusionary. Greater reflexivity about gerontology’s
use of “successful aging” and other normative models is needed.
Key words: Successful aging, Social gerontology, Critical gerontology
Successful aging currently holds a prominent position in
social gerontology research (Alley, Putney, Rice, & Bengtson,
2010). It became an increasingly popular model following
Rowe and Kahn’s introduction of the distinction between
“usual” and “successful” aging (1987) and their subsequent
work that explicated the three key components of successful
aging: the avoidance of disease and disability, the mainte-
nance of cognitive and physical function, and social engage-
ment (1997). Over the past two decades, successful aging
research has expanded beyond these end point criteria with
the development of models that describe processes that can
lead to successful aging (for a history of successful aging mod-
els, see Pruchno, Wilson-Genderson, Rose, & Cartwright,
2010). As Villar (2012) described, Rowe and Kahn’s model
“boosted interest in the biological, behavioural and social
factors which determine the attainment of ageing well,
and has encouraged the adoption of a new, preventive and
optimistic approach to the final decades of life” (p. 1089).
Over time, successful aging has been modified and inter-
preted in many different ways to the point where it is widely
acknowledged that there is no agreed upon definition of the
concept (Bowling & Iliffe, 2006; Ferri, James, & Pruchno,
2009; McLaughlin, Jette, & Connell, 2012). Nevertheless,
it appears in social gerontology research as frequently as the
theories that dominate the field (Alley et al., 2010).
Although successful aging models are prominently posi-
tioned, they have also been contested. One of the earliest
critiques of Rowe and Kahn’s model appeared in a 1998
letter to the editor in The Gerontologist, in which social
gerontologist Matilda Riley called the model “seriously
incomplete” (p. 151) for its sole focus on individual suc-
cess and its neglect of the structural and social factors that
influence aging. For over two decades, social gerontologists
have grappled with the ways in which successful aging has
and has not captured the personal, social, economic, and
political contexts of aging. Challenges to successful aging
frameworks range from those that suggest minor modifica-
tions to those that more deeply critique the core ideologies
embedded in the construct.
As Cole (1995) observed, “the growth of an intellec-
tually rich social gerontology depends on the continued
willingness to foster greater interactions between empiri-
cal research, interpretation, critical evaluation, and reflex-
ive knowledge” (p. S343). This study takes a step toward
building these “greater interactions” by creating a cohesive
summary of the critical questions raised since successful
aging’s 1987 introduction. Although much of the published
research on successful aging includes an overview of the
model and some mention of the gaps or weaknesses in one
or more successful aging frameworks, there has not yet been
a systematic review of the full range of concerns and cri-
tiques expressed over time about the concept. Such a review
can be useful in further building reflexive knowledge. By
identifying and analyzing the range of critiques of successful
aging, we may be better able to foster the intellectually rich
social gerontology that Cole speaks of and further develop
a dynamic science of aging that translates into practices and
policies that are supportive of people as they age. To that
end, we conducted a systematic review of the literature on
successful aging to answer the following question: Within
the social gerontology literature published since 1987, what
concerns have been expressed about successful aging mod-
els and what suggestions for improvement have been made?
Methods
In this systematic literature review, we examined peer-
reviewed articles in the Abstracts in Social Gerontology
(ASG) database published between January 1987 and
December 2013. Certainly, notable critiques of success-
ful aging have been published in scholarly publications
that are not included in the ASG database (Belgrave &
Sayed, 2013; Calasanti, Slevin, & King, 2006; Katz,
2013); however, we narrowed our search to the ASG
because it provided a broad range of interdisciplinary
research in social gerontology including, for example,
biological, psychological, sociological, economic, cul-
tural, and critical studies in aging. We searched for arti-
cles that had successful aging/ageing in the title or all
text (n = 453), then selected those that included a cri-
tique of successful aging models as a key component of
the article. Using the earlier criteria, we identified 67
articles, which included empirical studies, theoretical
analyses, and editorials.
As a configurative review, qualitative methods were used
to analyze the data in order to identify key themes and
inductively configure meanings across the range of critiques
of successful aging (Gough, Oliver, & Thomas, 2012). We
conducted initial coding to name the key points made in
each paper’s critiques of successful aging and the proposed
ideas for improved models. In a second round of axial cod-
ing, we inductively identified key themes across codes and
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then named broader connections across these themes that
represented a higher level of abstraction. To enhance inter-
rater reliability, the two authors individually coded a subset
of 15 articles and met to discuss and compare their analyses
and identify common codes. We did the same thing when
placing the articles into key theme groupings and continued
with the analysis when we were confident that the codes
and categories were well defined.
Although the articles across categories sometimes over-
lapped in terms of their critiques of successful aging (e.g.,
the focus on physiological aspects of aging, the cultural
biases and limitations of criteria, the denigration of people
with disabilities or illness), they were placed in categories
that were distinguished by the recommendations made for
addressing those shortfalls. Four categories emerged: Add
and Stir, Missing Voices, Hard Hitting Critiques, and New
Frames and Names. The final stage of analysis involved
synthesizing these categories to offer an explanation for
what this body of research suggested about social gerontol-
ogy’s relationships to successful aging.
Findings
Theme 1: Add and Stir
Sixteen of the 67 reviewed articles accepted the idea that
successful aging could stand as a model but identified sev-
eral gaps in current models. Two kinds of solutions emerged
from these critiques: loosen the criteria given the very low
prevalence of successful aging using existing criteria and
expand the model by adding missing criteria. By keeping a
successful aging model as the baseline and offering a multi-
tude of additions to address the gaps, these critiques took a
kind of Add and Stir approach.
A Prevalence Problem
The results of Bowling and Iliffe’s (2006) study of the
prevalence of successful aging in Britain using a biomedi-
cal model, expanded biomedical model, social function-
ing model, psychological resources model, and lay model
derived from criteria found in the literature revealed rates of
16\%–24\%. Similarly, using four time points of the Health
and Retirement Survey, McLaughlin, Connell, Heeringa, Li,
and Roberts (2010) calculated the prevalence of successful
aging based on Rowe and Kahn’s model and found that no
more than 11.9\% of people aged 65 and older met the cri-
teria in any year. A follow-up study compared increasingly
relaxed criteria and found prevalence rates of 3.3\%–33.5\%
(McLaughlin et al., 2012). The researchers articulated con-
cerns about successful aging criteria being too narrow to
be of use for public health purposes “unless one wishes to
limit the study of healthy aging to those with near-perfect
health” (p. 787). McLaughlin and coworkers recommended
lowering the threshold or loosening the criteria while pre-
serving the foundation of Rowe and Kahn’s model.
Hank (2011) replicated the study of McLaughlin and
coworkers (2010) in a comparison of European countries
and Israel. He found that the U.S. rate of 11.9\% ranked it
in the middle of other countries. National income inequal-
ity was positively associated with lower rates of successful
aging, and welfare states played a likely role in enabling
or hampering successful aging. Hank (2011) acknowledged
the value of relaxing Rowe and Kahn’s criteria and also
called for “policy interventions supporting individuals’
opportunities for successful aging” (p. 230).
Additional Criteria
Several scholars identified gaps in various successful
aging models and recommended additional criteria. Like
others, Young, Frick, and Phelan (2009) critiqued the
emphasis on physiological aspects of aging in Rowe and
Kahn’s successful aging constructs. They offered a graded
approach that included physiological, psychological, and
social dimensions. Young and coworkers defined success-
ful aging as a state in which a person uses physical and
social adaptive strategies “to achieve a sense of well-being,
high self-assessed quality of life, and a sense of personal
fulfillment even in the context of illness and disability”
(p. 88–89). Other empirically based critiques of the Rowe
and Kahn model have called for its expansion by adding
the following: subjective criteria (Coleman, 1992); spiritu-
ality (Crowther, Parker, Achenbaum, Larimore, & Koenig,
2002); marital status and quality (Ko, Berg, Butner, Uchino,
& Smith, 2007); positive as opposed to pathological health
characteristics (Kaplan et al., 2008); and broader multidi-
mensional constructs encompassing cognitive and affec-
tive status, physical health, social functioning, engagement
and life satisfaction (Tze Pin, Broekman, Niti, Gwee, & Fe
Heok, 2009), and leisure activity (Lee, Lan, & Yen, 2011).
Researchers have also suggested modifications to Baltes
and Baltes’ (1990) selective optimization with compensa-
tion model of successful aging. Steverink, Lindenberg, and
Ormel (1998) proposed the Social Production Function
Theory to better integrate social context with behavior.
More recently, Villar (2012) proposed infusing criteria for
successful aging with a multifaceted generativity concept
incorporating social, community, and personal develop-
ment. He contended that gains coexist with losses and
that generation—in addition to loss regulation or mainte-
nance—must be factored into successful aging.
Theme 2: The Missing Voices
Almost half (30) of the 67 critiques of successful aging
models focused on the Missing Voices—the subjective
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definitions of successful aging from older adults. Similar
to the Add and Stir group, these authors critiqued the nar-
rowness of successful aging criteria. In contrast to the Add
and Stir critiques, this group explicitly named the need for
additional successful aging criteria that were derived from
the perspectives of elders.
Compare and Contrast
Given the disparity between self-rated rates of successful
aging and established criteria, several researchers called for
the addition of successful aging criteria generated by older
adults’ subjective measures. Strawbridge, Wallhagen, and
Cohen (2002) reported a significant difference between
self-ratings and ratings based on Rowe and Kahn’s crite-
ria (50.3\% vs. 18.8\%). Cernin, Lysack, and Lichtenberg
(2011) similarly found that 63\% of African American
elders in their sample reported aging successfully compared
with 30\% who met the Rowe and Kahn criteria. Phelan,
Anderson, LaCroix, and Larson (2004) also found that
subjective meanings of successful aging differed from those
of the published literature and that the multidimensional
perceptions of older adults (which encompassed physi-
cal, functional, social, and psychological health) were not
fully represented in any successful aging model. Based
on data from the Manitoba Follow-up Study, researchers
found that lay persons’ definitions may be relatively con-
sistent over time and should be taken into account (Tate,
Swift, & Bayomi, 2013). Pruchno, Wilson-Genderson, and
Cartwright (2010) proposed a two-part model of subjective
and objective measures. This included objective measures
of having few chronic conditions, maintaining functional
ability, and experiencing little pain, and subjective ratings
of how successfully one has aged, how well one is aging,
and how one would rate one’s life these days.
Three studies reported that avoidance of disability or
chronic physical illness was not predictive of subjective suc-
cessful aging. Strawbridge and coworkers (2002) found that
functional status specifically was not predictive of subjec-
tive successful aging. Montross and coworkers (2006) simi-
larly found that 92\% of their sample viewed themselves as
successfully aging, despite the fact that the majority expe-
rienced disability and chronic physical illness. Romo and
coworkers (2013) examined subjective rates of successful
aging among an ethnically diverse sample of older adults
with late-life disability, the majority of whom reported that
they had aged successfully.
This body of research that compared objective and
subjective measures identified a wide range of subjectively
defined criteria that should be added to current success-
ful aging conceptualizations, including several dimensions
of emotional well-being and spirituality (Lewis, 2011);
comportment and acceptance of change (Rossen, Knafi,
& Flood, 2008); self-acceptance and self-contentment
(Reichstadt, Sengupta, Depp, Palinkas, & Jeste, 2010); self-
care, accepting the aging process, and financial well-being
(Hilton, Gonzalez, Saleh, Maitoza, and Anngela-Cole,
2012); and living with family, and receiving emotional care
(Hsu, 2007). As a whole, and similar to the Add and Stir
group, this group of critiques presented a dizzying array of
missing components offered to strengthen current success-
ful aging conceptualizations.
Cultural Relevance and Variability
For over a decade, researchers have critiqued the lack of
cultural breadth of successful aging models and asserted
the need to better capture subjective meanings of success-
ful aging from diverse cultural perspectives. Soondool
and Soo-Jung (2008) suggested additional subjective cri-
teria including “success of adult children” and “a positive
attitude toward life” (p. 1061) after examining meanings
of successful aging among low-income elders in South
Korea. Lewis (2011) interviewed Alaskan Natives Elders
in southwest Alaska and found that successful aging was
best defined through a culturally congruent concept of
elderhood and its four key components as articulated by
the study participants. Hilton and coworkers (2012) found
culturally embedded meanings expressed by older Latinos
that were absent from criteria used in dominant models,
and they called for greater clarity on the multiple dimen-
sions and processes of successful aging.
Many have critiqued the Western, white, middle class
bias in successful aging conceptualizations (Kendig,
2004; Ng et al., 2011). Two studies challenge Rowe and
Kahn’s (1997) and Phelan and coworkers’ (2004) meas-
ures of successful aging in terms of their cross-cultural
relevance to Japanese Americans (Iwamasa & Iwasaki,
2011; Matsubayashi, Ishine, Wada, & Okumiya, 2006).
Iwamasa and Iwasaki (2011) generated a model with six
components that shared broad similarities with existing
measures of physical, psychological, social, and cognitive
health but included culturally specific dimensions of these
measures that differed in meaning from existing measures.
The Japanese Americans’ approach to independence, for
example, focused more on a collectivist concern for oth-
ers and “adjusting one’s needs to maintain group harmony”
(p. 274) rather than taking a more individualistic focus on
oneself. Iwamasa and Iwasaki’s model also included crite-
ria of financial security and spirituality. Ng and coworkers
(2011) examined Chinese cultural contexts of successful
aging and recommended a model that included both car-
ing and productive forms of engagement as substitutes for
Rowe and Kahn’s engagement with life component.
Adding new dimensions to cultural analyses of successful
aging, Torres (1999, 2001, 2003, 2006, 2009) explored the
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complexity of value orientations that underlie definitions
of successful aging for older adults who migrated between
cultures—Iranians who migrated to Sweden. Torres (2006)
found great variability not only in how people define suc-
cessful aging but also in how they arrive at those defini-
tions and what understandings are imbedded within those
definitions. This intracultural approach problematized cul-
turally specific notions of successful aging as her findings
demonstrated not only intercultural differences but also
differences within cultures. As Torres asserted, “although
cultural values might guide the way in which people make
sense of what constitutes a good old age, these values do
not necessarily predispose people to conceive of successful
aging in any one particular way” (p. 20). Torres thereby
challenged the relevance of culture-specific and static meas-
ures of successful aging, and she called for a broadening
of gerontological frameworks of successful aging (Torres,
2001).
Overall, these Missing Voices critiques challenged the
lack of subjective meanings and consequential cultural
relevance in dominant models of successful aging. As with
the Add and Stir group, this group of critiques called for
changes to the models but kept the broader notion of suc-
cessful aging as an ideal relatively intact.
Theme 3: Hard Hitting Critiques
Fourteen articles, ranging in publication date from 1990
to 2013, presented critiques of the “assumptions, con-
ceptualization, and application” (Scheidt, Humpherys, &
Yorgason, 1999, p. 277) of the successful aging paradigm
and raised serious concerns about its continued usage in
gerontology and biomedicine (Dillaway & Byrnes, 2009).
These articles were notable for the breadth and depth of
their critiques of successful aging and thus became a major
component of the literature review findings. The Hard
Hitting Critiques were grounded in a variety of disciplines
including critical gerontology, critical studies, feminist dis-
ability studies, narrative gerontology, and critical discourse
analysis. Although the critiques varied in their particular
focus, they shared one or more key concerns about success-
ful aging, including its individualistic approach, implied
ageism and ableism, neoliberal contexts, negative influ-
ences on society and the lived experiences of older adults,
and impacts on social justice. Furthermore, they rejected
the notion of “successful” aging more broadly and called
for alternative frameworks.
Individualism
This literature articulated repeated concerns about the indi-
vidual focus of the successful aging paradigm as unrealis-
tic and exclusionary (Angus & Reeve, 2006; Holstein &
Minkler, 2003; Morell, 2003; Scheidt et al., 1999; Stone,
2003). Critics argued that representing aging—and in
particular, physical and cognitive health—as being within
the control of individuals through the adoption of spe-
cific behaviors and attitudes, reflected a medicalized view
of aging that ignored social, economic, and cultural con-
texts of people’s lives (Clarke & Griffin, 2008; Dillaway &
Byrnes, 2009; Leibing, 2005), including the inequities in life
chances by class, gender, race, ability, and other intersect-
ing social locations (Minkler, 1990). Scheidt and coworkers
(1999) provided an early critique of the narrow, individual-
istic view of the successful aging perspective and noted that
successful aging failed to take into account the sociostruc-
tural contexts of aging that “play a powerful determinative
role in how we age” (p. 278).
Over the years, critics have repeatedly argued that these
broader contexts, such as access to education, employment,
quality housing conditions, healthy food, and recreation,
work in favor of the most privileged populations and make
them more likely to age successfully, whereas marginalized
(less privileged) groups are less likely to experience such
success (Dillaway & Byrnes, 2009; Holstein & Minkler,
2003). Furthermore, describing successful aging as an end
point erroneously constructs aging as “not a broad bioso-
cial process that involves the development of new roles,
viewpoints, and many interrelated social contexts but,
rather, a game which can be won or lost on the basis of
whether individuals are diagnosed as successful or usual”
(Dillaway & Byrnes, 2009, p. 706).
Ageism and Ableism
Several critics noted the often-unrecognized and inter-
twined ageism and ableism that are inherent in successful
aging models (Holstein & Minkler, 2003; Minkler, 1990;
Morell, 2003; Stone, 2003). Successful aging names the
avoidance of disease and disability as the ideal and implic-
itly good aging, whereas the presence of usual aging pro-
cesses is deemed undesirable or bad aging. This binary
of successful versus unsuccessful aging is said to create a
“new ageism” (Angus & Reeve, 2006, p. 143) or “polar-
ized ageism” (attributed to Cole, 1992 and McHugh, 2003
in Rozanova, Northcott, & McDaniel, 2006). As Holstein
and Minkler (2003) pointed out, “normative terms such
as successful aging are not neutral; they are laden with
comparative, either-or, hierarchically ordered dimensions”
(p. 791). Others explained that by naming the avoidance
of disease and disability as success, successful aging carries
an “implied hostility toward aging bodies” (Morell, 2003,
p. 69) and, in particular, toward disabled or diseased bodies
that are by default deemed failures. This creates a powerful
dichotomy that “values cognitive and physical ability while
denigrating any kind of disability” (Stone, 2003, p. 62) and
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blaming elders with disabilities and illness for their con-
ditions and subjecting them to moral judgments by soci-
ety (Clarke & Griffin, 2008; Holstein & Minkler, 2003;
Morell, 2003; Rozanova et al., 2006).
Neoliberal and Conservative Contexts
Many of the Hard Hitting Critiques highlighted successful
aging’s neoliberal ideological underpinnings. By focusing
the responsibility on individuals to maintain physical and
cognitive function, the successful aging paradigm reflects
and serves efforts to limit the state’s responsibility to pro-
vide social and other supports for elders and people with
disabilities and, notably, to address the social and structural
inequities that create illness and disability in the first place
(Dillaway & Byrnes, 2009; Minkler, 1990; Morell, 2003;
Scheidt et al., 1999; Sinding & Gray, 2005). As Holstein
and Minkler (2003) described, this further marginalizes
older populations who rely on safety net programs:
Policies promoting increased Medicare coverage for
home modifications and assistive devices, as well as
increased Supplemental Social Security Income payments
that would bring elderly and disabled recipients above
the poverty line, may well suffer at the hands of a popu-
lace and a legislature that has bought the stereotypes of
a new breed of successfully aging seniors who no longer
need much in the way of government support. (p. 793)
Dillaway and Byrnes (2009) emphasized the historical con-
texts in which successful (and productive) aging paradigms
first emerged. The rise of these paradigms in the 1980s and
1990s coincided with a rising conservatism that sought to
place blame for U.S. economic crises on the welfare state
and, in particular, on Social Security and Medicare. Because
these models appear to blame aging individuals for their
failure to avoid disability or dependence, their timely emer-
gence “may have facilitated and bolstered” (p. 708) the
government’s increasing anxiety about the burden of the
aging population and been used as “tools for furthering
negative conceptualizations of aging and reducing the pub-
lic burden of aging individuals” (pp. 708–709).
Influences, Applications, and Internalizations
Scheidt and coworkers (1999) raised early concern about
the successful aging model’s placement of moral value on
the individual’s ability to avoid illness and disability and
the “value transfer to the public domain” (p. 278). More
recently, several studies demonstrated that there has indeed
been a value transfer of these moral hierarchies to the pub-
lic as people internalize, integrate, and sometimes resist the
ideal as they negotiate their own aging identities. Media
portrayals of old age reflect and reproduce successful
aging discourses. Rozanova and coworkers (2006) found a
powerful narrative of successful aging in The Globe & Mail
newspaper’s portrayal of aging. This narrative, often cap-
tured through interviews with older adults, focused on per-
sonal control, the avoidance of disease and disability, and
a valuing of successful over unsuccessful agers. Rozanova’s
(2010) subsequent research linked successful aging, polar-
ized ageism, and the neoliberal contexts of individual
responsibility and cost containment. As she explained,
[T]he newspaper texts highlight individuals’ public duty
to age successfully…and bring a morally-laden message
that an …
Not Your Parents’ Test Scores: Cohort Reduces Psychometric
Aging Effects
Elizabeth M. Zelinski and
University of Southern California
Robert F. Kennison
California State University, Los Angeles
Abstract
Increases over birth cohorts in psychometric abilities may impact effects of aging. Data from 2
cohorts of the Long Beach Longitudinal Study, matched on age but tested 16 years apart, were
modeled over ages 55–87 to test the hypothesis that the more fluid abilities of reasoning, list and
text recall, and space would show larger cohort differences than vocabulary. This hypothesis was
confirmed. At age 74, average performance estimates for people from the more recently born
cohort were equivalent to those of people from the older cohort when they were up to 15 years
younger. This finding suggests that older adults may perform like much younger ones from the
previous generation on fluid measures, indicating higher levels of abilities than expected. This
result could have major implications for the expected productivity of an aging workforce as well
as for the quality of life of future generations. However, cohort improvements did not mitigate age
declines.
Keywords
cohort aging; longitudinal; cognition; intelligence
Over the last 50 years, there have been systematic increases in fluid intelligence measures
across birth cohorts in many developed countries (e.g., Flynn, 1987). Despite this finding,
the vast majority of studies in cognitive aging (e.g., Salthouse, 2004) have compared people
of different ages and generations to estimate aging effects. Their conclusions therefore rest
on the assumption that cohort does not bias results. In this paper, we test hypotheses about
the role of cohort on age changes on five different cognitive psychometric tests. Cohort-
sequential panel data from the Long Beach Longitudinal Study were analyzed over age
using latent growth modeling, with cohort effects tested as differences between two panels
of participants from the same age ranges but initially tested 16 years apart. Findings of
cohort differences in psychometric aging would not only have implications for theories of
Copyright 2007 by the American Psychological Association
Correspondence concerning this article should be addressed to Elizabeth M. Zelinski, Leonard Davis School of Gerontology, Andrus
Gerontology Center, University of Southern California, Los Angeles, CA 90089-0191. [email protected]
Elizabeth M. Zelinski, Leonard Davis School of Gerontology, University of Southern California; Robert F. Kennison, Department of
Psychology, California State University, Los Angeles.
The contributions of the authors were equal.
NIH Public Access
Author Manuscript
Psychol Aging. Author manuscript; available in PMC 2014 September 19.
Published in final edited form as:
Psychol Aging. 2007 September ; 22(3): 546–557. doi:10.1037/0882-7974.22.3.546.
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cognitive decline, but may translate into the lengthening of the productive life span, as well
as to reduced prevalence of cognitive impairment in late old age.
Cohort Change in Intelligence
Flynn (1987) reported increases of up to 1.5 standard deviations in reasoning scores between
19-year-olds tested in 1950 and those in 1980. Those tested in 1950 were born during the
Great Depression and those in 1980 after World War II. Today, those Depression-era adults
would be in their late 70s and postwar adults would be in their late 40s. The mean
differences between individuals aged 48 and 78 on reasoning in a cross-sectional study
conducted in 2008 would theoretically include that 1.5 standard deviation difference
documented at age 19. This would inflate estimates of the 30-year age difference. Such
biasing effects could have profound consequences for conclusions about cognitive aging
because reasoning, which is considered representative of fluid intelligence, shows earlier
and more substantial age declines than tasks that are more representative of crystallized
intelligence. (e.g., McArdle, Ferrer-Caja, Hamagami, & Woodcock, 2002). Inflated age
estimates could also arise in single-panel longitudinal studies, as they generally include a
wide range of ages over a relatively short retest interval and are often analyzed over age
rather than measurement occasion (e.g., McArdle et al., 2002).
Cohort differences in abilities have been consistently observed in comparisons of different
birth groups in multicohort studies such as the Seattle Longitudinal Study (Schaie, 1996).
Estimates suggest average increases in reasoning performance for people born in 1910
compared to those born in 1896 (e.g., Schaie, 1996) suggesting that such cohort trends have
been a phenomenon of at least the past century. The dramatic rise in fluid reasoning
observed by Flynn (1987) is likely to be based on continuous increments that happened to be
sampled at a wide time interval (see also Flynn, 2003; Raven, 2000).
Despite substantial generational increases in fluid abilities, changes in normative data in
children and young adults for more crystallized abilities have been mixed. For example,
minimal cohort differences have been reported for the Mill Hill Vocabulary tests (e.g.,
Raven, 2000) and also for the arithmetic subtest of the Wechsler Intelligence Scale for
Children—Revised (Flynn, 2003). Alwin (1991; Alwin & McCammon, 2001) suggested that
once effects of education are removed, there is a reversal of the Flynn effect in a population
sample, with more recent cohorts poorer in vocabulary ability than earlier born ones.
However, this finding may be related to a confound between sampling of particular ages and
cohorts in that study; a recent study extending cohort-sequential modeling to the sample and
vocabulary test evaluated by Alwin indicated cohort increases (Bowles, Grimm, & McArdle,
2005; see also Wilson & Gove, 1999).
Although some theorists disagree whether the Flynn effect is based on actual changes in
ability levels or to a lack of psychometric invariance (e.g., Rodgers, 1999)—that is, that
differences across cohorts in intelligence exist because the scores do not have the same
measurement properties such as equal factor loadings, uniquenesses, and factor intercepts—
invariance or at least partial invariance has been established for some indices of fluid
abilities across cohorts of children and young adults in developed countries (Wicherts et al.,
Zelinski and Kennison Page 2
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2004). Despite disagreements about the broad explanations proposed by Flynn and
colleagues (e.g., Dickens & Flynn, 2001) to explain the eponymous effect (Loehlin, 2002;
Rowe & Rodgers, 2002), and some recent studies suggesting that the Flynn effect may have
recently plateaued or reversed for military conscripts in the 1990s in two Scandinavian
countries (e.g., Sundet, Barlaug, & Torjussen, 2004; Teasdale & Owen, 2005), it is likely
that the skills underlying fluid ability performance increased during young adulthood for
cohorts that are now aging.
The most widely cited explanations for the Flynn effect are those of cultural changes,
including improvements in nutrition and hygiene, population movement from rural to urban
areas, increased access to schooling in the first half of the 20th century, increased
educational levels of parents, smaller families, parental engagement in practices that
encourage cognitive development (e.g., Williams, 1998), and changes in processing from
more characteristically verbal to more iconic representations due to the rise of visually
oriented modalities in film, television, computer games, and other media (for descriptions
see Greenfield, 1998). Blair, Gamson, Thorne, and Baker (2005) suggested that recent fluid
ability increases additionally reflect a shift in the content of mathematical curricula in
primary and secondary schools toward fluid-like tasks that involve working memory and
improve frontal functioning.
The less consistent findings of cohort-related increases for some types of crystallized
abilities have also been interpreted as due to historical changes in reinforcement.
Instructional time spent imparting traditional school related knowledge has been reduced
(see Williams, 1998), and people are more likely to watch movies and television than to
read. The visual environment of movies and television promotes basic vocabulary and use of
contextualized grammatical structures rather than the more advanced vocabulary and
complex, decontextualized grammatical forms of written literature, leading to stable
vocabulary scores on intelligence tests yet simultaneously declining verbal SAT scores (e.g.,
Greenfield, 1998). Consistent with this explanation, Bowles et al. (2005) reported that a
cohort-sequential analysis over age showed greater improvement in more recently born
cohorts for basic vocabulary items than for advanced ones.
In summary, it has been suggested that culture affects the cognitive environment so that
cognitive abilities adapt to it (e.g., Barber, 2005). This leads to the hypothesis that
discrepancies in cohort effects in older populations will vary to the extent that larger cohort
increases will be observed for the fluid-like cognitive skills that have been more emphasized
in recent decades than previously, whereas crystallized skills that have been consistently
emphasized over the past century would show less cohort change. The fluid/crystallized
theory (e.g., Horn & Cattell, 1967) also predicts age effects that parallel the cohort effects,
that is, that age declines are larger for fluid than crystallized abilities. However, it is
important to vary age and cohort systematically to determine whether the declines attributed
to age are confounded with cohort.
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Cohort and Aging
Although it has been suggested that cohort differences may be responsible for much of the
observed age decline in fluid abilities (Raven, 2000), it is not likely that they explain all
apparent age-related effects, as there are substantial and reliable declines for a wide range of
cognitive abilities with age, including the crystallized-like abilities (e.g., Salthouse, 2004).
The finding of consistent age differences across abilities suggests that, if tracked over age,
different cohorts would show parallel age declines. However, it is conceivable that cohort
would interact with age due to selective attrition.
People who drop out from longitudinal studies perform more poorly and tend to be older
than those who remain (e.g., Cooney, Schaie, & Willis, 1988; Kennison & Zelinski, 2005).
There are also age differences in initial selection into a sample. Simply being willing to
participate in cognitive testing signals greater selectivity in older adults because advanced
age is associated with higher rates of refusal to complete cognitive tests in a population
survey (e.g., Zelinski, Burnight, & Lane, 2001) and in normative studies of intelligence
(e.g., Raven, 2000). Even if later-born cohorts are intellectually advantaged, elderly
individuals from earlier cohorts may be more select than younger ones just because they
have survived to the age at which they are tested (see Rabbitt et al., 2002; Verhaeghen,
2003). Because there are likely to be stronger survival effects in earlier cohorts, more recent
cohorts may be less likely to show those benefits because they are relatively less select (e.g.,
Singer, Verhaeghen, Ghisletta, Lindenberger, & Baltes, 2003). Thus cohort could
conceivably have no biasing effect in cross-sectional studies because the cohort advantage
may wash out.
Age Declines
Cohort effects may be implicated in the rate of average decline with age, which is not likely
to be constant across the entire span of late adulthood. Neugarten (1975) coined the terms
“young-old” (below age 75) and “old-old” (above 75) to differentiate age groups in the
elderly population. There are clear age differences between the young-old and the old-old,
with worse performance on cognitive tasks in old-old people, even when differences in
education and health have been accounted for (e.g., Zelinski, Crimmins, Reynolds, &
Seeman, 1998). Longitudinal studies generally report an acceleration of estimated declines
in the old-old (e.g., Rabbitt et al., 2002; Singer et al., 2003; Sliwinski, Hofer, Hall, Buschke,
& Lipton, 2003). Hypotheses based on the fluid-crystallized distinction suggest greater
acceleration of declines in the old-old for more fluid than crystallized ones (Horn & Cattell,
1967), which has been supported longitudinally (e.g., Singer et al., 2003). Thus it is
important to evaluate change across a wide range of ages in late adulthood.
Interval Scaling
Tests of the generality of the Flynn effect require direct comparisons across cognitive
measures. However, with raw scores, it is impossible to determine whether an age or cohort
difference of, say, 5 points on a memory task is equivalent to a difference of 5 points on a
reasoning test. Another problem with raw scores is that across individuals, differences
between scores on the same test may not be equivalent at different points of the scale
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(Wright & Stone, 1979). For example, the 2-point difference between scores of 20 and 18 on
a 20-item recall task may not be interpreted as reflecting the same amount of difference in
performance as the difference between scores of 14 and 12, or 2 and 0, even though the
relative ordering of individuals’ scores is clear. This is a problem for testing interactions,
where assumptions of statistical tests require that scores are equivalent across their full range
(Embretson, 1996). Mathematical transformations of raw scores, such as z scores or
proportion correct, do not redistribute them so that differences between points on the scale
are equal (Wright & Stone, 1979). However, Rasch scaling can be applied to data to assure
equivalence of scores across tests and persons by using an algorithm that treats item
difficulty and person ability separately. It ensures that the differences between scores at
every point of the scale are the same and that these differences can be directly compared
across variables through logistic transformation (see, e.g., Zelinski & Gilewski, 2003). Thus,
whether age declines accelerate differentially across psychometric tests has only been
directly evaluated by McArdle et al. (2002), who used the Rasch scaled Woodcock-Johnson
test battery. They found smaller declines that occur later in the life span for crystallized
abilities than for more fluid ones for people under age 75.
In the present study, Rasch scaled scores were used for five measures that are likely to show
differential cohort and age patterns. We evaluated decline patterns in people ages 55–87 and
tested the hypothesis that average decline accelerates with age. We estimated changes with
age and cohort independently with cohort-sequential analyses (Schaie, 1965). Two
longitudinal panels, which were treated as different cohorts studied over the same range of
ages but born 16 years apart, were examined to determine whether patterns of decline are
similar, even if there are cohort differences in performance at the intercept.
Schaie’s (1996) longitudinal estimates, as well as cross-sectional estimates in standard score
scaling for similar tasks by Salthouse (2004), suggest that slopes of age declines should be
comparable for reasoning and space. Using the same items and time restrictions for the
vocabulary test as Schaie, we expected that the age effect for vocabulary would be similar to
those of the other psychometric tests largely because that test has a strong speed component
(Hertzog, 1989; Zelinski & Lewis, 2003). Yet only small cohort effects were anticipated
because the vocabulary subtest of the Schaie–Thurstone Adult Mental Abilities Test
(STAMAT; Schaie, 1985) is of a crystallized-like ability. Extrapolating from Schaie’s and
Salthouse’s estimates, we expected accelerating age changes for vocabulary, space, and
reasoning. Both Schaie’s and Salthouse’s estimates suggest minimal acceleration of decline
in late old age for recall tasks.
Method
The Long Beach Longitudinal Study design, participants, and measures are described in
detail elsewhere (Zelinski & Burnight, 1997; Zelinski & Lewis, 2003). Participants are
volunteers residing in the communities of Long Beach and Orange County, California. The
convenience sample shows performance characteristics similar to a representative sample of
older Americans who have at least a high school education (e.g., Zelinski, Burnight, & Lane,
2001). This suggests that the sample represents the upper levels of older adult performance.
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Participants
The data of two cohorts of participants varying in age from 55–87 were used for the
analyses. Cohort 1 participants (baseline n = 456) were born between 1893 and 1923 and
were tested on as many as five test occasions in 1978, 1981, 1994, 1997, and 2000 (see top
panel of Table 1). Cohort 2 participants (baseline n = 482) were born between 1908 and
1940 and were tested up to four times in 1994, 1997, 2000, and 2003. It is important to note
that the overlap in the birth years of the two cohorts does not confound comparisons because
the age matching held the 16-year cohort difference constant. However, Cohort 1
participants could have an advantage because they had been in the study longer than Cohort
2. To determine whether there might be retest effects for Cohort 1 participants in 1994,
when Cohort 2 was initially tested, participants aged 71–87 were compared on their 1994
scores. There were 76 individuals from Cohort 1 and 294 from Cohort 2 in the analyses of
variance. There were no differences on four of the tasks with Fs(1, 368) ranging from 0.0 to
2.7; however, Cohort 1 participants had significantly better 1994 scores on reasoning, F(1,
368) = 5.8, p < .05, suggesting minimal retest bias.
The mean baseline age for Cohort 1 (M = 69.81, SD = 7.17) was reliably younger than for
Cohort 2 (M = 72.15, SD = 8.46), F(1, 935) = 20.81, MSE = 61.74. Members of Cohort 1 (M
= 12.54, SD = 2.76) reported fewer years of formal education than Cohort 2 (M = 13.69, SD
= 2.94), F(1, 935) = 36.42, MSE = 8.12. Cohort 1 consisted of 53.3\% women and Cohort 2
consisted of 47.8\% women; there were no differences in gender representation across
cohorts, χ2(1, N = 937) = 0.08.
Test intervals were approximately 3 years apart with the exception of a 13-year interval
between the second (1981) and third (1994) testings of Cohort 1. The irregularity of this
interval is assumed to have no undue influence on data modeling because the data were
analyzed over age rather than time. In addition, Zelinski and Burnight (1997) reported no
differences in 1978 scores for Cohort 1 participants who returned in 1994, regardless of
whether they were tested in 1981 or not. All had better initial scores than permanent
dropouts. This suggests general selection effects for Cohort 1 participants returning in 1994
rather than practice effects.
Psychometric Tests
Five measures of cognitive performance were examined. Three of them were from the
STAMAT: Recognition Vocabulary, reasoning (Letter and Word Series), and space (Figure
and Object Rotation). Recognition Vocabulary required selection of definitions for 50 target
words from an array of four choices in 4 min. Reasoning was a composite score of the
STAMAT Letter and Word Series tests. Letter Series required selection of the next item in
30 series, such as a b c c b a d e f f e, in 6 min, and Word Series was a parallel version with
items using days of the week and months. Space was a composite score of the STAMAT
Figure and Object Rotation tests. In these tasks, participants had 6 min to select up to three
rotations of a target from an array of six choices. The items for Figure Rotation were
abstract line figures, whereas those for Object Rotation were line drawings of common
household items such as a bleach bottle. There were 20 items in this test. List recall was
immediate written recall of a list of 20 concrete high-frequency nouns. The words were
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presented on a sheet of paper and participants were given 3.5 minutes to study the list. The
test was not timed. Text recall involved immediate written recall of a 227-word passage
containing 104 idea units. The passage was read by participants while they also listened to
an audio reading of it presented at a rate of approximately 155 words per minute. The
proportion of idea units correctly recalled according to the parsing model of Turner and
Greene (1977) was the dependent measure of text recall.
Rasch Scaling
Interval measurement scaling is based on the following equation (Rasch, 1966):
(1)
where fni1 is the person n’s probability of scoring 1 rather than 0 on item i, bn is the ability
of person n, and di1 is the difficulty of the item. Rasch scaling assumes that the construct
being measured is unidimensional; difficulty of items on a cognitive test is consistent with
ability such that correct scores on more difficult items reflect greater ability and more
difficult items always have a lower probability of being correctly answered than less
difficult ones, independent of person ability. It also assumes that individuals with greater
levels of ability will be more likely to score correct on more items. They always have a
higher probability of correctly answering any item, independent of item difficulty, than
those with low ability (Wright & Stone, 1979).
In Rasch scaling, person parameters are conditioned out of the model when item difficulties
are being calibrated, and item parameters are conditioned out of the model when person
parameters are being calibrated by repetitive inversion of the items and persons data matrix.
Items are ordered by difficulty and persons by ability, with maximum-likelihood modeling
used to identify items that best discriminate responses and people from one another. The
most discriminating items are those that have an equal likelihood of obtaining a correct or
incorrect response at a given level of ability. The logarithmic transformations of the item
and person data shown in Equation 1 convert the ordinal data into interval data. The size of
the intervals is determined by the item and person performance probabilities. Rasch scaled
person scores are log odds units or logit scores representing the 50\% probability of
responding correctly to items at the level of ability, 75\% probability of being able to respond
correctly to items 1 logit below the ability level, and 25\% probability of being able to
respond correctly to items 1 logit above the ability level (Bond & Fox, 2001). When data are
rescaled, the logit properties remain but vary with the scaling factors used to create the
desired score properties. For example, rescaling list recall in the present study from a
logistic score with a mean of 0 to a 0–100 range involved rescaling the logit units from 1 to
11.15. Thus, if a participant declined 11.15 points, that would indicate a 25\% probability of
responding to items that previously would have been associated with a 50\% probability. An
increase of 11.15 points on the recall task would indicate a 75\% probability of responding
correctly to items associated with a 50\% probability previously.
Fit indexes for Rasch analyses are computed separately for persons and items. They use
mean squares to show the amount of distortion in the data relative to the Rasch model. The
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expected value of the mean squares is 1.0. Values substantially less than 1.0 indicate
underfit, with possible unmodeled noise in the data; values substantially greater than 1.0
indicate overfit. Values between 0.5 and 1.5 are productive for measurement, and those
between 1.5 and 2.0 are unproductive but suggest that the measurement is not degraded;
values over 2.0 are problematic (Linacre, 2006).
The infit mean square is a fit statistic sensitive to unexpected patterns of observations made
by persons on items at their approximate ability level and by items on persons at the item’s
approximate difficulty level. The outfit mean square is a fit statistic sensitive to unexpected
observations made by persons on items that are expected to be either very easy or very
difficult or by items on persons of very low or high ability. The overall root-mean-square
error (RMSE) for the model is the square root of the average error variance computed over
persons or items. It indicates the upper limit to the reliability of measures based on the items
and persons sampled (Linacre, 2006). Reliabilities are computed separately across persons
and items, in contrast to reliabilities such as Cronbach’s alpha, which is computed for
persons only. However, the values of the person and item reliabilities are interpreted as is
alpha, with values close to 1 indicating high reliability.
The WINSTEPS Rasch measurement program Version 3.61.1 (Linacre, 2006) was used for
the interval scaling. Individual items for all tasks were the units of analysis, that is, a 1
(correct) or 0 (incorrect) for each item on each test. For the recall tasks, each word or
proposition in the study materials served as an item. Item scores within each test were
calibrated with the data stacked over occasions and cohorts so that each observation for a
particular subject was treated as independent, as would be done in the computation of z
scores over occasions. Scores were initially scaled so that at the item level they had a mean
of zero. The relative range of mean age performance could be identified from the person
ability scores. Table 2 provides fit information for the Rasch calibration of each of the five
tests. All results were good fitting and discriminating based on their infit and outfit mean
squares, low RMSEs, and high reliability for individuals and for items. Examples of interval
item scores converted from raw total scores for list recall and a mental status test are found
in Zelinski and Gilewski (2003).
For the analyses, we rescaled the Rasch item scores from the logistic scores to a 0–100 range
to increase interpretability. The rescaled means (and standard deviations) of the person
scores were, for reasoning, M = 39.66 (13.07); list recall, M = 54.78 (12.67); text recall, M =
40.29 (7.30); space, M = 63.72 (5.83); and vocabulary, M = 68.25 (15.18). The scaling
factors for the logits were 6.12, 11.15, 7.80, 6.72, and 7.4, respectively.
Longitudinal Analysis
We used growth modeling (McArdle & Bell, 2000) with the Mplus program (Version 4.2;
Muthén & Muthén, 1998–2007) to test hypotheses about age and cohort differences in
longitudinal performance on the Rasch-scaled measures. The models were fit to data
configured over 3-year age “buckets” to increase the number of observations for the ages
studied (e.g., Bowles et al., 2005). The 3-year age ranges at which people were tested were
treated as manifest variables, and those age ranges at which they were not tested as latent
variables. The ranges were 55–57, 58–60, 61–63, 64–66, 67–69, 70–72, 73–75, 76–78, 79–
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81, 82–84, and 85–87. For simplicity, we refer to these age buckets by the middle value for a
given bucket. For example, the 73–75 bucket will be referred to as age 74.
Growth models that utilize maximum likelihood methods provide accurate parameter
estimates even with missing data, provided that the missing at random assumption is met
(e.g., McArdle & Hamagami, 1991; Schafer, 1997). This assumption requires that
missingness can be estimated from the data included in the analyses. Logistic regression
analyses predicting dropout from the study by the fourth testing were conducted to aid in the
selection of …
613
Copyright 2002 by The Gerontological Society of AmericaThe Gerontologist
Vol. 42, No. 5, 613–620
Vol. 42, No. 5, 2002
Rowe and Kahn’s Model of Successful Aging
Revisited: Positive Spirituality—The
Forgotten Factor
Martha R. Crowther, PhD, MPH,
1
Michael W. Parker, DSW,
2
W. A. Achenbaum, PhD,
3
Walter L. Larimore, MD,
4
and Harold G. Koenig, MD
5
Purpose:
We explain a new concept, positive spirituality,
and offer evidence that links positive spirituality with
health; describe effective partnerships between health
professionals and religious communities; and summa-
rize the information as a basis for strengthening the exist-
ing successful aging model proposed by Rowe and
Kahn.
Design and Methods:
A missing component to
Rowe and Kahn’s three-factor model of successful aging is
identified, and we propose strengthening the model with a
fourth factor, positive spirituality.
Results:
We devel-
oped an enhanced model of successful aging based on
Rowe and Kahn’s theoretical framework. Evidence pre-
sented suggests that the addition of spirituality to interven-
tions focused on health promotion has been received
positively by older adults.
Implications:
Leaders in ger-
ontology often fail to incorporate the growing body of sci-
entific evidence regarding health, aging, and spirituality
into their conceptual models to promote successful aging.
The proposed enhancement of Rowe and Kahn’s model
will help health professionals, religious organizations,
and governmental agencies work collaboratively to pro-
mote wellness among older adults.
Key Words: Religion, Faith-based interventions,
Churches, Older adults
The spiritual dimension of older adults has not
been integrated into promising intervention models
that promote successful aging. The lack of interest in
issues of spirituality and aging may be analogous to
the unwillingness of older people to act upon or com-
ply with prescribed treatments. “As we find ways to
improve the lives of older people and ameliorate the
diseases which afflict them, we are also confronted by
the reality that we are often unable to successfully uti-
lize these discoveries” (Antonucci, 2000, p. 5).
As a means of consolidating knowledge and prac-
tice, the MacArthur Foundation offered a promising
set of studies on successful aging. In summarizing the
findings, Rowe and Kahn’s (1998) model provided
scientifically grounded parameters for understanding
health across the life course and goals for construct-
ing a framework for interventions. However, despite
the advantages of their model, it does not incorporate
research in the area of spirituality and health that
would strengthen it as a framework for promoting
successful aging interventions. This article has two
aims. First, to assert that spirituality is an important
component of health and well-being outcomes among
older adults. Second, to argue for interventions which
incorporate spirituality with underserved populations
as a guide to health professionals, religious organiza-
tions, and governmental agencies.
Clarifying Concepts
Part of the problem with incorporating spirituality
into scientific thinking has been the confusion associ-
ated with the terms
religion
and
spirituality
(Krause,
1993). When descriptive adjectives like
intrinsic
or
extrinsic
are added, the problem is compounded. Re-
ligious variables in early research were typically lim-
ited to declarations of nominal religious affiliation or
were totally excluded from consideration (Larson,
Pattison, Blazer, Omran, & Kaplan, 1986). There is a
need to define and distinguish spirituality and religion
so that research can proceed with greater clarity and
consistency. In support of this clarification, we use
definitions offered by Koenig and colleagues (Koenig,
McCullough, & Larson, 2000), and we define a new
term—
positive spirituality
. The distinctions between
Although the views expressed in this article are the exclusive opinions
of its authors, we gratefully acknowledge the assistance of The John A.
Hartford Foundation’s Geriatric Social Work Faculty Scholars Program.
Address correspondence to Martha R. Crowther, PhD, MPH, The Uni-
versity of Alabama, Department of Psychology, Box 870348, Tuscaloosa,
AL 35487-0348. E-mail: [email protected]
1
Department of Psychology, The University of Alabama, Tuscaloosa.
2
Department of Social Work, The University of Alabama, Tuscaloosa.
3
College of Humanities, Fine Arts and Communication, The University
of Houston, TX.
4
Focus on the Family, Colorado Springs, CO.
5
Duke University Medical Center, and GRECC, VA Medical Center,
Durham, NC.
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614 The Gerontologist
religion, spirituality, and positive spirituality are de-
scribed below and in Table 1.
Religion.—
“Religion is an organized system of be-
liefs, practices, rituals and symbols designed (a) to fa-
cilitate closeness to the sacred or transcendent (God,
higher power, or ultimate truth/reality), and (b) to
foster an understanding of one’s relation and respon-
sibility to others in living together in a community”
(Koenig et al., 2000, p. 18).
Spirituality.—
“Spirituality is the personal quest for
understanding answers to ultimate questions about
life, about meaning, and about relationship to the sa-
cred or transcendent, which may (or may not) lead to or
arise from the development of religious rituals and the
formation of community” (Koenig et al., 2000, p. 18).
Positive Spirituality.—
Positive spirituality involves a
developing and internalized personal relation with
the sacred or transcendent that is not bound by race,
ethnicity, economics, or class and promotes the well-
ness and welfare of self and others. Positive spiritual-
ity uses aspects of both religion and spirituality. It also
incorporates the work of the Fetzer work groups,
which suggests that religion and spirituality are mul-
tidimensional constructs (Fetzer Institute, 1999). Our
focus extends the contributions of the Fetzer work
groups, namely, to capture health-relevant domains
of religiousness and spirituality, by focusing on
only
positive aspects of spirituality or religion within the
context of a conceptual model related to successful
aging. The addition of positive spirituality to Rowe
and Kahn’s model of successful aging helps bridge
the gap between theory and practice at a time when
the Congressional and Executive branches of the gov-
ernment are enacting rules for collaboration between
government and the faith community in serving the
poor (e.g., Personal Responsibility and Work Oppor-
tunity Reconciliation Act, 1996).
To discuss more fully what we mean, it becomes
necessary to address what positive spirituality is not.
There
is general agreement that certain religious be-
liefs and activities can adversely affect both mental
and physical health (Koenig, 2001). Spirituality may
be restraining rather than freeing and life enhancing
(Pruyser, 1987). Religious beliefs have been used to jus-
tify hypocrisy, self-righteousness, hatred, and prejudice.
The aspects of spirituality or religion that separate
people from the community and family (e.g., hypocrisy,
self-righteousness), or that encourage
unquestioning
devotion and obedience to a single charismatic leader,
or promote religion or spiritual traditions as a healing
practice to the total exclusion of any medical care, are
likely to adversely affect health over time. For exam-
ple, we would not suggest that Reverend Jim Jones
and the Guyana mass suicide of nearly 900 people,
the David Koresh cult in Waco, Texas, or the terrorist
attack on September 11th that destroyed the World
Trade Center Towers were guided by positive spiritu-
ality. Many Western and Eastern religious traditions
emphasize an intimate relation with a transcendent
force, place high value on personal relations, stress re-
spect and value for the self, yet place emphasis on hu-
mility. The resulting emphasis on relations—relation
to a transcendent force, to others, and to self—may
have important mental health consequences, especially
in regard to coping with the difficult life circumstances
that accompany poor health and chronic disability.
Positive spirituality may reduce the sense of loss of
control and helplessness that accompanies illness.
Positive spiritual beliefs provide a cognitive frame-
work that reduces stress and increases purpose and
meaning in the face of illness. Spiritual activities like
prayer and being prayed for may reduce the sense of
isolation and increase the patient’s sense of control
over illness or disease. Public religious behaviors that
improve coping during times of physical illness in-
clude, but are not limited to, participating in worship
services, praying with others (and having others pray
for one’s health), and visits from religious leaders
Table 1. Distinctions Between Religion, Spirituality, and Positive Spirituality
Religion Spirituality Positive Spirituality
Community focused Individualistic Seeks to identify those features of religion and
spirituality that have yielded or are associated with
positive outcomes. The blend between community
focused and individualism.
Observable, measurable,
organized and/or more
extrinsic
Less visible and measurable, more subjective
and/or more intrinsic
Measurable, extrinsic, and intrinsic
Formal, orthodox, organized Less formal, orthodox Less formal, orthodox, and systematic
Behavior oriented, outward
practices
Emotionally oriented, inward directed Emotion and behavior oriented
Authoritarian in terms
of behavior
Not authoritarian, little accountability Accountable to engaging in positive actions
Doctrine separating good
from evil
Unifying, not doctrine oriented Unifying, promoting life enhancing beliefs
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615Vol. 42, No. 5, 2002
such as a chaplain, pastor, priest, or rabbi at home or
in the hospital.
Rowe and Kahn’s Model of Successful Aging
and Positive Spirituality
In their original model, Rowe and Kahn (1987) de-
fined successful aging as the avoidance of disease and
disability. More recently they have expanded their
model to include maintenance of physical and cogni-
tive function and engagement in social and produc-
tive activities (Rowe & Kahn, 1997, 1998), making it
ready for future intervention studies (Riley, 1998).
However, their notion of successful aging has not
been without criticisms.
Rowe and Kahn’s (1998) model has been criticized
for not emphasizing biological research (Masoro,
2001) and for not including social structure and self-
efficacy (Riley, 1998). We argue that the social and bi-
ological components to aging successfully are portrayed
adequately within the existing model as “avoidance of
disease and disability” and “active engagement with
life” (Rowe & Kahn, 1998, p. 39). Additionally, we
agree with Rowe and Kahn (1998) that self-efficacy,
as a psychological construct, properly rests within
their original conceptualization of cognitive and men-
tal fitness, and that it does not represent a separate,
distinct component to successful aging.
Although we maintain that Rowe and Kahn’s
(1998) synthesis of the literature addresses these crit-
icisms adequately without necessary modification of
their framework, their model falters systemically on
two counts. First, their work does not endorse the
growing body of research examining the relation be-
tween spirituality and health outcomes (see reviews
by Levin, 1996; Matthews & Larson, 1995). Spiritu-
ality has been associated with an improvement in sub-
jective states of well-being (Ellison, 1991), a reduc-
tion in levels of depression and distress (Williams,
Larson, Buckler, Heckmann, & Pyle, 1991), a reduc-
tion in morbidity, and an increase in life span (Levin,
1996). Second, their neglect of spirituality as a major
construct handicaps their call for efficacious applica-
tions with their model. National surveys have consis-
tently shown that the vast majority of older Ameri-
cans, in particular ethnic and minority elders, report a
religious or spiritual component to their lives (Prince-
ton Religious Research Center, 1987, 1994).
In the following section, we introduce positive spir-
ituality into Rowe and Kahn’s (1998) model, as illus-
trated in Figure 1. We maintain that this expanded
model will enhance the percentage of older adults
who age successfully by affirming an important and
positive aspect in the lives of many older Americans,
while in no way disenfranchising those to whom spir-
ituality is not important. Furthermore, the theoretical
incorporation of spirituality into models of successful
aging represents an important scientific acknowledge-
ment of the research findings of the past four decades.
Rowe and Kahn’s model has three components: (a)
minimizing risk and disability, (b) engaging in active
life, and (c) maximizing physical and mental activi-
ties. The three components of the model have the fol-
lowing characteristics: (a) each is a part of an overall
system and each is therefore temporally related to the
others, (b) the variables are activating characteristics
that describe both weaknesses and strengths, and (c)
each must consider both individual characteristics as
well as contextual factors. We argue that positive spir-
ituality is the missing component in the model; it ad-
dresses the interrelatedness between the older adults’
beliefs and values, the community, and the efficacy of
interventions focused on successful aging.
Rowe and Kahn (1997) indicated that the stage is
set for intervention studies to identify effective strate-
gies that enhance wellness among older adults. We
maintain, with our broadened Rowe and Kahn model,
that aging is multifaceted and consists of interdepen-
dent biological, psychological, social, and
spiritual
processes. Further, we assume that lives are lived
within a social and historical context, and that the re-
lation between individuals and society is multidimen-
sional and interactive. For example, positive spirituality
fosters active engagement in life, through religious and/
or community activities, prayer, meditation, and
other practices. In addition, the literature has found
an association between spiritual and/or religious ac-
tivities and the reduction in disability and disease,
thus allowing seniors to remain actively engaged.
The intellectual acceptance of spirituality as a
major facet of life will help reopen doors of opportu-
nity with groups who have avoided or become reluc-
tant recipients of traditional health promotion in-
terventions. A person’s spirituality is not bound by
race and socioeconomic status, and its acceptance
in theory will provide gerontologists the option of
considering spiritual tools and paradigms in design-
ing efficacious, evidence-based health promotion in-
terventions that cut across traditional racial, ethnic,
and economic boundaries.
Positive Spirituality and Wellness
Except for the past two centuries, religion and med-
icine have been closely linked for most of recorded
history. Yet until nearly the end of the 20th century,
science has not seriously studied the relation between
measures of religion, spirituality, health, and aging
(Koenig, 1999; McFadden, 1996). Because of the grow-
ing recognition that religious and spiritual beliefs and
Figure 1. Revised Rowe and Kahn Model of Successful Aging.
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616 The Gerontologist
practices are widespread among the American popula-
tion and that these beliefs and practices have clinical rel-
evance, professional organizations are increasingly call-
ing for greater sensitivity and better training of clinicians
concerning the management of religious and spiritual is-
sues in assessment, treatment, and research (Accredita-
tion Council for Graduate Medical Education, 1994;
American Psychiatric Association, 1995; American Psy-
chological Association, 1992; Council on Social Work
Education, 1995; The Joint Commission on the Accred-
itation of Healthcare Organizations in 1996, 2001).
Positive Spirituality, Psychological, and
Physical Health Outcomes
There are multiple psychological, social, behav-
ioral, and physiological mechanisms by which reli-
gious involvement may impact health and speed re-
covery from disease. Several researchers have found
that religious activity—particularly when it occurs in
the setting of community such as involvement in reli-
gious worship services—and related voluntary activ-
ity is associated with longer life span (Glass, Mendes
de Leon, Marottoli, & Berkman, 1999; Hummer,
Rogers, Nam & Ellison, 1999; Oman & Reed, 1998).
Additionally, several studies have shown a positive as-
sociation between religious involvement and better
adaptation to medical illness (Ell, Mantell, Hamo-
vitch, & Nishimoto, 1989; Jenkins & Pargament,
1995; Kaczorowski, 1989) or to the burden of caring
for those with medical illness (Keilman & Given,
1990; Rabins, Fitting, Eastham, & Zabora, 1990).
Religious activity has also been associated with better
compliance with antihypertensive therapy (Koenig,
George, Cohen, et al., 1998).
Religiously committed persons are less likely to en-
gage in health behaviors like cigarette smoking and
excessive alcohol use (Koenig et al., 2000). In this
way, religion may help to prevent the negative health
consequences that follow these unhealthy behaviors.
On the other hand, these persons are often involved in
close family systems and supportive communities,
which may have effects on health through other ex-
planatory mechanisms.
Level of religious commitment also predicts speed
of recovery from depression regardless of initial de-
pression severity, an effect that is strongest in those
with chronic physical disability that is not responding
to medical therapies (Koenig, George, & Peterson,
1998). A positive association between religious in-
volvement and mental health in persons with physical
disability has also been found in studies of hospital-
ized medical patients (Idler, 1995; Larson, 1993). Sim-
ilarly, studies of mental health and substance abuse
have shown that religious activity buffers against the
negative effects of physical illness or stressful life
events (Kendler, Gardner, & Prescott, 1997). Nearly
850 studies have now examined the relation between
religious involvement and some indicator of mental
health. Many of the studies have been conducted in
medically ill patients or older persons suffering with
chronic disability. The vast majority of such studies
do indeed find that religious involvement is associated
with greater well-being and life satisfaction, greater
purpose and meaning in life, greater hope and opti-
mism, less anxiety and depression, more stable mar-
riages and lower rates of substance abuse (Koenig,
McCullough, & Larson, 2000).
Religious Coping, Psychological, and Physical
Health Outcomes
In an examination of the association between reli-
gious coping and depression, Koenig and colleagues
(1995) found that religious coping may reduce the af-
fective symptoms of depression, but appeared less ef-
fective for the biological symptoms that are probably
more responsive to medical treatments. More re-
cently, Koenig and collaborators examined the associ-
ation between 21 types of religious coping and a host
of physical and mental health characteristics (Koenig,
Pargament, & Nielsen, 1998). Offering religious help
to others (e.g., praying for others) was one of the
most powerful predictors of high quality of life, low
depressive symptoms, greater level of cooperativeness,
and greater stress-related growth. Other types of reli-
gious coping associated with positive mental health in-
cluded reappraising God as benevolent, collaborating
with God, seeking a connection with God, and seek-
ing support from clergy or other church members.
These coping behaviors were strongly related to
stress-related growth, enabling patients to experience
greater psychological growth from these stressful
health problems. Coping behaviors that focused pri-
marily on the self (self-directed coping) without de-
pending on God, were related to greater depression,
lower quality of life, and significantly lower stress-
related growth. Some studies show that religious cop-
ing is also associated with improved attendance at
scheduled medical appointments (Koenig, 1995).
Several studies report an association between reli-
gious involvement and immune system function. Dull
and Skokan (1995) developed a cognitive model to
explain the relation between spirituality and the im-
mune system. In their model they posit that spiritual-
ity is a complex system of beliefs that can have an im-
pact on all aspects of an individual’s daily life.
Spiritual practices may affect a person’s cognitions
and subsequently impact health practices and out-
comes. For example, a cancer patient with spiritual
beliefs may assign a larger meaning to the illness, thus
reducing the negative effects of stress on health.
Investigations in patients with AIDS show that
those who are more involved in religious activities
have measurably stronger immune function (Woods,
Antoni, Ironson, & Kling, 1999). Likewise, studies at
Stanford University in patients with breast cancer
show better immune functioning among women with
greater religious expression (Schaal, Sephton, Thore-
son, Koopman, & Spiegel, 1998). The findings pre-
sented above suggest a positive association between re-
ligion and reduced levels of psychological stress and
could point to physiological consequences that impact
physical health as well. However, this research is in its
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617Vol. 42, No. 5, 2002
earliest stages, with the results highly preliminary and
not definitive. Prospective studies and clinical trials
are needed to determine the order of the effects.
The Role of Positive Spirituality in Health Promotion
Health promotional efforts are designed to trans-
form the more traditional biomedical models that ac-
centuate the physician’s responsibility to treat disease,
to an ideal in which individuals are increasingly respon-
sible for optimizing their health by attending to the
quality of their self-care. Hooyman and Kiyak (1999)
suggest that health promotion makes “explicit the im-
portance of people’s environments and lifestyles as
determinants of their health status” (p. 117). As a re-
flection of and in reaction to the aging demography
of America and the world, the American Association
for World Health (1999) has adopted the theme,
“Healthy Aging, Healthy Living—Start Now.” Prac-
titioners have not used specified exercises for self-
care consistently in the development of innovative
wellness initiatives (Prochaska & DiClemente, 1984;
Prochaska, Velicer, DiClemente, & Rossi, 1993). Only
rarely and recently are the implications of these re-
search domains considered in the development of well-
ness and health promotion programs (Parker, Fuller,
Koenig, Bellis, Vaitkus, & Eitzen, 2001).
The National Academy on an Aging Society (2000)
has released information that portrays the health pro-
motional challenge with seniors. Almost all of the at-
risk conditions are associated with chronic illnesses
such as hypertension, heart disease, diabetes, cancer,
and stroke. Though many older people are at risk for
chronic conditions because of genetic predisposition,
gender and age, many risk factors are related to mod-
ifiable health behaviors.
Can religious and spiritually minded organizations
participate more actively in these efforts? Can they
help fill the void in funding of intervention initiatives?
We offer evidence to support these assertions. The
role religious organizations can play and have played
in providing support for aging members in the com-
munity and hospital has often been overlooked or not
acknowledged in the literature on successful aging.
Religious communities have the most valuable re-
source in society—people. By supporting community-
dwelling older adults and their caregivers, religious
communities could potentially reduce both the length
and frequency of hospital admissions and perhaps delay
nursing home placement. Religious denominations,
spiritually minded nonprofit organizations, ecumenical
groups, churches, synagogues, and other religious in-
stitutions represent viable sources that can be engaged
in partnerships that provide health promotional and
prevention opportunities to groups that are more diffi-
cult to reach (Parker et al., 2000; Parker et al., 2002).
Models of Intervention That Incorporate
Positive Spirituality
The African American religious community has
helped establish the connection between health pro-
motion and spirituality. In their 20-year review of lay
health advisor programs among African Americans,
Jackson and Parks (1997) reviewed the growing lay
health advisor movement. Among their findings was
the recommendation that professional educators
should rely on the collective wisdom of the commu-
nity to identify, recruit, select, and train lay health ad-
visors, and they cite a number of studies that confirm
the value of seeking the collective wisdom of the Afri-
can American religious community in health promo-
tional outreach programs.
Smith, Merritt, and Patel (1997) examined the im-
pact of education and support provided by African
American churches in encouraging health promotion
activities for blood pressure management. In a related
program, Kong (1997) described a community-based
program, which included churches, that played a
valuable role in increasing the number of African
American hypertensives that received treatment.
There is also evidence that supports the role of minis-
ters in providing assistance for African Americans
(Okwumabua & Martin, 1997; Neighbors, Musick,
& Williams, 1998).
Jackson and Reddick (1999) describe the Health
Wise Church Project, a community outreach initiative
between a diverse group of African American churches
and a university health education program. The pri-
mary objective was to develop early detection and ill-
ness prevention networks among older church mem-
bers. Their four-stage model for the establishment of
academic–church collaborations is similar to a model
used by Parker and colleagues (2000, 2001), which
adopted the Rowe and Kahn model of successful ag-
ing with the addition of positive spirituality. As illus-
trated in Figure 2, we have taken the Parker and col-
leagues model and adapted it for use with faith-based
and non–faith-based organizations. This model is a
unifying theoretical framework that fosters interdisci-
plinary thinking as well as program development and
research in the area of health promotion. The model
demonstrates how prevention information can be dis-
seminated to older adults by gaining access to com-
munity organizations. The inclusion of both faith and
non–faith-based organizations captures older persons
who consider themselves spiritual but do not associ-
ate with organized religion.
The model considers a variety of social, biological,
cultural, and economic factors that influence health
and health behavior. Experts recommend diet and ex-
ercise to alter individual health practices, to create
healthier environments, and to enlighten attitudes
and expectations toward health (Rowe & Kahn,
1998). By interacting with older adults through faith
and non–faith-based organizations as proposed in the
model, the more traditional biomedical models that
accentuate the physician’s responsibility to treat dis-
ease are transformed to an ideal in which individuals
are increasingly responsible for optimizing their
health by attending to the quality of their self-care
(Hooyman & Kiyak, 1999).
Faith and non–faith-based organizations can
work across denominational and racial boundaries
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618 The Gerontologist
Figure 2. Proposed model for community-level health promotion for seniors.
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619Vol. 42, No. 5, 2002
in conjunction with public and private health care
providers and academia and research organizations
to forge partnerships. These partnerships can provide
the impetus and resources necessary for communities
to organize conferences, programs, or workshops
that promote successful aging. This model symbolizes
the potential of community partnerships in address-
ing institutional forms of diversity that limit outreach
with disadvantaged groups. The unifying framework
proposed marks a needed reversal in the trend towards
separation of spirituality, organized religion, non–
faith-based institutions, academia, and health care pro-
fessionals that has occurred over the past several years.
Conclusion
We have briefly …
The Forum
Copyright 1997 by
The Cerontological Society of America
The Cerontologist
Vol. 37, No. 4, 433-440
Substantial increases in the relative and absolute number of older persons in our society
pose a challenge for biology, social and behavioral science, and medicine. Successful aging
is multidimensional, encompassing the avoidance of disease and disability, the
maintenance of high physical and cognitive function, and sustained engagement in social
and productive activities. Research has identified factors predictive of success in these
critical domains. The stage is set for intervention studies to enhance the proportion of our
population aging successfully.
Key Words: Aging, Cognition, Physical function, Engagement, MacArthur Foundation
Successful Aging1
John W. Rowe, MD2 and Robert L Kahn, PhD3
In an earlier article (Rowe & Kahn, 1987), we pro-
posed the distinction between usual and successful
aging as nonpathologic states. Our purpose in
doing so was to counteract the longstanding ten-
dency of gerontology to emphasize only the distinc-
tion between the pathologic and nonpathologic,
that is, between older people with diseases or dis-
abilities and those suffering from neither. The im-
plicit assumption of that earlier gerontology was
that, in the absence of disease and disability, other
age-related alterations in physical function (such as
increases in blood pressure and blood glucose) and
Cognitive function (such as modest memory impair-
ment) were normal, determined by intrinsic aging
processes, primarily genetic, and not associated
with risk.
We hoped that the distinction between two
groups of nondiseased older persons — usual (non-
pathologic but high risk) and successful (low risk and
high function) — would help to correct those ten-
dencies, stimulate research on the criteria and deter-
minants of successful aging, and identify proper tar-
gets for interventions with normal elderly. In
recent years, successful aging has. become a famil-
iar term among gerontologists (Abeles, Gift, & Ory,
1994; Baltes & Baltes, 1990; Garfein & Herzog, 1995;
Hazzard, 1995) and a considerable body of research
has accumulated on its characteristics. Much of this
work was supported by the MacArthur Foundation
Supported by the John D. and Catherine T. MacArthur Foundation,
Chicago, IL
Address correspondence to John W. Rowe, MD, President, Mount Sinai
School of Medicine and The Mount Sinai Hospital, Mount Sinai Medical
Center, One Custave L. Levy Place, New York, NY 10029.
University of Michigan, Institute for Social Research, Ann Arbor, M l .
Research Network on Successful Aging. In this article
we summarize the central findings of that work, pro-
pose a conceptual framework for successful aging,
and consider some pathways or mechanisms that
make for successful old age.
Defining Successful Aging
We define successful aging as including three
main components: low probability of disease and
disease-related disability, high cognitive and physi-
cal functional capacity, and active engagement with
life. All three terms are relative and the relationship
among them (as seen in Figure 1) is to some extent
hierarchical. As the figure indicates, successful
aging is more than absence of disease, important
though that is, and more than the maintenance of
functional capacities, important as it is. Both are im-
portant components of successful aging, but it is
their combination with active engagement with life
that represents the concept of successful aging
most fully.
Each of the three components of successful aging
includes subparts. Low probability of disease refers
not only to absence or presence of disease itself,
but also to absence, presence, or severity of risk
factors for disease. High functional level includes
both physical and cognitive components. Physical
and cognitive capacities are potentials for activity;
they tell us what a person can do, not what he or
she does do. Successful aging goes beyond poten-
tial; it involves activity. While active engagement
with life takes many forms, we are most concerned
with two — interpersonal relations and productive
activity. Interpersonal relations involve contacts and
transactions with others, exchange of information,
Vol. 37, No. 4,1997 433
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AVOIDING
DISEASE AND
DISABILITY
SUCCESSFUL
AGING
ENGAGEMENT
WITH LIFE
HIGH COGNITIVE
AND PHYSICAL
FUNCTION
100
Figure 1. A model of successful aging.
emotional support, and direct assistance. An activity
is productive if it creates societal value, whether or
not it is reimbursed. Thus, a person who cares for a
disabled family member or works as a volunteer in a
local church or hospital is being productive, al-
though unpaid (Herzog & Morgan, 1992).
Staying Healthy: Reducing Risk Factors for Disease
and Disability in Late Life
The concept of usual aging as a large subset of
those elderly previously considered to be normal
is depicted in Figure 2 (Rowe, 1990). The curve
farthest to the right, labeled Death, displays the
1980 age-specific mortality experience of the United
States. The area to the left of the curve labeled
Disability estimates that portion of the population
without disability, and the envelope between the
Death and Disability curves denotes the disabled
population. The area to the left of the curve labeled
Disease represents the nondiseased, nondisabled
population. The final curve, labeled Risk, esti-
mates the portion of the nondiseased population at
significant risk for developing disease. The increas-
ing dominance of this population with advancing
age reflects emergence of the usual aging syn-
drome associated with risk of chronic disease. The
area at the extreme left and bottom of the figure in-
cludes the nondiseased population at lowest risk,
i.e., those who are aging successfully with respect
to risk of emergence of disease. While the death,
disability, and disease curves traditionally originate
at 100\%, i.e., with none of the population affected at
birth, the risk curve arbitrarily originates at 80\% not
e
UJ
50
UJ
u
DC
UJ
Q .
Death
Disability
Disease
25 50
AGE (years)
75 100
Figure 2. Relation of risk of disease to presence of disease,
disability, and death in an aging population.
affected, to reflect the fact that many individuals
begin at risk, either because of genetic factors or the
psychosocial environment in which they are born.
Heritability, Lifestyle, and Age-related Risk
The previously held view that increased risk of
diseases and disability with advancing age results
from inevitable, intrinsic aging processes, for the
most part genetically determined, is inconsistent
with a rapidly developing body of information that
many usual aging characteristics are due to lifestyle
and other factors that may be age-related (i.e., they
increase with age) but are not age-dependent (not
caused by aging itself).
A major source of such information is the Swed-
ish Adoption/Twin Study of Aging (SATSA), a subset
of the Swedish National Twin Registry that includes
over 300 pairs of aging Swedish twins, mean age 66
years old, half of whom were reared together and
half who were reared apart. About one third are
monozygotic, while two thirds are dizygotic. Com-
parison of usual aging characteristics in twins of dif-
fering zygosity and rearing status enables estima-
tion of the relative contributions of heritable and
environmental influences.
SATSA-based studies have determined the heri-
tability coefficients (the proportion of total variance
attributable to genetic factors) for major risk factors
for cardiovascular and cerebrovascular disease in
older persons. These are .66-.70 for body mass
index, .28-.78 for individual lipids (total cholesterol,
low- and high-density lipoprotein cholesterol,
apolipoproteins A-1 and B, and triglycerides), .44 for
systolic and .34 for diastolic blood pressure (Heller,
deFaire, Pedersen, Dahlen, & McClearn, 1993; Hong,
deFaire, Heller, McClearn, & Pedersen, 1994;
Stunkard, Harris, Pedersen, & McClearn, 1990).
Heritability trends across decades of advanced
age revealed a reduction in the heritability coeffi-
cients for apolipoprotein B and triglycerides (see
Figure 3) and for systolic blood pressure (.62 for
people under 65 years old and .12 for those over 65).
434 The Gerontologist
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SERUM TRIGLYCERIDES
100
\% VARIANCE
100
50-62 54-66 58-72 62-76
AGE INTERVAL
6640 70-84
GENETK ENVIRONMENTAL
Figure 3. Relative contributions of heredity and environment
with advancing age to serum triglycerides in Swedish twins,
adapted from Heller, D. et al., 1993.
Consistent with these age-related reductions in her-
itability are mortality data from a 26-year follow-up
of the entire Swedish Twin Registry, 21,004 twins
born between 1886 and 1925 (Marenberg, Risch,
Berkman, Floderus, & deFaire, 1994). Among male
identical twins, the risk of death from coronary
heart disease (CHD) was eightfold greater for those
whose twin died before age 55 than for those
whose twin did not die before age 55, and among
male nonidentical twins the corresponding risk was
nearly four times greater. When one female identi-
cal twin died before the age of 65, the risk of death
for the other twin was 15 times greater than if ones
twin did not die before the age of 65, and 2.6 times
greater in the case of female nonidentical twins.
Overall, the magnitude of the risk associated with
ones twin dying of CHD decreased as the age at
which the twin died increased, independent of gen-
der and zygosity.
Beyond twin studies, other evidence indicates the
importance of lifestyle factors in the emergence of
risk in old age. For instance, advancing age is associ-
ated with progressive impairment in carbohydrate
tolerance, insufficient to meet diagnostic criteria for
diabetes mellitus but characterized by increases in
basal and post-glucose challenge levels of blood
sugar and insulin. The hyperglycemia of aging carries
increased risk for coronary heart disease (Donahue,
Abbott, Reed, & Yano, 1987) and stroke (Abbott,
1987), with progressive increases in the usual aging
range associated with increasing risk. Similarly, the
hyperinsulinemia associated with aging is an inde-
pendent risk factor for coronary heart disease (Fty-
orala, 1979; Foster, 1989). Several studies have now
demonstrated that the dominant determinants of this
risk are age-related but potentially avoidable factors,
such as the amount and distribution of body fat
(Elahi, Muller, Tzankoff, Andres, & Tobin, 1982; Kohrt,
Staten, Kirwan, Wojta, & Holloszy, 1990) and reduced
physical activity and dietary factors (Zavaroni et al.,
1986).
Substantial and growing evidence supports the
contention that established risk factors for the
0.5 T
0.4 • •
0.3 • • ^
« 0.2 ••
0 . 1 • •
Evans County blacks (RR = 1.08)
* * * . . . Evans County whites {RR= 1.83)
Tecumseh (RR = 3.87)
N Gothenburg {RR = 4.00)
Eastern Finland (RR = 2.63)
Low High
Level of Social Integration
Note: RR Indicates the relative risk ratio of mortality at the
lowest versus highest level of social integration
Figure 4. Relation of level of social integration to age-adjusted
mortality in five prospective studies, adapted from House, J. et
al., 1988.
emergence of diseases in older populations, such as
cardiovascular and cerebrovascular disease, can be
substantially modified (Hazzard & Bierman, 1990;
Sticht & Hazzard, 1995). In a study demonstrating
the modifiability of usual aging, Katzel and col-
leagues (Katzel, Bleecker, Colman, Rogus, & Sorkin,
1995) conducted a randomized, controlled, pro-
spective trial comparing the effects of a 9-month
diet-induced weight loss (approximately 10\% of
body weight) to the effects of a constant-weight aer-
obic exercise program and a control program on a
well characterized group of middle-aged and older
men at risk for cardiovascular disease. The study
participants were nondiabetic and were obese
(body mass index 30 kg/m2), with increased waist-
hip ratios and modest increases in blood pressure,
blood glucose, insulin, and an atherogenic lipid
profile. Compared to controls, the reduced-energy
intake diet resulted in statistically significant reduc-
tions in weight, waist-hip ratio, fasting and post-
prandial glucose and insulin levels, blood pressure
and plasma levels of triglycerides, low-density
lipoprotein/cholesterol, and increases in high-den-
sity lipoprotein/cholesterol. While the older weight
loss subjects (over 60 years old) lost less weight
than the middle-aged subjects and had more mod-
est improvements in carbohydrate tolerance, they
participated fully in the reductions in other risk fac-
tors. In general, the weight loss intervention had
greater effects than the constant-weight aerobic ex-
ercise intervention.
Taken together, these reports reveal three consis-
tent findings. First, intrinsic factors alone, while
highly significant, do not dominate the determina-
tion of risk in advancing age. Extrinsic environmen-
tal factors, including elements of lifestyle, play a
very important role in determining risk for disease.
Second, with advancing age the relative contribu-
tion of genetic factors decreases and the force of
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nongenetic factors increases. Third, usual aging
characteristics are modifiable. These findings un-
derline the importance of environmental and be-
havioral factors in determining the risk of disease
late in life.
Intra-lndividual Variability: A Newly Identified
Risk Factor in Older Persons
The traditional repertoire of risk factors identified
in studies of young and middle-aged populations
may not include some additional risk factors unique
to, or more easily identified in, elderly populations.
In this regard, the MacArthur Foundations Studies
of Successful Aging point to a previously unrecog-
nized risk factor — altered within-individual vari-
ability in physiologic functions — which may be im-
portant in determining the usual aging syndrome.
Most gerontological research, and indeed re-
search in all age groups, is not geared to the mea-
surement of short-term variations and changes.
Study designs generally focus on the absolute level
of a variable, perhaps comparing levels at two or
more time points that may be separated by months
or years. Nesselroade and colleagues (Kim, Nessel-
roade, & Featherman, 1996), reasoned that short-
term variability in a number of physiological or per-
haps psychological characteristics might reflect a
loss of underlying physiological reserve and repre-
sent a risk factor for emergence of disease or dis-
ability. To study the impact of short-term variability,
they examined between-person differences in simi-
larly aged residents of a retirement community.
They assessed various aspects of biomedical, cogni-
tive, and physical functioning every week for 25
weeks in a group of 31 individuals and a matched
group of 30 assessed only at the outset and the end
of the 25-week period, and they followed the sub-
jects for several years to ascertain the relationship
between within-person variability and its risk.
Within-person variability of a joint index of physi-
cal performance and physiological measures (gait,
balance, and blood pressure) was an excellent pre-
dictor of mortality five years later (R = 0.70, R2 =
0.49). Variability of the composite measure was a
better predictor of mortality than mean level, which
did not represent a statistically significant risk factor
(Nesselroade, Featherman, Agen, & Rowe, 1996). A
similar pattern of findings held for the psychologi-
cal attributes of perceived control and efficacy, for
which average level was not a significant predictor
of mortality but intra-individual variability scores
predicted 30\% of the variance in mortality (Eizen-
man, Nesselroade, Featherman, & Rowe, in press).
It should be emphasized that some functions are
highly variable under normal conditions and others
much less so. The significant aspect of intra-individ-
ual variability as a potential measure of decreased
capacity and increased risk must be a change from
the normal variability, regardless of whether the
change is an increase or decrease. For example, a
decline in beat-to-beat variability in heart rate has
been shown to be a predictor of mortality in patients
who have previously suffered a myocardial infarc-
tion. While in the physiological measurement used
in this study, an increase in variability was associated
with increased risk; in other highly regulated sys-
tems, a decrease in variability may be detrimental
and represent decreased reserve and increased risk.
Maximizing Cognitive and Physical Function
in Late Life
A second essential component of successful
aging is maximization of functional status. One
common concern of older people relates to cogni-
tive function, especially learning and short-term
memory. Another functional area of major interest
is physical performance. Modest reductions in the
capacity to easily perform common physical func-
tions may prevent full participation in productive
and recreational activities of daily life.
The MacArthur Foundation Research Network on
Successful Aging conducted a longitudinal study of
older persons to identify those physical, psycholog-
ical, social, and biomedical characteristics predic-
tive of the maintenance of high function in late life.
The 1,189 subjects in this three-site longitudinal
study were 70-79 years old at initial evaluation and
were functionally in the upper one third of the gen-
eral aging population. Smaller age- and sex-
matched samples (80 subjects in the medium func-
tioning group and 82 subjects in the low functioning
group) were selected to represent the middle and
lowest tertiles. Initial data included detailed assess-
ments of physical and cognitive performance,
health status, and social and psychological charac-
teristics (the MacArthur battery), as well as the col-
lection of blood and urine samples. After a 2.0-2.5
year interval, 1,115 subjects were re-evaluated, pro-
viding a 91\% follow-up rate for the study.
Predictors of Cognitive Function
Cognitive ability was assessed with neuropsycho-
logical tests of language, nonverbal memory, verbal
memory, conceptualization, and visual spatial abil-
ity. In the initially high functioning group, four
variables — education, strenuous activity in and
around the home, peak pulmonary flow rate, and
self-efficacy — were found to be direct predictors
of change or maintenance of cognitive function, to-
gether explaining 40\% of the variance in cognitive
test performance. Education was the strongest pre-
dictor, with greater years of schooling increasing
the likelihood of maintaining high cognitive func-
tion (Albert et al., 1995). This finding is consistent
with several cross-sectional studies, which identify
education as a major protective factor against re-
ductions in cognitive function. Since all the subjects
had high cognitive function at first evaluation, it is
unlikely that the observed effect merely reflected
ability to perform well on cognitive tests or was the
result of individuals with greater innate intelligence
having received more education. Instead, the re-
sults suggest either or both of two explanatory
mechanisms: a direct beneficial effect of education
436 The Gerontologist
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early in life on brain circuitry and function, and the
possibility that education is a proxy for life-long in-
tellectual activities (reading, crossword puzzles,
etc.) which might serve to maintain cognitive func-
tion late in life.
Pulmonary peak expiratory flow rate was the sec-
ond strongest predictor of maintenance of cogni-
tive function. In previous studies, this function was
a predictor of total and cardiovascular mortality and
a correlate of cognitive and physical function in el-
derly populations (Cook et al., 1989).
A surprising finding of this study was that the
amount of strenuous physical activity at and around
the home was an important predictor of maintain-
ing cognitive function. In a follow-up study to eval-
uate a possible mechanism of this effect, Neeper,
Gomez-Pinilla, Choi, and Cotman (1995) measured
the effect of exercise on central nervous system lev-
els of brain-derived neurotrophic factor (BDNF) in
adult rats. These investigators found that increasing
exercise was associated with very substantial dose-
related increases in BDNF in the hippocampus and
neocortex, brain areas known to be highly respon-
sive to environmental stimuli. These data provide a
potential mechanism whereby exercise might en-
hance central nervous system function, particularly
memory function.
A personality measure, perceived self-efficacy, was
also predictive of maintaining cognitive function in
old age. The concept of self-efficacy developed by
Bandura is defined as peoples beliefs in their capa-
bilities to organize and execute the courses of action
required to deal with prospective situations (Ban-
dura, 1995). In students and young adults, self-effi-
cacy influences persistence in solving cognitive
problems (Brown & Inouye, 1978), heart rate during
performance of cognitive tasks (Bandura, Cioffi, Tay-
lor, & Brouillard, 1988), mathematical performance
(Collins, 1982), and mastery of computer software
procedures (Cist, Schwoerer, & Rosen, 1989). Lach-
man and colleagues have proposed a role for self-ef-
ficacy beliefs in maintenance of cognitive function
among older people (Lachman, & Leff, 1989; Lach-
man, Weaver, Bandura, Elliott, & Lewkowicz, 1992).
In addition to these findings of predictors of main-
tenance of cognitive function, evidence is accumulat-
ing to indicate that it can be enhanced in old age. For
example, older people who showed a clear age-
related pattern of decline in fluid intelligence (induc-
tive reasoning and spatial orientation) showed sub-
stantial improvement after five training sessions that
stressed ways of approaching such problems and
provided practice in solving them (Schaie & Willis,
1986). Moreover, repeated measurement indicated
that the improvements were maintained. Studies
from the Max Planck Institute in Berlin confirm the
finding that cognitive losses among healthy older
people are reversible by means of training, although
they also show a substantial age-related training ef-
fect in favor of younger subjects (Kliegl, Smith, &
Baltes, 1989). There is a double message in these
findings: first, and most important, the capacity for
positive change, sometimes called plasticity, persists
in old age; appropriate interventions can often bring
older people back to (or above) some earlier level of
function. Second, the same interventions may be still
more effective with younger subjects, which sug-
gests an age-related reduction in reserve functional
capacity. These demonstrations of plasticity in old
age are encouraging in their own right and tell us
that positive change is possible.
Predictors of Physical Function
In the MacArthur studies, maintenance of high
physical performance, including hand, trunk, and
lower extremity movements and integrated move-
ments of balance and gait, was predicted by both
socio-demographic and health status characteristics.
Being older and having an income of less than
$10,000 a year increased the likelihood of a decline
in physical performance, as did higher body mass
index (greater fat), high blood pressure, and lower
initial cognitive performance. Behavioral predictors
of maintenance of physical function included mod-
erate and/or strenuous leisure activity and emo-
tional support from family and friends. Moderate
levels of exercise activity (e.g., walking leisurely) ap-
peared in these studies to convey similar advantages
to more strenuous exercise (e.g., brisk walking).
Continuing Engagement with Life
The third component of successful aging, engage-
ment with life, has two major elements: mainte-
nance of interpersonal relations and of productive
activities.
Social Relations
At least since Durkheims classic study of suicide
(Durkheim, 1951), isolation and lack of connected-
ness to others have been recognized as predictors
of morbidity and mortality. Five prospective studies
of substantial populations have now demonstrated
causality throughout the life course in such associa-
tions: being part of a social network is a significant
determinant of longevity, especially for men (see
Figure 4; House, Landis, & Umberson, 1988).
Research on the health protective aspect of net-
work membership has emphasized two kinds of
supportive transactions: socio-emotional (expres-
sions of affection, respect and the like) and instru-
mental (direct assistance, such as giving physical
help, doing chores, providing transportation, or giv-
ing money (Cassel, 1976; Cobb, 1976; House, Kahn,
McLeod, & Williams, 1985; Kahn, & Antonucci, 1981;
Kahn & Byosiere, 1992).
The three-community MacArthur study tested
both instrumental and emotional support as predic-
tors of neuroendocrine function and physical per-
formance. Neuroendocrine measures were also
studied as possible mediators of the effects of sup-
port. Over a three-year period, marital status (being
married), presumably a source of emotional sup-
port, protected against reduction in productive ac-
tivity (Glass, Seeman, Herzog, Kahn, & Berkman,
1995). Men with higher emotional support had sig-
Vol. 37, No. 4,1997 437
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nificantly lower urine excretion of norepinephrine,
epinephrine, and cortisol, and for both men and
women, emotional support was a positive predictor
of physical performance. Instrumental support, on
the other hand, had few significant neuroendocrine
relations for men, none for women, and was associ-
ated with lower physical performance, probably as
an effect rather than a cause (Seeman, Berkman,
Blazer, & Rowe, 1994; Seeman, Berkman, Charpen-
tier, Blazer, Albert, & Tinetti, 1995).
These varying effects of social support are consis-
tent with research relating the effect of support to
the specific situation in which it is offered. For ex-
ample, instrumental support rather than emotional
support influenced the promptness with which
older people who experienced cancer-suspicious
symptoms actually saw a physician (Antonucci,
Kahn, & Akiyama, 1989). Opposite results came from
a nursing home experiment, however: socio-emo-
tional support (verbal encouragement) had positive
performance effects, whereas instrumental support
(direct assistance) had negative effects on perfor-
mance (Avorn & Langer, 1982).
Several conclusions seem warranted regarding
the properties of social relations and their effects:
a. Isolation (lack of social ties), is a risk factor for
health.
b. Social support, both emotional and instrumen-
tal, can have positive health-relevant effects.
c. No single type of support is uniformly effective;
effectiveness depends on the appropriateness
of the supportive acts to the requirements of
the situation and the person.
Productive Activities
Older people are not considered old by their
families and friends, nor do they think of themselves
as old, so long as they remain active and produc-
tive in some meaningful sense (Kaufman, 1986). In
legislative policy, Congressional discussion as to
whether the nation can afford its older people is as
much a debate about their productivity as their re-
quirements for service, especially medical care.
Part of the confusion stems from lack of clarity
about what constitutes a productive activity. Our
national statistics define Gross Domestic Product
(GDP) in terms of activities that are paid for, and ex-
clude all unpaid activities, however valuable. Sev-
eral current studies (ACL, MacArthur, HRS) utilize a
broader definition that includes all activities, paid or
unpaid, that create goods or services of economic
value (Kahn, 1986), and these studies have gener-
ated age-related patterns very different from those
for paid employment alone (Herzog, Antonucci,
Jackson, Kahn, & Morgan, 1987; Herzog, Kahn, Mor-
gan, Jackson, & Antonucci, 1989).
The nationwide Americans Changing Lives (ACL)
study found that, contrary to the stereotype of un-
productive old age, most older people make pro-
ductive contributions of some kind, more as infor-
mal help-giving and unpaid volunteer work than
paid employment. When all forms of productive ac-
tivity are combined, the amount of work done by
older men and women is substantial. Among those
aged 60 or more, 39\% reported at least 1500 hours
of productive activity during the preceding year;
41\% reported 500-1499 hours, and 18\% reported
1-499 hours. The relationship between age and pro-
ductive activity depends on the activity. While
hours of paid work drop sharply after age 55, hours
of volunteer work in organizations peak in the mid-
dle years (ages 35-55), and informal help to friends
and relatives peaks still later (ages 55-64) and re-
mains significant to age 75 and beyond.
Both the ACL and MacArthur studies address the
question of what …
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*** In Task section I’ve chose (Economic issues in overseas contracting)"
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e a 1 to 2 slide Microsoft PowerPoint presentation on the different models of case management. Include speaker notes... .....Describe three different models of case management.
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Summary & Evaluation: Reference & 188. Academic Search Ultimate
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While you must form your answers to the questions below from our assigned reading material
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5 The family dynamic is awkward at first since the most outgoing and straight forward person in the family in Linda
Urien
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After viewing the you tube videos on prayer
Your paper must be at least two pages in length (not counting the title and reference pages)
The word assimilate is negative to me. I believe everyone should learn about a country that they are going to live in. It doesnt mean that they have to believe that everything in America is better than where they came from. It means that they care enough
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Single Subject Chris is a social worker in a geriatric case management program located in a midsize Northeastern town. She has an MSW and is part of a team of case managers that likes to continuously improve on its practice. The team is currently using an
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Compose a 1
Optics
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Be 4 pages in length
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