Optimal Aging, Part I: Demographics and Definitions

The first of a two-part article from the author on optimal aging. Part II will appear in the December issue of the journal.

In 1997, the oldest person to have ever lived died at age 122 years and 164 days.¹ Jeanne Louise Calment lived in France, took up fencing at age 85, and still rode a bicycle at 100. She was from a family of long-lived persons: her father died at age 93, her mother at 86, and her brother at age 97. She did quit smoking when she was 117, reportedly because she was nearly blind and felt embarrassed asking for a light. In 1965, when she was 90 and had no living heirs (she had outlived her daughter and grandson), she entered into a legal agreement to sell her condominium apartment to lawyer Francois Raffray, who was then age 47. He agreed to pay a monthly sum, similar to a “reverse mortgage,” until she died, so that he would obtain the apartment. Unfortunately for him, she survived him, and his widow had to continue the payments. In many ways, one can view the life of Jeanne Calment as an example of “optimal aging.”

The concept of healthy aging is attractive for many reasons. Virtually all people hold the vision of an active and independent older person in high esteem. With the growing number of baby boomers nearing age 65, a surge in publications and marketing strategies are capitalizing on healthy aging. GeezerJock magazine² caters to master athletes. Exercise clubs are forming specifically for people over age 50. Health maintenance organizations advertise to the Medicare population using pictures of active older adults, in part to increase the number of enrollees with lower risk. Retirement communities market their facilities with emphasis on wellness programs, access to alternative medicine, and state-of-the art exercise facilities. Healthy aging is big business.

We are witnessing a remarkable transformation. Only 40 years ago, the baby boomers listened to songs talking of there being no useful life after age 30. Aging was seen in uniformly negative terms, a time for disengagement, and becoming “senile” was an expected part of a long life. Major psychological theories saw the primary developmental task of old age as readying oneself for decline and death.³ As the baby boomers have aged, the notion of inevitable decline, helplessness, and dependency is being discarded.

What is Healthy Aging?

But what exactly is healthy aging, and how should it be defined? Many terms have been suggested. Perhaps the most common has been successful aging, as suggested by Rowe and Kahn.⁴ Others include aging well, effective aging,⁵ robust aging, positive aging, elite aging, and even anti-aging. Using Rowe’s definition, successful aging contains three essential components: absence of disease and disability; high cognitive and physical functioning; and active engagement with life. Usual aging, on the other hand, describes the common mode of aging in which there are significant physiological losses along with substantial loss of reserve capacity. Some have felt uncomfortable with these definitions. Many persons over age 65 have a chronic disease; the majority of those over 85 have one or more chronic diseases and have functional deficits. Are we to label the vast majority of those over age 85 “unsuccessful?” The opposite of success is failure. Is frailty (however one may define it) the ultimate failure? Furthermore, the world loves the story of those who have overcome cancer or serious heart conditions to return to meaningful life activities. Are not such persons successful? Finally, most such definitions are locked into a world-view that is primarily biomedical, focusing on health or disease. Is it not likely that a psychosocial orientation that emphasizes one’s connection to others, contributions to humankind, or creative work, regardless of health status, a true measure of success?

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Table I: Definitions Optimal Aging:
The capacity to function across many domains—physical, functional, cognitive, emotional, social, and spiritual – to one’s satisfaction and in spite of one’s medical conditions

Successful Aging:
Absence of disease and disability; high cognitive and physical functioning; and active engagement with life
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There is also evidence that older people themselves view success differently than others, especially healthcare providers. Studies have queried elderly persons as to their views on successful aging. In these studies, elderly people agree with about 30-60% of the attributes that have been used to define successful aging.^6-8 While almost all elderly persons ascribed to such items as “remaining in good health” and “being able to take care of myself,” far fewer saw “living a very long time” or “being able to work” as important. In another study, most community-dwelling older adults viewed themselves as aging successfully despite having chronic physical illnesses and some disability.⁹ Strawbridge¹⁰ found in the Alameda County Study that 50% of aged participants rated themselves as aging successfully, but only 19% met Rowe and Kahn’s criteria. Finally, in a remarkable speech by Dr. Ben Eiseman, an 87-year-old graduate at the 65th reunion of the Yale Class of 1939, he reported the results of his survey of the surviving classmates. Using a self-rating of quality of life, the average response was 7.6 out of a possible 10 (10 being “ideal quality”), in spite of the presence of numerous infirmities and losses.¹¹ It is clear from studies that involve older persons in the creation of a definition of successful aging that a broader and more fluid perspective is needed.

The Root of Optimal Aging

“Optimal aging,” first suggested by Baltes and Baltes¹² and expanded by Walsh,¹³ is a useful construct to deal with this need. It implies that no matter what state of health the person is in, one may still seek to optimize one’s capabilities or satisfaction with life. It takes off from the concept of compression of morbidity, promulgated by Fries,¹⁴ whereby illness is forestalled into the last final years of one’s life, but not necessarily avoided. Optimal aging goes beyond good health and longevity. It deals with capacity to function across many domains—physical, functional, cognitive, emotional, social, and spiritual. This capacity is rooted in the concept of adaptation. The many changes of life itself, and the frequently accompanying vicissitudes of illness, functional loss, changes in the family, economic struggles, and other stressors, offer opportunities to adjust and adapt. Optimal aging accounts for the tremendous interindividual variability and intraindividual plasticity.

The adaptation that older adults make to the many challenges of aging involves selection, optimization, and compensation.¹² A person may select certain activities that are most satisfying and meaningful. Behaviors can be modified to optimize performance in these activities. When capacity is lost or reduced, an older person can compensate by choosing different methods of accomplishing the task, or altogether different activities. Arthur Rubinstein (1887-1982), the noted pianist, played into his 90s. Over the years he adapted by: (1) reducing the number of pieces that he played (selection); (2) putting in more hours of practice (optimization); and (3) decreasing the speed of his playing prior to a fast movement, thereby creating the impression of speed when he entered the faster movement (compensation).¹² Clinical studies of elderly persons have validated this viewpoint.¹⁵

Optimal aging should be seen from a biopsychosocial viewpoint. It doesn’t require the absence of disease or disability. In fact, these problems can be viewed as opportunities for growth and development of new capabilities. It utilizes a systems perspective, where lower levels of the system affect higher, and vise versa. A particularly useful model for explaining the interrelationships of various aspects of the biopsychosocial approach to optimal aging is the health field model (also called the determinants of health model).¹⁶ In this model, all aspects of the disease-health continuum are addressed, including the patient’s genetic endowment and behavior, the social environment and support system, the psychological resources and stressors, the physical environment, and the healthcare system. Clinicians, including many geriatric providers, tend to focus on one small (if expensive) component of the model, namely disease and its management.

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Table II: Determinants of Health

• Function
• Disease
• Social environment and support system
• Physical environment
• Genetic endowment
• Individual responses – behavior and biology
• Healthcare system
• Well-being
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Yet it is abundantly clear that the management of many, if not all, health problems in older persons is significantly affected by a host of other factors. The patient’s social support system is a critical factor in rehabilitation outcomes. The physical environment may determine whether the patient who uses a wheelchair can remain at home or need a ground floor apartment. The contributions of genetic endowment are only beginning to be understood. In addition, each of the components interacts with the others in different ways at different times in one’s life. The complexity of this dynamic process is great, but it is likely that the interaction of the various components is at the root of optimal aging.

Conclusions

“Optimal aging” is a more useful, and realistic, concept than “successful aging” for describing the desired experience of growing old and coping with the common changes of life. While most people may not want to live as long as Jeanne Louise Calment, almost all older people are interested in a life that is meaningful, fulfilling, and relatively independent. As the population of older persons increases, more will be interested in knowing what kinds of activities will increase the likelihood of optimal aging. Part II of this article will take a systems approach to discussing interventions to promote optimal aging.

The author reports no relevant financial relationships.