Successful Aging: The Public Policy Imperative

1. Successful Aging: The Public Policy Imperative Rachel Pruchno, Ph.D. UMDNJ-SOM

2. Why is Successful Aging Important? • The demographic facts: • The number of people age 65+ will grow from 35 million in 2000 to 71 million in 2030. • The epidemiologic transition: • From acute illness and infectious disease to chronic disease and degenerative illnesses • In 2001 the leading causes of death were cardiovascular diseases and cancer, followed by respiratory diseases. (JAMA, 2003)

3. The demographic facts + the epidemiologic transition = Challenges for public health

4. Public Health Challenges • Increased health care costs • Medicare • From 2.7% of GDP to 8% by 2030 (Schulz & Binstock, 2006) • Broader health care system • Uncovered pharmaceuticals • Costly new medical treatments and diagnostic tests • Expenditures to reach 19% of GDP by 2030 (Schulz & Binstock, 2006) • Personal resources • Family resources

5. Successful Aging. . . • If we can figure out how to get the Baby Boomers to arrive at old age in better shape: • Society’s health care costs will be reduced • Life-long personal resources will be saved • Families will be less burdened

6. Successful Aging • Little agreement re: • Definitions • Measurement • Predictors • Is it objective or subjective? • The role of age (Depp & Jeste, 2006) • The most consistent predictor of successful aging was younger age • 87% of empirical studies find a significant relationship between age and successful aging

7. Focus on Old People

8. A Developmental Perspective • No one is born old • Life as part of a continuous and dynamic stream with a beginning and an end • Lifespan as context for success Schulz & Heckhausen (1996)

9. Whom to Study? • Should we be studying only old people? • Beyond survivor effects • Where to begin?

10. Mean age of onset

11. Cancer: Mean Age of Onset

12. Defining ‘Success’ • Dictionary: • “having a favorable outcome” • “obtaining something desired or intended” • Thesaurus: • “accomplished” • “flourishing” • “prosperous” • “thriving”

13. Can people age successfully if they have a chronic condition?

14. Rowe & Kahn (1987)’s definition: • Few or no age-related declines • Implies that it is possible to reach advanced age relatively free of age-associated disease and functionally intact • Paradigm shift, but number of persons experiencing successful aging is small

15. Rowe & Kahn (1998) • Ability to maintain low risk of disease and disease-related disability • High levels of mental and physical health and • Active engagement with lifeNew criteria set the bar even higher!

16. Normal aging vs. optimal aging, but • 46% of the general population • 88% of people 65+ Have at least one chronic disorder (Bodenheimer, Wagner, & Grumbach, 2002)

17. Problems with Rowe & Kahn • Focus is on minority • Based on medical model • Younger age is best predictor of success

18. Other definitions • Schmidt (1994). “Minimal interruption of usual function” • Baltes & Carstensen (1996). “Doing the best with what one has” • Shifts the focus from minority to majority • Major differentiator: extent to which a person can have a chronic disease or functional disability and still be considered to be aging successfully

19. Conceptual Dimensions of Success • Measureable domains of functioning: • Objective • Subjective • Broad societal consensus regarding desirability • Variability within population

20. Defining Successful Aging in Younger People • Objective criteria: • Avoiding chronic conditions • Maintaining functional abilities • Experiencing minimal pain • Subjective evaluation: • Aging well • Aging successfully • Positive life rating

21. Criteria Measureable domains of functioning Broad societal consensus regarding desirability Variability Cognitive ability Lacks variability Social engagement 13% include Inconsistent findings Psychological resources 10.6% include Inconsistent constructs *Bowling, 2007 Successful Aging?

22. Empirical Evidence • Testing the 2-factor model of successful aging • Are there people who are successful according to one, but not the other definition? • To what extent do early influences set the stage for successful aging? • What role do current behaviors have?

23. Sample

24. ORANJ BOWL • Ongoing Research on Aging in New Jersey: Bettering Opportunities for Wellness in Life • Eligibility criteria: • Age 50-74 • New Jersey • Able to participate in a 1-hour English language phone interview

25. Why New Jersey? • NJ’s demographics largely mirror those of U.S. as a whole • Among the 50 states, NJ has 2nd largest proportion of people age 50+ • Among the 50 states, NJ has 3rd fastest growth rate among its age 50+ population • With 2nd highest cancer rate among 50 states, NJ is an efficient source of subjects for aging & debilitating disease studies • Trend toward ever-increasing urbanization, NJ is a glimpse of the future (NJ is only state with no designated rural county.) • NJ among the most ethnically & racially diverse states in USA

26. Sampling Strategies • CATI • 1+ List-Assisted Random Digit Dial (RDD) • Provided by Marketing Systems Group • Geographically proportional to the population of the State of New Jersey • No over-sampling for any subgroup • Coverage: • 4% of households of persons 50-74 in NJ are cell phone only • Conservative overall coverage estimate is 91%

27. Each region includes a somewhat equal proportion (16% to 26%) of New Jersey’s population. Sample is released into the CATI system by region. Data collection efforts focus on a single region for 2 to 3 months at a time.

28. Screening & Eligibility • 2000 U.S. Census reveals that 1,876,194 New Jersey residents were age 50 to 74, suggesting that 22.3% of NJ’s population is age-eligible to participate • Interviews are conducted in English only and with the research subject directly. Proxies for those physically or mentally incapable of participation are not allowed.

29. Within Household Selection • If screening determines there to be 2+ age-eligible household members, all of these members are rostered with one chosen via computerized gender-weighted random algorithm • No substitutions permitted (e.g., when one member refuses or is incapable and another is willing to participate, no household member may be invited to participate)

30. The Numbers • 151,246 land-line phone numbers in the population • 32,678 complete screen (21.6%) • 9,685 eligible (20.6%) • 5,688 complete interviews (58.7%) • 1,060,838 calls made • 7.01 average calls made to complete each case

31. Response Rates (AAPOR)

32. ORANJ BOWL Participants(N = 5,688) • Age 50-74 (mean = 60.7 years; s.d. = 7.1) • 63.7% women; 36.3% men • Current marital status: • 56.7% married • 14.2% widowed • 17.3% divorced • 9.2% never married

33. ORANJ BOWL Participants(N = 5,688) • Mean years of education: 14.5 (s.d. = 2.7) • Race: • 83.8% White • 11.8% African American • 1.6% Asian • 2.8% Hispanic

34. Measures of Successful Aging

35. Objective Success: Avoiding Chronic Conditions • Self-rated: • Arthritis (40.2%) • Hypertension (46.5%) • Heart conditions (16.1%) • Cancer (14.7%) • Diabetes (15.7%) • Osteoporosis (20.2%) • Stroke (3.9%) • Lung conditions (18.6%)

36. Objective Success: Maintaining Functional Abilities • How difficult is it for you to: • Walk ¼ mile (26.7%) • Walk up 10 steps without resting (21.3%) • Stand for 2 hours (40.9%) • Stoop and get up (50.7%)(% any difficulty)

37. Objective Success: Minimal Pain • “How often are you troubled with pain?” (mean = 1.04; s.d = 1.04) • “How bad is the pain most of the time?” (mean = 1.00; s.d. = .94) • “How often does the pain make it difficult for you to do your usual activities?” (mean = .55; s.d. = .88) 4-point Likert scales (0 = low; 3 = high)

38. Subjective Success • Rating from 0-10 • Where ‘0’ means not aging successfully at all and ’10’ means completely successful. (mean = 7.8; s.d. = 1.8) • Where ‘0’ means not well at all and ’10’ means extremely well to describe how well you are aging (mean = 7.8; s.d. = 1.8) • Where ‘0’ means the worst possible life and ’10’ means the best possible life, rate your life these days. (mean = 7.8; s.d. = 1.6)

39. Measurement Model

42. Successful Aging

43. 4 Groups • Latent profile analysis: • Neither objectively nor subjectively successful (N = 445; 8.3%) • Objective Success only (N = 472; 8.5%) • Subjective Success only (N = 549; 10.0%) • Both objectively and subjectively successful (N = 4,050; 73.1%)

44. Questions • To what extent do early influences set the stage for successful aging? • What role do current behaviors have?

45. Independent Variables

46. Early Influences • Gender (1=male; 2 = female) • Education (years) • Never married (0=ever married; 1 = never) • Race (0 = White; 1 = African American) • Prison (0 = no; 1 = yes); 3.5% • Childless (0=no; 1 = yes); 17.8% *All analyses control for age

47. Current Health Behaviors

48. BMI • Mean = 28.4; SD = 6.2 • BMI categories: • Underweight (BMI <18.5) = 1.1% • Normal (BMI >=18.5 – BMI < 25) = 29.7% • Overweight (BMI >=25- BMI < 30) = 36.6% • Obese (BMI>=30 = 32.6%)

49. Exercise (hours/week) • Over the past 30 days how much time did you do any: • Vigorous • Moderate • Walking • Mean = 4.5 hours (SD = 5.2) • 11.7% no exercise • 10% 12 hours or more

50. Alcohol Consumption • ‘In a typical week, on how many days do you have at least one drink of alcohol?’ • None (54.4%) • 1 day (15.1%) • 2-3 days (12.9%) • 4-5 days (7.0%) • 6-7 days (10.6%)