What is successful ageing and who should define it? Bowling A & Dieppe P.

1. What is successful ageing and who should define it?Bowling A & Dieppe P. BMJ2005;331:1548–51 Prof Y Barak, MD, MHA

2. Decline and fall? Goya’s Les Vieilles “Time of the Old Women” Prof Y Barak, MD, MHA

3. The Controversy • 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? Prof Y Barak, MD, MHA

4. Method • Included in analysis were 170 papers presenting reviews or overviews of the topic, data from cross sectional and longitudinal surveys, and qualitative studies. • Also included were lay definitions elicited from our own recent survey of successful ageing. Prof Y Barak, MD, MHA

5. Lay views There are a few investigations into older people’s views of what is successful ageing. Prof Y Barak, MD, MHA

6. UK Survey • A national, random population survey of perceptions of successful ageing among 854 people aged 50 or more, living at home in Britain. • Part of an Office for National Statistics omnibus survey. • Of these people, 75% (631) rated themselves as ageing successfully “Very well” or “Well” Prof Y Barak, MD, MHA

7. Lay Definitions • The most commonly mentioned definition of successful ageing, in response to open ended questioning, was having good health and functioning. • These were rarely mentioned in isolation, and most people mentioned more than one definition Prof Y Barak, MD, MHA

8. Additional lay definitions • Accomplishments • Enjoyment of diet • Financial security • Neighbourhood • Physical appearance • Productivity and contribution to life • Sense of humour • Sense of purpose • Spirituality Prof Y Barak, MD, MHA

9. Policy implications:lay opinions • With greater recognition that older people are not a homogeneous group, health professionals need more balanced, interdisciplinary perspectives of older age. • Clinicians need to be aware of their patients’ values and expectations of ageing in order to enhance mutual understanding of their health goals and priorities, and to consider interventions that will optimize their chances of “ageing successfully” in their terms. Prof Y Barak, MD, MHA

10. Successful Aging Vaillant & Mukamal, Am J Psychiatry, June 2001. Prof Y Barak, MD, MHA

11. Epidemiology • In 1990 there were 4 million Americans age 85 and older • In 2040 there will be X10 that many • The increase is mainly due to more people living to age 65 Prof Y Barak, MD, MHA

12. Conceptualizing Aging • Aging can be seen from 3 dimensions • Decline • Change • Development Prof Y Barak, MD, MHA

13. Decline • By age 70 we identify only 50% of the smells • Night vision declines…by age 80 few can drive at night • By age 90 50% can not use public transportation Prof Y Barak, MD, MHA

14. Change • Hair, waistline, skin…change • Making love shifts from 3/week to 2/month • Our ability to love and be loved does not diminish • Our capacity for joy is undiminished Prof Y Barak, MD, MHA

15. Development • At 70 we are more • Patient • Accepting of affect in ourselves • Likely to tolerate paradox Prof Y Barak, MD, MHA

16. The Berlin Aging StudyBaltes & Mayer, 1999.The MacArthur Study of AgingRowe & Kahn, 1999. • The 2 most important predictors of successful aging were: • High level of education • Extended family network “Our greater longevity is resulting in LESS, not more, years of disability.” Prof Y Barak, MD, MHA

17. A Prospective Study of Successful Aging:The Study of Adult DevelopmentVaillant & Mukamal, 2001 • Until now we have NOT known how to predict successful aging • All large-scale prospective studies were flowed by “selective mortality” : by beginning in late life these studies failed to include those who died before age 60 or 70 • The Study of Adult Development (SAD) provides a way around some of these difficulties Prof Y Barak, MD, MHA

18. The Study of Adult DevelopmentBackground • The SAD was initiated in Harvard • Two socially diverse cohorts of adolescents (college vs. core-city) were followed until they became great-grandfathers • Birth cohort was limited to the period 1918-1932 • Gender (male), Nationality (USA) and Skin Color (white) were held constant Prof Y Barak, MD, MHA

19. The Study of Adult DevelopmentDefinitions & Domains • Six domains of function were chosen to classify old-age along a continuum from ”happy-well” to “sad-sick” • Individuals who did well in all 6 areas until age 80 were classified as “happy-well” • Those who were both psycho-socially unhappy and physically disabled were “sad-sick” • Those who fell in between were classified as intermediate Prof Y Barak, MD, MHA

20. Physician assessed objective physical health and absence of irreversible physical disability Subjective physical health (instrumental tasks of daily living) Length of active life (No. of years before age 80 without objective/subjective physical disability) Objective mental health (evidence of competence in 4 domains: work, relationship, play and NO psychiatric care/medication) Subjective life satisfaction Social support (objective evidence of friends) The Study of Adult DevelopmentOutcome Domains Prof Y Barak, MD, MHA

21. The Study of Adult DevelopmentSubjects • College cohort: • 268 subjects • Harvard sophomores • Selected for physical and mental health • Core-city cohort: • 456 subjects • Nondelinquent • Mean IQ 95 • Mean education 10 years Prof Y Barak, MD, MHA

22. Smoking (pack years) Alcohol abuse/dependence (DSM-III) BMI (at age 50) Years of education (core-city only) Regular exercise (500 kCal/week) Stable marriage Maturity of defenses (at age 47; DSM-IV Defensive Functioning Scale) Depression (before age 50) Parental social class Warmth of childhood Ancestral longevity (mean mother’s and father’s age at death) Stable childhood temperament (parental report) Objective disability (at age 50) The Study of Adult DevelopmentIndependent Predictor Variables Prof Y Barak, MD, MHA

23. College (237) Happy-well=26%(62){>80} Intermediate=32%(75){77.6} Sad-sick=17%(40){71.4} Prematurely dead=25%(60){62.3} Note: ( )=N, { }=age at death/disability Core-city (332) Happy-well=29%(95){>70} Intermediate=34%(114){65.6} Sad-sick=14%(48){62.3} Prematurely dead=23%(75){55.0} Note: ( )=N, { }=age at death/disability The Study of Adult DevelopmentResults (1)Quality of Aging Prof Y Barak, MD, MHA

24. The Study of Adult DevelopmentResults (2)Rates of permanent Disability or Death after age 50 • Disability and death for the 2 groups increased over time • The slopes in the graph are similar • College-men reached every stage 10 years LATER than the core-city cohort Prof Y Barak, MD, MHA

25. The Study of Adult DevelopmentResults (3)Correlation of Predictor variables (before age 50) with 5 aging Outcomes • Controllable variables: • Smoking • Alcohol • Exercise • BMI • Stable marriage • Maturity of defenses • Uncontrollable variables: • Depression • Parental social class • Warmth of childhood • Ancestral longevity • Childhood temperament • Objective disability at age 50 Prof Y Barak, MD, MHA

26. The Study of Adult DevelopmentResults (4)Correlation of Predictor variables (before age 50) with 5 aging Outcomes For both college and core-city men absence of alcohol and cigarette abuse (less than 30 pack-years) before age 50 were the most IMPORTANT protective factors for successful aging Prof Y Barak, MD, MHA

27. The Study of Adult DevelopmentResults (5)Correlation of Predictor variables (before age 50) with 5 aging Outcomes • Exercise and education are indirect measures of self-care and perseverance • Both appeared to be important predictors of multiple domains of successful aging • Preseverance (tested by the 5 mts treadmill test) at age 19 predicts 61% happy-well vs. 13% of the sad-sick (NOT explained by physical fitness) p=0.005 Prof Y Barak, MD, MHA

28. The Study of Adult DevelopmentResults (6)Multivariate model • Each of the 6 factors over which an individual has some control predicted successful aging when other factors were statistically controlled • The importance of alcohol abuse (core-city) and smoking (college) were masked by colinearity • Uncontrollable factors • NOT significant: • Parental social class • Unhappy childhood • Ancestral longevity • Significant: • Depressive disorder before 50 Prof Y Barak, MD, MHA

29. The Study of Adult DevelopmentMESSAGE • The 7 protective factors that distinguish happy-well from sad-sick are under some personal control • We have considerable control over our weight, exercise, education, smoking & alcohol abuse • Hard work/therapy can modify our coping styles & relationship with spouse. Prof Y Barak, MD, MHA

30. The Future Successful old-age may lie not so much in our stars and genes as in ourselves Prof Y Barak, MD, MHA

31. Joseph S. Alpert, MD “12 Guides to Health, Happiness, and Longevity” The American Journal of Medicine, Vol 121, No 7, July 2008 Prof Y Barak, MD, MHA

32. Guide #1: Try to be born into a family with a history of longevity. There is no replacement for good genes. This is the single factor that one cannot influence with a change in lifestyle or attitude. Prof Y Barak, MD, MHA

33. Guide #2: Never smoke! If you are unlucky enough to be a current smoker, quit the moment you finish hearing this lecture. Prof Y Barak, MD, MHA

34. Guide #6: Don’t get fat. It is okay to be a few kilograms (and only a few) over your ideal weight. If you are 5 kilograms or more over your ideal body weight, start a program of dieting and exercise. Consult Prof Y Barak, MD, MHA

35. Guide #9: Cultivate family and friends. Enjoy conversation, dining, and recreation with people whom you like (for example, your spouse). Spend as little time as possible with folks you don’t like or who make you uncomfortable. Prof Y Barak, MD, MHA

36. Guide #11: Be informed, but try not to be overwhelmed by current events as portrayed by the popular media. Prof Y Barak, MD, MHA

37. Thank you for your attention !!! Prof Y Barak, MD, MHA