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

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why is successful aging important
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)
public health challenges
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
successful aging
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
successful aging6
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
a developmental perspective
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)

whom to study
Whom to Study?
  • Should we be studying only old people?
  • Beyond survivor effects
  • Where to begin?
defining success
Defining ‘Success’
  • Dictionary:
    • “having a favorable outcome”
    • “obtaining something desired or intended”
  • Thesaurus:
    • “accomplished”
    • “flourishing”
    • “prosperous”
    • “thriving”
rowe kahn 1987 s definition
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
rowe kahn 1998
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!
normal aging vs optimal aging but
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)
problems with rowe kahn
Problems with Rowe & Kahn
  • Focus is on minority
  • Based on medical model
  • Younger age is best predictor of success
other definitions
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
conceptual dimensions of success
Conceptual Dimensions of Success
  • Measureable domains of functioning:
    • Objective
    • Subjective
  • Broad societal consensus regarding desirability
  • Variability within population
defining successful aging in younger people
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
successful aging21
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?
empirical evidence
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?
oranj bowl
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
why new jersey
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
sampling strategies
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%
slide27
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.

screening eligibility
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.
within household selection
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)
the numbers
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
oranj bowl participants n 5 688
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
oranj bowl participants n 5 68833
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
objective success avoiding chronic conditions
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%)
objective success maintaining functional abilities
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)
objective success minimal pain
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)

subjective success
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)

4 groups
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%)
questions
Questions
  • To what extent do early influences set the stage for successful aging?
  • What role do current behaviors have?
early influences
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

slide48
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%)
exercise hours week
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
alcohol consumption
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%)
smoke cigarettes
Smoke Cigarettes
  • 0=no; 1=yes
  • 15.8% current smokers
current social relationships
Current Social Relationships
  • Married (0 = not married; 1 = married)
  • Work status (0 = not working; 1 = working = 56.1%)
  • Volunteer status (0 = not volunteering;

1 = volunteering = 42.8%)

social connections
Social Connections
  • 5-point Likert scale (1=low; 5=high)
    • Someone listens to you
    • Someone gives you good advice about a problem
    • Someone shows you love and affection
    • Someone you can count on to provide you with emotional support
religiosity
Religiosity
  • Likert Scales
    • To what extent do you consider yourself a spiritual person?
    • How often do you attend religious services?
    • How often do you read the Bible or other religious literature?
    • How often do you watch or listen to religious programs on TV or radio?
    • How often do you pray privately?
    • To what extent do you consider yourself a religious person? *(Higher score is more religious)
multinomial logistic regression
Multinomial Logistic Regression
  • Reference group:
    • Successful according to both criteria
  • Early influences
  • Early influences + current behaviors and relationships
unsuccessful are
Early Influences:

Younger (+)

More likely to be women

Less likely to be African American (+)

Less educated

More likely to have been in prison

More years of cigarette use

*Never married no longer sig.

Current:

Less likely to be currently married

Less likely to be working

Less likely to be volunteering

More likely to smoke

Less likely to drink

Higher BMI

Less time exercising

Poorer social relationships

Unsuccessful are:
subjective only are
Early Influences:

Older

More likely to be women

Less educated

More likely to have been in prison

*Never married, African American, no longer significant

Current:

Less likely to be currently married

Less likely to be working

Less likely to be volunteering

Less likely to drink

Higher BMI

Less time exercising

Poorer social relationships

More religious

Subjective Only are:
objective only are
Early Influences:

Younger

Less educated

More likely to have never married

More likely to have been in prison

Current:

Less likely to be currently married

Less likely to be working

Less likely to be volunteering

Less likely to drink

Higher BMI

Less time exercising

Poorer social relationships

Objective only are:
logistic regression results no differences
Logistic Regression Results:No differences
  • Education
  • Never Married
  • African American
  • Prison
  • Childless
  • Currently married
  • Volunteer work
  • Alcohol consumption
  • Current smoker
logistic regression results differences
Logistic Regression ResultsDifferences
  • Subjective Only:
    • Older
    • More women
    • Less likely to be working
    • Higher BMI
    • Less exercise
    • Better social relationships
    • More religious
conclusions
Conclusions
  • Life-span approach enhances perspective on successful aging
  • Objective components of successful aging can be distinguished from subjective ones
  • Objective and subjective success have different predictors
caveats
Caveats
  • Younger sample
  • Components of objective success are specific to this age group
  • Reliance on self-report data
  • Cross-sectional design
successful aging the public policy imperative68
Successful Aging: The Public Policy Imperative
  • Little of aging experience is genetic
    • Less than 1/4 of the biological process of aging is attributed to genetics (Gurland et al., 2004)
    • The potency of genes that affect aging declines even further after age 65 (Finch & Tanzy, 1997).
lifestyle choices
Lifestyle Choices
  • Diet
  • Exercise
  • Smoking
  • Drinking
social factors
Social Factors
  • Marriage
  • Family
  • Friends
  • Religiosity
  • Work
  • Volunteering
neighborhood data
Neighborhood Data
  • U.S. Census (2000)
  • New Jersey Uniform Crime Report
  • New Jersey Department of Agriculture’s Division of Marketing and Development (milk)
  • New Jersey’s Department of Law and Public Safety’s Division of Alcohol Beverage Control
neighborhood
Neighborhood
  • Wealth:
    • % College Degree
    • % Professionals
    • # people with incomes > $150,000
neighborhood74
Neighborhood

Social Vulnerability

  • % Female headed HH
  • % HH on Public Assistance
  • % Unemployed males
neighborhood75
Neighborhood
  • Crime:
    • # Robberies
    • # Rapes
    • # Aggravated Assaults
neighborhood76
Neighborhood
  • Residential stability
    • Year HH moved in
    • % 5+ years in same HH
neighborhood77
Neighborhood
  • Density
    • # Bars/pubs
    • # Grocery stores
    • # Local convenience stores
neighborhood78
Neighborhood
  • Availability of Physicians
    • # Primary care doctors
    • # Specialists
neighborhood79
Neighborhood
  • Built environment:
    • Connectivity (alpha, gamma,

#streets per square mile)

    • Air Pollution (particulate matter, ozone)
next steps
Next Steps
  • Connecting neighborhood characteristics and health