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:
– 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)
The demographic facts + the
epidemiologic transition =
Challenges for public health
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. . .

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 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
Focus on Old People
Rowe & Kahn (1998) MacArthur Study
70-79 (M = 74)
Strawbridge et al. (2002)
65-99 (M = 75)
Phelan et al. (2004)
65+ (M = 80)
Bowling & Iliffe (2006)
65+
34% 65-70
28% 70-75
21% 75-80
17% 80+
Montross et al. (2006)
60+ (M = 80.4)
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?
Should we be studying only old people?
 Beyond survivor effects
 Where to begin?

Mean age of onset
Arthritis
55 years
Diabetes
51.1 years
Emphysema/Chronic
bronchitis
60 years
Heart disease
65.4 years
Cancer: Mean Age of Onset
Breast
61 years
Colon
71 years
Esophagus
68 years
Prostate
68 years
Skin
60 years
Lung
71 years
Defining ‘Success’

Dictionary:
– “having a favorable outcome”
– “obtaining something desired or intended”

Thesaurus:
–
–
–
–
“accomplished”
“flourishing”
“prosperous”
“thriving”
Can people age
successfully if they have a
chronic condition?
Rowe & Kahn (1987)’s definition:
– Few or no age-related declines
– Implies that it is possible to reach
advanced age relatively free of ageassociated disease and functionally intact
– Paradigm shift, but number of persons
experiencing successful aging is small
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 life

New criteria set the bar even higher!
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
Focus is on minority
 Based on medical model
 Younger age is best predictor of
success

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

Measureable domains of functioning:
– Objective
– Subjective
Broad societal consensus regarding
desirability
 Variability within population

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 Aging?
Criteria
 Measureable domains of
functioning
 Broad societal
consensus regarding
desirability
 Variability

Cognitive ability

Social engagement

Psychological resources
– Lacks variability
– 13% include
– Inconsistent findings
– 10.6% include
– Inconsistent constructs
*Bowling, 2007
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?

Sample
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?

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


CATI
1+ List-Assisted Random Digit Dial (RDD)

Geographically proportional to the population
of the State of New Jersey
– Provided by Marketing Systems Group
– 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%

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

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

If screening determines there to be 2+
age-eligible household members, all of
these members are rostered with one
chosen via computerized genderweighted 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
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

Response Rates (AAPOR)
Response Rate Cooperation
(RR5)
Rate (Coop3)
ORANJ BOWL 58.7%
72.9%
2006 BRFSS
(National)
51.4%
74.5%
2006 BRFSS
(New Jersey)
46.5%
63.0%
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 = 5,688)
Mean years of education: 14.5 (s.d. =
2.7)
 Race:

– 83.8% White
– 11.8% African American
– 1.6% Asian

2.8% Hispanic
Measures of
Successful Aging
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

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

“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

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)
Measurement Model
Successful Aging
Neither objective nor
subjective
Subjective only
Objective only
Both objective and
subjective
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
To what extent do early influences set
the stage for successful aging?
 What role do current behaviors have?

Independent Variables
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
Current Health
Behaviors
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)

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

‘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
0=no; 1=yes
 15.8% current smokers

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

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

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)
Results
Multinomial Logistic Regression

Reference group:
– Successful according to both criteria
Early influences
 Early influences + current behaviors and
relationships

How important are early
influences?
Neither
Objective Only
Subjective
Only
Age
n.s.
younger
older
Gender
women
n.s.
women
Education
less
less
less
Never married
more
more
more
African
American
n.s.
n.s.
more
Prison
more
more
more
Childless
n.s.
n.s.
n.s.
Early Influences,
Current Behaviors
Early Influences, Current
Behavior
Early
Influences
Cox & Snell
.10
Early
Influences &
Current
Behavior
.32
Nagelkerke
.13
.39
Pearson Chisquare
4,502, df =
4,215 p = .001
16,721, df =
16,569, p = .20
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
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
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
The Objective Only vs.
the Subjective Only
Logistic Regression Results:
No differences
 Education
 Never Married
 African American
 Prison
 Childless
 Currently married
 Volunteer work
 Alcohol consumption
 Current smoker
Logistic Regression Results
Differences

Subjective Only:
–
–
–
–
–
–
–
Older
More women
Less likely to be working
Higher BMI
Less exercise
Better social relationships
More religious
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
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 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
Diet
 Exercise
 Smoking
 Drinking

Social Factors
Marriage
 Family
 Friends
 Religiosity
 Work
 Volunteering

Neighborhood Effects
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

Wealth:
– % College Degree
– % Professionals
– # people with incomes > $150,000
Neighborhood
Social Vulnerability
– % Female headed HH
– % HH on Public Assistance
– % Unemployed males
 Crime:
Neighborhood
– # Robberies
– # Rapes
– # Aggravated Assaults
Neighborhood
 Residential
stability
– Year HH moved in
– % 5+ years in same HH
 Density
Neighborhood
– # Bars/pubs
– # Grocery stores
– # Local convenience stores
Neighborhood
 Availability
of Physicians
– # Primary care doctors
– # Specialists
Neighborhood

Built environment:
– Connectivity
(alpha, gamma,
#streets per square mile)
– Air Pollution
(particulate matter, ozone)
Next Steps

Connecting neighborhood
characteristics and health
Successful Aging:
The Public Policy
Imperative