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 Book Review Successful Aging and Adaptation New York, Springer Publishing Company, 2003 In important concept papers published in Science1 and the Gerontologist2 in 1987 and 1997 respectively, Rowe and Kahn argued that the idea of successful aging separates the effects of disease from the aging process itself. In their book entitled Successful Aging: The MacArthur Foundation Study,3 these authors define successful aging as follows: avoiding disease and disability, maintaining physical and mental functioning, and being actively engaged with life. The Poon et al. book combines the concept of successful aging with the concept of adaptation to chronic disease. This is consistent with commentaries that have followed the Rowe and Kahn1 work, such as Riley et al's4 ideas on the importance of "social structural opportunities necessary for realizing success" and Baltes and Baltes5 model of selection-optimization-compensation, which relates to doing the best with what you have. Baltes and Baltes give the example of the pianist Arthur Rubinstein. He explained his ability to continue concert performances in old age by limiting his repertoire (selection), practising much more than he had been used to practising (optimization), and giving the impression of great speed when it was called for by deliberately reducing the tempo of preceding passages (compensation). In the Poon et al. book, some of the chapters contain investigators' reports from five studies, and other chapters provide commentaries on these study reports. The first two chapters discuss the results of surveys in which people were asked about their successful aging, and take into account chronic health conditions. Chapter 1 is based on a 1999 follow-up survey of people 65 to 99 years of age who are part of the Alameda County Study, a longitudinal study of determinants of health and functioning that began in 1965. This chapter provides interesting information about the operational definitions that investigators have used in "successful aging" analyses, including the Manitoba Study of Aging definition. Regression analyses show that aging successfully is associated with not smoking, being physically active, avoiding obesity, protecting hearing, maintaining good personal relationships, and being active in community groups. Chapter 2 reports on a survey of residents and staff of assisted living accommodation that explores reciprocity among older adults. These facilities, in Rhode Island, southeastern Massachusetts and Connecticut, were "high-end" facilities according to the authors. The sites had large entrance lobbies, spacious dining rooms with vaulted ceilings, on-site meal preparation and wait staff, ice cream parlours with sitting areas, pubs with pool tables, an exercise room, hairdressing room, library with computer access, a private dining room for resident-reserved functions, large common room with television, on-site health care staff, and local transportation. All sites also had an activities director and were built specifically for the services they provide. Reciprocity was operationally defined in this study with the use of Likert questions that combined ideas of successful aging with doing things for others, and a Reciprocity Index was developed for the first time. This index should be further studied for the robustness of its measurement properties in studies of other groups, since it has not been developed to a point where facility managers can use it. Chapter 3, by Robert Kahn, provides a commentary on both of these studies and links them to theories on successful aging and adaptation to chronic disease that have been presented since his work with Rowe in the late 1980s. Kahn's chapter is a thoughtful discussion of the concepts and their research implications. According to Kahn and others whom he cites, community policies are important in supporting successful aging. Through them, communities can provide resources that increase seniors' opportunities and thus facilitate behaviours that contribute to successful aging. Early diagnosis of symptoms, for example, is more likely when there is easy access to family physicians. Neighbourhood walks in the summer and mall walks in the winter for physical activity are more tempting when neighbourhoods and malls are attractive and safe. Involvement in voluntary organizations, often recommended for older people, may require convenient and inexpensive public transportation. The issue of community policies is not covered in the five studies reported in the Poon et al. book. Health expectancy, or expected length of life without disease and disability, is the topic of Chapter 4. Using data from the 1994 US National Health Interview Survey, the authors report health expectancies for different groups according to their ability to carry out activities of daily living (ADL), their self-assessed health, different chronic diseases, gender, and race. These results challenge the societal notion that old age is fraught with disability. For example, at age 65, of the 17.4 years of life expectancy, 10.5 years are estimated to be lived "disability free". For most of the disabled years, older people will require assistance with instrumental activities of daily living (IADL) tasks rather than experiencing the more severe disability posed by ADL restrictions. Chapter 5 reports the findings of a MacArthur Foundation Research Network on Successful Aging survey in 1988-1989 and a follow-up survey in 1991-1992 involving the same high functioning men and women 70 to 79 years of age. Their functioning level was known, as they had participated in the Established Populations for the Epidemiological Study of the Elderly (EPESE), conducted in the early 1980s. The authors report on the risk and protective factors pertaining to physical functioning. One of the exciting findings reported has to do with levels of functioning and patterns of change in functioning over time. These were influenced by potentially modifiable factors - physical activity, social support, self-efficacy beliefs, and psychological symptoms - independent of the presence of chronic conditions or other aspects of health status and of differences in socio-demographic characteristics. Chapter 6 is a commentary on the health expectancy and high functioning studies reported in the previous two chapters. The authors of Chapter 6 point out that the health expectancy focus on disease as disability, as reflected in ADL and IADL demands, is consistent with the Rowe and Kahn concept of successful aging. They also assert that the subjective assessment of personal health may reflect active engagement with life, at least to a degree deemed acceptable to the older adult respondent. With regard to the Baltes and Baltes' conceptualization of successful aging as "selective optimization with compensation", the authors of Chapter 6 assert that optimization cannot be captured in years lived with disease or years lived with disability. They argue that the high functioning study's comprehensive examination of lifestyle factors and individual change over time, however, begins to reveal some elements of optimization, for example, physical activity patterns. Analyses of this type will be possible in Canada with the proposed Canadian Longitudinal Study on Aging, which has received initial funding from the Canadian Institutes of Health Research (CIHR) and high levels of interest from CIHR's Institute on Aging and other CIHR institutes. In Chapter 7, Poon and his colleagues provide a systematic review of the topic of coping with chronic health conditions. The aim was to determine how such conditions affect older individuals and what strategies are effective in coping with them. They conclude that health coping is disease-, context-, and individual-specific. The literature reports both positive and negative effects of coping with chronic disease. An example of a positive effect was the finding that belief in the controllability/curability of the disease is related to better functioning. An example of a negative effect is that more avoidance is associated with greater symptom severity. The authors of this chapter selected 483 of the studies that reported on the impact of coping strategies on chronic disease. Rather than classify studies on the basis of their research design, the authors classified them according to coping strategies for 12 chronic diseases and whether these strategies were a) effective and regularly used, b) ineffective or infrequently used, or c) in need of further research or gave no indication of effectiveness. The authors of Chapter 8 focus on what is known about the impact of concurrent chronic diseases among people with cardiovascular disease. They report on a study that examined the impact of concurrent chronic diseases on people with arthritis, high blood pressure, diabetes, hearing problems, lung problems, osteoporosis, problems with vision, urinary or bladder problems, cancer, and stroke. The chapter ends with a proposed model of the effects of coping with co-morbidity. A number of theoretical issues are raised, but it is difficult to imagine a study design that would enable investigators to tease out all the issues included in the proposed model. Chapter 9 reports on a study of independent community living of people who were in a senior membership program at a community hospital in northeastern United States. The 122 participants, 55 years of age and older, were asked to report their multiple chronic conditions. The number of conditions reported was not associated with age groupings. Focus groups were then held to explore the range of experiences and strategies that these older adults employed to get through daily life while suffering from multiple chronic conditions. The authors propose a model for managing everyday living with multiple chronic conditions that is based on the literature reviews in Chapters 7 and 8 and the in-depth interviews with the 122 study subjects. This model needs to be tested in future studies, which will have to overcome a number of issues related to the concepts outlined in the model, such as "encountering chronicity", "feeling challenged", "living with it", "monitoring", and "continuing on". Chapter 10 is a commentary on the content of Chapters 7 to 9. This chapter calls for more research on understanding how people cope with concurrent chronic conditions by establishing patterns of disease management. That is, some individuals may have similar patterns that could be shown to be "standard" trajectories of how they cope through time. Different models are also proposed here connecting "chronic stress", "external demands", "appraisal", and "coping". While the conceptualization of these models is clearly presented, future research must use measures that validly tap into these concepts. The book ends with a chapter (Chapter 11) on "ways of knowing". It comments on the different methodological approaches used by the chapter authors and refers to their philosophy of science positions of positivism, postmodernism and/or neo-modernism. The authors conclude that this book on successful aging and adaptation to chronic disease benefits from the incorporation of all these approaches. My overall conclusion is that this is a valuable book offering a useful understanding of theories related to successful aging and adaptation to chronic disease. In addition, those conducting research on the topics covered in the book will find that it provides excellent descriptions of the methods used and methodological critiques of these methods. References
Larry W Chambers, PhD, FACE, HonFFPH(UK) |
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