Prof Y Barak, MD, MHA 1

What is successful ageing and who should

define it?Bowling A & Dieppe P.

BMJ 2005;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 Development

Vaillant & 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

The Study of Adult Development

Outcome Domains 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)

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

The Study of Adult Development

Independent Predictor Variables 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)

Prof Y Barak, MD, MHA 23

The Study of Adult DevelopmentResults (1)

Quality of Aging 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

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

0

10

20

30

40

50

50 55 60 65 70 75

AGE

%

College

Core-city

Core-College

Prof Y Barak, MD, MHA 25

The Study of Adult Development

Results (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 Development

Results (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 Development

Results (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 Development

Results (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 Development MESSAGE

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

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 31

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 32

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 33

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 34

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 35

Guide #11:

Be informed ,but try not to be overwhelmed

by current events as portrayed by the popular media.

Prof Y Barak, MD, MHA 36

Prof Y Barak, MD, MHA 37

Thank you for your attention !!!