The Short Guide to Aging and Gerontology

de Medeiros, Kate

• Publisher: Policy Press
• Year: 2016
• ISBN:
  9781447328391
• Topic: Social Sciences
• Subtopic: Gerontology
• Index: Social Sciences

As the field of aging and gerontology grows worldwide, this exciting guide introduces students to key issues and concepts. It covers topics related to the phenomena of advancing aging, including how older age has been defined historically, cultural myths related to advanced age, health and function in later life, how older age is financed throughout the world, and other key questions. Taking a multiple-perspective approach (including humanities, social and behavioral sciences and policy studies), the book's features include further reading for each chapter, a glossary of key terms, and tables that provide easy reference points.

FOUR

Health and functional abilities in later life

This chapter provides an overview of some of the ways that health, disease, and wellbeing have been defined, conceptualized and studied in gerontology. Fears of decline in health and loss of function in later life have been linked to fears of aging. This could be seen in the stages of life that were introduced in Chapter Two, whereby ‘green old age’ or the Third Age and ‘sad decrepitude’ or the Fourth Age are distinguished by functional ability. Therefore, it is important to consider what is meant by health; historical perspectives of how to achieve a ‘good old age’; health and the discourse of decline; distinctions between disease, normal aging and disability; morbidity and wellbeing; and social correlates of health. As has been highlighted throughout the Short Guide, health is rooted in the political and geographic. Structures such as social class, which affect one’s access to nutrition, care and disease prevention, can ultimately play an important role in later life health. What constitutes ‘health’, how health is defined and what is viewed as ‘normal’ and ‘pathological’ aging will frame the beginning of this chapter. The latter part of the chapter will look more closely at concepts related to health measurement as well as the cognitive aspects of aging. It will not look at prevalence of individual diseases associated with older age, but instead will examine health and functioning from a broad context. Although social location and environmental determinants of health are discussed in more detail in Chapter Seven, they will also be briefly addressed here.

Health and the notion of ‘aging well’

Aristotle used the word ‘eugeria’ to refer to ‘a long and happy life in which independence was maintained and there was no pain or suffering’ (Mulley, 2012). The key to a healthy long life, according to Lukian in the Macroboi, is ‘climate, diet, occupation, physical fitness, and mental alertness’ (Thane, 2000, p 37). Cicero, as cited by Patrick McKee (1982), came to a similar conclusion. Cicero wrote, ‘But it is our duty, my young friends, to resist old age; to compensate for its defects by a watchful care; to fight against it as we would fight against disease; to adopt a regimen of health; to practice moderate exercise; and to take just enough of food and drink to restore our strength, not to overburden it’ (p 31). These early frameworks for ‘a good old age’ have continued, more or less, until the present. For example, according to John Morley (2004), Roger Bacon, a Franciscan friar of the 13th century, suggested that ‘old age could be warded off by eating a controlled diet, proper rest, exercise, moderation in lifestyle, good hygiene, and inhaling the breath of a young virgin’ (p 1133). Today, most of these (except inhaling the breath of a young virgin) are still believed to be components of maintaining health into old age; there is a large body of research to support this (Burke et al, 2001; Houston et al, 2008; Chodzko-Zajko, 2014).

But what is health? Health, many have argued, can be an elusive concept, especially in a field like gerontology where such terms may carry different meanings depending on the perspective used. Farzana Alli and Pranitha Maharaj (2013) write that ‘in its earliest conceptions, good health was viewed as a divine gift by the gods while poor health was viewed as a punishment’ (p 54). Later, Susan J. Simmons (1989) argued that health was more of a generalized idea than a clearly defined one. She writes: ‘The ancient Greek view of health, as formulated by Hippocrates in 400 B.C., stated that human well-being was influenced by the totality of environmental factors: living habits, climate, and the quality of air, water and food’ (p 156). Eventually, the notion of health began to include other aspects of wellbeing beyond the physical. Since 1946, the World Health Organization (WHO) has defined health as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’ (WHO, 2015b). Chatterji and colleagues (2015) note that the WHO definition ‘does not equate health with diseases or diagnostic classifications, but recognises a chain through which risk factors and environmental factors are determinants of diseases, and diseases and environmental factors, in turn, are determinants of health states’ (p 565).

Parts of the WHO definition can be found in John Rowe and Robert Kahn’s (1997) perspective on successful aging (see Table 2.1). They define successful aging as the ability to maintain ‘low risk of disease and disease-related disability, high mental and physical function, and active engagement with life’ (p 38). The body of research accompanying successful aging has been aimed at understanding why some individuals seem to age ‘successfully’ while others do not. Findings from the MacArthur Studies of Successful Aging (a series of studies based on Rowe and Kahn’s definition) revealed several important components that seemed to be associated with function in later life. These included strong emotional support and better cognitive performance (Seeman, Lusignolo, Albert, & Berkman, 2001); social inequality and poorer health outcomes (Seeman et al, 2004); high levels of recreational activity and reduced inflammatory markers, which resulted in better health (Reuben, Judd-Hamilton, Harris, & Seeman, 2003); a nutritional diet and better physical function (Depp & Jeste, 2006), and many others. Interestingly, these findings are not all that different from what Cicero, Bacon and many others have suggested, although the structure of systematic research will hopefully provide better insight into why these outcomes occur rather than just the observation that these relationships between variables exist.

It should be noted that there are many criticisms of Rowe and Kahn’s (1997) definition of successful aging and these were briefly mentioned in Chapter One. These criticisms include the focus on individual agency versus environmental and social factors that can lead to poor health (Rubinstein & de Medeiros, 2014); differences in definitions and measurement (such as what comprises ‘high cognitive function’ and what instruments are used to measure it) across studies (Depp & Jeste, 2006); and lack of personal assessments of whether one thinks he or she has aged ‘successfully’ (Montross et al, 2006). As noted in the earlier chapter, conceptualizations of successful aging that preceded Rowe and Kahn’s (1997) placed more emphasis on an individuals’ subjective assessment, on whether they considered themselves to be ‘successfully aged’, rather than by standardized performance levels (Havighurst, 1961; Havighurst, 1963). This difference in how successful aging is defined is an excellent example of how two different perspectives within gerontology may use the same terms or phrase but for two different reasons. Rowe and Kahn (1997), for example use successful aging as a construct through which to measure and compare health and function across groups of people. Havighurst (1963) and others use it as a term to describe one’s personal assessment of one’s life. In a similar way, health can be understood in terms of subjective evaluation (for example, ‘I rate myself as healthy’) or through outside determinants (for example, ‘a person who performs at level x on a measurement of overall health is determined to be less healthy than a person who performs at level y’.) Topics related to determining health and disability status are discussed in further detail later in the chapter.

Health and challenging the discourse of decline

As was mentioned in Chapter Two, gerontology was founded as a way to learn more about how to avoid or remedy many illnesses associated with old age. The pathogenic (Greek ‘pathos’ or suffering) view of health sees health as ‘the absence of disability, disease, and premature death’ (Keyes, 2007, p 96). While on the one hand it is difficult to discuss concepts like health and function in later life without slipping into talk of decline and loss, ignoring the effects and experiences of disease in later life can lead to a ‘discourse of denial’, which is also problematic. There are several concepts that challenge the discourse of decline without overlooking the effects of disease and change which are under the large umbrella of salutogenic (from the Greek word ‘salus’ or health) models of health and aging (Antonovsky, 1996; Lindström & Eriksson, 2006; Keyes, 2007). These concepts include flourishing (Keyes, 2007; Keyes, 2010), resilience (Werner & Smith, 1982; Wagnild & Collins, 2009; Lipsitt & Demick, 2011) and hardiness (Kobasa, Maddi, & Kahn, 1982). In contrast, there are other concepts that particularly look at decline – frailty and sarcopenia– as ways to better direct research and clinical efforts. Each is described in the following subsections, along with an explanation of the term ‘functional abilities’ that will be used throughout the chapter.

Salutogenic models

Aaron Antonovsky (1996) introduced the salutogenic model as a response to limits in health promotion that focused on disease and risk factors. He writes: ‘When we look closely at the concept of “lifestyles” as it appears in the literature, however, what is found is a list of (generally well-documented) risk factors: smoking, other substance abuse, overnutrition, drunken driving, unsafe sex, exposure to injuries. We remain squarely in the realm of disease prevention’ (p 13). He argues that rather than seeing health and disease as two dichotomous conditions, one should view all people as somewhere on a continuum. He adds that ‘Salutogenic orientation, then, as the basis for health promotion, directs both research and action efforts to encompass all persons, wherever they are on the continuum’ (p 14). Examples of salutogenic models relevant to aging include flourishing, resilience and hardiness. Corey Keyes (2002; Keyes, 2007) defines flourishing as the promotion and maintenance of mental health, rather than the absence of a condition. There are three broad positive dimensions of flourishing: emotions, psychological functioning and social functioning. ‘Flourishing’ captures the idea that health is not just the absence of disease, but a state of being in which a person positively functions.

The second salutogenic model, resilience, overlaps many of the concepts of flourishing. Werner Greve and Ursula Staudinger (2006) describe resilience in later life as ‘a central concept for both the life span perspective on human development and for developmental psychopathology. It conveys the idea that individuals can avoid negative outcomes or decreasing trajectories of development despite the presence of significant risk factors in their environment or potentially harmful experiences during their lives’ (p 797). Key to resilience is the concept of plasticity, which is a dynamic system of gains and losses that occurs across the life span and can act in a compensatory way in some individuals. Constructs of resilience propose that individuals can return to their initial level of function despite negative exposures because of their ability to act in a compensatory way.

Finally, the third salutogenic model is hardiness, which was described by Suzanne Kobasa, Salvatore Maddi and Stephen Kahn (1982) as a combination of commitment, control and challenge within an individual that allowed him or her to counter the effects of stressful life events without ill effects. The orienting idea in this approach was that stress produced negative health outcomes and that hardy individuals use a combination of resources (for example, social connections), personality and past experience through previous exposure to stressful situations or observing modelled coping behaviors by others to reduce the negative effects of a given exposure. Overall, these models suggest a continued, positive dynamic that can occur throughout one’s life despite physical, emotional, financial and other changes.

Frailty and sarcopenia

On seemingly the flip side of salutogenic perspectives are two syndromes associated with decline in later life: frailty and sarcopenia. Frailty, has been described by Linda Fried and colleagues (2001) as ‘a biologic syndrome of decreased reserve and resistance to stressors, resulting from cumulative declines across multiple physiologic systems and causing vulnerability to adverse outcomes’ (p M146). This would appear to be the point in which resilience or other compensatory strategies are no longer effective. In their work, they found that the likelihood of frailty was more common in people with lower socioeconomic status and women, the latter possibly because of differences in muscle mass in women as compared to men.

The second syndrome, sarcopenia, is derived from the Greek roots ‘sarx’ (flesh) and ‘penia’ (loss) (Rosenberg, 1997), and describes a geriatric syndrome characterized by age-related decline in muscle mass and strength. Sarcopenia is sometimes considered within the frailty construct since loss of muscle mass is one of the systems that may decline. Prevalence estimates in the world range from 5 to 13% for people aged 60–70 years and from 11 to 50% for people aged 80 years and over (Cruz-Jentoft et al, 2010). Under- and overnutrition have been identified as risk factors. Returning to the ‘stages of life’ discussed in Chapter One, frailty and sarcopenia would be associated with the Fourth Age or periods in which one experiences decline and increased dependency. These are some of the negative aspects of aging that have led to fears of growing old.

Functional abilities

The term ‘functional abilities’ is being used here as a broad description to capture physical, cognitive and emotional changes that occur in later life. It is also a linguistic attempt to move away from the decline model by focusing on abilities rather than losses. ‘Function’ here includes the concepts of disease, health, disability and wellbeing, all of which are discussed in the sections that follow.

As with all aspects of aging, there are individual, societal, geographical and cultural factors to consider. For example, individuals may make choices about their health such as what to eat. However, those choices will be limited to what resources are available to purchase particular foods (societal), what foods can be grown (geographical), what is considered appropriate to eat or drink (cultural) and other factors that are beyond the control of individuals themselves. The same applies to encounters with health professionals....