Successful Aging: The Public Policy Imperative

1
Successful Aging The Public Policy Imperative

• Rachel Pruchno, Ph.D.
• UMDNJ-SOM

2
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)

3
The demographic facts the epidemiologic
transition Challenges for public health
4
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

5
Successful Aging. . .

• If we can figure out how to get the Baby Boomers
  to arrive at old age in better shape
• Societys health care costs will be reduced
• Life-long personal resources will be saved
• Families will be less burdened

6
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

7
Focus on Old People
8
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)

9
Whom to Study?

• Should we be studying only old people?
• Beyond survivor effects
• Where to begin?

10
Mean age of onset
11
Cancer Mean Age of Onset
12
Defining Success

• Dictionary
• having a favorable outcome
• obtaining something desired or intended
• Thesaurus
• accomplished
• flourishing
• prosperous
• thriving

13
Can people age successfully if they have a
chronic condition?
14
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

15
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!

16
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)

17
Problems with Rowe Kahn

• Focus is on minority
• Based on medical model
• Younger age is best predictor of success

18
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

19
Conceptual Dimensions of Success

• Measureable domains of functioning
• Objective
• Subjective
• Broad societal consensus regarding desirability
• Variability within population

20
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

21
Successful Aging?

• 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

22
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?

23
Sample
24
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

25
Why New Jersey?

• NJs 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

26
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

27

• Each region includes a somewhat equal proportion
  (16 to 26) of New Jerseys 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.

28
Screening Eligibility

• 2000 U.S. Census reveals that 1,876,194 New
  Jersey residents were age 50 to 74, suggesting
  that 22.3 of NJs 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.

29
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)

30
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

31
Response Rates (AAPOR)
32
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

33
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

34
Measures of Successful Aging
35
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)

36
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)

37
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)

38
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)

39
Measurement Model
40
(No Transcript)
41
(No Transcript)
42
Successful Aging
43
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)

44
Questions

• To what extent do early influences set the stage
  for successful aging?
• What role do current behaviors have?

45
Independent Variables
46
Early Influences

• Gender (1male 2 female)
• Education (years)
• Never married (0ever married 1 never)
• Race (0 White 1 African American)
• Prison (0 no 1 yes) 3.5
• Childless (0no 1 yes) 17.8
• All analyses control for age

47
Current Health Behaviors
48
BMI

• Mean 28.4 SD 6.2
• BMI categories
• Underweight (BMI lt18.5) 1.1
• Normal (BMI gt18.5 BMI lt 25) 29.7
• Overweight (BMI gt25- BMI lt 30) 36.6
• Obese (BMIgt30 32.6)

49
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

50
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)

51
Smoke Cigarettes

• 0no 1yes
• 15.8 current smokers

52
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)

53
Social Connections

• 5-point Likert scale (1low 5high)
• 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

54
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)

55
Results
56
Multinomial Logistic Regression

• Reference group
• Successful according to both criteria
• Early influences
• Early influences current behaviors and
  relationships

57
How important are early influences?
58
Early Influences, Current Behaviors
59
Early Influences, Current Behavior
60
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

61
Subjective Only are

• 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

• Early Influences
• Older
• More likely to be women
• Less educated
• More likely to have been in prison
• Never married, African American, no longer
  significant

62
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

63
The Objective Only vs. the Subjective Only
64
Logistic Regression ResultsNo differences

• Education
• Never Married
• African American
• Prison
• Childless
• Currently married
• Volunteer work
• Alcohol consumption
• Current smoker

65
Logistic Regression ResultsDifferences

• Subjective Only
• Older
• More women
• Less likely to be working
• Higher BMI
• Less exercise
• Better social relationships
• More religious

66
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

67
Caveats

• Younger sample
• Components of objective success are specific to
  this age group
• Reliance on self-report data
• Cross-sectional design

68
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).

69
Lifestyle Choices

• Diet
• Exercise
• Smoking
• Drinking

70
Social Factors

• Marriage
• Family
• Friends
• Religiosity
• Work
• Volunteering

71
Neighborhood Effects
72
Neighborhood Data

• U.S. Census (2000)
• New Jersey Uniform Crime Report
• New Jersey Department of Agricultures Division
  of Marketing and Development (milk)
• New Jerseys Department of Law and Public
  Safetys Division of Alcohol Beverage Control

73
Neighborhood

• Wealth
• College Degree
• Professionals
• people with incomes gt 150,000

74
Neighborhood

• Social Vulnerability
• Female headed HH
• HH on Public Assistance
• Unemployed males

75
Neighborhood

• Crime
• Robberies
• Rapes
• Aggravated Assaults

76
Neighborhood

• Residential stability
• Year HH moved in
• 5 years in same HH

77
Neighborhood

• Density
• Bars/pubs
• Grocery stores
• Local convenience stores

78
Neighborhood

• Availability of Physicians
• Primary care doctors
• Specialists

79
Neighborhood

• Built environment
• Connectivity (alpha, gamma,
• streets per square mile)
• Air Pollution (particulate matter, ozone)

80
Next Steps

• Connecting neighborhood characteristics and health

81
Successful Aging The Public Policy Imperative