Funded by NIH Grant NINR 10271. Assistance of the following colleagues and graduate students is appreciated: Jeffrey S. Kahana, Ph.D., Loren D. Lovegreen, Ph.D., Jane A. Brown, Ph.D., Julie Chaya, MA, Cory Cronin, MA, Relebohile Morojele, MA, and Sarah Schick, BA
Interventions to promote health and well-being among older adults are widely implemented and recommended in an effort to enhance quality of life in old age. Yet, the very idea that there is a need for interventions to achieve success is at variance with prevailing orientations about successful aging (Rowe & Kahn, 1998). To the extent that successful aging presupposes good health, financial and social resources, and adaptability, there should be little need for interventions to achieve success in late life. Such assumptions would be warranted if we define successful aging as an outcome rather than a process. Interventions could only assist those individuals who are not aging successfully, as defined by poor physical health or cognitive limitations. In the context of outcome oriented models of healthy and successful aging, such interventions would be viewed as prosthetic measures to aid vulnerable, and by definition, unsuccessful elders.
However, based on process oriented theoretical orientations to successful aging, criteria for success becomes much broader (Depp & Jeste 2006; Schulz & Heckhausen, 1996). Indeed, evidence for human plasticity in old age has been noted, based on the success of interventions that alter patterns of behavior in late life (Baltes & Baltes, 1993). Furthermore, gerontologists have increasingly recognized variability in patterns of aging, based on structural constraints on the one hand (Dannefer, 2003) and the normative stressors in old age, on the other (Kahana & Kahana, 2003). There is also a moral imperative for making room at the table of successful aging for the vast majority of older adults who develop chronic illnesses and disabilities during the final years of life (Young, Frick & Phelan, 2009; Verbrugge & Jette, 1994).
As part of the working group on successful aging for the NIA sponsored conference grant on successful aging, our assignment has been to review and discuss interventions for promoting successful aging. We embraced this task with eagerness to learn about theoretical, methodological and substantive challenges that have been encountered by those attempting to improve the quality of life among older adults. In order to achieve an organized approach to reviewing this field we are utilizing the theoretical approaches of the stress paradigm (Pearlin, 1989). The theory of Preventive and Corrective Proactivity that we have formulated in the context of the stress paradigm provides a useful framework for categorizing interventions that can promote successful aging (Kahana & Kahana 1996; Kahana & Kahana, 2003; Kahana, Kahana & Kercher, 2003). Figure 1 depicts key components of the Proactivity Model of Successful Aging. This theoretical framework proposes that normative stressors of aging include chronic illnesses, social losses, and lack of person-environment fit. These stressors threaten both psychological and social well-being. We consider external social resources and internal coping resources as factors that ameliorate the adverse effects of stressors on the quality of life (QOL).
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A unique contribution of this framework is the inclusion of proactive behavioral adaptations activated by resources. These resources can diminish the adverse effects of stressors on QOL outcomes. Proactivity-based models of successful aging are increasingly acknowledged as valuable in the gerontology and psychology literatures (Ouwehand, deRitter & Bensing, 2007; Aspinwall, 2010). A detailed review of alternative models of successful aging is offered in “Definitions of Successful Aging” (Martin, Kelly et al. , 2012), the first working paper that is part of our larger conference initiative. In their review of major existing models of successful aging, these authors highlight the historical evolution of alternative conceptualizations relevant to successful aging. Some of these models, such as Rowe & Kahn’s widely cited 1998 formulation, emphasize outcomes such as absence of disease and high functional capacities, along with active engagement in life, as hallmarks of successful aging. Other well-known models are more process oriented, such as Baltes & Baltes (1993) model of selective optimization with compensation. Prior models of successful aging provide relatively few alternative domains for consideration to help classify the broad array of existing approaches to intervention. The Proactivity Model utilized here (Kahana & Kahana, 1996; 2003) affords a greater range of process as well as outcome oriented criteria for classification of diverse existing interventions. Utilizing the stress theory-based Proactivity Framework, we can organize interventions based on their goals as relevant to: (1) reducing stress exposure (Component A); (2) improving internal resources and coping strategies (Component B); (3) enhancing external resources (Component C); (4) promoting diverse proactive adaptations, both preventive and corrective (Component D), and (5) directly enhancing quality of life outcomes (Component E). The Proactivity framework helps us classify the goals of interventions. These alternative goals are important to identify, as they often shape the types of interventions implemented.
Having a meaningful framework for classifying diverse interventions, we can further refine our review by considering different approaches and methods of interventions. Thus, for example, interventions may utilize individual therapeutic efforts or group centered strategies. Interventions may be implemented by professionals on the one hand, or elderly peers on the other. Program modalities may range from educational approaches to therapeutic orientations and to web-based technological interventions. Furthermore, the locus of interventions may be on a micro level, impacting individual older adults; on the meso level, impacting organizations; or on a macro level, influencing laws and policies.
The environmental context of the intervention is an important criterion, particularly for distinguishing community-based interventions from those that take place in health care settings; specifically, in long-term care facilities (Kahana, Lovegreen & Kahana, 2011). Another important criterion for evaluating interventions relates to their evidence base. Reports of interventions vary in terms of the strength and rigor of research designs. These can range from randomized control trials to anecdotal descriptions of program efficacy (Moher & Lepage, 2001). A useful introduction to understanding the variety of interventions that may contribute to successful aging is the consideration of reviews or meta-analyses that are focused on specific types of interventions. In this context, interventions designed for younger age groups may also be relevant to older adults. An important cautionary note relates to the frequent lack of an organizing framework for classifying interventions in meta-analyses. Consequently, it is common to find a long and unwieldy list of interventions that may differ in goals, theoretical foundations, methodological approaches, and conclusions about efficacy. We aim to minimize these limitations through reliance on our theory-based organizing framework.
The following review offers a bird’s eye view of interventions that can promote successful aging. We thus offer some illustrative examples of interventions that address different components of the Proactivity Model of Successful Aging that was outlined above. Our aim in this paper is to stimulate thinking in the field of gerontology about diverse orientations to promoting successful aging through interventions. Our review tends to focus on person oriented interventions that are prevalent in the field of psychology, as these are more limited and replicable approaches relative to more macro interventions that target system change (Marshall & Altpeter, 2005).
For each of the subject areas chosen, we started our literature review by considering existing meta-analyses of prior studies on the topic, where available. We further considered studies conducted subsequent to the latest existing literature review. In addition, we selected specific studies that provide unique insights about the benefits and methodological challenges of intervention research to enhance successful aging. The senior authors of the paper, Eva and Boaz Kahana, enlisted the help of a talented group of sociology students and research associates working at the Elderly Care Research Center at Case Western Reserve University, who are listed as contributors to this paper.
Interventions to Reduce Stress Exposure (Component A)
In the framework of Proactive Aging theory, normative stressors of aging generally include chronic illnesses and associated functional limitations of late life (Kahana & Kahana, 2003). In addition, social losses including bereavement, due to death of family members and close friends, frequently occur in late life. Environmental factors can also result in stress exposure by creating excessive demands or presenting noxious stimuli, resulting in incongruence or lack of person-environment fit between needs of the older adults and their life situations. Stress exposure in late life can also relate to non-normative events that are based on social forces creating adversity. Stresses may thus arise as a function of inadequate or neglectful care of older adults. These iatrogenic stressors can range from restraints in long term care settings (Capezuti, Strumpf, Evans, Grisso, & Maislin, 1998) to elder abuse in a family context (Lachs & Pillemer, 2004). Such non-normative stressors reflect an extension of the original Proactivity model shown in Figure 1 (Kahana & Kahana, 1996; 2003).
It is difficult to design interventions that could avert the occurrence of normative stressors, such as social losses. Thus, interventions are usually aimed at enhancing coping skills for dealing with stressors more effectively, or offering social supports to help older adults maintain good quality of life despite social losses and environmental challenges. Interventions to avert or delay the onset of illness will be discussed as related to preventive proactive adaptations. Interventions focused on reducing stress exposure in late life are typically related to diminishing iatrogenic effects of health care and adverse social conditions. In addressing iatrogenic stressors, such as abuse or poor care, environmental interventions are possible by creating greater safety and less exposure to harm for older adults.
We also recognize that, in the context of the stress paradigm, researchers may label an intervention, based on the stressors impinging on older adults, even where the approaches of the intervention are focused on amelioration (Kahana, Kahana, Kelley-Moore, & Brown, 2011). Thus, for example interventions to reduce social isolation (a stressor) typically offer social support to isolated elders. Similarly, interventions to reduce chronic illnesses (stressors) typically focus on facilitation of self- care or health promotion efforts.
Ageism and Elder Abuse. To illustrate interventions targeting reduction of stress exposure, we focus on the ubiquitous stressor of ageism in society. Robert Butler (1989) persuasively argued that dispelling ageism is the most cross-cutting intervention that can promote successful aging. Nevertheless, there has been a paucity of formal interventions to accomplish this goal. Some modest evidence exists about effectiveness of educational interventions to influence students’ perceptions about aging (Knapp & Stubblefield, 2000).
The prevalence and deleterious impact of ageist attitudes have been documented in areas ranging from inadequate health care delivery to elder mistreatment, abuse and neglect (Nelson, 2000). There has been international acknowledgement that elder abuse, (reflecting physical, psychological, sexual, spiritual, and financial exploitation), is a pervasive and growing problem (Lachs & Pillemer, 2004). This recognition has given rise to diverse interventions to reduce prevalence and incidence of abuse (Kleinschmidt, 1997; Mosqueda , Burnight, Liao & Kemp, 2004). A broad array of organization-centered interventions has been initiated to combat elder mistreatment. However, there has been an absence of systematic research to evaluate efficacy of interventions in this field (Ploeg, Fear, Hutchison, MacMillan & Bolan, 2009). The majority of interventions target education of caregivers. In addition, legislation for mandatory reporting of abuse has gained momentum (Daly & Schoenfelder, 2011). Here we offer a sampling of extant intervention efforts.
A model intervention for elder abuse relevant to dementia has been described by Anetzberger et al. (2000). Patients suffering from Alzheimer’s disease constitute a particularly vulnerable group. These patients constitute a notable example of a group requiring interventions to help them achieve some potential for successful aging. We concur with disability scholars and activists who argue that all human beings, no matter how disabled, deserve to live with dignity and in safe environments (Shakespeare, 2006). The abuse prevention intervention conducted by Anetzberger and colleagues (2000) involved development of a handbook for caregivers of persons with dementia, in order to self-identify the risk for engaging in elder abuse and to encourage them to seek treatment to prevent occurrence of abuse.
Another innovative elder abuse prevention program has been organized in the framework of a long term care setting (Reingold, 2006). The Weinberg Center of the Hebrew Home at Riverdale, New York offered training to different organizations to teach them how to recognize elder abuse and to report instances of abuse. Thus, for example, bank tellers were trained to recognize financial abuse, especially among adults suffering from dementia. The organization extended services to provide a safe shelter to more than 3,000 older adults who have experienced abuse and neglect in their homes, in three neighboring communities. Abused adults were screened for short term or long-term residential accommodations. With the adoption of a multidisciplinary team approach that involved collaboration with non-profit agencies and governmental organizations, the intervention was reported to yield positive results (Reingold, 2006).
Another innovative abuse prevention initiative is offered by The Financial Abuse Specialist Team (FAST) program to intervene in financial abuse cases in Santa Clara County. This program was implemented by the Department of Aging and Adult Services – DAAS (Malks, Schmid & Austin, 2002). FAST is a team of multi-disciplinary personnel, trained in the prevention, identification, and treatment of elder- abuse. The team utilizes services of the County Counsel that handles civil litigations and the District Attorney’s office. When cases of financial abuse are reported, they are transferred to FAST, where evidence to support the case is gathered with the assistance of a police officer. FAST has been successful at intervening, recovering asserts, and preventing possible future exploitation (Malks et al., 2002).
Contrasting with the above agency-based interventions, a new model for integration of social and medical services has been implemented by the Vulnerable Adult Specialist team (VAST) (Mosqueda et al., 2004) that provides adult protective services and criminal justice agencies with access to medical experts who can examine victims of abuse. These coordinated services can facilitate both documentation and remediation of abuse.
As reflected in the above examples, elder abuse interventions do not lend themselves to traditional evaluation designs or randomized control trials (RCT). Interventions can range from those aimed at prevention of stress exposure among high risk groups, remediation of adverse stress sequelae, and prevention of re-victimization among those who already endured maltreatment. Although domestic and interpersonal violence can occur at all ages, older persons are particularly vulnerable as targets, and reducing this insidious and extreme form of stress is a requisite of successful aging.
Interventions to Promote Internal Resources (Component B)
The key role of personal coping resources and strategies in helping to alleviate adverse effects of stress exposure has been recognized (Folkman, 2010). As shown in our model (Figure 1), hopefulness, altruism and self-esteem reflect dispositional or trait-like qualities of the individual that afford psychological supports in the face of stress exposure. Coping strategies represent a unique internal resource that has been widely studied in the context of modifiable psychological characteristics (Aldwin, 2000). These can help maintain good quality of life, even in the aftermath of stressful life situations (Kahana & Kahana, 2003). Nevertheless, it is noteworthy that the vast literature on coping does not have a clear counterpart in the intervention literature (Coyne & Racioppo, 2000).
Illness Management. Self- efficacy represents a psychological coping resource that has been addressed in interventions. There is an extensive literature on chronic illness management interventions that targets behavior change by enhancing self-efficacy beliefs (Lorig, Sobel, Stewart et al., 1999). Using principles of Social Learning Theory (Bandura, 1977), programs generally focus on modeling desirable behaviors, action planning, and problem solving training that is directed at achieving self-established goals. It is important to emphasize that coping resources, such as self-efficacy beliefs, are generally viewed by those conducting interventions as precursors to proactive self-care and health care utilization behaviors. The success of diverse illness self-management interventions, using social learning principles, has been documented with older adults suffering from a wide variety of chronic diseases (Lorig, Ritter, Laurent & Fries, 2004). Nevertheless, it is useful to note that the causal linkages between self-efficacy and health behaviors may operate in a bidirectional fashion. Thus physical activity interventions with the elderly have also been found to increase self-efficacy beliefs (Netz, Wu, Becker, & Gershon, 2005).
Our literature review has not located any meta-analyses of interventions specifically focused on improved coping orientations among older adults. Even individual studies tend to be focused on coping with specific diseases and interventions to enhance targeted illness adaptations. We developed a conceptual framework that delineates illness adaptations that can improve approaches to coping with cancer and can guide interventions (Kahana & Kahana, 2010). Numerous individual studies also exist focused on improving patients’ coping skills with chronic illnesses ranging from HIV/AIDS (Vance & Stgruzick, 2008) to cancer (Radziewicz et al., 2009) and diabetes (Delameter et al., 2001). There has also been some interesting work promoting coping competencies related to investment in the future (Bode, de Ridder, Kuijer & Bensing, 2007). Strategies for enhancing coping skills often overlap with psychotherapeutic approaches. These will be discussed later in this paper as we consider interventions to improve mental health outcomes.
There has been a growing emphasis in the literature on stress and coping with regard to the resilience of older people in the face of mounting challenges posed by normative stressors of aging. Interventions have been proposed to promote resilience in this population through creative engagement (McFadden & Basting, 2010). Using qualitative methodologies, investigators propose that cognitive enhancement and mastery may be achieved by older adults who are engaged in creative pursuits such as crafts or art work. Some of these approaches are anchored in the work of Gene Cohen (2009), who has advocated that creative engagement in late life is an integral part of successful aging.
Interventions to Enhance External Resources and Social Supports (Component C)
Interventions that promote external financial or social resources are shown as Component C of our model. Some of the efforts to increase financial resources are implemented through social policies, such as Social Security, that offer financial safety nets to older persons (Binstock,1994). These programs are critically important for well-being in late life ,but are not typically described in empirical studies. Although age based economic supports, such as Medicare and Social Security are universal entitlements, the role of cumulative disadvantage conferred by race and gender on disadvantaged segments of the population are well documented (Dannefer, 2003).
Social Connectedness. The important contributions of social relationships, social capital, and social support for maintaining good quality of life in the face of social stressors have been extensively documented (Cornwell & Waite, 2009). Interventions to reduce loneliness and social isolation may be focused on building social skills on the one hand and building social opportunities on the other (Rook, 1984). It is the latter approach focused on enhancing external resources that best fits our discussion. In the context of the stress paradigm, targeting loneliness and social isolation would be particularly helpful to counteract social losses. Interventions to enhance informal support networks may be beneficial to offer needed instrumental, informational and emotional support for older adults who are facing health related and environmental stressors.
While there is consensus about the potential benefits of interventions to reduce social isolation and loneliness and to enhance social networks among the elderly, well designed empirical studies of interventions targeting older adults are relatively scarce. A meta-analysis of social support interventions covering a broad spectrum of ages has been published by Hogan, Linden, and Najarian (2002). According to this review interventions that targeted elderly populations find limited support for effectiveness of programs, such as friendly visitors, for building social ties.
A more recent systematic review of interventions targeting social isolation among the elderly was conducted by Dickens, et al. (2011). Only reports of interventions utilizing randomized control trials (RCT) or quasi-experimental designs were considered for inclusion in the review.
Overall, interventions were found to be efficacious, with 80% of interventions reporting improvements in at least one outcome considered. Those interventions that offered activities or support in a group format were found to have greatest effectiveness relative to individual friendly visitor or to Internet based programming. It is useful to note that both community-based and long term care-based interventions from diverse geographic locales were included in this review. A few examples of social support interventions conveying approaches of specific studies are provided below.
A promising set of early interventions for enhancing supportive networks among older adults was described by Pilisuk and Minkler (1980). In this intervention public health nurses set up programs for checking blood pressure among isolated inner city elders in an effort to learn more about common interests, facilitate social interactions and ultimately to develop informal clubs which foster social connectedness.
Some social-support interventions have focused on facilitating long-distance family relationships through technology. This type of intervention is particularly valuable for institutionalized or isolated older adults who may have few family contacts. The feasibility of using video-phones for family elder visits was demonstrated in a study by Mickus and Luz (2002).
Interventions to enhance friendship networks to reduce loneliness among women in later life were conducted by Stevens, et al. (2006). These programs were based on cognitive approaches to enhance self-esteem and relational competence through practice of relevant social skills. More participants in the intervention (63%) reported that they developed new friendships relative to the control group (46%).
Social support interventions span a wide range of programs and may overlap with other forms of intervention, such as health promotion or psychotherapy. Nevertheless, it is useful to recognize that the common primary goal of social support interventions is that of enhancing quality-of-life outcomes through social connectedness.
Interventions to Promote Proactive Adaptations (Component D)
As shown in Figure 1, we classify proactive behavior as preventive adaptations (health promotion, planning ahead and helping others) and corrective adaptations (marshaling support, role substitution and environmental modifications). It should be noted that in later formulations of our Proactivity Model, we also included emergent adaptations (technology use, health care consumerism, and self-improvement) (Kahana, Kahana & Kercher, 2003).
In our discussion of interventions for successful aging, we make note of technology use, particularly in terms of computer and Internet use, across multiple domains of interventions. Specific discussion of technology use for assistive devices is included as part of our discussion of environmental modifications. Proactive adaptations of health care consumerism and self-improvement are generally self-initiated. Nevertheless, educational interventions can also contribute to enhanced self-improvements and patient initiatives reflecting health care consumerism. Interventions aimed at enhancing communication skills of patients have demonstrated successful skill development (Kinnersley et al., 2008).
Health Promotion. Interventions to promote healthy lifestyle behaviors represent some of the most commonly used and also the most efficacious programs that target older adults. The preventive goals of these interventions relate to sustaining good health and delaying the onset of disability (Marquez, Bustamante, Blissmer & Prohaska, 2009). In addition to their preventive value, healthy lifestyle interventions can also serve corrective goals as they become a key component of chronic illness management (Marquez et. al, 2009). In this section of our working paper, we offer illustrative examples of exercise or activity-based interventions, and also of interventions aimed at improving dietary behaviors. In discussing health promotion interventions, we also highlight the growing importance of Internet-based and technology assisted interventions (Webb et al., 2010).
Activity. Interventions to improve physical activity are among the most widely studied in the field of gerontology. A number of reviews of the effectiveness of such interventions have been done, and they report success in contributing to a positive self-image and overall health (Baker, Meisner, Logan, Kungl, & Weir, 2009; Rejeski, King, Katula, Kritchevsky, & Miller, 2008; Rosenberg, Bombardier, Hoffman, & Belza, 2011). Existing recommendations and guidelines currently suggest that older adults should participate in endurance, resistance, flexibility, and balance exercises on a regular basis (Chodzko-Zajko et. al, 2009). A regimen of regular physical activity can minimize the physiological effects of aging and increase active life expectancy by limiting the development and progression of chronic diseases and disabling conditions (Chodzko-Zajko et. al, 2009).
Exemplifying these approaches, one study utilized a six-month neighborhood-based physical activity intervention for people aged 65 to 74 years to increase their total physical activity levels (Jancey, Lee, Howat, Clarke, Wang, & Shilton, 2008). This program was successful in increasing weekly time for physical activity among older adults and in identifying factors that affect their commitment to physical activities. Another physical activity intervention (Baker et al., 2009), confirmed the importance of exercise in promoting successful aging as defined by Rowe and Kahn (1998). The criterion of successful aging in this study included three distinct components: the low probability of disease or disease-related disability, high cognitive and physical functional capacity, and active engagement with life. This study found that older individuals with high levels of physical activity were more than twice as likely, and those with moderate levels of activity were over one and a half times more likely to be aging successfully than respondents who were not physically active (Baker et al., 2009). This research is of particular interest for its articulation of linkages between health promotion interventions and successful aging.
It is also notable that physical activity interventions are useful for both healthy and for physically ill elderly individuals. For example, one study examined adults over the age of 70 with deficits in mobility, who were involved in a walking intervention (Rejeski et. al, 2008). The participants of this study had favorable changes in satisfaction with their physical function as well as in their self-efficacy. Based on these studies, it can be concluded that elderly individuals will exercise more regularly, increase their activity level, and will also experience positive health and psycho-social benefits based on their participation in a physical activity intervention. An important group of health promoting interventions relates to falls prevention programs. Falls are a very common occurrence in late life that put elders at the risk for further health related complications (Chang, et al., 2004). Exercise programs are widely utilized to reduce risk of falling in late life.
Diet. Interventions to improve the diet of older adults have also been advocated as important lifestyle contributors to the promotion of successful aging. Dietary interventions typically target older adults who have a chronic illness or conditions such as diabetes or obesity (Ganley, 1989; Heshka, Anderson & Atkinson, et al., 2003; McGuire, Wing, Klem, Lang & Hill, 1999). One study tested the efficacy of a dietary intervention with older adults to increase the intake of fruits and vegetables on psychosocial and food consumption behaviors (Greene, Fey-Yensan, Padula, Rossi, Rossi & Clark, 2008). The majority of participants reported maintaining a healthy diet and improved overall health. Another study compared three non-dieting interventions among obese/overweight women that focused on lifestyle change rather than weight loss. Focus of this research was on the sustainability of improvements in lifestyle behaviors, and psychological distress, and medical symptoms after two years (Hawley, Horwath, Gray, Bradshaw, Katzer, Joyce & O’Brien, 2008). After completing the trials participants were found to have reduced psychological distress and chronic medical symptoms, even in the absence of weight loss.
Interventions to Promote Planning Ahead
Interventions to promote planning ahead in late life have been generally limited to promoting the use of advanced directives in order to limit invasive medical care at the end of life (for a review see Tamayo-Velasquez et al., 2010). Although we recognize the importance of planning for a good death, we argue that the preventive functions of planful competency in late life relate to a more extended period, spanning years rather than days (Kahana, Lovegreen & Kahana, 2011). Indeed, it has been recently recognized that older adults can benefit from engagement in planning activities that are preparatory to competent coping with stressful life events that might ensue later (Aspinwall & Taylor, 1997).
A notable program, pursuing this line of intervention, offered education for promoting proactive coping competencies among community-based older adults (Bode, et al., 2007). This program succeeded in improving competencies that facilitated future oriented self-regulation. Specifically, professionals used a standard protocol for helping participants identify the advantages of preparing for the future. Participants were trained to identify proactive ways of coping with warning signals of impending problems related to aging. A parallel line of work reported by Pinquart and Sorensen (2005) focused on practical approaches to the identification and preparation for future care needs by older adults. This is a promising approach to interventions, but few examples of such program initiatives currently exist.
Interventions to Promote Helping, Volunteering, and Civic Engagement
The value of helpful engagement in the social arena has been extensively documented in the gerontological literature with regard to promoting successful aging (Kahana & Force, 2008). Such activities are beneficial for building social capital and for contributing to well-being and quality of life (QOL) of the aged (Cornwell 2011; Carr & Moorman, 2011).
A comprehensive review of programs related to civic engagement has been created by the National Council on Aging (Endres & Holmes, 2006) with the title of “Respect Ability in America.” This monograph identifies the most promising practices to promote civic engagement among older adults in the US. Thirty-four civic engagement initiatives are described that demonstrated tangible results in their local communities. These civic engagement programs were oriented toward simultaneously meeting the needs of older adults for meaningful involvement and meeting the needs of nonprofit organizations for volunteer manpower. Civic engagement has been conceptualized as a meaningful retirement role for aging Americans. Accordingly, we may consider civic engagement interventions both as facilitators of helping by the elderly and as another form of role substitution (Kaskie, Imhof, Cavanaugh, & Culp, 2008). Civic engagement relevant interventions may also contribute to system change that facilitates successful aging.
Interventions to facilitate civic engagement have targeted both very high functioning and relatively vulnerable older adults. The Experience Corps (Rebok et al., 2011), provides a civic engagement based public health intervention that brings the skills of older adults to introduce health promotion programs into public schools. Volunteer activities by elders helped support educational success of young children. By placing 12 to 20 volunteers in each school, the team structure helps develop social capital of participating elders while at the same time enhancing their self-esteem through their contributions to the younger generation.
It is notable that success has also been reported in developing and implementing intergenerational volunteer programs for frail older adults with mild to moderate dementia (George, 2010). This type of programming exemplifies our inclusive orientation toward promoting successful aging even among older adults who suffer from chronic health conditions (Young, et al, 2009). By volunteering and giving back to society, participants in this program fulfilled their own needs for generativity. They thus successfully mastered a major developmental stage of later life (Erikson, Erikson & Kivnick, 1986).
Corrective Proactive Adaptations
Interventions that Facilitate Marshaling Support
An important criterion for the maintenance of good quality of life in the face of stressful life events involves the ability to self-disclose problem situations and thereby to elicit social supports (Pennebaker & Francis, 1996). Furthermore, successful care-getting requires both initiative and advocacy by older patients (Kahana, Kahana, & Wykle, 2010). Given the propensity of older adults to be compliant, interventions designed to improve elder communication skills can serve important functions to ensure successful aging among older adults who require informal and formal supports. Typically, communication interventions have been undertaken to train physicians, nurses and other health care professionals. More recently, the potential of patient focused educational interventions to improve the advocacy and communication skills of older adults has been recognized (Kahana at al., 2011).
Patient targeted interventions have been found to be of great value for enhancing patients’ competence in the medical encounter(Auerbach, 2009). Health care is most effective when physicians interact with knowledgeable and engaged patients(Thompson, Robinson & Beisecker, 2004). Providing older patients with the tools to be active and knowledgeable partners in primary care represents a significant and much needed new approach to preventive care (Kinnersley, Edwards, Hood et al., 2008). Interventions aimed at enhancing communication skills of patients have demonstrated successful skill development, and general improvement in patient health care and health status(Griffin, Kinmonth, Veltman et al., 2004). Not only do trained older patients seek more information, but they also obtain more information from their physicians than do untrained patients (Cegala & Post, 2009).
One of the unique stressors facing older adults relates to the loss of social roles in late life (Rosow, 1967). Role losses, such as retirement and widowhood, may result in a reduction of meaningful activities and social isolation. The link between successful aging and leisure has been documented in the gerontological literature (Brown at al., 2008). Accordingly, interventions to promote meaningful participation in recreational activities, such as dancing and art, have been shown to be successful. The impact of interventions that promote arts participation on health outcomes for older adults has been the reviewed by Castora-Binkley, et al. (2010). Based on a careful analysis of the literature these authors conclude that the limited existing literature supports expectations regarding physical and mental health benefits of participation in arts programs for older adults.
Interventions to Promote Environmental Modifications
Environmental modifications can help reduce negative consequences of poor person environment fit, as explicated in the proactive aging model (Kahana & Kahana, 2003). Such interventions are particularly useful in dealing with stressors of frailty, functional limitations and disability in late life. It is noteworthy that home modifications and home improvements are far more common intervention strategies in European countries than in the United States (Kahana, Lovegreen & Kahana, 2010). The Proactivity Model of Successful Aging (Kahana & Kahana , 2003) is predicated on older adults initiating environmental modifications and using assistive devices. Consideration of interventions moves beyond such individual initiatives and typically involves professionally initiated programs.
A useful example of this type of intervention is provided by a randomized trial of a multi component home intervention that was designed to reduce functional difficulties of older adults (Gitlin et al., 2006). This study enrolled 319 community dwelling older adults who reported difficulties with activities of daily living. The goals of this intervention were to reduce home hazards, diminish the fear of falling and enhance self-efficacy in older adults with chronic health conditions. These goals effectively contribute to successful aging even in the face of health-related challenges. The treatment involved occupational and physical therapy sessions that promote home modifications and train participants in their use. The success of the intervention was demonstrated in 6 month and 12 month follow-ups. Intervention participants had less difficulty than controls in activities of daily living, had fewer home hazards and portrayed a reduced fear of falling.
While the above described treatment was focused on improving coping skills of older adults and their use of environmental modifications, other interventions are more specifically focused on environmental design. The latter approach is particularly important for helping older adults with disabilities to continue functioning independently in the community and living meaningful lives (Dewsbury et al., 2004). Home modifications as well as the use of digital technology are key to making environments accessible to older persons with disabilities. Such accessibility helps actualize the desire of most older people to remain in their homes, even when they experience functional limitations (Milner & Madigan, 2004).
Interventions to Improve Quality-of-Life Outcomes (Component E)
Those interventions that are directly aimed at improving psychological well-being outcomes, particularly as related to stressful life situations faced by older adults, may generally be classified as mental health interventions. Some of these interventions directly address successful aging in the framework of psychology, by focusing on enhancing life satisfaction or meaningfulness of late life. Others are more clearly anchored in a medical model and are oriented to diminishing mental health symptomatology such as clinical depression. Traditional approaches to interventions for enhancing mental health outcomes include medications and various forms of psychotherapy. These range from individual therapy sessions with professional psychologists, psychiatrists and social workers, to family or couples therapy, and group therapy modalities. Group therapy may sometimes involve peer-to-peer counseling in the context of support groups dealing with particular stressors, such as bereavement or a cancer diagnosis. There is some discussion in the clinical literature about underutilization of psychotherapy by the elderly, partially based on stigma associated with identifying oneself as having mental health problems (Wyman, Gum & Arean, 2006).
Prevalent individual psychotherapeutic approaches for elderly persons include cognitive behavioral therapy, interpersonal therapy (IPT), and brief dynamic therapy. It is noteworthy that these therapeutic approaches are also widely used with younger patient populations. However, modifications for special circumstances of older adults have been recommended. These include slower pace of treatment, user-friendly presentation of material, and adapting the therapy to accommodate to patients’ disabilities. Reminiscence therapy and “life review” are unique therapeutic approaches designed for older adults. Problem-solving therapy aims to address stressors faced by older patients. The literature exploring the efficacy of these therapeutic approaches generally supports their value relative to no treatment control groups (Klausner et al., 1998). However, studies are generally based on small patient populations and offer only modest evidence base for the effectiveness of these alternative approaches (Arean, et al.,1993).
Group therapy interventions have also been recommended for older adults and are seen as particularly valuable because of their utilization of peer support and their cost-effectiveness. They also offer participating patients the opportunity to practice social skills. However, there is less formal evidence for the effectiveness of group therapy compared to cognitive behavioral approaches.
A useful example of nontraditional interventions, aimed at improving the mental health of older adults who have experienced stressful life situations is provided by Mindfulness-Based Stress Reduction (MBSR) interventions. Exemplifying this technique is research by Young & Baime (2010) comparing psychological distress among older adults prior to and following an eight week MBSR intervention. This study found promising results with 141 elderly participants who showed improvements in depressive symptomatology. However, the research design did not involve randomization or use of a control group, thereby limiting generalizability of findings.
A positive aging orientation to gero-psychology interventions has been examined by Hill (2011).The interventions discussed appear to be consistent with the proactive adaptation framework, as they focus on mobilizing latent resources in response to stressful life situations. This approach recommends a focus on fostering gratitude, forgiveness and altruistic responses for the preservation of psychological well-being. Although these approaches are recommended as beneficial to the elderly, there is very limited research evidence documenting their usefulness.
A notable development in therapeutic approaches and interventions aimed at facilitating psychological well-being among older adults who are seriously ill and nearing the end of life, is offered by “dignity therapy” developed by Chochinov and associates (2005). The aim of this therapeutic approach is to address the psychosocial and existential distress during this highly stressful and often lonely phase of life. In the course of this therapy patients are invited to discuss issues that matter to them most and how they would want to be remembered. Therapy sessions are transcribed and edited and then offered to the patient as a potential bequest to friends and family. Having established the feasibility and usefulness of this approach, Chochinov and collaborators developed a Phase two randomized controlled trial in order to assess the acceptability and potential effectiveness of this novel method (Hall at al., 2009). They observed encouraging results and are currently proceeding to a formal Phase 3 trial.
A meta-analysis of psychosocial interventions to prevent depression in older adults was conducted by Forsman, Schierenbeck & Wahlbeck (2011). Based on 30 different research studies representing prospective controlled trials, the authors conclude that overall psychosocial interventions had a small but significant effect on reducing depressive symptoms. It is noteworthy that social activity-based interventions had the most consistent positive effects. In contrast, physical exercise, skill training, and reminiscence did not prove to be highly effective.
As we consider the different approaches to interventions it becomes clear that the mechanisms utilized to achieve better psychological outcomes often overlap with interventions targeting social supports or proactive adaptations. It is also important to note that patient evaluations of the efficacy of various approaches to treatment of depression are often at variance with formal professional evaluations. The opportunity now exists to evaluate patient perspectives on the relative value of different forms of self-care as well as professional treatments to address depression or other mental health problems. On websites such as CureTogether.com, patients cite physical exercise as the most prevalent and efficacious approach to diminishing clinical depression. These new self-empowerment approaches to crowd-sourced interventions offer a glimpse of new directions for interventions of the future.
This review of interventions to promote successful aging is limited in scope. The interventions described cover a very broad range and are intended to be illustrative rather than exhaustive. Since the majority of gerontologically focused interventions used limited research designs, typically there was little information on effect sizes, long term effects, treatment fidelity or dissemination. Consequently, our review focused on the diversity of existing approaches and does not provide rigorous methodological detail about the interventions reviewed. Some of the meta-analyses cited on specific topics, such as exercise and illness management offer further methodological detail. The important consideration of individual and contextual influences that are likely to impact the uptake of interventions were also beyond the scope of this review. It should be noted that the full descriptions of the Proactivity model address the role of both temporal and spatial contextual influences( Kahana & Kahana, 2003). A final intriguing unanswered question relates to the potential and actual cumulative effects of interventions that target distinct components of the model.
Our review of the literature suggests that innovative interventions can play important roles to facilitate successful aging by reducing stress exposure in late life, by enhancing social supports and coping resources and by promoting the use of both preventive and corrective proactive adaptations by older adults. Furthermore, we found evidence that interventions can also directly enhance psychological well-being and meaningfulness in late life among older adults. We have been impressed by the diversity of approaches that have been employed to enhance successful aging and quality of late life. A wide variety of programs have been implemented by professionals, organizations and even through grassroots community efforts. We also see indications of great resilience among elderly persons, as reflected in their desire to participate in programs and as they undertake and welcome initiatives to cope with challenging life situations. Existing interventions have been described as useful or promising, even though the evidence base for such conclusions is typically not very strong. Our review of interventions followed trends in the literature that focus on relatively small-scale programs. Effect sizes and long term benefits of interventions are rarely available. We anticipate that methodological approaches of interventions that can contribute to successful aging will improve in time and that evidence based guidelines will become more readily available. At the same time older adults can also benefit from new and creative approaches to interventions. In concluding our discussion, we also want to affirm the key importance of universal safety nets such as Social Security and Medicare in the U.S. that comprise the backbone of interventions and social programs that enable older adults to age successfully.
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