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BOOK REVIEW |
School of Public Health University of Minnesota Minneapolis, MN 55455
Aging in Good Health: Multidisciplinary Perspectives, edited by Sue E. Levkoff, Yeon Kyung Chee, and Shohei Noguchi. Springer Publishing Company, New York, 2001, 356 pp., $48.95 (cloth).
Health Promotion and Aging: Practical Applications for Health Professionals, 3rd edition, by David Haber. Springer Publishing Company, New York, 2003, 483 pp., $59.95 (cloth).
Public Health and Aging: An Introduction to Maximizing Function and Well-Being, by Steven M. Albert. Springer Publishing Company, New York, 2004, 287 pp., $46.95 (cloth).
Successful Aging and Adaptation With Chronic Diseases, edited by Leonard W. Poon, Sarah Hall Gueldner, and Betsy M. Sprouse. Springer Publishing Company, New York, 2003, 252 pp., $48.95 (cloth).
These four books, two single authored and two edited collections, deal with health matters. Conceptually, they raise intrinsic difficulties in sorting out the material. My original fascination was the challenge of considering a new book, Public Health and Aging: An Introduction to Maximizing Function and Well Being, by Steven M. Albert. Public health and aging are rarely tackled in a book-length treatment. Not since a volume of the same title (but without the subtitle) edited by Hickey, Speers, and Prohaska (1997), has anyone tried to capture that territory. That 1997 volume, the result of a 1994 conference, was in itself an unusual endeavor. Hybrid that I am, as a self-proclaimed gerontologist who for 20 years has drawn my paycheck as a faculty member of a school of public health, I have an interest in trying to decide the extent to which my work on aging and long-term care truly belongs to the field of public health, and I am motivated to explore what a public health approach to aging might look like in the current century.
Public health concerns itself with the health of populations and with the prevention and early identification and treatment of disease in populations. So, too, does the Albert book, quite imaginatively, creatively, and with extensive scholarship, though it does not do so comprehensively. For instance, the Albert book does not claim to deal with public health practice, a topic that is well handled by David Haber's book, Health Promotion and Aging: Practical Applications for Health Professionals, now in its third edition. Meanwhile, both these books and the two other edited collections required me to ponder the boundaries between public health issues and health care per se, which are particularly murky when the population under consideration is an older one. Further, this set of books provokes questions about how health care policies for seniors fit into public health concerns. At this historical juncture, proposed changes in Medicare, Medicaid, and even Social Security should certainly be considered public health issues. Finally, and most fascinating to me, is the issue that is illuminated to some extent in all these books, about the proper outcomes to consider as goals of effective public health programs and policies for older people. Are successful aging and a good quality of life on the table? Steven Albert would say yes. And if the good life is on the table, how should the good life be defined, and how should disparate goals related to well-being be prioritized?
This group of books suggests the confusing relationships among public health, health care, health policy, and successful aging. These distinctions are much more perplexing when seniors are being considered because older people are usually under routine health care and because many investments related to the prevention of health problems for older people occur much further upstream. I also tried to fit any generalizations into the lives of my parents: my mother, who experienced her last illness and death at age 89 during the months the books were in my charge, and my father, who is living in his home in the community at age 97. Between them, they could lay claim to many of the chronic illnesses and disabilities that older people are prone to and that public health programs try to prevent, mitigate, screen for and treat early, or treat in such a way that complications are prevented. Of course, working from individual cases to population approaches is risky, but I do think our thoughts should travel in both directions as we think of the well-being of individual old people and of older populations.
Before I attempt some cautious generalizations, I will lay the groundwork and do my reviewer duty by briefly discussing each book, in chronological order of publication.
Levkoff and Colleagues on Aging in Good Health
Aging in Good Health: Multidisciplinary Perspectives is edited by Sue E. Levkoff, Yeon Kyung Chee, and Shohei Noguchi. It attempts in 20 chapters to review aspects of good health from four perspectives: six chapters on psychological understandings of aging, four chapters on sociological understandings, six chapters on biological understandings, and four chapters on service delivery. Inevitably, the chapters are uneven and many are unsatisfactorily general. The choice of chapters at times seems idiosyncratic as well. For example, a chapter on music therapy and its role in successful aging gets equal space in the psychological section with chapters on stressful life events, life review, emotional health, spirituality, and family.
In the introduction, the editors explain their project in terms of successful and productive aging. They define the former as "arriving at a level of physical, social, and psychological well-being in old age (p. 4)," reminiscent of the language of the World Health Organization's venerable definition of health. They define productive aging as "engagement over a lifetime in paid or unpaid activities that produce goods or services valued by the self and by society" (p. 4). (Only consider how far we will need to go to make a definition like this operational!)
The book achieves its goals of being multidisciplinary, but it is left for the reader to pull it all together into a picture about health and well-being. Some of the chapters provide particularly helpful overviews of research on a topic. Especially, I commend Xing-jia Cui and George Valliant on stressful life events, Chee and Levkoff on alcohol abuse in old age, and Maria Fiataroni Singh on integration of exercise and nutrition in geriatric medicine. The last, in particular, is a virtuoso interpretative trip through extensive research. Its critical approach to its 80 citations contrasts to the tone and organization of the majority of chapters. Also noteworthy is the interesting essay on spirituality written by Miles Sheehan. Most chapters, however, are more introductory. This volume could be utilized as a text for a beginning course, but the instructor would need to connect the dots to illuminate what it really says about its title theme, aging in good health.
Poon and Colleagues on Successful Aging and Adaptation to Chronic Illness
Successful Aging and Adaptation With Chronic Diseases, edited by Leonard W. Poon, Sarah Hall Gueldner, and Betsy M. Sprouse, is more focused than the volume by Levkoff and colleagues. It is built around several research projects funded by the AARP-Andrus Foundation. As such, its chapters present a broad range of studies, including those entailing original data collection, those entailing analysis of large data sets, and those presenting literature reviews. The driving impetus for the collection was consideration of how chronic disease affects everyday life and successful aging.
The first section deals with the now-familiar formulations of successful aging by John Rowe and Robert Kahn (1988). This paradigm for success required a combination of physical health (absence of selected chronic diseases of late life, no limitations in seven activities of daily living [ADLs], physical health, and absence of key risk factors for ill health), high physical and cognitive functioning, and high social engagement. In the first section, William Strawbridge and Margaret Wallhagen present empirical data to show the imperfect match between older persons' perceptions of successful aging and the definition expressed by Rowe and Kahn. In Chapter 2, William Rakowski and colleagues present data from a small qualitative study done in assisted living settings (increasingly a place for convenience samples of older people presumed to have some health problems and disability) to examine the relationship between reciprocity and perceived successful aging. In passing, they note the lack of attention among assisted living staff to ways they could enhance the residents' likelihood of being involved in the giving end of reciprocal relationships.
In a commentary, Kahn thoughtfully and without defensiveness discusses the construct of successful aging as he and Rowe developed it. Referring to critiques of successful aging by Matilda White Riley and others, as well as to the critiques inherent in the first two chapters of the Poon volume, he concedes limitations to the Rowe-Kahn formulation and concludes that the Baltes selection-optimization-compensation (SOC) model (which emphasizes how individuals can make the most of what they have) is complementary to the Rowe-Kahn approach. He also concludes that Riley's emphasis on dynamic societal processes is critical to consideration of how opportunities can be provided to enhance individual success. Indeed, incorporating the Riley approach moves the whole dialogue away from individual biology and functioning to what could become a public health approach to promoting successful aging for populations.
The other two sections of the book follow the same model as the first, with a number of formal papers followed by reaction chapters. The middle section presents work with large data sets to illuminate "health expectancy" and raise interesting measurement issues. The last section turns to the subject of coping with chronic illness, presenting both reviews of existing research and the results of a study by Janice Penrod, Gueldner, and Poon on how 122 older people coped on an everyday basis with chronic illness and stayed in control of their lives. The two discussion chapters raise interesting questions, including the relative role of distal influences in coping with chronic illnesses in old age, and a post-modern critique of an overly mechanistic approach to successful aging. This is not a particularly easy book to read, but it is worthy of the effort because of its many nuances. The bottom line, expressed by Peter Martin in his comment on the last section, is that these related studies demonstrate that "successful aging should be defined not by the absence of disease but rather by the way people cope with the disease" (p. 219). Perhaps this is not a blinding insight, yet so many of our policies and programs are oriented towards controlling morbidity and mortality that it is worth remarking.
Haber on Health Promotion and Aging
David Haber has established his expertise in three editions of his volume, Health Promotion and Aging. Steven Wallace reviewed the 1999 edition in this journal as part of an essay that discussed how an individual, as opposed to a community, focus dominates health promotion activities, American style (Wallace, 2000). That review commended the book to a wide variety of health professionals because of its practicality as well as its reliance on up-to-date research evidence. The new edition remains evidence-based (the author mentions in the preface that it contains 450 citations appearing between 2000 and 2003), and it is still pragmatic, replete with checklists, tools, illustrations, resources, and discussion questions. Refreshingly, the author refuses to cling to a comprehensive theory to guide interventions that would change health behavior. He reviews such theories on health behavior, but reaches what he calls the "politically incorrect" conclusion that no theories are sufficiently powerful to use in designing interventions. Rather, his strategy is to build interventions based on clinical observations, research findings, and concepts that appear useful and to use theory to further refine interventions or interpret results. As a result, his "ten tips for changing health behavior" have the ring of truth. Haber's book is easy to read, and he liberally and usually successfully uses humor to make his points.
The added material in the 2003 edition moves the book towards greater inclusion of social outcomes and towards more discussion of societal, as opposed to individual, choices. The sections added or particularly enhanced are health behavior, complementary and alternative medicine, mental health, diversity, and public health. The concluding section on public health briefly lists public health functions and describes the lack of emphasis on aging in the public health establishment. The bulk of the chapter presents a whimsical view of a set of policies and programs that the author, were he in charge of the country, would consider more ideal, which includes a cabinet-level Wellness General to replace the Surgeon General, whose operational programs will be financed by a junk food tax, and an NIH Wellness Center to replace the Center for Complementary and Alternative Medicine. Wellness goals will be promulgated and monitored, in part, through additional performance measures to be added to the indicators that are part of the Health Plan Employer Data and Information System (HEDIS) indicators used to accredit managed care programs. Universal health insurance continues to be one of Haber's major public health recommendations, along with the full financing of tested health and wellness promotion activities. He also makes passing reference to providing more humane long-term care environments. Unlike the many detailed chapters on health promotion, these policy recommendations are a bit off-the-cuff and not buttressed by research.
Personally, I am not fond of the term "wellness," perhaps because of too much exposure to "wellness nurses" in assisted living settings who are not authorized to provide direct care to a population much in need of good management of their chronic diseases. The name aside, a national wellness focus without clear definitions of what such a focus might mean for octogenarians and those even older might emphasize younger people and limit initiatives for seniors to a narrow range of initiatives, such as disease screening, smoking cessation, flu vaccines, and exercise programs. These would be logical starting points, and probably could continue to fly under the banner of health promotion. Although I would avoid the term "wellness," the concept of an expanded definition of well-being is a good one, and for that we turn to the last book.
Albert on Public Health and Aging
Steven Albert uses the term "public health" in his title, and his is the volume in this quartet most pertinent to classic consideration of the health of populations as illuminated by epidemiological research. Indeed, Albert places his concern at the nexus of clinical geriatrics in the title of his first chapter, "Between Clinical Geriatrics and the Epidemiology of Aging—Defining Public Health and Aging." The chapters that follow include rich material on the demography of aging (Chapter 3), mortality (Chapter 4), and morbidity or disability in old age (Chapter 5). Chapter 5 is particularly helpful in its identification of the varying ways that the World Health Organization has modeled disability and illustrates the implications of each for a research and policy agenda. Chapters 6 and 7 look in detail at cognitive impairment and at affective function, respectively, as population problems; affective function is broadened beyond mental illness to examine neglect and abuse and social isolation.
The most unique and noteworthy feature of the Albert book is its articulation of desired outcomes to include successful aging and quality of life. Chapter 2 contains a cogent discussion of how that much-bandied concept "successful aging" has been specified and discusses the work of Strawbridge and Wallhagen, which appears directly in the Poon volume. Like others, he casts appropriate doubts on the validity of the Rowe and Kahn objective constructs for successful aging, given that the real drama of later life includes adaptation to and management of a variety of chronic diseases and functional limitations. Like the Poon contributors, he finds Rowe-Kahn criteria too narrow given the widespread prevalence of chronic diseases after one's middle years and the prevalence of disability in those age 65 and older. Surely, successful aging and the good old age should be defined in that context rather than requiring absence of disease and disability. But, then, what should the criteria be? Is it, after all, possible to posit universally applicable criteria in a world of infinite individual and cultural variation? It is to Albert's credit that his book encourages pondering these questions.
Albert's key dependent variable is quality of life (QOL), which he discusses in the all-important last chapters of his book. He makes the usual distinction between health-related QOL, which he sees as most related to clinical indicators of health, and what he calls, somewhat awkwardly, "non health or environment-based QOL." He sees measures in this latter sphere as belonging to the social indicators or social ecology tradition. Health-related QOL domains, he suggests, include patient reports of functional status, discomfort, pain, energy levels, and social engagement and will, therefore, track more closely with clinical indicators of health than with broader QOL domains, such as "the capacity to form friendships, appreciate nature, or find satisfaction in spiritual and religious life." There follows an effort to identify domains in both health-related and non-health-related QOL. The former is built around features of daily life or health status likely to vary as health status varies or respond to health care, such as functional status and disability, mental status, emotional well-being, social engagement, and symptom status. The latter, he posits, includes aspects of the natural and built environment, such as economic resources, housing, air and water quality, community stability, access to the arts and entertainment, as well as an individual's personal resources. Although not specified in the book, perhaps those personal resources would mirror but go beyond the community resources in the built environment to include housing, income, social milieu, companionship, stimulation, and perception of meaning in life. Albert argues that non-health-related QOL would not be improved as a result of health care interventions.
Albert then plays out a QOL paradigm with examples. He shows how health-related QOL can be measured by cross-tabulating self-perceived physical health and self-perceived mental health. Under such a measure, older people do fairly well because they tend to report relatively positive mental health. He also presents a 30-cell model based on cross-tabulation of a 5-point measure of self-perceived health and a 6-point measure of activity limitation. With this model, community-dwelling people age 65 and older tend to be in cells representing worse perceived health and more functional limitation. Albert then discusses efforts to apply utility weights ranging from 1 to 0.1 for the 30 cells and speculates on the cost effectiveness of various programs that might move an older person from a lower to a higher cell through health interventions. He makes this difficult and abstract content come alive by positing an older person who had a heart attack at age 60 and experiences Parkinson's disease symptoms beginning at age 66. Any of us can imagine such a person in our families or among our acquaintances. Although the mathematics may be jarring to a humanist, the exercise raises a compelling question: What is a move among various cells that reflect health-related QOLs worth as an investment, compared to other investments that could be made on behalf of older people or people of any age?
By contrast with health-related QOL, Albert turns to non-health-related personal or environmental QOL and suggests these outcomes need not decline and might actually improve with age. Citing the work that preoccupied Powell Lawton in the last decade of his life (Lawton, 1991), he points out that frail older people will have better QOL if they have a "loved spouse, a fulfilling relationship with a child, an area of expertise that can be applied despite the illness, a sphere of life where autonomy can still be exercised, or an ideology that organizes the meaning of pain, suffering, life, and death" (p. 212, quoting Lawton, p. 8). Albert, as did Lawton, suggests that it is this sort of QOL that is the basis for attachment to life and the desire to survive and cope with the effects of illness.
To some extent people can try throughout their lives to structure their internal and external worlds to promote non-health-related QOL. But promoting such QOL on a population basis is surely a job for public health.
In his last chapter, Albert applies a public health paradigm to aging, using examples such a preventing falls, strengthening independence, applying "preventive cognitive remediation," promoting chronic disease management, making patients and families partners in medical care, and curbing polypharmacy. In his last 15 pages, he tackles the issue of enhancing the care environments in institutions and in the community as a public health effort. Despite use of a term that cannot too soon be antiquated, "custodial care," and despite the necessary brevity of the section, the book ends in contemplating what I see as the most important challenges ahead, namely, findings levers to change the quality of life for the most frail and bereft among us, including some with advanced dementia. The suggestions, briefly touched on, involve environmental change, training and support of care personnel, support of family, breaking down rigid barriers between palliative care and curative care, and even modifying the philosophy of care to emphasize values that are most important to the person. In short, Albert has written a commendable addition to the small body of work on public health on aging, and I recommend that it be in the library of gerontologists concerned with the topic.
Connecting the Dots
Where do these books point on the road to better old age for populations using the full array of health care and public health measures? Without ignoring the presence and ever-present threat of infectious diseases, all authors and editors concur that chronic diseases are a dominant fact of later life. Years ago, an elderly colleague told me that the secret to a long life is to get a chronic disease and take good care of it. Agreement seems widespread that the first stop for individual efforts to enhance health, functioning, and well-being for many older people is with their health care providers. At the same time, all these books make the point that some broad vision of well-being in later years should be the goal of both public health and health care. Successful aging, productive aging, and quality of life are among the terms used to expand the vision beyond health status and even functional status.
The Haber book also provides recommendations for screening intervals for various diseases and conditions, suggests positive health behavior, and proposes programs that might work to promote a healthy lifestyle for older people outside the auspices of health care. It seems the case for exercise has been well made. Yet it also seems that exercise only takes one so far. Both my parents believed in being active, doing floor exercises, walking, and swimming. I have been asking myself whether my father continues to be healthy because he continues vigorous activity into his late 90s, or whether he continues to be active because he is relatively healthy. When my mother stopped exercising and became sedentary, did that cause or result from her poor health? Even longitudinal data do not fully answer this question. We can know about exercise levels across the life span but still not pinpoint the timing of more subtle physiological changes well enough to explain causal relationships.
Early habits of the body and mind may, of course, postpone disease and help the individual summon coping skills. Snowden's elegant study of aging nuns (2001) showed a relationship between the ability to use language in complex and nuanced ways in teenage applications to enter the order and the likelihood that the same person would develop Alzheimer's disease in old age. Inevitably, I return to individual circumstances. My mother's linguistic skills did not protect her from Alzheimer's disease but perhaps had something to do with her ability to continue doing difficult crossword puzzles when recent memory and reasoning were severely compromised. That she was able to live in the community until a final 2-month-long hospitalization and a few days of posthospital nursing home care may, in part, be a testament to strategic SOC techniques (making the most of what she had) but was even more a tribute to the support system created by my father and other relatives. In terms of the public policy nexus, the Canadian health system with its universal coverage surely also helped her through many of her earlier health milestones, such as breast cancer at about age 70, osteoporosis, and chronic bronchitis.
At a certain point in the life cycle, the issue of prevention is almost moot, other than with reference to the prevention of complications of illness and its treatment or disability and its management. Chronic diseases and disability will hold sway for many people, and we are left with determining how to define and promote as good a life as possible. Attendees at the 2004 annual meeting of The Gerontological Society of America all received a slim volume, courtesy of Merck and the Centers for Disease Control and Prevention, which provided a national and state-by-state report card on the health of older people and showed improvement in 15 selected markers over time (Centers for Disease Control and Prevention, 2004). Some of the markers were outcomes related to disability and sickness status and to particular conditions, such as hospitalization for hip fracture and losing all one's teeth. Other markers were indicators of receipt of preventive services, such as screening for specific diseases or vaccinations. The authors used the data they had at hand to point out that despite improvement, we have fallen short of even modest goals and that state-by-state variation is considerable. This was a useful example of how one can display and use health data and was accompanied by action steps towards better results on each of the measured outcomes.
In time, we could hope to generate displays of other indicators of well-being that are more social and psychological in nature. The list would surely include being in a nursing home (as a negative marker), which we know has substantial interstate variation and perhaps even income and housing parameters in old age. At the individual level, we also need to bite the bullet and collect and benchmark quality-of-life measures, which can best be gathered by self-report of the older people involved. I would also like to see other documents that display information on aging-friendly communities, which would highlight transportation systems, public safety, housing, cultural opportunities, service availability, and, if possible, participation of frail older people in mainstream community life. Perhaps as nursing homes as we know them change to more livable settings, we will also be able to benchmark their variation on matters other than bedsore and infection rates.
Public health as a field developed with a huge and appropriate emphasis on preventing or postponing death and disease. We have not, as yet, given a great deal of attention to the end game emphasis—to markers of a good death, of an as-good-as-possible life with Alzheimer's disease or other cognitive impairments, or of a good life with serious chronic illnesses. Albert starts us off in that direction. He did not connect the dots as to how a public health paradigm might promote such outcomes. Yet, we can try to do so, using the key public health activities identified in a landmark Institute of Medicine (IOM) study on the future of public health (Institute of Medicine, 1988) which offers some clues. The IOM committee organized public health activities under the rubric of assessment (e.g., surveillance of health status, analyzing causes of disease and disability, research on determinants of health, and outcome evaluation), policy development (e.g., planning, training, mobilizing resources, and advocacy), and assurance (e.g., monitoring, encouraging the private sector, providing services, and regulating).
All the public health activities that the IOM listed can be applied in a positive way to aging, using a much broader approach to outcomes than do health and functional parameters alone. To take just one example, we may do well to ponder what a regulatory system would look like if it gave weight to quality of life as much as safety. If we began looking at determinants of the good life for people with health problems, I suspect that we will find that one of the determinants is absence of ageism. This, in turn, would lead to a research focus on ageism and how that phenomenon varies. (Of course, even to reach this conclusion, we would need to make the construct "ageism" conceptually operational at the community level, so as to grade or characterize communities in terms of attitudes towards older people.) If older people with disabilities start appearing with greater frequency in public (at shopping centers and movie theaters, on buses, and at weddings and other private gatherings), arguably the life circumstances for older people with health problems will be altered for the better, as will the circumstances of elderly family members. Some such greater acceptance will come as the large baby boom age cohort affects social institutions and popular culture.
The dots to public policy also need to be connected. Let's take a few examples. Consider the Americans with Disabilities Act (ADA) of 1990, which established the right to accommodations for people with disability in workplaces and elsewhere. The Olmstead Supreme Court decision of 1999, which reinforced that people with disabilities have the right to care in community settings integrated within the mainstream, was based on the ADA. A series of grants to states from the Centers for Medicare & Medicaid Services issued annually thereafter provides resources and technical assistance to that end. Older people and their advocates and public health authorities could use this policy plank as a way to improving quality of life in old age. The ADA can be a vehicle for better transportation policies, more individualized medical equipment policies, and a more user-friendly form of personal assistance services to extend the effects of home health care. Up until now, the ADA has most often been applied to younger people with disabilities, but virtually every older person eligible for a nursing home has a disability that qualifies for accommodation under this legislation.
Many other examples could be suggested. Medicare and Medicaid policies could be reshaped to advance well-being in old age. At present, much home care available to seniors is home health care, offered to those who are homebound. If we were to make personal assistance programs available that enable the older person to get assistance to pursue activities in the community, we would enhance well-being. Some funded programs are too narrowly framed, such as transportation assistance that is earmarked for medical reasons or restrictions on electric wheelchairs under Medicare to many seniors deemed unable to make enough use of them. My 97-year-old dad is legally blind; transportation policies and programs that allow him to shop and lead a social life are available in Ontario. They could even help him travel to a nursing home where we believe he will volunteer, and perhaps the social stimulation of that activity might help prevent him from ever needing to move in.
A basic public health paradigm addresses individual risk factors and promotes appropriate services to maximize well-being. Such services should enhance individual efforts, such as coping by providing both social and environmental supports. But such efforts need to be played out on an individual basis, taking into account that person's health conditions, social circumstances, personality, and preferences.
At the very least, our next generation of gerontologists and public health researchers concerned with aging will need to study and improve the built environment and the policy environment if older people are to be able "to make the most of what they have" towards well-being in later years. It is appropriate that two of our most distinguished gerontologists, M. Powell Lawton and Matilda White Riley, both of whom are sorely missed, are evoked in these books. Their kind of research and conceptualization is the sort needed to get a grasp of how to promote population health in the broadest sense in later years.
References
This article has been cited by other articles:
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  A. Bowling and S. Iliffe Which model of successful ageing should be used? Baseline findings from a British longitudinal survey of ageing Age Ageing, November 1, 2006; 35(6): 607 - 614. [Abstract] [Full Text] [PDF]
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