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Article Contents

C ognitive d ecline, d epression, t he h ormonal f ountain of y outh, f railty /s arcopenia, c ardiovascular d isease, i mmune s ystems and a ging, “t he m erchants of i mmortality ”, s ystems in g eriatrics, c onclusion.

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The Top 10 Hot Topics in Aging

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John E. Morley, The Top 10 Hot Topics in Aging, The Journals of Gerontology: Series A , Volume 59, Issue 1, January 2004, Pages M24–M33, https://doi.org/10.1093/gerona/59.1.M24

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I enjoy talking with very old people. They have gone before us on a road by which we, too, may have to travel, and I think we do well to learn from them what it is like. —Socrates, in Plato's The Republic

EACH year in January, I have tried to review the cutting edge of geriatrics over the previous 2 years ( 1 , 2 ). This review is based to some extent on the high impact articles in the literature ( 3 , 4 ), but also on emerging areas. The Journals of Gerontology Series A also continue to welcome articles from some of our distinguished colleagues who have gone before us on the exploration of the wonders of aging and remain active contributors to the field of gerontology ( 5–8 ). This year, being my last year as editor of the Journal of Gerontology: Medical Sciences , I have decided to list what I believe are the top 10 hot areas in geriatrics.

There is no question that finding solutions to cognitive decline and the behavioral problems associated with it is a central area in geriatrics ( 9–11 ). Our knowledge of the pathophysiology of Alzheimer's disease is moving forward rapidly. While beta-amyloid has taken center stage, both as a neurotransmitter that produces learning and memory disturbances ( 12 , 13 ) as well as an initiator of tissue destruction, possibly through free radical activation ( 14 , 15 ), there is also increasing understanding of the tauopathies ( 16 ). A recent article showed that measuring tau protein in lip epithelial tissue could possibly be used to diagnose Alzheimer's disease ( 17 ).

There is an increasing awareness of the importance in early recognition of mild cognitive impairment ( 18 , 19 ). Acute illness causes not only short-term but also long-term functional decline in persons with preexisting cognitive impairment ( 20 ). In particular, it is now becoming clear that cognitive decline is associated with a decline in physical performance ( 19 , 21–27 ). This is in part due to the decrease in reaction time associated with central nervous system damage ( 22 ). Cognitive dysfunction, whatever the cause, is associated with a high rate of medical comorbidity ( 23 , 28 ) and earlier mortality ( 24 , 29 ). The effects on mortality are worsened when cognitive dysfunction coexists with depression ( 29 ).

Over the last decade, there has been much enthusiasm for the possibility that hormone replacement therapy may improve cognition and slow progression of Alzheimer's disease ( 30–33 ). However, the Women's Health Initiative (WHI) in older women showed that hormone replacement therapy resulted in both a greater degree of cognitive dysfunction and an increase in the incidence of Alzheimer's disease ( 34 , 35 ). At the same time, as these results have become known, there is an increasing belief that testosterone in males may improve cognitive function ( 36–38 ). A relationship between elevated homocysteine and vitamin B 12 and folate deficiency with Alzheimer's disease has been found ( 30 , 39 ). Other studies have suggested that hypercholesterolemia may play a key role in the development of Alzheimer's disease and worsening cognitive function ( 40 , 41 ). Centenarians with high HDL (high-density lipoprotein) levels have better cognitive function and exceptional longevity ( 42 ). It is possible that cholesterol-lowering, especially in mid-life, results in a decline in atherothrombotic brain infarction, which may, in itself, be a causative agent for Alzheimer's disease ( 43–46 ).

In the arena of treatment for Alzheimer's disease, data continue to emerge that cholinesterase inhibitors slow the progression of the disease ( 9 ). Memantine, a drug that modulates the glutamate/NMDA system, can now be added to our therapeutic armamentarium and may prove useful either alone or in combination with cholinesterase inhibitors ( 47 ). Studies continue to appear that gingko biloba is a useful therapeutic adjuvant for persons with Alzheimer's disease ( 48 ). The effects of gingko appear to be equivalent to some of the more mainstream therapeutic agents ( 49 ). There is an urgent need for high-quality, large (i.e., sufficiently well powered) studies utilizing this agent. An exciting recent study has shown that aerobic fitness reduces brain tissue loss in humans ( 50 ). Resistance exercise has recently been shown to improve function in people with dementia ( 51 ). These findings strongly reinforce the calls in the Journals to continue to exercise throughout life and maintain healthy lifestyle habits in order to compress morbidity ( 52–55 ).

While antibodies to beta-amyloid can reverse cognitive dysfunction in mice ( 48 , 49 ), the human immunization studies led to disastrous consequences, with some of the patients developing an inflammatory disease of the central nervous system ( 56 ). Thus, while we await the potential of antisense to beta-amyloid that can switch off its production or drugs that can inhibit the function of the amyloid precursor protein cleavage enzymes (secretases) ( 10 , 57 , 58 ), most of the care of patients with Alzheimer's disease still need to focus on end-of-life care ( 59 ). As has been demonstrated by Simmons and colleagues ( 60 ), feeding the older demented patient takes an inordinately long time. New methods need to be developed to accurately quantify the amount of food consumed by older patients ( 61 ). Protein energy malnutrition can cause a marked decline in quality of life in nursing homes ( 62 ). Small changes in the emotional status of institutionalized elders can markedly alter food intake ( 63 , 64 ). Innovative programs such as the “Eden” alternative or even mechanical pet therapy need to be put in place to improve quality of care in nursing homes ( 65–68 ). As so eloquently suggested by John Schnelle ( 69 ), we need to “capture the voice of cognitively impaired elders” to improve their quality of life. Kane and colleagues ( 70 ) have provided one approach to doing this. Kane ( 71 ) has also called for professionals who have the experience of having loved ones cared for in long-term care facilities to band together in an attempt to find new solutions that will improve the quality of care in institutions. Volicer ( 11 ) has provided great insight into the management of behavioral systems in the demented person. It is important to realize that behavioral management and appropriate attention to the caregiver's needs are far more powerful tools than the use of drugs to deal with behavioral problems. The recent explosion of the use of expensive antipsychotics, any of which have no proven efficacy, to treat behavioral problems in nursing homes is particularly to be deplored!

Finally, there is an increased awareness of the problems associated with driving in older cognitively impaired individuals and the need to more fully develop adequate transportation systems ( 72 , 73 ). Richardson and colleagues ( 74 ) have highlighted the importance of visual attention in maintaining driving skills. Global positioning devices are emerging as the best way to test true driving skills in older persons ( 75 ). Given the horrendous accident that occurred in California when an older person drove into a group of persons and couldn't stop, better testing tools are badly needed! Previously, a survey of geriatricians suggested that they have little comprehension when an older person is no longer a safe driver ( 76 ).

An excellent review by Dan Blazer has summarized that state of the art for the management of depression ( 77 ). Depression remains underrecognized and undertreated in older persons, highlighting the need for continued screening ( 51 , 53 , 63 , 78 ). Physicians need to be made more aware of the effectiveness of treatment for depression. This is particularly important, as depression is associated with worse outcomes following a myocardial infarction, in persons with diabetes or congestive heart failure, or in those undergoing rehabilitation ( 55 , 77 , 79 ). Persons with depression are more likely to fall ( 80 , 81 ). Depression is also associated with increased mortality ( 29 ). The good outcomes seen with electroconvulsive therapy, particularly when bipolar electrodes are used, needs to be more widely advertised among physicians and the elderly population. In addition, resistance exercise has been shown to be an excellent adjuvant therapy for depression ( 82 ).

The importance of mobility as an emerging area in geriatrics was highlighted by the fact that a single issue of the Journals was devoted to this topic ( 83–88 ). Lan and colleagues ( 89 ) have developed an objective index of mobility-related limitation. Walking speed is becoming recognized as an excellent measure of function. The ability to walk rapidly over a distance involves not only muscle strength ( 90–92 ), but also the integration of cardiovascular fitness ( 86 ), vision ( 93 ), postural stability ( 94 , 95 ), pain ( 91 ), and cognitive processing time ( 96 ). Habitual walking has been shown to decrease the onset of physical disability in older persons ( 97 ).

Undernutrition continues to be demonstrated to be a major factor associated with mortality in older persons ( 98 ). DeCastro ( 99 ) has painstakingly demonstrated the changes in eating behavior that occur with aging, including the decreased snacking between meals, that lead to the physiological anorexia of aging ( 100 , 101 ). Abnormal eating behaviors such as dietary restriction occur commonly in older women ( 102 ), but only in the minority of cases do they lead to disease processes such as recurrence of anorexia nervosa or anorexia tardive ( 103 ). The physiological factors involved in the pathophysiology of this aging-related anorexia have been recently reviewed in the Journals ( 95 , 104 ). Ghrelin, a hormone that stimulates eating and releases growth hormone, is emerging as a potentially important hormone in the regulation of feeding behavior. It is released from the stomach in response to fasting. Studies so far in older humans have shown no change or a small decrease with aging ( 105 , 106 ). PYY (3-36) , another gut hormone, has been shown to inhibit feeding in humans ( 107 ) and cause weight loss in mice ( 108 ). To date, however, the best evidence for the early satiation that occurs in older persons implicates cholecystokinin ( 109 ).

New approaches to the management of weight loss in older persons have included using taste enhancers ( 110 ) and giving caloric supplements between meals rather than with the meal ( 111 ). A clearly emerging area is the use of orexigenics to stimulate appetite ( 112 , 113 ). Yeh and colleagues ( 114 ) have shown in a controlled trial that megestrol acetate produces weight gain in malnourished older persons. Its effect appears to be mainly due to inhibition of cytokines. The orexigenic effect of megestrol has been confirmed in other studies ( 115 ). Megestrol, however, does decrease testosterone levels in males ( 116 ). Thus, in males, when it is used, consideration should be given to giving testosterone at the same time. Females have better weight gain than males when they are given megestrol. For centuries, cannabis has been known to create the desire to eat ( 117 ). Recently dronabinol, a pure tetrahydrocannabinol, has become available as an orexigenic. It has a smaller orexigenic effect than does megestrol. Its ideal use is most probably in the palliative care arena, where, not only does it increase food intake, but it also decreases pain and nausea and improves mood. There is a need for large studies to determine the utility of orexigenic agents in the treatment of undernutrition.

Unfortunately, little attention is being paid to the role of vitamin and trace element deficiency in the pathogenesis of functional impairment in older persons. Certainly, they can play an important role in delirium; now that the yellow intravenous multivitamin (“banana bag”) mix is widely available again, consideration should be given to its use in older hospitalized patients. Urinary incontinence is a major reason for institutionalization in older persons ( 118 , 119 ). Vitamin B 12 deficiency has been associated with the development of incontinence ( 120 ). Zinc deficiency is extremely common, especially in older diabetics ( 121 , 122 ). It is associated with anorexia, immune dysfunction, and poor wound-healing. More studies are needed on the role of zinc deficiency in chronically ill elderly individuals. Creatine supplementation enhances isometric strength when utilized together with resistance training in older adults ( 123 ).

While inadequate attention is paid to undernutrition and vitamin and mineral deficiency, a large amount of research is actively exploring the role of dietary restriction as a means to extend life span. Bodkin and colleagues ( 124 ) have suggested, from early studies in dietary-restricted rhesus monkeys, that this approach may decrease mortality and morbidity. Banks and colleagues ( 125 ), in studying Ethiopian baboons over the life span, suggested that dietary restriction really represents prevention of obesity, as baboons in the wild have minimal fat stores as measured by leptin. While dietary restriction does not appear to prevent central nervous system damage ( 126 ), it certainly decreases glycation in nonhuman primates ( 127 ) and improves beta-cell sensitivity ( 128 ). Banks and colleagues ( 129 ) found that some garbage-eating baboons in Kenya developed the metabolic (insulin resistance) syndrome. Their studies strongly suggested that the environment interacts with the genome to produce this syndrome, as not all the baboons were affected. In the human studies in Biosphere 2, caloric restriction appeared to have a number of potentially beneficial effects ( 130 ).

The WHI has created great disarray among the adherents to the concept that hormonal replacement will reverse the stigmata of aging. While the WHI did not show that estrogen/progestagen replacement increased mortality, it did show an increase in breast cancer, heart disease, and pulmonary embolism ( 131 , 132 ). This was offset by a decrease in colon cancer and hip fracture. This enormously expensive study was stopped prematurely based on a convoluted formula for early stoppage of the trial, thus leaving room for doubt about whether long-term hormone replacement therapy would increase or decrease mortality. In addition, as already alluded to, the study showed worsening cognitive function in the women receiving hormones ( 34 , 35 ). The estrogen-alone arm of this study continues and may help give further insight into these conundrums. Progesterone clearly increases the propensity to form thrombi and may also have played a major role in the pathogenesis of breast carcinogenesis. The women in this study were older, and thus the study provided little guidelines for the appropriate use of hormonal replacement therapy at the time of the menopause. However, it would seem clear that women in their sixties and beyond should not receive combination hormonal therapy.

In males, the enthusiasm for testosterone replacement continues unabated, but is based on a relatively small body of evidence-based medicine ( 36 , 133–135 ). A number of studies on testosterone replacement in older males have appeared in the Journals ( 136–139 ). Overall, testosterone in older men appears to be a quality-of-life drug improving libido ( 134 ) and the ability to obtain an erection when phosphodiesterase inhibitors are taken ( 140 ), as well as increasing muscle mass and possibly strength ( 141 ), and bone mineral density ( 142 , 143 ), while decreasing body fat ( 136 ). The effects of testosterone on cognition are controversial ( 36 , 138 , 141 , 142 , 144 , 145 ). Testosterone clearly increases hematocrit in older men. The effects of testosterone on prostate cancer carcinogenesis are controversial ( 36 , 133 ). The need for a large men's health study to determine the efficacy and safety of testosterone in older males should be a national imperative. The intriguing hypothesis of Bhasin and colleagues ( 146 ) that testosterone plays a role in determining the fate of mesenchymal pluripotent stem cells may hold a major key to understanding the aging process. The role of testosterone in the development of frailty in older women is also coming of age ( 147 ).

While data suggesting that growth hormone and insulin-growth factor-1 may play a role in maintaining muscle mass ( 144 , 148 , 149 ), the enthusiasm for the use of growth hormone in the aged appears to be ebbing ( 150 , 151 ). One publication did, however, suggest that, in a single large family, growth hormone dwarfs had a shorter life span than their normal-sized siblings ( 152 ). This would appear to be in contradiction to animals where growth hormone deficiency confers longevity ( 153 , 154 ).

The role of vitamin D beyond its importance in maintaining bone mineral density remains controversial. There is a suggestion that it may play a role in preventing disability in older persons ( 155 ). There is, however, evidence that physicians continue to fail to diagnose and treat osteoporosis in older persons ( 156 , 157 ).

As originally highlighted by Fried and colleagues ( 158 ) in the Journals , frailty is becoming a highly important geriatric syndrome. Frailty appears to be an important precursor of disability and functional decline (which in themselves are key predictors of mortality in older persons) ( 159 , 160–162 ). The causes of frailty are multiple and include not only alterations in muscle function, but also cognitive impairment and a decline in VO 2 max ( 163 , 164 ). Diseases such as diabetes and cardiovascular disease are clearly important in accelerating the onset of the frailty syndrome ( 165–169 ). Pain can increase the level of disability ( 170 ). As older adults are already performing their activities of daily living at close to maximum capacity, a small change can tip them over into the realm of disability ( 171 ). Exercise, particularly resistance exercise, appears to be the major weapon in the therapeutic armamentarium to reverse frailty and its consequences ( 172–181 ). Falls are a sentinel event that can cause a frail person to transition to disability and functional impairment ( 182 ). Fear of falling in frequent fallers can lead to further disability ( 183 ). The American Geriatrics Society guidelines represent an excellent approach to the management of falls ( 184 ).

Loss of muscle mass (sarcopenia) is a major proximate occurrence in the development of frailty in older persons ( 169 , 185 , 186 ). The importance of sarcopenia and its causes was highlighted by a series of review articles in the Journals towards the end of last year ( 187–194 ).

Cardiovascular disease is present in over half of the older population and an even greater number of nursing home residents ( 195 ). The Journals has continued to carry a number of review articles to keep its readers abreast of the rapid developments in this field ( 196–200 ). Many of these have been written by Bill Aronow, a true geriatric giant who ages extraordinarily successfully as one of the most productive geriatricians, at an age when most have retired, and as a highly competitive tennis player. As an iconoclast who hates to embrace new expensive therapy in the older person, your editor, nevertheless, feels it incumbent upon him to point out the growing evidence of the superiority of angiotensin receptor blockers for the treatment of hypertension and heart failure ( 201–203 ).

The management of hypertension in older persons, and particularly the old-old is one full of opinions and still short on evidence ( 197 , 204 ). To highlight this area, James Goodwin ( 205 ) wrote an excellent review article, which was subject to a careful dissection by a variety of commentators ( 206–214 ). It is this kind of discourse that forces us to carefully examine the true state of evidence-based medicine in the older person. It is very important that geriatricians do not fall into the trap of considering trials conducted in middle-aged persons or even the young old as being appropriate to guide aggressive therapy in our unique population.

Finally, when treating hypertension in older persons, it is important to remember that white coat hypertension, pseudohypertension, orthostasis, and postprandial hypotension occur commonly. Orthostatis and postprandial hypotension occur more commonly in the morning than later in the day ( 215 , 216 ). Postprandial hypotension appears to be due to the release of vasodilatory peptides, such as calcitonin gene-related peptide ( 217 ).

The deterioration of the immune system with aging is well recognized ( 218 , 219 ). The development of protein energy malnutrition can further cause deterioration in the immune system, resulting in a decrease in CD 4 + T cells ( 220 ). Both nutritional supplementation and exercise have been demonstrated to boost the immune system ( 154 , 221–223 ); older persons appear to be particularly susceptible to anthrax when used as a tool of bioterrorism ( 222 ). As might be expected, older persons have worse outcomes when exposed to some of the new infectious disease outbreaks such as West Nile Virus ( 224 ) and SARS ( 225 ). Transfusion-related West Nile virus is more common in older than in younger persons ( 224 ). This reminds us all of the importance of vaccination against influenza in our older population ( 226 , 227 ).

From the start of human history, alchemists have attempted to prolong the human life span ( 228 ). The extension of life remains an appropriate area of research for gerontologists, though we should continuously be on guard for science that extends longevity without compressing morality, as was the case for Tithonus, the morning lover of the goddess of dawn, Aurora. The appropriate approach to antiaging research has been the subject of a number of commentaries in the Journals ( 229–233 ). A particularly aggressive area of longevity research is to study the factors that distinguish the successful old-old, especially centenarians, from the rest of the population in the hope of unlocking the genetic keys of longevity ( 234–241 ). This area has been closely linked to similar research in animals ( 242 , 243 ).

The mechanisms of cellular senescence, as originally shown by Leonard Hayflick, remain an important arena of immortality research ( 244–246 ). It was these studies that led initially to the search for telomerase ( 247 ). Originally thought to hold the secrets to cellular mortality, this area is now more of one in which researchers are hoping to treat cancer by controlling the enzyme. Hayflick's original studies are also the basis for modern embryonic stem cell research an area that offers promise for tissue rejuvenation ( 248 ).

The ethics of longevity research, particularly in an era of capitalistic ownership of the “useful” human genes, is clearly a slippery slope. However, it should be recognized that, while the well-meaning argue how to move forward appropriately, those who are driven by fewer misgivings will likely not be deterred, allowing this area to be controlled by those who perhaps we would prefer did not hold the secrets to our future.

Kane ( 249 ) has argued that geriatrics is at the crossroads and that to some extent we have failed, and we should remove ourselves from the mainstream and become the physicians for chronic care hospitals. This viewpoint was hotly contested by a variety of gerontological experts ( 250–259 ).

While geriatrics has not always delivered at the level I think many of us who entered the field in the 1980s hoped for, it certainly has changed the face of modern medicine. My colleagues and I have previously argued that a major role of geriatricians and our health care colleagues is to develop and run systems that decrease errors and improve care for elderly patients ( 260–262 ). This argument was based on the pioneering work of Larry Rubenstein on the value of Geriatric Evaluation and Management Units ( 263 ), whose value has been clearly confirmed ( 264 , 265 ). The importance for the installation of effective Continuous Quality Improvement systems to prevent errors is no longer in doubt ( 266 , 267 ). The addition of a high-quality computerized medical record to such a system will further enhance care ( 268 ).

Since the introduction of the geriatric evaluation and management unit concept, geriatrics has provided a number of other innovative projects that improve patient outcomes, e.g., Acute Care For the Elderly Units (ACE) ( 269 ), Delirium Intensive Care Units ( 270 ), Subacute Care Units ( 271 ), a geriatric-friendly nurse in the emergency department ( 272 ), and Program of All-Inclusive Care for the Elderly (PACE) ( 273 ), we have recognized the importance of controlling the rampant polypharmacy created by our other subspecialty colleagues ( 274 ). We have shown the ability of early screening to detect treatable geriatric problems ( 275 , 276 ). The geriatric Glidepaths have been created to help primary care physicians provide appropriate care to the wide range of older persons they encounter in practice ( 277 ). While our colleagues and administrators have been slow to incorporate these systems, they are slowly penetrating the high-technological environment of modern medicine. None of these systems function without well-trained geriatricians at their helm.

The future of geriatrics would appear to be more exciting at this moment than any time in the past. To conclude this editorial, I would, however, like to look back into our past, because where we are today in geriatrics is reflective of the small steps of the giants who created modern American geriatrics. This year, David Solomon celebrated his 80th birthday and was appropriately honored by a special supplement of the Journal of the American Geriatrics Society ( 278–282 ). David, together with John Beck, created the “West Coast geriatrics culture.” While extraordinarily different men in both personality and interest, David and John are truly the giants of modern geriatrics following in the footsteps of Bob Butler's extraordinary achievement on the East Coast. I would like to add my happy birthday wishes to David and thank both David and John, not only for the inspiration they were to me, but also for their leadership in the gerontological world that I hold so close to my heart.

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Robison J, Gruman C, Gaztambide S, Blank K. Screening for depression in middle-aged and older Puerto Rican primary care patients. J Gerontol Med Sci. . 2002 ; 57A : M308 -M314.

Morley JE, Flaherty JH. It's never too late: health promotion and illness prevention in older persons. J Gerontol Med Sci. . 2002 ; 57A : M338 -M342.

Flaherty JH, McBride M, Marzouk S, et al. Decreasing hospitalization rates for older home care patients with symptoms of depression. J Am Geriatr Soc. . 1998 ; 46A : 31 -38.

Hubert HB, Bloch DA, Oehlert JW, Fries JF. Lifestyle habits and compression of morbidity. J Gerontol Med Sci. . 2002 ; 57A : M347 -M351.

Rosenthal MJ, Fajardo M, Gilmore S, Morley JE, Naliboff BD. Hospitalization and mortality of diabetes in older adults—a 3-year prospective study. Diabetes Care. . 1998 ; 21 : 231 -235.

Akiyama H, Barger S, Barnum S, et al. Inflammation and Alzheimer's disease. Neurobiol Aging. . 2000 ; 21 : 383 -421.

Banks WA, Farr SA, Butt W, Kumar VB, Franko MW, Morley JE. Delivery across the blood-brain barrier of antisense directed against amyloid beta: Reversal of learning and memory deficits in mice overexpressing amyloid precursor protein. J Pharmacol Exper Ther. . 2001 ; 297 : 1113 -1121.

Kumar VB, Vyas K, Franko M, et al. Molecular cloning, expression, and regulation of hippocampal amyloid precursor protein of senescence accelerated mouse (SAMP8). Biochem Cell Biol [Biochim Biol Cell]. . 2001 ; 79 : 57 -67.

Michel J-P, Pautex S, Zekry D, Zulian G, Gold G. End-of-life care of persons with dementia. J Gerontol Med Sci. . 2002 ; 57A : M640 -M644.

Simmons SF, Babineau S, Garcia E, Schnelle JF. Quality assessment in nursing homes by systematic direct observation: feeding assistance. J Gerontol Med Sci. . 2002 ; 57A : M665 -M671.

Berrut G, Favreau AM, Dizo E, et al. Estimation of calorie and protein intake in aged patients: validation of a method based on meal portions consumed. J Gerontol Med Sci. . 2002 ; 57A : M52 -M56.

Crogan NL, Pasvogel A. The influence of protein-calorie malnutrition on quality of life in nursing homes. J Gerontol Med Sci. . 2003 ; 58A : 159 -164.

Minicuci N, Maggi S, Pavan M, Enzi G, Crepaldi G. Prevalence rate and correlates of depressive symptoms in older individuals: the Veneto Study. J Gerontol Med Sci. . 2002 ; 57A : M155 -M161.

Paquet C, St-Arnaud-McKenzie D, Kergoat M-J, Ferland G, Dube L. Direct and indirect effects of everyday emotions on food intake of elderly patients in institutions. J Gerontol Med Sci. . 2003 ; 58A : 153 -158.

Morley JE, Flaherty JH. Putting the “home” back in nursing home. J Gerontol Med Sci. . 2002 ; 57A : M419 -M421.

Thoesen Coleman M, Looney S, O'Brien J, Ziegler C, Pastorino CA, Turner C. The Eden alternative: findings after 1 year of implementation. J Gerontol Med Sci. . 2002 ; 57A : M422 -M427.

Banks MR, Banks WA. The effects of animal-assisted therapy on loneliness in an elderly population in long-term care facilities. J Gerontol Med Sci. . 2002 ; 57A : M428 -M432.

Tamura T, Yonemitsu S, Itoh A, et al. Is an entertainment robot useful in the care of elderly people with severe dementia? J Gerontol Med Sci. . 2004 ; 59A : 83 -85.

Schnelle JF. Improving nursing home quality assessment: capturing the voice of cognitively impaired elders. J Gerontol Med Sci. . 2003 ; 58A : 238 -239.

Kane RA, Kling KC, Bershadsky B, et al. Quality of life measures for nursing home residents. J Gerontol Med Sci. . 2003 ; 58A : 240 -248.

Kane RL. Professionals with personal experience in chronic care (PPECC). J Gerontol Med Sci. . 2003 ; 58A : 867 .

Flaherty JH, Stalvey B, Rubenstein L. A consensus statement on nonemergent medical transportation services for older persons [Guest Editorial]. J Gerontol Med Sci. . 2003 ; 58A : 826 -831.

Margolis KL, Kerani PK, McGovern P, Songer T, Cauley JA. Ensrud KE for the Study of Osteoporotic Fractures Research Group. Risk factors for motor vehicle crashes in older women. J Gerontol Med Sci. . 2002 ; 57A : M186 -M191.

Richardson ED, Marottoli RA. Visual attention and driving behaviors among community-living older persons. J Gerontol Med Sci. . 2003 ; 58A : 832 -836.

Porter MM, Whitton MJ. Assessment of driving with the Global Positioning System and video technology in young, middle-aged, and older drivers. J Gerontol Med Sci. . 2002 ; 57A : M578 -M582.

Miller DJ, Morley JE. Attitudes of physicians toward elderly drivers and driving policy. J Am Geriatr Soc. . 1993 ; 41 : 722 -724.

Blazer DG. Depression in late life: review and commentary. J Gerontol Med Sci. . 2003 ; 58A : 249 -265.

Blazer DG. The prevalence of depressive symptoms. J Gerontol Med Sci. . 2002 ; 57A : M150 -M151.

Evans WJ. Exercise as the standard of care for elderly people. J Gerontol Med Sci. . 2002 ; 57A : M260 -M261.

Cesari M, Landi F, Torre S, Onder G, Lattanzio F, Bernabei R. Prevalence and risk factors for falls in an older community-dwelling population. J Gerontol Med Sci. . 2002 ; 57A : M722 -M726.

Thomas VS, Hageman PA. Can neuromuscular strength and function in people with dementia be rehabilitated using resistance-exercise training? Results from a preliminary intervention study. J Gerontol Med Sci. . 2003 ; 58A : 746 -751.

Singh NA, Clements KM, Singh MAF. The efficacy of exercise as a long-term antidepressant in elderly subjects: a randomized, controlled trial. J Gerontol Med Sci. . 2001 ; 56A : M497 -M504.

Morley JE. Mobility performance: a high-tech test for geriatricians. J Gerontol Med Sci. . 2003 ; 58A : 712 -714.

Newman AB, Haggerty CL, Kritchevsky SB, Nevitt MC. Simonsick EM, for the Health ABC Collaborative Research Group. Walking performance and cardiovascular response: associations with age and morbidity—the Health, Aging and Body Composition Study. J Gerontol Med Sci. . 2003 ; 58A : 715 -720.

Lan T-Y, Deeg DJH, Guralnik JM, Melzer D. Responsiveness of the index of mobility limitation: comparison with gait speed alone in the longitudinal aging study Amsterdam. J Gerontol Med Sci. . 2003 ; 58A : 721 -727.

Bean JF, Leveille SG, Kiely DK, Bandinelli S, Guralnik JM, Ferrucci L. A comparison of leg power and leg strength within the InCHIANTI Study: which influences mobility more? J Gerontol Med Sci. . 2003 ; 58A : 728 -733.

Alexander NB, Dengel DR, Olson RJ, Krajewski KM. Oxygen-Uptake (VO 2 ) kinetics and functional mobility performance in impaired older adults. J Gerontol Med Sci. . 2003 ; 58A : 734 -739.

Brandon LJ, Gaasch DA, Boyette LW, Lloyd AM. Effects of long-term resistive training on mobility and strength in older adults with diabetes. J Gerontol Med Sci. . 2003 ; 58A : 740 -745.

Lan T-Y, Melzer D, Tom BDM, Guralnik JM. Performance tests and disability: developing an objective index of mobility-related limitation in older populations. J Gerontol Med Sci. . 2002 ; 57A : M294 -M301.

Sicard-Rosenbaum L, Light KE, Behrman AL. Gait, lower extremity strength, and self-assessed mobility after hip arthroplasty. J Gerontol Med Sci. . 2002 ; 57A : M47 -M51.

Reid MC, Guo ZC, Towle VR, Kerns RD, Concato J. Pain-related disability among older male veterans receiving primary care. J Gerontol Med Sci. . 2002 ; 57A : M727 -M732.

Slade JM, Miszko TA, Laity JH, Agrawal SK, Cress ME. Anaerobic power and physical function in strength-trained and non-strength-trained older adults. J Gerontol Med Sci. . 2002 ; 57A : M168 -M172.

Cromwell RL, Newton RA, Forrest G. Influence of vision on head stabilization strategies in older adults during walking. J Gerontol Med Sci. . 2002 ; 57A : M442 -M448.

Lord SR, Murray SM, Chapman K, Munro B, Tiedemann A. Sit-to-Stand performance depends on sensation, speed, balance, and psychological status in addition to strength in older people. J Gerontol Med Sci. . 2002 ; 57A : M539 -M543.

Hamerman D. Molecular-based therapeutic approaches in treatment of anorexia of aging and cancer cachexia. J Gerontol Med Sci. . 2002 ; 57A : M511 -M518.

Bean JF, Kiely DK, Leveille SG, et al. The 60 minute walk test in mobility-limited elders: What is being measured? J Gerontol Med Sci. . 2002 ; 57A : M751 -M756.

Wong CH, Wong SF, Pang WS, Azizah MY, Dass MJ. Habitual walking and its correlation to better physical function: implications for prevention of physical disability in older persons. J Gerontol Med Sci. . 2003 ; 58 : 555 -560.

Liu L, Bopp MM, Roberson PK, Sullivan DH. Undernutrition and risk of mortality in elderly patients within 1 year of hospital discharge. J Gerontol Med Sci. . 2002 ; 57A : M741 -M746.

de Castro JM. Age-related changes in the social, psychological, and temporal influences on food intake in free-living, healthy, adult humans. J Gerontol Med Sci. . 2002 ; 57A : M368 -M377.

Morley JE, Silver AJ. Anorexia in the elderly. Neurobiol Aging. . 1988 ; 9 : 9 -16.

Morley JE. Anorexia of aging—physiologic and pathologic. Am J Clin Nutr. . 1997 ; 66 : 760 -773.

Hays NP, Gathalon GP, Roubenoff R, Lipman R, Robert SB. The association of eating behavior with risk for morbidity in older women. J Gerontol Med Sci. . 2002 ; 57A : M128 -M133.

Miller DK, Morley JE, Rubenstein LZ, Pietruszka FM. Abnormal eating attitudes and body image in older undernourished individuals. J Am Geriatr Soc. . 1991 ; 39 : 462 -466.

Choy NL, Brauer S, Nitz J. Changes in postural stability in women aged 20 to 80 years. J Gerontol Med Sci. . 2003 ; 58A : 525 -530.

Strum K, MacIntosh CG, Parker BA, Wishart J, Horowitz M, Chapman IM. Appetite, food intake, and plasma concentrations of cholecystokinin, ghrelin, and other gastrointestinal hormones in undernourished older women and well-nourished young and older women. J Clin Endocrinol Metab. . 2003 ; 88 : 3747 -3755.

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Batterham RL, Cohen MA, Ellis SM, et al. Inhibition of food intake in obese subjects by peptide YY3-36. N Engl J Med. . 2003 ; 349 : 941 -948.

Morley JE, Flood JF. An investigation of tolerance to the actions of leptogenic and anorexigenic drugs in mice. Life Sci. . 1987 ; 41 : 2157 -2165.

MacIntosh CG, Morley JE, Wishart J, et al. Effect of exogenous cholecystokinin (CCK)-8 on food intake and plasma CCK, leptin, and insulin concentrations in older and young adults: evidence for increased CCK activity as a cause of the anorexia of aging. J Clin Endocrinol Metab. . 2001 ; 86 : 5830 -5837.

Mathey MFAM, Siebelink E, de Graaf C, Van Staveren WA. Flavor enhancement of food improves dietary intake and nutritional status of elderly nursing home residents. J Gerontol Med Sci. . 2001 ; 56A : M200 -M205.

Wilson MMG, Purushothaman R, Morley JE. Effect of liquid dietary supplements on energy intake in the elderly. Am J Clin Nutr. . 2002 ; 75 : 944 -947.

Morley JE. Anorexia and weight loss in older persons. J Gerontol Med Sci. . 2003 ; 58A : 131 -137.

Thomas DR. The relationship between functional status and inflammatory disease in older adults [Guest Editorial]. J Gerontol Med Sci. . 2003 ; 58A : 995 -998.

Yeh SS, Wu SY, Levine DM, et al. The correlation of cytokine levels with body weight after megestrol acetate treatment in geriatric patients. J Gerontol Med Sci. . 2001 ; 56A : M48 -M54.

Karcic E, Philpot C, Morley JE. Treating malnutrition with megestrol acetate: literature review and review of our experience. J Nutr Hlth Aging. . 2002 ; 6 : 191 -200.

Lambert CP, Sullivan DH, Evans WJ. Effects of testosterone replacement and/or resistance training on interleukin-6 tumor necrosis factor alpha, and leptin in elderly men ingesting megestrol acetate: a randomized controlled trial. J Gerontol Med Sci. . 2003 ; 58A : 165 -170.

Morley JE, Logi P, Bensusan AD. The subjective effects of dagga: including comparative studies with Britain and America. S Afr Med J. . 1973 ; 47 : 1145 -1149.

Wilson MMG. Urinary incontinence: bridging the gender gap. J Gerontol Med Sci. . 2003 ; 58A : 752 -754.

Nuotio M, Tammela TLJ, Luukkaala T, Jylha M. Predictors of institutionalization in an older population during a 13-year period: the effect of urge incontinence. J Gerontol Med Sci. . 2003 ; 58A : 756 -762.

Endo JO, Chen S, Potter JF, Ranno AE, Asadullah S, Lahiri P. Vitamin B 12 deficiency and incontinence: is there an association? J Gerontol Med Sci. . 2002 ; 57A : M583 -M587.

Kinlaw WB, Levine AS, Morley JE, Silvis SE, McClain CJ. Abnormal zinc metabolism in type II diabetes mellitus. Am J Med. . 1983 ; 75 : 273 -277.

Niewoehner CB, Allen JI, Boosalis M, Levine AS, Morley JE. Role of zinc supplementation in type II diabetes mellitus. Am J Med. . 1986 ; 81 : 63 -68.

Brose A, Parise G, Tarnopolsky MA. Creatine supplementation enhances isometric strength and body composition improvements following strength exercise training in older adults. J Gerontol Biol Sci. . 2003 ; 58A : 11 -19.

Bodkin NL, Alexander TM, Ortmeyer HK, Johnson E, Hansen BC. Mortality and morbidity in laboratory-maintained Rhesus monkeys and effects of long-term dietary restriction. J Gerontol Biol Sci. . 2003 ; 58A : 212 -219.

Banks WA, Phillips-Controy JE, Jolly CJ, Morley JE. Serum leptin levels in wild and captive populations of baboons (Papio): implications for the ancestral role of leptin. J Clin Endocrinol Metab. . 2001 ; 86 : 4315 -4320.

Morgan WW, Richardson AG, Nelson JF. Dietary restriction does not protect the nigrostriatal dopaminergic pathway of older animals from low-dose MPTP-induced neurotoxicity. J Gerontol Biol Sci. . 2003 ; 58A : 394 -399.

Sell DR, Lane MA, Obrenovich ME, et al. The effect of caloric restriction on glycation and glycoxidation in ski collagen of nonhuman primate. J Gerontol Biol Sci. . 2003 ; 58A : 508 -516.

Gresl TA, Colman RJ, Havighurst TC, Allison DB, Schoeller DA, Kemnitz JW. Dietary restriction and beta-cell sensitivity to glucose in adult male rhesus monkeys. J Gerontol Biol Sci. . 2003 ; 58A : 598 -610.

Banks WA, Altmann J, Sapolsky RM, Phillips-Conroy JE, Morley JE. Serum leptin levels as a marker for a syndrome X-like condition in wild baboons. J Clin Endocrinol Metab. . 2003 ; 88 : 1234 -1240.

Wolford RL, Mock D, Verdery R, MacCallum T. Calorie restriction in Biosphere 2: alterations in physiologic, hematologic, hormonal, and biochemical parameters in humans restricted for a 2-year period. J Gerontol Biol Sci. . 2002 ; 57A : B211 -B224.

Manson JE, Hsia J, Johnson KC, et al. Estrogen plus progestin and the risk of coronary heart disease. N Engl J Med. . 2003 ; 349 : 523 -534.

Roussouw JE, Anderson GL, Prentice RL, et al. Risks and benefits of estrogen plus progestin in healthy postmenopausal women—principal results from the Women's Health Initiative randomized controlled trial. JAMA. . 2002 ; 288 : 321 -333.

Morley JE. The need for a men's health initiative. J Gerontol Med Sci. . 2003 ; 58A : 614 -617.

Anderson JK, Faulkner S, Cranor C, Briley J, Gevirtz F, Roberts S. Andropause: knowledge and perceptions among the general public and health care professionals. J Gerontol Med Sci. . 2002 ; 57A : M793 -M796.

Morley JE, Perry HM. Andropause: an old concept in new clothing. Clin Geriatr Med. . 2003 ; 19 : 507 -528.

Wittert GA, Chapman IM, Haren MT, Mackintosh S, Coates P, Morley JE. Oral testosterone supplementation increases muscle and decreases fat mass in healthy elderly males with low-normal gonadal status. J Gerontol Med Sci. . 2003 ; 58A : 618 -625.

Kenny AM, Prestwood KM, Gruman CA, Fabregas G, Biskup B, Mansoor G. Effects of transdermal testosterone on lipids and vascular reactivity in older men with low bioavailable testosterone levels. J Gerontol Med Sci. . 2002 ; 57A : M460 -M465.

Kenny AM, Prestwood KM, Gruman CA, Marcello KM, Raisz LG. Effects of transdermal testosterone on bone and muscle in older men with low bioavailable testosterone levels. J Gerontol Med Sci. . 2001 ; 56A : M266 -M272.

Tariq SH, Haleem U, Omran ML, Kaiser FE, Perry HM, Morley JE. Erectile dysfunction: etiology and treatment in young and old patients. Clin Geriatr Med. . 2003 ; 19 : 539 -551.

Sih R, Morley JE, Kaiser FE, Perry HM, Patrick P, Ross C. Testosterone replacement in older hypogonadal men—a 12-month randomized controlled trial. J Clin Endocrinol Metab. . 1997 ; 82 : 1661 -1667.

Morley JE. Andropause: is it time for the geriatrician to treat it? J Gerontol Med Sci. . 2001 ; 56A : M263 -M265.

Christmas C, O'Connor KG, Harman SM, Tobin JD, et al. Growth hormone and sex steroid effects on bone metabolism and bone mineral density in healthy aged women and men. J Gerontol Med Sci. . 2002 ; 57A : M12 -M18.

Tan RS, Pu SJ. A pilot study on the effects of testosterone in hypogonadal aging male patients with Alzheimer's disease. Aging Male. . 2003 ; 6 : 13 -17.

Morley JE. Testosterone and behavior. Clin Geriatr Med. . 2003 ; 19 : 605 -616.

Bhasin S. The mechanisms of androgen effects on body composition: mesenchymal pluripotent cell as the target of androgen action. J Gerontol Med Sci. . 2003 ; 58A : 1103 -1110.

Morley JE, Perry HM, III. Androgens and women at the menopause and beyond. J Gerontol Med Sci. . 2003 ; 58A : 409 -416.

Waters DL, Yau CL, Montoya GD, Baumgartner RN. Serum sex hormones, IGF-1, and IGFBP3 exert a sexually dimorphic effect on lean body mass in aging. J Gerontol Med Sci. . 2003 ; 57A : 648 -652.

Baumgartner RN, Waters DL, Gallagher D, Morley JE, Garry PJ. Predictors of skeletal muscle mass in elderly men and women. Mech Ageing Develop. . 1999 ; 107 : 123 -136.

Bartke A, Coschigano K, Kopchick J, et al. Genes that prolong life: relationships of growth hormone and growth to aging and life span. J Gerontol Biol Sci. . 2001 ; 56A : B340 -B349.

Morley JE. Growth hormone: fountain of youth or death hormone? J Am Geriatr Soc. . 1999 ; 47 : 1475 -1476.

Benson A, Salemi S, Gallati S, et al. Reduced longevity in untreated patients with isolated growth hormone deficiency. J Clin Endocrinol Metab. . 2003 ; 88 : 3664 -3667.

Dozmorov I, Galecki A, Chang Y, Krzesicki, , Vergara M, Miller RA. Gene expression profile of long-lived Snell dwarf mice. J Gerontol Biol Sci. . 2002 ; 57A : B99 -B108.

Ikeno Y, Bronson RT, Hubbard GB, Lee S, Bartke A. Delayed occurrence of fatal neoplastic diseases in Ames Dwarf Mice: correlation to extended longevity. J Gerontol Biol Sci. . 2003 ; 58A : 291 -296.

Zamboni M, Zoico E, Tosoni P, et al. Relation between vitamin D, physical performance, and disability in elderly persons. J Gerontol Med Sci. . 2002 ; 57A : M7 -M11.

Kamel HK, Perry HM, Morley JE. Hormone replacement therapy and fractures in older adults. J Am Geriatr Soc. . 2001 ; 59 : 179 -187.

Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. . 2000 ; 109 : 326 -328.

Fried LP, Tangen CM, Walston J, et al. Frailty in older adults: evidence for a phenotpye. J Gerontol Med Sci. . 2001 ; 56A : M146 -M156.

Thomas DR. Focus on functional decline in hospitalized older adults. J Gerontol Med Sci. . 2002 ; 57A : M567 -M568.

McCusker J, Kakuma R, Abrahamowicz M. Predictors of functional decline in hospitalized elderly patients: a systematic review. J Gerontol Med Sci. . 2002 ; 57A : M569 -M577.

Gill TM, Kurland B. The burden and patterns of disability in activities of daily living among community-living older persons. J Gerontol Med Sci. . 2003 ; 58A : 70 -75.

Valderrama-Gama E, Damian J, Ruigomez A, Martin-Moreno JM. Chronic disease, functional status, and self-ascribed causes of disabilities among noninstitutionalized older people in Spain. J Gerontol Med Sci. . 2002 ; 57A : M716 -M721.

Lipsitz LA. Dynamics of stability: the physiologic basis of functional health and frailty. J Gerontol Biol Sci. . 2002 ; 57A : B115 -B125.

Morley JE, Perry HM, III, Miller DK. Something about frailty. J Gerontol Med Sci. . 2002 ; 57A : M698 -M704.

Ottenbacher KJ, Ostir GV, Peek MK, Goodwin JS, Markides KS. Diabetes mellitus as a risk factor for hip fracture in Mexican American older adults. J Gerontol Med Sci. . 2002 ; 57A : M648 -M653.

Newman AB, Gottdiener JS, McBurnie MA, et al. Associations of subclinical cardiovascular disease with frailty. J Gerontol Med Sci. . 2001 ; 56A : M158 -M166.

Rodriguez-Saldana J, Morley JE, Reynoso MT, et al. Diabetes mellitus in a subgroup of older Mexicans: prevalence, association with cardiovascular risk factors, functional and cognitive impairment, and mortality. J Am Geriatr Soc. . 2002 ; 50 : 111 -116.

Miller DK, Lui LYL, Perry HM, Kaiser FE, Morley JE. Reported and measured physical functioning in older inner-city diabetic African Americans. J Gerontol Med Sci. . 1999 ; 54 : M230 -M236.

Iannuzzi-Sucich M, Prestwood KM, Kenny AM. Prevalence of sarcopenia and predictors of skeletal muscle mass in healthy, older men and women. J Gerontol Med Sci. . 2002 ; 57A : M772 -M777.

Reid MC, Guo Z, Towle VR, Kersn RD. Concato. Pain-related disability among older male veterans receiving primary care. J Gerontol Med Sci. . 2002 ; 57A : M727 -M732.

Hortobagyi T, Mizelle C, Beam S, DeVita P. Old adults perform activities of daily living near their maximal capabilities. J Gerontol Med Sci. . 2003 ; 58A : 453 -460.

Miszko TA, Cress ME, Slade JM, Covey CJ, Agrawal SK, Doerr CE. Effect of strength and power training on physical function in community-dwelling older adults. J Gerontol Med Sci. . 2003 ; 58A : 171 -175.

Nicklas BJ, Dennis KE, Berman DM, Sorkin J, Ryan AS, Goldberg AP. Lifestyle intervention of hypocaloric dieting and walking reduces abdominal obesity and improves coronary heart disease risk factors in obese, postmenopausal, African American and Caucasian women. J Gerontol Med Sci. . 2003 ; 58A : 181 -189.

Figueroa A, Going SB, Milliken LA, et al. Effects of exercise training and hormone replacement therapy on lean and fat mass in postmenopausal women. J Gerontol Med Sci. . 2003 ; 58A : 266 -270.

Hortobagyi T. The positives of negatives: clinical implications of eccentric resistance exercise in older adults. J Gerontol Med Sci. . 2003 ; 58A : 417 -418.

LaStayo PC, Ewy GA, Pierotti DD, Johns RK, Lindstedt S. The positive effects of negative work: increased muscle strength and decreased fall risk in a frail elderly population. J Gerontol Med Sci. . 2003 ; 58A : 419 -424.

Carmeli E, Kessel S, Coleman R, Ayalon M. Effects of a treadmill walking program on muscle strength and balance in elderly people with down syndrome. J Gerontol Med Sci. . 2002 ; 57A : M106 -M110.

Trappe S, Williamson D, Godard M. Maintenance of whole muscle strength and size following resistance training in older men. J Gerontol Biol Sci. . 2002 ; 57A : B138 -B143.

Singh MAF. Exercise comes of age: rationale and recommendations for a geriatric exercise prescription. J Gerontol Med Sci. . 2002 ; 57A : M262 -M282.

Signorile JF, Carmel MP, Czaja SJ, et al. Differential increases in average isokinetic power by specific muscle groups of older women due to variations in training and testing. J Gerontol Med Sci. . 2002 ; 57A : M683 -M690.

Dubbert PM, Cooper KM, Kirchner KA, Meydrech EF, Bilbrew D. Effects of nurse counseling on walking for exercise in elderly primary care patients. J Gerontol Med Sci. . 2002 ; 57A : M733 -M740.

Morley JE. A fall is a major event in the life of an older person. J Gerontol Med Sci. . 2002 ; 57A : M492 -M495.

Murphy SL, Dubin JA, Gill TM. The development of fear of falling among community-living older women: predisposing factors and subsequent fall events. J Gerontol Med Sci. . 2003 ; 58A : 943 -947.

Lundebjerg N, Rubenstein LZ, Kenny RA, et al. Guideline for the prevention of falls in older persons. J Am Geriatr Soc. . 2001 ; 59 : 664 -672.

Kenny AM, Dwason L, Kleppinger A, Iannuzzi-Sucich M, Judge JO. Prevalence of sarcopenia and predictors of skeletal muscle mass in nonobese women who are long-term users of estrogen-replacement therapy. J Gerontol Med Sci. . 2003 ; 58A : 436 -440.

Aronow WS, Ahn C. Elderly diabetics with peripheral arterial disease and no coronary artery disease have a higher incidence of new coronary events than elderly nondiabetics with peripheral arterial disease and prior myocardial infarction treated with statins and with no lipid-lowering drug. J Gerontol Med Sci. . 2003 ; 58A : 573 -575.

Morley JE. Sarcopenia revisited [Editorial]. J Gerontol Med Sci. . 2003 ; 58A : 909 -910.

Marcell TJ. Sarcopenia: causes, consequences, and preventions [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 911 -916.

Yarasheski KE. Exercise, aging, and muscle protein metabolism [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 918 -922.

Barton E, Morris C. Mechanisms and strategies to counter muscle atrophy [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 923 -926.

Leeuwenburgh C. Role of apoptosis in sarcopenia [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 999 -1001.

Bhasin S. Testosterone supplementation for aging-associated sarcopenia [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 1002 -1008.

Hawkins SA, Wiswell RA, Marcell TJ. Exercise and the master athlete—a model of successful aging? [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 1009 -1011.

Roubenoff R. Sarcopenia: effects on body composition and function [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 1012 -1017.

Aronow WS, Ahn C, Gutstein H. Prevalence and incidence of cardiovascular disease in 1160 older men and 2464 older women in a long-term health care facility. J Gerontol Med Sci. . 2002 ; 57A : M45 -M46.

Aronow WS. Management of the older person with atrial fibrillation. J Gerontol Med Sci. . 2002 ; 57A : M352 -M363.

Aronow WS. What is the appropriate treatment of hypertension in elders? J Gerontol Med Sci. . 2002 ; 57A : M483 -M486.

Vogel T, Verreault R, Turcotte J-F, Kiesmann M, Berthel M. Intracerebral aneurysms: a review with special attention to geriatric aspects. J Gerontol Med Sci. . 2003 ; 58A : 520 -524.

Aronow WS. Treatment of unstable angina pectoris/non-ST-segment elevation myocardial infraction in elderly patients [Review Article]. J Gerontol Med Sci. . 2003 ; 58A : 927 -933.

Aronow WS. Should hypercholesterolemia in older persons be treated to reduce cardiovascular events? J Gerontol Med Sci. . 2002 ; 57A : M411 -M413.

White HD. Should all patients with coronary disease receive angiotensin-converting-enzyme inhibitors? Lancet. . 2003 ; 362 : 755 -757.

Pfeffer MA, Swedberg K, Granger CB, et al. Effects of candesartan on mortality and morbidity in patients with chronic heart failure: the CHARM-Overall Programme. Lancet. . 2003 ; 362 : 759 -766.

McMurray JJV, Ostergren J, Swedberg K, et al. Effects of candesartan in patients with chronic heart failure and reduced left-ventricular systolic function taking angiotensin-converting enzyme inhibitors: the CHARM-Added trial. Lancet. . 2003 ; 362 : 767 -771.

Hajjar I, Miller K, Hirth V. Age-related bias in the management of hypertension: a national survey of physicians' opinions on hypertension in elderly adults. J Gerontol Med Sci. . 2002 ; 57A : M487 -M491.

Goodwin JS. Embracing complexity: a consideration of hypertension in the very old. J Gerontol Med Sci. . 2003 ; 58A : 653 -658.

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Older adults’ suggestions of research topics on ageing well in urban environments – A participatory study

Roles Conceptualization, Investigation, Project administration, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Institute of General Practice and Family Medicine, Charité - Universitätsmedizin Berlin, Berlin, Germany

Roles Data curation, Formal analysis, Investigation, Project administration, Writing – original draft

Roles Supervision, Writing – review & editing

Affiliation Institute of Medical Sociology and Rehabilitation Science, Charité – Universitätsmedizin Berlin, Berlin, Germany

Roles Conceptualization, Funding acquisition, Project administration, Supervision, Writing – review & editing

• Philip Oeser, 
• Nora Bruckmann, 
• Paul Gellert, 
• Wolfram J. Herrmann

• Published: October 4, 2023
• https://doi.org/10.1371/journal.pone.0292214
• Peer Review
• Reader Comments

Ageing societies and urbanization are global phenomena that pose new challenges for care delivery. It is important to create a scientific evidence base to prepare for these changes. Hence, the aim of our study was to assess which research agenda older adults living in an urban environment in Germany suggest.

A total of 1000 participants aged 65 years or older from five different neighborhoods of Berlin were randomly chosen and were sent a single item questionnaire allowing them to freely propose research topics regarding ageing well in the city. Codes were developed inductively and clustered into categories. In a second stage, these results were discussed with the participants and local stakeholders in a workshop and video calls.

102 persons suggested 18 research topics in 6 categories: health, living environment, social issues, mobility, and accessibility to information and communication. Proposed research topics ranged from accessibility of health care, green spaces and recreational means to social involvement and loneliness.

There is a substantial interest of older adults for research regarding their living situation. Research projects and local urban planning committees are encouraged to invite older adults to participate and integrate their perspectives suggested by older adults.

Citation: Oeser P, Bruckmann N, Gellert P, Herrmann WJ (2023) Older adults’ suggestions of research topics on ageing well in urban environments – A participatory study. PLoS ONE 18(10): e0292214. https://doi.org/10.1371/journal.pone.0292214

Editor: Grant Rich, Walden University, UNITED STATES

Received: August 7, 2023; Accepted: September 15, 2023; Published: October 4, 2023

Copyright: © 2023 Oeser et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: The data on Berlin neighborhood statistics is publicly available. Amt für Statistik Berlin-Brandenburg, Statistischer Bericht A | 16 – hj 2 / 20, available online at: [XLSX] https://download.statistik-berlin-brandenburg.de/ebfcd0da83f4fef4/474f2236e32a/SB_A01-16-00_2020h02_BE.xlsx [PDF] https://download.statistik-berlin-brandenburg.de/ffbcda9dc9cd780d/e7ab2379e8c3/SB_A01-16-00_2020h02_BE.pdf Senatsverwaltung für Stadtentwicklung, Bauen und Wohnen; Bericht Monitoring Soziale Stadtentwicklung Berlin 2019, available online at https://www.berlin.de/sen/sbw/stadtdaten/stadtwissen/monitoring-soziale-stadtentwicklung/bericht-2019/#Indikatoren The raw dataset consisting of the answers received from the participants of this study are available online under this identifier: https://zenodo.org/record/8318537 .

Funding: The project on which the article is based was supported by the Berlin Institute of Health (BIH) QUEST Center for Responsible Research. It was funded with 17,810 € in total over a duration of six months by the QUEST Grant for Patient and Stakeholder Engagement. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Ageing societies and urbanization are two global developments which pose challenges for healthy ageing in urban areas. The share of persons 70 years or older will double globally from 5.9% in 2020 to 11.3% in 2050, a shift that is also pronounced in Germany with an estimated increase from 15.9% in 2020 to 23.6% in 2050 [ 1 ]. An ageing population changes the demands for healthcare, with the focus shifting from acute care to long-term care, chronic conditions, and non-communicable diseases. Furthermore, the worldwide urban population is expected to increase from 4.22 billion in 2018 up to 6.68 billion in 2050, while the worldwide rural population is declining from 3.41 billion people in 2018 to 3.09 billion people in 2050 [ 2 ]. Germany already has a high degree of urbanization and ranks 14th in the decline of rural population until 2050. An urban living environment is associated with a high population density and more diverse population regarding gender, migration background and socio-economic status (SES) [ 3 ]. Healthcare and social care in urban areas are at the same time highly fragmented with several different providers available. Making cities age-friendly is becoming an important research area with a high public relevance [ 4 ].

What do older adults, the people who are directly affected, have to say about ageing well in urban environments? In a qualitative study from the United States based on interviews with community-dwelling adults older than 60 years, self-acceptance, self-growth and the pursuit of active engagement were defined as fundamental to ageing successfully [ 5 ]. A qualitative study with older adults on facilitators and barriers to growing old at home named physical and mental health, family environment and financial stability as key elements for quality of life while criticizing not being taken into account as a demographic by society, especially when living in an urban environment [ 6 ]. Reciprocal and trusting relationships with neighbors were the basis for satisfaction in another study on solitary older women’s perspectives on their residential living area and its impact on health and wellbeing [ 7 ]. Based on data from the Belgian Ageing Studies, it was shown how the physical environment can positively influence feelings of safety in older adults when the neighborhood is adapted to their physical needs [ 8 ]. A recent qualitative study in Germany on dementia risk reduction in urban environments, involving older adults and stakeholders, explored different perspectives on designing urban environments that support older adults’ needs to promote brain health, and encourages public policy to involve community members as co-creators for these spaces [ 9 ]. In an Australian study by the National Ageing Research Institute, the question of what older people want from healthcare was extensively assessed using a mixed-methods approach with focus group interviews and an online survey, emphasizing on topics surrounding health care [ 10 ].

Common to all these studies is that older adults merely participated in the research process and did not shape the research agenda themselves. Research on projects that allow older adults, as laypersons, to specifically define research topics is limited. Thus, the aim of our study was to assess which research agenda older adults living in an urban environment in Germany suggest.

This project had a participatory design following two stages: a survey stage and a workshop stage. First, we selected five different neighborhoods in Berlin to conduct the project. For the selection process, we used publicly available data from the Senate Department for Urban Development and Housing Berlin (Senatsverwaltung für Stadtentwicklung und Wohnen Berlin), and the Office of Statistics Berlin-Brandenburg (Amt für Statistik) [ 11 , 12 ] with an extensive insight in their demographics (number of inhabitants, share of inhabitants 65 years and older, SES, migration background). The selection was conducted jointly with local authorities, agreeing on neighborhoods with a heterogeneous population of older adults regarding socioeconomic status and migration background. Key figures of the five neighborhoods are presented in Table 1 .

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https://doi.org/10.1371/journal.pone.0292214.t001

For the survey phase, we inquired at the Agency for Civil and Regulatory Affairs in Berlin (Landesamt für Bürger- und Ordnungsangelegenheiten, LABO) to randomly choose 200 citizens in each of these neighborhoods. Inclusion criteria were age of 65 years or older (the age of retirement in Germany), no active legal guardianship, and registration of main residency in the respective neighborhood. The study information and a single open-ended item was developed and pre-tested with other researchers and senior representatives from different neighborhoods in Berlin. The single open-ended item questionnaire was: “The following topics regarding ageing in the city should be researched in the future” [translation by the authors, original phrase in German: “Folgende Themen sollten zum Altwerden in der Stadt zukünftig erforscht werden”]. By giving no research question examples or topical suggestions, we aimed to achieve a variety of research themes. In the beginning of October 2021, we sent the study information to each citizen by mail, including one page with the single item questionnaire, and a stamped return envelope. We followed up with a reminder a week later, and another reminder two weeks after the initial letter was sent. The citizens had the possibility to anonymously submit their response by three different means: 1) respond via mail by using the stamped return envelope, 2) call us on a telephone hotline and leave a message on an answering machine, and 3) by using a website with the same open-ended questionnaire item allowing for direct text input in a text box. In case of phone calls, answers were transcribed into text by the second author.

Data analysis was conducted in six steps, of which the first four steps were conducted in a team (first, second, and last author). Those steps included 1) data familiarization through repeated reading and assurance to understand all answers, 2) splitting the answers into units of meaning, 3) constructing at least one code for each unit of meaning, 4) clustering of the codes into categories, 5) using the resulting coding scheme to code the whole text corpus, and 6) descriptive statistic of the coding results. For the data analyses, we used MAXQDA 2020 (VERBI Software, 2021). In many cases, one written response addressed several different topics, in these cases the responses were split into several single segments (462 segments in total, median = 4 segments per participant). Not all these segments were eventually classified into categories. For example, 14 of these segments described subjective conceptions on ageing in general, and 19 segments were complaints or opinions on (communal) political topics, so we decided to exclude them from further coding. The exemplary segments in the results section of this article were translated from German by the second author.

For the workshop phase, we sent a fourth letter to all citizens that were initially chosen to participate in the study and invited them to participate in a local workshop in each of the neighborhoods. Additionally, we invited local government representatives and stakeholders (i.e., NGOs) suggested by local government. The aim was to present the clusters with representative codes and relevant quotes and discuss them. The workshops were planned for November and December 2021. Due to increasing COVID-19 incidence in late 2021 in Berlin, only the workshop in Treptow-Köpenick could be conducted face-to-face. For the other neighborhoods, we offered the possibility to discuss the results via online meeting or through telephone calls to reduce risk of COVID-19 transmission.

Participants were informed about the content of the study, data protection and privacy rights. Participants were asked to answer without revealing any identifying information and were informed that by answering anonymously to the survey, implied consent was given to participation in the study and publication of its results. The study was approved by the ethics committee (Ethikkommission der Charité – Universitätsmedizin Berlin, Reference Number: EA1/254/21).

A total of 163 participants responded to the survey, of which 102 (10.2%) could be included in the evaluation. We received most of the valid responses (n = 78, 76.5%) via mail using the stamped return envelope. 91 (89.2%) of these answers could be assigned to a planning area: 30 (29.4%) came from Allende II (Treptow-Köpenick), 18 (17.6%) from Hohenschönhauser Straße (Lichtenberg), 15 (14.7) from Maulbeerallee (Spandau) and 14 (13.7%) from Treuenbrietzener Straße (Reinickendorf) and Böhlener Straße (Marzahn-Hellersdorf) respectively.

From the material, we constructed 18 codes which were clustered in six categories: Health, Living Environment, Social Issues, Mobility, Prevention, and Accessibility of Information and Communication. Fig 1 gives an overview of the categories, their respective codes and the number of individual participants whose answers contributed to these categories.

https://doi.org/10.1371/journal.pone.0292214.g001

Regarding health topics, responses from participants focused on health care delivery, but also on the adaptation of health care to the needs of older people and specific diseases. Participants mentioned the geographical distance to health services and the accessibility of health services as issues that should be investigated. The following quote demonstrates a specific research question on the distribution of allied health professions like physiotherapy:” I am 76 years old and had several surgeries last year , which is why I am very limited in my mobility . I would like to become fit again . However , there are not enough opportunities for physiotherapy to work on becoming fit again . Someone should think about this . How much and which kind of physiotherapy is actually needed per citizen depending on age . " (P14) Similarly, participants mentioned their desire that research on health services should have a stronger focus on older adults’ needs with regard to specific diseases and conditions:” Problems with pain are not taken seriously by doctors . (…) In the field of health care , we should research pain in old age . ” ( P 23)

Living environment

Respondents suggested further investigation into different topics in terms of lived environment, for example in the field of urban planning, green spaces and their impact on quality of life ( ”I would be interested to know about the influence of soil sealing of urban green spaces (…) on the quality of life and health of the older urban population . " P11). This also included comments on appropriate seating (i.e. benches, chairs), availability of public restrooms, and parks. Regarding their housing situation, participants expressed the importance of age-appropriate apartments, proposing to explore forms of assisted care living, the cause of rising rents, and the geographical distance and potentially difficult logistics of buying groceries and other supply of daily needs. Participants wished for further research on adjustments of the environment to their needs to be conducted.

Social issues

Loneliness was a topic that – despite being a well-established problem in literature – was still a prominent issue for older adults participating in our study, asking how to address the feeling of isolation in old age. Many participants wondered how social participation in the city can be strengthened while also highlighting the need for feeling safe and wondered how poverty in old age influences the possibility of interacting with others, social contacts and quality of life. Meeting places and leisure activities for older adults seem to be frequented regularly and rated as important social hubs. Some participants expressed that they would like to pursue their professional interests (” Looking for opportunities for successful older people to contribute their knowledge and experience “, P51) or get involved in cross-generational activities and networking (” Old people should be brought together with young people so that they’re not so lonely “, P97).

Research ideas for mobility included suggestions on individual traffic by car, bicycle or by foot. One participant mentioned the aspect of equality in traffic:” Research should look into a solution to increase traffic safety , where older adults have equal rights on the road . " (P90) Another respondent proposed the idea of bonus programs for older adults who relinquish their driver’s license. Few participants wrote about using the bicycle as means of transport, underlining the topic of safety on the road and the issues of sidewalks sometimes being shared by pedestrians and bikers at the same time. For some participants, the city in general did not seem very accessible. Use and accessibility of local public transport was also named a topic to be researched further:” I would like to use public transport again (e . g ., bus , train) . However , there is little attention to older adults with walking aids (e . g ., buses start too quickly after entering into) . " (P29)

Participants suggested that more research on prevention of diseases should be conducted. Specific research projects suggested were: age-appropriate physical and mental activities, at what age prevention should begin, how nutrition influences older adults’ health, but also proposing more research on early screening programs and dealing with substance abuse. A topic mentioned several times was preventing dementia:” Develop a screening program for early Alzheimer and dementia detection . If possible , include these in general preventive medical check-ups (like colon and breast cancer etc . ) for people in certain age groups . ” (P44)

Accessibility of information and communication

In this category, participants described their difficulties receiving relevant information in their area (i.e., on local age-centered activities, public transport schedules, for example through the internet or by other means). Participants also reported on problems with reading and understanding foreign languages, or medical jargon on their prescribed medication. They proposed to investigate ideas on how to reach older adults through different means (i.e., via doctors, media, and direct communication), underlining that digital information should not be seen as a mandatory information source for everyone.

When asked to suggest research topics from an older adults’ perspective, participants expressed their ideas on a wide range of topics that were clustered into six main categories: health, living environment, social issues, mobility, prevention and accessibility of information and communication. Most suggestions focused on topics of health care delivery and the living environment, but also tackled topics like social interaction and loneliness.

While differing in study design, the topics suggested in our research are in line with results of a qualitative study by Walker et al. [ 7 ], in which social networks, close relationships with other people in the neighborhood and proximity of services were defined as important by participants. The findings highlight that older adults suggest research topics from what they experience in their vicinity and what matters to them personally in their daily lives. In another study by Röhr et al., three main themes were defined regarding the design of urban environments to promote brain health: social participation, accessibility and proximity of health care, cultural events and public restrooms, as well as possibilities of local recreation and well-being [ 9 ]. All these topics were suggested by older adults in our study, who also mentioned the need for further investigation on disease prevention, specifically dementia prevention. Regarding health care topics, the National Ageing Research Institute of the Victorian Department of Health in Australia described older adults’ needs even more extensively than in the health segment of our study and defined important topics together with older adults, such as healthy and active ageing, independent living, sense of community, as well as care in medical crises and during end of life [ 10 ]. Self-acceptance and self-growth were found to be important for successful ageing in a study by Reichstadt et al. [ 5 ], but our participants did not specifically mention these themes as further research topics regarding urban ageing.

Research on participatory studies in which participants are actively engaged in designing a research agenda in an open format is limited, which makes it difficult to directly compare our results to similar projects. Also, the open format might have posed a potential intellectual challenge to the participants and may exclude older adults with a lower education from participation. Accordingly, only some of the responses were written in form of a definitive research topic. Responses were often phrased as issues and wishes or gave individual opinions on different topics ranging from national politics to general statements on growing old. We excluded the more general opinions that did not express any area for potential scientific research. Nevertheless, we were able to include many responses into our analysis to define categories, even when they were not specifically phrased as a hypothesis. Due to legal and ethical considerations, the letter sent out to the citizens contained five pages of descriptions on privacy and legal statements, which may have been discouraging especially for older adults who have a lower competency in reading. As the study information was only available in German, some citizens that received our mailings may have not understood their content. We received, however, one single answer in Russian which we had translated into German by a fellow researcher from our Institute. While the open format of the study might have been overwhelming for some, the overall response rate with more than 10% is still satisfactory for a postal survey with older adults who are not used to these kinds of projects. The age threshold that we chose as inclusion criteria (age 65 and older) was based on the earliest possible age of retirement in Germany, but it does not acknowledge possible differences in research ideas from the “young-old” adults (55–75 years) and the “old-old” adults (75+ and above) as described by Neugarten [ 13 ].

Unfortunately, the pandemic did not allow to conduct the second, workshop-based stage of the project as planned, so instead of five, only one workshop (in Treptow-Köpenick) could be conducted face-to-face. There, the panel consisted of older adults as well as local stakeholders (district officials, social workers) and allowed for a lively discussion on the presented topics, giving participants the chance to connect with each other. For the other four neighborhoods, we offered phone calls to present the results of the study individually and held video conferences with local stakeholders and interested participants. Online and via phone, the participation was not as strong as the local workshop, but it still gave us the possibility to present the results to stakeholders and interested citizens.

There is a substantial interest of older adults in urban environments on research regarding their living situation, especially focusing on health care delivery, living environment and psychosocial aspects, such as loneliness, interpersonal interaction, and concerns about living conditions. The focus on older adults’ daily lives should be more elaborated in the identified categories to promote aging well in cities. The suggested research topics can serve as a base for researchers on which to select themes that need further investigation, and involve different age groups of older adults to better reflect and integrate their perspectives.

Acknowledgments

We thank all participants and stakeholders for their contributions to this study. We also appreciate the assistance of our colleague Konrad Laker in language editing for the revised manuscript.

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Lifelong Learning Attracts Older Adults for Personal Growth and Cognitive Health

by Brittne Kakulla, AARP Research , March 2022

Read the Detailed Findings

• Lifelong Learning Among 45+ Adults (Report, PDF)
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Driven to seek personal growth, 55% of Americans age 45 and older are actively learning new things, according to a recent AARP study on lifelong learning. 

Studying the detailed complexities of history. Playing a musical instrument. Kneading dough while delving into the science of breadmaking. Attempting to keep pace with technology breakthroughs. These passion projects and individual interests are just a few of the pursuits lifelong learners take to stay mentally sharp and intellectually stimulated as they age.

The study asked participants to reflect on personal definitions, experiences, motivations, and pitfalls with learning driven by personal gain and self-betterment as opposed to work and career advancement, and it found a wide range in areas of interest. The most popular were history, food and drink, mental health, basic technology, and diet and nutrition.

While 42% of adults 45 and older identify as a “lifelong learner” many more say they intend  to engage in learning as they age, the study found. If those who indicate they would engage in lifelong learning in the future were to do so, the lifelong learning market would equate to more than 92 million people spending an estimated $6.9 billion annually. 

Investing in Learning 

The market size related to lifelong learning is substantial, already representing $5.6 billion annually. That equates to each lifelong learner currently spending an average of $75 a year on their interests.

In the popular field of learning a new technology, with a potential 43.3 million adults 45 and older interested, the average person is likely to spend about $60 annually. Other areas of interest have people willing to spend even more, including $120 a year on learning a new sport or physical activity, and $100 annually on developing a new skill or pursuing a passion project. 

Independent and Self-Directed

Learning is personal, the study revealed. Three quarters (76%) learn best by reading on their own, and the majority (71%) choose to read or gather information by themselves, then find opportunities to apply their new knowledge. 

Still, 72% turn to the internet, and YouTube in particular, when seeking new information. This is especially true when seeking information on a new technology (66%) or developing a new skill (63%). Because the research was conducted amid the COVID-19 pandemic, the findings reflect the recent growth in online engagement including things like video conferencing, the researchers noted.

Engagement in learning is particularly high among those with passion projects and those interested in new technology. 

Cognitive Health: Staying Sharp

As people seek education, the primary drivers are to gain new knowledge and stay mentally sharp. Learners are driven less often by social pressure, and both men and women saw learning as part of controlling their personal well-being, with the vast majority (83%) believing it is vitally important to keep your brain active. Similarly, 54% are motivated to stay sharp or promote brain health.

This concept of cognitive health fuels many to already identify as a lifelong learner, but it also motivates others to express a desire to learn something new in the future. 

Yet there are significant engagement gaps between being interested in learning something and currently pursuing new knowledge. For instance, while 41% are interested in learning basic technology skills, only a quarter of people are actively learning those skills. Similar engagement discrepancies are found among those with the most popular interests. But an engagement gap exists even among those with the least popular interest areas. For instance, only half of the 20% who said they wanted to play a sport actually do. 

The study found some gender differences between women and men, with women having more and varied interests than their male peers. Still, engagement gaps between a desire to learn and actively learning are high among both men and women, with more than two-thirds of men (68%) and women (69%) planning to engage in lifelong learning in the future. Learning a new technology is the top area of interest for nonlearners, with 32% saying they plan to take on that endeavor.

For those who are currently engaged in learning, the likelihood they will continue as lifelong learners is high. This momentum to learn more is significant, with 97% of current learners intending to pursue learning in the future. 

Barriers: Cost, Time, and Ageism 

While intentions for staying mentally engaged in new challenges are high, there are potential pitfalls. Ageism, cost, and time constraints are the primary barriers. A quarter of people (26%) cite cost as preventing them from taking on learning objectives, yet income does not make a difference in engaging with learning as those with high and low income are engaging in learning at about the same rate. 

A lack of time is of particular concern among adults ages 45–49, who say family duties are taking precedent. Among those 60 and older, however, fear of ageism becomes a factor, with 16% saying their age makes them feel uncomfortable. This internalized ageism results in viewing themselves as being too old, and it can impact attitudes toward learning new things. 

Experiencing ageism from others is also an obstacle for some, with 7% saying others make them feel uncomfortable about their age. Active learners are more likely to name fear of ageism as a barrier than those not currently engaged in learning (18% vs. 13%).

Methodology

The online survey of 1,516 Americans age 45 and older was conducted September 24–October 4, 2021 for AARP by Research Strategy Group, using the Dynata online panel. The data were weighted by age, region, and ethnicity to reflect the U.S. 45+ population. 

For more information, please contact Brittne Kakulla at [email protected] . For media inquiries, please contact External Relations at [email protected] .

Suggested citation:

Kakulla, Brittne. Lifelong Learning Among 45+ Adults. Washington, DC: AARP Research, March 2022.  https://doi.org/10.26419/res.00526.001

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• v.2018; 2018

Perspectives of Older Adults on Aging Well: A Focus Group Study

Hadeel halaweh.

1 Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden

2 Department of Physiotherapy & Rehabilitation, Faculty of Health Professions, Al-Quds University, Jerusalem, State of Palestine

Synneve Dahlin-Ivanoff

3 Centre for Ageing and Health, AGECAP, University of Gothenburg, Gothenburg, Sweden

Ulla Svantesson

Carin willén, associated data.

The data used to support the findings of this study are available from the corresponding author upon request.

With increasing number of older adults worldwide, promoting health and well-being becomes a priority for aging well. Well-being and physical and mental health are closely related, and this relation may become more vital at older ages as it may contribute to aging well. The state of well-being is a multifaceted phenomenon that refers to an individual's subjective feelings, and exploring perspectives of older adults on aging well is developing to be an important area of research. Therefore, the aim of this study was to explore perceptions on aging well among older adult Palestinians ≥60 years.

A qualitative research design in the context of focus group discussions was used; seven focus groups were conducted including fifty-six participants (aged 63–81 years). Data were analyzed using a qualitative interpretative thematic approach described by Braun and Clarke.

Three major themes were identified, “sense of well-being , ” “ having good physical health , ” and “ preserving good mental health.” The participants perceived that aging well is influenced by positive feelings such as being joyous, staying independent, having a life purpose, self-possessed contentment, and financially secured, in addition to be socially engaged and enjoying good physical and mental health.

This study contributes to get a better insight concerning older adults' perspectives on aging well. Enhancing physically active lifestyle, participation in social and leisure activities, healthy eating habits, having a purpose in life, and being intellectually engaged are all contributing factors to aging well. Vital factors are to be considered in developing strategic health and rehabilitative plans for promoting aging well among older adults.

1. Introduction

Worldwide, the age group of sixty years old and older is growing faster than any other age group [ 1 ]. With this remarkable increase of older adults; promoting health and well-being becomes a priority for aging well [ 2 ]. Aging well is conceptualized using different contemporary theoretical frameworks in the last decades, including healthy aging, positive aging, productive aging, active aging, and successful aging [ 3 , 4 ]. These theoretical frameworks integrate both biological and social sciences, considering social participation, psychology, lifestyles, activities, finances, and other domestic and environmental factors as well [ 4 ]. The WHO defines active aging [ 1 ] as “the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age including those who are frail, disabled, and in need of care.” As a policy framework [ 1 , 5 ], active aging allows people to realize their potential for physical, social, and mental well-being throughout the life course and to participate in society. The concept of active aging can be applied for promoting aging well in both developed and developing countries and this is consistent with our study setting in the West Bank/Palestine.

The state of well-being is a multifaceted phenomenon in the older population which generally involves happiness, self-contentment, satisfying social relationships, and autonomy [ 6 ]. The sense of well-being refers to an individual's feelings, in this case, based on how older persons perceive the concept of well-being. Thus, the term “subjective well-being” is frequently used [ 7 ]. Well-being is also subject to other persons' feelings about oneself whether that is positive or negative. According to McNulty et al. [ 8 ], well-being is determined jointly by the interplay between individual characteristics and qualities of people's social environments.

With advanced age, well-being might be adversely influenced by declining physical health and functioning due to age-related changes [ 9 , 10 ]; older adults may consequently encounter more challenges in pursuing aging well [ 7 , 11 , 12 ]. Maintaining good physical health and functioning plays an important role in facilitating mobility and enables older adults to perform more integrated functional tasks which include activities of daily living, fulfillment of social roles, and recreational activities [ 7 , 13 ]. Evidence suggests that better physical functioning is associated with physical activity, an interaction that is positively reflected on physical and functional well-being [ 14 – 16 ]. In addition, good physical functioning contributes to decrease falls' incidence [ 17 – 19 ] and prevent the negative impact of falling consequences including social isolation and activity restriction in older adults [ 20 , 21 ].

Older adults are strongly concerned about cognitive health in term s of keeping a good memory and prevent cognitive decline. Therefore, cognitive functioning was addressed as a primary contributor to aging well [ 22 , 23 ]. Good cognitive health is linked to social connectedness, independence, and life activities, and it might be preserved and enhanced by maintaining an intellectually engaged and physically active lifestyle [ 24 , 25 ]. Furthermore, having positive mental attitudes towards aging and one's capabilities may contribute to healthier mental health, higher level of satisfaction, and lower levels of anxiety and depression among older adults [ 26 ].

Well-being and physical and mental health are closely linked and the link may become more important at older ages, a connection that contributes to aging well in terms of life satisfaction, feelings of happiness, having sense of purpose, and meaning in life [ 27 – 30 ]. In the West Bank/Palestine, about one-third of adult Palestinians ≥18 years reported low levels of well-being; this was influenced by different socioeconomic factors including marital status, living standard, and community participation [ 31 ]. These contributing factors to well-being can be more prominent among older adult Palestinians, a marginalized growing population age group with a high rate of poverty, unemployment, and chronic diseases that requires further studies and research [ 32 , 33 ]. To our knowledge, this is the first qualitative study exploring perceptions of older adult Palestinians on aging well. Thus, the aim of this study was to explore perceptions about aging well among older adult Palestinians who were 60 years old and older at the time of the data collection.

2.1. Study Design

Focus group method was used to acquire data about perceptions of older adults towards aging well. Focus groups are defined as “carefully planned series of discussions designed to obtain perceptions on a defined area of interest in a permissive, nonthreatening environment” [ 34 ]. Group interaction is a fundamental part of this method, in which the vital group discussions among the participants produce the data of the studied topic [ 35 , 36 ].

2.2. Participants

A convenient sample was selected from previous related cross sectional studies [ 16 , 19 ], addressing physical activity and physical functioning among older adults ( n =176). The inclusion criteria were being community dwelling older adults (aged ≥60 years), living in the West Bank (Palestine), being able to walk with or without walking aids, and having no communication deficits that would make interviewing and discussions impossible.

In order to obtain a broader view of the participants' perceptions about aging well; heterogeneity was taken into consideration [ 34 , 35 ] through inviting older adults with different age and levels of education. Issues related to heterogeneity and homogeneity within the groups were considered during groups' formation in order to enhance an interactive discussion and to get a broad range of experience that covering a wide scope of the studied topic [ 34 , 35 ].

All participants were given verbal and written information about the aim of the study and they signed an informed consent form. The participants were ensured confidentiality and informed that participation was voluntary and that they could drop out of the study at any time. The study received ethical approval from the research Ethics Committee of Al-Quds University, Palestine (Ref No: 1/REC/13), which complies with the Declaration of Helsinki.

2.3. Procedure

All focus groups were arranged by the first author as a moderator. Focus group sessions were conducted in familiar, comfortable, and accessible settings for the participants and took place in community and physiotherapy centers in the West Bank (Palestine).

The moderator started the group sessions by welcoming the participants and clarifying the purpose of the study. Subsequently, the participants were invited to introduce themselves and were given a chance to ask if they had any inquiry regarding the study.

The moderator clarified that the discussion would be carried out involving the participants themselves as knowledgeable and expert persons of the studied topic and that the moderator would not contribute to answer the questions. The moderator guided the discussion and encouraged all participants to share and ensured giving sufficient time for each participant to express his or her own view; in addition, comprehension probes were used if needed to clarify responses.

The sessions were initiated with a starting question “ How do you describe aging well ,” followed by these questions:

•   What do you think about older adults' lifestyles in our community?
•   How do you think aging well can be achieved? Meaning how aging well can be facilitated?
•   What obstacles stand in the way of aging well?

The focus groups lasted from 90 to 120 minutes; the interviews were digitally audio-recorded. All interviews were transcribed verbatim by the first author and translated from Arabic to English by the first author in collaboration with a bilingual translator.

2.4. Data Analysis

The analyzing process was conducted using the interpretative thematic analysis described by Braun and Clarke [ 37 ]. The initial phase of the analysis “becoming familiar with the data” was initiated with reading and rereading the transcripts for several times. Repeated reading contributed to get a better understanding and enhanced researchers' familiarity with the data. Following the initial stage, “generating initial codes (coding)” from the data set that had a reoccurring pattern was performed in the second phase. Coding was carried out through systematic way of organizing and gaining meaningful characteristics of data related to the research question. The first author began the process of initial coding; all transcriptions were coded one by one. Research team meetings were held to discuss the generating initial codes; exchanges that helped create an interpretative space for testing the findings and confirming coding analyses. This process was repeated until coding consensus was reached. The software NVivo 10 [ 38 ] was used as a helpful tool for analysis. The third phase “searching for themes” focused on a broader level of analysis and involved the researchers identifying suitable themes to which codes could be attributed, initial codes pertinent to research question were integrated into themes considering how relationships were formed between codes and potential themes. To visualize and explore trends and relationships in the source data, codes, and themes, a tree mapping was formulated using NVivo wizards. Derived themes were reviewed in phase four of the analysis, through cyclical process that involves back and forth movements between phases of data analysis until consensus was reached on the final themes. Consequently, in phase five, “Defining and naming themes” was completed, through refining existing themes and subthemes that will be presented in the final analysis.

3.1. Descriptive Information

A total of 56 participants were recruited in this study, the mean age was 68.3 ± 4.72, ranged between 63 and 81 years old. The participants were assigned into different groups according to their place of residency and their preferences to participate in groups that consisted of only women, only men, or women and men together in one group. Accordingly, seven focus groups were formulated: four women groups, two men groups, and one group of women and men together. Participants in all seven groups ranged from 5 to 10 participants. The developed groups were homogenous in terms of independence level and place of residency. The majority of the participants (78%) had one or more chronic diseases, and all participants who lived alone (16%) were women. Participants' demographic and clinical characteristics are illustrated in Table 1 . The participants' names were changed to preserve the anonymity of the participants.

Demographic and clinical characteristics of the participants ( n =56).

3.2. Perceptions on Aging Well

Three major themes were identified, and twelve interrelated subthemes were derived. These themes and subthemes were elicited from the discussions for all focus groups combined within the scope to which they were supported by the qualitative data. Themes and subthemes are presented in the following sections.

3.2.1. Sense of Well-Being

Sense of well-being was highlighted through discussions in different focus groups as an important attribute to aging well. This theme was categorized into four related subthemes; feeling joyous, self-possessed contentment, satisfying social relationships, and staying independent.

(1) Feeling joyous was viewed as a catalyst to go on in life “joy extends life span,” “joy makes you energetic”; in these words, the participants expressed on the importance of being happy. They have connected happiness with living to advanced age, it was important for them to keep sweet flavor to their lives, no matter how difficult their circumstances were.

•   Nelly (F, 65y) : Despite life is full with troubles and blues, I continue.
•   Nadia (F, 73y) : I try to be happy, means one accepts everything, no matter bad or good.
•   Nelly : Yes, we need something taking us out of our concerns and make us happy.
•   Shafiq (M, 68y) : Absolutely right, being happy is very important for us in this age.

The participants found ways to add joys to their lives through different strategies such as gatherings, spending time with grandchildren, and sharing activities with others. For them, having leisure activities was of great importance in the context of aging well for older adults.

•   Fatima (F, 70y) : We get together from time to time, where we joke and laugh, listening traditional songs or singing together, this encourages us and makes us happy .
•   Sara (F, 64y) : For me, the sweetest thing I do is playing with grandson .
•   Ibrahim (M, 67y) : Yes, grandsons are dearest of sons, they refresh my heart .
•   Sara : I feel energized; I play with them as a young girl .

(2) Self-possessed contentment was apparently viewed as an important concern for older adults. Throughout the participants' discussions, feeling secured and being satisfied were frequently mentioned, self-contentment was manifested in the necessity of having access to needed resources in terms of health services and daily-life requirements. In this context, feeling financially secured contributed to the state of self-contentment and was described as a facilitating mean to manage life pressures for being able to age well:

•   Zeinab (F, 65y) : When you get old and there is no income, you may be in destitution .
•   Ribhieh (F, 67y) : Financial status plays a big role in our life .
•   Zeinab : This brings you many worries and occupies your mind .
•   Ibrahim (M, 67y) : Yes, the fact if one at ease can eat better can dress better, can live better, this reflects on the state of well-being for us as old people .

(3) Satisfying social relationships were viewed as an attribute to aging well at both familial and community levels. Among different groups' discussions, the participants talked about how important it was for them to be accepted and involved in an area of life. They reflected on how being isolated and lonely might be a serious obstacle to aging well. This subtheme was mostly prominent among women:

•   Nayfeh (F, 66y) : I live alone, nobody knocks my door, that's hard .
•   Mariam (F, 70y) : I live alone too, but my son lives in the first floor (same building). My daughter lives in town, and they are always around, that helps a lot, they do n 't let me alone at all .
•   Huda (F, 65y) : Yes, It's hard to live alone, but I go out, I share in different occasions, social participation is a good motivator for us as we growing old .

Staying socially active was described in different phrases and was manifested about “having good neighbors and visiting friends,” “highly motivated person towards life,” and “not being dismal.” Participation in community events was described by some participants as a helpful tool for older adults to stay socially active. Additionally, being socially active was connected with community voluntary work. The participants, both men and women commented on how vital for them it was to do voluntary activities, which helped them as older adults to efficiently spend their free time by doing something sensible to serve their own community. The participants reflected on how voluntary work or being involved in charitable work may enhance their state of well-being.

(4) Staying independent was viewed as a major characteristic of aging well. Apart from the participants' living status (alone or with family), the importance of being independent was connected with the autonomous status of the older adults. A major concern that was frequently mentioned was not being or becoming a burden to others. Along the interactive discussions in all groups, the participants reflected on the necessity of staying independent in performing their daily life activities including both personal and instrumental activities.

•   Seham (F. 65y) : I am taking care of myself, my health is good, I need to stay healthy and mentally oriented, so I w on 't seek anybody help .
•   Hannah (F, 81y) : I live alone, I have a big house. I do everything by myself; nobody brings me even a glass of water .

3.2.2. Throughout the Second Theme “Having Good Physical Health”

Throughout the second theme “having good physical health,” the participants have considered maintaining physical health as an important component of aging well, through our analysis, having good physical health was categorized into five related subthemes; staying active, free from debilitated illness, healthy eating habits, fall prevention, and having a good physical appearance.

(1) Staying active was connected to aging well, the participants prominently commented on the importance of staying active by keep on moving. The participants viewed staying active as a key factor for good health. Frequently, the participants talked about staying active in terms of walking which was viewed as a useful tool for aging well; walking was the most prevalent mode of physical activity and has been mentioned repeatedly as a routine activity. Staying active was also connected to good physical functioning, helping older adults to maintain good physical functioning, and keeping good health.

•   Hannah (F, 81y) : I like going out even I have pain in my legs, if I stay home, I will be destructed .
•   Salwa (F, 66y) : Me too, I' am taking care of my health, I walk a lot .
•   Zarifeh (F, 67y) : You know, I have a brother in law, he is 81 years old, he is still working and going out everywhere by feet .

Staying active was also revolved around continuing to work, which was described differently by the participants; men talked more about income generating and community work, while women talked about household and charitable work. Despite there were different perspectives on the concept of “continuing to work,” still it was considered as an important attribute for good physical health and for aging well throughout women and men expressions.

In other circumstances, staying active has been linked to gardening. The participants expressed on the importance of doing some gardening in order to stay active and energetic.

•   Salem (M, 72y) : I work in my garden, and I see myself more active than my sons .
•   Nelly (F, 65y) : Ohh, I love gardening a lot, I spend like two hours caring of my plants, digging around them. Always my plants look good, my whole garden is tidy, and that keeps me active and energetic .

(2) Free from debilitated illness , staying healthy in terms of absence of debilitated diseases was highlighted during group discussions as an important attribute to good physical health and consequently to aging well. The participants described how occurrences of illness may influence their physical health and their daily-life activities.

•   Ribhieh (F,67y) : Illness sometimes over shadow, I try to forget it, but it is dominated .
•   Fatima (F, 70y) : After rheumatism, I am not able to walk like before, that affected me a lot .
•   Ribhieh : Yes, it caused me gloominess sometimes .
•   Nelly (F, 65y) : Ahh, you know, I underwent two surgeries, and I've suffered a lot, but I've challenged every pain and every disease, I try to live my life .

(3) Healthy eating habits were evoked and being discussed in all groups, the participants reflected on this by focusing on the importance of taking healthy foods. Culturally, ideas regarding the Palestinian diet, which consists mainly of olives oil and lots of vegetables, were mentioned frequently. The participants related healthy diet with good physical health and longevity.

Within this subtheme, promoting healthy eating habits related to aging well were addressed. The participants talked about healthy habits to be taken as well as unhealthy eating style to be skipped. In this context, overeating or getting a full stomach was described as a source of disease, a behavior that has to be prevented in order to maintain good health. Unhealthy eating habits like skipping breakfast and excessive use of salt and sugar were viewed as aggravating factors for some disease symptoms.

(4) Falls prevention was a persistent topic that has been discussed among the participants as an important contributor to good physical health. For them, it was vital to stay active but constantly they were concerned about falling. They have viewed falling at this age as a devastating problem, thinking about fall consequences both physically and socially. The participants connected their concern of falling with the associated physical decline.

•   Majida (F, 70y) : I prefer using a cane rather than falling down .
•   Wardeh (F,77y) : Yah, me too, I pay attention to prevent slipping or falling .
•   Majida : Before I got sick, there was no problem, I did n 't never ever catch any handrails .
•   Mariam (F, 70y) : Yes I see, it is hard to fall and get fracture at this age, healing is not granted .

(5) Having a good physical appearance was viewed as an important trait to age well. The participants talked about how vital it was for them to keep in good physical appearance; this was connected with “keeping good shape,” “having good stature,” and “maintaining external appearance.” Others pointed out that older persons who are aging well “maintaining good external appearance and dressed well.”

3.2.3. Preserving Good Mental Health

The vitality of maintaining good mental health was viewed as an important attribute to aging well. This theme was categorized into three related subthemes: staying alert, having a positive attitude, and modes to keep good mental health.

(1) Staying alert : participants valued their state of mental alertness related to being independent, having control over their own affairs, and being self-governing. Being mentally alert and having a good memory was mentioned frequently as an imperative dimension of aging well.

•   Salma (F, 68y) : I was living with my mother in law, she reached her nineties, and she had a clear mind, everyone respected her, and I've learned a lot from her .
•   Ribhieh (F, 66y) : Yes I agree, If the brain is still good, you will be fine .

(2) Having a positive attitude emerged as an important attribute to aging well, and it was diversely characterized as follows: “my spirit is strong, I just follow my mind,” “I don't let anybody put me down,” and “I'm in any way, I want to live.” The participants commented on the importance of getting this impulse of life by staying positive. In this context, having positive attitudes towards own capabilities as older adults was reflected by fulfilling own ambitions and having a life purpose in pursuit of one's aspiration.

Being positive was also connected with spiritual merits, having faith, praying, and trust in God; these traits have been mentioned frequently through discussions in different groups. The participants commented on the importance of reaching a state of serenity and tranquility as an important attribute to aging well.

(3) Modes to keep good mental health including actions such as reading newspapers and books, watching TV and listening to the radio, eating certain foods like nuts, staying active, and playing mental games. All these statements were mentioned to describe taken activities by the participants in order to keep good mental health and to age well:

•   Farida (F, 64y) : I read newspaper every day, that keeps me oriented .
•   Nayfeh (F, 66y) : For me, I can't read well, watching TV and hearing radio amuses me and keeps me alert .
•   Hannah (F, 81y) : I work with letters and numbers, Sudoku is good if you manage to deal with it .
•   Farida : Ohh, That's good too .

Willingness to learn new skills was also considered by some participants as a way to keep a good mind; the new skills were mostly revolving around computer uses, handcrafts, and simple maintenance work.

4. Discussion

Happiness, self-contentment, satisfying social relationships, and independence are primary characteristics of the state of well-being that contribute to aging well in the older population [ 6 ]. A study by Tamir and Ford [ 39 ] indicated that people who generally wanted to feel more happiness and less anger experienced greater well-being. Corresponding with our results, as illustrated in the first theme, the participants have considered joy and happiness an important tool to age well. Feeling joyous was viewed as a catalyst to go on in life and was connected with living to advanced age. When older adults experience well-being, they are also experiencing the sense of self-contentment which is connected to the feeling of being happy and satisfied. Self-contentment in this study was manifested in feeling financially secured and in the necessity of having access to needed resources in terms of health services and daily-life requirements. The findings are consistent with a similar study [ 40 ], where financial security appeared to be an essential contributor to aging well.

Well-being is also subject to how a person feels that other people in their surroundings perceive them, whether this is positive or negative [ 8 ]. The findings are corresponding with our results in the subtheme “satisfying social relationships,” and the participants commented on the importance of having social connections at both familial and community levels. These findings are in harmony with the concept of active aging [ 1 ], which enables older people to realize their diverse potentials for well-being. However, the well-being of a person does not only depend on the individual, rather well-being has a social component as well, and it is determined jointly by the interplay between individual characteristics and qualities of people's social environments [ 39 ].

The participants reflected on how sensible for them it was not to be ignored and isolated at this age, and they thought being isolated and lonely as a serious obstacle to aging well. This concern was mostly prominent among older women who are more likely to spend their later stage of their lives alone [ 32 ]. Related to literature, living alone and low social participation were found to be significant risk factors for later disability onset [ 41 ]. Older adults who live alone report more fatigue and more health difficulties than older adults who do not live lonely [ 42 , 43 ], issues that are negatively contributing to aging well.

Our findings revealed that autonomy and independence were viewed as primary attributes to age well. Concern of being a burden to others was very prominent throughout participants' expression. Older adults in other cultural circumstances as well placed a high value on personal independence and self-reliance, where staying independent was viewed as a major trait for aging well [ 24 , 44 ]. The participants related their level of independence to their physical and mental health; a sensible understandable relation as a higher level of physical functioning enables older adults to perform more integrated functional tasks which include activities of daily living and the fulfillment of social roles as well as recreational activities [ 7 ], issues that are essential to age well.

Throughout the second theme “having a good physical health,” the participants connected their good physical health with staying active. Often, they have talked about staying active in terms of walking. This can be explained as walking was viewed as one of the most popular forms of physical activity among older adults and can easily be adapted into daily lifestyle [ 45 ].

In this study, walking was connected to good physical functioning and has been mentioned repeatedly as a routine activity, helping older adults to maintain good physical functioning and keeping good health. Findings are consistent with similar studies indicating that walking is positively associated with physical and functional well-being in older adults [ 14 , 15 ].

Physical health was addressed according to Phelan et al. as being in good health and absence of chronic diseases [ 46 ]. In Rowe and Kahn's model, it was addressed as avoiding disease and maintaining high cognitive and physical function [ 47 ]. In this study, the majority of the participants, about 78% had one or more chronic diseases. For them, the concern about physical health in term of diseases was more prominently about being free from debilitated illness that may incapacitate their abilities and limit their daily-life activities. Results that are consistent with a related study showed that participants with higher prevalence of chronic diseases recorded lower level of physical activity [ 15 ].

Promoting healthy eating habits related to aging well was also addressed in this study. The participants related healthy diet with good physical health and consequently to aging well, a subtheme that was also found among perceptions of older Japanese adults in a study towards aging well [ 40 ].

Additionally, falls prevention was a persistent topic that has been discussed among the participants as an important contributor to good physical health. For them, especially women, it was imperative to stay active but constantly they were concerned about falling. This can be attributed to the fact that higher incidence of falls is associated with higher age, and women tend to fall more frequently than men [ 48 , 49 ]. Participants have viewed falling at this age as a big problem, thinking about fall consequences both physically and socially. A subtheme is consistent with other studies [ 17 – 19 ], which have shown that good physical health and physical functioning play an important role in decreasing falls' incidence and fear of falling and, in turn, prevent the negative impact of falling consequences including social isolation, activity restriction, and enhance state of well-being in older adults [ 20 , 21 ].

In this study, preserving good mental health and staying alert were viewed as important attributes to aging well, and good mental health was connected to staying independent and being self-governing. In a study by Laditka et al. [ 24 ], maintaining good cognitive health was linked to social connectedness, independence, and life activities that are difficult to maintain with poor cognitive health. Within the second theme, “having a positive attitude” was described as an attribute to good mental health and to age well. This can be understandable as having positive attitudes towards aging and owns capabilities may contribute to healthier mental health. More positive attitudes were associated with higher level of satisfaction and lower levels of anxiety and depression in older adults [ 26 ].

Within this theme, participants related having a positive attitude to spiritual merits, having faith, praying, and trust in God. These traits have been mentioned frequently in different groups where the participants commented on the importance of reaching a state of serenity and tranquility that can be achieved through spiritual dimension as an important attribute to aging well. A spirituality dimension of aging well was found in similar studies [ 24 , 40 ] as well under categories such as faith, religion, blessings, and internal peace.

The state of well-being is positively influenced by having a life purpose that can motivate older adults to sustain independence, social life, and make life meaningful for older adults [ 29 ]. The feeling of having a purpose in life was also contributing to aging well in our study that was manifested by fulfilling ambitious and having a life goal in pursuit of one's aspiration.

Evidence suggests that cognitive functioning may be preserved and enhanced by maintaining an intellectually engaged and physically active lifestyle. Meaningful social engagement is also an important factor of better maintenance of cognitive functioning in old age [ 25 ]. Keeping good mental health was an important concern for older adults in this study; different modes were described to maintain good mental health including being mentally engaged (reading, playing mental games), taking good foods for the brain like nuts and staying physically active.

4.1. Strengths and Limitations

The aim of this study was to explore perceptions about aging well among older adults, as the state of aging well refers to an individual's subjective feelings and is basically dependent on the older adults' views [ 7 , 50 ]. Therefore, a qualitative research design in the context of focus group discussions was used; this qualitative thematic analysis approach contributed to get better insight into older adults' perceptions and experiences that cannot be elicited through quantitative studies.

Using focus group discussion as a method of data collection has enabled the researchers to get both individual and interactive opinions by the participants. This method is effectively used in research on aging [ 51 , 52 ], and it is considered appropriate for collecting the views and experiences of a selected group through dynamic interaction and vital group discussion of a studied topic [ 35 , 36 ]. In addition, focus group method was used, because it is a friendly respectful research method and not a condescending method [ 53 ] to be used with older adult participants. To assure permissive and nonthreatening environment for conducting this study [ 34 ], participants were assigned into different groups according to their place of residency and their preferences to participate in groups that consist of only women, only men, or women and men together. This procedure contributed to a relaxed discussion atmosphere through having familiar, comfortable, and accessible settings for the participants.

The groups' size in this study was determined based on the research question, taking into consideration that small groups with less than five participants may limit the range of interactive discussions, while large groups meaning more than ten participants can be hard to be managed by the moderator and may bound the participants' opportunities to share their thoughts and experiences [ 34 , 54 ].

The relationship between the researcher (first author) and the participants has been developed progressively through several interviews. Our sample was selected conveniently from previous related cross-sectional studies [ 16 , 19 ], addressing physical activity, physical functioning, and fall-related efficacy among older adults. Familiarity of researcher with the participants gave a chance to create a comfortable interviewing atmosphere, which helped the researcher build a trusting connection with the participants and encouraged the participants to talk more freely.

This study addresses aging well in a holistic manner that includes state of well-being, physical and mental health, independence, and social participation [ 3 , 55 ]. This helped us in giving a better understanding about the interaction between different physical, social, and mental functioning dimensions regarding the state of well-being among older adults. However, further studies addressing each dimension in more depth may add additional evidence towards a better understanding of the concept of aging well.

A possible limitation of this study could be that we recruited older adults who are relatively independent and functioning and living in the community at own homes within a family or alone, and most of them rated their self-fitness between good and very good. Further studies are needed to explore perspectives on aging well among older adults living in institutions with lower level of functioning and independence.

5. Conclusion

This study gives in-depth understanding of the dynamic multidimensional physical, social, and mental functioning on the state of well-being among older adults. Findings contribute to get better insight about older adults' perspectives on aging well. Aging well is positively influenced by feeling joyous, staying independent, self-possessed contentment, and being financially secured, in addition to being socially engaged and enjoying good physical and mental health. Enhancing a physically active lifestyle, social participation, and leisure activities as well as healthy eating habits and having a purpose in life and intellectually engagement are all important factors to promote aging well. Vital factors are to be considered in developing strategic health and rehabilitative plans for promoting aging well among older adults.

Acknowledgments

This study is based on a doctoral thesis [ 56 ], which was supported by Gothenburg University and Al-Quds University. The authors would like to thank all the participants for their valuable contributions to this study.

Data Availability

Conflicts of interest.

The authors declare that they have no conflicts of interest.

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Pesco-vegetarian diets best for reducing risk of death in elderly, research suggests

by Ansel Oliver, Loma Linda University Adventist Health Sciences Center

A variety of vegetarian diets appear to protect against risk of mortality and contributing conditions, with a pesco-vegetarian diet—which includes fish—providing the most protection against risk in very elderly people, according to a new study.

The study, "Cause-specific and all-cause mortalities in vegetarian compared to non-vegetarian participants from the Adventist Health Study-2 cohort," was published August 2 in the American Journal of Clinical Nutrition .

Researchers at Loma Linda University Health found that vegetarian diets are associated with lower risk for all-cause mortality and many cause-specific mortalities, especially among males and in middle-aged subjects. However, slightly higher risks were observed among very elderly vegetarians for neurological conditions such as stroke, dementia, and Parkinson's Disease.

Despite this, the pesco-vegetarian diet continued to offer a small but noticeable advantage over other vegetarian and non- vegetarian diets , even in elderly people .

Gary Fraser, MBCHB, Ph.D., distinguished professor at Loma Linda University School of Public Health and principal investigator of the study, said a vegetarian diet appears to offer protection from risk of death through middle-aged years, but once it helps people get into their 80s, that overall advantage seems to disappear for those adhering to a strict vegetarian diet.

"These increased risks of neurological conditions among vegetarians in their 80s weren't huge, but something is going on there that we shouldn't ignore if we wish the vegetarian advantage to continue for all vegetarians in their later years," Fraser said.

The study used data from the Adventist Health Study-2, a massive cohort of nearly 96,000 people who identify as Seventh-day Adventist and lived in the United States and Canada during the study's baseline recruitment between 2002 and 2007, with follow-up through 2015. Data from that group has been used for numerous studies on health , disease, and mortality over the years.

This study analyzed data from more than 88,000 subjects and approximately 12,500 deaths in the study cohort. Dietary data were collected using a questionnaire and then categorized into five patterns: non-vegetarian, semi-vegetarian, pesco-vegetarian, lacto-ovo-vegetarian, and vegan.

Fraser said his team found that Adventist vegetarians overall had about a 12% less risk of death compared to Adventist non-vegetarians. Study participants with a pesco-vegetarian diet had an 18% less risk of death.

Those with a lacto-ovo-vegetarian diet (including dairy and eggs) had a 15% less risk of death. Vegans overall had a less than 3% decreased risk of death, but male vegans fared much better than non-vegetarians, in contrast to females.

"Overall, this is some of the clearest data that American vegetarians are greater protected from premature death than non-vegetarians," Fraser said.

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