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Successful Aging in the Oldest Old
Who Can Be Characterized as Successfully Aged?
Margaret von Faber, MA;
Annetje Bootsma–van der Wiel, MD;
Eric van Exel, MD;
Jacobijn Gussekloo, MD, PhD;
Anne M. Lagaay, MD, PhD;
Els van Dongen, MA, PhD;
Dick L. Knook, PhD;
Sjaak van der Geest, MA, PhD;
Rudi G. J. Westendorp, MD, PhD
Arch Intern Med. 2001;161:2694-2700.
ABSTRACT
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Background Successful aging is a worldwide aim, but it is less clear which indicators
characterize elderly persons as successfully aged. We explored the meaning
of successful aging from 2 perspectives.
Methods Analysis of data from the first cross-sectional part of the longitudinal
Leiden 85-plus Study, conducted in Leiden, the Netherlands. All inhabitants
of Leiden aged 85 years were eligible. Data were obtained from 599 participants
(response rate, 87%). Successful aging from a public health perspective was
defined as a state of being. All participants were classified as successful
or not successful based on optimal scores for physical, social, and psychocognitive
functioning and on feelings of well-being, using validated quantitative instruments.
Qualitative indepth interviews on the perspectives of elderly persons were
held with a representative group of 27 participants.
Results Although 45% (267/599) of the participants had optimal scores for well-being,
only 13% (79/599) had optimal scores for overall functioning. In total, 10%
(58/599) of the participants satisfied all the criteria and could be classified
as successfully aged. The qualitative interviews showed that most elderly
persons viewed success as a process of adaptation rather than a state of being.
They recognized the various domains of successful aging, but valued well-being
and social functioning more than physical and psychocognitive functioning.
Conclusions If successful aging is defined as an optimal state of overall functioning
and well-being, only a happy few meet the criteria. However, elderly persons
view successful aging as a process of adaptation. Using this perspective,
many more persons could be considered to be successfully aged.
INTRODUCTION
SUCCESSFUL AGING is a worldwide aim. Demographic changes challenge policy
makers to put increasing effort in dealing with the consequences of an aging
population.1 Many research programs, conferences,
and political reports deal with the subject of successful aging, healthy aging,
or other variants of a positive way of growing old. The concept of successful
aging, however, lends itself to more than one interpretation. Two main perspectives
exist: one that looks at successful aging as a state of being, a condition
that can be objectively measured at a certain moment; and one that views it
as a process of continuous adaptation. Rowe and Kahn2
hold the former view and describe successful aging as the positive extreme
of normal aging, while others3 use definitions
such as the elite of healthy elderly persons or robust aging. In these definitions,
successful aging is a better than normal state of being old. Several population-based
studies4-8
on successful aging have adopted this concept. Others, like Baltes and Baltes,9 see successful aging as a successful adaptation of
the individual to changes during the aging process. In a similar view, Havighurst10 and Keith et al11
define successful aging as reaching individual goals or experiencing individual
feelings of well-being.
Successful aging as an optimal state implicates more than physical well-being
and fits the World Health Organization's definition of health as a state of
complete physical, mental, and social well-being and not merely the absence
of disease or infirmity.12 However, the internal
relationships between these domains are disputed, and there are no operational
definitions for assessment. This problem holds equal when using other models,
like the International Classification of Impairments, Disabilities, and Handicaps
model.13 As a consequence, measuring health
or, parallel to that, measuring successful aging reflects the individual preferences
of scientists.
To gain a deeper insight into the concept of successful aging, we will
describe successful aging from 2 perspectives. In a quantitative approach,
we defined successful aging as an optimal state of being. In a qualitative
approach, the aging process as experienced by elderly persons was the point
of departure. Therefore, we measured the optimal functioning and well-being
with established quantitative instruments in a community-based sample of 85-year-old
persons, and conducted in-depth interviews with a representative number of
participants. We explored the differences between the state of being, which
mimics a public health perspective, and the perspective of the elderly persons
themselves.
PARTICIPANTS AND METHODS
The Leiden 85-plus Study is a population-based prospective follow-up
study on functioning and well-being in a delineated cohort of 85-year-old
persons. The aims of the present study are to investigate determinants and
preventable causes of unsuccessful aging and to explore the possibilities
for investing in successful aging. The study was approved by the institutional
medical ethical committee, and informed consent was provided by the participants
or, in case of severe cognitive impairment, by the most significant other.
RESPONSE RATE AND GENERAL DEMOGRAPHICS
All the inhabitants (n = 705) of Leiden, the Netherlands, born between
September 1, 1912, and September 1, 1914, were invited for this study shortly
after their 85th birthday. There was no exclusion on health, cognitive functioning,
or living situation. Fourteen persons died before they could be enrolled,
and 92 refused to participate. Data were obtained from 599 participants; the
response rate was 87%.
Table 1 shows the demographic
characteristics of the participants. The proportion of women was 66%, more
than half of the participants (58%) were widowed, and 18% of all participants
were institutionalized. Demographic characteristics are representative for
the general Dutch population of 85-year-old persons.14
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Demographic Characteristics of the Participants*
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QUANTITATIVE MEASUREMENTS
According to the World Health Organization's definition of health, the
domains of physical, social, and psychocognitive functioning were assessed
as was the domain of general well-being. Established quantitative instruments
were chosen after consultation with researchers from other studies of elderly
persons. Trained physicians and research nurses visited the participants twice
at home, and assessment took place in face-to-face interviews.
Physical functioning in daily life was measured using the Groningen
Activity Restriction Scale (GARS).15 This is
a unidimensional questionnaire that assesses disability in the area of the
basic and instrumental activities of daily living (self-care, mobility, and
housekeeping).
Social functioning was measured with the Time Spending Pattern Questionnaire
(TSP), which lists regular involvement in social and leisure activities, leading
to a sum score for 10 social activities (eg, receiving visitors, visiting
others, contact by telephone, and participation in church and associations).16
Psychocognitive functioning was measured with the Mini-Mental State
Examination (MMSE) as a screening instrument for severe cognitive impairment
and dementia17-18 and the short
Geriatric Depression Scale19 as a screening
instrument for depression.
Well-being was assessed by the Cantril ladder,20
a visual analog scale on perceived quality of life varying from 1 to 10 points,
and by a general question: "Are you, in general, satisfied with your present
life?" Answers varied from 1 (very unsatisfied) to 5 (very satisfied).21 Loneliness was screened by a questionnaire developed
by de Jong–Gierveld and Kamphuis.22
In case of severe cognitive impairment, defined by a score of 18 or
less on the MMSE, depression and loneliness could not be assessed.
CLASSIFICATION OF SUCCESSFUL AGING
We defined successful aging as the optimal state of overall functioning
and well-being. Figure 1 gives an
overview of this classification. Criteria for each domain were based on the
quantitative scores at the moment of measurement. Cutoff points were chosen
at the 33rd percentile to include the best third for each domain in addition
to standard cutoff values. This led to the following quantitative criteria
for classification.
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Figure 1. Quantitative model of successful
aging.
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Optimal State of Overall Functioning
The optimal state for physical functioning included minor physical disabilities
(GARS sum score at the 33rd percentile or less); for social functioning, regular
social activities (TSP sum score at the 33rd percentile or greater); and for
psychocognitive functioning, the absence of cognitive impairment (MMSE score
greater than 18), and the absence of marked depressive feelings (Geriatric
Depression Scale score of less than 4).
Optimal State of Well-being
The optimal state for well-being included a good quality of life (Cantril
ladder score at the 33rd percentile or greater), satisfaction with present
life (score of 5-point question at the 33rd percentile or greater), and the
absence of marked feelings of loneliness (Loneliness Scale score of less than
4).
Alternative Criteria
To investigate the influence of the previously mentioned cutoff at the
33rd percentile on the outcome of successful aging, we used alternative criteria
as well. Optimal physical functioning was defined as having no disabilities
in the basic (self-care) activities of daily living. Optimal social functioning
was defined as having at least 4 social activities within 2 weeks. Optimal
well-being was defined as being satisfied with one's present life and awarding
a pass mark of 7 or higher on the Cantril ladder, without being lonely.
QUALITATIVE MEASUREMENTS
The anthropologist (M.F.) held in-depth interviews with 27 participants.
The central research questions focused on the experience of growing old and
being old, the perception of the concept of successful aging, and the role
of health in successful aging from the perspective of the elderly persons.
The unstructured and open-ended interviews enabled the researcher to discover
motivations, ideas, and determinants from the perspective of the elderly persons.23-24 Experiences and opinions of the elderly
participants were not limited to the moment of measurement; past and present
experiences and expectations about the future were included.
Participants were selected in consultation with the other researchers
of the study (A.B.W. and E.E.), irrespective of the outcomes of the questionnaires
and functional scales, as we were not interested in an "on average" view of
the elderly population.23 Criteria for selection
were a representative proportion of men and women. We interviewed participants
with different physical conditions and in different housing situations. These
participants turned out to be representative compared with the overall study
group. Their demographic characteristics are presented in Table 1. Persons with severe cognitive impairment were excluded
because their impairment would prevent them from taking part in an in-depth
interview. Most of the participants were visited twice or more often. Observation
of the participants in their home situation was a complementary tool.
All interviews were recorded on audiotape and transcribed. In the analytic
process, data were coded, closely examined, and compared for similarities
and differences. Concepts such as health, successful aging, and social functioning
were elaborated in terms of their properties, dimensions, and relationships.25
In this article, the perceptions of the elderly persons about physical,
social, and psychocognitive functioning and well-being are compared with the
quantitative measurements at baseline to see whether these are concordant.
TEAM DISCUSSION
To evaluate the classification of successful aging, the findings of
the first 150 participants were the subject of multidisciplinary discussions.
In a standard procedure, participants were discussed on an individual basis
to clarify patterns, new determinants, and discrepancies. Arguments for and
against the classification of successful aging were recorded. The team consisted
of a nurse, an anthropologist (M.F.), a geriatrician (A.M.L.), a general practitioner
(J.G.), and 2 research physicians (A.B.W. and E.E.).
RESULTS
PHYSICAL FUNCTIONING
Quantitative Findings
Physical functioning varied from total dependence of bedridden participants
(GARS score, 72) to total independence (GARS score, 18). The median GARS score
was 28. Poor physical functioning was reported by 20% of the participants
who were dependent in 1 or more basic activities, mainly dressing and washing
the whole body. The best third, a total of 203 persons, had a GARS score of
23 or less and were classified as having an optimal state of physical functioning.
This subgroup reported only minor disabilities in instrumental activities,
meaning that they were independent in daily living but experienced minor difficulties
in some activities like heavy housework and cutting toenails.
Qualitative Findings
Participants compared their functioning with the functioning of peers.
Most elderly persons talked about health at this age as the maintenance of
basic functions (vision, hearing, and mobility) and the absence of life-threatening
diseases, such as cancer. The multidimensional process of adaptation to changes
(eg, to the slowing of pace and the diminishing of strength) was found to
be inherent in aging. Elderly persons who were limited in their functioning,
as shown in case 1, stated that acceptance and adaptation are essential in
maintaining a feeling of well-being. Those who enjoyed good health said they
had been lucky and did not regard their health as a personal "success." Persons
tended to influence their functioning by anticipation (like moving to live
near children), risk-avoiding behavior (like stopping cycling to prevent falling
and breaking a hip), and investing in a good physical condition (like using
a home trainer or doing gymnastic exercises). Optimal physical functioning
was perceived as an ideal situation but conflicted with the common knowledge
that afflictions may occur unexpectedly at the age of 85 years.
Case 1
"I am disabled, but I feel healthy." Reinier Baan, a friendly man, lives
on his own. (To preserve the privacy of informants, all names are chosen by
the anthropologist or the informants themselves.) For a long time, he took
care of his parents and he never got married. He is confined to a wheelchair
after having experienced a stroke, almost 24 years ago. He has arranged many
supportive aids in his home, and although limited, he feels healthy and independent.
It takes him all morning to put clean sheets on his bed, but he is proud to
be able to do so without assistance. In his view, acceptance and adjustment
to physical limitations is a characteristic of successful aging: "I am dependent
in some aspects of my life, nobody can ever change that. But in other aspects,
I will try to remain independent as long as I can."
SOCIAL FUNCTIONING
Quantitative Findings
Social functioning varied from no involvement in any of the social activities
(TSP score, 10) to regular involvement in various activities (TSP score, 29).
The median score was 18. Poor social functioning was reported by 40% of the
participants who were regularly involved in only 1 or 2 activities, mainly
having visitors. The best third, a total of 218 persons, had a TSP score of
20 or greater and were classified as having an optimal state of social functioning.
They reported regular involvement in more social activities, especially visits
and telephone calls, playing round games, going to clubs, and attending church
services.
Qualitative Findings
Most elderly persons perceived social functioning as essential for well-being
and successful aging. A significant group stated that the social contacts
in old age reflected their investments at an earlier age. Notions of reciprocity,
individual character, and the importance of choices influenced their statements.
Investments in social contacts were perceived as coping mechanisms to avoid
loneliness. While social activities might have decreased as a consequence
of physical dysfunction, social contacts continued to be important and influenced
positive self-esteem. In case 2, the couple evaluated their social functioning
not as individuals but as a joint venture. Furthermore, one missing contact
could count more than many existing ones, as case 3 shows.
Case 2
"We are successful together, but when the other dies . . . " Joost van
der Meer feels fortunate that he and his wife can still live together. They
complement each other well. Mr van der Meer is a good listener and has a special
relationship with one son and one grandson. His son and his grandson have
a mental illness. They often come to visit him, and he gives them moral support.
His wife has special contact with one of their other grandchildren. As a couple,
they have many social contacts. Marian van der Meer takes the initiative by
making telephone calls to friends, relatives, and acquaintances in their neighborhood.
Mr van der Meer accompanies his wife on visits, because she has difficulty
walking.
Case 3
Appearances are deceptive. Klaas and Vera Philipsen are well-to-do,
live in a beautiful house with a garden, and have many social contacts. Their
ability to stay in control and to adjust to old age is well illustrated in
their decision to adopt a young dog. When the anthropologist (M.F.) asked
Ms Philipsen whether she regarded herself as successful in her life, she said
she was not. Years ago, there had been a conflict between her husband and
her daughter. At the time, she chose her husband's side and since that incident
the daughter has severed all contacts with them. The fact that she has lost
all contact with her daughter gives her a continuing feeling of loss. All
her successes in life are overshadowed by this failure.
PSYCHOCOGNITIVE FUNCTIONING
Quantitative Findings
Severe cognitive impairment (MMSE score,  18) was found in 99 persons
(17%). Marked depressive feelings (Geriatric Depression Scale score,  4)
were found in 118 persons, 24% of 500 participants without severe cognitive
impairment. The median MMSE score was 26, and the median Geriatric Depression
Scale score was 2. Instead of selecting the best third, persons were excluded
based on severe cognitive impairment or depressive feelings. This left 382
persons (64%) who met the criteria for classification of optimal psychocognitive
functioning.
Qualitative Findings
Physical functioning and cognitive functioning were perceived as part
of health. Most participants feared cognitive decline because dementia is
perceived as losing one's personality. They felt lucky to have good cognitive
functioning, and some tried to invest in maintaining this level by memory-training
activities.
Temporarily, 3 participants felt sad and downcast because of the loss
of a loved one. Two other participants had depressive feelings. Feelings of
depression could be linked to facts and factors beyond their cognitive and
emotional personality, like the social context, as case 4 shows.
Case 4
"They have put a lock on my mouth." Elizabeth Kooistra lives in a sheltered
home. Her husband died 3 years ago. She has already lost 4 of 6 children.
At night, when she cannot sleep, she talks to their portraits in the living
room. Ms Kooistra has limited mobility due to chronic pain and, therefore,
spends most of her time in her apartment. She feels depressed, not only because
of her pain and the loss of her loved ones but most of all because she cannot
tell others what is on her mind. Her son lives far away in France. Nobody
wants to listen to complaints. One day, her son reacted: "Mother, stop it
now! I want to hear no more sad stories, I want to have a happy mother!" Ms
Kooistra wants emotional support and sympathy from family and peers, but they
show little understanding for her depressed mood.
WELL-BEING
Quantitative Findings
Well-being varied from very unsatisfied (score, 1) to very satisfied
(score, 5) with one's present life; the median score and the 33rd percentile
score were both 4. Scores on the Cantril ladder varied from 1 to 10; the median
score and the 33rd percentile score were both 8. Marked loneliness (Loneliness
Scale score, 4) was measured in 81 persons, 16% of 500 participants without
severe cognitive impairment; the median score was 1. The best third, 290 persons,
were satisfied with their present life (score, 4 or 5) and had high scores
(8) on the Cantril ladder; 23 were excluded based on marked feelings of
loneliness. This left 267 persons (45%) who were classified as having an optimal
state of well-being.
Qualitative Findings
For most elderly persons, well-being was equivalent to successful aging.
The ability to adjust to circumstances, counting one's blessings like social
contacts, and focusing on gains instead of losses were said to be crucial
(eg, case 1). At the same time, adjustments had to be within certain limits
to be in line with self-image and individual personality. Character and personality
were mentioned as influencing factors in achieving and maintaining feelings
of well-being. Cases 5 and 6 show that the actual feeling of well-being could
also relate to earlier life experiences or anticipation of life after death.
Being content despite one's limitations was influenced by religious and cultural
values.
Case 5
"I thank God that I don't have to wait too long before I see my wife
again!" Frans and Johanna van Lijn, married for almost 62 years, had moved
from their house to a home for elderly persons. After a few months, Ms van
Lijn died in the hospital after surgery. Mr van Lijn had to move again, this
time to a single room. Despite these major changes and several increasing
health complaints, his feeling of well-being remains high. He is grateful
to God for the happy years he shared with his wife, and is expecting to meet
her again. His life perspective includes life after death.
Case 6
This was an example of a happy present vs a traumatic past. Maartje
Verbeek compares her present situation with the difficult and traumatic period
of her youth. Powerlessness and fear due to an incestuous relationship with
her father dominated her life as a child. After that miserable period, a happy
marriage followed in which she was able to come to terms with her past. Now,
in her old age, she enjoys the affection of her children and grandchildren.
She considers herself a happy person. Her positive evaluation of her present
situation is closely linked to the memories of her youth. For Ms Verbeek,
her physical limitations are of minor importance. She has invested during
her life in social contacts with relatives and friends.
SUCCESSFUL AGING
Quantitative Findings
Successful aging as a state of optimal overall functioning and well-being
was defined by before-mentioned domains, as shown in Figure 1. Of all the participants, 26% failed to meet the criteria
of any of the functional domains, whereas optimal states in overall functioning
were assessed for 79 persons (13%). An optimal state of well-being was assessed
for 267 persons (45%). In total, 58 persons (10%) had an optimal state of
overall functioning and well-being and were, thus, classified as successfully
aged. Elderly persons living in institutions were rarely classified as successfully
aged (2 of 102 participants). The demographic characteristics of sex, marital
state, income, and education were not associated with the outcome of successful
aging (data not shown).
Outcomes were not materially different when using alternative criteria
(see the "Alternative Criteria" subsection of the "Participants and Methods"
section). The proportion of those who could, thus, be classified as successfully
aged varied between 9% and 16%.
Qualitative Findings
Of the 27 elderly participants who were interviewed, 22 described themselves,
individually or as a couple, as content with their lives and successfully
aged.
Many older persons made no clear distinction between physical and cognitive
functioning as a part of health. Both were perceived as important factors
in successful aging, but only necessary for functioning on a desired social
level. When physical or cognitive functioning had decreased, the decrease
was usually accepted as an unavoidable result of growing old, which had nothing
to do with a person's own achievement. In contrast, some participants who
functioned well on a physical level did not feel successful, because of conflicts
in the social context.
Participants believed that keeping in touch with friends and relatives
was their own merit and that contacts reflected investments at an earlier
age in their role of parent, family member, friend, neighbor, or colleague.
The quality of social contacts proved to be more important to elderly persons
than the quantity of contacts, as one missing contact could count more than
many existing ones.
From the perspective of the elderly persons, aging and successful aging
are adaptive processes that are personal and context bound. In all domains,
participants made reference to their personal life history and their social
environment. Character and attitude (making the best of it) were mentioned
as the main instruments in overcoming limitations.
Team Discussion
The team discussions were held to evaluate the classification of successful
aging. Discussions focused on those who gave the impression of being successfully
aged but were not classified as such. The researchers had divergent judgments,
based on their conversations and observations, that were not part of the various
instruments. Main topics of discussion concerned the specific domains and
the classification in general.
In the domain of physical functioning, a discrepancy was found between
independence and poor physical functioning. Various persons with a disability
could manage their affairs well. Some did so without any help, while others
with financial means arranged assistance. Other discrepancies in the scores
for physical functioning were influenced by sex roles. Married men regularly
reported disabilities in household activities that were due to inexperience
rather than physical incapability. In addition, enabling factors, such as
nearby shops, or disabling factors, such as stairs, influenced physical functioning.
In the domain of social functioning, the discrepancy between passive
and active social functioning dominated team discussions. Most team members
believed that activities on one's own initiative should be judged differently
from participating in activities arranged by others. Social activities that
might be important for this age group were missed in the questionnaire, like
ordinary conversation within a joint household, with neighbors, or with storekeepers.
The quality of activities was not taken into account. Some participants were
content with few social activities and preferred to be left alone to do things
they enjoyed. It was argued that it was inappropriate to classify these participants
as less successful because of their lower scores for social functioning. Furthermore,
the focus on social activities instead of social contacts and interaction
was debated.
Regarding the exclusion of elderly persons with a severe cognitive impairment
or marked depressive feelings, it was remarked that some participants with
dementia felt well and were not bothered by their cognitive impairment. Furthermore,
cases of depressive feelings as a way of coping with negative life events
sparked team discussions. Coping abilities were found to be important for
psychocognitive functioning and were missed as part of the classification.
In the domain of well-being, discussions focused on assessing the marks
of the Cantril ladder. While some persons would never award themselves 10
points, others easily gave themselves 9 or 10 points. The frame of reference
of the participants was missed in understanding the mark they gave themselves
on the Cantril ladder.
In discussions on the classification of successful aging in general,
it was often argued that using the same set of strict criteria did not leave
any room for flexibility on personal, environmental, or temporary circumstances.
Especially, the moment of measurement was believed to limit the individual
classification. Some elderly persons had lower scores on the domains of functioning
because of temporary reasons beyond their control, like the illness of a partner
or a holiday period. Interestingly, team members sometimes confused the question,
"Is this person successfully aged?," with the question, "Do you want to be
like this yourself when you're old?"
COMMENT
We described successful aging from 2 perspectives. In the quantitative
part of the study, successful aging was defined as a state, a condition at
the moment of measurement, which mimics a public health perspective. This
approach made it possible to select a few elderly persons who were successful
by all means. In total, 10% of all participants could be classified as successful,
having an optimal state of overall functioning and well-being. This selective
group of the oldest old had only minor physical disabilities, regular social
activities, good psychocognitive function, and high feelings of well-being.
Even when we used alternative criteria in the domains of functioning and well-being,
the proportion of the elderly persons who could be classified as successful
remained similarly low. The classification for an optimal state of overall
functioning turned out to be more selective than the classification for an
optimal state of well-being. Almost half of the oldest old reported an optimal
state of well-being. Many persons were satisfied with their recent life despite
limited functioning. This phenomenon is known as the "disability paradox,"
prevalent in all age groups.26-27
The qualitative part of the study showed that the proportion of elderly
persons who perceived themselves as successfully aged was much higher. From
the perspective of participants, the different domains constituting successful
aging were recognized. However, they regarded social contacts as the most
important condition for well-being and—as a consequence—for successful
aging. The absence of limitations and losses does not constitute one's success
at old age; rather, success is measured by the way these limitations and losses
are integrated into one's attitude to old age.28
Successful aging is not so much a matter of objectively measured physical
functions but—seen as a process—the successful adaptation to physical
limitation; successful in the sense of satisfactory to the person concerned.
A life span perspective helps us to understand people's appreciation
of success in old age. From the qualitative analyses, a different model for
successful aging was hypothesized, as shown in Figure 2. The domains of functioning and well-being are not equally
important, as assumed in the quantitative research, but there is a hierarchy
of domains in the experience of successful aging. The process of adaptation
is added to this model. The relative weight that elderly persons assign to
the various domains of functioning and well-being explains the disability
paradox. Specific for elderly persons is that they expect deterioration of
physical functioning because of their chronological age.29
In this respect, the hierarchy of the different domains may change during
a life span, as hypothesized by the social production function theory.30
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Figure 2. Qualitative model of successful
aging.
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The main benefit of this research lies in showing the "relativity" and
"qualification" of the results.31 To our knowledge,
we are the first to provide insight into the process of measuring successful
aging within the elderly population. Other studies4-8
on successful aging are primarily focused on physical aspects. These studies
find other proportions of the outcome of successful aging, using other criteria
for successful aging in younger study populations. They aim to show determinants
of the outcome rather than describe the outcome itself.
The team discussions showed many shortcomings in the assessments and
classification of the participants. Aspects that appeared to be important,
like character, social contacts, and contextual factors, had not been measured
or were only limitedly measured. Participants and team members believed that
coping was an important part of successful aging. However, coping was not
measured because existing questionnaires tended to be too abstract or too
long in combination with the other questionnaires. Because we emphasized the
importance of adaptation in successful aging, we stress the importance of
developing coping questionnaires suitable for an assessment in a general population
of the oldest old.
The implications of the present research concern physicians, researchers,
and policy makers. We did not aim to reach a consensus between the different
perspectives or to give a gold standard for successful aging. A focus on success
by all means is unrealistic and ignores the value of adaptation to limitations
and losses that are inherent to aging. We do, however, stress physicians to
be aware that physical and cognitive functioning are perceived as the means
for functioning on a desired social level. Researchers should be challenged
to investigate more than the easy-to-measure physical aspects. Finally, policy
makers have the responsibility to consider not only medical goals, like health
as an optimal state, but also more personal goals, like well-being, when putting
effort into dealing with the consequences of demographic changes in their
societies.
AUTHOR INFORMATION
Accepted for publication April 18, 2001.
This study was funded in part by the Dutch Ministry of Health, Welfare,
and Sports, The Hague.
Ms von Faber and Dr Bootsma–van der Wiel equally contributed to
this article.
Corresponding authors: Margaret von Faber, MA, and Annetje Bootsma–van
der Wiel, MD, Section of Gerontology and Geriatrics, Department of General
Internal Medicine, Leiden University Medical Center, C2-R, Room 133, Albuminusdreef
2, PO Box 9600, 2300 RC Leiden, the Netherlands (e-mail: leiden85plus{at}lumc.nl).
From the Section of Gerontology and Geriatrics, Department of General
Internal Medicine, Leiden University Medical Center, Leiden, the Netherlands
(Ms von Faber and Drs Bootsma–van der Wiel, van Exel, Gussekloo, Lagaay,
Knook, and Westendorp); and Division of Medical Anthropology, University of
Amsterdam, Amsterdam, the Netherlands (Ms von Farber and Drs van Dongen and
van der Geest).
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