Behavioral and lifestyle factors have a profound impact on health throughout the lifespan. Older adults can help to prevent disease and disability and improve their quality of life through healthy behaviors such as proper nutrition, exercise, use of preventive health care, and avoiding smoking and alcohol abuse. Several particularly encouraging studies have shown that disability rates are declining. NIA research is focusing on ways to sustain and even accelerate the decline in disability, including the use of behavioral interventions and optimizing use of the health care system by older people. In addition, important research efforts, such as the national Health and Retirement Study, continue to collect and analyze demographic data that inform public policy and planning for the health, economic, and social needs of a growing older population.
This section on behavioral and social research begins with a Story of Discovery, which follows the initially startling finding of a decline in the rate of disability among older Americans. The narrative then describes research advances in assessing reduced mortality rates in developed nations and in examining the influence of attitudes and emotions on health in older people. Selected future directions for research focus on the use of demographic research to assess and improve the health of the older population, social and behavioral influences on cognitive aging, and behavioral medicine and interventions.
Story of Discovery: The Declining Disability of Older Americans
Older Americans are healthier and they are living longer. As a result, they may be able to stay in the workforce longer and need less medical care as they advance in age. But they are also growing in number, as the baby boom ages and the proportion of the population over 65 increases dramatically. The changing demographics of the aging population are proving a challenge to policymakers, who need to account for these population trends in looking at the future of such key national programs as Social Security and Medicare. In the mid-1970s, for example, the Social Security Administration made life expectancy projections based on the assumption that mortality rates would stay constant, and that life expectancy would not improve over time. It soon became clear that such an approach was not accurate. In 1982, the National Commission on Social Security Reform was established to determine how to maintain Social Security solvency in the face of projected life expectancy increases at ages 65 and over. The commission recommended an increase in the normal retirement age for Social Security beneficiaries from 65 to 67 years in increments from 2000 to 2022. These modifications to the Social Security program were based on changes in life expectancy and did not address the health status of older individuals.
In 1993, a surprising new analysis suggested that the health status of older people might be changing radically as well, with equally important ramifications for policy and planning for an aging America. Researchers looking at trends from 1982 through 1989 in the National Long Term Care Survey (NLTCS) found that disability rates had declined significantly in the older population. In 1994, new NLTCS data confirmed that a decline was occurring in chronic disability and researchers and policymakers began looking even more closely at the data. At least 1.2 million fewer older Americans were disabled in 1994 than there would have been if disability rates had not improved since 1982. Today, a preliminary update from the same survey suggests a continuation of the decline and perhaps even a reduction in the absolute number of elderly disabled persons.
Additional studies, using different databases, have since confirmed the NLTCS findings. An analysis of data from the Survey of Income and Program Participation in 1998 showed a reduction in disability rates from 1984 to 1993 in every age group of elderly Americans 50 years and over. The 1991 to 1996 Medicare Current Beneficiary Survey also showed disability declines occurring at an even more rapid rate than in the NLTCS. These corroborating findings have helped establish that the observed disability decline may reflect real improvements in underlying physiological health of older people.
The implications of these studies are important. It is hoped that better functioning among growing numbers of older people could help hold down the demand for health care and, in turn, help to reduce health care costs, over and above investments in research, preventive health care, and treatment that might be needed to maintain or accelerate the decline in disability. The decline might also have an effect on the ratio of working age people to the disabled elderly. This is important because a continued decline in disability rates, with fewer disabled older people, might increase the ratio of working age people to disabled elderly, possibly reducing the burden of support that the younger population might have to bear for programs for an aging population. Research to understand these potential long-term impacts of the decline is underway, looking at economic consequences, the adoption of new medical technology, and changes in the burden of caregiving, including informal care, home health services, and institutional long-term care.
Research has also begun to focus on factors contributing to the decline in disability so that specific interventions and behavioral changes can be identified that might accelerate trends in improved function among older Americans. Some of these efforts are described in this section's discussion of selected future directions in behavioral and social research.
Mortality Continues To Decline in Industrialized Countries
During the twentieth century, mortality rates have shown steady and significant declines in the G7 countries of Canada, France, Italy, Germany, Japan, the United Kingdom, and the U.S. Mortality decline has occurred most significantly in older populations due to decreases in deaths from heart attack, stroke, and cancer. Examining mortality data of the G7 industrialized countries over the last five decades, researchers found that long-term patterns in mortality rates have continued to decline exponentially at a remarkably constant rate, without evidence of slowing. Therefore, official estimates of longevity in the G7 countries underestimate life expectancy and also understate the ratio of people 65 and older to working age people (20–64 year olds). By the year 2050, these ratios may be between 6 percent (UK) and 40 percent (Japan) higher than official projections. These findings have significant implications for public policy regarding future demands on health care, long-term care, retirement support, and other services.
Potential Impact of Attitudes on Health and Behavior
Emotional state has been associated with health and functional status in old age. Both positive and negative attitudes or emotions can influence health and physical and cognitive function.
Emotional Vitality Protects Against Mortality and Progression of Disability in Disabled Older Women. Using data from the Women's Health and Aging Study, a longitudinal study of community-dwelling disabled women aged 65 years and older, researchers examined whether emotional vitality protects against progression of disability and mortality. At the start of this study, a substantial proportion of even the most disabled older women were identified as emotionally vital. Three years later, results showed that these upbeat, positive women did better than women who were not emotionally vital in maintaining physical function over time. These results suggest that helping older people maintain a high level of emotional vitality might play an important role in slowing or preventing a downward spiral in health status. Further study may be warranted of why and when positive emotions protect against health decline in older people.
The Influence of Stereotypes on Cardiovascular Health and Cognitive Function. Recent research indicates that exposure to negative beliefs about aging can contribute to adverse health outcomes, even when an individual is not consciously aware of such exposure. In this study, exposure to negative stereotypes elicited heightened cardiovascular stress (increased blood pressure and heart rate in older adults) in response to mathematical and verbal challenges designed to elicit a stress response. Positive messages about aging protected participants from a stress response. The older adults exposed to positive stereotypes also exhibited more confidence in their ability to perform computations than those exposed to negative stereotypes, and then outperformed them as well. These preliminary findings suggest that further research is need to examine the potentially powerful influence of stereotypes not only on the physical well being of older adults but also on their performance in tasks known to become progressively more difficult with age. Perhaps positive age-related stereotypes could be used to reduce cardiovascular responses to stress and to improve cognitive performance and daily function.
Selected Future Directions in Behavioral and Social Research
Using Demographic Research To Assess and Improve Health, and Reduce Disability. As the world's older population grows, demographic research can be used to assess the impact of population aging on the global burden of chronic disease and disability. Health and economic trends can be identified, helping to target opportunities for research on their causes and impact. NIA will collaborate with other NIH institutes in studying the changes in health and functional status over time of disabled and chronically ill older people. Research is being developed to improve data on burdens and costs of diseases. One growing area of interest centers on the possible addition of biological measures of health in social surveys.Demographic research is also planned to track the dynamics underlying the increase in old-age life expectancy in the U.S. and to define the implications of changes in health, disability, and life expectancy for national policies on retirement and on programs for the elderly. A particular focus is being developed to provide the necessary data for understanding the large variations in health across racial and ethnic populations.
Special efforts are underway to identify more precisely factors that have specifically contributed to recent declines in disability, as discussed in the Story of Discovery above. Past demographic and health research has provided clues, noting the social, educational, public health, and biomedical variables that affect health and function. Further research will examine specific trends likely to extend the disability decline, such as improvements in health-related behaviors, increased education among older people, improved availability and effectiveness of assistive devices, disease prevention, and better treatment for conditions that lead to disability.
Another area of emphasis is work, retirement, and health.The NIA is the primary sponsor of the Health and Retirement Study (HRS), one of the largest and most innovative efforts done in the U.S. to understand the dynamics of health and retirement. Analyses of HRS data will focus on the relationships between health and wealth with age and the variability in savings at various income levels. Additional research in this area will examine the determinants of work and the influence that pension systems and incentives have on the decision to work or retire.
Social and Behavioral Influences on Cognitive Development. The cognitive health of older adults is influenced by a number of factors, and additional research is needed to understand the social and behavioral contributions in this area. NIA behavioral and social scientists are collaborating closely with the Institute's neuroscience program to encourage research that: (1) examines the influence of contexts (behavioral, social, cultural, and technological) on cognitive and day-to-day function of older individuals, (2) investigates the effects of age-related changes in cognition on activities of daily living, social relationships, and health status, and (3) develops strategies for improving everyday function through cognitive interventions. Such research will be in line with activities suggested by the National Research Council's recent report on The Aging Mind. In addition, studies will also look at the role that individual differences, such as motivation, self-efficacy, beliefs about aging, emotion, sensory limitations, experience, and expertise, may play in cognitive function.
Behavioral Medicine and Interventions. It is well known that a wide range of healthy and unhealthy behaviors influence health and well being at any age. Research in this area will look at the dynamic interrelationships among aging, health, and behavior, expanding traditional studies of behavioral medicine by adding an aging perspective. This area of research should encompass a wide range of health and illness behaviors, including healthy lifestyle practices, medical self-management, and coping with chronic illness and disability. Epidemiological and behavioral research identifying risk factors as well as influences on health will guide intervention studies in this area. Increasingly, interventions may be viewed as multilevel, focusing not only on older individuals, but on family and societal changes as well. An important aspect of this work will be an emphasis on strategies for disseminating and translating findings and information as new interventions are developed.