Encyclopedia of Geropsychology (gnv64) PDF

Nancy A.
Pachana
Editor
Encyclopedia of
Geropsychology
Encyclopedia of Geropsychology
Nancy A. Pachana
Editor
Encyclopedia of
Geropsychology
With 148 Figures and 100 Tables

Editor
Nancy A. Pachana
The University of Queensland
Brisbane, QLD, Australia
ISBN 978-981-287-081-0 ISBN 978-981-287-082-7 (eBook)

ISBN 978-981-287-083-4 (print and electronic bundle)
DOI 10.1007/978-981-287-082-7
Library of Congress Control Number: 2016953014
# Springer Science+Business Media Singapore 2017

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Foreword: The Frontiers of
Geropsychology
In Undaunted Courage, the late historian, Stephen Ambrose (1996) chronicled

the challenges faced by Meriwether Lewis as he set out on the Lewis and Clark
expedition. He and his band of explorers were emissaries of President Thomas
Jefferson, seeking a northwest passage and exploring the western territories of
a young nation. Throughout the expedition, Lewis sent scouts back to Presi-
dent Jefferson, reporting on the landscape and the ora and fauna of the young
nations largely unknown territory.
In many ways, the entries of this comprehensive encyclopedia are like
Lewiss scouts reports, only the territory being described is at once universal
and immediately personal: the psychology of aging. Although concerns about
aging and the latter part of the life span can be traced to the ancient Greeks
(Abeles 2015), G. Stanley Halls (1922) Senescence: The Last Half of Life
marked psychologys formal acknowledgment of the relevance of later life for
psychology and psychologys relevance for understanding that portion of the
lifespan. In the almost one hundred years since Halls publication, the eld of
geropsychology has expanded tremendously in breadth and depth.
When someone asks What does psychology have to do with aging? there
are simple and complex answers. The simple answer: Lots!
Paul Baltes (1987, 1997; Baltes et al. 2007) outlined a more complex
answer. He suggested that psychological models of adult development and
aging had to account for four key elements: multidirectionality; plasticity; the
historical context; and multiple causation. Baltes reminded us that aging
includes both growth and decline (a lesson highlighted in Freund
et al. (2016) entry). He also highlighted that compensatory skills can be
learned to accommodate changing abilities. (Kuhn and Lindenberger
(2016) would later differentiate plasticity from exibility, a differentiation
found in Wahl and Wettsteins (2016) contribution to this encyclopedia.)
Baltess emphasis on the historical context was a reminder of the inuence
of cohort and historical moments on individuals and societies, a theme echoed
in Kennison, et al.s (2016) entry. Finally, by highlighting multiple causation,
Baltes focused our attention on the interaction between and among inuences
that shape the development and expression of psychological functioning,
including biological and psychological elements (again, reected in Rifn
and Loeckenhoffs (2016) entry).
Editor Nancy Pachana is to be commended for the range of talented
scholars and important topics she has assembled in this encyclopedia; both
v
vi Foreword: The Frontiers of Geropsychology
are impressive. Together, hundreds of scholars have shared their expertise to

report on the state of the art in geropsychology in the early twenty-rst century.
Along the way, they have demonstrated range of methods (observational and
experimental), design (longitudinal, cross-sectional, cohort-sequential), and
measurement strategies (intensive, repeated measures; single time surveys;
etc.) Highlighting both inter- and intra-individual differences in rates and
processes of aging, they have expanded Baltess outline and helped us answer
three important questions: How do psychological processes affect aging? How
does aging affect psychological processes? How do the contexts of individuals
affect the interaction of aging and psychological processes?
Throughout the encyclopedia, various psychological processes are
highlighted for their impact on the processes of aging: for example, resilience
(Staudinger and Greve 2016); the positivity effect (Reed and Carstensen
2016); social cognition (von Hippel et al. 2016); and social exchange (Wan
and Antonucci 2016).
Conversely, some have focused on the impact of aging processes on
psychological and social functions: for example, cognition (Schaie and Willis
2016); executive function (Karbach and Unger 2016); attention (Ruthruff and
Lien 2016); memory (Zimprich and Kurtz 2016); decision-making (Mata
2016); personality (Helmes 2016; Diehl and Brother 2016); sexuality
(Connaughton and McCabe 2016); and sexual orientation (Kimmel 2016).
At the same time, the contributors have focused on the impact of various
contexts on the interplay of aging and psychological functioning: for example,
social policy (Lum and Wong 2016); advocacy (DiGilio and Elmore 2016);
technology (Lane et al. 2016); and work and retirement (Desmette and
Fraccaroli 2016).
This encyclopedia will be a resource for many audiences: students of
gerospsychology who seek an introduction to the methods and ndings of
the eld; teachers and scholars who seek insightful summaries of the complex
literatures encompassed by geropsychology; and clinicians who are involved
in translational research and service, extending the implications of basic
research paradigms into the lives of aging adults, their families, and their
communities.
The encyclopedias scholar scouts of the territory of aging, who include
the very capable associate editors of this text, have given us detailed reports on
both the process and substance of exploring the territory. They allow us to
understand aging in new ways and to see new prospects and new challenges in
a territory we thought we knew. They also remind us of how far we have come
in understanding the very human experience of aging. Savor the journey.
References
Abeles, N. (2015). Historical perspectives on clinical geropsychology. In

P. Lichtenberg & B. T. Mast (Eds.). APA handbook of clinical geropsychology:
Vol. 1. History and status of the eld and perspectives on aging (pp. 317).
Washington: American Psychological Association. doi: 10.1037/14458-02.
Foreword: The Frontiers of Geropsychology vii
Ambrose, S. E. (1996). Undaunted courage: Meriwether Lewis, Thomas

Jefferson, and the opening of the American West. New York: Simon &
Schuster.
Baltes, P. B. (1987). Theoretical propositions of life-span developmental
psychology: On the dynamics between growth and decline. Developmental
Psychology, 23, 611626.
Baltes, P. B. (1997). On the incomplete architecture of human ontogeny:
Selection, optimization as foundation of developmental theory. American
Psychologist, 52, 366380.
Baltes, P. B., Lindenberger, U., & Staudinger, U. M. 2007. Life span theory
in developmental psychology. In Handbook of child psychology (Vol. I, p. 11).
doi: 10.1002/9780470147658.chpsy0111.
Connaughton, C., & McCabe, M. (2016). Sexuality and aging.
In N. Pachana (Ed.), Encyclopedia of geropsychology. New York: Springer.
Desmette, D., & Fraccaroli, F. (2016). From work to retirement.
Diehl, M., & Brother, A. (2016). Self theories of the aging person.
Freund, A., Napolitano, C., & Knecht, M. (2016). Life management
through selection, optimization, and compensation. In N. Pachana (Ed.),
Encyclopedia of geropsychology. New York: Springer.
Hall. G. (1922). Senescence: The last half of life. New York: Appleton.
doi: 10.1037/10896-000.
Helmes, E. (2016). Stage theories of personality. In N. Pachana (Ed.),
Karbach, J., & Unger, K. (2016). Executive functions. In N. Pachana (Ed.),
Kennison, R., Situ, D., Reyes, N., & Ahacic, K. (2016). Cohort effects.
Kimmel, D. (2016). History of sexual orientation and geropsychology.
Khn, S., & Lindenberger, U. (2016). Research on human plasticity in
adulthood: A lifespan agenda. In K. W. Schaie & S. L. Willis (Eds.), Handbook
of the psychology of aging (8th ed., pp. 105123). Amsterdam: Academic
Press. doi: 10.1016/B978-0-12-411469-2.00006-6.
Lum, T., & Wong, G. (2016). Social policies for aging societies.
Matas, R. (2016). Decision making. In N. Pachana (Ed.), Encyclopedia of
geropsychology. New York: Springer.
Rifn, C., & Loeckenhoff, C. (2016). Life span developmental psychology.
Ruthruff, E., & Lien, M. (2016). Aging and attention. In N. Pachana (Ed.),
Schaie, K. W., & Willis, S. (2016). History of cognitive aging research.
Staudinger, U., & Greve, W. (2016). Resilience and aging. In N. Pachana
(Ed.), Encyclopedia of geropsychology. New York: Springer.
viii Foreword: The Frontiers of Geropsychology
Wahl, H., & Wettstein, M. (2016). Plasticity of aging. In N. Pachana (Ed.),

Zimprich, D., & Kurtz, T. (2016). Process and systems views of aging and
memory. In N. Pachana (Ed.), Encyclopedia of geropsychology. New York:
Springer.
Michael A. Smyer
Professor of Psychology
Bucknell University
Preface
Geropsychology is a relatively young eld which spans a range of topic areas

covering a subject of perennial interest to researchers, practitioners, and lay
persons namely, the psychology of later life. This book aims to thoroughly
cover the main subtopics within the eld of geropsychology, including histor-
ical and theoretical perspectives, clinical and applied geropsychology, cogni-
tive and experimental geropsychology, geriatric neuropsychology and
neuroscience, social geropsychology, health perspectives in geropsychology,
work and retirement in later life, and longitudinal aging and centenarian
studies.
The aim is to cover all aspects of geropsychology in a comprehensive way,
with an international perspective and attention paid to both established and
emerging topics in the eld. The illustrations and high quality of the images, as
well as the breadth of topics covered, will be key to its success.
In recent years, several advances in theory, measurement, and application
across these many areas within geropsychology, coupled with innovations in
domains ranging from genetics to social media and the Internet, have dramat-
ically expanded the eld. Simultaneously, the aging of the population in the
developing and the developed world has enlivened interest in geropsychology.
I hope that this book serves as a timely addition to the growing body of
literature on this topic.
Brisbane Australia Nancy A. Pachana

December 2016
ix
ThiS is a FM Blank Page
Acknowledgments
The Encyclopedia of Geropsychology has been a truly international collabo-

rative effort. I would like to thank all of the wonderful researchers across the
globe who contributed entries to this work, my subsection editors for their
diligence and creativity, the patience and support of all of the staff at Springer,
the encouragement of my colleagues, friends, and family, and the love and
support of my husband Tim.
xi
About the Editor
Nancy A. Pachana
School of Psychology
The University of Queensland
Brisbane, Queensland, Australia
Dr. Nancy A. Pachana is a clinical

geropsychologist, neuropsychologist, and pro-
fessor in the School of Psychology at The Uni-
versity of Queensland and is codirector of the
UQ Ageing Mind Initiative, providing a focal
point for clinical, translational aging-related
research at UQ. She has an international reputation in the area of geriatric mental
health, particularly with her research on late-life anxiety disorders. She is
codeveloper of the Geriatric Anxiety Inventory, a published brief self-report
inventory in wide clinical and research use globally, translated into over two
dozen languages. She has published over 200 peer-reviewed articles, book
chapters, and books on various topics in the eld of aging and has been awarded
more than $20 million in competitive research funding, primarily in the areas of
dementia and mental health in later life. Her research is well cited and she
maintains a clear international focus in her collaborations and research interests,
which include anxiety in later life, psychological interventions for those with
Parkinsons disease, nursing home interventions, driving safety and dementia,
teaching and learning in psychogeriatrics, and mental health policy and aging.
Nancy was elected a Fellow of the Academy of Social Sciences in Australia in
2014. She is also a Fellow of the Australian Psychological Society and is the
recipient of numerous prizes and awards, including an Australian Davos Con-
nection Future Summit Leadership Award, for leadership on aging issues in
Australia. She serves on the editorial boards of several journals, including the
Journals of Gerontology: Psychological Science, one of the top two journals in
the world for publication of research in the science of the psychology of aging.
Originally from the United States, Nancy was awarded her A.B. from Princeton
University in 1987, her Ph.D. from Case Western Reserve University in 1992, and
completed postdoctoral fellowships at the Neuropsychiatric Institute at UCLA,
Los Angeles, and the Palo Alto Veterans Medical Center, Palo Alto, California.
She is an avid bird watcher and photographer and an intrepid traveller.
xiii
Section Editors
Christopher Hertzog School of Psychology, Georgia Institute of Technol-

ogy, Atlanta, USA
Marcia G. Ory Health Promotion and Community Health Sciences, School

of Public Health, Texas A&M Health Science Center Texas, Texas, USA
xv
xvi Section Editors
Deborah Attix Duke Clinical Neuropsychology Service, Department of Psy-

chiatry and Behavioral Sciences, Department of Neurology, Duke University
Medical Center, Durham, USA
Bob G. Knight School of Psychology and Counseling, University of South-

ern Queensland, Toowoomba, Queensland, Australia
scar Ribeiro Institute of Biomedical Sciences Abel Salazar of the Univer-

sity of Porto (UNIFAI & CINTESIS), University of Aveiro, Department of
Education and Psychology, Higher Institute of Social Service of Porto, Porto,
Portugal
Section Editors xvii
Mnica Yassuda Gerontology and Neurology Departments, University of

So Paulo, So Paulo, Brazil
Daniela S. Jopp University of Lausanne, Institute of Psychology, Gopolis,

Lausanne, Switzerland
Hannes Zacher School of Management, Queensland University of Technol-

ogy, Brisbane, Queensland, Australia
xviii Section Editors
Catherine Haslam School of Psychology, The University of Queensland,

Queensland, Australia
Helene Fung Chinese University of Hong Kong, Shatin, Hong Kong
Fiona Alpass School of Psychology, Massey University, Palmerston North,

New Zealand
Section Editors xix
Sherry Ann Beaudreau Psychiatry Service, Sierra Pacic Mental Illness

Research Education and Clinical Center (MIRECC), VA Palo Alto Health
Care System, Palo Alto, CA, USA
Department of Psychiatry and Behavioral Sciences, Stanford University
School of Medicine, Stanford, CA, USA
School of Psychology, University of Queensland, Brisbane, Australia
Matthias Kliegel Department of Psychology, University of Geneva, Geneva,

Switzerland
Center for the Interdisciplinary Study of Gerontology and Vulnerability, Uni-
versity of Geneva, Geneva, Switzerland
Swiss National Center of Competences in Research LIVESOvercoming
vulnerability: life course perspectives, University of Lausanne Gopolis build-
ing, Lausanne, Switzerland
xx Section Editors
Chris Stephens School of Psychology, Massey University, Palmerston

North, New Zealand
Hans-Werner Wahl Department of Psychological Aging Research, Univer-

sity of Heidelberg, Hauptstrasse, Heidelberg, Germany
Colette Browning RDNS Institute, Victoria, Australia

Contributors
Marja Aartsen NOVA Norwegian Social Research, Oslo and Akershus

University College, Oslo, Norway
Phillip L. Ackerman School of Psychology, Georgia Institute of Technol-
ogy, Atlanta, GA, USA
Stphane Adam Psychology of Aging Unit, University of Lige, Lige,
Belgium
Janne Adolf Max Planck Institute for Human Development, Berlin, Germany
Rosa Marina Afonso Department of Psychology and Education, University
of Beira Interior, Covilh, Portugal
UNIFAI-ICBAS and CINTESIS, University of Porto, Porto, Portugal
Kozma Ahacic Centre for Epidemiology and Community Medicine, Health
Care Services, Stockholm County Council, Stockholm, Sweden
Department of Public Health Sciences, Karolinska Institutet, Stockholm,
Sweden
Andrew J. Ahrendt University of Nevada, Reno, NV, USA
Julia Alber Center for Health Behavior Research, Perelman School of Med-
icine, University of Pennsylvania, Philadelphia, PA, USA
Carolyn Aldwin Center for Healthy Aging Research, Oregon State Univer-
sity, Corvallis, OR, USA
Jason C. Allaire Department of Psychology, North Carolina State Univer-
sity, Raleigh-Durham, NC, USA
Mathias Allemand Department of Psychology and University Research
Priority Program Dynamics of Healthy Aging, University of Zurich, Zurich,
Switzerland
Joanne Allen School of Psychology, Massey University, Palmerston North,
New Zealand
Rebecca S. Allen The University of Alabama, Tuscaloosa, AL, USA
Philip A. Allen Adult Development and Aging Psychology, The University
of Akron, Akron, OH, USA
xxi
xxii Contributors
Fiona Alpass School of Psychology, Massey University, Palmerston North,

New Zealand
Lori J. P. Altmann Department of Speech, Language, and Hearing Sciences,
University of Florida, Gainesville, FL, USA
Karen Andersen-Ranberg Epidemiology, Biostatistics and Biodemography,
Institute of Public Health, University of Southern Denmark, Odense C,
Denmark
Kaarin J. Anstey Centre for Research on Ageing Health and Wellbeing,
Research School of Population Health, The Australian National University,
Canberra, ACT, Australia
Toni C. Antonucci University of Michigan, Ann Arbor, MI, USA
Ivan Aprahamian University of So Paulo, So Paulo, SP, Brazil
Jundia Faculty of Medicine, Jundia, Brazil
Yasumichi Arai Center for Supercentenarian Research, Keio University
School of Medicine, Tokyo, Japan
Lia Arajo UNIFAI and CINTESIS, ICBAS University of Porto, Porto,
Portugal
Portugal and Polytechnic Institute, ESEV and CI&DETS, Viseu, Portugal
Neal M. Ashkanasy UQ Business School, The University of Queensland,
Martin Asperholm Division of Psychology, Department of Clinical Neuro-
science, Karolinska Instituet, Stockholm, Sweden
Catherine R. Ayers Department of Psychiatry, University of California,
San Diego School of Medicine, San Diego, CA, USA
Research Service, VA San Diego Healthcare System, San Diego, CA, USA
Christian Bakker Department of Primary and Community Care: Center for
Family Medicine, Geriatric Care and Public Health, Radboud University
Medical Center, Nijmegen, The Netherlands
Florence, Mariahoeve, Center for Specialized Care in YoungOnset Dementia,
Den Haag, The Netherlands
Radboud Alzheimer Center Nijmegen, Radboud University Medical Center,
Nijmegen, The Netherlands
P. Matthijs Bal School of Management, University of Bath, Bath, UK
Andrs Losada Baltar Department of Psychology, Universidad Rey Juan
Carlos, Madrid, Spain
James Banks Institute for Fiscal Studies, London, UK
School of Social Sciences, University of Manchester, Manchester, UK
Contributors xxiii
Fiona Kate Barlow School of Applied Psychology and Menzies Health

Institute Queensland, Grifth University, Brisbane, QLD, Australia
Magdalena Bathen Kassel, Germany
Sarah Bauermeister School of Psychology, Faculty of Medicine and Health,
University of Leeds, Leeds, UK
Christine Beanland Royal District Nursing Service (RDNS) Institute, Mel-
bourne, VIC, Australia
Sherry A. Beaudreau Department of Psychiatry and Behavioral Sciences,
Stanford University School of Medicine, Stanford, CA, USA
Sierra Pacic Mental Illness Research Education and Clinical Center, VA Palo
Alto Health Care System, Palo Alto, CA, USA
School of Psychology, The University of Queensland, Brisbane, QLD, Australia
Terry A. Beehr Central Michigan University, Mount Pleasant, MI, USA
Margaret E. Beier Department of Psychology, Rice University, Houston,
TX, USA
Raoul Bell Heinrich Heine University Dsseldorf, Dsseldorf, Germany
Sylvie Belleville Psychology Department, Research Centre, Institut
Universitaire de Griatrie de Montral, Montral, QC, Canada
Vern L. Bengtson School of Social Work and Edward R. Roybal Institute on
Aging, University of Southern California, Los Angeles, CA, USA
Kate M. Bennett Department of Psychological Sciences, University of Liv-
erpool, Liverpool, UK
Karianne Berg Norwegian University of Science and Technology, Trond-
heim, Norway
Marilena Bertolino Department of Psychology, University de Nice Sophia
Antipolis, Nice, France
Maxime Bertoux Norwich Medical School, University of East Anglia, Nor-
folk, UK
Department of Clinical Neurosciences, University of Cambridge, Cambridge,
UK
Sunil S. Bhar Department of Psychological Sciences, Swinburne University
of Technology H99, Hawthorn, VIC, Australia
Allison A. M. Bielak Department of Human Development and Family Stud-
ies, Colorado State University, Fort Collins, CO, USA
Simon Biggs School of Social and Political Sciences, University of Mel-
bourne, Melbourne, VIC, Australia
Magdalena Bathen: deceased.

xxiv Contributors
Erin D. Bigler Department of Psychology and Neuroscience Center,

Brigham Young University, Provo, UT, USA
Department of Psychiatry, University of Utah, Salt Lake City, UT, USA
Kira S. Birditt Institute for Social Research, University of Michigan, Ann
Arbor, MI, USA
Alex J. Bishop Human Development and Family Science Department, Okla-
homa State University, Stillwater, OK, USA
Patrizia S. Bisiacchi Department of General Psychology, University of
Padova, Padova, Italy
Pr Bjlkebring Department of Psychology, University of Gothenburg,
Gothenburg, Sweden
Kathrin Boerner Department of Gerontology, John W. McCormack Gradu-
ate School of Policy and Global Studies, University of Massachusetts Boston,
Boston, MA, USA
Walter R. Boot Institute for Successful Longevity, Department of Psychol-
ogy, Florida State University, Tallahassee, FL, USA
Sarah Borish University of California, San Francisco, San Francisco, CA,
USA
Axel Brsch-Supan Munich Center for the Economics of Aging, Max-
Planck-Institute for Social Law and Social Policy, Munich, Germany
Tom Borza Centre for Old Age Psychiatric Research, Innlandet Hospital
Trust, Oslo, Norway
Nicholas T. Bott Sierra Pacic Mental Illness Research, Education, and
Clinical Centers (MIRECC), VA Palo Alto Health Care System, Palo Alto,
CA, USA
Pacic Graduate School of PsychologyStanford PsyD Consortium, Stanford,
CA, USA
Catherine E. Bowen Wittgenstein Centre for Demography and Global
Human Capital (IIASA, VID/AW, WU), Vienna Institute of Demography/
Austrian Academy of Sciences, Vienna, Austria
S. K. Bradshaw Heart of England Foundation Trust, Birmingham, UK
Caitlin Brandenburg The University of Queensland, St Lucia, Brisbane,
QLD, Australia
Daniela Brando UNIFAI and CINTESIS, ICBAS University of Porto,
Porto, Portugal
Jochen Brandtstdter Department of Psychology, University of Trier, Trier,
Germany
Tina Braun Life-Span Developmental Psychology Laboratory, University of
Leipzig, Leipzig, Germany
Contributors xxv
Mary Breheny School of Public Health, Massey University, Palmerston

North, New Zealand
Dawn Brooker University of Worcester Association for Dementia Studies,
Institute of Health and Society, University of Worcester, Worcester, UK
Allyson Brothers Department of Human Development and Family Studies,
Colorado State University, Fort Collins, CO, USA
Colette J. Browning Royal District Nursing Service, St Kilda, VIC,
Australia
International Primary Health Care Research Institute, Shenzhen, China
Monash University, Melbourne, VIC, Australia
Halina Bruce Department of Psychology, Center for Research in Human
Development, Concordia University, Montral, QC, Canada
Hannah Brunet University of California, San Francisco, San Francisco, CA,
USA
Axel Buchner Heinrich Heine University Dsseldorf, Dsseldorf, Germany
Romola S. Bucks School of Psychology, University of Western Australia,
Crawley, WA, Australia
Gina Bufton School of Psychology, J. S. Coon Building, MC0170, Georgia
Institute of Technology, Atlanta, GA, USA
Adam Bulley School of Psychology, The University of Queensland, St
Lucia, QLD, Australia
David Bunce School of Psychology, Faculty of Medicine and Health, Uni-
versity of Leeds, Leeds, UK
Cline N. Brki University Center for Medicine of Aging, Felix Platter
Hospital, Basel, Switzerland
Department of Radiology, University of Basel Hospital, Basel, Switzerland
Anne Burmeister Leuphana University of Lneburg, Lneburg, Germany
Katherine Burn Department of Medicine - Royal Melbourne Hospital, The
University of Melbourne, Parkville, VIC, Australia
Richard A. Burns Centre for Research on Ageing Health and Wellbeing,
Nicola W. Burton School of Human Movement and Nutrition Sciences, The
University of Queensland, St Lucia, Brisbane, QLD, Australia
Alissa M. Butts Mayo Clinic, Rochester, MN, USA
Department of Psychiatry and Psychology, Division of Neurocognitive Dis-
orders, Mayo Clinic, Rochester, MN, USA
xxvi Contributors
Lisa Calvano West Chester University of Pennsylvania, West Chester, PA,

USA
Julieta Camino Faculty of Medicine and Health Sciences, University of East
Anglia, Norwich, UK
Katherine Campbell Clinical Psychologist, Department of Psychiatry, The
M. Teresa Cardador School of Labor and Employment Relations, Univer-
sity of Illinois, Urbana-Champaign, IL, USA
Keisha D. Carden The University of Alabama, Tuscaloosa, AL, USA
Brian D. Carpenter Department of Psychology, Washington University, St.
Louis, MO, USA
Laura L. Carstensen Department of Psychology, Stanford University,
Stanford, CA, USA
Maria Teresa Carthery-Goulart Center of Mathematics, Computing and
Cognition (CMCC), Federal University of ABC (UFABC), So Bernardo do
Campo, So Paulo, Brazil
Cognitive and Behavioral Neurology Unit, Hospital das Clnicas, School of
Medicine, University of So Paulo (HCFMUSP), So Paulo, So Paulo, Brazil
Lindsey A. Cary Department of Psychology, University of Toronto, Toronto,
ON, Canada
Erin L. Cassidy-Eagle Research and Evaluation, ETR, Scotts Valley, CA,
USA
Casey Cavanagh Department of Psychology, West Virginia University, Mor-
gantown, WV, USA
Jane H. Cerhan Department of Psychiatry and Psychology, Division of
Neurocognitive Disorders, Mayo Clinic, Rochester, MN, USA
Eric Cerino School of Social and Behavioral Health Sciences, College of
Public Health and Human Sciences, Oregon State University, Corvallis, OR,
USA
Veronique S. Chachay School of Human Movement and Nutrition Sciences,
School of Medicine, The University of Queensland, Brisbane, QLD, Australia
Faculty of Health and Behavioural Sciences, The University of Queensland,
Dorey S. Chaffee Department of Psychology, Colorado State University,
Fort Collins, CO, USA
Michael C. H. Chan Department of Psychology, Chinese University of
Hong Kong, Hong Kong, China
Contributors xxvii
Anna Chapman RDNS Institute, Melbourne, VIC, Australia

School of Primary Health Care, Monash University, Melbourne, VIC, Australia
Neena L. Chappell Centre on Aging and Department of Sociology, Univer-
sity of Victoria, Victoria, BC, Canada
Susan T. Charles Department of Psychology and Social Behavior, Univer-
sity of California, Irvine, CA, USA
Neil Charness Institute for Successful Longevity, Department of Psychol-
ogy, Florida State University, Tallahassee, FL, USA
Alison L. Chasteen Department of Psychology, University of Toronto,
Toronto, ON, Canada
Xinxin Chen Institute of Social Science Survey, Peking University, Beijing,
China
Sheung-Tak Cheng Department of Health and Physical Education, The
Education University of Hong Kong, Hong Kong, China
Department of Clinical Psychology, Norwich Medical School, University of
East Anglia, Norwich, UK
Monique M. Cherrier Department of Psychiatry and Behavioral Sciences,
University of Washington School of Medicine, Seattle, WA, USA
Karen Siu-Lan Cheung Sau Po Centre on Ageing and Department of Social
Work and Social Administration, The University of Hong Kong, Hong Kong,
China
Adrienne K. Chong University of Nevada, Reno, NV, USA
Kysa M. Christie Boston VA Healthcare System, Boston, MA, USA
Christina Chrysohoou 1st Cardiology Clinic University of Athens, Athens,
Greece
Research Institute for Longevity and Prevention of Geriatric Diseases, Athens,
Greece
Lindy Clemson Ageing, Work and Health Research Unit, Faculty of Health
Sciences, The University of Sydney, Lidcombe, NSW, Australia
Jeanette N. Cleveland Department of Psychology, College of Natural Sci-
ences, Colorado State University, Fort Collins, CO, USA
Simon Cloutier Psychology Department, Research Centre, Institut
Universitaire de Griatrie de Montral, Montral, QC, Canada
Giorgia Cona Department of Neuroscience, University of Padova, Padova,
Italy
Casey Conaboy Palo Alto University, Palo Alto, CA, USA
Catherine Connaughton Institute for Health and Ageing, Australian Cath-
olic University, Melbourne, VIC, Australia
xxviii Contributors
Kaitrin Conniff Palo Alto University, Palo Alto, CA, USA

Veterans Affairs Palo Alto Health Care System, Palo Alto, CA, USA
Sarah E. Cook Duke University, Durham, NC, USA
Joel Cooper Princeton University, Princeton, NJ, USA
Ashley D. Cooper Central Michigan University, Mount Pleasant, MI, USA
Laura Coopersmith Palo Alto University, Palo Alto, CA, USA
Nick Corriveau-Lecavalier Psychology Department, Research Centre,
Institut Universitaire de Griatrie de Montral, Montral, QC, Canada
John Crawford Centre for Healthy Brain Ageing, University of New South
Wales, Sydney, NSW, Australia
Dimity A. Crisp Faculty of Health, University of Canberra, Canberra, ACT,
Australia
Tegan Cruwys School of Psychology, The University of Queensland,
Robert A. Cummins Deakin University, Melbourne, VIC, Australia
Sara J. Czaja University of Miami Miller School of Medicine, Miami, FL, USA
Catriona Daly Centre for Healthy Brain Ageing, University of New South
Marleen Damman Netherlands Interdisciplinary Demographic Institute
(NIDIKNAW), The Hague, The Netherlands
University Medical Center Groningen, University of Groningen, Groningen,
The Netherlands
Tanya Dash Centre de recherche, Institut universitaire de griatrie de Mon-
tral, Montral, QC, Canada
cole dorthophonie et daudiologie, Facult de mdecine, Universit de
Montral, QC, Canada
Judith Davey Institute for Governance and Policy Studies, Victoria Univer-
sity of Wellington, Wellington, New Zealand
Danielle K. Davis University of Florida, Gainesville, FL, USA
Liesbeth De Donder Vrije Universiteit Brussel/University College Ghent,
Brussels, Belgium
Kiki M. M. De Jonge University of Groningen, Groningen, The Netherlands
Margarida Pedroso de Lima Faculty of Psychology and Educational Sci-
ences, University of Coimbra, Coimbra, Portugal
Jonas Jardim de Paula Faculdade de Cincias Mdicas de Minas Gerais,
Intituto Nacional de Cincia e Tecnologia em Medicina Molecular, Federal
University of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
Contributors xxix
Ans De Vos Antwerp Management School, Antwerp, Belgium

University of Antwerp, Antwerp, Belgium
Marjolein E. de Vugt School for Mental Health and Neuroscience,
Alzheimer Center Limburg, Maastricht University Medical Center, Maas-
tricht, The Netherlands
Nico De Witte Vrije Universiteit Brussel/University College Ghent, Brus-
sels, Belgium
University College, Ghent, Belgium
Christina Degen Section of Geriatric Psychiatry, Heidelberg University,
Heidelberg, Germany
Serhiy Dekhtyar Division of Psychology, Department of Clinical Neurosci-
ence, Karolinska Instituet, Stockholm, Sweden
Marguerite DeLiema Stanford Center on Longevity, Stanford University,
Stanford, CA, USA
Julia A. M. Delius Center for Lifespan Psychology, Max Planck Institute for
Human Development, Berlin, Germany
Jrgen Deller Institute of Strategic HR Management Research and Devel-
opment (SMARD), Leuphana University of Lneburg, Lneburg, Germany
Natalie L. Denburg Department of Neurology, University of Iowa Carver
College of Medicine, Iowa, IA, USA
Christian J. Lalive dEpinay Faculty of Sciences of the Society, CIGEV,
University of Geneva, Geneva, Switzerland
Donatienne Desmette Institute of Research in Psychological Sciences,
Universit catholique de Louvain, Louvain-la-Neuve, Belgium
Manfred Diehl Department of Human Development and Family Studies,
Colorado State University, Fort Collins, CO, USA
Deborah A. DiGilio American Psychological Association, Washington, DC,
USA
Josie Dixon London School of Economics and Political Science, London, UK
Friederike Doerwald Department of Psychology, University of Groningen,
Groningen, The Netherlands
Marisa E. Domino Gillings School of Global Public Health, University of
North Carolina at Chapel Hill, Chapel Hill, NC, USA
William H. Dow School of Public Health, University of California, Berkeley,
CA, USA
Colleen Doyle Australian Catholic University and Villa Maria Catholic
Homes, Melbourne, VIC, Australia
National Ageing Research Institute, Melbourne, VIC, Australia
xxx Contributors
Mary E. Dozier San Diego State University/University of California, San

Diego Joint Doctoral Program in Clinical Psychology, San Diego, CA, USA
Research Service, VA San Diego Healthcare System, San Diego, CA, USA
Brian Draper School of Psychiatry, University of NSW, Sydney, NSW,
Australia
Academic Department of Old Age Psychiatry, Prince of Wales Hospital,
Randwick, NSW, Australia
Natlia Duarte UNIFAI and CINTESIS, ICBAS University of Porto,
Porto, Portugal
Patrick Dulin Department of Psychology, University of Alaska, Anchorage,
AK, USA
Sandra Dzel Center for Lifespan Psychology, Max Planck Institute for
Kaitlyn Dykes Sidney Kimmel Medical College, Thomas Jefferson Univer-
sity, Philadelphia, PA, USA
Catherine Earl Federation Business School, Federation University Austra-
lia, Churchill, VIC, Australia
Joanne K. Earl Flinders School of Business, Flinders University, Adelaide,
SA, Australia
Barry Edelstein Department of Psychology, West Virginia University, Mor-
gantown, WV, USA
Rohan A. Elliott Monash University Centre for Medicine Use and Safety,
Melbourne, VIC, Australia
Austin Health Pharmacy Department, Melbourne, VIC, Australia
Michelle L. Ellis School of Aging Studies, University of South Florida,
Tampa, FL, USA
Diane Elmore Policy Program, UCLA-Duke University National Center for
Child Traumatic Stress, Washington, DC, USA
Tammy English Washington University in St. Louis, St. Louis, MO, USA
Alexandra Ernst LEAD CNRS UMR 5022, Universit de Bourgogne,
Dijon, France
University of Burgundy, Dijon, France
J. Kaci Fairchild Sierra Pacic Mental Illness Research Education and
Clinical Center, VA Palo Alto Health Care System, Stanford University School
of Medicine, Palo Alto, CA, USA
Yang Fang Department of Psychology, The Chinese University of Hong
Kong, Hong Kong, China
Contributors xxxi
Thomas J. Farrer Department of Psychiatry and Behavioral Sciences, Duke

University Medical Center, Durham, NC, USA
Ulrike Fasbender Department of Business and Management, Oxford

Brookes University, Oxford, UK
Joanne Feeney The Irish Longitudinal Study on Ageing, Department of

Medical Gerontology, Trinity College Dublin, Dublin, Ireland
Centre for Public Health, Queens University Belfast, Belfast, Northern Ire-
land, United Kingdom
Lei Feng Department of Psychological Medicine, Yong Loo Lin School of

Medicine, National University of Singapore, Singapore, Singapore
Qiushi Feng Department of Sociology, National University of Singapore,

Singapore, Singapore
Daniela Figueiredo School of Health Sciences, University of Aveiro, Aveiro,

Portugal
Center for Health Technology and Services Research (CINTESIS.UA),
Aveiro, Portugal
Karen Fingerman Human Development and Family Sciences, Population

Research Center, The College of Liberal Arts, University of Texas-Austin,
Austin, TX, USA
Gwenith G. Fisher Department of Psychology, Colorado State University,

Fort Collins, CO, USA
Jane E. Fisher Department of Psychology/298, University of Nevada, Reno,

NV, USA
Amy Fiske Department of Psychology, West Virginia University, Morgan-

town, WV, USA
Emma Flanagan Norwich Medical School, University of East Anglia, Nor-

folk, UK
Matt Flynn Centre for Research into the Older Workforce (CROW), New-
castle University, Newcastle upon Tyne, UK
Kitty-Rose Foley Department of Developmental Disability Neuropsychiatry,

School of Psychiatry, University of New South Wales, Sydney, NSW,
Australia
Cooperative Research Centre for Living with Autism (Autism CRC), Long
Pocket, Brisbane, QLD, Australia
Evgenia Folts Department of Pediatrics, University of Iowa Carver College

of Medicine, Iowa, IA, USA
Simon Forstmeier Faculty II Department of Education Studies and Psy-

chology, Developmental Psychology, University of Siegen, Siegen, Germany
xxxii Contributors
Franco Fraccaroli Department of Psychology and Cognitive Science, Uni-

versity of Trento, Trento, Italy
Susan Freiberg Institute for Work and Health of the German Social Accident
Insurance, Dresden, Germany
Alexandra M. Freund Department of Psychology, University of Zurich,
Zurich, Switzerland
University Research Priority Program Dynamics of Healthy Aging, University
of Zurich, Zurich, Switzerland
Helene H. Fung Department of Psychology, The Chinese University of Hong
Rebecca Funken Institute of Strategic HR Management, Leuphana Univer-
sity of Lneburg, Lneburg, Germany
Trude Furunes Norwegian School of Hotel Management, University of
Stavanger, Stavanger, Norway
Alyssa A. Gamlado School of Aging Studies, University of South Florida,
Tampa, FL, USA
Christina Garrison-Diehn Geriatric Research, Education, and Clinical Cen-
ter, VA Palo Alto Health Care System, Palo Alto, CA, USA
Department of Psychiatry and Behavioral Science, Stanford University School
of Medicine, Stanford, CA, USA
Daniela Garten Department of Politics and Public Administration, Univer-
sity of Konstanz, Konstanz, Germany
Joseph E. Gaugler School of Nursing, University of Minnesota, Minneapo-
lis, MN, USA
Zvi D. Gellis School of Social Policy and Practice, Center for Mental Health
and Aging, University of Pennsylvania, Philadelphia, PA, USA
Debby L. Gerritsen Department of Primary and Community Care: Center
for Family Medicine, Geriatric Care and Public Health, Radboud University
Medical Center, Nijmegen, The Netherlands
Denis Gerstorf Institute of Psychology, Humboldt University, Berlin,
Germany
Michael M. Gielnik Institute of Strategic HR Management, Leuphana Uni-
versity of Lneburg, Lneburg, Germany
Jacqueline M. Gilberto Department of Psychology, Rice University, Hous-
ton, TX, USA
Contributors xxxiii
Karen Glanz Perelman School of Medicine, University of Pennsylvania,

Philadelphia, PA, USA
Lisa H. Glassman VA San Diego Healthcare System, San Diego, CA, USA
University of California, San Diego, San Diego, CA, USA
Judith Glck Department of Psychology, Alpen-Adria-Universitt Klagen-
furt, Klagenfurt, Austria
Rowena Gomez Pacic Graduate School of Psychology, Palo Alto Univer-
sity, Palo Alto, CA, USA
Yasuyuki Gondo Department of Clinical Thanatology and Geriatric Behav-
ioral Science, Osaka University Graduate School of Human Sciences, Suita,
Japan
Xianmin Gong Department of Psychology, The Chinese University of Hong
B. Heath Gordon Mental Health, G.V. (Sonny) Montgomery Veterans
Affairs Medical Center, Jackson, MS, USA
Christine E. Gould Department of Psychiatry and Behavioral Sciences,
Geriatric Research, Education, and Clinical Center (GRECC), VA Palo Alto
Health Care System, Palo Alto, CA, USA
Alan J. Gow Department of Psychology, Heriot-Watt University, Edinburgh,
UK
Jeffrey J. Gregg Durham Veterans Affairs Medical Center, Durham, NC,
USA
Julie Gretler Palo Alto University, Palo Alto, CA, USA
Werner Greve Hildesheim University, Hildesheim, Germany
Catherine Grotz Psychology of Aging Unit, University of Lige, Lige,
Belgium
Danan Gu United Nations Population Division, New York, NY, USA
Angela H. Gutchess Brandeis University, Waltham, MA, USA
Thomas Hadjistavropoulos Department of Psychology and Centre on
Aging and Health, University of Regina, Regina, SK, Canada
Joachim Hallmayer Department of Psychiatry and Behavioral Sciences,
Stanford University School of Medicine, Stanford University, Stanford, CA,
USA
Sierra Pacic Mental Illness Research Education and Clinical Center
(MIRECC), VA Palo Alto Health Care System, Palo Alto, CA, USA
xxxiv Contributors
Madison E. Hanscom Department of Psychology, College of Natural Sci-

ences, Colorado State University, Fort Collins, CO, USA
Nathan Hantke Sierra Pacic Mental Illness Research, Education, and Clin-
ical Centers (MIRECC), VA Palo Alto Health Care System, Palo Alto, CA,
USA
Lynn Hasher Department of Psychology, University of Toronto, Toronto,
ON, USA
Rotman Research Institute, Baycrest, Toronto, ON, USA
Hideki Hashimoto Department of Health and Social Behavior, The Univer-
sity of Tokyo School of Public Health, Bunkyo, Tokyo, Japan
S. Alexander Haslam School of Psychology, The University of Queensland,
Catherine Haslam School of Psychology, The University of Queensland,
Louise C. Hawkley Academic Research Centers, NORC at the University of
Chicago, Chicago, IL, USA
Tyler Haydell Stanford University, Stanford, CA, USA
Becky I. Haynes School of Psychology, Faculty of Medicine and Health,
University of Leeds, Leeds, UK
Jutta Heckhausen Department of Psychology and Social Behavior, School
of Social Ecology, University of California, Irvine, CA, USA
Chyrisse Heine College of Science Health and Engineering, Department of
Community and Clinical Allied Health, School of Allied Health, La Trobe
University, Melbourne, VIC, Australia
Edward Helmes Department of Psychology, James Cook University, Towns-
ville, QLD, Australia
Gert-Jan Hendriks Pro Persona Institute for Integrated Mental Health Care,
Centre for Anxiety Disorders Overwaal, Nijmegen, The Netherlands
Radboud University Nijmegen, Behavioural Science Institute, Nijmegen, The
Netherlands
Radboud University Medical Centre, Department of Psychiatry, Nijmegen,
The Netherlands
Julie D. Henry School of Psychology, The University of Queensland, Bris-
bane, QLD, Australia
Noreen Heraty Kemmy Business School, University of Limerick, Limerick,
Ireland
Contributors xxxv
Agneta Herlitz Division of Psychology, Department of Clinical Neurosci-

ence, Karolinska Instituet, Stockholm, Sweden
Guido Hertel Department of Psychology, University of Mnster, Mnster,
Germany
Christopher Hertzog School of Psychology, Georgia Institute of Technol-
ogy, Atlanta, GA, USA
Thomas M. Hess Department of Psychology, North Carolina State Univer-
sity, Raleigh, NC, USA
Stephanie Hicks Psychology Department, Fordham University, Bronx, NY,
USA
Patrick L. Hill Department of Psychology, Carleton University, Ottawa, ON,
Canada
Thomas Hinault Aix-Marseille Universit and CNRS, Marseille, France
Gregory A. Hinrichsen Department of Geriatrics and Palliative Medicine,
Icahn School of Medicine at Mount Sinai, New York, NY, USA
Courtney von Hippel School of Psychology, The University of Queensland,
William von Hippel School of Psychology, The University of Queensland,
Nobuyoshi Hirose Center for Supercentenarian Research, Keio University
School of Medicine, Tokyo, Japan
Andreas Hirschi Institute of Psychology, University of Bern, Bern,
Switzerland
Rayna Hirst Palo Alto University, Palo Alto, CA, USA
Henry C. Y. Ho School of Public Health, University of Hong Kong, Hong
Kong, China
Lieve Hoeyberghs University College, Ghent, Belgium
Joanna Hong Department of Psychology and Social Behavior, University of
California, Irvine, CA, USA
Karen Hooker School of Social and Behavioral Health Sciences, College of
Public Health and Human Sciences, Oregon State University, Corvallis, OR,
USA
Christiane A. Hoppmann Department of Psychology, University of British
Columbia, Vancouver, BC, Canada
Michael Hornberger Norwich Medical School, University of East Anglia,
Norfolk, UK
Lena-Alyeska M. Huebner Department of Psychology, College of Natural
Sciences, Colorado State University, Fort Collins, CO, USA
xxxvi Contributors
J. W. Terri Huh VA Palo Alto Health Care System, Palo Alto, CA, USA
Martijn Huisman NOVA Norwegian Social Research, Oslo and Akershus

University College, Oslo, Norway
EMGO Institute for Health and Care Research, VU University Medical Center,
Amsterdam, The Netherlands
Department of Epidemiology and Biostatistics, VU University Medical Cen-
ter, Amsterdam, The Netherlands
Department of Psychiatry, VU University Medical Center, Amsterdam, The
Netherlands
Mary Lee Hummert Communication Studies Department, University of

Kansas, Lawrence, KS, USA
Ye In (Jane) Hwang Department of Developmental Disability Neuropsychi-

atry, School of Psychiatry, University of New South Wales, Sydney, NSW,
Australia
Maria Iankilevitch Department of Psychology, University of Toronto,

Toronto, ON, Canada
Kazunori Ikebe Department of Prosthodontics, Gerodontology and Oral

Rehabilitation, Osaka University Graduate School of Dentistry, Suita, Japan
Hiroki Inagaki Research Team for Promoting Independence of the Elderly,

Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
Jennifer Inauen Department of Psychology, Columbia University, New

York, NY, USA
Derek M. Isaacowitz Department of Psychology, Northeastern University,

Boston, MA, USA
Yoshiko Lily Ishioka Tokyo Metropolitan Institute of Gerontology, Tokyo,

Japan
Graduate School of Science and Technology, Keio University, Yokohama,
Japan
Tatsuro Ishizaki Tokyo Metropolitan Geriatric Hospital and Institute of

Gerontology, Tokyo, Japan
Shelly L. Jackson Institute of Law, Psychiatry and Public Policy, University

of Virginia, Charlottesville, VA, USA
Lori E. James Psychology Department, University of Colorado, Colorado

Springs, CO, USA
Contributors xxxvii
Soong-Nang Jang Red Cross College of Nursing, Chung-Ang University,

Seoul, South Korea
Jolanda Jetten School of Psychology, The University of Queensland,

Garima Jhingon Pacic Graduate School of Psychology, Palo Alto Univer-

sity, Palo Alto, CA, USA
Da Jiang Department of Psychology, Chinese University of Hong Kong,

Hong Kong, China
Yves Joanette Centre de recherche, Institut universitaire de griatrie de

Montral, Montral, QC, Canada
Boo Johansson Department of Psychology, University of Gothenburg, Goth-

enburg, Sweden
Mary Ann Johnson Department of Foods and Nutrition, University of

Georgia, Athens, GA, USA
Claire S. Johnston Institute of Psychology, University of Bern, Bern,

Switzerland
Daniela S. Jopp Institute of Psychology, University of Lausanne, Lausanne,

Switzerland
Swiss Centre of Competence in Research LIVES, Overcoming Vulnerability:
Life Course Perspectives, Lausanne, Switzerland
Josh Jordan Department of Psychiatry and Behavioral Sciences, Stanford

University School of Medicine, Stanford University, Stanford, CA, USA
California School of Professional Psychology, Alliant International Univer-
sity, Alhambra, CA, USA
Bruce Judd Australian School of Architecture and Design, Built Environ-

ment, University of New South Wales, Sydney, NSW, Australia
Seojung Jung Fordham University, New York, NY, USA
Franziska Jungmann Institute for Work, Organizational and Social Psy-

chology, University of Technology, Dresden, Dresden, Germany
Elise K. Kalokerinos Department of Psychology and Educational Sciences,

KU Leuven, Leuven, Flemish Brabant, Belgium
Kei Kamide Department of Health Science and Department of Geriatric

Medicine and Nephrology, Osaka University, Graduate School of Medicine,
Suita, Japan
Ruth Kanfer School of Psychology, J. S. Coon Building, MC0170, Georgia

Institute of Technology, Atlanta, GA, USA
Julia Karbach Goethe-University Frankfurt, Frankfurt, Germany

xxxviii Contributors
Michele J. Karel Mental Health Services, Department of Veterans Affairs

Central Ofce, Washington, DC, USA
Julia E. Kasl-Godley Palo Alto VA Health Care System, Palo Alto, CA,
USA
Joseph S. Kay Department of Psychology and Social Behavior, School of

Social Ecology, University of California, Irvine, CA, USA
Hal Kendig Australian National University, Canberra, ACT, Australia
Robert F. Kennison Department of Psychology, California State University,

Los Angeles, CA, USA
Rose Anne Kenny The Irish Longitudinal Study on Ageing, Department of

Medical Gerontology, Trinity College Dublin, Dublin, Ireland
Mercers Institute for Successful Ageing, St. James Hospital, Dublin, Ireland
Ngaire Kerse Department of General Practice and Primary Health Care,

School of Population Health, The University of Auckland, Auckland, New
Zealand
Eva-Marie Kessler MSB Medical School Berlin Hochschule fr Gesundheit

und MedizinCalandrellistrasse, , Berlin, Germany
Kim M. Kiely Centre for Research on Ageing Health and Wellbeing,

Douglas C. Kimmel City College, City University of New York, New York,
NY, USA
David B. King IRMACS Centre, Simon Fraser University, Burnaby, BC,

Canada
Susan Kirkland Departments of Community Health and Epidemiology and

Medicine, Dalhousie University, Dalhousie, NS, Canada
Douglas A. Kleiber University of Georgia College of Education, Athens,

GA, USA
Matthias Kliegel Department of Psychology, University of Geneva, Geneve

4, Switzerland
Center for Interdisciplinary Study of Gerontology and Vulnerability (CIGEV),
University of Geneva, Carouge, Switzerland
Andrzej Klimczuk Warsaw School of Economics, Warsaw, Poland
Michaela Knecht Department of Psychology, University of Zurich, Zurich,

Switzerland
University Research Priority Program Dynamics of Healthy Aging, University
of Zurich, Zurich, Switzerland
Contributors xxxix
Jamie E. Knight Department of Psychology, University of Victoria, Victoria,

BC, Canada
Dorien Kooij Department of Human Resource Studies, Tilburg University,

Tilburg, Netherlands
Raymond T. C. M. Koopmans Department of Primary and Community

Care: Center for Family Medicine, Geriatric Care and Public Health, Radboud
University Medical Center, Nijmegen, The Netherlands
Joachim en Anna, Center for specialized geriatric care, Nijmegen, The
Netherlands
Anna E. Kornadt Department of Psychology, Bielefeld University, Biele-

feld, Germany
Pavel Kozik Department of Psychology, University of British Columbia,

Vancouver, BC, Canada
Abigail Kramer Sierra Pacic Mental Illness Research, Education, and

Clinical Centers (MIRECC), VA Palo Alto Health Care System, Palo Alto,
CA, USA
Pacic Graduate School of Psychology, Palo Alto University, Palo Alto, CA,
USA
Joel Kramer Unviersity of California, San Francisco, San Francisco, CA,

USA
Ralf T. Krampe Brain and Cognition, University of Leuven, Leuven,

Belgium
Jutta Kray Saarland University, Saarbrcken, Germany

Department of Psychology, Saarland University, Saarbrcken, Saarland,
Germany
Kamini Krishnan Mayo Clinic, Rochester, MN, USA
Andreas Kruse Institute of Gerontology, University of Heidelberg, Heidel-

berg, Germany
Alexis Kuerbis Silberman School of Social Work, Hunter College of the City
University of New York, New York, NY, USA
Florian Kunze Department of Politics and Public Administration, University

of Konstanz, Konstanz, Germany
Ute Kunzmann Life-Span Developmental Psychology Laboratory, Univer-

sity of Leipzig, Leipzig, Germany
Tanja Kurtz University of Mainz, Mainz, Germany

xl Contributors
Dawn La Palo Alto University/Pacic Graduate School of Psychology, Palo

Alto, CA, USA
Sierra Pacic Mental Illness, Research Education and Clinical Centers at the
Geoffrey Lane Psychology Service, VA Palo Alto Healthcare System
Livermore Division, Livermore, CA, USA
Douglas Warren Lane Geriatrics and Extended Care Service, VA Puget
Sound Healthcare System, Seattle, WA, USA
Department of Psychiatry, University of Washington, Seattle, WA, USA
Frieder R. Lang Institute of Psychogerontology, Friedrich-Alexander-Uni-
versity of Erlangen-Nrnberg, Nrnberg, Germany
Jos Miguel Latorre Postigo Department of Psychology, Faculty of Medi-
cine, University of Castilla-La Mancha, Albacete, Spain
Bobo Hi-Po Lau Faculty of Social Sciences, The University of Hong Kong,
Hong Kong, China
Gary D. Laver Psychology and Child Development Department, Cal Poly,
San Luis Obispo, CA, USA
Jennifer C. Lay The University of British Columbia, Vancouver, BC,
Canada
George Lazaros 1st Cardiology Clinic University of Athens, Athens, Greece
Greece
Malloy-Diniz Leandro Fernandes Department of Mental Health, Instituto
Nacional de Cincia e Tecnologia em Medicina Molecular, Federal University
of Minas Gerais, Belo Horizonte, Minas Gerais, Brazil
Shinduk Lee Texas A&M Health Science Center, School of Public Health,
College Station, TX, USA
Yunhwan Lee Department of Preventive Medicine and Public Health, Ajou
University School of Medicine, Suwon, Republic of Korea
Institute on Aging, Ajou University Medical Center, Suwon, Republic of
Korea
Cik Yin Lee Royal District Nursing Service (RDNS) Institute, Melbourne,
VIC, Australia
Centre for Medicine Use and Safety, Monash University, Melbourne, VIC,
Australia
Patrick Lemaire Aix-Marseille Universit and CNRS, Marseille, France
Shu-Chen Li Department of Psychology Chair of Lifespan Developmental
Neuroscience, TU Dresden, Dresden, Germany
Contributors xli
Center for Lifespan Psychology, Max Planck Institute for Human Develop-
ment, Berlin, Germany
Karen Z.H. Li Department of Psychology, Center for Research in Human
Development, Concordia University, Montral, QC, Canada
Tianyuan Li Department of Psychological Studies and Centre for Psycho-
social Health, Hong Kong Institute of Education, Tai Po, New Territories,
Hong Kong, China
Mei-Ching Lien School of Psychological Science, Oregon State University,
Corvallis, OR, USA
Ulman Lindenberger Center for Lifespan Psychology, Max Planck Institute
for Human Development, Berlin, Germany
Victoria Liou-Johnson University of California, San Francisco, CA, USA
Shuang Liu School of Communication and Arts, The University of Queens-
land, Brisbane, QLD, Australia
Kimberly M. Livingstone Department of Psychology, Northeastern Univer-
sity, Boston, MA, USA
Vanessa M. Loaiza University of Essex, Colchester, United Kingdom
Ada Lo The University of Queensland, St Lucia, QLD, Australia
Corinna E. Lckenhoff Department of Human Development, Cornell Uni-
versity, Ithaca, NY, USA
Peggy Lockhart Iowa State University, Ames, IA, USA
Alexandra Lopes Institute of Sociology, University of Porto, Porto, Portugal
Andrs Losada-Baltar Department of Psychology, Facultad de Ciencias de
la Salud, Universidad Rey Juan Carlos, Madrid, Spain
Katie Louwagie School of Nursing, University of Minnesota, Minneapolis,
MN, USA
Martin Lvdn Aging Research Center, Karolinska Institutet and Stockholm
University, Stockholm, Sweden
Judy Lowthian School of Public Health and Preventive Medicine, Monash
University, Melbourne, VIC, Australia
Minjie Lu Department of Psychology, The Chinese University of Hong
John A. Lucas Department of Psychiatry and Psychology, Mayo Clinic,
Jacksonville, FL, USA
Terry Lum The University of Hong Kong, Hong Kong, China
xlii Contributors
Angela Lunde Mayo Clinic, Rochester, MN, USA

Mary A. Luszcz Flinders University, Adelaide, SA, Australia
David Madden Brain Imaging and Analysis Center, Duke University Med-
ical Center, Durham, NC, USA
Justin Marcus Ozyegin University, Istanbul, Turkey
Jennifer Margrett Iowa State University, Ames, IA, USA
Rodrigo Mario Oral Health Cooperative Research Centre, Melbourne Den-
tal School, University of Melbourne, Melbourne, VIC, Australia
Mara Mrquez-Gonzlez Departament of Biological and Health Psychol-
ogy, Universidad Autnoma de Madrid, Madrid, Spain
Donel M. Martin Black Dog Institute, School of Psychiatry, University of
New South Wales, Sydney, NSW, Australia
Peter Martin Iowa State University, Ames, IA, USA
Yukie Masui Tokyo Metropolitan Geriatric Hospital and Institute of Geron-
tology, Tokyo, Japan
Rui Mata University of Basel, Basel, Switzerland
Karen A. Mather Centre for Healthy Brain Ageing, University of New
South Wales, Sydney, NSW, Australia
Katey Matthews CMIST, School of Social Sciences, University of Man-
chester, Manchester, UK
Susanne Mayr Heinrich Heine University Dsseldorf, Dsseldorf, Germany
University of Passau, Passau, Germany
Marita McCabe Institute for Health and Ageing, Australian Catholic Uni-
versity, Melbourne, VIC, Australia
Jean McCarthy Kemmy Business School, University of Limerick, Limer-
ick, Ireland
Shawn M. McClintock Division of Psychology, Department of Psychiatry,
UT Southwestern Medical Center, Dallas, TX, USA
Division of Brain Stimulation and Neurophysiology, Department of Psychia-
try and Behavioral Sciences, Duke University School of Medicine, Durham,
NC, USA
Michael Thomas McGann School of Social and Political Sciences, Univer-
sity of Melbourne, Melbourne, VIC, Australia
Judy McGregor AUT University, Auckland, New Zealand
Bernard McKenna The University of Queensland, Brisbane, QLD,
Australia
Contributors xliii
Christopher McLoughlin Federation Business School, Federation Univer-

sity Australia, Churchill, VIC, Australia
Verena H. Menec University of Manitoba, Winnipeg, MB, Canada
Claudia Meyer RDNS Institute, St Kilda, VIC, Australia

Centre for Health Communication and Participation, School of Psychology
and Public Health, LaTrobe University, VIC, Australia
Lisa Mieskowski University of Alabama, Tuscaloosa, AL, USA
Victoria Michalowski Department of Psychology, University of British

Joany K. Millenaar School for Mental Health and Neuroscience, Alzheimer

Center Limburg, Maastricht University Medical Center, Maastricht, The
Netherlands
Brent Mills Palo Alto University, Palo Alto, CA, USA

Beyon Miloyan Department of Mental Health, Johns Hopkins Bloomberg

School of Public Health, Baltimore, MD, USA
Eneida Mioshi Faculty of Medicine and Health Sciences, University of East

Anglia, Norwich, UK
Leander K. Mitchell School of Psychology, The University of Queensland,

Sepideh Modrek School of Medicine, Stanford University, Palo Alto, CA,

USA
Scott D. Moffat Georgia Institute of Technology, Atlanta, GA, USA
Darya Moghimi Department of Psychology, University of Groningen, Gro-

ningen, The Netherlands
Victor Molinari School of Aging Studies, University of South Florida,

Tampa, FL, USA
Terri G. Monk Department of Anesthesiology and Perioperative Medicine,

University of Missouri-Columbia, Columbia, MO, USA
Alison A. Moore Division of Geriatric Medicine, David Geffen School of

Medicine at UCLA, Los Angeles, CA, USA
Caitlin S. Moore Ryan Dolby Brain Health Center, California Pacic Med-
ical Center Neurosciences Institute, San Francisco, CA, USA
H. C. Moorey Heart of England Foundation Trust, Birmingham, UK

xliv Contributors
Lafaiete Guimares Moreira Universidade Fundao Mineira de Educao

e Cultura - FUMEC, Belo Horizonte, Minas Gerais, Brazil
Georgina Moreno Department of Psychology, New York University, New
York, NY, USA
Mike Morgan Oral Health Cooperative Research Centre, Melbourne Dental
School, University of Melbourne, Melbourne, VIC, Australia
Steven Morrison School of Physical Therapy and Athletic Training, Old
Dominion University, Norfolk, VA, USA
Moyra E. Mortby Centre for Research on Ageing, Health and Wellbeing,
The Australian National University, Canberra, ACT, Australia
Thomas A. Morton Psychology, College of life and Environmental Sci-
ences, University of Exeter, Exeter, UK
Chris J.A. Moulin LEAD CNRS UMR 5022, Universit de Bourgogne,
Dijon, France
Christopher Moulin Laboratoire de Psychologie and Neurocognition
(LPNC), CNRS-UMR 5105, University Grenoble Alpes, Grenoble, France
Julia Muenchhoff Centre for Healthy Brain Ageing, University of New
Andreas Mller Institute for Occupational and Social Medicine, Medical
Faculty, Dsseldorf University, Dsseldorf, Germany
Jo Munro Ageing, Work and Health Research Unit, Faculty of Health
Sciences, The University of Sydney, Lidcombe, NSW, Australia
Alexa M. Muratore Sydney, NSW, Australia
Marama Muru-Lanning James Henare Research Centre, The University of
Auckland, Auckland, New Zealand
Reidar J. Mykletun Molde University College, Molde, Norway
Noemi Nagy Institute of Psychology, University of Bern, Bern, Switzerland
Christopher M. Napolitano Department of Psychology, University of
Zurich, Zurich, Switzerland
Paul Nash Centre for Innovative Ageing, Swansea University, Wales, UK
James Nazroo School of Social Sciences, University of Manchester, Man-
chester, UK
Holly Nelson-Becker Loyola University School of Social Work, Chicago,
IL, USA
Karl M. Newell The University of Georgia, Athens, GA, USA
Nicky J. Newton Wilfrid Laurier University, Waterloo, ON, Canada
Contributors xlv
MyNhi Nguyen School of Psychology, The University of Queensland,

Victoria Nieborowska Department of Psychology, Center for Research in
Human Development, Concordia University, Montral, QC, Canada
Jonna Nilsson Aging Research Center, Karolinska Institutet and Stockholm
University, Stockholm, Sweden
Ina Nitschke Clinic for Gerodontology and Special Care Dentistry, Univer-
sity of Zurich, Zurich, Switzerland
J. Farley Norman Department of Psychological Sciences, Ogden College of
Science and Engineering, Western Kentucky University, Bowling Green, KY,
USA
Thomas A. Norton School of Psychology, The University of Queensland,
Nanna Notthoff Institute of Psychology, Humboldt University, Berlin,
Germany
Klaus Oberauer University of Zurich, Zurich, Switzerland
Claire OCallaghan Behavioral and Clinical Neurosciences Institute, Uni-
versity of Cambridge, Cambridge, UK
Michael P. ODriscoll School of Psychology, University of Waikato, Ham-
ilton, New Zealand
Ruth OHara Department of Psychiatry and Behavioral Sciences, Stanford
University School of Medicine, Stanford, CA, USA
School of Psychology, The University of Queensland, Brisbane, QLD, Australia
Michelle Olaithe School of Psychology, University of Western Australia,
Crawley, WA, Australia
Norm ORourke Department of Public Health, Ben-Gurion University of the
Negev, Beer Sheva, Israel
Marcia G. Ory Health Promotion and Community Health Sciences, Texas
A&M Health Science Center and School of Public Health, College Station,
TX, USA
Nancy A. Pachana School of Psychology, The University of Queensland,
Laura E. Paige Brandeis University, Waltham, MA, USA
Nicole E. Pardo Remind Technologies Inc., Houston, TX, USA
Sang Chul Park Department of New Biology, DGIST, Daegu, South Korea
xlvi Contributors
Stacey L. Parker School of Psychology, The University of Queensland,

Mario A. Parra Department of Psychology, Centre for Cognitive Ageing
and Cognitive Epidemiology, and Human Cognitive Neuroscience, The Uni-
versity of Edinburgh, Edinburgh, UK
Department of Psychology, HeriotWatt University, Edinburgh, UK
Alzheimer Scotland Dementia Research Centre, The University of Edinburgh,
Edinburgh, UK
UDPINECO Foundation Core on Neuroscience (UIFCoN), Diego Portales
University, Santiago, Chile
Constana Pal UNIFAI and CINTESIS, ICBAS University of Porto,
Porto, Portugal
Yaritza D. Perez-Hooks Princeton University, Princeton, NJ, USA
Giovanni Mario Pes Department of Clinical and Experimental Medicine,
University of Sassari, Sassari, Sardinia, Italy
National Institute of Biostructures and Biosystems, University of Sassari,
Sassari, Italy
Andrew J. Petkus Department of Psychology, University of Southern Cali-
fornia, Los Angeles, CA, USA
Louise H. Phillips University of Aberdeen, Aberdeen, UK
I. Philp Heart of England Foundation Trust, Birmingham, UK
Andrea M. Piccinin Department of Psychology, University of Victoria,
Victoria, BC, Canada
Christos Pitsavos 1st Cardiology Clinic University of Athens, Athens, Greece
Greece
Leonard W. Poon University of Georgia, Athens, GA, USA
Lauren E. Popham Greenwald & Associates, Washington, DC, USA
Michel Poulain IACCHOS Institute of Analysis of Change in Contemporary
and Historical Societies, Universit catholique de Louvain, LouvainLa
Neuve, Belgium
Estonian Institute for Population Studies, Tallinn University, Tallinn, Estonia
Emma E. Poulsen School of Psychology, The University of Queensland,
Catherine C. Price Department of Clinical and Health Psychology, Univer-
sity of Florida, Gainesville, FL, USA
Department of Anesthesiology, University of Florida, Gainesville, FL, USA
Contributors xlvii
Elizabeth C. Price Department of Psychology, West Virginia University,

Morgantown, WV, USA
Janice C. Probst Arnold School of Public Health, University of South
Carolina, Columbia, SC, USA
Jeffrey Proulx Department of Neurology, School of Medicine, Oregon
Health and Science University, Portland, OR, USA
Amy C. Pytlovany Department of Psychology, Portland State University,
Portland, OR, USA
Sara Honn Qualls Gerontology Center, University of Colorado, Colorado
Springs, Colorado Springs, CO, USA
Patrick Rabbitt Department of Experimental Psychology, University of
Oxford, Oxford, UK
Wiebke Rahmlow Department of Psychiatry and Psychotherapy, University
of Leipzig, Leipzig, Germany
Parminder Raina Department of Clinical Epidemiology and Biostatistics,
McMaster University, Hamilton, ON, Canada
Peter Rammelsberg Department of Prosthodontics, University Hospital
Heidelberg, Heidelberg, Germany
G. Kevin Randall Human Sciences Extension and Outreach, Partnerships in
Prevention Science Institute, Iowa State University, Ames, IA, USA
Signe Hoei Rasmussen Epidemiology, Biostatistics and Biodemography,
Institute of Public Health, University of Southern Denmark, Odense C,
Denmark
Philippe Rast Department of Psychology, University of Victoria, Victoria,
BC, Canada
Andrew E. Reed Department of Psychology, Stanford University, Stanford,
CA, USA
Gwyneth Rees Department of Surgery, Centre for Eye Research Australia,
Royal Victorian Eye and Ear Hospital, Ophthalmology, University of Mel-
Laura Simpson Reeves Institute for Social Science Research, The Univer-
sity of Queensland, Brisbane, QLD, Australia
Barbara Resnick University of Maryland School of Nursing, Baltimore,
MD, USA
Nancy Reyes Department of Psychology, California State University, Los
Angeles, CA, USA
Stephen Rhodes Department of Psychology, Centre for Cognitive Ageing
and Cognitive Epidemiology, and Human Cognitive Neuroscience, The Uni-
versity of Edinburgh, Edinburgh, UK
xlviii Contributors
Oscar Ribeiro UNIFAI and CINTESIS, ICBAS University of Porto, Porto,

Portugal
Higher Institute of Social Service (ISSSP), Porto, Portugal
University of Aveiro, Aveiro, Portugal
Eric F. Rietzschel University of Groningen, Groningen, The Netherlands
Catherine A. Rifn Department of Human Development, Cornell Univer-
sity, Ithaca, NY, USA
Gail Roberts Australian Catholic University and Villa Maria Catholic
Homes, Melbourne, VIC, Australia
Jean-Marie Robine INSERM & EPHE, Paris and Montpellier, France
Gail A. Robinson Neuropsychology Research Unit, School of Psychology,
The University of Queensland, Brisbane, QLD, Australia
Neuropsychology, Department of Neurology, Royal Brisbane and Womens
Hospital, Brisbane, QLD, Australia
Natlia Pessoa Rocha Laboratrio Interdisciplinar de Investigao Mdica,
Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo
Horizonte, MG, Brazil
Maree Roche School of Psychology, University of Waikato, Hamilton, New
Zealand
Rachel Rodriguez VA Palo Alto Health Care System, Palo Alto, CA, USA
Jan Philipp Rer Heinrich Heine University Dsseldorf, Dsseldorf,
Germany
Nina T. Rogers Department of Epidemiology and Public Health, University
College London, London, UK
Alexia Rohde The University of Queensland, St Lucia, Brisbane, QLD,
Australia
Anna Rolleston Te Kupenga Hauora Mori, Faculty of Medical and Health
Sciences, The University of Auckland, Auckland, New Zealand
David Rooney Macquarie University, Sydney, NSW, Australia
Tanya Rose The University of Queensland, St Lucia, Brisbane, QLD,
Australia
Luis Rosero-Bixby University of California, Berkeley, CA, USA
University of Costa Rica, San Jos, San Jos, Costa Rica
Kathrin Rosing Psychology of Entrepreneurial Behavior, Institute of Psy-
chology, University of Kassel, Kassel, Germany
Christoph Rott Institute of Gerontology, Heidelberg University, Heidelberg,
Germany
Contributors xlix
Olivier Rouaud LEAD CNRS UMR 5022, Universit de Bourgogne, Dijon,

France
CMRR Dijon, Dijon, France
Cort W. Rudolph Saint Louis University, Saint Louis, MO, USA
Clair Rummel VA Puget Sound Health Care System Seattle Division,

Seattle, WA, USA
Eric Ruthruff Department of Psychology, University of New Mexico, Albu-

querque, NM, USA
Paul Sacco University of Maryland School of Social Work, Baltimore, MD,

USA
Perminder Sachdev Centre for Healthy Brain Ageing, University of New

Marian Saeed Department of Surgery, Centre for Eye Research Australia,

Royal Victorian Eye and Ear Hospital, Ophthalmology, University of Mel-
Rinat Saifoulline Faculty of Business Administration, University of Applied

Sciences, Dresden, Germany
Erin Sakai VA Palo Alto Health Care System, Palo Alto, CA, USA
Karen L. Salekin The University of Alabama, Tuscaloosa, AL, USA
Manisha Salinas Department of Health Promotion and Behavior, College of

Public Health, The University of Georgia, Athens, GA, USA
Viktoriya Samarina Barrow Neurological Institute, Phoenix, AZ, USA
Kimberly Sangster Loyola University School of Social Work, Chicago, IL,

USA
Kristen Sarkinen School of Nursing, University of Minnesota, Minneapolis,

MN, USA
Christine Sattler Department of Industrial and Organizational Psychology,

Institute of Psychology, Heidelberg University, Heidelberg, Germany
K. Warner Schaie Department of Psychiatry and Behavioral Sciences, Uni-

versity of Washington, Seattle, WA, USA
Susanne Scheibe Department of Psychology, University of Groningen, Gro-

Oliver K. Schilling Department of Psychological Ageing Research, Institute

of Psychology, Ruprecht-Karls-Universitt, Heidelberg, Germany
Hannah Schmitt Saarland University, Saarbrcken, Germany

l Contributors
Antje Schmitt Department of Business Psychology, Economics and Manage-

ment and Institute of Psychology, University of Kassel, Kassel, Germany
Eric Schmitt Institute of Gerontology, University of Heidelberg, Heidelberg,
Germany
Katharina M. Schnitzspahn School of Psychology, University of Aberdeen,
Aberdeen, UK
Jos Schols Maastricht University, Maastricht, The Netherlands
Urte Scholz Department of Psychology, University of Zurich, Zurich,
Switzerland
Peter Schnknecht Department of Psychiatry and Psychotherapy, Univer-
sity of Leipzig, Leipzig, Germany
Johannes Schrder Section of Geriatric Psychiatry, Heidelberg University,
Heidelberg, Germany
Institute of Gerontology, Heidelberg University, Heidelberg, Germany
Anika Schulz Department of Psychology, University of Groningen, Gro-
ningen, Netherlands
Henk Schut Department of Clinical and Health Psychology, Utrecht Univer-
sity, Utrecht, The Netherlands
Benjamin Schz Division of Psychology, University of Tasmania, Hobart,
TAS, Australia
Nadine A. Schwab Department of Clinical and Health Psychology, Univer-
sity of Florida, Gainesville, FL, USA
Forrest Scogin University of Alabama, Tuscaloosa, AL, USA
Theresa L. Scott School of Psychology, The University of Queensland, St
Lucia, QLD, Australia
Michael K. Scullin Department of Psychology and Neuroscience, Baylor
University, Waco, TX, USA
Jori Sechrist Department of Sociology, McMurry University, Abilene, TX,
USA
Geir Selbaek National Norwegian Advisory Unit on Ageing and Health,
Vestfold Hospital Trust and Oslo University Hospital, Oslo, Norway
Juan Pedro Serrano Selva Department of Psychology, Faculty of Medicine,
University of Castilla-La Mancha, Albacete, Spain
Susan Sharp Memphis Veterans Affairs Medial Center, Memphis, TN, USA
Michael Sharratt Schlegel-University of Waterloo Research Institute for
Aging, Kitchener, ON, Canada
Veronica L. Shead South Texas Veterans Health Care System, San Antonio,
TX, USA
Contributors li
Christine Sheppard University of Waterloo, Waterloo, ON, Canada

Bruyre Research Institute, Ottawa, ON, Canada
Yee Lee Shing Center for Lifespan Psychology, Max Planck Institute for
Jelena S. Siebert Department of Psychological Aging Research, Institute of
Psychology, Heidelberg University, Heidelberg, Germany
Mersina Simanski Stanford University, Stanford, CA, USA
David Situ Department of Psychology, California State University, Los
Angeles, CA, USA
John Skoumas 1st Cardiology Clinic University of Athens, Athens, Greece
Greece
Glenn E. Smith Mayo Clinic, Rochester, MN, USA
University of Florida College of Public Health and Health Professions,
Gainesville, FL, USA
Matthew Lee Smith Department of Health Promotion and Behavior, College
of Public Health, The University of Georgia, Athens, GA, USA
Department of Health Promotion and Community Health Sciences, Texas
A&M Health Science Center and School of Public Health, College Station,
TX, USA
Jacqui Smith Health and Retirement Study, Survey Research Center, Insti-
tute for Social Research, University of Michigan, Ann Arbor, MI, USA
James Smith Rand Corporation, Santa Monica, CA, USA
Amanda Sonnega Health and Retirement Study, Survey Research Center,
Institute for Social Research, University of Michigan, Ann Arbor, MI, USA
Rachita Sood University of Miami Miller School of Medicine, Miami, FL,
USA
Cyndy G. Soto University of Nevada, Reno, NV, USA
Cline Souchay Laboratoire de Psychologie & Neurocognition (LPNC),
CNRS-UMR 5105, University Grenoble Alpes, Grenoble, France
Laura K. Soulsby School of Psychology, Eleanor Rathbone Building, Liv-
erpool, UK
Anne K. Soutter Department of Management Marketing and Entrepreneur-
ship College of Business and Law, University of Canterbury, Christchurch,
New Zealand
Dario Spini Faculty of Social and Political Sciences and Swiss National
Centre of Competence in Research LIVES, University of Lausanne, Lausanne,
Switzerland
lii Contributors
Ekaterina Staikova Emory University Brain Health Center, Atlanta, GA, USA
Christian Stamov-Ronagel Jacobs University, Bremen, Germany
John M. Starr Alzheimer Scotland Dementia Research Centre, University of
Edinburgh, Edinburgh, Scotland, UK
Ursula M. Staudinger Columbia Aging Center, Columbia University, New
York, NY, USA
Allison A. Steen University of Illinois, Urbana, IL, USA
Christodoulos Stefanadis 1st Cardiology Clinic University of Athens, Ath-
ens, Greece
Greece
Michelle Steffens School of Psychology, The University of Queensland,
Andrew Steptoe Department of Epidemiology and Public Health, University
College London, London, UK
Harvey L. Sterns The University of Akron, Akron, OH, USA
Brendan Stevenson School of Public Health, Massey University, Palmerston
North, New Zealand
Cassandra Stevenson Physical Medicine and Rehabilitation Service, VA
Northern California Healthcare System, Martinez, CA, USA
Elizabeth A. L. Stine-Morrow University of Illinois, Urbana, IL, USA
John Strauss School of Economics, University of Southern California, Los
Angeles, CA, USA
David L. Strayer The University of Utah, Salt Lake City, UT, USA
Carla M. Strickland-Hughes University of Florida, Gainesville, FL, USA
Margaret Stroebe Department of Clinical and Health Psychology, Utrecht
University, Utrecht, The Netherlands
Jessica V. Strong Geriatric Mental Health, VA Boston Healthcare System,
Boston, MA, USA
Bonnie Adele Sturrock Department of Surgery, Centre for Eye Research
Australia, Royal Victorian Eye and Ear Hospital, Ophthalmology, University
of Melbourne, Melbourne, VIC, Australia
Claire Surr Faculty of Health and Social Sciences, Leeds Beckett University,
Leeds, UK
Makoto Suzuki Okinawa Research Center for Longevity Science, Urasoe,
Okinawa, Japan
Faculty of Medicine, University of the Ryukyus, Okinawa, Japan
Contributors liii
Cassandra Szoeke Department of Medicine - Royal Melbourne Hospital,

Consultant Neurologist Department of Neuroscience, Melbourne Health, The
Vanessa Taler University of Ottawa and Bruyre Research Institute, Ottawa,
ON, Canada
Kristine M. Talley School of Nursing, University of Minnesota, Minneapo-
lis, MN, USA
Sarah (Uma) K. Tauber Department of Psychology, Texas Christian Uni-
versity, Fort Worth, TX, USA
Benjamin Tauber Department of Psychological Aging Research, Institute of
Psychology, Heidelberg University, Heidelberg, Germany
Philip Taylor Federation Business School, Federation University Australia,
Churchill, VIC, Australia
Ruth Teh Department of General Practice and Primary Health Care, School
of Population Health, The University of Auckland, Auckland, New Zealand
Antnio Lcio Teixeira Laboratrio Interdisciplinar de Investigao
Mdica, Faculdade de Medicina, Universidade Federal de Minas Gerais,
Belo Horizonte, MG, Brazil
Laetitia Teixeira UNIFAI and CINTESIS, ICBAS University of Porto,
Porto, Portugal
Adam Theobald Centre for Healthy Brain Ageing, University of New South
Shane A. Thomas School of Primary Health Care, Monash University,
Melbourne, VIC, Australia
International Primary Health Care Research Institute, Shenzhen, China
Susan P. Thompson University of Nevada, Reno, NV, USA
Steven R. Thorp VA San Diego Healthcare System, San Diego, CA, USA
Franka Thurm Department of Psychology Chair of Lifespan Developmen-
tal Neuroscience, TU Dresden, Dresden, Germany
Eileen C. Toomey Saint Louis University, Saint Louis, MO, USA
Dayna R. Touron University of North Carolina at Greensboro, Greensboro,
NC, USA
Andy Towers School of Public Health, Massey University, Palmerston
North, New Zealand
Samuel D. Towne, Jr Department of Health Promotion and Behavior, Col-
lege of Public Health, The University of Georgia, Athens, GA, USA
liv Contributors
Julian Trollor Department of Developmental Disability Neuropsychiatry,

School of Psychiatry, University of New South Wales, Sydney, NSW,
Australia
Donald M. Truxillo Department of Psychology, Portland State College of
Liberal Arts and Sciences, Portland State University, Portland, OR, USA
Kerstin Unger Department of Neuroscience, Brown University, Providence,
RI, USA
Willy Marcos Valencia Geriatrics Research, Education and Clinical Center
(GRECC), Miami VA Medical Center, Miami, FL, USA
Department of Public Health Sciences, University of Miami Miller School of
Medicine, Miami, FL, USA
S. P. J. van Alphen Department of Clinical and Life Span Psychology, Vrije
Universiteit Brussel (VUB), Brussels, Belgium
Silvia D. M. van Dijk University Center for Psychiatry, University Medical
Center Groningen, Groningen, The Netherlands
Beatrice Van der Heijden Institute for Management Research, Radboud
University, Nijmegen, The Netherlands
Open University of the Netherlands, Heerlen, The Netherlands
Katie Van Moorleghem Palo Alto University, Palo Alto, CA, USA
Nico W. Van Yperen Department of Psychology, University of Groningen,
Groningen, The Netherlands
Hilde Verbeek Department of Health Services Research, Faculty of Health,
Medicine and Life Science, CAPHRI School for Public Health and Primary
Care, Maastricht University, Maastricht, The Netherlands
Paul Verhaeghen Georgia Institute of Technology, Atlanta, GA, USA
Frans R. J. Verhey School for Mental Health and Neuroscience, Alzheimer
Center Limburg, Maastricht University Medical Center, Maastricht, The
Netherlands
Dominique Vert Vrije Universiteit Brussel/ University College Ghent,
Brussels, Belgium
Eimee Villanueva Palo Alto University, Palo Alto, CA, USA
Manuel C. Voelkle Institute of Psychology, Humboldt University Berlin,
Berlin, Germany
Max Planck Institute for Human Development, Berlin, Germany
Contributors lv
Deborah Vollmer Dahlke Health Promotion and Community Health Sci-

ences, Texas A&M Health Science Center and School of Public Health,
College Station, TX, USA
Hans-Werner Wahl Department of Psychological Aging Research, Institute
of Psychology, Heidelberg University, Heidelberg, Germany
Network Aging Research (NAR), Heidelberg University, Heidelberg, Germany
Tomoko Wakui Tokyo Metropolitan Institute of Gerontology, Tokyo, Japan
Katherine E. Walesby Alzheimer Scotland Dementia Research Centre and
Centre for Cognitive Ageing and Cognitive Epidemiology, University of
Edinburgh, Edinburgh, Scotland, UK
Nicole Walker School of Psychology, The University of Queensland,
Ruth V. Walker The University of Akron, Akron, OH, USA
Sarah J. Wallace The University of Queensland, St Lucia, Brisbane, QLD,
Australia
Wylie H. Wan Oregon Health and Science University, Portland, OR, USA
Anne Wand School of Psychiatry, University of NSW, Sydney, NSW,
Australia
South East Sydney Local Health District, Sydney, NSW, Australia
Yafeng Wang Institute of Social Science Survey, Peking University, Beijing,
China
Daniela Weber World Population Program, Wittgenstein Centre for Demog-
raphy and Global Human Capital, International Institute for Applied Systems
Analysis, Laxenburg, Austria
Jennifer C. Weeks Department of Psychology, University of Toronto,
Toronto, ON, USA
Rotman Research Institute, Baycrest, Toronto, ON, USA
Matthias Weigl Institute and Outpatient Clinic for Occupational, Social, and
Environmental Medicine, Ludwig-Maximilians-University, Munich, Germany
Stephanie Y. Wells VA San Diego Healthcare System, San Diego, CA, USA
Yvonne Wells La Trobe University, Melbourne, VIC, Australia
Kathleen A. Welsh-Bohmer Departments of Psychiatry and Neurology,
Duke University Medical Center, Durham, NC, USA
Britta Wendelstein Section of Geriatric Psychiatry, Heidelberg University,
Heidelberg, Germany
Institute of Gerontology, Heidelberg University, Heidelberg, Germany
lvi Contributors
Robert West Department of Psychology, Iowa State University, Ames, IA,

USA
Robin L. West University of Florida, Gainesville, FL, USA
Markus Wettstein Department of Psychological Aging Research, Institute

of Psychology, Heidelberg University, Heidelberg, Germany
Network Aging Research (NAR), Heidelberg University, Heidelberg,
Germany
Bradley Willcox Okinawa Research Center for Longevity Science, Urasoe,

Okinawa, Japan
Hawaii Lifespan and Healthspan Studies, Kuakini Medical Center, Honolulu,
HI, USA
Department of Geriatric Medicine, John A. Burns School of Medicine, Uni-
versity of Hawaii, Honolulu, HI, USA
The Queens Medical Center, Honolulu, HI, USA
D. Craig Willcox Okinawa Research Center for Longevity Science, Urasoe,

Okinawa, Japan
Department of Human Welfare, Okinawa International University, Ginowan,
Okinawa, Japan
Hawaii Lifespan and Healthspan Studies, Kuakini Medical Center, Honolulu,
HI, USA
Department of Geriatric Medicine, John A. Burns School of Medicine, Uni-
versity of Hawaii, Honolulu, HI, USA
Sherry L. Willis Department of Psychiatry and Behavioral Sciences, Uni-

versity of Washington, Seattle, WA, USA
Tim D. Windsor Flinders University, Adelaide, SA, Australia
Barbara Wisse Department of Psychology, University of Groningen, Gro-

ningen, Netherlands
Amber E. Witherby Department of Psychology, Texas Christian University,

Fort Worth, TX, USA
Oliver T. Wolf Department of Cognitive Psychology, Institute of Cognitive

Neuroscience, Ruhr University Bochum, Bochum, Germany
Gloria Wong The University of Hong Kong, Hong Kong, China
Linda Worrall The University of Queensland, St Lucia, Brisbane, QLD,

Australia
Camille B. Wortman Department of Psychology, SUNY Stony Brook,

Stony Brook, NY, USA
Contributors lvii
Sarah Wright Department of Management Marketing and Entrepreneurship

College of Business and Law, University of Canterbury, Christchurch, New
Zealand
Carsten Wrosch Concordia University, Montreal, QC, Canada
Susanne Wurm Institute of Psychogerontology, Friedrich-Alexander
Universitt Erlangen, Nrnberg (FAU), Germany
Jean F. Wyman School of Nursing, University of Minnesota, Minneapolis,
MN, USA
Lale M. Yaldiz Department of Psychology, Portland State University,
Portland, OR, USA
Zixuan Yang Centre for Healthy Brain Ageing, University of New South
Melissa A. Yanovitch PGSP-Stanford PsyD Consortium, Palo Alto, CA,
USA
Mnica Sanches Yassuda University of So Paulo, So Paulo, SP, Brazil
Dannii Y. Yeung Department of Applied Social Sciences, City University of
Hong Kong, Hong Kong, China
Brian Yochim Department of Medicine, National Jewish Health, University
of Colorado School of Medicine, Denver, CO, USA
Carmen K. Young Department of Psychology, Rice University, Houston,
TX, USA
Hannes Zacher Department of Psychology, University of Groningen, Gro-
Sara Zaniboni Department of Psychology and Cognitive Science, Universit
degli studi di Trento, Rovereto, TN, Italy
Yi Zeng Center for the Study of Aging and Human Development and Geri-
atrics Division, School of Medicine, Duke University, Durham, NC, USA
Center for Healthy Aging and Development Studies, National School of
Development, Peking University, Beijing, China
Andreas Zenthfer Department of Prosthodontics, University Hospital Hei-
delberg, Heidelberg, Germany
Yaohui Zhao National School of Development, Peking University, Beijing,
China
Hanna Zieschang Institute for Work and Health of the German Social
Accident Insurance, Dresden, Germany
Daniel Zimprich Department of Psychology, Ulm University, Ulm, Baden-
Wrttemberg, Germany
A
Acceptance and Commitment more similar than one would think from looking
Therapy at their names in the DSM-V, as they involve
dysfunction in the same dimensions. In this
Mara Mrquez-Gonzlez1 and regard, many anxiety, depressive, or addictive
Andrs Losada Baltar2 disorders, among others, have in common
1
Departament of Biological and Health that they involve experiential avoidance and
Psychology, Universidad Autnoma de Madrid, cognitive fusion. These processes will be dened
Madrid, Spain later. Also, as a consequence of ACTs focus on
2
Department of Psychology, Universidad Rey the context of psychopathology, it situates
Juan Carlos, Madrid, Spain psychological problems in the broader context
of peoples lives. Hence, aspects such as
purpose, meaning, personal values, or sense of
Synonyms coherence are germane to understanding psycho-
logical problems and to working out solutions
ACT; Contextual therapy; Third generation of to them.
behavioral therapies; Third wave of behavioral
therapies
Psychological Interventions with Older
Adults
Definition
With the aging of the population there is expected
Acceptance and Commitment Therapy (ACT) is a to be a signicant increase in the number of
behavioral experiential psychotherapy which elderly people suffering psychological distress.
reformulates and synthesizes previous genera- Research has already shown that there are psycho-
tions of behavioral and cognitive therapy and logical interventions that work for helping dis-
carries them forward into questions, issues, and tressed older adults, with most of the evidence
domains previously addressed primarily by other coming from cognitive-behavioral interventions
traditions, in hopes of improving both understand- (Gatz 1997). Evidence has been put forward
ing and outcomes (Hayes 2004). ACT takes a supporting the efcacy of Cognitive Behavioral
transdiagnostic and functional approach to Therapy (CBT) for treating depression and sleep
psychological problems: it is the function of problems in older adults, with effect sizes within
behavior that matters, not its shape. Consequently, the range of those found for younger adults
different clinical diagnoses are, in essence, (Satre et al. 2006).
N.A. Pachana (ed.), Encyclopedia of Geropsychology,
DOI 10.1007/978-981-287-082-7
2 Acceptance and Commitment Therapy
In spite of this, there is some justication for standard-bearer of this third generation, and its
further research on alternative therapeutic characteristics make it especially suitable for
approaches targeting the elderly population. One older adults, as discussed later.
of them has to do with the nature of CBT, which
may limit its efcacy for some older adults psy-
chological problems. The basic assumption in What Is Acceptance and Commitment
CBT is that individuals can be trained in strategies Therapy?
to understand the factors that maintain their prob-
lems, as well as in techniques for dealing with A basic assumption in ACT is that psychological
them, which usually involve changing thoughts suffering is an inherent characteristic of human
and behaviors (e.g., cognitive restructuring, skills life (Hayes 2004). ACT makes a strong criticism
training, or relaxation). However, many problems of the healthy normality hypothesis that seems
older adults face include aspects that are not easily to underlie mainstream Western psychology,
modiable. Even though growth and gains in dif- according to which humans are, by their nature,
ferent domains can occur in old age, aging brings psychologically healthy, and well-being and hap-
with it important and irremediable changes or piness is the hallmark of psychological health.
losses in physical (e.g., health problems) and This assumption is a correlate of the welfare soci-
social resources (e.g., death of loved ones), as ety prevalent in the West and in the richer coun-
well as in the contexts or scenarios people live in tries in general, but sharply contrasts with
(e.g., retirement, empty nest). Challenging the peoples everyday experience, which demon-
validity of thoughts, emotions, or behaviors asso- strates that problems, losses and difculties, and
ciated with these changes may not be the best way the associated suffering, are more the norm than
to face the problems, given the realistic nature of the exception in human life. Experiences such as
the problems (Petkus and Wetherell 2013). being worried, having intrusive thoughts or feel-
Older adults psychological or emotional probing sadness, anxiety, anger, or other uncomfort-
lems are frequently related to difculties in able emotions are normal psychological
adapting to their changing realities. Despite the experiences that go hand in hand with human
fact that some studies nd aging to be related to existence. Assuming that these aversive experi-
improvements in emotion and self-regulation ences are normal, and being able to accept them
strategies (Reed and Carstensen 2014), it is nev- and tolerate them while acting in the direction of
ertheless true that when faced with losses and personal values, are essential requirements for
changes in important life domains, many older adaptation and psychological health. According
adults have problems accepting them. Conse- to ACT, the hallmark of human ability for adap-
quently, they tend to avoid the situations, tation and psychological health is psychological
thoughts, and emotions associated with these exibility, dened as the ability to act in chosen
events, which leads to maladaptive behavior pat- directions, in line with ones personal values,
terns that can result in disengagement from life regardless of the uncomfortable internal experi-
and affect their well-being. ences (thoughts, emotions, or sensations) one is
In recent decades, the eld of psychological having at that moment, and while remaining in
intervention has witnessed the emergence of the contact with the present (Hayes et al. 2011). Many
so-called third generation of behavioral therapies different forms of psychopathology are manifes-
(Hayes 2004), which place the emphasis of inter- tations of psychological rigidity, which consists of
vention on increasing peoples ability to accept the following six processes (also called hexaex):
the hassles and problems inherent to life, as well (a) experiential avoidance; (b) cognitive fusion;
as the aversive experiences associated with (c) attachment to the conceptualized self; (d) loss
them (thoughts, sensations, and emotions), while of contact with the present moment (inexible
acting in the direction of personal values. Accep- attention); (e) disruption of values; and
tance and Commitment Therapy (ACT) is the (f) inaction.
Acceptance and Commitment Therapy 3
(a) Experiential avoidance is the opposite ten- at helping people develop coherent and satis-
dency to acceptance and has been described factory lives, despite the presence of unavoid-
as the unwillingness to remain in contact with able suffering. A
particular private events such as emotions, (b) Cognitive fusion is the tendency to be psy-
thoughts, or behavioral predispositions chologically entangled with and dominated
(Hayes et al. 2011). According to ACT, by the form or content of thoughts, believing
many forms of psychopathology are not in their literal content, or, in more general
abnormal behavior, emotions or thoughts, terms, the excessive or improper regulation
but rather bad solutions that people apply of behavior by verbal processes, such as
to solve their distress or, in other words, rules and derived relational networks (Hayes
unhealthy efforts to escape and avoid emo- et al. 2011). When people rigidly believe (are
tions, thoughts, memories, and other private fused with) the contents of their mind (e.g.,
experiences (Hayes et al. 1996). Research elderly people are unable to learn new
shows that avoidance can have undesired things or I dont have anything interesting
effects: trying to suppress a thought or an to say), they will have trouble being aware of
emotion may generate a boomerang effect, contextual or direct experience clues, and will
increasing the frequency and intensity of act in a maladaptive way (e.g., not attending
these experiences (Campbell-Sills et al. courses to learn new things, or not participat-
2006; Hooper and McHugh 2013). Thoughts ing in debates or conversations with other
or emotions associated with relevant negative people). Being fused with verbal or cognitive
life events such as the death of a loved one are rules (e.g., I am not interesting for other
not easily changeable, and trying to ght them people. People do not like me) is maintained
(suppress or reject them) may limit peoples in part because compliance with verbal rules
chances to continue living their lives in an is rewarding. Cognitive fusion is also related
adaptive way. to checking behavior of clues that may con-
As already pointed out, ACT starts out rm or disconrm the thought or verbal rule
from the belief that human suffering is a ubiq- (e.g., That expression on her face means that
uitous experience. It highlights the need to shes bored with my conversation). This
strengthen, in clinical practice, peoples abil- checking behavior limits peoples behavioral
ity to accept this suffering and deal with it in repertoire and action opportunities for living
appropriate ways. This does not involve res- in the present. An important manifestation of
ignation or helplessness, but rather acknowl- cognitive fusion is an excessive entanglement
edgement and active embracement of the with giving reasons, which leads some peo-
aversive experiences associated with prob- ple to prefer to be right than to be happy
lems and losses, in order to be able to integrate (e.g., I didnt go to the party because I am not
them and continue living rich and meaningful good company and because I was feeling anx-
lives. In clinical practice, this involves helping ious). ACT tries to change the way one
people to make room for undesired emo- relates to thoughts by undermining these mal-
tions and thoughts, understanding the paradox adaptive verbal contexts (literality and giving
of control, (the harder we try to control reasons), generating new scenarios in which
these experiences, the more difcult it maladaptive functions of thought are dimin-
becomes) and both the futility and cost of ished. Specically, cognitive defusion tech-
avoidance. niques include deliteralization (e.g., the
Hence, ACT does not focus on the elimi- Milk, Milk, Milk exercise; word repetition)
nation or reduction of aversive experiences, (Titchener 1916), and physicalizing exercises
but on peoples personal values and goals. (e.g., Imagine that your thought is an object
These motivational variables are the frame- inside your head: what shape has it? What color
work of intervention in ACT, which is aimed is it?) among others (Snyder et al. 2011).
ACT also includes many interesting exercises and not something based on a decision mak-
for undermining reasons as causes of behavior ing process, nor the opinion of others. For
(Hayes 2004; Hayes et al. 2011). example, a woman chooses to care for her
(c) Conceptualized self or cognitive fusion with husband with dementia at home, on the basis
self-concept occurs when a person is rigidly of her value to love my husband and keep
fused with his or her self-concept (Im an old him safe and secure. ACT aims to help peo-
and lonely man) or self-story, and nds great ple clarify or reconnect with their personal
reward in telling coherent self-narratives. In values, which are the main source of meaning
this context, people are likely to attend to and and sense of purpose, cornerstones of well-
process stimuli and information conrming being.
their schemas and to behave consistently with (f) Behavior inconsistent with values. When peo-
them (e.g., not interacting with other people, ple have not claried their values or are dis-
not involving themselves in activities). This connected from them, it is more likely that
usually leads to a reduced likelihood of being they will show passivity (lack of action),
open to new or exible ways of thinking about inconsistent behavior (acting in ways that are
and coping with problems, as well as to self- inconsistent with ones values), impulsivity, or
fullling prophesies (to behave like a lonely persistent avoidance. In ACT, patients are
man can indeed generate more loneliness). encouraged to commit to their values, that is,
ACT aims to train patients in skills for to develop stable patterns of effective behavior
decentering from their self-concept-related consistent with their personal values. This
thoughts, emotions and sensations, and taking involves helping them to initiate and maintain
perspective (experiencing self-as-context), actions that are values-based, redirecting
that is, acting as observers of these experiences, behavior towards the desired values, and
in order to facilitate more exible ways of maintaining the purposes in the face of barriers
analyzing their problems and provide possible (Hayes et al. 2011). It also involves discover-
alternatives of thinking and behavior. ing and overcoming barriers to committed
(d) Lack of contact with the present moment. The actions, which usually implies the use of tra-
tendency to focus on the past (e.g., rumina- ditional behavioral techniques such as skills
tion) or the future (e.g., worry) is another training, exposure, or problem-solving, which
manifestation of psychological rigidity. This are perfectly compatible with ACT.
process involves loss of contact with the pre-
sent moment (here and now) and a pattern of
inexible attention, which interferes with the Why Is ACT an Interesting Therapeutic
ability to live in the present moment and fully Approach for Older Adults?
perceive and experience the consequences of
behavior. Such rigidity can prevent adaptive As already pointed out, a substantial proportion of
and exible ways of coping with problems. elderly people suffering from different forms of
ACT sets out to train people to attend to the psychopathology have a long history of efforts to
present moment and enrich their experience of reduce the distress associated with their psycho-
the here and now by fostering attentional logical problems. This history of failures may be
control. For this purpose, ACT uses mindful- related to the fact that many of these problems
ness techniques, which involve awareness of involve difculties for adapting to hard-to-change
and focused attention on breathing and body factors, such as irremediable losses (e.g., death of
sensations, among other experiences. loved ones) and changes (e.g., retirement), and
(e) Disruption of values. Another source of psy- to the aversive experiences associated with them
chological distress is related to the lack of (e.g., sadness or self-devaluative thoughts). These
clarication of or disconnection from personal hard-to-change events usually have a great impact
values. In ACT, a value is a personal choice, on older adults set of personal values, as some of
them may be more difcult to pursue and some platform from which to develop psychological
goals and objectives may be no longer attainable. interventions aimed at helping older people
In these circumstances, exible goal adjustment is adapt to changes, losses and life transitions, A
required in order to keep the person engaged in which are frequently involved in psychological
life and committed to their personal values. This problems in old age. This can be illustrated in
adjustment involves disengaging from inappropri- the following clinical case: an elderly man gets
ate goals and replacing them with more feasible depressed after retirement, because he has always
ones, processes that have been found to be asso- had the value of being a good professional as a
ciated with better emotional well-being (Wrosch priority in his life, to the detriment of other areas
et al. 2006). of values (friendship, leisure time, etc.). As this
However, the truth is that, when faced with value is no longer possible for him to follow and
these life events and the associated uncomfortable he has not claried or committed to other areas of
experiences (emotions, sensations, or thoughts), values, he is likely to experience an emptiness
many older adults have considerable difculty of values, and to become caught up in patterns
adjusting their set of goals, reformulating their of experiential avoidance that eventually lead to
affected values, or restructuring their values hierar- depression. Cognitive fusion with thoughts such
chy, and end up experiencing a blockage or discon- as I am no longer useful or I am nished is
nection from important valued life domains. These also very likely in this case. Therapeutic work
types of problems frequently experienced by older from ACT would focus on fostering acceptance
adults make particularly interesting the use in this of his current circumstances and the associated
population of an alternative therapeutic approach aversive experiences, and helping him to clarify
such as ACT which, instead of promoting a and commit to personal values that bring meaning
control-oriented approach focused on change, fos- and purpose to his life. This may involve:
ters acceptance as the main way of coping with the (a) reformulating his former main value, identify-
difculties and problems (Petkus and Wetherell ing the underlying sources of meaning and satis-
2013). faction, in order to generate a related but
It is important to note here that ACTs focus on attainable value, such as being productive or
the importance of values clarication and the useful for other people; (b) helping him to
development of patterns of behavior consistent retrieve and strengthen other values; and
with personal values ts very well with two of (c) undermining verbal dysfunctional processes
the main theoretical models of human develop- (cognitive fusion and conceptualized self)
ment across the lifespan: the Selective Optimiza- through training in cognitive defusion techniques
tion with Compensation Model of successful and strengthening the self-as-context perspective.
ageing (SOC) (Baltes and Baltes 1990) and the Other characteristics that make ACT a suitable
Motivational Theory of Life-Span Development therapeutic approach for older adults are the
(Heckhausen et al. 2010). A basic assumption of following:
these approaches is that people are active and
goal-oriented agents in their lifespan develop- (a) Transdiagnostic approach. The high preva-
ment, who strive for adaptation to losses and lence of subsyndromal psychological prob-
changes throughout the lifespan, displaying moti- lems and the frequent comorbidity between
vational processes such as goal selection, goal anxiety and depression in the elderly popula-
pursuit, and goal disengagement. tion may be related to the limitations of cur-
As suggested in the above paragraph, motiva- rent diagnostic criteria for use with this
tion, values-oriented action, and exible goal population. The transdiagnostic nature of
adjustment are essential elements of adaptation ACT makes this therapy particularly suitable
throughout the lifespan and, particularly, in old for the elderly (Petkus and Wetherell 2013).
age. The combination of theoretical models of (b) Methodology. ACT departs from psychoedu-
human development with ACT provides a useful cational and verbal techniques, which are
central in CBT, and uses a methodology satisfaction (p. 60). This motivational change
mainly involving metaphors, paradoxes, and has some consequences, such as a reduction in
experiential exercises. These techniques are self-centeredness and in interest in superu-
particularly suitable for many older adults ous social interaction and material things, or a
who, due to cohort differences (e.g., lower shift from egoism to altruism. Once again,
level of formal education) or other reasons older adults tendency for self-transcendence
(e.g., cognitive impairment), may show limi- is highlighted in gerontological theory.
tations in abstract thinking or verbal reason- These considerations point to the possibil-
ing ability. ity that older adults mental health and well-
(c) Focus on eudaimonic well-being (values and being involve more eudaimonic aspects, as
goals). According to Socioemotional Selectiv- they are related to the fulllment of particular
ity Theory (Carstensen et al. 1999), the goals of motivational tendencies. In this regard, an
older adults are focused on optimizing emo- association has been found between wisdom
tional meaning and well-being, and they usu- and eudaimonic well-being, suggesting that
ally invest more cognitive and behavioral wise persons mental health is largely deter-
resources than their younger counterparts in mined by their involvement in values-related
pursuing their emotionally meaningful goals. meaningful activities (Webster et al. 2014).
For its part, Eriksons theory of development A comparison between CBT and ACT sug-
(Erikson 1950) states that the major psychoso- gests that, while cognitive-behavioral therapy
cial crisis to be resolved in old age is ego is grounded in a somehow more individualis-
integrity versus despair. This crisis is precipi- tic and self-centered perspective, more
tated by the awareness of mortality. The focused on hedonic well-being since it aims
achievement of ego integrity requires that peo- at decreasing negative affect (anxiety and
ple review their life-career to determine depression), ACT is more focused on
whether it was a success or a failure. Older eudaimonic well-being, being aimed at help-
adults who succeed in this crisis are those ing people to live their life in accordance with
who are able to accept how things have turned their personal and intrinsic values. As Petkus
out in their lives, and nd order and meaning in and Wetherell (Petkus and Wetherell 2013)
it. There is some evidence suggesting the great suggest, this therapeutic objective may reso-
importance of having achieved generativity in nate more with older adults (p. 49). ACT
order to satisfactorily resolve the ego integrity seems to t better with older adults tendency
crisis (James and Zarrett 2006). for self-transcendence and generativity, to the
On the other hand, generativity is a moti- extent that its main therapeutic objective is
vational tendency that can be dened as con- precisely to help people fulll their motiva-
cern for and commitment to establishing and tional tendencies. Indeed, there is some evi-
guiding the next generation (Erikson 1950). It dence that attrition rates are lower among
has been found to increase in old age, in which older adults treated with ACT when compared
many people are mainly interested in to those who received CBT (Wetherell
obtaining emotional meaning through the pur- et al. 2011).
suit of values and goals related to the achieve- (d) More focus on strengths. In relation to its
ment of younger generations well-being focus on eudaimonic well-being, and as
(Sheldon and Kasser 2001). Petkus and Wetherell (Petkus and Wetherell
Finally, the gerotranscendence theory 2013) suggest, ACT may also be particularly
(Tornstam 1989) states that aging persons suitable for older adults because it is more
gradually develop a shift in meta- focused on and takes more advantage of the
perspective, from a materialistic and rational persons strengths and resources. Gerontolog-
vision to a more cosmic and transcendent one, ical research evidence reveals aging-related
normally followed by an increase in life gains and growth in different domains, such
as those of resilience (Gooding et al. 2012) or and effort devoted to living according to their own
emotion regulation (Scheibe and Carstensen values. In addition, participants in the ACT inter-
2010). vention reported a reduction in the belief that A
medication is the sole or principal treatment for
their pain.
Research Studies on ACT and Aging Karlin and colleagues (2013) compared an
ACT treatment for depression in veterans aged
The empirical evidence in support of ACT as a 1864 and 65-plus who sought treatment for
helpful therapy for older adults is reviewed in the depression. ACT training consisted of up to
following paragraphs. 16 sessions, and there was no control group. The
Wetherell et al. (2011) provide data on 12 adults treatment protocol did not have specic content
aged 60 or more with a principal diagnosis of related to older adults. They found large effect
Generalized Anxiety Disorder (GAD). Partici- sizes for their intervention, both for older adults
pants were randomized to ACT or CBT individual and the under-65s. They also reported increases in
treatment, consisting of 12 sessions. The authors quality of life and therapeutic alliance.
conclude that an ACT intervention for older adults Other studies have been conducted with sam-
with GAD is feasible, with reductions in worry ples that included participants from different age
and depressive symptoms. They suggest that nov- groups, including older adults. For example,
ice therapists may conduct this type of interven- Wetherell and colleagues (in press), in a study
tion. However, they reported that the effects on the comparing ACT and CBT for adults with chronic
7 participants in the ACT intervention in this pain, found data suggesting that older adults are
study were substantially lower than those more likely to respond to ACT, as compared to
observed in younger adult samples with GAD. younger adults, who are more likely to respond to
They suggest that an adaptation of the interven- CBT. In addition, they suggest that ACT is partic-
tion with fewer elements, but relevant to older ularly appropriate and acceptable for older adults
adults, may increase the effects. considering that older adults may have experi-
McCracken & Jones (2012) conducted an ACT enced a greater number of failed efforts to reduce
intervention for 40 participants with chronic pain their pain; thus, an intervention that focuses on
aged 60 and over. The main aim of the interven- living well with pain, as opposed to pain reduc-
tion was to increase psychological exibility. tion, may have more appeal to older individuals.
There was no control group or randomization to McCracken, Sato and Taylor (2013) carried out a
different interventions. The intervention was study analyzing the effect of an ACT intervention
delivered over a period of 3 or 4 weeks, 5 days a for people with chronic pain. In that study, a
week, by an interdisciplinary team. Medium to signicant proportion of the sample was aged
large effects in the expected directions were 65 or older. The ndings showed that the inter-
observed in pain intensity, pain acceptance, phys- vention was associated with a decrease in depres-
ical disability, psychosocial disability, mindful- sion, lower disability, higher pain acceptance, and
ness, and depression. other ratings of overall improvement. Acceptance
Alonso, Lpez et al. (2013) published a pilot and Commitment Therapy has also been proposed
study on an ACT intervention for nursing home as a promising therapeutic approach for helping
residents with chronic pain, compared to a control family caregivers of people with dementia.
group. Ten older adults participated in the inter- (Mrquez-Gonzlez et al. 2010), through a pilot
vention, which was based on a combination of study of an eight-session ACT intervention for
ACT and the Selective Optimization with Com- dementia caregivers delivered in group format,
pensation Model (Baltes and Baltes 1990), and found preliminary data suggesting the potential
consisted of ten 2-hour sessions. The results sug- interest of this therapy for helping dementia fam-
gest that this intervention was successful for ily caregivers. These promising results have been
increasing participants satisfaction with the time conrmed in a recent randomized controlled trial
in which the differential efcacy of an ACT inter- In conclusion, ACT seems to be a promising
vention and a Cognitive Behavioral Therapy for approach for understanding and treating many
dementia family caregivers was analyzed psychological problems in the elderly, helping
(Losada et al. 2015). Both interventions were them to: (a) accept and be open to their uncom-
delivered in an individual format, and a signicant fortable experiences in the here and now;
statistical and clinical effect of the ACT interven- (b) choose valued life-directions that provide
tion was found for the reduction of caregivers them with meaning and purpose; and (c) take
anxiety and depressive symptoms. action, engaging in stable patterns of values-
consistent behavior.
Conclusions and Suggestions

for the Future
Cross-References
The revised studies point in the direction of
Aging and Psychological Well-being
supporting ACT as a treatment option that may
Clinical Issues in Working with Older Adults
contribute to helping elderly people suffering dis-
Cognitive Behavioural Therapy
tress. However, there is a gap in the availability of
Contextual Adult Life Span Theory
outcomes from randomized controlled trials, and
for Adapting Psychotherapy (CALTAP) and
there is also a clear need for new research studies
Clinical Geropsychology
aimed at analyzing and identifying the specic
Life Management Through Selection,
processes and action mechanisms involved in
Optimization, and Compensation
ACT interventions (e.g., increase of acceptance,
Motivational Theory of Lifespan Development
cognitive defusion, clarication of values,
increase in values-consistent behavior), which
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10 Active Aging
History of the Concept

Active Aging
The model of active aging emerged in the after-
Constana Pal1 and Alexandra Lopes2 math of the demographic changes experienced
1
UNIFAI and CINTESIS, ICBAS University of across most of the western world from the 1950s
Porto, Porto, Portugal onward. Its roots date back to the 1960s and to the
2
Institute of Sociology, University of Porto, Porto, inuential work of Havighurst (1963) in the
Portugal United States and his activity theory. This author
supported the idea that successful ageing means
the maintenance as far and as long as possible of
Synonyms activities and attitudes of middle age (Havighurst
1963, p. 8), stressing that the maintenance of such
Aging well; Optimal aging; Positive aging; activities in later stages of life are associated with
Productive aging; Successful aging higher levels of wellbeing and quality of life.
According to the formulation, people should
keep active and replace professional activities by
Definition others when they have to retire from the labor
market, or replace friends by others when the
The World Health Organization (WHO) denes former have died. This activity theory brought
active aging as . . .the process of optimizing an alternative approach to aging in opposition to
opportunities for health, participation and secu- the theory of disengagement of Cumming and
rity in order to enhance quality of life as people Henry (1961), which considered the mutual with-
age (WHO 2002, p. 12). For many years, the drawal between old people and society. Eager of a
WHO has emphasized healthy aging, primarily more positive approach to old age, a stage in life
dened as aging without major pathologies. In that more and more people were achieving, aca-
the early 1990s, it has begun developing the con- demics and professionals working in the eld
cept of active aging, jointly with other govern- have welcomed this activity theory and from
mental and nongovernmental organizations inception it gathered wide enthusiasm. Later
initiatives, offering a policy framework that Neugarten (1964) would stress the relevance of
emphasizes the link between activity, health, inde- being socially engaged and active to age success-
pendence, and aging well. Active aging emerged fully. This became one of the most inuential
as a more comprehensive concept than healthy theories to inform aging policies up to the emer-
aging, as it considers not only health indicators gence in the late 1980s of the concept of success-
but also psychological, social, and economic ful aging by Rowe and Kahn (1987, 1997, 1998)
aspects, which are to be looked at the community in the United States. Slightly more moderate
level, within gender and cultural perspectives. approaches are found in work inspired by the
Currently the WHOs active aging concept theory of continuity of Atchley (1989) who claims
leads the global policy strategy in Europe that, despite the importance of maintaining activ-
(Walker 2009). The document produced by the ities of middle age in later life to achieve higher
WHO (2002), although not exempt of criticism, levels of wellbeing in old age, it is not so much the
was adopted as a guide in many health and social amount of activities that matters but instead the
inclusion national plans all over the world and it meaning activities carry for the individual. More-
has denitely changed the dominant approach to over, alongside the maintenance of meaningful
old age that for many decades had been grounded activities, Atchley stresses that processes of
in the decit theories. Some go further consider- adjustment and adaptation also mark later stages
ing that it opened the way to a new model of of life. Also more moderate is the proposal of
governance of aging (Boudiny and Mortelmans Caradec (2007) that offers a conceptual frame-
2011). work to discuss active aging that puts the process
Active Aging 11
of aging in the crossroads of two opposing forces, denition itself: participation, health, and security.
the pressure toward disengagement and the pres- Recently, the International Longevity Centre of
sure toward remaining connected to the world. Brazil (2015) whose president is Alexandre A
Managing the tension between these two forces Kalache, the previous responsible for the active
is the challenge of aging (lpreuve). Active aging approach launched by WHO, released a
aging, in that sense, involves the process but also report titled Active Ageing: A policy framework
the outcome of the reorganization of activities that in response to the longevity revolution. In this
allow us to manage the tension between disen- piece of work, Kalache revises the concept of
gagement and continuity. Caradec further adds active aging to incorporate more recent and new
that individuals will experience this process dif- developments in life course perspectives. To the
ferently according to the resources they control, original pillars a new one was added lifelong
both personal and social (Caradec 2010). learning that supports all the other pillars and
The overarching use of the concept of active puts information as vital to active aging. Besides
aging though was not so much the result of the formal education, and work-related knowledge
conceptual developments headed by the academia acquisition, it presents a more inclusive approach
but rather the outcome of the inclusion of the term to lifelong learning to diminish vulnerability,
in the agenda of some supranational institutions, namely, among older persons.
the one holding the highest impact being the The proposed model encompasses six groups
World Health Organization (WHO). The rst ref- of determinants of active aging, each one includ-
erences to the term active aging can be traced back ing several aspects: (1) health and social services
to some documents issued by the European Union (promoting health and preventing disease, health
(1999a, b, 2002) and the OECD (2000). In all services, continuous care, mental health care);
cases, the term appears alongside the discussion (2) behavioral (smoking, physical activity, food
on the challenges of demographic aging. More intake, oral health, alcohol, medication); (3) per-
specically, active aging is portrayed as the way sonal (biology and genetics and psychological
out from the pressures on welfare systems stem- factors); (4) physical environment (friendly envi-
ming from the increasing number of older people ronment, safe houses, falls, absence of pollution);
with some form of dependence or as the way out (5) social (social support, violence and abuse,
from the pressures on pension systems. education); and (6) economic (wage, social secu-
But the nal kick that boosted the concept of rity, work). These determinants of active aging are
active aging to the global arena comes with the embedded in cultural and gender contexts. These
WHO declaration on the principles of policy that so-called determinants, appearing in the model are
nations should adopt to promote active aging (WHO not mutually exclusive and there are overlaps
2002). From then onward, there has been a prolifer- between them, mixing individual as well as soci-
ation of policy initiatives at both global, regional, etal aspects and transient and life course issues.
and local levels that follow closely the guidelines put The WHO (2002) report recommended that health
forward by the WHO and that constitute the frame- policy for old people be implemented through
work that is taken as a reference across most Health Plans at global regional, national, and
countries not only for organizations operating in local levels.
aging-related issues but also for individuals and for According to the WHO document on active
the way they experience the aging process. aging (WHO 2002), the key aspects of active
aging are (1) autonomy which is the perceived
ability to control, cope with, and make personal
The Active Aging Model and Its decisions about how one lives on a day-to-day
Applications basis, according to ones own rules and prefer-
ences; (2) independence, the ability to perform
The concept of active ageing (WHO 2002) is functions related to daily living i.e., the capacity
based on three pillars that are mentioned in the of living independently in the community with no
12 Active Aging
and/or little help from others; (3) quality of life social protection systems) but also about consid-
that is an individuals perception of his or her ering the economic and the social value added by
position in life in the context of the culture and other activities not directly related to the labor
value system where they live, and in relation to market (e.g., voluntary work, family care). Fur-
their goals, expectations, standards and concerns. thermore, the WHO concept of active aging
It is a broad ranging concept, incorporating in a includes clearly nonproductive activities as exam-
complex way persons physical health, psycholog- ples of activities with which individuals can
ical state, level of independence, social relation- engage to achieve quality of life as they age
ships, personal beliefs and relationship to salient (e.g., spiritual activities).
features in the environment(Harper and Power Thirdly, the concept of active aging of the
1998). As people age, quality of life is largely WHO embeds what one could label as an inclu-
determined by the ability to maintain autonomy sive approach to the process of aging. It acknowl-
and independence and healthy life expectancy, edges that processes are formed along the life
which is how long people can expect to live with- course and that the way one lives in old age is
out disabilities. largely conditioned by prior phases of life and
There are some distinctive elements in how the inscribed in individual life trajectories. It also
WHO denes active aging in terms of its implica- emphasizes that active aging is a bottom-up pro-
tions for policy design and for all sorts of inter- cess where people participate in building the
ventions in aging-related issues. Firstly, the WHO appropriate conditions to age with quality of life.
sees active aging as a domain of collective respon- This is quite important as it grounds active aging
sibility. Although one could argue that there is in the recognition of differences in how people
also an orientation to individual responsibility age and in the need to respect and accommodate
phrased in the statement that individuals must the specicities of everybody. Finally, it notes that
participate in certain types of activities and adopt there are individuals that accumulate disadvan-
certain types of behavior, ultimately this is condi- tages and as such are at higher risk of being
tioned by the opportunities individuals have to deprived from the chances of aging actively.
fulll their potential. Optimizing these opportuni- That is the case of those who have physical
ties is clearly a domain for societal action and and/or cognitive impairments or who are disad-
opens the space for a discourse on rights and on vantaged economically.
state obligations. This is further reinforced by the The objective of the WHO model is to guide
emphasis the WHO puts on the resources that policies on aging in order to avoid incapacity and
need to be made available to individuals to max- its high nancial costs for societies that are facing
imize their opportunities to age with quality a deep demographic change toward aging. But in
of life. doing so, the concept of active aging looks for
Secondly, the WHO sees active aging as a ways to reconcile the need to contain social and
process that is materialized in a vast array of nancial costs of aging with the recognition of
multidimensional activities and not exclusively rights of older people as well as the recognition
in productive labor-market-related activities. of the potential to add value to societies along the
This is very relevant as it clearly distinguishes life course and also in old age.
the WHO approach to active aging from the one
of other supranational organizations such as the
OECD which focuses on labor market productiv- Operationalization and Evaluation
ity issues associated with population aging. of Policies Versus Evaluation
Active aging therefore is not just about creating of Individual Outcomes
the conditions to postpone the exit from the labor
market of older workers (which has been the The concept of active aging is nevertheless a very
dominant topic in many national debates on how complex one, and researchers soon began trying
to face the challenges of demographic aging for to understand what it means to laypeople as well
Active Aging 13
as nding ways to operationalize and evaluate its of the concept, old people can overcome difcul-
applications (e.g., Fernandez-Ballesteros et al. ties and keep highly motivated to participate in the
2010). Bowling reported that the most common social world, and engage in healthy behavior, A
perceptions of active aging were having/ which in turn has a positive impact in quality of
maintaining physical health and functioning life during the aging process. In line with this,
(43%), leisure and social activities (34%), mental actions targeting active aging have to take into
functioning and activity (18%), and social rela- account the prevention of health problems across
tionships and contacts (15%) (Bowling 2008). the life span and the promotion of psychological
The predictors of positive self-rated active aging resilience, avoiding loneliness or increasing hap-
were optimum health and quality of life. More piness and subjective wellbeing. These actions
recently, Stenner et al. (2011) described the sub- can occur at both the individual and social policy
jective aspects of active aging by inquiring people level. Examples of actions at the social policy
about the meaning of the expression active level are mechanisms that guarantee adequate
aging. The authors have shown that most people income and policies to plan retirement and to
mention physical activity but also autonomy, guarantee the sustainability of pension systems.
interest in life, coping with challenges, and keep-
ing up with the world. Frequently people mix
physical, mental, and social factors and stressed Critical Perspectives for the Future
agentic capacities and living by ones own norms.
Stenner et al. (2011) have used this evidence to The balance between individual and social
critically question the deterministic view of the responsibility in aging well is probably the key
WHO model and have emphasized the need for a aspect of the active aging model as both contribute
challenge and response framework, a psycho- to aging outcomes that means people should adopt
social approach to the conict between facts and a healthy life style and stay engaged with society
expectations and the proactive attitude of people. but this can only be achieved in friendly and
In an attempt to test empirically the WHO supportive contexts that guarantee access to a
active aging determinants model, Pal et al. diversity of services and value individual options
(2012) arrive to the conclusion that the most and dignity.
important determinants of active aging appears One major implication of the active aging
organized in a factor that can be dened as per- model as it has been spreading among policy
ceived and objective health and independent func- makers is the emphasis it puts on a productivist
tioning and a factor where personal determinants perspective that focuses mostly on the extension
like psychological distress, loneliness, personality of working life ignoring other forms of nonpaid
characteristics, happiness, and optimism emerge work (Foster and Walker 2014). The foundational
as highly relevant to individual active adaptation rhetoric of active aging is the recognition of
to the aging process. autonomy and capacity of older citizens to engage
In sum, active aging and other similar terms, in meaningful social action, as opposed to disen-
such as successful aging, positive aging, or aging gagement. Therefore it is focused on eliminating
well, are viewed as scientic concepts operation- age barriers to the participation of older workers in
ally portrayed by a broad set of bio-psycho-social the labor market and it is very hostile to the culture
factors assessed through objective and subjective of early exit from the labor market. As a result, it
indicators as well as being closely related to lay paves the way to a new legitimacy to what is
concepts reported cross-culturally by older per- considered successful aging, one that is largely
sons (Fernandez-Ballesteros 2011). dependent on an almost endless participation in
Objective as well as subjective health and func- the productive sphere of society (or in some sort of
tionality seem to be major components of active equivalent). In terms of public policies, this trans-
aging in line with Pruchno et al.s (2010a, b) lates into pressures toward postponing retirement,
ndings. By keeping active in the broader sense into investments in training of older workers,
14 Active Aging
among others. Authors such as Foster and Walker Psychological Theories of Successful Aging
consider that there are other forms of creation of Psychological Theories on Health and Aging
social value that are outside the realm of the labor Psychology of Longevity
market and that need to be included in the public Psychosocial Well-Being
policies forum, such as nonpaid family care and
voluntary work. Although these are included in
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C. Tibbitts, & W. Donahue (Eds.), Process of ageing
(Vol. 1, pp. 299320). New York: Atherton.
Activity Theory, Disengagement Theory, International Longevity Centre Brazil. (2015). Active age-
and Successful Aging ing: A policy framework in response to the longevity
Aging and Psychological Well-Being revolution. Rio de Janeiro. www.ilcbrazil.org
Aging and Quality of Life Neugarten, B. (1964). Personality in middle and late life:
Empirical studies. New York: Atherton, 231 p.
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OECD. (2000). Reforms for an ageing society, OECD able to adapt to the challenges of aging than
publishing, Paris. doi: http://dx.doi.org/10.1787/ others.
9789264188198-en.
Pal, C., Ribeiro, O., & Teixeira, L. (2012). Active ageing: Activity and disengagement theories of aging A
An empirical approach to the WHO model. Current were the rst to use social science data to explain
Gerontology and Geriatrics Research, 1. doi:10.1155/ why some individuals, or groups, are more adap-
2012/382972. tive or successful in meeting the multiple and
Pruchno, R. A., Wilson-Genderson, M., & Cartwright,
F. (2010a). A two-factor model of successful aging. inevitable challenges of aging than other persons.
The Journals of Gerontology. Series B, Psychological These theories for the rst time focused on social,
Sciences and Social Sciences, 65, 671679. psychological, and interpersonal factors in addi-
Pruchno, R. A., Wilson-Genderson, M., Rose, M., tion to more observable physiological and medi-
et al. (2010b). Successful aging: Early inuences and
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821833. to the positive and healthy aspects of aging rather
Rowe, J. W., & Kahn, R. L. (1987). Human aging Usual than frailty, decline, and decrement which was
and successful. Science, 237, 143149. doi:10.1126/ the focus at the time, not only of the medical
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Rowe, J. W., & Kahn, R. L. (1997). Successful aging. The establishment in geriatrics but also within social
Gerontologist, 37, 433440. doi:10.1093/geront/37.4.433. services and public policy for the aged. The
Rowe, J., & Kahn, R. (1998). Successful aging. New York: debates following activity and disengagement
Pantheon. theories changed scientic discourse, service
Stenner, P., McFarquhar, T., & Bowling, A. (2011). Older
people and active ageing: Subjective aspects of ageing delivery and policy in the decades following
actively. Journal of Health Psychology, 16, 467477. 1960, providing evidence of the power of theories
Walker, A. (2009). Commentary: The emergence and to alter research and practice in gerontology.
application of active aging in Europe. Journal of Activity and disengagement theories were
Aging & Social Policy, 21, 7593.
WHO. (2002). Active aging: A policy framework. Geneva: based on a developmental perspective applied to
WHO. later life, a view that aging involved a progression
from one stage to another rather than a decline
from middle age to an end state. These theories
also involved an interdisciplinary perspective on
Activity Theory, Disengagement aging based on medical/physiological data on
Theory, and Successful Aging age-related conditions, but also psychology, soci-
ology, and later social work perspectives on func-
Marguerite DeLiema1 and Vern L. Bengtson2 tioning. These were immense contributions to the
1
Stanford Center on Longevity, Stanford developing eld of gerontology in the 1950s and
University, Stanford, CA, USA 1960s.
2
School of Social Work and Edward R. Roybal
Institute on Aging, University of Southern
California, Los Angeles, CA, USA Activity Theory of Aging
Activity is any regulated or patterned action

Synonyms beyond routine physical or personal maintenance
(Lemon et al. 1972; Havighurst 1961). Types of
Activity theory of aging; Disengagement theory activity include interaction with family and
of aging; Successful aging friends, participation in organizations, and more
solitary recreational activities like reading,
watching television, and doing household chores.
Definitions The basic premise of activity theory of aging is
that individuals should maintain the activities and
Interdisciplinary gerontological perspectives that orientations of middle age for as long as possible,
attempt to explain why some individuals are better and then nd substitutes for those activities which
16 Activity Theory, Disengagement Theory, and Successful Aging
they must give up as they age in order to maintain It was not until much later that a systematic
high life satisfaction in retirement (Havighurst empirical test of the theory was provided by
1961). According to the theory, active engage- Lemon, Bengtson and Peterson in 1972. They
ment in various new roles (e.g., taking up volun- amplied the concepts and mechanisms of the
teer activities following retirement) is successful theory and developed a set of axiomatic state-
adaptation to aging. ments based on social theorist George Herbert
Activity theory goes something like this: As Meads symbolic interactionist theory. These
people age they experience life events such as axioms articulated how activities provide role
widowhood, failing health, and retirement that supports that help sustain positive self-concepts
reduce participation in normative mid-life social leading to higher life satisfaction. They postulated
roles. If uncompensated, these role losses lead that the greater the activity level formal social
to lower activity, which may result in lower life activities like participating in organizations, infor-
satisfaction and functional decline, particularly mal activities such as getting together with
when the event, such as retirement, is not the friends, or solitary activities such as reading
individuals choice. According to activity theory, the greater the role support one will receive. The
people should nd substitute roles for the work more role support one receives, the greater the
and parenting roles they left behind in mid-life in contribution to a positive self-concept, leading,
order to maintain their sense of self-worth. Active in turn, to higher life satisfaction in later life. Six
engagement in new social roles appropriate for hypotheses were derived from these axioms and
older adults volunteering, grandparenting is tested with data. Only one high levels of infor-
further reinforced by cultural norms, fostering mal social activity such as with friends, family,
personal feelings of self-worth and higher life and neighbors was positively related to life
satisfaction in older age (Lemon et al. 1972; satisfaction for elderly persons. Other activity
Havighurst 1961). types high formal activity in organizations, for
Activity theory was rst proposed based on example; or high solitary mental activity such as
empirical evidence by Havighurst and Albrecht reading were not signicantly related to life
in their 1954 book, Older People (Havighurst satisfaction (Lemon et al. 1972).
and Albrecht 1953). Their data, drawn from the In 1982, Longino and Kart replicated the
rst large-scale American social survey of the Lemon et al. (1972) study using a more socioeco-
elderly, showed that older adults who participated nomically diverse sample (to avoid its possible
in appropriate social roles for the aged, like spend- middle-class bias) and included more in-depth
ing time with grandchildren and attending church, measures of activity (asking respondents to recon-
were happier and more adjusted in later life than struct the previous days activities from morning
those who were not similarly engaged in social through bedtime). They found, again, that infor-
roles. Thus, social engagement was seen as a mal social activities with friends and family had a
causal factor in maintaining high levels of adjust- positive effect on life satisfaction in all socioeco-
ment, or life satisfaction, in the later years. nomic groups, but that formal activities such as
Activity theory was labeled an implicit the- attending group meetings were negatively associ-
ory of aging (Havighurst 1961) because it natu- ated with life satisfaction. Solitary activities, like
rally guided most medical and social work reading, writing and watching television, had no
practice in the Post World War II era and still effect (Longino and Kart 1982).
does, to some extent, since it so well reects Reitzes, Mutran, and Verrill extended activity
American values of productivity and the desire theory using more direct measures of role support
to remain youthful (Bengtson and Kuypers and examined whether certain activity types
1971). Activity theory offered a conceptual justi- increase self-esteem in later life (Reitzes
cation underlying many programs for the elderly, et al. 1995). Only leisure activities were
inuencing the passage of the Older Americans positively associated with self-esteem. There
Act in 1965. were considerable gender differences mediating
the relationships; that is, for men, solitary activi- he belongs to (Cumming and Henry 1961). This
ties were signicantly related to positive self-esteem, was the rst formal attempt to explain normal or
and for women, activities with relatives and work successful late life development from a perspec- A
friends were signicant as were other types of activ- tive that combined psychodynamics with social
ities when commitment to the role was high. systems analysis in the tradition of Durkheim and
Further support for Lemon et al.s (1972) study Talcott Parsons. Adults who disengaged were
of activity theory was found in an English context. viewed as well adjusted; those who did not were
Knapp (1977) found a signicant relationship social impingers (Cumming 1963).
between informal activity (the hours per week The ideas of disengagement theory were rst
spent with friends and family) and life satisfac- articulated by Cumming and Henry in 1959, a few
tion, but the association between formal activities years after they had joined Havighursts Univer-
and solitary activities with life satisfaction was sity of Chicago team. Cumming, a sociologist,
weak (Knapp 1977). More recently Zaraneck and Henry, a psychoanalyst, developed their con-
and Chapeleski (2005) reported some support for cepts while analyzing data from Havighursts
the theory in a study of casino gambling as a social Kansas City Study of Adult Life, an interdisci-
activity among urban elderly, although partici- plinary community-based investigation to
pants who visited the casino most frequently examine health, employment, leisure, and
(monthly or more) reported poorer social support civic participation activities of older adults
and less participation in other social activities than (Achenbaum and Bengtson 1994).
the infrequent gamblers (Zaranek and Chapleski The concept of disengagement reected Durk-
2005). heimian functionalist theory by way of Talcott
In short, it is surprising that so few empirical Parsons, which was the reigning theoretical para-
studies to date have tested the principal assertion digm in American sociology in the 1950s and
of activity theory that maintaining levels of 1960s. According to disengagement theory, as
socio-emotional engagement is associated with a individuals age there is a gradual but inevitable
sense of life satisfaction among older individuals. constriction in social life space, evidenced by
This is the basis of the activity theory of aging, yet declines in the number of social partners and
only engagement in informal activities has frequency of social interactions. At the same
received sufcient empirical support, suggesting time there is withdrawal from social institutions
that different forms of activity have a different (transition from work to retirement). Disengage-
impact on life satisfaction. Despite lack of robust ment, therefore, is functional for both the social
evidence for all types of activity participation, this system and for the individual: It prepares society
perspective is still the predominant view of how to for the loss of the individual through the disen-
age successfully in the United States. Activity gagements of retirement and then death; it pre-
theory ts well with American cultural values pares the individual for death through progressive
(Keep active! Be productive!) and has received disengagement from society (role loss). Thus,
new life in recent years within the much- through this process of mutual withdrawal there
publicized successful aging paradigm reviewed is no disruption to the social equilibrium
at the end of this chapter. (Cumming and Henry 1961; Cumming 1963;
Achenbaum and Bengtson 1994).
According to Cumming and Henry, disengage-
Disengagement Theory ment is partially explained by older adults inter-
nalization of Western cultural values that esteem
In Growing Old (1961), Elaine Cumming and youth over age primarily vitality, productivity,
William E. Henry described disengagement as, and efciency. Withdrawal is thus regarded as an
An inevitable mutual withdrawal or disengage- obligation to the functional maintenance of the
ment, resulting in decreased interaction between social system because it allows younger genera-
the aging person and others in the social systems tions to replace older adults in positions of
18 Activity Theory, Disengagement Theory, and Successful Aging
increasing power and importance. Disengagement conceptual critique, arguing that disengagement
is also caused by increasing physical frailty and by theory was non-falsiable individuals who
psychological changes involving a greater interi- didnt disengage were simply labeled unsuccess-
ority of experiencing a psychic turning inward. ful and maladjusted, rather than considered as
According to Growing Old, the process is inevi- counter evidence to the theory. In addition, disen-
table, irreversible, and universal it happens to gagement theory presents a deterministic view of
older people in all cultures and throughout all time successful aging. It assumes that if older adults
periods (Cumming and Henry 1961). willingly disengage, that this is advantageous to
The reception disengagement theory received both them and to society (Hochschild 1975).
from the gerontological community was This barrage of criticism left disengagement
immediate and negative, particularly among theory with few researchers who appeared moti-
sociologists. Maddox (1964) criticized Cumming vated to test or modify the theory further, and the
and Henrys claim that disengagement theory is term disengagement theory appears very seldom
intrinsic and inevitable, noting the considerable in current gerontological research literature. How-
variability between study participants in the indi- ever, its development represented an important
cators of psychological and social disengagement historic milestone in gerontology. As a theory, as
once age was held constant (Maddox 1964). Rose an explanation for normal human aging, it was
(1964) was concerned with the ethnocentric parsimonious, data driven, and logically
assumption that disengagement is universal explicit in short, scientic. The upshot of the
across societies and across time. He contended disengagement theory is that it set the stage for the
that disengagement emerged as a function of formulation of other gerontological theories
American culture, arising from Western trends in (Achenbaum and Bengtson 1994), most notably
longevity and institutions like Social Security that Socioemotional Selectivity Theory (Carstensen
created a new and special role for the aged (Rose 1995), which represents in some respects a logical
1964). Neugarten (1969) herself a part of the extension of disengagement theory. Carstensen
University of Chicago research team but who (1995) noted that the declines and withdrawals
was critical of her colleagues psychoanalytic were not universal across all realms of engage-
focus, suggested that disengagement theory ment, but rather selective as older people decided
ignored the heterogeneity of older people noting where to place their emotional bets and where to
that the Kansas City panel was comprised largely cut their losses. This involved socioemotional
of White, upper-middle class adults. She also selectivity, a process by which older people opti-
claimed that disengagement theory discounted mize coping strategies (Carstensen 1995).
the impact of social status and social structure on
the aging experience (Neugarten 1969). Bengtson
(1969) questioned the functionalist assumptions Successful Aging as a Concept or Theory
of the universalistic processes of disengagement.
Using data from a subsequent University of Chi- In 1961, Robert Havighurst published a journal
cago cross-national study of aging directed by article that introduced the term successful aging
Havighurst and Neugarten, Bengtson showed to the gerontological literature (Havighurst 1961);
that disengagement was not universal across soci- 28 years later, John Rowe and Robert Kahn
eties nor across occupational groups of retirees. published their immensely-successful book by
Instead, there were a variety of socio-emotional the same title, Successful Aging (Rowe and Kahn
activity patterns some high, some low that 1998). Havighursts conception of successful
linked to high levels life satisfaction (Bengtson aging is reected in the activity theory summa-
1969). rized above (Lemon et al. 1972; Havighurst
Fifteen years after its initial statement, the 1961). Many of these same ideas are reected in
debate over disengagement theory was still Rowe and Kahns formulations for successful
going strong. Hochschild (1975) presented a aging (Rowe and Kahn 1987, 1998).
Rowe and Kahn (1998) argued that most sociological and psychological processes to bio-
research on aging normalizes the disease process logical outcomes: an expansion of Havighursts
as a natural part of growing old but does not early conception of successful aging. Also, A
sufciently account for differences in lifestyle, Rowe and Kahns ideas reect the growing focus
nutrition, exercise, social support, and social on life course theories of aging, including cumu-
structure that moderate the effects of aging and lative advantage/disadvantage theories that guide
determine the extent to which a person becomes much of the research on individual aging today.
disabled or ill. They classied normal aging as
either usual or successful. In usual aging, extrinsic
factors such as poor diet, lack of exercise, and Conclusion
poverty accelerate the effects of aging alone;
whereas in successful aging, extrinsic factors Activity theory, disengagement theory, and suc-
play a neutral or positive role. These two path- cessful aging advanced the eld of gerontology in
ways are differentiated by extrinsic factors only; important ways. First, all three perspectives focus
Rowe and Kahn argue that there are no intrinsic attention on normative and positive aging, rather
factors innately linked to chronological age. In than aging as a disease. In the 1960s, disengage-
other words, disease and disability are age related, ment and activity theories shifted the medical/
not age dependent. physiological focus on human aging to research
Rowe and Kahn (1998) suggest that the exploring the social and emotional lives of older
three components of successful aging are adults. Decades later, Rowe and Kahns success-
(1) avoiding disease, (2) engagement with life, ful aging paradigm combined the biological
and (3) maintaining high physical and mental aspects of aging with psychosocial factors,
functioning. A person can meet these three criteria thereby advancing interdisciplinary perspectives
by eating healthy foods, exercising regularly, and on aging and promoting the application of
remaining socially and intellectually active life course and developmental theories to
through close interpersonal relationships and pro- gerontology.
ductive activities that provide meaning to the Whereas the scientic community quickly
older person. A major tenet of the successful dismissed disengagement theory, the principles
aging paradigm is that aging is plastic; that is, of activity theory mainly that older adults should
individuals have the capacity to modify their stay active to remain satised with life gained
aging trajectory through changes in lifestyle, momentum and inuence much of the research on
nutrition, and other behaviors. aging today. Activity and successful aging theo-
While Rowe and Kahn (1998) emphasize ries profoundly inuenced public policy and the
activity and social engagement as components of development of health and social services for the
successful aging, they do not acknowledge aged. The ideas also guide popular discourse on
Havighursts prior theoretical work in activity how people can successfully adapt to the
theory nor the empirical work that failed to sup- changes associated with aging, reected in our
port activity theory. They also fail to explicitly cultures persistent desire to remain t, produc-
discuss the contributions of disengagement the- tive, and mentally sharp. In addition to shaping
ory, or how social structures and economic forces policy, disengagement, activity, and successful
act to expand or constrict an individuals ability to aging theories helped establish gerontology as a
age successfully according to their three princi- discipline and older age as a unique stage of life.
ples. These are agendas for future work on the
successful aging paradigm.
Rowe and Kahns work transcended the aca- References
demic community and was immensely popular
among general audiences. A major contribution Achenbaum, W. A., & Bengtson, V. L. (1994).
of their ideas is that they explicitly linked Re-engaging the disengagement theory of aging: On
20 Adaptive Resources of the Aging Self, Assimilative and Accommodative Modes of Coping
the history and assessment of theory development in

gerontology. The Gerontologist, 34(6), 756763. Adaptive Resources of the Aging Self,
Bengtson, V. L. (1969). Cultural and occupational differ-
ences in level of present role activity in retirement. In Assimilative and Accommodative
R. J. Havighurst, J. M. A. Munnichs, B. L. Neugarten, Modes of Coping
& H. Thomae (Eds.), Adjustment to retirement: A cross-
national study (pp. 3553). Assen: Van Gorkum. Jochen Brandtstdter
Bengtson, V. L., & Kuypers, J. A. (1971). Generational
difference and the developmental stake. The Interna- Department of Psychology, University of Trier,
tional Journal of Aging and Human Development, 2(4), Trier, Germany
249260.
Carstensen, L. (1995). Evidence for a life-span theory of
socioemotional selectivity. Current Directions in Psy-
chological Science, 4, 151156. Synonyms
Cumming, E. (1963). Further thoughts on the theory of
disengagement. International Social Science Journal, Adaptation to disability and loss; Benet nding;
15(3), 377393. Flexibility; Goal adjustment; Goal pursuit; Resil-
Cumming, E., & Henry, W. E. (1961). Growing old: The
process of disengagement. New York: Basic Books. ience; Sources of meaning; Tenacity
Havighurst, R. J. (1961). Successful aging. The Gerontol-
ogist, 1(1), 813.
Havighurst, R. J., & Albrecht, R. E. (1953). Older people. Definition
New York: Longmans, Green.
Hochschild, A. R. (1975). Disengagement theory:
A critique and proposal. American Sociological Resilience and well-being across the life-span
Review, 40(5), 553569. hinge on the balanced interplay between two
Knapp, R. J. (1977). The activity theory of aging: An adaptive processes: On activities through which
examination in the English context. The Gerontologist,
17(6), 553559. individuals try to achieve goals and maintain a
Lemon, B. W., Bengtson, V. L., & Peterson, J. A. (1972). desired course of personal development
An exploration of the activity theory of aging: Activity (assimilative activities), as well as on the adjust-
types and life satisfaction among in-movers to a retirement of personal goals to changing action
ment community. Journal of Gerontology, 27(4),
511523. resources (accommodative processes). The con-
Longino, C. F., & Kart, C. S. (1982). Explicating activity cepts of assimilative persistence (or tenacious
theory: A formal replication. Journal of Gerontology, goal pursuit) and accommodative exibility
37(6), 713722. (or exible goal adjustment) refer to individual
Maddox, G. L., Jr. (1964). Disengagement theory:
A critical evaluation. The Gerontologist, 4, 8082. differences in these two modes of coping.
Neugarten, B. L. (1969). Continuities and discontinuities A persons life course is generally a mixture of
of psychological issues into adult life. Human Devel- intended action outcomes and unintended events,
opment, 12, 121130. of gains and losses; the balance of these factors
Reitzes, D. C., Mutran, E. J., & Verrill, L. A. (1995).
Activities and self-esteem continuing the varies on historical as well as in individual-
development of activity theory. Research on Aging, ontogenetic dimensions of time. Given this gen-
17(3), 260277. eral fact about personal development, notions of
Rose, A. (1964). A current theoretical issue in social ger- positive development and successful aging cannot
ontology. The Gerontologist, 4, 456460.
Rowe, J. W., & Kahn, R. L. (1987). Human aging: Usual be simply dened in terms of efcient goal pursuit
and successful. Science, New Series, 237(4811), and avoidance of loss. Rather, a comprehensive
143149. theoretical explication of these concepts also
Rowe, J. W., & Kahn, R. L. (1998). Successful aging. New needs to consider how people cope with diver-
York: Pantheon Books.
Zaranek, R. R., & Chapleski, E. E. (2005). Casino gences between desired and factual developmen-
gambling among urban elders: Just another social activ- tal outcomes, how they adjust goals and ambitions
ity? Journal of Gerontology Social Science, 60B, to changing developmental resources and con-
S74S81. straints, and how they can disengage without
Adaptive Resources of the Aging Self, Assimilative and Accommodative Modes of Coping 21
lasting grief or regret from desired life paths that self and personal development. In developmental
have remained unaccomplished. settings and phases of life that involve changes in
Among older adults, personal potentials of personal resources of control, the balanced inter- A
action and development are often constrained by play between assimilative and accommodative
functional losses, by a shrinking of social and processes becomes a key criterion of resilience;
material resources, and not to the least by the old age is a prototypical example.
fading of time yet-to-be-lived. Contrary to expec-
tations, however, longitudinal and metaanalytic
studies have found considerable stability in mea- Outline of the Dual-Process Model
sures of well-being and subjective life quality in
the transition to old age (Brandtstdter et al. 1993; The model of assimilative and accommodative
Diener et al. 1999). The apparent resiliency of the coping braids together action-theoretical and
aging self against experiences of loss and con- developmental perspectives. Both processes are
straint may be considered as a further example of basic to the life-long process of intentional self-
the so-called paradoxes of satisfaction that have development (Brandtstdter and Lerner 1999;
often been reported in research on well-being and Greve et al. 2005). In contrast to assimilative
happiness; it becomes less paradoxical when pay- activities, however, accommodative processes
ing heed to the dynamics of changing and need not, and often cannot, be intentionally
adjusting ambitions and to the interplay between activated. Although one may eventually be able
goal pursuit and goal adjustment. to change personal preferences, ambitions, or
To integrate these aspects, the dual-process beliefs by strategies of self-management (which
model of assimilative and accommodative coping would already count as assimilative activities),
(DPM) has been proposed (Brandtstdter 2006; one cannot bring about such changes by a simple
Brandtstdter 2007; Brandtstdter and act of will. This draws attention to the automatic
Greve 1994; Brandtstdter and Renner 1990; mechanisms that subserve accommodative
Brandtstdter et al. 1998). Both modes of coping processes.
reduce goal discrepancies and divergences Assimilative activities: Assimilative activities
between actual and desired conditions of personal comprise all types of intentional behavior through
development, but do so in different ways. In the which people try to achieve or maintain a desired
assimilative mode, the individual tries to avoid or course of personal development; in later life,
diminish goal discrepancies and developmental maintenance of resources and valued compe-
losses by instrumental, self-corrective, or com- tences through prevention or compensation of
pensatory activities. A second way of neutralizing loss become increasingly important as targets of
discrepancies between actual and desired states assimilative effort. In the assimilative mode,
consists in adjusting goals and ambitions to attention is focused on information that seems
given situational conditions and constraints. relevant for effective goal pursuit, and cognitions
These latter accommodative processes involve that support or help to maintain an intended course
disengagement from blocked goals and the low- of action become more available: Attractive
ering of aspirations; they come into play when aspects of the goal as well as beliefs related to
active-assimilative efforts become difcult or personal efcacy and the attainability of goals are
remain futile. emphasized, whereas stimuli or enticements that
The frame of personal goals and ambitions on could distract from a chosen course of action are
which people base their evaluation of self and blunted out. When obstacles impede goal attain-
personal development changes over the life ment, cognitive resources and action reserves are
course; according to the DPM, it tends to change mobilized, which is often supported by a reactant
in ways that help to maintain a positive outlook on increase in the valence of goals.
A key feature of assimilative modes of coping mode is the exible adjustment of goals and ambi-
is the tenacious adherence to goals. Assimilative tions to losses and constraints as they arise from
efforts will have benecial effects as long as per- age-graded as well as from historical changes, but
sonal goals are commensurate with action likewise from critical life events that affect phys-
resources; in cases of mismatch, the intentional ical, social, and material resources.
focus of assimilation may shift toward expanding As regards cognitive mechanisms, the accom-
action resources and acquiring new skills or modative mode involves an increased availability
knowledge that may be relevant to efcient goal of cognitions that shed doubt on the attractiveness
pursuit, and eventually to activities of optimiza- and attainability of the blocked goal, thus enhanc-
tion or compensation. Optimizing and compensa- ing a positive reappraisal of the given situation.
tory activities mark a late state of assimilative A heuristic-divergent, bottom-up mode of infor-
effort; they often draw on resources that are them- mation processing supersedes the more top-down,
selves subject to age-graded loss. Under condi- convergent mindset that characterizes assimila-
tions of progredient loss and constraint, tion; the attentional eld widens and becomes
assimilative efforts may rst increase, but then responsive again to stimuli and action tendencies
drop gradually when the costs of further goal that have been warded off in the assimilative
pursuit outweigh the benets (Brandtstdter and phase.
Rothermund 2003; Brandtstdter and Wentura Moderating conditions: Problems of depres-
1995). sion and rumination indicate that the shift from
According to prevailing clinical notions, feel- assimilative to accommodative modes of coping
ings of helplessness and depression arise when is not always a smooth one. The DPM species
goals and desired self-representations drift out of personal and situational conditions that may
the feasible range; from the perspective of the selectively enhance or impede the two modes of
dual-process model, however, this is the critical coping. Generally, people nd it more difcult to
point where the system shifts toward give up goals that are central to their identity and
accommodation. not easily substitutable by equivalent alternatives.
Accommodative processes: The attractive A high degree of self-complexity, i.e. a diversied
valence of goals largely derives from their relation and multifocal structure of personal projects, can
to other goals and values; eventually goals may thus enhance accommodation. Furthermore,
remain attractive even when the individual sees no availability of cognitions that supports a positive
way to attain them. Maintaining a commitment to reappraisal of initially aversive circumstances, as
barren goals, however, becomes maladaptive well as low beliefs of control over the critical
when it impedes reorientation toward other more situation, facilitate the accommodative process,
promising goals. Accommodative processes but weaken the motivation to invest assimilative
counteract such states of escalated commitment. effort. People harboring strong self-beliefs of
While assimilative activities are driven by the control are typically more enduring to reach a
hedonic difference between current situations goal and to overcome obstacles; at the same
and intended goal-states, the adaptive function of time, however, they are more prone to
accommodative mode essentially consists in unproductive persistence and more likely to miss
deconstructing this difference. Facets of accom- alternative options. While partly converging with
modative coping include the downgrading of, and theoretical positions that emphasize the benets of
eventually disengagement from, blocked goals, as strong self-beliefs of control, the DPM also
well as a rescaling of ambitions and self- highlights potential negative effects. Such side-
evaluative standards processes that promote effects may also account for counterintuitive nd-
the readiness to accept given circumstances and ings of positive correlations between measures of
redirect action resources toward new goals. In perceived control and depression (e.g., Coyne
sum, the key characteristic of the accommodative 1992).
Implications for Successful Aging which points to an increasing dominance of

accommodative over assimilative modes of cop-
Although assimilative and accommodative pro- ing in late adulthood. Considering the fading of A
cesses are antagonistically related, they can syn- action resources and the cumulation of irrevers-
ergistically complement each other in concrete ible losses in later life, this pattern conforms to
episodes of coping: Problems such as bodily theoretical predictions. A broad array of ndings
impairment, chronic illness, or bereavement con- attests to the particular importance of accommo-
stitute a multifaceted complex of problems that dative exibility for coping with age-typical prob-
often call for different ways of coping. Under lems. In moderated regression analyses, FGA has
limited action resources, disengagement from been found to dampen the negative emotional
some goals can also facilitate the maintenance of impact of losses and constraints; such buffering
other, more central ones. Conicts between assim- effects have emerged with regard to bodily
ilative and accommodative tendencies may occur impairments, health problems, losses in sensory
when goal-related efforts reach capacity limits. functions, chronic pain, and problems of bereave-
Such critical constellations often arise in late life, ment (e.g., Boerner 2004; Darlington et al. 2007;
when questions of how, and into which projects, Kranz et al. 2010; Seltzer et al. 2004; Van Damme
scarce action resources and life-time reserves et al. 2008). Flexible individuals adjust their
should be invested become an acute concern. desired self more stringently to their actual self,
When important goals are at stake, the wavering and negative experiences in specic areas of life
between holding on and letting go is experienced compromise the overall sense of well-being to a
as stressful. The accommodative process, how- lesser degree among individuals scoring high
ever, engages cognitive mechanisms that eventu- in FGA.
ally dissolve such conicts. A tendency to nd benets in adversity has
Dispositional differences: Individuals differ in been reported for cancer patients, accident vic-
the degree to which they prefer, or tend to use, tims, and other disadvantaged groups (Afeck
assimilative or accommodative ways of and Tennen 1996). The DPM, however, does not
coping and life-management. To assess such imply a general tendency toward benet nding.
interindividual differences, two scales are used: Positive reappraisals of an aversive situation
Tenacious Goal Pursuit (TGP) as a measure of would inhibit active problem-solving efforts;
assimilative persistence and Flexible Goal Adjust- accordingly, the DPM proposes that palliative
ment (FGA) as a measure of accommodative ex- cognitions are more strongly expressed in the
ibility. TGP and FGA constitute largely accommodative mode when aversive circum-
independent facets of coping competence, show- stances seem irreversible. In line with these
ing slightly negative or close to zero intercorrela- assumptions, higher scores in the FGA were
tions in most studies. Across all age levels, found to predict an increased availability of
however, both scales show substantial positive uplifting thoughts when subjects are confronted
correlations with measures of subjective life qual- with threatening scenarios. Furthermore, exible
ity such as satisfaction, optimism, self-esteem, individuals are less negatively affected by the
or emotional stability (Brandtstdter 2006; prospect of fading life-time reserves, and conno-
Brandtstdter and Renner 1990). Assimilative tations of being old become more positive with
persistence and accommodative exibility appar- advancing age (Rothermund et al. 1995; Wentura
ently improve the affect balance in different ways; et al. 1995).
while TGP seems to enhance positive affect, FGA Although accommodative processes are trig-
dampens negative affect (Coffey et al. 2014; Heyl gered by a loss of control over particular goals,
et al. 2007). they can contribute to maintaining self-beliefs of
At the same time, however, TGP and FGA control in later life. Notions of self-efcacy and
show opposed regressions on the age variable, control imply condence in the attainability of
personally important goals; when such goals are to nd solutions to given problems; when it yields
no longer attainable, reducing their importance no results, however, attainability beliefs should be
can thus help to preserve a general sense of ef- weakened and accommodative tendencies be
cacy. Considering the age-related increase of activated. The TGP and FGA scales predict
accommodative tendencies, this rationale can corresponding differences in ruminative styles;
account in part for the stability of self-percepts among people disposed toward assimilative per-
of control in later life, which has repeatedly been sistence, ruminative thought primarily revolves
reported (e.g., Grob et al. 1999). around possible problem solutions, whereas it
Over the life span, exible goal adjustment seems more strongly oriented toward positive
also enhances developmental transitions and role reappraisal and benet nding among exible indi-
changes, which often require a restructuring of viduals (see Brandtstdter 2007; Brandtstdter and
goals and life plans. For example, people scoring Rothermund 2002).
high in FGA have fewer difculties to adjust their Counterfactual emotions, regret: Feelings of
goals and maintain personal well-being after anger, disappointment, or regret typically occur
retirement; this holds in particular when goal when one believes that a given undesired course
changes are in accordance with the demands of of events was avoidable; thus, they can help to
the new situation (cf. Nurmi and Salmela-Aro avoid similar mistakes in the future. Moreover,
2002; Trpanier et al. 2001). anticipated regret can shield goal pursuit against
Further implications of the DPM for positive situational enticements; such anticipations typi-
development and successful aging concern issues cally tend to overpredict the strength and duration
of depression, rumination, and regret. of regret (Gilbert and Wilson 2000). From the
Depression and rumination: People harboring perspective of the DPM, this bias can be explained
strong self-beliefs of personal control and efcacy as a joint result of the tendency to accentuate the
are more persistent in their efforts to cope with aversiveness of failure during goal pursuit, and of
stressful events, and are less vulnerable to depres- processes that reduce attractiveness of goals after
sion; the positive relationship of the TGP scale such failure.
with measures of well-being converges with this Feelings of disappointment and regret indicate
well-established assumption. The DPM suggests a persisting attachment to opportunities and goals
that another important risk factor that contributes that have remained unachieved; they tend to lose
to strength and duration of depressive episodes is their adaptive value in late life when repairing past
the inability or reluctance to let go of barren goals mistakes becomes more difcult. In the process of
and life projects. At the same time, however, the life-review, accommodative exibility can thus
model highlights possible adaptive functions of help coming to terms with untoward biographical
depressive mood states: The behavioral inhibition outcomes. In line with this assumption, the FGA
that typically accompanies them can weaken scale has been found to dampen ruminative regret;
unproductive persistence and the escalating of this effect is particularly strong when mistakes
commitment. Furthermore, a mindset of depres- seem irreversible (cf. Brandtstdter 2006;
sive realism tones down positively biased assess- Brandtstdter and Rothermund 2002).
ments of personal efcacy and of the benets of
goal attainment, biases which support assimilative
persistence. From this theoretical perspective, Accommodating Meaning Perspectives
depressive reactions not only indicate problems and Final Decentration
of shifting from assimilative to accommodative
modes of coping, but at the same time can mediate Our activities gain motivating meaning from
this shift. future-related projects; we generally assume that
Similar arguments apply to processes of rumi- we will experience the outcomes of our actions
nation, which often are part of the depressive and decisions. When this basic assumption
syndrome. Ruminative thinking eventually helps becomes questionable, personal goals and
existential orientations should be profoundly disengagement (e.g., Baltes and Staudinger 2000;
affected. Loss of future meaning can breed feel- Wink and Helson 1997) or, as one could also put
ings of depression and void; accommodating per- it, between assimilative and accommodative A
sonal goals and life-plans to fading life-time modes of life-management and coping.
reserves prevents such consequences. More spe-
cically, the experience of a shrinking personal
future should induce tendencies to de-emphasize, Conclusion
and eventually disengage from, goals centering
primarily on future benets. At the same time, it The model of assimilative and accommodative
can promote an orientation towards more intrin- coping suggests that resiliency and well-being in
sic, time-transcendent sources of meaning; moral later adulthood basically depend on the interplay
or religious ideals, as well as altruistic and socio- of two adaptive processes: On activities that aim
emotional strivings, may be considered as at preventing losses and maintaining a desired
examples. course of personal development, as well as on
Questionnaire studies in fact suggest that in the the exible adjustment of personal goals and
transition to old age, strivings of power, achieve- ambitions to situational constraints. These adap-
ment, and competence are increasingly outranked tive processes are functionally antagonistic, but
by goals related to spirituality, altruism, and inti- not mutually exclusive; rather, they constitute
macy. Accommodation-theoretical perspectives complementary modes of maintaining self-
suggest that the shift toward intrinsic, value- continuity and self-esteem. The model applies to
related goals primarily depend on an increasing the entire life span; it species moderating condi-
awareness of lifes nitude. This is substantiated tions affecting the two basic processes of coping
by experiments with younger samples where mor- and the balance between them, thus providing a
tality was made salient by a questionnaire that basis for explaining individual differences in cop-
addressed issues of death and dying (e.g., how ing with developmental transitions, functional
one would deal with a serious illness). Effects on losses, and critical life events. The explanatory
subsequently assessed value orientations were range of the model extends to phenomena of ben-
largely similar to age-related effects, suggesting et nding, rumination, regret, as well as to issues
a weakening of individualistic and egocentric of wisdom and self-transcendence.
strivings; at the same time, tendencies of
assimilative-offensive coping were signicantly
reduced (cf. Brandtstdter 2007; Brandtstdter
et al. 2010). It is of note that clinical studies with Cross-References
patients suffering a terminal illness have reported
a similar change toward unselsh, altruistic goals Aging and Psychological Well-Being
(e.g., Coward 2000). Life Span Developmental Psychology
A growing awareness of lifes nitude in later Psychology of Wisdom
life thus seems to enhance an orientation toward Self-Theories of the Aging Person
timeless, self-transcendent values; this particular
accommodative process has been denoted as
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Advocacy with Older Adults 27
Wentura, D., Rothermund, K., & Brandtstdter, J. (1995). policy and advocacy efforts across the profes-
Experimentelle Analysen zur Verarbeitung belastender sional lifespan. In fact, several recent professional
Informationen: differential- und alternspsychologische
Aspekte [Experimental studies of the processing of guidance documents have included specic refer- A
negative information: Differential and age-related ence to policy and advocacy as important compo-
aspects]. Zeitschrift fr Experimentelle Psychologie, nents of competency in geropsychology. First,
42, 152175. Guideline 2.0 of the American Psychological
Wink, P., & Helson, R. (1997). Practical and transcendent
wisdom: Their nature and some longitudinal ndings. Association (APA) Guidelines for Psychological
Journal of Adult Development, 4, 115. Practice with Older Adults (2013) states Psy-
chologists strive to be knowledgeable about pub-
lic policy, state and federal laws and regulations
related to the provision of and reimbursement for
Advocacy with Older Adults psychological services to older adults and the
business of practice. The health care landscape
Deborah A. DiGilio1 and Diane Elmore2 continues to change. Psychologists who serve
1 older adults are encouraged to be alert to changes
American Psychological Association,
Washington, DC, USA in health care policy and practice that will impact
2 their professional work including practice estab-
Policy Program, UCLA-Duke University
National Center for Child Traumatic Stress, lishment, state laws that govern practice, potential
Washington, DC, USA for litigation, and reimbursement for services
(American Psychological Association 2014).
Next, the Pikes Peak Model for Training in Pro-
Synonyms fessional Geropsychology includes language that
urges geropsychologists to apply scientic
Advocacy; Inuencing policy; Political action; knowledge to geropsychology practice and policy
Political engagement advocacy which is viewed as a leadership skill to
be encouraged through training, mentoring, and
Psychologists have signicant training in science career development (Knight et al. 2009). Increas-
and/or clinical practice but often have less formal ingly, the geropsychology community is incorpo-
preparation and hands-on experience in policy rating policy engagement and advocacy as a
and advocacy. While most psychologists have key component of professional identity and
not received formal training in policy and advo- competence.
cacy, an understanding of and involvement in
policy and advocacy activities can have a positive
impact on their professional identities and on the How Can Geropsychologists Engage in
lives of the older adults whom they serve. Such Advocacy?
policy and advocacy engagement can also help to
raise awareness of the contributions of psycholog- There are several key elements of getting involved
ical research and clinical practice in meeting the in advocacy, including identifying policy issues of
needs of older adults and marshal much needed interest, communicating and developing relation-
resources for this growing segment of the popula- ships with policymakers, providing scientic and
tion in the USA and around the world. clinical expertise to inform the policymaking pro-
cess, and participating in political activities
(American Psychological Association 2012). Pol-
The Role of Policy and Advocacy in icy engagement and advocacy may occur at the
Geropsychology local, state, national, and international levels.
Many geropsychologists work individually
Professional psychology and geropsychology, in and with colleagues to advocate for improvements
particular, have identied an important role for in health and aging policies in their states and
28 Advocacy with Older Adults
localities. At the local level, geropsychologists its aging divisions and sections, other professional
serve on advisory boards of organizations such organizations such as Psychologists in Long-
as the Alzheimers Association, senior centers, Term Care and the Gerontological Society of
and Area Agencies on Aging and connect with America, and national coalitions such as the
their legislators in their communities. APAs Sci- Elder Justice Coalition, the Eldercare Workforce
ence Directorate is building upon this focus of Alliance, and the National Coalition on Mental
developing local connections with its Stand for Health and Aging.
Science campaign in which advocacy-trained Next, engagement from the geropsychology
scientists meet face-to-face with their legislators community on critical legal issues being consid-
in their local ofces or bring legislators and staff ered before the courts or by judicial and legal
in to tour their campus research labs. It is hoped reform task forces has also served as an important
that the real-world value of the research that form of advocacy. These efforts often occur in
policymakers are exposed to during such interac- collaboration with professional organizations or
tions will help them better understand psycholog- other stakeholder groups with common interests.
ical sciences contributions to improving health Geropsychologists can participate in the prepara-
and vitality. tion and submission of amicus briefs, which are
Geropsychologists also work alongside friend of the court briefs that an individual or
national organizations to impact aging policy at group who has an interest in the matter (but who is
the national level. They have and continue to play not a party to a lawsuit) can petition with the intent
an important role in informing and inuencing the of inuencing the courts decision. In addition,
development and implementation of federal laws psychologists can utilize psychological science
and initiatives related to the provision of health to inform policy change in elder law at the state
and aging services and support for aging research. and local levels. For example, psychologists
They urge policymakers to modify existing law or representing APA collaborated with the American
enact new laws to support psychologists in Bar Association and the National College of Pro-
addressing the needs of the older adults whom bate Judges to develop a series of handbooks,
they serve. The geropsychology community has including Judicial Determination of Capacity of
also been active in commenting on draft strategic Older Adults in Guardianship Proceedings
plans of government agencies and institutes to (American Bar Association Commission on
direct greater attention to, and funding of, aging- Aging et al. 2008). This document in turn helped
related programming and behavioral and social to inform development of a more detailed medical
science research. Examples of such advocacy certicate (guardianship and conservatorship
include efforts to improve psychologist reim- evaluation form) in the state of Massachusetts
bursement rates under Medicare, amend the effective in 2009, which requires information rel-
Older Americans Act to include a greater mental ative to the clinical diagnosis, decision-making
health services authority, expand the focus of the impairment, and functional impairment of the
rst National Plan to Address Alzheimers Dis- individual, as well as the individuals values and
ease to include greater attention to the critical social and risk factors and the interaction of the
behavioral and social aspects of this disease, and individual with his or her environment. Templates
authorize a comprehensive federal approach to and processes from the handbook are now being
combating elder abuse and neglect. In addition, utilized in other states as well as probate courts in
over the last four decades, psychologists have Canada and Australia to assist in the determina-
worked to inform and inuence White House tion of whether older adults retain their rights to
Conferences on Aging (WHCoA), an important self-determination.
forum designed to develop recommendations for The psychology and aging community also
research and actions related to aging. Organiza- engages in policy development and advocacy at
tions that play a leadership role in national aging the global level. These opportunities include par-
policy and advocacy in the USA include APA and ticipation in efforts of the United Nations
(UN) and its Committee on Ageing, the Interna- aware of these issues, others are just beginning
tional Association of Gerontology and Geriatrics, to learn about the important role of psychologists
and HelpAge International. Professional organi- as clinicians, researchers, and educators. Other A
zations, such as the APA and others, are health professionals such as physicians and nurses
accredited nongovernmental organizations are well known to policymakers and are often
(NGO) at the UN. This designation affords such considered primary experts on health care for
groups special consultative status with the UN older persons. Signicant work remains to edu-
Economic and Social Council (ECOSOC), cate and inform policymakers about the valuable
among other benets. APA appoints psycholo- expertise offered by psychologists and the range
gists to represent the organization within the of services they provide to older adults and their
NGO community at the UN headquarters in New families, both independently and as members of
York. These representatives work to identify interprofessional clinical care and research teams.
issues, organize programs and draft statements This work can best be carried out by psychologists
that bring psychological science and a psycholog- who are uniquely qualied to serve as effective
ical perspective to bear on global policies and advocates for the eld and the populations whom
programs, foster dialog and information exchange they serve. In order to gain necessary recognition
between psychologists/APA and UN diplomats/ and support, psychologists must actively engage
UN agencies, and serve as APAs conduit for in education and advocacy with policymakers as a
information about the UN (American Psycholog- core component of their professional identity.
ical Association 2015a). Both APA and the Inter- Whether the policy issue is research funding,
national Council of Psychologists are members of access to clinical services, or addressing issues of
the NGO Committee on Ageing that works to special signicance to the aging population (e.g.,
raise world awareness of the opportunities and cognitive aging, suicide prevention), it is critical
challenges of global aging. Its advocacy efforts that policymakers hear directly from their constit-
have included support for adoption of the UN uents. A common expression in US politics states
Principles for Older Persons, input to the devel- that all politics is local. This phrase refers to the
opment of the Madrid International Plan of Action signicant value that policymakers must place on
on Ageing (2002), and a focus on the develop- the basic needs of those whom they directly rep-
ment of a UN Convention on the Rights of Older resent. Psychologists can play a critical role as
Persons. Proponents of this convention, which is a both experts and constituents, by communicating
multilateral agreement binding under interna- with the policymakers who represent them both in
tional law second only to a treaty in formality their home districts and national ofces through
(United Nations 2015), believe that older adults in-person visits, letters and e-mails, telephone
should be explicitly recognized under interna- calls, participation in town hall meetings,
tional human rights laws, which is not the case at volunteering for campaigns, and exercising other
present. The UN Committee on Ageing is also rights to participate in the democratic process
instrumental in planning educational events, (American Psychological Association 2012).
including the annual Psychology Day at the UN Policymakers are especially responsive to educa-
as well as the International Day of Older Persons. tion and advocacy efforts that incorporate both
data and anecdotal information (e.g., local or per-
sonal stories) about how particular policies and
Educating and Informing Policymakers resources impact their families, community, and
About Aging and Geropsychology institutions. Such advocacy efforts by psycholo-
gists can have a signicant impact on a
The health and requisite long-term services and policymakers decision to support or oppose
support needs of older adults and their caregivers existing or proposed initiatives and policies.
are receiving ever-increasing attention from While psychologists can inform policymakers
policymakers. While many policymakers are on a broad range of issues, there are some specic
aging policy concerns for which psychologists psychological research can contribute to the for-
could serve as particularly helpful educators and mulation of sound public policy to address spe-
advocates. First, psychologists can help cic social problems and improve human welfare
policymakers understand that mental health is a (American Psychological Association 2015b).
critical component of overall health and an impor- Within APA, the Ofce on Aging and the
tant part of healthy aging. In addition, psycholo- Committee on Aging (CONA) have ongoing ini-
gists can help dispel common myths and tiatives to actively advocate for the application of
stereotypes about aging, including dissemination psychological research and clinical practice to
of facts that explain that depression and dementia issues affecting the health and well-being of
are not inevitabilities of aging and have risk fac- older adults. CONAs mission statement includes
tors that are amenable to intervention across the this goal: Contribute to the formulation and sup-
lifespan. port of public policies and associated regulations
Both ageism and stigma continue to surround that promote optimal development of older adults,
issues related to health and aging, across cultures facilitate psychological practice with older per-
and nations. Mental disorders are often sons, and expand scientic understanding of
overlooked among older adults because they adult development and aging (American Psycho-
may coincide with, and are attributed to, other logical Association 2013). Areas of APA aging
medical illnesses or life events that commonly advocacy, which span the associations director-
occur as people age (such as loss of loved ones). ates of education, practice, public interest, and
Misinformation and stigma often prevent those in science, include building a competent workforce
need from seeking treatment and inhibit the devel- to serve older adults by expanding education and
opment and implementation of appropriate poli- professional development opportunities for prac-
cies to address the mental health needs of older titioners and researchers, increasing funding for
adults. aging research that contributes to understanding
Another issue ripe for advocacy is the lack of a and addressing the challenges and opportunities
sufcient health-care workforce capable of meet- presented by an aging society, and increasing the
ing the health needs of older adults. The Institute availability and reimbursement of publicly funded
of Medicine (IOM) estimated that each year health and mental health services and integrated
5.68.0 million older adults in the USA experi- models of health care. Further, APAs aging efforts
enced one or more of the 27 behavioral health have focused on promoting the application of
conditions that occurred in this population psychological knowledge to the well-being of
(Institute of Medicine 2012). Concerns about the older people, with special attention to the inu-
size and preparation of the workforce qualied to ences of gender, ethnicity, culture, sexual orienta-
care for older adults are highly applicable to psy- tion, and family in science, practice, and policy
chology, as a small number of psychologists spe- relating to older adults. Such attention to diversity
cialize in geropsychology and there has been and culture in aging policy and advocacy is essen-
limited growth in their numbers (Hoge tial in meeting the needs of the global aging pop-
et al. 2015). Psychologists have been very ulation, which is increasingly diverse. APA and
engaged in advocacy on this issue individually the psychology and aging community have devel-
and as part of organizational and coalition efforts. oped relationships with policymakers at the
national and international levels focused on
aging issues, including key US congressional
Aging Policy and Advocacy at the committees (e.g., Senate Special Committee on
American Psychological Association Aging), federal agencies and departments (e.g.,
Administration for Community Living, Depart-
Advocacy efforts within APA have been guided ment of Veterans Affairs), and stakeholder orga-
by the philosophy that public policy should be nizations (e.g., Partnership for Health in Aging,
based on available scientic knowledge and that National Alliance for Caregiving, UN Committee
on Ageing, and the World Federation of Mental on key aging-related provisions in the Afford-
Health). able Care Act. EWA is an interdisciplinary
Psychologists can also expand their knowledge coalition of nearly 30 national organizations A
and skills in aging policy by participating in representing physicians, nurses, psychologists,
hands-on policy education and training opportu- social workers, pharmacists, physical thera-
nities for psychologists and trainees, offered by pists, direct care workers, eldercare employers,
APA such as the Congressional Fellowship Pro- family caregivers, and consumers committed
gram, the Executive Branch Science Fellowship, to addressing the geriatric health-care work-
and the Public Interest Policy Internship for Grad- force shortages. EWA and its partners worked
uate Students. Similar programs are also open to throughout the US health reform legislative
psychologists and aging experts from other pro- process and secured critical language related
fessions, including the Health and Aging Policy to geriatric health professions education and
Fellows Program sponsored by the Atlantic Phi- training in the new US health reform law. Spe-
lanthropies and the John A. Hartford Foundation. cically, these provisions (1) expanded Geriat-
ric Academic Career Awards to include faculty
in psychology and other disciplines, (2) autho-
The Value of Collaborative and rized a new Geriatric Career Incentive Awards
Interdisciplinary Aging Advocacy program to include students of psychology and
other disciplines, and (3) expanded Geriatric
Much attention in recent years has focused on the Education Centers to include schools with pro-
value of interdisciplinary teams and collaborative grams in psychology and other disciplines.
models in clinical practice and research. Such Psychologists were involved in this interdisci-
models are particularly well suited for those work- plinary advocacy effort in a number of ways.
ing with older adults and on aging issues that are APA staff served in leadership roles in EWA,
often complex and multidimensional. Similar and psychologists participated in interdisci-
value can be found in the use of collaborative plinary National Advocacy Days, were
and interdisciplinary approaches to aging policy highlighted in an educational video, Advocat-
development and advocacy. ing for Team Care for Older Adults, and
In fact, many of the most successful, recent, presented on interdisciplinary panels at con-
aging policy initiatives have been collaborative in gressional briengs on its importance. The
nature. Multi-organizational efforts, particularly organizations continue to work collaboratively
efforts involving older adults and their families to ensure appropriate implementation and suf-
and caregivers, are viewed more favorably among cient funding of this new law.
policymakers than single-focused, discipline-
specic efforts. Psychologists have proven to be Example 2: The National Coalition on Mental
valued partners working alongside other health, Health and Aging (NCMHA) and the 2005 White
social service, and aging professionals as well as House Conference on Aging (WHCoA)
with consumers, families, and caregivers to advo- The WHCoA was rst held in 1961, with sub-
cate for needed aging policies. Two case examples sequent conferences in 1971, 1981, 1995,
of policy collaboration between the psychology 2005, and 2015. The conferences generate
community and aging policy allies are presented ideas and momentum prompting the establish-
below. ment of and/or key improvements in many of
the programs that represent Americas commit-
Example 1: The Eldercare Workforce Alliance ment to older Americans (American Psycho-
and the Affordable Care Act logical Association 2015c). At the 2005 White
Geropsychologists worked individually and in House Conference on Aging, three-quarters of
collaboration with the Eldercare Workforce the 1,200 national delegates voted to improve
Alliance (EWA), of which APA is a member, recognition, assessment, and treatment of
mental illness and depression among older Working with Older Adults, reminds us that psy-
Americans. This resulted in mental health chologists can maximize their efforts to assist this
being ranked in the top ten of the 50 WHCoA large and diverse segment of our society by being
policy resolutions resulting from the confer- armed with facts about the myths and realities of
ence. A major factor in this success was the aging, knowledgeable about the problems older
concerted effort by the mental health and aging adults face, cognizant of how to assess and treat
community, facilitated by the National Coali- older persons and familiar with the broader pro-
tion on Mental Health and Aging (NCMHA). fessional issues in aging. (American Psycholog-
NCMHA is comprised of over 50 professional, ical Association 1997). As the older adult
consumer, and government member organiza- population continues to increase in size and diver-
tions that work together towards improving the sity in the USA and around the world, psycholo-
availability and quality of mental health pre- gists have a professional and moral imperative to
ventive and treatment services to older Amer- actively engage in aging policy development and
icans and their families. NCMHAs 2005 advocacy.
advocacy efforts were well organized, collab-
orative, and interdisciplinary in nature. The
collective challenge of the group was how to Cross-References
take the available empirical evidence regarding
the importance of mental health and present it Age Stereotyping and Discrimination
to the WHCoA Policy Committee, staff, and Attitudes and Self-Perceptions of Aging
delegates in a compelling, usable format. The Mental Health and Aging
NCMHA did this by developing one clear
message supported by empirical evidence:
Its not just health it is mental health. References
That is, mental health is an integral component
American Bar Association Commission on Aging, Amer-
of general health and personal well-being. This ican Psychological Association, & National College of
collective, yet basic, message was dissemi- Probate Judges. (2008). Judicial determination of
nated by the NCMHA and its member organi- capacity of older adults: A handbook for judges. Wash-
zations over an eighteen-month period leading ington, DC: American Bar Association and American
Psychological Association.
up to the WHCoA and carried to the confer- American Psychological Association. (1997). What prac-
ence, and that message was heard. For the rst titioners should know about working with older adults.
time, in the history of the WHCoA, mental and Washington, DC: American Psychological
behavioral health emerged as a priority. Of Association.
American Psychological Association. (2012).
note, in preparation for the 2015 WHCoA, the PsycAdvocate modules. Washington, DC: American
White House recently issued a policy brief on Psychological Association.
healthy aging, which restates the importance of American Psychological Association. (2013). Association
optimizing behavioral health. rules, APA Committee on Aging. Washington, DC:
American Psychological Association.
American Psychological Association. (2014). Guidelines
for psychological practice with older adults. American
Psychologist, 69(1), 3465.
Conclusion American Psychological Association. (2015a). APA United
Nations team annual report 2014. Washington, DC:
American Psychological Association.
Policy and advocacy are essential elements of a American Psychological Association. (2015b). Guide to
psychologists professional identity. The advocacy and outreach. APA Website. Washington,
geropsychology community has a great deal to DC: American Psychological Association.
American Psychological Association. (2015c). APA Coun-
add to the health and aging policy debate locally, cil policy manual, resolution on the 2015 White House
nationally, and globally. The seminal APA publi- conference on aging. Washington, DC: American Psy-
cation, What Practitioners Should Know About chological Association.
Affect and Emotion Regulation in Aging Workers 33
Hoge, M. A., Karel, M. J., Zeiss, A. M., Alegria, M., & shaping a wide variety of organizational
Moye, J. (2015). Strengthening psychologys work- behaviors and outcomes (Barsade and Gibson
force for older adults: Implications of the Institute of
Medicines report to Congress. American Psychologist, 2007). Affect and emotion regulation also A
70(3), 265278. undergo substantial systematic (and mostly posi-
Institute of Medicine. (2012). The mental health and sub- tive) changes as employees age (Scheibe and
stance use workforce for older adults: In whose hands? Carstensen 2010). Knowledge about age
Washington, DC: National Academies Press.
Knight, B. G., Karel, M. J., Hinrichsen, G. A., Qualls, differences in affect and emotion regulation is
S. H., & Duffy, M. (2009). Pikes Peak model for therefore critical for researchers, managers, and
training in professional geropsychology. American employees.
Psychologist, 64(3), 205214.
United Nations. (2015). United Nations Treaty collection.
New York: United Nations.
Basics of Affect and Emotion Regulation
Affect is a term denoting persons neurophysio-

logical feeling state characterized by a particular
Affect and Emotion Regulation in valence and activation level, such as pleasure or
Aging Workers displeasure, arousal, or relaxation (Russell 2003).
Among affective states, moods are usually distin-
Susanne Scheibe, Barbara Wisse and Anika guished from emotions, although the difference
Schulz between moods and emotions is gradual rather
Department of Psychology, University of than categorical. Moods are relatively long last-
Groningen, Groningen, Netherlands ing, lack a discernable cause, and bias cognitions
more than actions. Emotions, in contrast, are more
short-term reactions, arise in response to discern-
Synonyms able events, and are more closely tied to behavior.
Emotions arise when persons encounter situations
Affect regulation; Core affect; Emotion manage- that they appraise to facilitate or hamper the
ment; Emotional intelligence; Emotional labor; achievement of current concerns, goals, or tasks.
Mood Because the achievement of tasks lies at the core
of behavior in organizations, emotions are highly
relevant to the organizational context. The focus
Definition of the current chapter therefore will be on emo-
tions more than moods, although moods will be
Affect (mood, emotions) denotes a persons neu- considered when relevant.
rophysiological state characterized by a particular Emotions have many important functions.
valence and activation level, such as pleasure or Some of these functions are more social in nature
displeasure, arousal, or relaxation. Affect can be (i.e., emotions may be used to communicate with
inuenced by emotion regulation, describing the and inuence others), while others are more con-
process by which a person shapes the nature, sequential for the person who experiences the
intensity, or duration of emotional experience emotion (i.e., tuning attention, providing feed-
and/or expression. back about goal progress, and facilitating action).
However, emotions are not always functional or
appreciated. In many work settings, employees
Affect and Emotion Regulation in Aging are well advised to modulate or hide their emo-
Workers tions, in order to safeguard their own well-being
and effectiveness or to adhere to emotional dis-
Affect and emotion regulation are centrally play norms. Emotion regulation refers to the pro-
involved in effective functioning in work settings, cess by which persons shape the nature, intensity,
34 Affect and Emotion Regulation in Aging Workers
or duration of an emotional experience and/or its Emotion regulation strategies differ in their
expression (Gross 2015). outcomes or how they impact on the unfolding
Emotion regulation always starts with a goal to emotional response and associated cognitions and
change the emotion-generative process, which behaviors. For instance, positive reappraisal of a
means that the ambition to alter the way in negative event tends to reduce the extent to which
which a person feels is triggered (Gross 2015). negative emotions are expressed and experienced.
This goal can be conscious or unconscious and In contrast, using suppression tends to reduce
concern own emotions or those of others, such as negative emotion expression but leaves the expe-
clients, supervisors, colleagues, or subordinates. rience unchanged (and may even enhance physi-
Moreover, emotion-regulatory goals can be ological activation; John and Gross 2004).
driven by hedonic considerations (wanting to Because of this differential impact, the habitual
feel pleasant emotions) or instrumental consider- use of certain strategies has downstream conse-
ations (wanting to feel useful emotions; Tamir quences for more distal outcomes, including
2009). Instrumental considerations arise from the social behavior, the quality of social relationships,
notion that affect can be a means to an end. For and general well-being. In general, antecedent-
example, anger facilitates confrontation, happi- focused strategies tend to have more positive
ness facilitates collaboration, joy facilitates crea- social and well-being consequences than
tivity, and fear facilitates threat avoidance. response-focused strategies and are therefore con-
Following the activation of an emotion- sidered more adaptive in the long run.
regulatory goal, a process (or strategy) is activated
to reach this goal. People usually have at their
disposal many different strategies to regulate Age-Related Differences in Emotion
emotions, and several classication systems have Regulation
been developed to organize these into more
coherent families of strategies. Parkinson and Theories of Emotion Regulation in Adulthood
Totterdell (1999) distinguish strategies based on Several lifespan theories propose that aging has a
how they are implemented cognitively or substantial impact on emotion-regulation goals,
behaviorally and whether the intention is to processes, and outcomes. Socioemotional selec-
engage with or disengage from the emotional tivity theory (Carstensen 2006) predicts
event. Gross (2015) distinguishes whether the action age-related changes in emotion-regulatory goals
of strategies is early (antecedent focused) or late as a function of shifts in future time perspective.
(response focused) in the emotion-generative pro- As individuals grow older, they perceive their
cess. For example, reappraising an unpleasant remaining time on this earth as increasingly lim-
customer interaction as a learning opportunity ited, which in turn elicits a stronger focus on
would be a cognitive, engagement, antecedent- current well-being relative to future-oriented pur-
focused strategy, whereas suppressing an angry suits. With aging, goals related to knowledge
look on ones face would be a behavioral, disen- acquisition, expanding ones social network, or
gagement, response-focused strategy. Impor- taking risks presumably give way to goals related
tantly, the various regulatory strategies rely on to nurturing existing relationships, helping others,
different capabilities (including emotional exper- and pursuing emotionally satisfying activities.
tise, cognitive control, and physiological exibil- Applied to emotion-regulation processes, this
ity), and some of those are more cognitively implies that emotion-regulatory goals are driven
effortful to implement than others (Consedine by hedonic considerations more than by instru-
and Mauss 2014; Richards and Gross 2000). For mental ones (Tamir 2009). This will be especially
instance, the antecedent-focused strategy of apparent in situations where negative emotions
reappraisal has been shown to be less cognitively can help to reach instrumental goals. When
effortful than the response-focused strategy of disagreeing with a coworker, for instance, youn-
suppression. ger workers may want to feel angry to more
effectively convey their point, whereas older On the other hand, declining cognitive and
workers may want to reduce their anger to sustain physiological capabilities should diminish older
their positive mood. Preferences for specic adults advantage in using strategies that rely A
types of affective states are also assumed to shift. heavily on these capabilities. For instance,
As a consequence of changes in physiological declines in physiological exibility with age
exibility, older adults increasingly prefer make regulation of emotional arousal more dif-
low-arousal affect (calm or bored) over high- cult (Charles and Luong 2013). Response-focused
arousal affect (excited or angry; Scheibe strategies, such as expressive suppression, are
et al. 2013). applied only after emotional arousal has been
Lifespan theories also predict that age impacts fully developed. Such strategies are among the
on the processes and outcomes of emotion regu- most cognitively effortful (Richards and Gross
lation. The general prediction is that capabilities 2000). Consequently, older adults are assumed to
needed for different emotion-regulation strategies use such strategies less often than younger adults
are subject to age-related changes, leading to and to have no advantage over younger adults
shifts in strategy use and effectiveness (Morgan when it comes to strategy effectiveness. In sum,
and Scheibe 2014; Urry and Gross 2010). On the lifespan theories converge in the prediction that
one hand, long-term experience and practice in antecedent-focused emotion-regulation strategies
dealing with emotional situations over time that avoid or mitigate negative emotions are used
should enhance emotional expertise, making more often and implemented more effectively
older adults generally more effective in handling with age, whereas response-focused emotion-
their emotions (Blanchard-Fields 2007). Indeed, regulation strategies are used less often and not
older people have been found to use more adap- implemented more effectively.
tive strategies (such as reappraisal) and less mal-
adaptive strategies (such as suppression) in daily Evidence from Worker Samples
life (John and Gross 2004). In addition, it takes While age differences in affect and emotion regu-
them less cognitive effort to successfully lation have been extensively studied in the general
reach emotion-regulation goals (Scheibe and aging literature, organizational researchers have
Blanchard-Fields 2009). Similarly, the strength only recently begun to test the generalizability of
and vulnerability integration theory (Charles and these ndings to work settings. Notably, the work
Luong 2013) maintains that older adults benet setting has several characteristics that have to be
from their higher emotional expertise when it taken into account when studying effects of age
comes to using emotion-regulation strategies that differences. For one, the working lifespan repre-
help to avoid or mitigate negative emotions. Older sents only a segment of the overall period of
adults presumably use antecedent-focused strate- adulthood. Given an average retirement age
gies such as situation selection (avoiding conict around 6065 years across most industrialized
situations), situation modication (problem- countries, the label older workers correspond
solving), and cognitive or behavioral disengage- to middle-aged adults in the aging literature.
ment (distracting away from negative situations) Therefore, age differences in future time perspec-
more often and more effectively than young tive and in capabilities relevant to emotion regu-
adults. One particularly well-supported proposi- lation are likely smaller in worker samples than in
tion is the positivity effect in older adults infor- samples spanning all of adulthood. Moreover, a
mation processing (Reed and Carstensen 2012). healthy worker effect must be taken into
The positivity effect entails that, compared to account, denoting a trend for ill-functioning
young adults, older adults pay more attention to, older workers to leave the workforce, which
and show better memory for, positive over nega- makes the active workforce a positively selected
tive information. They also pick up positive social group. Finally, work settings are often associated
cues more accurately than negative ones with a reduced repertoire of available emotion-
(Kellough and Knight 2012). regulation strategies; the choice of social partners
may be relatively restricted, and emotional dis- disengagement when facing workplace conict
play rules and work role obligations may override (e.g., yielding, delaying responding) more than
behavioral preferences (Davis et al. 2009). younger workers, based on behavior ratings by
These differences notwithstanding initial their coworkers (Davis et al. 2009). Young and
cross-sectional studies in a working population older workers were equally likely to use active
are consistent with assumptions of aging effects problem-solving (see also Johnson et al. 2013).
in emotion-regulation goals, processes, and out- However, another study with employees from dif-
comes. Most studies have been conducted in the ferent occupational sectors failed to replicate
service industry. For instance, research in the enhanced behavioral disengagement and instead
work domain seems to conrm the proposition found older workers to report more active
that hedonic emotion-regulatory goals get stron- problem-solving (Hertel et al. 2015). Two studies
ger with age: When being in uncomfortable cus- investigated self-reported use of reappraisal and
tomer situations, older workers were found to suppression; one found a positive age trend for
report trying to control their emotions more than reappraisal use (Yeung et al. 2011), but the other
their younger colleagues (Johnson et al. 2013). found age to be unrelated to reappraisal use (Bal
Other studies have investigated age differences and Smit 2012). Both studies converge in nding
in use of emotional labor strategies, which are no age difference in use of suppression.
emotion-regulation strategies that are employed Aside from strategy use, there is limited evi-
in order to align emotional experience with emo- dence that age may confer benets for effective
tional display demands (Dahling and Perez 2010; implementation of antecedent-focused emotion-
Cheung and Tang 2010; Sliter et al. 2013). Con- regulation strategies. Use of both emotion control
sistent with theories of emotional aging, a con- and problem-solving were more strongly linked
verging nding is that older workers show a more with low burnout symptoms in older service
adaptive prole of emotional labor strategies than workers, compared with their young colleagues
younger workers do. Specically, older workers (Johnson et al. 2013). In contrast, suppression has
display a more frequent use of deep acting been found to be particularly ineffective for older
(trying to experience the required emotion; an workers (Bal and Smit 2012). Specically, sup-
antecedent-focused strategy) and/or a less fre- pression mitigated the detrimental effect of psy-
quent use of surface acting (displaying the chological contract breach on positive affect in
required emotion but leaving the emotional expe- young workers but enhanced it in older workers.
rience unchanged; a response-focused strategy). However, a 5-day diary study among Chinese
The notion that aging facilitates the use of insurance workers revealed that suppression was
antecedent-focused emotion-regulation strategies associated with better affect in older workers
is further supported by the nding that older while it was unrelated to affect in young workers
workers required emotions align more often (Yeung and Fung 2012), thus suggesting that
with naturally felt emotions than those of younger cultural differences may also play a role in deter-
workers. Consistent with developmental theories mining age-contingent strategy effectiveness.
of affect and emotion regulation, age-related dif- Importantly, to the extent that older adults can
ferences in emotional labor strategy use were par- effectively use antecedent-focused emotion-
tially mediated by higher trait positive affect and regulation strategies, and thereby circumvent
self-reported emotional expertise (Dahling and negative situations, their effectiveness in using
Perez 2010; Sliter et al. 2013). suppression would matter little for their well-
Studies going beyond the service industry pro- being.
duced less consistent ndings regarding age dif- In sum, there is growing evidence in the
ferences in strategy use. Congruent with lifespan work domain that antecedent-focused strategies
theories of affect and emotion regulation, a study (problem-solving, behavioral disengagement,
with executives from different sectors found deep acting) are more often and more
that older workers engage in behavioral effectively used with advanced age, whereas
response-focused strategies (suppression, surface trends in job-related attitudes and well-being

acting) are less often and less effectively used. appear consistently, evidence on age differences
Yet, there are some inconsistencies in the litera- in experienced affect at work is much less con- A
ture, especially regarding non-service workers vincing. An intriguing possibility that would rec-
samples. In order to clarify the somewhat mud- oncile these seemingly inconsistent ndings is
dled picture that has emerged on the effects of that older workers have as many positive affective
aging and emotion regulation in the workplace, experiences as younger workers but attend to
it will be useful to broaden the perspective. them more and weigh them more heavily. This,
Namely, if employee aging indeed has an impact in turn may explain their higher ratings on job
on emotion regulation, this should be reected in attitude scales. Such an explanation would be
age-related differences in affect-driven work out- consistent with the age-related positivity effect in
comes. Below, three of those outcomes are con- information processing (Luchman et al. 2012).
sidered: occupational stress and well-being, Another possibility is that age differences are
organizational behavior, and leadership. apparent in low-arousal positive affect, but not
high-arousal positive affect, consistent with the
shifting affective preferences with age described
Consequences for Work Outcomes above. Unfortunately, prior studies have not sys-
tematically considered arousal.
Occupational Stress and Well-Being Most studies investigated linear relationships
Given the central role of emotion regulation in between age and occupational well-being; how-
shaping well-being, one may assume that the ever, some researchers have proposed that age and
age-related changes described above have down- well-being may be related in a curvilinear manner
stream positive consequences for occupational (Clark et al. 1996). They argue that because
stress and well-being (Scheibe and Zacher middle-aged workers face an accumulation of
2013). Indeed, a meta-analysis on age differences demands in the work and family domain, aging
in job attitudes revealed that older workers have benets for occupational attitudes and well-being
higher job satisfaction, lower levels of burnout, may not emerge until the late career. Indeed, in
and generally more favorable and less unfavor- some studies age and occupational attitudes and
able job attitudes (Ng and Feldman 2010). well-being (i.e., job satisfaction and emotional
Although age differences were only weak to mod- exhaustion) were found to be related in an
erate, they were surprisingly consistent for task-, inverted U-shaped manner (Clark et al. 1996;
people-, and organizational-related aspects of Rauschenbach and Hertel 2011; Zacher
well-being. For example, older workers seem to et al. 2014). Note that ndings like these under-
have fewer signs of burnout (task based), are more score the importance of taking into account the
satised with their supervisors (people based), fact that the work setting may differ in important
and show stronger organizational commitment ways across occupations.
(organization based). To date, only few studies directly tested affec-
Age-related enhancements in occupational tive processes underlying the positive effects of
well-being are further implied by studies showing age on well-being. In one study, older service
higher positive or lower negative affect with workers higher use of deep acting was found to
increasing worker age (Dahling and Perez 2010; mediate the positive relationship between age and
Sliter et al. 2013; Yeung et al. 2011). Neverthe- job satisfaction (Cheung and Tang 2010). Another
less, several cross-sectional and experience- study found older workers higher use of
sampling studies were unable to nd signicant reappraisal to partially mediate the positive rela-
associations between age and affect in worker tionship between age and positive affect (Yeung
samples (Bal and Smit 2012; Yeung and Fung et al. 2011). A third study found older workers
2012; Amabile et al. 2005; Lee and Allen 2002; higher use of problem-focused coping to be asso-
Sonnentag et al. 2008). Thus, while positive age ciated with a reduction in self-reported strain eight
months later (Hertel et al. 2015). These initial substance abuse, tardiness, and voluntary
ndings are consistent with developmental theo- absence (Ng and Feldman 2008). Given the
ries proposing stronger emotion-regulation goals importance of such behaviors for organizational
and effectiveness with age, which in turn, lead to effectiveness, these positive age trends demon-
improved well-being. strate that older workers contribute effectively
In sum, consequences of age-related changes to organizational goals. Again, while it is
in emotion regulation seem to have a positive likely that age differences in organizational
effect on occupational stress and well-being. Gen- behavior may at least partly be driven by aging-
erally, older workers are more satised with their related changes in affective processes, empirical
jobs as they are more motivated to maintain pos- tests of mediating relationships are lacking
itivity in comparison to young workers. However, to date.
as most studies investigated direct links between
age and well-being outcomes, more rigorous Leadership
research is needed to test emotion regulation as Leadership is the ability of a person to inuence,
the underlying mechanism of this effect. motivate, and enable others to contribute toward
the effectiveness and success of the organization
Organizational Behavior of which they are members. It has become clear
Besides occupational attitudes and well-being, that moods and emotions are deeply intertwined
affect and emotion regulation also shape organi- with this ability (Van Kleef et al. 2011): The
zational behavior. According to the affective affective states, emotion-regulation strategies,
events theory (Weiss and Cropanzano 1996), and emotional competencies of leaders affect
emotional reactions to affective work events leader behaviors and follower affective states
trickle down to inuence discrete work behaviors. and outcomes (Gooty et al. 2010; Rajah
In their emotion-centered model of voluntary et al. 2011). The issue of how age may affect
work behavior, Spector and Fox (2002) posit leadership via affective processes is particularly
that positive emotions will increase the likelihood interesting given the fact that those in leadership
that employees show organizational citizenship positions usually have a more advanced age than
behaviors (e.g., assisting others, showing loyalty), those they lead. This, coupled with the observa-
whereas negative emotions will increase the tion that the average age of the workforce in many
likelihood of counterproductive work behaviors countries is increasing, suggests that the share of
(e.g., coming late, neglecting instructions). older individuals in leadership positions will con-
Indeed, daily affective work events were tinue to grow.
shown to be linked with daily citizenship and Studies that have combined leader age, affec-
counterproductive behaviors through emotions tive processes, and one of the potential outcomes
(attentiveness, anger, and anxiety; Rodell and of leadership are largely lacking, but some inter-
Judge 2009). esting ndings have appeared. The existing
Given improvements in affect and emotion research illustrates a trend toward less change-
regulation with age, one may expect that older oriented behavior among older compared to
workers, compared to their younger counterparts, young leaders (see Walter and Scheibe 2013).
are generally more likely to show citizenship Young leaders tend to feel more comfortable in
behavior and less likely to show counterproduc- fast-changing environments and to be more will-
tive behavior. There is robust evidence that this ing to take risks and consider new approaches
is indeed the case. A meta-analysis linking age than older leaders do (Oshagbemi 2004). More-
with different aspects of job performance yielded over, it has been found that older leaders show
age-related increases in citizenship behaviors more passive leadership behaviors than younger
and age-related reductions in counterproductive leaders: They are more likely to display laissez-
work behaviors in general, as well as age-related faire leadership or management by exception (see
reductions in workplace aggression, on-the-job Walter and Scheibe 2013).
Older leaders relative lack of agency and Future Research Directions

change orientation and their more passive leader-
ship behaviors seem to be in line with the above- Research on affect and emotion regulation in A
described lifespan theoretical propositions of aging workers is historically young and incom-
age-related changes in goals and strategies of plete. In the previous sections, several gaps in the
emotion regulation. Specically, they t the pre- literature were pointed out that require further
mises of the socioemotional selectivity theory study. In the following, two additional fruitful
(Carstensen 2006) that the older people get, the avenues for future research will be suggested in
more they shift in focus from future-oriented pur- domains that have so far neglected worker aging
suits to current well-being. Such a shift in focus but may benet from taking into account
would arguably be reected in peoples efforts to age-related changes in affect and emotion
alter the status quo, because such behaviors are regulation.
usually conducted in the hope that they may pay
off in the future. Likewise, older adults tendency Group Affect
to prioritize positive over negative information One interesting avenue for future research is to
(Reed and Carstensen 2012), and their greater investigate how worker aging affects the develop-
attention to positive social cues than to negative ment of group affect or the consistent or homo-
ones (Kellough and Knight 2012) would diminish geneous affective reactions within a group
the perceived necessity of older leaders to act on (George 1990, p. 108). In organizations, where
or to interfere with the ongoing state of affairs. people often work in teams or subgroups, group
Additionally, older leaders more passive leader- affect develops frequently. Group affect is consid-
ship behaviors t well with earlier described nd- ered to occur as a result of affective interactive
ings of emotion-regulation strategy shifts with age sharing processes (the dynamic pathway) and/or
toward antecedent-focused strategies of conict dispositional or contextual factors that happen to
avoidance and behavioral disengagement. make group members feel similar (the static path-
Importantly, these more passive styles are not way; cf., Klep et al. 2011; Kelly and Barsade
always considered to be more negative in nature. 2001). Group affect has a substantial impact on
It has been argued that they are rooted in older various signicant outcome variables related to
leaders willingness to cooperate and delegate organizational functioning, such as cooperation,
more and that they are manifestations of older coordination, conict, creative and analytical per-
leaders general tendency to behave themselves formance, and absenteeism (Collins et al. 2013).
in a more calm and modest manner (Oshagbemi Therefore it is important to consider how aging
2004). Notably, their willingness to cooperate and may affect its development.
delegate may reect that they place more value on As described above, aging theories posit that
establishing intimacy with others in the present older adults have a stronger hedonic motivation, a
and developing a sense of belonging in the social preference for low-arousal positive affect, and an
environment (Carstensen 2006), while their calm aversion of high-arousal negative affect. As a
demeanor ts well with older peoples general consequence, older people often feel better or
motivation to experience low-arousal positive more positive than younger people do (Scheibe
states (Scheibe et al. 2013). In sum, age differ- and Zacher 2013). Arguably, this tendency should
ences in affect and emotion regulation seem to be reected in the development of group affect:
have important implications for leadership, and The higher the mean age of the group members,
the available evidence does seem to largely cor- the more likely it is that a positive group affective
roborate predictions from the general aging liter- state will develop. This, in turn, may have positive
ature. Yet, continued inquiry is necessary, because consequences for group functioning. However,
studies that have combined leader age, affective given that the development of group affect is
processes, and potential outcomes of leadership also largely dependent on affective interactive
are scarce. sharing processes, it may be that it arises less
frequently in groups that have higher average age. emotion-regulation goals, in the recruited strate-
Affective sharing processes demand that people gies to reach those goals, and in the outcomes of
attend to and notice other group members affec- strategy use. Age-related differences in emotion
tive states, so that over time people converge regulation can help explain positive age differ-
affectively. However, the accuracy in identifying ences a wide variety of work outcomes, including
others emotions (i.e., emotion recognition) job attitudes and well-being, organizational
declines with older age, especially as far as nega- behavior, and leadership. It appears that older
tive emotions are concerned, because this adults stronger motivation to maintain well-
demands high cognitive control and processing being and their increasing emotional expertise
speed and a willingness to process negative infor- represent a domain of strength for older workers
mation (Kellough and Knight 2012). In sum, and help them contribute to organizational effec-
future research may investigate the hypotheses tiveness in important ways. For future research, it
that when average group member age increases, will be fruitful to explore whether similarly posi-
group affect develops less often, but if it does it is tive age differences are found in further relevant
more positive in nature. occupational outcomes, such as group affect and
the regulation of other peoples emotions.
Regulating Others Emotions
The bulk of research on age and emotion regula-
tion in general, and in the work context in partic-
Cross-References
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of peoples own emotions. In comparison,
Age-Related Changes in Abilities
research on age differences in regulating other
peoples emotions is largely lacking to date. In
Conict Management and Aging in
many work situations, modifying another per-
the Workplace
sons emotional experience is, however, crucial
Job Attitudes and Age
to ensuring effective job performance. Psycho-
Job Crafting in Aging Employees
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Leadership and Aging
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Socioemotional Selectivity Theory
tions (Pletzer et al. in press). Service workers
Strength and Vulnerability Integration
sometimes need to calm down their emotionally
Stress and Well-being: Its Relationship to Work
aroused clients. Leaders can positively inuence
and Retirement for Older Workers
their subordinates by bringing them into a posi-
Workplace Mentoring, Role of Age
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mediator in the relationship between age and emotional Age and Blended Working
labor strategies in service employees. Experimental
Aging Research, 39, 466479. doi:10.1080/ Kiki M. M. De Jonge1, Nico W. Van Yperen2 and
0361073X.2013.808105. Eric F. Rietzschel1
Sonnentag, S., Binnewies, C., & Mojza, E. J. (2008). Did 1
you have a nice evening? A day-level study on recov- University of Groningen, Groningen, The
ery experiences, sleep, and affect. Journal of Applied Netherlands
2
Psychology, 93, 674. doi:10.1037/0021- Department of Psychology, University of
9010.93.3.674. Groningen, Groningen, The Netherlands
Spector, P. E., & Fox, S. (2002). An emotion-centered
model of voluntary work behavior: Some parallels
between counterproductive work behavior and organi-
zational citizenship behavior. Human Resource Man- Synonyms
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4822(02)00049-9.
Sy, T., Ct, S., & Saavedra, R. (2005). The contagious Distributed work; Flexwork; Mobile work;
leader: Impact of the leaders mood on the mood of Remote work; Telecommuting; Telework; Trust-
group members, group affective tone, and group based working.
Age and Blended Working 43
Definition increasingly common and mainly revolve around

obtaining, analyzing, and sharing knowledge,
Blended working is the opportunity to blend activities that can mostly be performed online A
on-site and off-site working (i.e., working and away from the ofce (Van Yperen
location- and time-independently), which is et al. 2014; McLennan 2008).
enabled by the utilization of information and com- Another major development in the world of
munication technologies (ICTs) that provide work is that since 2010, the global workforce is
workers with almost constant access to aging more rapidly than ever before, as post-
job-relevant information and coworkers. World War II cohorts are reaching ages 65 and
over (Hedge and Borman 2012). Many older
workers are delaying their retirement as a result
Introduction of the recent economic crisis (Elias et al. 2012) but
also with the intention to stay productive and
The workforce is aging rapidly, which means that mentally healthy (Lee et al. 2009). For organiza-
organizations will have to learn how to manage tions, it is important to retain older workers in
older workers better to avoid labor shortages and a order to avoid, or at least lower, the forecasted
loss of organizational effectiveness (Czaja and shortage of 20.8 million EU workers by 2030
Moen 2004). One way to do this, is to rely more (Sharit et al. 2009), and to keep workers with
on blended working practices, that is, the oppor- high levels of job expertise within the organiza-
tunity to blend on-site and off-site working tion (Hedge et al. 2006). This poses new chal-
enabled through modern information and commu- lenges to organizations and their personnel
nication technology (ICT) facilities (Van Yperen management strategies, since working for income
et al. 2014). This chapter summarizes and gives an and benets only does not satisfy the needs of
overview of the opportunities and threats that older workers (Hedge et al. 2006). Older workers
blended working may have for older workers, nd it increasingly important to feel intrinsically
and aims to show that blended working practices motivated in their job and put a stronger emphasis
can be helpful to retain older workers and can on learning and accomplishing new and worth-
keep them satised, motivated, and productive in while things (Hedge et al. 2006). At the same
their jobs. time, they nd it important to experience more
Working from the ofce, having a business exibility, to have more leisure time and time for
meeting with colleagues in a restaurant, preparing nonwork activities, and are less willing to work
a meeting in the train, online le sharing, and under high levels of stress (Hedge et al. 2006).
work-related use of tablets and smartphones are This suggests that implementing blended
the examples of blended working practices. working may be particularly relevant for older
Off-site working is becoming more and more workers. Blended working offers the potential to
common through the rise of, among others, the fulll older workers needs and desires by creat-
internet, email, video calling and chat, and ing a better balance between work and nonwork
cloud-based data storage. These technologies pro- activities, which can help them to stay satised
vide workers with constant and location- and effective in the job. It allows older workers to
independent access to job-relevant information (re)design their jobs in a way that suits them best
and coworkers (Van Yperen et al. 2014; and that appeals to their needs (Hedge and
McLennan 2008). Obviously, not all work types Borman 2012; Hedge et al. 2006; Cutler 2006).
are suited for blended working, as some work can Allowing for new and different work opportuni-
only be done on-site, at specic times, or through ties might therefore be a relatively simple and
face-to-face communication. Blended working is inexpensive method to keep the aging workforce
especially suited for knowledge and information satised, motivated, and productive in their job
work. These work types are becoming (Hedge et al. 2006).
On the negative side, blended working can Kurland 2002). Possibly, older workers have
pose several threats to older workers well-being gained enough job experience and earned suf-
and performance (Van Yperen et al. 2014; cient trust on part of the organization to make
McLennan 2008). Possible threats faced by the frequent off-site working a viable option (Lister
aging workforce are low levels of experience with and Harnish 2011). Blended working can also be
the computer technologies required for blended particularly relevant for the older workforce, as
working (Elias et al. 2012), as well as stereotypes this arrangement may help older workers to move
about older workers being ill suited for new com- more slowly towards retirement, enabling older
puter technologies (Sharit et al. 2004). If these workers to keep on working longer than when
threats are not addressed when implementing working traditionally at the ofce (Lister and
blended working practices, organizations and Harnish 2011).
their workers will not be able to reap the expected Balancing Work and Nonwork. Blended
benets and might even incur unexpected costs. working increases exibility with regard to time
Hence, we will next discuss the opportunities and and location, and therefore creates the opportunity
threats resulting from blended working in more to nd an optimal workhome balance (Van
detail, and zoom in on the effects of blended Yperen et al. 2014) (however, see below). This
working for the older workforce. opportunity is especially relevant for older
workers, as they tend to shift their emphasis
more towards leisure time and nonwork activities.
Blended Working: Opportunities They often want to continue working, but only if
work and nonwork activities can be aligned closer
Blended working has two core aspects: increased with their needs (Hedge et al. 2006). Blended
discretion to work from various locations working can be attractive to older workers,
and times and increased connectedness to because it enables them to obtain this balance
job-relevant information and coworkers via through new work arrangements such as com-
ICTs. Hence, blended working can result in saving pressed workweeks, reduced workdays, job shar-
time (due to reduced commuting time) and freeing and part-time working, as well as working
dom from distractions and interruptions when from home (Hedge and Borman 2012). The result
(partly) working from home (Van Yperen is that older workers can combine work and
et al. 2014; Cutler 2006). Working connectedly nonwork activities in a way that ts their needs
increases (efciency in) information access and (Hedge et al. 2006). This increases the probability
can provide workers with information and feed- that older workers will continue their working
back that they would not have obtained as easily careers and retain a positive work attitude
or quickly otherwise (Mazmanian et al. 2005). (Hedge and Borman 2012).
Further, working connectedly via online devices Freedom from Distractions. Blended work-
enables workers to maintain or even extend their ing offers workers the discretion to decide on their
contact with coworkers, and to avoid social optimal workplace and schedule. This way, one
impoverishment and isolation when working can more easily avoid working at a workplace that
off-site (Cutler 2006). Blended working, thus, is known to create distraction. This can be espe-
offers unprecedented opportunities for workers cially helpful for older workers, because stressors
to decide when, where, and how to work. Besides such as noise or an overcrowded environment
these general (potential) benets, blended work- distract them more easily (Hedge and Borman
ing offers some opportunities that are especially 2012). Having the opportunity to work at other
relevant for the older worker. places than the ofce helps them to deal with these
Older Workers and Off-site Working. stressors from their direct environment (Hedge
Research in the US indicates that people working and Borman 2012), which could result in their
from home tend to be older than the average continuing to work longer than they would have
worker (Lister and Harnish 2011; Bailey and in a traditional work arrangement.
Less Need to Commute. Blended working Blended Working: Threats

lowers the need to commute, as workers can com-
bine working at the ofce with working from Despite their clear potential benets, blended A
home (Cutler 2006; Thompson and Mayhorn working practices can also create several chal-
2012). Travelling to work everyday is thus no lenges or threats. Some of these are not specic
longer necessary. This results in efciency and to older workers. For example, being able to
time savings, and can help to overcome mobility decide when, where, and how to work may come
limitations. Older age brings health changes, and with the cost of increased complexity, and being
workers close to retirement age sometimes face constantly connected can result in feelings of
age-related health issues or mobility limitations external control, resulting from the pressure to
that can make it difcult to travel to and from the be constantly available (Van Yperen et al. 2014).
workplace (Thompson and Mayhorn 2012). As Task ambiguity may also arise, because being
the workforce is aging, the number of people continuously connected to coworkers makes it
facing such issues will increase (Czaja and Moen unclear whether, how, and when information will
2004). The use of blended working practices be pushed to ones workplace, while role ambigu-
offers older workers the possibility to manage ity can arise resulting from the increased
their health issues in a secure environment workhome interference. Lastly, working from
(Sharit et al. 2009) and hence increases the oppor- home increases the threat of procrastination
tunity to continue working rather than retire and cyberslacking, and increases the likelihood
(Czaja and Moen 2004). of getting interrupted or distracted by family
It should be noted that, while working solely members (Van Yperen et al. 2014; Mazmanian
from home can be associated with the risk of et al. 2005). While the above issues apply to the
professional and social isolation (out of sight, working population at large, there are some
out of mind) (Bailey and Kurland 2002), blended possible risks that seem particularly relevant for
working refers to the opportunity to combine dif- older workers. We will discuss these below, and
ferent ways of working (Van Yperen et al. 2014). where possible will address ways to mitigate these
Thus, it represents a benet, as workers are risks.
enabled to nd or create exactly the set of circum- Older Workers and Technology Use. Given
stances that work for them. that blended working requires extensive use of
Caregiving Responsibilities. Given the ICTs, it is essential that workers have the skills
increasing number of aging or elderly workers, it and condence to use these technologies. Unfor-
will become much more common for workers to tunately, older people sometimes lack computer
have to provide elderly care or to take care of a experience as computers were not yet available
sick or disabled partner or relative (Czaja and during their formal education (Elias et al. 2012).
Moen 2004). In fact, the majority of workers that Because of this, older workers report a lower use
need to provide such care are aged 45 years or of technology, more anxiety to start using these
over (MacDermott 2014). Blended working rep- technologies, and are more likely to have a nega-
resents an important opportunity for these tive attitude towards technologies relative to
workers, similar to the possibilities many young younger workers (Elias et al. 2012). Whereas
parents are given in order to be able to provide positive attitudes and successful experiences
childcare (Hedge and Borman 2012). Blended would result in better implementation of these
working practices allow older workers to balance technologies, anxiety often results in a negative
their work and family duties (Bailey and Kurland attitude towards these technologies, and lower
2002) and are found to be related to increased intentions to use these technologies (Elias
workfamily balance, lower workfamily con- et al. 2012). Research indicates that within cohorts
ict, greater job satisfaction and productivity, of age 50 onwards, people are less likely to own a
and lower absenteeism (Hedge and Borman computer, or to use the internet or computers in
2012). general (Cutler 2006). Of those aged 65 years and
over, only about 40% uses the internet (Charness older workers, which often results in denying
et al. 2010). them the right training opportunities (Hedge and
Older workers need more time to perform a Borman 2012). As older people in fact often do
computer-interactive task and make more errors have less experience with new technologies,
while doing so relative to younger workers (Sharit denying them training opportunities can result in
et al. 2004), but this disadvantage mainly arises their avoiding the use of new technologies alto-
due to a lack of experience with these technolo- gether. The result is a self-fullling prophecy and
gies rather than from chronological age itself a risk of stereotype threat: Their skills and knowl-
(Hedge et al. 2006). As an increasing amount of edge in the job become outdated, which reinforces
future older workers will already have built up the stereotypes about older workers (Hedge
experience with computer technologies, this dif- et al. 2006).
ference will probably diminish over time Training Older Workers. The (possible) lack
(Thompson and Mayhorn 2012). However, as of computer experience highlights the importance
older workers often face perceptual, physical, of providing appropriate training opportunities for
and cognitive declines, it may remain difcult older workers, in order for them to become more
for them to adopt rapidly changing technological familiar with computer technologies, to overcome
innovations. Because of this, a lag in technologi- anxiety, and accrue positive experiences with
cal knowledge may continue to exist (Thompson technology. Unfortunately, organizations are
and Mayhorn 2012). often resistant to provide older workers with train-
Stereotypes: Older Workers and Technology. ing opportunities. This is not only because of the
Problematically, the low rate of technology use above-mentioned negative beliefs and stereotypes
among older workers is reinforced by negative about older workers and technology use (Sharit
beliefs and stereotypes about them, and older peo- et al. 2009; Thompson and Mayhorn 2012), but
ple may be less likely to use new technologies also because older workers provide fewer years in
because of the social expectation that their age which organizations can reap the benets of their
group is less willing to do so (Cutler 2006). Ste- training investments. In fact, the shorter future
reotypes about older workers as well as age biases tenure is irrelevant, because training investments
against older workers are often present in the work- are likely to pay off within a few years. Hence,
place, and can negatively affect both the individual providing training to older workers who do not
older worker and the organization in general retire within 23 years or so, prevents organiza-
(Hedge and Borman 2012; Ng and Feldman tions from the loss of expertise when losing these
2012). Age biases can result in age discrimination workers. As older workers are known to show low
when implicit biases affect decision making and rates of absenteeism and turnover in the job, and
hence the opportunities given to older workers with high levels of organizational citizenship behavior,
regard to employment, promotions, or training it is cost effective for organizations to give older
opportunities (Hedge et al. 2006) (also see below). workers the appropriate training opportunities and
Typical stereotypes about older workers and to retain them in the organization (Czaja and
technology use (such as the belief that these Moen 2004; Ng and Feldman 2008).
workers lack the right technological experience Although research indicates that older workers
and newest technological skills, are afraid of are somewhat resistant to engage in training activ-
new technologies, and are less willing and able ities (Ng and Feldman 2012), this is not the case
to accept and adapt to new technologies (Hedge for technological training (Ng and Feldman
and Borman 2012; Ng and Feldman 2012)) are 2012). In fact, older workers are very willing to
already applied to individuals of age 40 (Elias learn the technological knowledge and skills
et al. 2012). Also, older workers are thought to required for their job, and their experience of
need more time to learn and to be slower and more success when using new technologies results in
forgetful. Because of this, training programs are favorable attitudes towards it (Czaja and Moen
assumed to be less effective and more costly for 2004; Cutler 2006; Ng and Feldman 2012).
To enable these positive outcomes, it is important (Mazmanian et al. 2005). Thus, it is important
to give the right type of training (Cutler 2006) and that older workers are not simply trained and
to include familiar tasks in the training program encouraged to use new ICTs but also that they A
(Czaja and Moen 2004). Possible physical and are encouraged to use them in the way that best
cognitive declines need to be taken into account, ts their personal situation.
and the training program must be aligned with the
needs of older workers (Thompson and Mayhorn
2012; Sharit and Czaja 2012). When older Integration and Practical Implications
workers have successful experiences with com-
puter technologies, they experience these technol- Blended working practices can fulll important
ogies as reducing the effort and time required to psychological needs, some of which are particu-
fulll job tasks and as increasing their job perfor- larly salient among older workers (such as the
mance, enabling them to keep working effectively need for a distraction-free environment or a better
and productive (Mitzner et al. 2010). workhome balance), but also introduces new
WorkHome Interference. As explained pitfalls some of which, again, may be particu-
above, blended working has the potential to meet larly relevant to older workers (such as intensive
older workers desire for a better workhome use of new technologies and having to deal with
balance, because it allows them the discretion to negative stereotypes). If this brief review shows
schedule their work activities and work location anything, it is that a contingency approach (Bailey
as they see t (Van Yperen et al. 2014; Hedge and Kurland 2002) is essential when it comes to
et al. 2006). Paradoxically, however, blended the implementation of blended working practices.
working practices also introduce the risk of Older workers job performance can increase
increased workhome interference, as workers when the work environment is changed so as to
may feel an expectation to be constantly available t more closely with their needs. They prefer a
and may experience a blurring of work and private work environment that does not entail many
life; this can put a strain on workers themselves changes, that allows for a exible approach in
and on their relations with partners, family mem- conducting tasks, and in which they feel
bers, and friends (Van Yperen et al. 2014; supported and receive the appropriate training
Mazmanian et al. 2005). This may be particularly (Hedge and Borman 2012). Taking workers age,
problematic for older workers. First, older needs, and motives into account will help deter-
workers have a stronger need to adequately bal- mine how blended working can best be put into
ance work and private life (and tend to put a practice for each individual worker, and can give
stronger emphasis on leisure time) (Hedge insight in what aspects would require (additional)
et al. 2006). Secondly, older workers are more training opportunities (Van Yperen et al. 2014).
likely to face health issues, both regarding their However, as noted, negative age stereotypes
own health (which may mean that they need more often result in excluding older workers from learn-
opportunities to recover from work) (Thompson ing and training opportunities and lower their
and Mayhorn 2012) and the health of their partner comfort to use these technologies. It should be
or other family members (which means that they stressed that such stereotypes are counterproduc-
may need more time to fulll caring duties) (Czaja tive and inconsistent with research evidence
and Moen 2004; Hedge and Borman 2012). (Thompson and Mayhorn 2012; Ng and Feldman
Successful implementation of blended work- 2012). Organizations should become aware of
ing practices among an aging working population these (implicit) biases and start changing their
requires that these issues are explicitly addressed. knowledge about older workers in accordance
The perceived pressure resulting from constant with what has been shown in the literature
connectedness is found to be contingent on the (MacDermott 2014; Ng and Feldman 2012).
presence or absence of a shared notion that The aging workforce is a fact, not an option.
different workers might use ICTs differently Therefore, the challenge is to implement blended
working in a way that matches older workers organizational psychology (Vol. 2, pp. 12451283).
needs and motives, while minimizing the associ- New York, NY: Oxford University Press, Inc.
Hedge, J. W., Borman, W. C., & Lammlein, S. E. (2006).
ated risks. While technological training can be Organizational strategies for attracting, utilizing, and
particularly helpful in this regard, it is not simply retaining older workers. Washington, DC: American
a matter of teaching older workers new tricks. Psychological Association.
Coworkers and supervisors will need to change Lee, C. C., Czaja, S. J., & Sharit, J. (2009). Training older
workers for technology-based employment. Educa-
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Age and Intraindividual Variability 49
overview of current work). The present article,

Age and Intraindividual Variability however, focuses on cognitive and neuropsycho-
logical work relating to IIV in older adulthood and A
Becky I. Haynes, Sarah Bauermeister and David provides an introduction to the construct, its the-
Bunce oretical and empirical basis, and potential not only
School of Psychology, Faculty of Medicine and to provide important insights into healthy and
Health, University of Leeds, Leeds, UK neuropathological brain ageing but also to help
assessment of neurological disorders in clinical
contexts. IIV can refer to within-person variability
Synonyms at the macro level (e.g., over days, months, or
even years) or at the micro level (e.g., moment-
Inconsistency; Reaction time variability; Within- to-moment variation recorded in milliseconds).
person variability Although variability at the macro and micro
level may be related, distinctions have been
made between them. For example, whereas exter-
Definition nal factors such as stress or fatigue may inuence
variability at a more macro level (e.g., across
Intraindividual variability is broadly dened as assessment sessions), endogenous factors related
the uctuation in an individuals cognitive perfor- to, for instance, neurobiological disturbance may
mance over time. This can refer to the moment-to- have greater inuence on moment-to-moment
moment uctuation in reaction time on a single variability as captured by successive trials of a
task, variation across multiple tasks in a cognitive cognitive task (Hultsch et al. 2008). A further
battery, or a single task repeated over a period of distinction has been made between moment-to-
days, months, or years. moment variability on a single cognitive task
(referred to as inconsistency) and variation
across different cognitive tasks (referred to as
Background dispersion) (Hultsch et al. 2002). As there is
evidence that both types of IIV are associated, it
While cognitive and experimental psychologists is thought that they may capture similar underly-
have long been interested in age differences as ing constructs. However, as an impressive body of
reected by mean level of performance on a par- work has built up around the micro inconsis-
ticular task, there has been increasing recent inter- tency operationalization of the construct, and
est in the way that individuals vary over time. This measures arising from this work have consider-
intraindividual variability (IIV), also referred to as able potential in clinical practice, the present entry
within-person variability and inconsistency, is not will primarily focus on intraindividual variability
only of interest to researchers in ageing but also to in reaction times (IIVRT) obtained from trial to
researchers in several other elds (e.g., schizo- trial for a given neurocognitive task.
phrenia, attention decit hyperactive disorder) as IIVRT data are generally collected for an indi-
it may provide valuable insights into a variety of vidual by recording response times (normally in
issues including personality, cognitive perfor- milliseconds) from a series of computer-generated
mance, neurological status, and a range of other stimuli presented in either the visual or audio
individual differences. modes. Researchers have historically tended to
Within geropsychology, interest in IIV has quantify performance on such tasks by computing
stimulated an expanding volume of research in accuracy or calculating measures of central ten-
areas including personality development, health dency such as mean or median RT. However, it
behavior, stress and anxiety, and medical rehabil- has long been recognized that such within-person
itation (see Diehl et al. 2015), for a broad series of RTs exhibit varying degrees of variability
50 Age and Intraindividual Variability
for a given cognitive task and are frequently punc- for clinical practice, this section will briey sum-
tuated by either phasic shifts in response speed or marize the main perspectives and interpretations
intermittent slower responses. Although largely of IIVRT. Broadly, perspectives fall within meth-
ignored within experimental psychology, odological, cognitive, neurocognitive, or neurobi-
Nesselroade (1991) has pointed out that such ological domains.
within-person variation is likely to convey impor- Error variance: As indicated earlier, IIV, and
tant information beyond that conferred by mea- particularly IIVRT, until recently has largely been
sures of central tendency. In the context of ignored by experimental and cognitive psycholo-
neurocognitive ageing, this has generated consid- gists as being random noise related to error vari-
erable interest as it has been suggested that IIVRT ance attributable to a variety of sources such as
may reect attentional lapses, or relatedly uctu- accidental key presses and computer logging
ations in attentional and executive control mech- errors. However, the rapid development of com-
anisms (Bunce et al. 1993, 2004; West puting power with millisecond accuracy together
et al. 2002), or at a biological level, neurobiolog- with the recognition that IIV varies systematically
ical disturbance (e.g., Hultsch et al. 2008). Rec- according to a range of individual differences
ognition that IIV represents more than random (e.g., age) and the complexity of the cognitive
error variance has generated an expanding body task and experimental condition has largely dis-
of empirical research and theoretical comment, pelled this idea and led to the body of research
and the interested reader is directed to several forming the focus of this entry.
authoritative sources for further information Faster and slower responses reecting similar
(e.g., Diehl et al. 2015; Hultsch et al. 2008). underlying cognitive operations: A second inter-
The present entry, however, will provide an pretation stems from the idea that faster and
overview of the main theoretical perspectives slower RTs for a given cognitive task qualitatively
that have been used to understand IIVRT and reect exactly the same underlying cognitive
then, given space limitations, provide a selective operations, but simply take differing lengths of
review of cross-sectional and longitudinal empir- time to initiate and complete. However, such
ical research in the ageing area. Given the impor- interpretations appear limited as (a) conceptually,
tance of work demonstrating that IIV is not simply they ignore the question of why a succession of
error variance, examples are provided of neuro- trials for the same cognitive task should vary over
imaging work suggesting that IIVRT varies sys- relatively short periods of time, and (b) they do
tematically in relation to the integrity of not take into account the accumulating empirical
neuroanatomical structures (e.g., white matter experimental, neuroimaging and clinical work
connective tracts) and functional brain activity. that clearly demonstrates IIV to systematically
As IIV measures have the potential to provide vary according to a variety of individual differ-
quick-to-use assessment tools in clinical contexts, ences and task-related factors.
issues are then highlighted that research should Attentional lapses and variation in attentional
address in developing the measures for possible and executive control mechanisms: An alternative
practitioner use. In the nal section, some of the explanation for IIV within the context of ageing
broader issues are emphasized where research has its roots in cognitive psychology and holds
effort is needed to increase our understanding that response speed variation over the course of a
of IIV. cognitive task reects age-related attentional
lapses or, relatedly, the strength of engagement
of attentional or executive control mechanisms
Theoretical Perspectives on IIVRT (Bunce et al. 1993, 2004; West et al. 2002). One
way to think of this is to imagine an attentional
Theoretically, how has IIVRT been viewed? As the spotlight, whereby RTs of different durations
answer to this question is central to the interpre- reect the extent to which the individual is
tation of empirical research and its implications focused on the task in hand; faster RTs indicate a
greater level of attentional engagement with a proposes that more general age-related deteriora-
narrower, more focused spotlight, whereas slower tion of the central nervous system is responsible
RTs reect a broader less focused attentional spot- for increased IIV in old age (e.g., Hultsch A
light. Layered onto these phasic shifts in the focus et al. 2008). Such deterioration might be related
of the attentional spotlight are intermittent and to specic neuropathology associated with, for
unusually slow RTs reecting attentional lapses example, the development of dementia or the con-
where inhibitory failure has allowed task irrele- sequence of major trauma such as brain injury.
vant information (e.g., internal momentary Evidence consistent with this view comes from
daydreaming or external environmental distur- work showing that increased IIV is associated
bance) to interfere with information processing. with mild dementia (e.g., Hultsch et al. 2000).
Although such interpretations have been conten-
tious, recent functional brain imaging work (e.g.,
Weissman et al. 2006) in younger adults is con- Empirical Research into Healthy
sistent with the view that trial-to-trial responses of and Neuropathological Ageing
differing speeds may reect the extent to which
attentional or executive control mechanisms are Given the foregoing theoretical perspectives,
engaged. what does the existing empirical literature say
Neural noise: An approach that integrates about age and IIVRT? The bulk of research tends
neurobiological perspectives proposes that to be cross-sectional, normally looking at individ-
age-related increases in neural noise are responsi- ual differences and/or the effects of experimental
ble for the broader cognitive decline observed in manipulations of task condition. Although this
old age. The idea that reductions in neural signal work provides important insights into a range of
to noise arising from age-related dopamine (one inuences on within-person variability, it says
of several neurotransmitters responsible for ef- little of causal or temporal factors related to
cient neural communication) depletion may IIV. Such issues are addressed by longitudinal
explain behavioral increases in IIV in old age is investigations which by comparison are in the
central to recent theoretical accounts. For exam- extreme minority. Here, the main ndings from
ple, using computational modeling techniques, Li cross-sectional and longitudinal studies investi-
and colleagues (2001) demonstrated that modify- gating age and IIVRT are selectively reviewed.
ing model parameters that simulate age-related
dopamine depletion lead to more random activa-
tion during signal processing. Computationally, Cross-Sectional Studies
this parallels age-related reductions in signal to
noise that compromise the distinctiveness of cor- There are a number of cross-sectional studies that
tical representations. The authors argue that a suggest a reliable increase in variability across the
behavioral consequence of this is an increase in adult lifespan. For example, in a meta-analysis of
the within-person variation of cognitive perfor- studies taking age into account (Dykiert
mance. Functional imaging work demonstrating et al. 2012), increased IIV was found for simple
a link between dopamine modulation and behav- or choice reaction time (RT) tasks in older
ioral IIV in older adults supports the view that (age 60+) relative to middle-aged (4059) and
age-related reductions in this neurotransmitter younger (age 2039) adults. As pooled effect
may be one of the neurobiological mechanisms sizes were larger for contrasts between older and
underpinning increased IIV in old age younger participants than for older and middle-
(MacDonald et al. 2012). aged participants, the ndings suggest that
Neurobiological disturbance: Whereas later increased IIV is not restricted to older age, but
accounts of the neural noise perspective link increases gradually across the lifespan. The asso-
increased IIV to a specic mechanism, dopamine ciation between IIV and age has also been shown
depletion, this account is more generic in that it in more complex tasks such as memory tests and
tasks requiring attentional or executive control subsequent cognitive decline. For example, one
(e.g., Hultsch et al. 2002). Across a variety of study (Lovden et al. 2007) had participants (aged
tasks, the evidence suggests that age differences 70102 years at baseline) complete cognitive
in IIV are increased with greater cognitive tasks, including perceptual speed and category
demands. uency, on ve occasions over a 13-year period.
In addition to increases in within-person vari- The results showed that longitudinal change in
ability in healthy ageing, elevated IIV has also IIVRT was highly correlated with change in level
been shown in persons exhibiting mild cognitive of performance. Increased IIVRT temporally pre-
impairment. As noted earlier, IIV is thought to be ceded cognitive decline, whereas lower cognitive
a marker of neurobiological disturbance and performance had a negligible inuence on subse-
increased variability has been shown in individ- quent change in variability. Importantly, this is
uals with mild dementia compared to neurologi- one of the rst studies to suggest that increased
cally intact controls or individuals with arthritis IIV may serve as an early marker of future cogni-
but no cognitive impairment (Hultsch et al. 2000). tive decline.
Because mild dementia is a disease of the central Longitudinal evidence also indicates that
nervous system while arthritis is not, this study increased IIVRT may be an early marker of
was one of the rst to suggest that IIVRT may be age-related neuropathology (Bielak et al. 2010).
particularly sensitive to central nervous system Over a 5-year period, community-dwelling older
integrity. Similarly, increased IIVRT has also adults aged 6492 years at baseline were grouped
been shown in patients with Parkinsons disease according to four classications of CIND
relative to healthy controls (de Frias et al. 2012), (cognitive impairment no dementia). Over the
and that this difference increases with task course of the study, participants either
complexity. (i) remained cognitive intact, (ii) remained stable
CIND, (iii) uctuated between CIND and
cognitively intact, or (iv) transitioned into
Longitudinal Studies CIND. Baseline IIVRT, computed from multi-
trial computerized tasks, not only differentiated
Although there is much less longitudinal work in between participants who were consistently intact
the area, there is evidence that IIVRT increases and those who were stable CIND over time, but
with age and is predictive of future cognitive importantly identied those who transitioned
decline and also of future neuropathology. For into CIND.
example, a large-scale study tested three age Further evidence that IIV can predict future
cohorts (20s, 40s, and 60s) at 4-year intervals neuropathology comes from a longitudinal study
over 8 years on simple RT and more complex that investigated whether change in variability
choice RT tasks (Bielak et al. 2014). Multilevel distinguished between Parkinsons disease
modeling adjusting for a range of potential inu- patients who did or did not develop dementia
ences including education level, health back- (de Frias et al. 2012). This study followed
ground (e.g., diabetes, hypertension), anxiety, Parkinsons disease patients aged 6584 and
and depressive symptoms showed an increase in 43 matched controls. Participants were assessed
simple RT variability over time in the older group. at three time points: baseline (T1), 18 months
Consistent with the view that more marked age (T2), and 36 months (T3). All participants had
effects are generally found in more complex tasks, normal cognition at T1 and T2; however, at T3
increases were also found over time for both the 10 Parkinsons disease patients were diagnosed
40s and 60s groups for a choice RT task, although with either dementia or cognitive impairment.
this trend was stronger in the older group. IIVRT measures were obtained from simple and
There is also longitudinal evidence that choice RT tasks at T1 and T2. Change in variabil-
increased IIV may be an early marker of ity differentiated the Parkinsons with dementia
age-related neuropathology and is predictive of group from the Parkinsons patients who
remained cognitively intact and the healthy con- resonance imaging (MRI) measures of white mat-
trol group. Specically, the Parkinsons with ter hyperintensities (WMH, microscopic white
dementia group showed an increase in variability matter lesions) or diffusion tensor imaging. For A
from T1 to T2, whereas the other groups did not. instance, a recent MRI study (Bunce et al. 2013)
IIVRT also predicts falls and gait impairment investigated WMH in relation to RT variability in
in old age. A recent systematic literature review healthy middle-aged adults. Consistent with the
(Graveson et al. 2015) identied ve studies (two view that elevated IIV is associated with neurobi-
prospective) reporting statistically signicant ological disturbance, greater frontal WMH burden
associations between IIV measures and falls. was related to increased IIVRT. Such associations
A further four studies investigated the association between frontal WMH and IIVRT are of interest as
between IIV and gait impairment nding more they are consistent with the idea that attentional
mixed evidence of an association although this mechanisms supported by the frontal cortex play a
may have been due to methodological differences key role in the degree of RT variability. As noted
between studies. However, this review clearly earlier, there is also evidence that the neurotrans-
underlines the potential of IIV measures to iden- mitter dopamine inuences the level of IIVRT in
tify older persons at risk of falling, although more old age. Positron emission tomography has been
prospective studies are required in the area. used to assess dopamine D1 binding potential in
Finally, several studies have shown that in younger (mean age 25 years) and older (mean age
older adults, increased IIV predicts all-cause mor- 70 years) adults relative to IIVRT on an interfer-
tality at least 12 years in the future (e.g., MacDon- ence task (MacDonald et al. 2012). Increased
ald et al. 2008). The ndings from these mortality variability was associated with older age and
studies are of note as they suggest that the neuro- diminished D1 binding in brain regions that form
logical disturbance that may be related to eventual part of the attentional network (e.g., dorsolateral
death is present more than a decade in advance of prefrontal cortex and anterior cingulate gyrus).
the event. These studies highlight the potential of The ndings suggest that dysfunctional dopamine
IIV measures to identify individuals at an early modulation in attentional networks may contrib-
stage in the course of age-related decline thereby ute to increased RT variability in older adults.
opening possibilities for intervention. (Although conducted in younger adults, the func-
Although a selective review, the examples of tional imaging study (Weissman et al. 2006) men-
individual studies detailed above, and evidence tioned earlier also provides some interesting
assimilated from qualitative and quantitative functional MRI evidence of the brain activity
reviews of the literature, are representative of the associated with IIV.)
broader body of research in that IIV increases over Although several imaging studies support a
time with age and also predicts future cognitive systematic association between IIV and brain
decline and neuropathology. structures, processes, and activity, a particularly
interesting insight into that association is provided
by recent work suggesting that an inverse rela-
Is IIV Systematically Related to Brain tionship may exist between behavioral measures
Structure and Activity? of IIVRT and variability in brain activity as mea-
sured by the blood oxygen level-dependent
A key part of our understanding of IIV stems from (BOLD) response (a measure of brain activity
brain imaging work that suggests that IIVRT is not obtained in MRI investigations). For example,
simply random noise, but rather is systematically Garrett and colleagues (2011) examined the rela-
associated with either neuroanatomical structures tionship between BOLD variability and IIV on
or brain processes such as neurotransmitter mod- three cognitive tasks (perceptual matching, atten-
ulation. Several studies, for example, have tional cueing, and delayed match to sample) in
described the relationship between IIV and brain younger (aged 2030 years) and older (aged
structural integrity reected in magnetic 5685 years) adults. Across tasks, being younger
and behaviorally faster and less variable was asso- remained statistically signicant. This suggests
ciated with greater BOLD variability relative to that although some of the age-related increase in
older, poorer-performing adults. This study not IIV was associated with age-related response
only provides important evidence that BOLD slowing, a portion of the variance arises from
activity is functionally associated with IIV but other sources.
also suggests that (a) BOLD variability decreases Another insight into this question comes from
with age and (b) greater BOLD variability is studies that show a dissociation between IIV and
related to superior behavioral performance mean RT measures from the same cognitive task.
(in this case, lower IIV). Therefore, increased That is, signicant effects in relation to outcome
variability at the neural level may reect greater are obtained for the IIV measure but not mean
signal to noise (i.e., more distinct signal) that, in RT. For example, Hultsch and colleagues (2000)
turn, feeds into higher behavioral performance found that IIV was uniquely predictive of neuro-
marked by less within-person variability. logical status (mild dementia compared with
In sum, the accumulating evidence suggests healthy older adult or arthritic control groups),
that the level of IIV is related to the structural and structural MRI studies also indicate a disso-
integrity of the brain and that behavioral IIV ciation between IIVand mean RT in relation to, for
varies systematically as a function of brain pro- example, frontal white matter hyperintensities
cesses and activity. Interestingly, early evidence (WMH) (Bunce et al. 2013).
also suggests that greater functional brain activity Together, this accumulating evidence suggests
may be inversely related to behavioral perfor- that IIV does provide unique information that
mance and that this association may change measures of mean RT from the same task do not
with age. capture. Given theoretical accounts that link
increased IIV to neurobiological disturbance and
empirical evidence supporting the association, a
What Does RT Intraindividual Variability key question is whether IIV measures have the
Convey Beyond Mean RT? potential to supplement commonly used neuro-
psychological assessment measures to help iden-
A key question concerns whether IIVRT measures tify age-related neuropathology. Indeed, is it the
from a given cognitive task provide information case that these measures are particularly sensitive
beyond that obtained from measures of mean or to the subtle early manifestations of neurological
median RT (i.e., measures of central tendency). disorders and therefore have potential as early
Because mathematically, shifts in the warning devices? This issue is considered in the
intraindividual RT standard deviation are closely next section.
linked to shifts in mean RT, researchers have
concerned themselves with disentangling the
effects of the two measures. One approach Clinical Implications and Practice
involves adjusting for mean RT in order to
conrm that IIV effects are independent. Several Some of the empirical studies reviewed clearly
studies have been published in older adults suggest that IIV measures can provide an early
relating to various outcomes that demonstrate marker of future cognitive decline or neurological
that IIV has independent effects. For example, disturbance (e.g., Lovden et al. 2007; Bielak
the aforementioned meta-analysis (Dykiert et al. 2010). This raises the possibility that the
et al. 2012) investigated age effects in variability measures may have potential in clinical practice
and generated pooled effect sizes for studies that either as supplements to neuropsychological
adjusted variability for mean RT in contrast to assessment batteries or as stand-alone metrics.
studies that were not adjusted. For both simple Use of variability measures is attractive for sev-
RT and choice RT, pooled effect sizes were eral reasons. First, they can be administered on
smaller when using mean-adjusted IIV but commonly available PCs, laptops, or tablets using
responses to stimuli appearing on a screen requir- different tasks best suited to different clinical con-
ing minimal linguistic content. The measures ditions and contexts?
may, therefore, possess advantages when used Relatedly, in quantifying the intraindividual A
with individuals from culturally and linguistically standard deviation (SD) measures used to estimate
diverse backgrounds. Second, administration IIV, investigators have used a range of metrics
requires minimal neuropsychological training, including the raw SD, the coefcient of variation
and assuming appropriate normative data, the (intraindividual SD/intraindividual mean),
measures may have considerable potential in pri- ex-Gaussian parameters (i.e., mu, sigma, tau),
mary healthcare. Finally, IIV measures are quick fast Fourier transformations, and procedures that
to administer. For example, a recent study in cog- statistically partial out potentially confounding
nitively intact community-dwelling middle-aged effects that inate IIV such as time-on-task effects
persons (Bunce et al. 2013) found statistically (e.g., practice, fatigue) and individual differences
reliable predictions of potential neuropathology (e.g., age). Though all of these measures have
(frontal cortex burden of WMH) were obtained been found to be signicantly associated with a
from as few as 20 RT trials taking approximately range of outcomes, important questions again
52 s to administer. Although it is not clear whether concern what is the most appropriate metric and
the WMH in this sample were indicative of future under what circumstances. Although existing
neuropathological disorders such as mild cogni- research (e.g., Lovden et al. 2007; Bunce
tive impairment (MCI) or dementia, the potential et al. 2013) suggests that different metrics produce
of IIVRT measures to provide quick and simple similar outcomes, issues such as psychometric
identication of persons at risk of such disorders specicity and sensitivity are important as well
is clear. An important direction for future work, as the practicalities of computation and interpre-
therefore, is to explore the potential of IIV mea- tation by time-pressured practitioners working in
sures in clinical contexts. busy clinics. Research is clearly required
regarding the suitability and rigor of different
computations of IIV. Further evidence is also
Future Research: Gaps in Knowledge needed of the number of trials that should be
administered in order to produce a reliable predic-
Clearly, IIV measures may not only provide tor of outcome.
important insights into ageing neurocognitive Third, as noted earlier, to what extent do IIV
processes but, as the foregoing section has measures provide information beyond that present
highlighted, also provide a potential neuropsy- in mean RT measures obtained from the same
chological assessment tool in clinical contexts. task? Although numerous studies have either
Against this background there are some important adjusted for mean level of performance (either
gaps in our knowledge that future research needs statistically or in the computation of the IIV mea-
to address. sure itself) or demonstrated a dissociation
First, to date, studies investigating IIVRT have between IIVRT and mean RT tasks where the for-
used a wide variety of cognitive tasks ranging mer but not the latter signicantly predict out-
from fairly straightforward psychomotor tasks come, more evidence is required of the
(e.g., simple or choice RT) to more complex atten- independence of IIVRT relative to mean RT.
tional or executive control tasks (e.g., Stroop and Fourth, most of the research to date has been
Flanker tasks). Although tasks of varying com- cross-sectional in nature, and so temporal rela-
plexities have been shown to be signicantly asso- tions between IIVRT and outcome need to be better
ciated with various outcomes, a key question is understood. Although research has shown IIV to
what type of task and level of complexity is most be predictive of future cognitive decline, MCI,
suited to identifying which condition and under mild dementia, falls, and all-cause mortality, it is
which circumstances. Indeed, is it possible to important that research provides more evidence of
develop one ubiquitous catch all task, or are the measures predictive utility.
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Weissman, D. H., Roberts, K. C., Visscher, K. M., & out the Western world, the average age of the
Woldorff, M. G. (2006). The neural bases of momentary populations is increasing due to decreased fertility
lapses in attention. Nature Neuroscience, 9, 971978.
West, R., Murphy, K. J., Armilio, M. L., Craik, F. I. M., & rates, increased longevity and the baby boom
Stuss, D. T. (2002). Lapses of intention and performance generation that is currently approaching their
variability reveal age-related increases in uctuations of retirement age. As a consequence, workforces
executive control. Brain and Cognition, 49, 402419. will be composed more and more of older
workers, and with many governments increasing
the statutory retirement age, the available pool of
potential employees will increasingly be consisted
Age and the Psychological Contract of older workers (Truxillo and Fraccaroli 2013).
As a consequence of these changes in the work-
P. Matthijs Bal force constitution, organizations have to adjust
School of Management, University of Bath, Bath, their policies and practices to facilitate older
UK workers to stay and remain motivated, productive,
and healthy contributors in the organization.
However, very few organizations actually manage
Synonyms to successfully implement policies and practices
to retain and motivate their older workers (Bal and
Aging workers; Employee motivation; Employ- Jansen 2015). One way the employment relation-
ment relationship; Older workers ship between employee and organization can be
understood is through the lens of the psychologi-
cal contract. The psychological contract describes
Definition the exchange relationship between employees and
the organization (Rousseau 1995), and is essential
Psychological contracts describe the exchange to understand the attitudes and behaviors of
relationships between employees and employees in their organizations. This chapter
58 Age and the Psychological Contract
explores how age may affect the psychological organization should do for the employee, and
contract between employees and organizations, what the employee should do in return. These
and explores the theoretical processes through mutual obligations may have arisen from
which age has an impact on psychological con- preemployment experiences, but are also commu-
tract dynamics. I describe three ways how the nicated via recruitment processes, communication
psychological contract is inuenced by employee from the organization (such as employer brand-
age. First, age can have an impact on the obliga- ing), and promises made by managers to the
tions employees exchange with their employers. employee (Rousseau 1995). Key to understanding
This means employers and employees develop the psychological contract is its subjectivity:
different expectations of each other when the employees form perceptions of the mutual obliga-
employees become older. Secondly, age can tions between them and their organizations, and
have an effect by inuencing the type of psycho- these perceptions lead their attitudes and behav-
logical contract employees have with their orga- iors (Zhao et al. 2007). Psychological contract
nization. Research has distinguished between research typically distinguishes between three
transactional and relational contracts (Rousseau ways the psychological contract can be
and McLean Parks 1993; Zhao et al. 2007), and approached; rst research has focused on the con-
previous studies have shown that age may be tent of the psychological contract, or the percep-
related to the type of contract one has with the tions of the employee about what is exchanged
organization (Vantilborgh et al. 2015). Finally, between employee and organization (Conway and
age inuences the responses employees show Briner 2005). Second, research focused on the
towards breach and violation of the psychological type of psychological contract that employees
contract (Bal et al. 2008). Below, each of the have negotiated or formed with their organization,
pathways through which age may impact the psy- and has distinguished between transactional and
chological contract will be outlined. relational contracts (Rousseau and McLean Parks
1993). Finally, the majority of research on psy-
chological contracts has focused on the breach of
The Psychological Contract the psychological contract and its consequences
on various outcomes, such as motivation and per-
The psychological contract has been developed as formance (Zhao et al. 2007; Bal et al. 2008). Each
a scientic construct in the early 1990s (Rousseau of these elements of the psychological contract
1989, 1995), while being introduced in the early may be related to employee age and will be
1960s in the research of Argyris (1960) who discussed in greater detail below. However, to do
described it as a relationship that developed so, rst a discussion will follow on the theoretical
between employees and their foremen at work. development of the concept of age in organiza-
The relationship consisted of expectations of tions in relation to psychological contracts.
employees and managers about each others
behavior beyond what is traditionally dened in Theories of Age and the Psychological
contracts such as the number of working hours Contract
and the remuneration. Argyris (1960) referred to Research on the role of employee age in the work-
this relationship as a psychological contract place can be traced back to the early 1980s (Maehr
between the two parties, and subsequent work by and Kleiber 1981; Rhodes 1983). While initial
Rousseau (1989, 1995) developed the construct interest primarily was on the direct effect age has
more thoroughly. Rousseau dened the psycho- on various work outcomes, such as job satisfac-
logical contract as the employees perceptions tion and job performance (Avolio et al. 1990),
about the mutual written and unwritten obliga- during the last year scientic work on the role of
tions between them and their organizations. In employee age in the workplace has advanced sub-
other words, the psychological contract is a men- stantially (see e.g., Kooij et al. 2008). More
tal model about what the employee thinks the specically, theory of aged heterogeneity
(Nelson and Dannefer 1992) postulates that the should be, and how they react to psychological
older people become, the more heterogeneous contract experiences. Time perspective causes
they become as well. Hence, recent work on people to shift from knowledge-related goals to A
aging in the workplace has acknowledged that emotional goals and well-being, and this also has
the predictive value of employee age with respect implications for psychological contracts.
to job attitudes and behaviors is very marginal The SOC-model of aging (Baltes and Baltes
(Bal and Jansen 2015; Kooij et al. 2008; Bal and 1990) postulates that people experience losses in
Kooij 2011). Because the aging process is associ- their capabilities when they age. To cope with these
ated with various changes, including changes in losses, they will use a number of strategies to adapt
personality, life styles, health, organizational to their environment, namely selection, optimiza-
experiences, and psychosocial perceptions, it has tion, and compensation. People select by
been argued that the older people become, the narrowing their range of activities to fewer but
more different they become from their peers. more important or rewarding goals. For instance,
Hence, older workers will also be more different employees may give up job responsibilities or
from each other and therefore also show more involve others in their less central tasks because
complex patterns in relation to work-related expe- the overall workload becomes too high. Optimiza-
riences, including psychological contract perception refers to acquisition of, and investment in,
tions, job attitudes and job behaviors. Hence, it is means and abilities to achieve the goals people set
important to ascertain the underlying changes that in their work. For instance, people who perceive
cause psychological contract perceptions and job that their competencies are becoming obsolete may
attitudes to change with age. Therefore, theories of search for alternative strategies to maintain their
gerontology and development psychology shed performance. Finally, people compensate for losses
more light on the changes that people experience through employing alternative means to maintain a
when aging at work. Especially the Socioemotional desired level of functioning. For instance, people
Selectivity Theory (SST; Carstensen 2006), and the use pragmatic means (e.g., how they present them-
Selective Optimization with Compensation model selves to others; Abraham and Hansson 1995) to
(SOC-model; Baltes and Baltes 1990) may inform make up for losses they experience. More speci-
theory about aging and psychological contracts. cally, people act in ways that minimize the effects
Socioemotional selectivity theory states that in of developmental losses on the evaluation of their
young adulthood time is perceived as expansive performance in the workplace (Abraham and
(Carstensen 2006). Young people prepare for a Hansson 1995, p. 96). Previous research has
long and unknown future and therefore primarily shown that people who are successful in employing
focus on growth and knowledge-related goals. For their SOC-strategies obtain a more satisfactory
older people, however, the experience of level of performance at work (Kooij et al. 2008).
approaching the end of life causes a shift towards Hence, the SOC-model may play an important role
present-related emotional goals over knowledge in explaining how older workers cope with
goals, and a focus on emotional well-being. Older age-related losses in forming their psychological
people increasingly focus on the present, and in contracts with the organization. Below, the chapter
particular on maintaining positive feelings and discusses how aging may impact the three elements
avoidance of negative feelings (Carstensen 2006; of the psychological contract, based on the main
Carstensen and Mikels 2005). Although older theoretical notions of aging.
people may be sensitive to emotional situations,
they are more focused on maintaining positive
feelings (Carstensen and Mikels 2005). The cen- Age and Content of the Psychological
tral idea of SST is that with increasing age, people Contract
have a different time perspective, and these
changes in time perspective are predictive of The content of the psychological contract is the
how they perceive their psychological contract rst element that can be affected by employee age.
The content of the psychological contract refers to Age and Psychological Contract Types
the employees beliefs about what the employer is
obligated to the employee and what the employee Type of psychological contract refers to the nature
owns in return (Rousseau 1995). Research has of the relationship between employee and organi-
shown that obligations that employees expect zation, and instead of describing the specic obli-
their organizations to deliver include nancial gations which are part of the exchange
rewards, interesting jobs, a nice working atmo- relationship, types dene the more generic nature
sphere, career development, and worklife bal- of the relationship. The most often studied psy-
ance (De Vos et al. 2003). Conversely, perceived chological contract types are transactional and
employee obligations include inrole behavior, relational contracts (Rousseau 1995). Transac-
such as job performance, extra-role behaviors, tional contracts refer to the short-term monetiz-
exibility, loyalty and ethical behavior (De Vos able aspects of the relationship where there is little
et al. 2003). Surprisingly, there is not much mutual involvement in the lives and activities of
research on the role of age in the development of each other (Rousseau and McLean Parks 1993).
these obligations. Schalk (2004) reported that in The focus is purely materialistic. Relational con-
general, employee obligations tend to increase tracts, however, entail aspects of the relationship
with age, while employer obligations show a that focus on mutual agreement with both
more complex pattern. Based on ndings that exchanges of monetizable elements and
older workers become more benevolent, Schalk socioemotional elements, including career devel-
(2004) concluded that older workers form a psy- opment. The focus is on establishment of a long-
chological contract that emphasizes the term and open-ended relationship (Rousseau and
employees contributions over that of the organi- McLean Parks 1993). Because of the focus of
zation. Hence, a rst conclusion is that over the relational contracts on career development, it
life course people will expect less from their could be argued that older workers over time
employer, while their perceptions of their own develop a more transactional and less relational
obligations may be stable even increase with contract. However, given the emotional nature of
aging. relational contracts, it can also be argued that
Theoretically, SST predicts that older people older workers develop a more relational contract
have a more constraint future time perspective and over time and given older workers longer average
therefore prioritize emotional goals over knowledge tenure in organizations, they might also develop
goals (Carstensen and Mikels 2005), and the less transactional contracts. Research shows
SOC-model states that in order to cope with inconsistent patterns of relationships. A meta-
age-related losses, older people become more analysis of Vantilborgh and colleagues
prevention-focused (Baltes and Baltes 1990). As a (Vantilborgh et al. 2015) showed that age was
consequence, older workers should be less focused negatively related to transactional contracts,
on employer obligations such as development, and while it was unrelated to relational contracts.
more on obligations such as worklife balance and Another study by Bal and Kooij (2011) found
social atmosphere, as they are more aligned with that the extent to which age has an impact on
emotional goals. However, research on the direct type of contract, depended upon how central the
impact of age on perceived obligations is scarce. role of work in the lives of older workers was.
Bal (2009) reported a negative correlation between While work centrality did not matter for younger
age and developmental obligations, but found no workers, they found that for older workers, the
signicant relation of age with other employer obli- centrality of work in their lives determined
gations. Hence, there is some tentative evidence for whether they were willing to invest in the rela-
an effect of age on content of the psychological tionship with the organization and develop a rela-
contract, indicating a decrease of employer devel- tional contract. In contrast, older workers with
opmental obligations over the life course, and low work centrality were more likely to have a
increase of employee obligations with age. transactional, tit-for-tat relationship with their
organization. However, given the complex nature the contract (Zhao et al. 2007; Bal et al. 2008).
of the meaning of age as well as type of psycho- Contract breach is dened as the cognition by the
logical contract, there is no denitive answer to employee that the employer has failed to fulll A
the question whether older workers have more one or more elements in the psychological con-
transactional or relational contracts. tract (Morrison and Robinson 1997). Contract
Other research on the relation between age and violation is subsequently dened as the emotional
types of psychological contracts has focused on reaction following a breach. Previous meta-
the degree of balance in employer versus analytic work has shown that contract breach
employee obligations (Vantilborgh et al. 2013). and violation are associated with a range of out-
Vantilborgh and colleagues (2013) found that in comes, including lower work motivation, job sat-
line with the benevolence hypothesis, older isfaction, organizational commitment, and job
workers tend to report more under obligations, performance, and higher employee turnover
while younger workers were more likely to report (Zhao et al. 2007; Bal et al. 2008). Hence, psy-
over obligation. This means that older workers chological contracts become salient for
perceived their own obligations to the organiza- employees and organization when there is a dis-
tion to be higher than what the organization ruption, and employees perceive a breach, since
should do for them, while younger workers this may have severe consequences for employee
reported that the organization owed them more attitudes and behaviors, which may be related to
than they owed the organization. This indicates negative consequences for the organization as
that while younger workers, who have more well. It is not surprising given the importance of
expanded future time perspectives (Carstensen breach that most of the research on the role of age
2006), focus on learning and development and in psychological contracts has focused on how
consequently expect the organization to deliver age inuences breach and reactions to breach.
upon these obligations. Older workers, however, The rst published study on the role of age in
have a lower future time perspective and therefore psychological contracts was in fact a meta-
have lower expectations concerning what the analysis looking at the moderating role of age in
organization should do for them, and they may the relations between contract breach and job atti-
fulll their emotional goals through different tudes (Bal et al. 2008). Based on SST, the authors
means than the organization. In sum, there is argued that when workers become older, they are
mixed evidence of the relationships of age with more focused on emotional goals and mainte-
type of psychological contract. While meta- nance of emotional well-being, and hence when
analytic evidence suggests that older workers they are confronted with a negative emotional
have less transactional contracts, there is also evi- experience such as a breach, they are focused on
dence that hints at the contingent nature of the maintaining their existing relationships. Hence, it
relation between age and relational contracts, with was expected that older workers would react less
a potential moderating effect of work centrality. intensely when a contract breach occurred as it
Hence, the extent to which older workers develop would disrupt their relationship with the organi-
different types of psychological contract depends zation. Bal et al. (2008) found overall support for
upon how they experience the aging process, the this hypothesis, and found that younger workers
role of work in their lives, and the goals they have reacted more strongly to breach in relation to trust
in their lives and at work. and organizational commitment. However, they
also found that older workers reacted more
strongly in relation to job satisfaction, and
Age and Psychological Contract Breach hence, more research was needed to ascertain the
and Violation specic relationships.
Theoretically, SST proposes that older people
The majority of studies on psychological con- have fewer future opportunities, and therefore
tracts have focused on breach and violation of concentrate on emotional well-being, and the
SOC-model proposes that in order to cope with the reactions to breach can be studied in greater
age-related losses, people become more focused detail. Finally, a study of Bal and Smit (2012)
on prevention of losses and maintenance of well- focused on the emotion regulation aspect of SST,
being and current functioning (Carstensen 2006; and proposed that older workers may be better in
Baltes and Baltes 1990). Hence, it is to be regulating their emotions once a breach has
expected that age may have different effects on occurred. They found support for this notion; the
breach and violation, and in particular the way relations of psychological contract breach with
people react to breach and violation. Following positive and negative affect were moderated by
these theoretical notions, a number of studies have age, and in line with their predictions, emotion
focused on explaining the different reactions peo- regulation strategies were also important in rela-
ple show in response to breaches. A study of De tion to breach. While in general suppression of
Lange and colleagues (2011) investigated the rela- emotions is negative, the study showed that
tions between breach and work motivation, and in because older workers are better in expressing
particular they ascertained the role of age-related their emotions, suppression has adverse effects
factors as moderators. Based on the idea that the for older workers in response to breach, while it
aging process entails different changes, they was benecial for younger workers in response to
looked in particular at the role of future time breach. Their results show that younger workers
perspective and regulatory focus. Their study do not yet have developed the appropriate emo-
indicated that older workers indeed experienced tion regulation strategies and therefore should be
a lower future time perspective as well as a lower careful with expressing what they feel, while older
promotion (i.e., learning and development) focus. workers in general have better skills to express
Moreover, they found that people with high future themselves after a breach has occurred.
time perspective and a low prevention focus In sum, these studies show that age has a strong
reacted more strongly to contract breach in rela- effect on how people react to psychological con-
tion to work motivation. Their study shows evi- tract breach and violation. In general, older
dence for a mediated moderation effect: the workers tend to react less intensely, but these
relations of contract breach with outcomes are reactions are dependent upon age-related changes
dependent upon employee age, but via future people experience over their lives. Because peo-
time perspective and regulatory focus. Taking ple when they become older have fewer opportu-
this idea further, Bal and colleagues (2013) tested nities in their future, are less promotion-focused
a model where the relations between breach and and more prevention-focused, they are inclined to
organizational commitment were moderated by react less intensely when they experience a con-
two age-related factors: future time perspective tract breach. However, older workers also have
and occupational expertise. The authors showed accumulated skills and expertise, through which
that while age was related to lower future time they feel more entitled and show stronger reac-
perspective, it was related to higher occupational tions to breach. Moreover, they have developed
expertise, as people develop their expertise over more appropriate emotion regulation skills and
time. They showed that while high future time therefore their reactions may also be qualitatively
perspective (i.e., younger workers) was related different from those of younger workers. How-
to stronger reactions of breach on commitment, ever, future research is needed to further ascertain
they also showed that high occupational expertise how younger and older workers differ in their
(i.e., older workers) also related to stronger reac- reactions to breach and violation.
tions to breach. Thus, they concluded that the
overall effect of age on the reactions to breach
may be nullied through the differential effects Conclusion
age has on time perspective and expertise. Thus,
by disentangling the effects age has on how peo- This chapter explored the role of employee age in
ple experience their environment and themselves, psychological contracts. Psychological contracts
describe the unwritten, mutual obligations survivors within organizations. Perhaps

between employees and their organizations, and employees with more relational and less transac-
are subjectively experienced by employees. tional contract may be more likely to stay in the A
Research has shown that psychological contracts, organization, while others with a more transac-
and in particular perceptions of breach and viola- tional contract leave or are made redundant more
tion, are profoundly related to various outcomes, easily. Hence, a negative correlation could be due
including lower motivation, commitment and per- to employees leaving the organizations, and older
formance, and higher employee turnover (Zhao workers being the survivors within the organiza-
et al. 2007; Bal et al. 2008). There are three tion. Theoretically, there are multiple reasons why
elements of the psychological contract that can older workers should have more transactional and
be inuenced by age: the content, the type, and more relational contracts, and it is through
the reactions to breach and violation. Building on research looking at contingency factors that we
theoretical notions of SST (Carstensen 2006) and obtain more understanding of the process through
the SOC-model (Baltes and Baltes 1990), age can which older workers develop their psychological
have a three-folded effect on the psychological contracts over time. For instance, Bal and Kooij
contract. (2011) showed that work centrality may be an
First, age can impact the obligations that important factor that determines whether older
employees perceive their organization has workers still invest in their relationship with the
towards them and the obligations that employees organization, or just accept a transactional agree-
themselves have towards their employer. While ment that only entails a number of hours and
there is some research on this, indicating some salary in exchange for work. Hence, future
benevolence of the older worker, there is still research can also shed more light on the relation-
much left to be investigated. More specically, ships between age and type of psychological
there is little known on whether obligations contract.
become less or more important as employees Finally, age can have an effect on how people
grow older, and whether obligations will change respond to psychological contract breaches. Meta-
more qualitatively. For instance, while worklife analytic work (Bal et al. 2008) and primary
balance may be important for younger workers to research has shown that older workers may show
have exibility to develop themselves in other different reactions to contract breaches, but these
areas outside their work, for middle-aged workers reactions may differ depending on the age-related
worklife balance can be important to be able to changes that people experience with the aging
fulll demands from work, family, and other process. For instance, research of Bal
domains, while for older workers worklife bal- et al. (2013) showed that future time perspective
ance may be important to balance the demands of and occupational expertise may have contrasting
the job with the decreased physical capabilities effects for older workers on the relationships of
that are associated with the aging process (Lub breach with organizational commitment. More-
et al. 2011). Hence, there may be no main effect of over, Bal and Smit (2012) showed the importance
age on these types of obligations, but the reasons of emotion regulation strategies for younger and
why people think their employer is obligated to older workers, and De Lange and colleagues
deliver something may differ substantially (2011) showed the important of time perspective
according to someones age, or needs resulting and regulatory focus. In sum, these studies show
from age-related changes, including time perspec- that it is important to assess the underlying
tive and prevention focus. changes associated with age that actually cause
Second, age may have an impact on the type of people to perceive their psychological contract
relationship one has with the employer. Meta- differently, and react in a different way to contract
analytic evidence shows a decline of transactional breach and violations. Age can thus have differ-
contract with age (Vantilborgh et al. 2015), but ential effects on the psychological contract, and
this effect may also be due to a selection of thus via inuencing the exchange relationship
between employee and organization, may have Bal, P. M., De Lange, A. H., Jansen, P. G., & Van Der
important effects on employee attitudes and Velde, M. E. (2008). Psychological contract breach and
job attitudes: A meta-analysis of age as a moderator.
behavior in the workplace. A nal note should Journal of Vocational Behavior, 72(1), 143158.
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cross-sectional in nature, or has used limited lon- contracts and their relations with organizational com-
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Vantilborgh, T., Dries, N., de Vos, A., & Bal, P. M. (2015). of time. Although human beings are highly adapt-
The psychological contracts of older employees. In able and human development is dened by a high
P. M. Bal, D. T. A. M. Kooij, & D. M. Rousseau degree of plasticity, many functions decline with
(Eds.), Aging workers and the employee-employer rela-
tionship (pp. 107127). Amsterdam: Springer. increasing age. At the same time, the nite nature
Zhao, H., Wayne, S. J., Glibkowski, B. C., & Bravo, of lifetime becomes progressively more salient.
J. (2007). The impact of psychological contract breach The goal of this contribution is to provide an
on work-related outcomes: A meta-analysis. Personnel overview of the various concepts and denitions
Psychology, 60(3), 647680.
related to age and time, consider how these
develop as people go through life, discuss recip-
rocal associations between age and time (Fig. 1),
and outline various approaches aimed at
Age and Time in Geropsychology disentangling age- and time-related processes.
First, the authors briey review demographic
Nanna Notthoff and Denis Gerstorf developments over time that have contributed to
Institute of Psychology, Humboldt University, the growing societal and scientic interest in age
Berlin, Germany and aging; particular attention is paid to differ-
ences in life expectancy, health outcomes, and
psychological functioning of members of differ-
Synonyms ent birth cohorts. The authors then explain how
chronological age and time-to-death are used to
Biological age; Biological clock; Historical time; situate individuals within the life course. Next, the
Life course; Social age; Subjective age; Time authors turn to the inuence of age and time on
perspective; Time-to-death peoples societal embeddedness, individual expe-
rience, and biology and consider interrelations
between these concepts. Additionally, relevant
Definition theories that are concerned with associations
between age and time and touch on methodolog-
Following the Merriam-Webster dictionary, we ical challenges are presented. To conclude, the
dene age (in a geropsychological context) as authors return to the issues revolving around the
66 Age and Time in Geropsychology
Age and Time in

Geropsychology,
Fig. 1 Interrelations
between age and time and
associated concepts
interrelations between age and time and deliberate entirely different than it did 150 years ago. Orig-
to what extent scientists have been successful at inally, rising life expectancy could be attributed to
disentangling the two and suggest future avenues decreases in childhood mortality. Subsequently,
on this quest. survival rates at higher ages grew (Vaupel 2010),
meaning that death has become more concen-
trated in later life (Kohli 1986). Thus, mean age
Historical Time and Age-Related at death has increased, whereas variability in age
Outcomes at death has decreased. In contrast, the maximum
life span or the age of the longest-lived human
Aging, Life Expectancy, and Life Span in being has remained essentially the same.
Historical Context About 30 years ago, Fries (1980) proposed that
Although aging encompasses processes that occur increases in life expectancy would be accompa-
throughout life and do not start at a particular nied by a greater delay in the age of onset of
number of years past birth, aging is generally morbidity than in the age of death; thus, the pro-
associated with the later years of life. Systematic portion of lifetime that is spent in good health
research on aging is a relatively new eld. Until would increase; this idea was referred to as com-
the 1980s, old age was not really recognized as pression of morbidity and has been the subject of
part of the life course (Kohli 1986). Life expec- studies in various elds over the past decades.
tancy or average life span, which refers to the age Whether it can be concluded that morbidity has
at which 50% of individuals are still alive, has been compressed into the later years of life seems
risen dramatically over the past century. Whereas to depend on its denition. If the number of med-
average life expectancy worldwide in 1840 was ical diagnoses of physical health conditions is
approximately 45 years in the longest-lived group considered, there is little evidence for a compres-
of people (Swedish women; (Oeppen and Vaupel sion of morbidity. The age of rst occurrence of
2002)), in 2012 it was 84 years in the longest- various health conditions (e.g., heart attacks) has
lived country (Japan) and 70 years worldwide remained largely the same (Crimmins and
(World Health Organization 2014), and it seems Beltrn-Snchez 2010). However, if morbidity is
to be continuously increasing (Oeppen and viewed as level of disability as indicated by
Vaupel 2002; Vaupel 2010). Thus, it is no surprise impairments in activities of daily living (ADLs),
that being a certain age today means something evidence from several longitudinal studies
suggests that morbidity has, indeed, been post- recognized that chronological age alone is a poor
poned (Fries et al. 2011). There is some contro- predictor of health and psychological outcomes
versy around whether this truly constitutes a (Neugarten 1982). Although biological factors are A
compression of morbidity because outside factors thought to determine the maximum life span of the
such as environments conducive to living with human species, genetics seem to play a relatively
chronic disease and better medical treatments minor role in determining individual life span,
seem to underlie the lower incidence and preva- explaining only about 2530% (Slagboom
lence of disability (Crimmins and Beltrn-S- et al. 2011); they may become increasingly impor-
nchez 2010). However, other experts argue that tant in people who have survived into advanced
the focus should be on disability-free life expec- age (Vaupel 2010). Gerontologists acknowledge
tancy, which has, indeed, increased historically that chronological age is only of limited utility for
(Cutler et al. 2013). understanding individual aging, but they continue
Historical improvements can also be observed to utilize chronological age frequently in empiri-
in psychological measures that are related to or cal research, for example, to select and describe
relevant in old age. Evidence is accumulating target groups.
that compared to earlier-born cohorts, later-born
cohorts have better cognitive performance and Time-to-Death
also report higher levels of well-being (Gerstorf One approach to dealing with the huge individual
et al. 2015). These developments are thought to differences in a given domain of functioning for
be the result of a myriad of secular advances, people of a certain chronological age has been to
including improvements in material and eco- focus on time-to-death or the time left in life.
nomic environments, medical practice, educa- Compelling evidence has accumulated to indicate
tional and media systems, as well as that the last years of life are accompanied by steep
psychological resources such as reading, writing, deteriorations in levels of functioning across a
and computer literacy. myriad of life domains, including physical health,
sensory functioning, cognitive tness, emotions,
and well-being (Gerstorf and Ram 2013). As a
Time and Organization of the Life Course consequence, time-to-death seems to be a valid
predictor for healthcare expenditures and is some-
The passage of time marks individuals moving times used to determine whether certain services
through the life course. People experience certain for older people such as hospice or palliative care
(prototypical) changes at different points of the should be awarded. A shift to awarding benets
life course; e.g., the later years of life often are and services in old age based on remaining life
associated with declines in physical functioning expectancy has its own challenges, among other
and gains in life experience. Time-based metrics things, because estimates rely on population sta-
are used to place individuals with regard to their tistics rather than individual statistics. Further
progression throughout life. operational denitions of the general time-to/
from-event logic to track event-related changes
Chronological Age in certain domains of functioning include meno-
Chronological age or time since birth is still the pause, retirement, disability, onset of a given
most popular marker of situating people in the life pathology, etc. (Ram et al. 2010).
course, even though it may not reveal how old
an individual really is or how old an individ-
ual feels. People of the same age often show huge Social Construction of Age and Time
individual differences in a given domain of func-
tioning; lifestyle choices and the historical period Peoples position in the life course shapes their
people are living in are only two of many contrib- embeddedness within society. Chronological age
uting factors. Decades ago, researchers have is present in frameworks to formally organize the
population. Furthermore, it seems to affect social grandchildren (Datan et al. 1987). Although peo-
perceptions. ple tend to afliate with others of similar age
outside the family and policy systems contribute
Age Stratification and Social Age to age stratication (Kohli 1986), the clear seg-
Chronological age plays a big role in structuring mentation of the life course into schooling, work,
society. Many policies are age based, meaning and retirement is slowly dissolving (Von Maydell
they only apply to people who have lived a certain et al. 2006). Still, in many regions of the world,
number of years; the most well-known concern age-based policies such as a mandatory retirement
formal schooling and entry into retirement. In fact, age are being upheld, and attempts to eliminate or
retirement is frequently viewed as a marker of even alter them slightly tend to result in signicant
entering old age. Retirees can expect to receive public opposition and reluctance.
a range of benets that are based primarily on their Another way of understanding the roles that
chronological age. In recent decades, however, are associated with distinct times in the life course
the call for a system that awards benets and is the idea of a social clock (Helson and McCabe
services based on needs has become louder 1994). According to this model, a set of social
because the group of retirees is by no means norms related to age is superimposed onto the
homogeneous (Neugarten 1982). At the same biological clock, which is supposed to reect bio-
time, retirement is beginning to be a less clear- logical processes related to aging per se; most of
cut transition because some people work beyond these concern family and work. In the Western
the mandated retirement age, some gradually world, it is typically expected that people enter
reduce their work, and still others return to work the workforce in their (early to mid) twenties after
for a while after their ofcial retirement. Still, the they have cognitively matured and completed for-
proportion of people who benet from retirement mal schooling. Social clocks can differ between
pensions has increased greatly since its formal cultures. For example, expectations regarding the
creation (Kohli 1986), and protests arise at discus- age at which people should enter the workforce
sions of raising retirement age by even a few years differ between developed and developing nations.
or months. With the surge of research on age and aging,
The age-group or age stratum that someone age stratication can be observed here, too, as a
belongs to can also inuence the social roles that way to understand the increasingly heterogeneous
the individual is willing or expected to play, sim- time of old age. Attempts are being made to
ilarly to social class. Unlike social mobility, all stratify based on characteristics other than chro-
people move through different age strata and the nological age, but even among aging researchers
associated roles; they can experience stress or this approach is not always implemented consis-
stigma if they adopt or are forced into a role that tently. Neugarten (1982) was perhaps one of the
is not commonly viewed as belonging into a par- rst to argue for a distinction by quality, rather
ticular age stratum (e.g., men becoming fathers at than by age. She dened the young old as those
60+ years). A relatively normative model of the older adults who are still healthy and active in
life course allows others (e.g., employers) to judge society; the old old, on the other hand, corre-
whether someone is following an orderly progres- spond to those older adults who t traditional
sion (Kohli 1986). These types of norms can views of aging by showing declines in physical,
differ by cohort. For example, the role of grand- mental, or social functioning and by being in need
parents has changed signicantly over time. First of help and care. The young old are also referred
of all, due to increased life expectancy, it is now to as people in the third age and the old old as
more likely for grandparents to be alive well into people in the fourth age (Baltes and Smith 2003).
their grandchildrens childhood and youth, some- Third versus fourth age can be dened based on
times adulthood. Secondly, grandparents tend to the population or the individual. In the former
be healthier than they were historically and are case, the transition from third to fourth age hap-
better able to step in to help with the care of their pens when 50% of a birth cohort have died (i.e., at
average life expectancy). Some argue for a slight inuential for outcomes in the health, cognitive,
modication, specically that the transition occurs and social domains. Although subjective percep-
when 50% of a birth cohort who had made it to tions of age and time are related to chronological A
5060 years have died. The person-based deni- age, there is no one-to-one correlation.
tion, in contrast, is based on estimates of an indi-
viduals maximum life span; the shift from third to Subjective Age
fourth age is thought to occur at the point at which The concept of subjective age considers individ-
future potential in terms quality of life is predom- uals own understanding of age. Research in this
inantly negative with dysfunctions and steep eld has arisen from examination of change ver-
declines across a broad spectrum of areas of life. sus stability in personality; researchers wanted to
However, the proportion of people that reaches the know whether people see themselves as changing
fourth age has begun to grow as well. As a result, with age (Ryff 1986). Generally, study partici-
further subdivisions of old age have emerged, pants are asked to indicate how old they feel,
but they continue to be dened by chronological and this subjective perception is linked to other
age, with young old referring to those roughly domains of life, be it as antecedent or outcome.
6574 years, middle old to those roughly 7584 People tend to feel younger than they actually are,
years, old old to those over age 85, and centenar- and the discrepancy between subjective and chro-
ians to those of at least 100 years of age. nological age increases the older people are.
Subjective age is shaped by demographic
Age Stereotypes: Associations with a Time developments in a given society, i.e., perceptions
Period in the Life Course about aging tend to differ between societies with
Although old age is a heterogeneous time period, longer compared to shorter life expectancies
people most often have negative associations with (Settersten and Hagestad 2015). Additionally,
it (Hummert 2011). The content of these associa- subjective age is inuenced by cohort member-
tions ranges from views regarding physical charac- ship; for example, the mentality that social class
teristics to social status/roles and behavior; for membership predetermines progression through
example, old age is often viewed as a period of the life course (e.g., with members of lower social
declines in physical and cognitive functioning, ill- classes experiencing old age earlier than those
ness, frailty, and loneliness. Images of old age or of higher social classes) seems to be more preva-
age stereotypes can be both explicit and implicit. lent in earlier- compared to later-born cohorts.
Positive age stereotypes also exist; they concern, Societal factors continue to contribute to the evo-
for example, a gain in wisdom and experience. Age lution of subjective age. Nowadays, age is
stereotypes are found across cultures, although increasingly attributed to individual agency,
specics around content may differ. Older people which can be experienced positively when it
hold age stereotypes, too; when these stereotypes comes to age-related gains, but can also have
are internalized and people act in accordance with negative consequences in the case of age-related
them, they can have long-term consequences. For losses.
example, positive views of ones own aging are The concept of subjective aging has been
associated with increased longevity (Levy extended by Diehl and Wahl (2010), who devel-
et al. 2002). Similarly to social policies, age stereo- oped a framework of awareness of age-related
types may also contribute to demarcation of old change (AARC). AARC refers to an individuals
age as a special time in the life course. awareness of changes that are the result of his or
her aging; these changes can be experienced as
either positive or negative. What distinguishes
Individual Experience of Age and Time AARC from traditional subjective age is that it
does not simply ask individuals to put a poten-
Individual differences exist in the experience of tially arbitrary number on how old they are feel-
both age and time. These personal views are ing. According to Diehl and Wahl (2010),
individuals are aware that age-related changes resources to compensate for the losses are
occur in multiple domains (health and physical diminishing (Brandstdter and Rothermund
functioning, cognitive functioning, interpersonal 2003).
relations, social-cognitive and social-emotional The idea that meaning-making becomes
functioning, and lifestyle and engagement). Mea- increasingly important as lifetime becomes lim-
sures assessing AARC therefore ask for individ- ited is also subject of other developmental theo-
uals subjective experience of changes in the form ries, e.g., Frankls theory of logotherapy and
of gains or losses they have noticed in the various Eriksons developmental theory of psychosocial
domains as they move through the life course. values. In Frankls and Eriksons theories, a focus
Factors inuencing these subjective experiences, on recognizing and seeking meaning was attrib-
for example, personality traits, are currently under uted to facing death and advancing through the
study. Experiences may not necessarily converge, life course, respectively. Socioemotional selectiv-
with gains experienced in some domains and ity theory posits that it is tied to subjective expe-
losses in others. rience of time left, but the experiences that prime
the eeting nature of time do not necessarily have
Time Perspective to be related to the end of life. Although time
Time perspective captures individuals subjective perspective tends to be correlated with age when
experience of time. It can be manipulated by out- comparing younger, middle-aged, and older
side factors; for example, situations that are expe- adults, other factors can also lead to constraints
rienced as interesting or pleasant appear to pass in time perspective, for example, terminal illness,
more quickly than boring or unpleasant situations end of a life stage marked by a signicant geo-
(Sches 2014). Personal values and experiences graphic relocation, and events that serve as
in the present constitute the basis for interpreting reminders that life is nite (e.g., September
the past and imagining and anticipating the future 11 attacks, SARS epidemic). As a consequence,
(Chappell and Orbach 1986). The experience of age and time perspective are often only moder-
time emerges gradually over the course of devel- ately interrelated when solely examining older
opment and is thought to be unique to humans adults.
(Wallace and Rabin 1960). Empirical evidence has begun to accumulate
As people age, more and more life events that future time perspective might differ by
accumulate and mark the passage of time, and domain. For example, people might have a
thus, the sense that one is closer to the end of life constrained time perspective with regard to their
is heightened (Kennedy et al. 2001). Philosophers occupation, but an open-ended one with regard to
maintain that being confronted with the nite their health. In addition, time perspective has been
nature of ones own life is a hallmark of age shaped by historical developments (Sches 2014).
(Sches 2014). According to socioemotional Before the industrial revolution, humans depen-
selectivity theory (Carstensen et al. 1999), time ded greatly on the temporal rhythms dictated by
perspective inuences the goals that people strive nature, e.g., the seasons and the day-and-night
for, such that those who have a relatively open- cycle; nature governed when people could pursue
ended future time perspective (usually, younger various activities. With industrialization, people
people) prepare for that open-ended future by started to be able to operate relatively indepen-
expanding their social networks and acquiring dently of these natural forces. The experience of
information, whereas those who have a more lim- time pressure became more prevalent, and nowa-
ited future time perspective (usually, older people) days, there even seems to be value placed on
savor the present by seeking out meaningful rela- it. Developments in the realm of communication
tionships and situations. An additional reason for that permit instant exchange between people have
the shift in socioemotional goals associated with a accelerated the pace of life. Simultaneously,
reduced time perspective may be the desire or norms have changed such that people are expected
necessity to avoid losses because temporal to always be reachable. Various programs and
apps that allow their users to track their time use An agreed-upon denition of biological age
also promote the hastening of lifes pace and the does not seem to exist (Ludwig and Smoke
optimization of time use. However, old age might 1982). Some interpretations are based on mani- A
not be conducive to keeping up with this ever- festations of physical diseases, whereas others
increasing pace. On the one hand, some degree of focus on cellular processes. Existing denitions
slowing in physical and cognitive functions with also differ in that some rely on one indicator and
advancing age can objectively be observed. On others on multiple. One way to understand bio-
the other hand, the value placed on a fast-paced logical age is the notion that the more vulnerable
lifestyle would mean that older adults would be an organism is to environmental pressures, the
rushing toward the end of life and may not be older the organism is biologically, presumably
compatible with their constrained time horizons. because underlying aging processes make the
organism more susceptible. In another approach,
overall morbidity is considered a proxy for bio-
Biology, Age, and Time logical age. A third interpretation suggests that the
accumulated genetic error in somatic cells is an
More and more, attention is being devoted to index for biological age. Genetic error can accrue
guring out the biology behind life-span develop- as a result of environmental factors (physical,
mental trajectories. The ultimate goal is to disen- chemical, or biological) and of DNA replication
tangle age and time. errors. A recently developed framework (Lpez-
Otn et al. 2013) has expanded upon this latter
Biological Age denition and suggests that indications of age can
The concept of biological age is an attempt to be observed in nine areas: (1) genomic instability,
understand age per se. Biological age is not as (2) shortening of telomeres, (3) epigenetic alter-
rmly linked to the passage of time as chronological ations, (4) loss of proteostasis, (5) deregulation of
age (Ludwig and Smoke 1982). However, it is often nutrient sensing, (6) mitochondrial dysfunction,
impossible to resolve whether degenerative pro- (7) cellular senescence, (8) exhaustion of stem
cesses are due to the passage of time, age, or dis- cells, and (9) deregulation of intercellular commu-
ease. The concept of biological age acknowledges nication. Regardless of which denition one
that the rate at which aging occurs varies between adopts, biological age is measured most accu-
organs and functions, i.e., some organs age more rately by autopsy, looking for the types of cellular
rapidly than others, and some functions deteriorate changes that are described above.
sooner than others. For example, activities of daily It is important to recognize that degenerative
living (ADLs) can be categorized by the time at processes that are associated with biological age
which they are lost; dressing and personal hygiene are inuenced by behavior (Siegler and Davey
fall into the early loss category, whereas toilet use, 2012). Engaging in behaviors that are considered
transfer, and locomotion fall into the middle loss risk factors (e.g., inactivity, dwelling on negative
category, and nally, bed mobility and eating are emotions) can speed up deterioration, whereas
contained in the late loss category (Morris engaging in behaviors that are considered protec-
et al. 1999). Differential development can also tive factors (e.g., physical activity, seeking social
be observed in the cognitive domain, meaning that support) can slow it down. This is not only true
different functions have divergent developmental with regard to physical health, but also applies to
trajectories. Specically, crystallized intelligence the cognitive domain (Anstey 2014). The degree
(e.g., knowledge of vocabulary) is stable into old to which these risk and protective factors inu-
age, whereas uid intelligence (e.g., reasoning, ence declines seems to change throughout the life
working memory, processing speed) starts to course; some behaviors are more inuential early
decline in young adulthood already (Anstey on, and others kick in at the very end of life
2014). Additionally, the variability in the aging of (Siegler and Davey 2012). In some cases, the
organs differs between individuals. biological mechanisms that underlie the link
between risk factors and health or cognition out- Interestingly, circadian rhythms change as peo-
comes are known. For example, chronic inamma- ple get older; they shift from being monophasic in
tion occurs with many chronic diseases such as younger years to being polyphasic in older age
diabetes and impacts the functioning of the organ- (Chokroverty 2009). Several factors seem to con-
ism. Protective health behaviors may lead to the tribute to this shift. First, the suprachiasmatic
development of a reserve capacity that protects nucleus and the brainstem hypogenic neurons
against behavioral and environmental risk factors. the inner time keepers change with increasing
The concept of reserve capacity is not fully under- age. Second, social activity tends to transform
stood, e.g., it is unclear whether it has to be with age. Third, older people who live in institu-
established by a certain age. The heterogeneity in tions such as nursing homes may be exposed to
the aging process points to its existence. Scientic different external time cues than older adults
evidence is available in some domains, e.g., cogni- living in the community.
tion, where the link between cognitive engagement Age is associated with a phase advance in the
and preserved cognitive functioning is relatively circadian rhythm such that older people wake up
well established. However, in many areas (e.g., and sleep earlier than younger people
link between positive social support and cognitive (Chokroverty 2009). During sleep, there is a
functioning), mechanisms linking lifestyles and reduction of amplitude and incidence of delta
outcomes remain elusive (Anstey 2014). waves in slow-wave sleep; a decrease in
The concept of biological age also appears in a non-REM stages 3 and 4; a decrease in frequency,
popular scientic context. The perhaps most well- amount, and amplitude of sleep spindles; and a
known example is the RealAge test developed by reduction in eye movements per minute in REM
Roizen (1999). Widgets to calculate ones own sleep. The cyclic pattern between REM and
biological age have caught on in the general non-REM sleep is preserved, but the rst cycle is
public. They rely on equations that take into con- often reduced. Although the total amount of REM
sideration statistics on average life expectancy at sleep is shorter at advanced ages, its proportional
the individuals specic age, genetic predisposi- contribution to the total amount of sleep remains
tions (e.g., gender, age of grandparents), health- the same because overall nighttime sleep amount
promoting behaviors (e.g., physical activity, fruit diminishes as well.
and vegetable intake, smoking), and psychosocial Shifts can also be observed in body tempera-
factors (e.g., stressful life events, social support). ture rhythm, which is advanced and attenuated in
Departing from an individuals actual age, time is older age and inuences the circadian rhythm, and
added for favorable genetic predispositions and in EEG measures. During waking, a slowing of
lifestyles and subtracted for unfavorable ones. the alpha rhythm and an increase of fast activities,
diffuse slow activity, and focal slow waves is
Inner Biological Clocks evident. To the best knowledge of the authors,
Being oriented in time seems to be an important the effects of these age-related changes on psy-
marker of functioning, and is therefore frequently chological outcomes have not been studied sys-
used to evaluate cognitive and psychosocial status tematically to date. It would, however, be highly
(Hendricks 2001). Many biological functions, interesting to examine if changes in EEG during
e.g., breathing and heartbeat, only operate nor- waking are associated with age-related cognitive
mally in a specic rhythm. The most obvious declines.
manifestations of the timing of the human
organism are sleep-wake cycles or circadian
rhythms. Although some individual differences Links Between Concepts
exist in circadian rhythms, for example, some
people operate better in the morning and others Time emerges as the overarching link between the
in the evening, all reasonably healthy human concepts discussed in our contribution. The pro-
beings have a circadian rhythm. gression of time determines a persons place
within the life course, which can be described by focuses only on consequences of events without
chronological age or time-to-death. Beyond indi- considering process-based change is that it may
vidual lifetimes, passage of time is associated with miss the inuence of factors that led to the event A
demographic developments at the population and the outcome of interest.
level and with differences in signicant historical Another advance in life-span developmental
events experienced by particular groups of indi- research concerns the consideration of different
viduals (cohorts) at distinct points in their lives. time spans. In addition to examining outcomes
Historical time is accompanied by an evolution of over long time frames such as lifetime or years,
norms and values, which in turn shapes societal scientists in this eld are now concerned (again)
embeddedness and individual experience of age with variations over shorter time frames such as
and time. The time-based measures chronological days and hours. Such advances have been aided
age and time-to-death affect how individuals are and made possible by technology. Investigations
perceived by society and how they perceive them- of short-term variability rely on experience sam-
selves. Interrelations between social and self- pling. Here, participants are provided with a
perceptions are also being uncovered, but the device (e.g., smartphone, tablet) that allows them
mechanisms explaining them are not yet well to complete self-report questionnaires (e.g., time
understood. Biological developments are related use, emotional experience) and objective assess-
to chronological age and time-to-death. What ments (e.g., cognitive performance) on the go. An
remains unclear to date is how biological devel- ever-growing number of activity monitors that
opments and social and self-perceptions of age rely on accelerometry also allows for the objective
and time are related. measurement of behaviors such as physical activ-
ity and sedentary behavior.
Methodological Issues
Conclusion and Outlook
The interconnectedness of age and time is
represented in methods used in life-span develop- The association between age and time has been
mental research. A move toward the longitudinal examined and described in a variety of ways. It is
study of development reects the realization that reected in methodological approaches and theo-
cross-sectional comparisons do not allow us to ries in life-span developmental research and is
disentangle the effect of age itself versus time also present in everyday life. Society dictates
(inuence of the historical period or a specic many age-related expectations that may have
cohorts reactions to historical events) on group nothing to do with how old an individual feels or
differences (Alwin and Campbell 2001). Despite how old an individual is according to measures
these obvious advantages, longitudinal studies to that are not based on the passage of time since
date also have a limitation in that most of them are birth. In this contribution, methods aimed at mea-
purely observational and cannot employ any suring age objectively and accurately and
experimental manipulations (Anstey 2014). With disentangling it from time were described, and
technological evolution in the form of high- the associated challenges were identied. The
capacity computing, modeling of longitudinal authors conclude that to date, age and time con-
change has become much more feasible. tinue to have to be viewed as highly interrelated.
For quite some time, life-span developmental Furthermore, approaches acknowledging high
research has employed both event-based and degrees of variability in individuals subjective
process-based strategies. In an event-based experience of age and time were highlighted.
approach, the consequences of certain life events Future research should pinpoint how and when
are examined, whereas a process-based approach the various operational denitions of age and time
focuses on gradual changes over time (Alwin and (see Fig. 1) do and do not overlap. For example,
Campbell 2001). One caveat with research that when or for whom do biological and subjective
age converge, and how do the predictors and out- Chokroverty, S. (2009). Sleep disorders in the elderly. In
comes of different facets of age and time coincide S. Chokroverty (Ed.), Sleep disorders medicine. Basic
science, technical considerations, and clinical aspects
versus diverge? In the quest to further understand (pp. 606620). Philadelphia: Saunders Elsevier.
the heterogeneity of old age and independent Crimmins, E. M., & Beltrn-Snchez, H. (2010). Mortality
contributions of age and time to human develop- and morbidity trends: Is there a compression of mor-
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76 Age Discrimination
Age Discrimination, Table 1 Key Concepts and implicit social cognition, such as the implicit-
Components association test (IAT), or via stereotype priming
Concept Components (see Levy and Banaji (2002) for a review).
Target age Young
Old Level of Expression
Age operationalization Objective Age discrimination may be expressed interindi-
Subjective
vidually, by individual actors toward other indi-
Outcome valence Positive
Negative viduals and acting on the basis of their actual or
Measurement Implicit perceived age, or may be expressed at the broader
Explicit institutional level, in terms of governmentally
Level of expression Individual regulated social policy, normative social conven-
Institutional tions within an industry or sector, or organiza-
tional practices (see Iversen et al. (2009) for a
review). Illustratively, institutional age discrimi-
research by Finkelstein et al. (2012) has nation may include events such as governments
documented type and prevalence of both positive denying scholarships for graduate education for
and negative stereotypes and meta-stereotypes individuals above a certain age, birthday cards
toward both younger and older adults. poking fun at individuals on the basis of their
age, or organizations denying promotions to indi-
Age Operationalization viduals on the basis of their age.
Age may be either objective chronological age or
subjective perceived age the age that an individual,
or others, view him or her to be (Kooij et al. 2008). History and Evolution of Definitions
Illustratively, some older individuals may appear
younger than their age, and may therefore be sub- Early research on age discrimination took place
jectively perceived as younger than the typical indi- during the 1950s and focused exclusively on atti-
vidual in their age-group; vice versa for younger tudes toward older adults (i.e., individuals
individuals who appear older than their age. advanced in chronological age). In what was per-
haps the very earliest study of the phenomenon,
Outcome Valence Tuckman and Lorge (1952) examined age dis-
In line with evidence establishing older adults to crimination against older workers by graduate
fall into the incompetent but warm quadrant of the students. Other early researchers studying age as
stereotype content model (Fiske et al. 2002), the a facet of group identity in the 1950s, 1960s, and
denition recognizes that age discrimination may 1970s likewise followed suit and studied only
be either positive (benevolent ageism) or negative older adults and workers. The term ageism
(hostile ageism). was rst introduced by Robert Butler to describe
this topic of study in the mid-twentieth century
Measurement (Butler 1969, 1975, 1980). Over two dozen formal
Explicit age discrimination refers to conscious denitions of ageism have since appeared in the
and controllable behaviors elicited toward indi- extant literature. A comprehensive review of all
viduals on the basis of their age. In contrast, denitions of ageism, excepting the newest de-
implicit age discrimination refers to such nitions, such as those provided by Bal et al. (2011)
countervailing behaviors that exist and operate and Posthuma et al. (2012), may be found in
without conscious awareness, intention, or control Iversen et al. (2009).
(Levy and Banaji 2002). Whereas explicit age
discrimination is most commonly measured Target Age
through self-report or observation, implicit age Perhaps as a result of the early focus in the
discrimination may be measured via measures of mid-twentieth century on exclusively older adults
and workers, Butlers (1975, 1980) denitions considered old given the normative distribution of
indicated ageism as applying only to older age in a particular institution), and life-span age
adults and the elderly. Surprisingly, Butlers (an individuals current life stage or family cycle; A
original 1969 denition recognized ageism as Kooij et al. 2008).
existing toward all age-groups, but his later de- All of these latter denitions of age may be
nitions became, for no apparent reason, narrower. conceptualized as subjective age, by way of ref-
Concomitantly, conceptualizations of age dis- erence to subjective perceptions regarding an indi-
crimination have been mixed with regard to the vidual or groups physical capabilities, physical
operationalization of age, with some authors appearance and social conduct, normative age
dening age discrimination as applying to both within an institution, or normative age within the
younger and older adults (e.g., Finkelstein life-span standards of a given society. It is thereby
et al. 2012) and some authors dening it as the necessary to explicitly address the fact that age
exclusive province of older adults (e.g., Iversen discrimination may occur on the basis of either
et al. 2009; Posthuma et al. 2012). actual (objective/chronological) or perceived
To an extent, this inconsistency may reect (subjective) age. The denition provided in this
debate within the scientic community itself, chapter addresses this gap in the literature, by
with the result being that the question of whether clearly dening age as being both objective and
age discrimination applies only to older adults, or subjective.
to both younger and older adults, remains
unsolved. The denition provided in this chapter Outcome Valence
argues for the latter, by specifying no particular Butlers original denitions of ageism incorpo-
age-group as being the sole target of age discrim- rated only negative attitudes on the basis of age.
ination, for categorical membership is the imme- Most authors dening ageism in the 1980s and
diate precursor of prejudice (Gaertner and 1990s followed suit and discussed only negatively
Dovidio 2000), and because the category of age valenced outcomes, until the seminal work of
logically includes members within all categorical Palmore (1999). On the basis that ageist attitudes
points. could be either hostile or patronizing (benevolent
ageism and age discrimination), Palmore (1999)
Age Operationalization rst dened age discrimination as a phenomenon
All extant denitions of ageism and age discrim- that could be either positively or negatively
ination, both the earliest and the latest, narrowly valenced. Following him, Cuddy and Fiske
constrict age to only the realm of objective chro- (2002) and Fiske et al. (2002) categorized older
nological age, either explicitly through reference adults as falling into the incompetent but warm
only to chronological age or by way of omission quadrant of the stereotype content model and sim-
with regard to perceived (subjective) age. This is ilarly recognized the existence of both hostile and
an unfortunate omission, because chronological benevolent ageism. Thereby, most researchers
age fails to represent the life-span perspective on studying ageism within the last decade (as of this
aging, which is better represented by other sub- writing) have recognized the existence of both
jective facets of age, such as psychosocial or positive and negative age discrimination. The cur-
psychological age (see Kooij et al. (2008) for a rent denition follows these recent advances in
review). Recent advances in the theory of aging the study of ageism and recognizes that age dis-
have expanded the denition of age to include crimination may be valenced either positively or
four subjective facets in addition to chronological negatively.
age, including functional age (the extent to which
chronological age limits the capabilities of any Measurement
particular individual), psychosocial age (the age Almost all denitions of ageism and age discrim-
that one is socially perceived to be), organiza- ination are explicit; work on implicit ageism was
tional age (the extent to which an individual is largely lacking until the seminal work of Becca
Levy, Mahzarin Banaji, and colleagues (cf., Levy consequences, moderators, and mediators is
and Banaji 2002). Nevertheless, some recent de- displayed in Fig. 1. The gure does not causally
nitions of ageism have begun to recognize the role distinguish between age prejudice and age dis-
of unconscious and implicit attitudes in directing crimination, as these latter components of the
human behavior (e.g., Iversen et al. 2009). The broader attitudinal variable that is ageism are
denition provided in the current chapter follows commonly understood to occur together, with
these recent advances and denes age discrimina- age prejudice representing emotive responses
tion as occurring both implicitly and explicitly. that go hand in hand with the countervailing
behavioral responses that represent age
Level of Expression discrimination.
Perhaps resultant of a lack of computer technology
to statistically model multilevel relations between Antecedents
phenomena, early work on age discrimination Prejudice begins with group membership,
focused only on the individual level of analysis whereby membership in a devalued or out-group
and failed to incorporate the possibility of ageism category gives rise to prejudice in the form of
occurring at the broader institutional level. More affective, cognitive, and behavioral responses
recently, beginning in the late 1990s, and carrying (Gaertner and Dovidio 2000). Categorical age
forward to the current decade, researchers have membership, be it objective or subjective, is
begun to largely recognize the existence of age thereby understood to be the ultimate antecedent
discrimination at the institutional level. The current of age discrimination.
denition follows suit and expresses age discrimi-
nation as occurring at both the microlevel of the Mediators
individual and at the broader level of societal, Ageist cognitions, including age stereotypes and
sectoral, industrial, and organizational institutions. age meta-stereotypes, represent the mediating
mechanisms between categorical age membership
and age prejudice/discrimination. Meta-analytic
Nomological Net evidence indicates that relative to their younger
counterparts, older adults and workers are viewed
A nomological net depicting the relations between more stereotypically in general and are stereo-
age discrimination and its antecedents, typed as being less competent, less motivated,
Categorical Age Ageist Affect and Outcomes

Membership Ageist Cognitions Behavior Individual
Age Stereotypes
Objective Age Age Prejudice Organizational
Age Metastereotypes
Subjective Age Age Discrimination Societal
Environmental
Individual
Differences
Differences
Methodological
Surface Level
Contextual
Deep Level
Societal
Age Discrimination, Fig. 1 Nomological net of age discrimination

less trusting, more vulnerable to work-family and behavioral outcomes (Marcus and Fritzsche
imbalance, having less potential for training and 2015). These may include, but not be limited to,
professional/career development, being less lowered life and job satisfaction, less positive and A
adaptable, less interpersonally skilled, less more negative affect, higher turnover, reduced job
healthy, more reliable, and more stable (Bal and organizational commitment, lower self-
et al. 2011; Gordon and Arvey 2004; Kite esteem and self-efcacy, greater incidence of job
et al. 2005; Ng and Feldman 2012). The prime burnout, reduced well-being, reduced standards of
dimensions of stereotypes for older adults include living, limitations in career advancement, lower
perceived incompetence and perceived warmth income, limitations in personal and professional
(Fiske et al. 2002), and these two prime dimen- development, isolation, and poorer mental health.
sions have been identied to signicantly mediate At the institutional level, age discrimination may
relations between categorical age membership result in the economic and social marginalization
and age prejudice/discrimination (Krings of age-stigmatized groups.
et al. 2011). Less is known about age meta-
stereotypes, but the interested reader is referred Individual Difference Moderators
to Finkelstein et al. (2012) for a discussion. Individual differences include surface-level mod-
erators and deep-level moderators. Surface-level
Age Prejudice and Age Discrimination moderators include all demographic variables,
For age prejudice, meta-analytic evidence indi- including sex, gender, tribe (dened as those
cates that relative to their younger counterparts, groupings of individuals based upon communal
older adults and workers are evaluated as less afliation, such as race, religion, and ethnicity;
attractive and are given more negative overall Marcus and Fritzsche 2015), education, marital
evaluations (Bal et al. 2011; Gordon and Arvey status, socioeconomic status, and disability status.
2004; Kite et al. 2005). For age discrimination, Additionally, subjective age may also be concep-
meta-analytic evidence indicates that relative to tualized as a moderator of relations between
their younger counterparts, older adults and objective age and outcomes. Deep-level modera-
workers are more likely to be recommended pro- tors include all psychological variables, such as
fessional evaluation after experiencing memory affectivity, attitudes, cultural orientation, and per-
failure, are less likely to be helped, are given sonality. As depicted, individual differences may
poorer assessments based on observed interac- moderate relations between age and ageist stereo-
tions, experience more adverse selection out- types (upstream moderators), ageist stereotypes
comes, and are given poorer performance and age prejudice/discrimination (downstream
evaluations (Bal et al. 2011; Kite et al. 2005). moderators; Posthuma et al. 2012), or age preju-
Less is known about age prejudice and age dis- dice/discrimination and outcomes of ageism.
crimination specically targeted toward younger Very little is known about the conuence of age
adults and workers, indicating the need for future and other surface- or deep-level moderator vari-
research to investigate ageism at the lower end of ables in predicting outcomes; the study of age
the age spectrum. Less is also known about age discrimination sorely needs research on
prejudice and age discrimination based upon disentangling complex relationships, interactive
purely subjective age. For example, would an effects, and effects of multiple group member-
older adult who looks young experience similar ships (Posthuma and Campion 2009). To that
outcomes related to age prejudice/discrimination? end, recent theoretical advances identify the exis-
Future research is needed to disentangle the tence of unique archetypes for different types of
effects of objective vs. subjective age on ageism. older adults and workers (e.g., older White
females vs. older White males) and specify differ-
Outcomes of Age Discrimination ing patterns of outcomes for older adults and
Individuals who are the targets of age discrimina- workers depending upon multiple group member-
tion experience detrimental affective, cognitive, ships (Marcus and Fritzsche 2015).
Environmental Difference Moderators between age and institutional level outcomes.

As depicted, environmental differences may also Hence, future research examining the roles of
moderate relations between age and ageist stereo- societal culture and other macrolevel variables
types (upstream moderators), ageist stereotypes on relations between age and outcomes would
and age prejudice/discrimination (downstream benet the study of age discrimination.
moderators; Posthuma et al. 2012), or age
prejudice/discrimination and outcomes of
ageism. Environmental differences may be Conclusion
broadly divided into three classes of moderators:
moderators stemming from differences in It has been almost half a century since Robert
sampling, design, measurement, and analysis Butler rst coined the term ageism. On the
(methodological), moderators stemming from the positive side, consensus now exists on the notion
larger study context (contextual), and moderators that age discrimination refers to the behavioral
stemming from overarching societal cultures and component of the broader attitudinal variable
institutional policies (societal). that is ageism, with ageist stereotypes and age
Meta-analytic evidence is plentiful when it prejudice representing the accompanying cogni-
comes to methodological moderators. The largest tive and affective components, respectively (Bal
effect sizes of age discrimination are observed et al. 2011). Yet, half a century on, debate still
when ratings are provided by middle-aged respon- seems to persist within the scientic community
dents, older women rather than older men are regarding the exact nature of the concept of age
targets, job applicants rather than job incumbents discrimination itself, with no consistency found in
are targets, within-subject designs are utilized, specications regarding its valence, measure-
negative information is presented, potential for ment, level of expression, potential targets of age-
development ratings is considered, lab rather ism, and even the nature of age as a construct
than eld studies are conducted, minimal infor- itself. The denition provided in this chapter
mation is presented, and the overall generalizabil- addresses this issue and represents the most com-
ity of the data decreases (Bal et al. 2011; Gordon prehensive denition of age discrimination within
and Arvey 2004; Kite et al. 2005). the extant literature, incorporating all of the key
The prime contextual moderator variable in concepts and components. Such a denition is
relations between age and outcomes has been arguably needed in order to expand the study of
identied to be contextual age salience. In terms age discrimination to individuals of varying
of older workers, contextual age salience includes stripes and across the life cycle and to gain a
the extent to which the current job matches ones nuanced understanding of the phenomenon as it
prior work experiences, the age type of the job, the occurs across methods, contexts, and cultures.
level of the job, and the normative age distribution Poorer still is our understanding regarding the
in the job (Marcus and Fritzsche 2015). The role mediating processes and boundary conditions of
of context remains an emerging area of research age discrimination. Little research on age discrim-
on age discrimination although well-grounded ination has been done to investigate mediating
theory exists, there is not much empirical evi- age-stereotype processes (see Krings et al.
dence on the issue, indicating the need for future (2011) for initial evidence); no research has been
research. conducted to investigate mediating agemeta-
The least amount of theory and evidence exists stereotypes processes; no research has investi-
for societal moderators. Very little is known about gated more complex mediating relationships
the ways by which national culture moderates the such as mediated moderation or moderated medi-
relations between age and age discrimination ation. Despite a wealth of meta-analytic evidence,
(Posthuma and Campion 2009). Likewise, very concomitantly little research has investigated the
little is known about the moderating role of moderating roles of either individual or environ-
broader institutional-level policies on relations mental differences, with all meta-analyses to date
on the issue largely focusing on methodological persons. In T. D. Nelson (Ed.), Ageism: Stereotyping
variables and ignoring broader societal or contex- and prejudice toward older persons (pp. 326). Cam-
bridge, MA: MIT Press.
tual variables. To an extent, this may reect a lack Finkelstein, L. M., Ryan, K. M., & King, E. B. (2012). A
of primary studies on interactive relations What do the young (old) people think of me? Content
between variables within the nomological net of and accuracy of age-based metastereotypes. European
age discrimination. Journal of Work and Organizational Psychology, 21,
125.
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age discrimination beyond crude main effects at tence and warmth respectively follow from perceived
the individual level and that are largely obtained status and competition. Journal of Personality and
Social Psychology, 82, 878902.
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of these and other related issues within this chap- intergroup bias: The common in-group identity model.
ter, via clarication of the denition of the term Philadelphia: Psychology Press.
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Butler, R. N. (1975). Why survive? Being old in America. (2012). Age stereotypes and workplace age discrimina-
New York: Harper and Row. tion. In J. W. Hedge & W. C. Borman (Eds.), The
Butler, R. N. (1980). Ageism: A foreword. Journal of Oxford handbook of work and aging (pp. 298312).
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82 Age Diversity at Work
workforce. Explanations include increased mor-

Age Diversity at Work tality, decreased fertility rates, and economic con-
ditions, requiring older workers to delay
Amy C. Pytlovany1 and Donald M. Truxillo2 retirement (Eurostat 2013; Toossi 2012). This
1
Department of Psychology, Portland State has led to increased age heterogeneity within
University, Portland, OR, USA organizations and teams, meaning that people of
2
Department of Psychology, Portland State different ages are now working side-by-side more
College of Liberal Arts and Sciences, Portland than ever before. This trend has important impli-
State University, Portland, OR, USA cations, as research indicates both positive and
negative effects of diversity at all organizational
levels.
Synonyms
This entry will focus on the theoretical expla-
nations and current research relating to age diver-
Age differences; Age heterogeneity; Multi-
sity at work. Future directions will also be
generational workforce
recommended.
Definition
Theoretical Frameworks and Current
In general, diversity is dened as difference, or a Research
composition of, different elements. Age diversity at
work, therefore, refers to differences in age distri- Although some research has consistently demon-
bution among employees and is used to describe strated effects related to age diversity, such as
composition of the organization as a whole or com- increased turnover and absenteeism, studies
position of workgroups within an organization. examining the direct effects of age diversity on
Diversity is often described using social iden- other outcomes, including performance, have
tity theory (Tajfel 1974) and social-categorization revealed conicting results (Williams and
theory (Turner 1985). These frameworks explain OReilly 1998). This has highlighted the need to
how people categorize themselves and others examine the processes through which age diver-
according to prominent demographic characteris- sity inuences outcomes and under what condi-
tics (e.g., age, race, gender), aligning themselves tions positive (or negative) effects occur.
with similar others and distinguishing themselves As discussed above, social identity theory
from dissimilar others. (Tajfel 1974) and self-categorization theory
In the age and work literature, age groups are (Turner 1985) are two key frameworks for under-
usually discussed in terms of younger, middle- standing diversity. Expanding on this, and with
aged, and older workers. Categorization is not application of the similarity-attraction paradigm
dependent on chronological age alone; numerous (Byrne 1971), relational demography research
contextual factors inuence the designation of an investigates how individual differences relating
employee into these categories. Conceptualiza- to age (and other demographic characteristics)
tions, in addition to chronological age, include inuence attitudes and behaviors. The similarity-
subjective age, relative age (age in comparison to attraction paradigm helps explain why individuals
work context), cultural and professional norms, are more likely to have a favorable bias to similar
and societal regulations (Truxillo et al. 2014). others (positive evaluations, increased attraction)
and an unfavorable bias to dissimilar others
(negative evaluations, decreased attraction). Age
Key Concepts diversity has the largest impact on employees who
are most different from the group. For example,
Globally, there is an upward trend in the percent- employees with greater age differences in relation
age of older employees in the industrialized to the rest of the team have reported higher
Age Diversity at Work 83
absenteeism and turnover and have received inaccurate, they persistently inuence attitudes
lower supervisor ratings of performance and pro- and behaviors.
motability (Truxillo et al. 2014; Williams and Currently researchers are investigating stereo- A
OReilly 1998). types through a variety of lenses. One method
Group Processes. Related to relational investigates stereotype content on the dimensions
demography, research on fault lines investigates of perceived warmth and perceived competence
subgroup divides that occur when multiple per- (stereotype content model; Fiske et al. 2002), in
sonal attributes are shared among team members which older people are perceived to be warm but
(e.g., similar in age and race, similar in age and not competent; however, what is meant by older
gender). Divides are perpetuated by desires to in this framework may be in very late life, beyond
achieve balance between belonging (to the when most people are typically working. This
in-group) and distinction (from the out-group). model articulates that stereotype content can fall
Attempts to achieve this balance encourage posi- into one of four categories, and according to the
tive interactions among group members and neg- behavior from intergroup affect and stereotypes
ative interactions between groups. The most (BIAS) map, the category a stereotype is associ-
commonly studied constructs in relation to fault ated with then predicts how others behave toward
lines include results indicating increased conict, individuals in that group. Resulting behaviors are
decreased team cohesion, reduced team perfor- active facilitation (high on warmth, e.g., helping)
mance, and diminished team satisfaction active harm (low on warmth, e.g., harassment),
(Thatcher and Patel 2011). passive facilitation (high on competence, e.g.,
Fault line strength depends on a variety of cooperation), or passive harm (low on compe-
factors including the number of shared character- tence, e.g., neglect). These dimensions also inu-
istics (e.g., similar across multiple categories), ence affect. For example, evaluations of low
how the particular similar characteristics align warmth and low competence trigger contempt,
among group members (e.g., percentage of each perceptions of high warmth and low competence
demographic representation within the group) and elicit pity, appraisals of low warmth and high
group size, and the number of potential subgroup competence cause envy, and appraisals of high
possibilities. Characteristics other than demo- warmth and high competence foster admiration
graphic information can inuence formation of (Cuddy et al. 2008).
fault lines. However, because demographic attri- Building on stereotype research, another
butes such as age are immediately visible, these developing framework for investigating
have a stronger inuence on categorization intergenerational relationships is metastereotypes.
(Thatcher and Patel 2011), at least initially. Metastereotypes refer to how a person believes
Stereotypes (generalized characteristics others perceive them based on their group mem-
assumed to be true of someone based on their bership (Vorauer et al. 1998). For example, older
group membership) are also used to classify and workers may believe others stereotype them as
categorize others and thus inuence how out-of-touch, and younger workers perceive they
employees of different ages work together. are stereotyped as unreliable (Finkelstein
Although research on middle-aged stereotypes is et al. 2013). When framed around older and youn-
limited, this group is generally considered the ger age groups working together, these beliefs,
referent to which young and old are compared. positive or negative, are likely to inuence
Older worker stereotypes include perceptions that interactions and group processes. However,
they are resistant to change but also that they are workplace research on metastereotypes is scant,
dependable (Posthuma and Campion 2009). and thus the outcomes of these workplace age
Younger stereotypes include perceptions that metastereotypes are unknown.
they are lazy and unmotivated but also that they Fortunately, research based on intergroup con-
are enthusiastic and energetic (Finkelstein tact theory (Allport 1954) has demonstrated how
et al. 2013). Although stereotypes are often negative attitudes associated with intergroup bias
(e.g., stereotypes and prejudice) can be reduced collective identity that allows them to
through increasing the positive interpersonal con- overcome differences in age (Williams and
tact between members of different groups. This OReilly 1998).
effect is enhanced when the contact is structured Individual Differences Due to Age. Investi-
according to four optimal conditions: equal gating changes across the life span is another
status among groups/members, common goals, important element of workplace age diversity
intergroup cooperation, and institutional support. research. This includes changes in cognitive and
Over time, as more information becomes avail- physical capabilities, motives, and personality. It
able, surface-level (demographic) assessments of is important to note that numerous factors (e.g.,
others become less important, and categorization genetics, personal experiences, generation) inu-
becomes based on deeper-level traits (e.g., per- ence the aging process, so although research looks
sonality, skills; Harrison et al. 2002). Although at statistical averages, there is a great deal of
the optimal conditions outlined do boost this variation between individuals in how quickly
effect, they are not absolutely necessary. The pos- they age and in what ways.
itive effects of contact over time have been dem- Aging is generally associated with physical
onstrated across a wide range of contexts and and cognitive declines. Physical changes that
generalize beyond just those out-group members have been reported include eyesight and hearing
involved in the contact scenario (Pettigrew and loss, reduced muscle strength and exibility, and
Tropp 2006). Specically relating to age decreased immune response. Age is also related to
differences, intergenerational contact positively clinical health indicators, including elevated
impacts stereotype content and facilitation behav- blood pressure and cholesterol levels; however,
iors and reduces intentions to quit. Dual identity, meta-analytic results have revealed no declines
which refers to categorization according to two in mental health, or self-reported physical health
different attributes, such as a group identity (e.g., problems, and there is limited research linking
age group) and collective identity (e.g., common physical declines to changes in work performance
goals), has been shown to be the linking mecha- (Truxillo et al. 2015).
nism. When two identity-related categorizations In general, cognitive abilities related to crys-
intersect, one is more likely to have a stronger tallized intelligence increase across the life span
inuence; therefore, promoting a collective iden- and, on average, only begin to decline around age
tity can help reduce negative intergroup relations 60. Between age 60 and age 80, modest
(Iweins et al. 2013). losses occur, but substantial differences are not
Information and decision-making theories are exhibited until after age 80. These abilities include
also important contributions for examining inter- inductive reasoning, spatial orientation, verbal
actions within age-diverse groups. Diverse indi- ability, and verbal memory. Losses in numerical
viduals contribute a broad range of knowledge, ability begin somewhat earlier, starting to decline
skills, abilities, information, experiences, and in the 50s. Abilities associated with uid intelli-
networks that help strengthen team and organiza- gence, such as processing speed and working
tional processes. Numerous factors inuence the memory, begin to decline much earlier in life,
likelihood that a diverse team will be able to with loss beginning around age 25. It is interesting
capitalize on this diversity. First, information and to note cognitive decrements associated with age
resource-sharing is most relevant when teams are signicantly attributed to changes in percep-
work on tasks that are complex and/or tual speed (Schaie 1994). These effects can be
nonroutine. Second, age differences may lead to minimized for older employees through consider-
avoidance behavior, misunderstandings, or con- ation of workplace and goal conditions, especially
ict, thereby mitigating the possible benets of time pressure.
having diverse resources available. Finally, levels Personality traits are commonly studied in
of task- and goal-interdependence inuence work literature and are related to outcomes includ-
the likelihood that team members will develop a ing performance and social interactions (Barrick
and Mount 1991). Although personality traits Higher-Level Influences on Age Diversity
have historically been considered stable over
time, research demonstrates mean-level changes As previously discussed, context has a critical A
do occur across the lifespan. Conscientiousness, impact on the processes and outcomes associated
emotional stability, and social dominance with age diversity at work. This includes inu-
(a dimension of extraversion) show an increase ences beyond the group and individual level,
between age 20 and age 40; agreeableness begins including organizational-, occupational-, and
to decline in the 50s. Openness to experience and industry-related factors. At these levels, categori-
social vitality (another dimension of extraversion) zation and stereotypes again come into play. Job
increases throughout adolescence and then begins or industry stereotypes develop when a specic
to decrease in the 60s (Roberts et al. 2006). workforce is comprised of primarily one demo-
One theory used to explain how these changes graphic group (e.g., young-typed or old-typed)
inuence behavior is selective, optimization, and and employees not in the majority group face
compensation (SOC) theory which posits that negative biases. This occupational demography
older adults react to age-related changes by also inuences the boundaries of age group cate-
reallocating their resources toward minimizing gorization. For example, a middle-aged person in
losses and maximizing gains (Baltes and Baltes an industry or occupation that is primarily young
1990). Selection occurs when individuals priori- (e.g., high-tech gaming) will be perceived as old
tize specic goals that best match utilization and in comparison. The same middle-aged person
maintenance of current resources. Optimization working in a setting dominated by older workers
indicates strategies used to allocate effort and (top management in a corporation) would be per-
resources toward goal achievement, and compen- ceived as young. Fortunately, job-age stereo-
sation involves processes aimed at off-setting types are fairly susceptible to change (Truxillo et
age-related losses. For example, an aging worker al. 2014).
may reduce their number of tasks to focus on Organizational age climate also has a signi-
those for which they have the greatest skill and cant effect on determining if diversity operates as
that can be most efciently attained with current a strength or weakness. Organizational age cli-
resources. mate refers to the shared perceptions about an
Another commonly used framework for organizations diversity-related attitudes and
explaining differences across the life span is expectations, as communicated through policies,
socioemotional selectivity theory (SST; Carstensen procedures, and rewards. If human resource
et al. 1999). This theory describes how the salience (HR) practices communicate that differences are
of social goals uctuates over time according to valued, benets such as information- and
ones perception of time, thereby inuencing resource-sharing are more likely to occur.
motivational and behavioral change. Younger indi- Researchers have only recently begun to examine
viduals perceive time to be limitless. They are more age diversity climates specically, but initial nd-
likely to spend energy-building knowledge and ings are encouraging. Age diversity climate has
networks, focus efforts on expanding their been demonstrated as a linking mechanism
experiences, and work toward accomplishing between age-inclusive HR practices and both
goals such as work-related advancement and company performance and collective turnover
achievement. Work behavior is more strongly intentions (as explained by collective perceptions
related to growth- and extrinsic motives. Older of social exchange; Bhm et al. 2014b). Addi-
individuals perceive their time to be more limited. tional empirical evidence links diversity climate
As a response, energy and efforts are more likely and workgroup performance through the effects
allocated toward maintenance of close relation- of diversity climate on discrimination (Bhm
ships and having meaningful experiences. At et al. 2014a).
work, motivation becomes more intrinsically Age diversity climate is therefore important
linked (Kooij et al. 2011). not only for business-related outcomes but also
for preventing discrimination and the accompany- content and accuracy of stereotypes. According
ing litigation. Despite laws protecting older to the stereotype content model, older people are
workers, research reveals they still face discrimi- perceived to be warm and incompetent. However,
nation related to hiring and layoff decisions, train- this content appraisal may be more directly
ing opportunities, and performance appraisals related to older people beyond working age who
(Truxillo et al. 2014). In 2013, monetary payouts fall into the category elderly. Stereotype
related to the Age Discrimination in Employment content is likely to differ within a work context;
Act totaled $97.9 million (Equal Employment research in this area suggests that older workers
Opportunity Commission 2014) in the US- are seen as having a number of positive
A. Although research on younger workers is less attributes (Truxillo et al. 2012; Bertolino
common, it is likely that younger employees et al. 2013) such as higher conscientiousness and
experience bias, and due to lack of protections, organizational citizenship. Additionally, little
this discrimination may be even more blatant. attention has been paid to stereotypes about youn-
ger or middle-aged workers (Truxillo et al. 2014).
Future research should examine these and also
Conclusion and Future Directions explore how content impacts processes and out-
comes. These contributions would aid in under-
In conclusion, workplace age diversity has impor- standing age-diverse workers and their
tant implications for individual, group, and orga- interactions.
nizational processes and outcomes. However, as Metastereotypes research is one area that has
noted earlier, results are not always consistent, begun to explore younger and middle-aged ste-
and thus more research is needed to identify the reotypes, as well as older stereotypes (Finkelstein
conditions under which age diversity is most et al. 2013). Understanding how an employees
likely to have an impact and through what mech- behavior is inuenced by how they believe others
anisms these effects occur. perceive them provides an exciting new lens for
As described above, fault lines provide a useful which to examine workplace relationships. This
framework for examining group processes and out- nomological net is still being developed and thus
comes. Given the complexity involved, there are provides bountiful opportunities for future
many opportunities for further investigation. research. Investigations into if, how, and when
A claried understanding of how group composi- metastereotypes impact intergroup behaviors and
tion promotes fault line formation and strength outcomes would be very informative. For exam-
would be useful. For example, how does the num- ple, a belief that others hold negative stereotypes
ber of shared attributes (in addition to age) and the could result in avoidance and conict, thereby
alignment of age with other non-demographic attri- inuencing performance.
butes factor in? Additionally, differences in the Although most stereotype research examines
distribution of power among groups may help explicit attitudes, there is a growing interest in
explain inconsistent ndings in relation to out- exploring implicit stereotypes (automatic
comes. Further, it is likely that certain conditions responses of which an individual may not be
promote or discourage fault line formation. Devel- cognizant of). Implicit responses can be measured
oping a collective identity and encouraging posi- using a range of indirect self-report assessments
tive diversity attitudes are two possible strategies including word fragment completions, response
that may hinder subgroup divides and facilitate latency measures of association (e.g., the Implicit
intergenerational collaboration. Initial research Association Test, IAT; Greenwald et al. 1998),
relating to this looks promising (Iweins and even by examining brain activity responses
et al. 2013). (e.g., functional magnetic resonance imaging). At
Stereotype research can also help to explain this point, very little research has examined
how age diversity operates in the workplace. implicit age stereotypes at work, and such
Researchers should continue to explore the research into unconscious age stereotyping may
provide guidance for how to promote positive increasingly age-diverse workforce. More conclu-
outcomes related to workplace age diversity. sive research and a wider scope are needed.
Future research should continue to explore how A
to structure the workplace and develop training
programs to best address motivational and cogni- Cross-References
tive differences among an age-diverse workforce.
Environmental factors that inuence personality Age Stereotypes in the Workplace
and motivational changes should also be exam- Age Stereotyping and Discrimination
ined. Further, efforts should be made to answer Age Stereotyping and Views of Aging,
the call for advancement in measures assessing Theories of
the various dimensions of motivation (e.g., Age, Self, and Identity: Structure, Stability, and
achievement motivation, motivation to retire; Adaptive Function
Kanfer et al. 2013; Kooij et al. 2011). Age-Related Changes in Abilities
As the workforce continues to become more Crystallized Intelligence
age-diverse, identifying the best strategies for Intergenerational Relationships
managing diversity will become increasingly rel- Job Attitudes and Age
evant. As discussed above, promoting a positive Leadership and Aging
age diversity climate can be benecial and should Motivational Theory of Lifespan Development
be researched further. One suggestion is to inves- Organizational Strategies for Attracting,
tigate which HR practices and policies are most Utilizing, and Retaining Older Workers
inuential on both diversity climate and desired Recruitment and Selection of Older Workers
outcomes (cf. Bhm et al. 2014b). Researchers Selection, Optimization, and Compensation
should also consider how individuals, groups, at Work in Relation to Age
and the organization differentially relate to age Training at Work and Aging
diversity climate as both antecedents and out- Work Design and Aging
comes. Finally, leadership is likely to relate to Work Motivation and Aging
age diversity climate in multiple ways and should
be included in the research as age diversity cli-
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Age Stereotypes in the Workplace 89
particular group, and the inference that all mem-

Age Stereotypes in the Workplace bers of that group hold or display these same
characteristics. From a cognitive perspective, age A
Eileen C. Toomey and Cort W. Rudolph stereotypes represent mental schema through
Saint Louis University, Saint Louis, MO, USA which characteristics and expectations of a partic-
ular individual are based on his or her age group
membership (Hamilton and Sherman 1996). Ste-
Synonyms reotype endorsement can lead to biases in infor-
mation processing (e.g., biased judgments that
Age bias; Ageism lead to discriminatory behavior during decision-
making processes in selection, promotion deci-
sions, and training identication (Bal
Definition et al. 2011). A great deal of research on age
stereotypes in the workplace focuses on beliefs
Age stereotypes refer to overgeneralized expecta- and expectations about older workers rather than
tions and beliefs about the characteristics and middle-aged or younger workers (Posthuma and
traits of individuals on the basis of age. In the Campion 2009; Ng and Feldman 2012; Hassell
workplace, age stereotypes often take the form and Perrewe 1995). Moreover, research typically
of distorted and usually inaccurate perceptions of examines overgeneralized beliefs about the abili-
worker characteristics on the basis of age. ties of older workers in comparison to those of
As the workforce becomes more age diverse, younger workers (Posthuma and Campion 2009;
interpersonal exchanges between members of this Finkelstein et al. 1995). In addition to evidence for
multigenerational workforce will become more age stereotypes that characterize older workers,
frequent. Considering this, understanding the research has also begun to focus on characteristics
mechanisms that contribute to positive and nega- indicative of younger workers (Perry et al. 2013).
tive interpersonal interactions between individ-
uals at different stages of the work-life span is
essential (Rudolph and Zacher 2015). In this Defining Age in the Workplace
vein, a great deal of scholarship has focused on
how work-related age stereotypes affect the suc- Before reviewing the literature on the content of
cess of the interpersonal interactions between dif- common age stereotypes that characterize older
ferent age groups and the treatment of individuals workers, it is important to dene the term older
across the work-life span. Understanding the worker. Age can be conceptualized in a chrono-
nature, function, and effects of age stereotypes in logical sense or as a continuous stage in ones
the workplace is important for both individual lifespan or careerspan. Lifespan perspectives on
level and organizational level outcomes, as ste- age argue that young, middle, and older ages
reotype endorsement and application can lead to represent unique stages of development, which
age discrimination and negatively impact include distinct events that shape identity, as
employees by creating barriers to employment, well as personal and professional relationships.
promotion, and training opportunities (Bal Moreover, each stage is marked by its own set of
et al. 2011). challenges and goals. As experiences occur and
In general, stereotypes refer to the shape these stages at different chronological time
overgeneralized expectations and beliefs about points for individuals, there is not one set age
the characteristics and traits of social outgroup range to dene these stages (Kooij et al. 2008).
members (Fiske 1998). Stereotypes represent neg- Thus, there is a reluctance to establish or place
ative, distorted, and usually inaccurate percep- boundaries on specic chronological ages when
tions of individuals due to their membership in a examining groups of individuals from different
90 Age Stereotypes in the Workplace
life stages (e.g., when studying characterizations represent a lower return on investment in terms of
of younger, middle-aged, or older workers). How- training efforts (Posthuma and Campion 2009).
ever, in past research, age ranges for older workers Despite this belief, research suggests that there is
vary from 40 years and above (Ng and Feldman no empirical evidence to support the notion that
2012; Hassell and Perrewe 1995) to 55 and above older workers are more resistant to change (Ng and
(Finkelstein et al. 1995). Feldman 2012). However, there is some evidence
to suggest that older workers may be less willing to
partake in training and career development oppor-
Common Workplace Age Stereotypes tunities (Ng and Feldman 2012).
Older workers are commonly perceived as hav-
Recent scholarship has reviewed the most coming a lower ability to learn, develop themselves,
mon age stereotypes against older workers rela- and master new skills and concepts required of
tive to younger workers, presented evidence their jobs than younger workers (Posthuma and
refuting some of these beliefs as mischaracteriza- Campion 2009). Evidence for the validity of this
tions, and discussed boundary conditions sur- perception is inconsistent. For example, some
rounding the endorsement of age stereotypes research indicates that older workers need no
(e.g., the presence of job relevant information, more training than their younger coworkers and
perceived correct age for a job position, and do have the ability to learn and develop
supervisory status, (Posthuma and Campion (Broadbridge 2001), while other research sup-
2009; Finkelstein et al. 1995). One of the more ports the belief that older workers are slower at
common age stereotypes is that older workers are mastering skills and concepts (Kubeck
poorer performers relative to their younger et al. 1996). However, it is important to note that
coworkers (Ng and Feldman 2012; Posthuma research supporting this belief reports relatively
and Campion 2009). Considering this stereotype, small effects (Kubeck et al. 1996).
related miscategorizations suggest that is com- Another common age stereotype towards older
monly expected that older workers are less capa- workers is the belief that older workers will retire
ble, productive, motivated, and competent than or turnover faster resulting in shorter job tenure
their younger counterparts, resulting in lower (Posthuma and Campion 2009). This belief is
average job performance. However, a great deal based on the notion that older workers are, by
of evidence has been presented to refute the notion denition, later in their careers than younger
that performance declines with age (Posthuma workers. Relatedly, it is often incorrectly assumed
and Campion 2009). On the contrary, empirical that older workers are less healthy, more at risk for
evidence suggests that job performance ratings work/family conict, and closer to retirement than
increase with age, any decreases in cognitive abil- their younger counterparts. As a result, it is
ity are not signicantly related to performance due assumed that older workers possess lower poten-
to various compensation and coping strategies, tial return on investment for training, develop-
and that health and well-being are more important ment, and retention initiatives (Hedge
indicators of performance than chronological age et al. 2006; Ng and Feldman 2012). In line with
(Posthuma and Campion 2009). this stereotype is the belief that due to higher
Another common age stereotype is that older wages, increased need for health benets, and
workers are resistant to change. Related stereotypes later career stage, older workers are more costly
characterize older workers as harder to develop, to the organization (Posthuma and Campion
less exible, and more difcult to train (Posthuma 2009). However, evidence suggests that older
and Campion 2009; Ng and Feldman 2012). More- workers are less likely to turnover than younger
over, older workers are perceived as being less workers, refuting the idea that they represent
willing to participate in training and/or career lower returns on investment (Hedge et al. 2006).
development programs (Ng and Feldman 2012). It is important to note that not all age stereo-
This can lead to the belief that older workers types of older workers are inherently negative
(Posthuma and Campion 2009; Hassell and the inuence of ingroup bias on the strength of age
Perrewe 1995; Broadbridge 2001; Bal stereotypes. Evidence suggests that older workers
et al. 2011). Older workers are frequently per- who identify with and consider themselves a part of A
ceived as being more dependable, honest, reliable, their own age group hold more positive beliefs
loyal, trustworthy, and committed to the organi- about themselves than do younger workers. On
zation and job (Hassell and Perrewe 1995; the other hand, some older workers hold the same
Broadbridge 2001). There is some research to beliefs about members of their own age cohort and
support these stereotypes as evidence does sug- these judgments can affect their decision making
gest that older workers are less likely to engage in (Hassell and Perrewe 1995; Posthuma and Cam-
counterproductive work behaviors such as overt pion 2009). Again, the effect of negative stereo-
theft and absenteeism (Broadbridge 2001; Hedge types is ameliorated when older workers identify
et al. 2006). Additionally, older workers are often with these individuals as part of their ingroup
characterized as possessing higher levels of insti- (Posthuma and Campion 2009).
tutional knowledge and accrued wisdom associ- The extent to which age stereotypes bias infor-
ated with extended tenure and job experience. mation processing in the workplace is also dimin-
While a majority of research has focused on ished when job-relevant information is present
stereotypes towards older workers, there is some and used during decision-making processes. Evi-
evidence for stereotypes towards younger dence suggests that stereotype endorsement is
workers (Perry et al. 2013). This evidence sug- reduced when information about the job is used
gests these stereotypes are not merely the opposite to evaluate applicants during employment inter-
of the stereotypes against older workers (Perry views (Kite et al. 2005). When information spe-
et al. 2013). For example, common age stereo- cic to the qualications and abilities of the
types that characterized younger workers are that applicant and aspects of the job position are avail-
they tend to be more productive, creative, ambi- able and used during selection processes, the
tious, eager, and efcient. Additionally, younger effects of age stereotypes towards older workers
workers as seen as better able to cope with job are less likely to affect employment decisions
stressors more likely to seek immediate feedback (Fiske and Neuberg 1990). Lastly, research sug-
on performance (Perry et al. 2013). Overall, there gests that the effects of age stereotypes are stron-
is an abundance of evidence examining stereo- ger when there is a perceived correct age of an
types towards older workers with comparatively applicant for a job role (Hassell and Perrewe
little focusing on the beliefs against individuals in 1995; Posthuma and Campion 2009). Thus, appli-
other age groups such as younger and middle- cants are viewed negatively if there is an incon-
aged workers (Perry et al. 2013; Posthuma and sistency between the age of the applicant and the
Campion 2009). correct age of the job (Finkelstein et al. 1995;
Research suggests that the extent to which Hassell and Perrewe 1995; Posthuma and Cam-
workplace age stereotypes are endorsed and inu- pion 2009). Moreover, evidence suggests that
ence decision-making processes is affected by a there are particular jobs, professions, and indus-
number of factors (Hassell and Perrewe 1995; tries that seem more appropriate for different age
Posthuma and Campion 2009). For example, groups (Finkelstein et al. 1995; Posthuma and
research indicates that hourly workers hold more Campion 2009).
positive attitudes towards older workers than
supervisors, and that these attitudes become
increasingly positive with age (Hassell and Contemporary Perspectives on
Perrewe 1995). Additionally, research has found Stereotyping
that age and supervisory status interact, such that
as supervisor age increases so do the negative Descriptive Versus Prescriptive Stereotypes
stereotypes held against older workers (Hassell Age stereotyping in the workplace represents a
and Perrewe 1995). This research also underscores socialcognitive process in which cognitive
schemas guide beliefs and judgments about older behaviors of a member of a certain group), recent
workers based on their membership in a particular scholarship has examined metastereotypes and
age group. Moreover, due to the inherent inaccu- their presence and rate of endorsement in the
racies of stereotypes, endorsement of these mis- workplace (Finkelstein et al. 2012). Age
characterizations can lead to discriminatory metastereotypes refer to expectations that individ-
workplace behavior. In line with social-cognitive uals feel other age groups hold about people of
perspectives, recent scholarship has made a dis- their own age (Finkelstein et al. 2012). This is a
tinction between descriptive and prescriptive age relational concept, which arises from the tendency
stereotypes and explicated more relational mech- to be concerned about how individuals are viewed
anisms behind perceptions and beliefs towards by others. As humans, we tend to think more
older workers on the basis of their age (North about our social reputations and behavior from
and Fiske 2013). Traditional perspectives on age other peoples point of view rather than our own
stereotypes focus on the descriptive perceptions (Finkelstein et al. 2012). Much like research
about what older individuals typically do. suggesting the inaccuracy of aging stereotypes in
Prescriptive age stereotypes, on the other hand, general, research suggests that metastereotypes
describe beliefs about what older workers should might not be indicative of what individuals in
do in regard to their use of social resources (North the referent outgroup actually think about individ-
and Fiske 2013). Theory would suggest that there uals in the ingroup (i.e., age metastereotypes are
are three ways in which younger workers expect themselves likely to be quite inaccurate;
their older coworkers to use social resources (Finkelstein et al. 2012).
(North and Fiske 2013): (1) succession of their The content and accuracy of age
employment position, political inuence, and metastereotypes in the workplace has been exam-
wealth, (2) limitation of their consumption of pub- ined empirically (Finkelstein et al. 2012). Evi-
lic and shared resources (e.g., pension and social dence suggests that older workers are viewed
welfare funds), and (3) prevention of identity positively by both younger and middle-aged
transgressions (e.g., older workers acting in workers (i.e., both age groups report age stereo-
ways typically conceptualized as young). types towards older workers that are mostly pos-
This age-specic prescriptive stereotype model itive; (Finkelstein et al. 2012). In regards to
proposes that younger workers may judge older metastereotypes towards younger and middle-
workers more harshly if they act in ways that are at aged workers, older workers are more likely to
odds with these prescriptive stereotypes. In report negative characteristics (i.e., older workers
regards to the succession prescriptive stereotype, tend to believe workers from other age groups
older workers delaying retirement may pose a view them negatively; (Finkelstein et al. 2012).
threat to younger workers, as this limits their Additionally, research indicates that younger
own progress toward professional goals and workers tend to believe others (in particular,
opportunities (Hassell and Perrewe 1995). Addi- their middle-aged coworkers) will stereotype
tionally, older workers would violate the con- them negatively. Evidence also suggests that
sumption prescriptive stereotype if they abused middle-aged workers are more likely to report
their access to pension funds (North and Fiske negative characteristics towards younger workers.
2013). In summary, individuals may become Moreover, younger workers metastereotypes
biased in their judgments and evaluations of about middle-aged workers reect these
their coworkers based on these descriptive or pre- ndings younger workers expect middle-aged
scriptive age stereotypes (North and Fiske 2013). workers to list few positive traits when describing
their age group and hold expectations in line with
Metasterotyping negative stereotypes more often (Finkelstein
While the majority of research focuses on other- et al. 2012). However, research indicates that
referenced stereotypes towards older workers despite evidence that older workers view younger
(i.e., perceptions of the characteristics and workers in terms of both negative and positive
stereotypes, younger worker metastereotypes supervisory status, level of exposure to different

towards older workers are generally negative age groups, possible correct age for a position;
(i.e., younger workers tend to expect older (Posthuma and Campion 2009). As the age com- A
workers to describe them in terms of negative position of the workforce continues to diversify, it
stereotypes). is necessary to better understand the nature of both
Some important conclusions can be drawn other-referenced age stereotypes and age
from this evidence. For example, it could be that metastereotypes in an effort to facilitate effective
younger workers expect middle-aged workers to interpersonal interactions.
view them negatively based off of social consen-
sus cues in their work environment. Middle-aged Generational Stereotyping
workers may feel threatened by the potential for Another emerging area of research examines
competition with younger workers for similar jobs other-referenced stereotypes surrounding the
and may endorse these negative stereotypes to three generational groups that make up the current
protect themselves psychologically (Finkelstein workforce. While there is a substantial research on
et al. 2012). On the other hand, older workers age stereotypes, there is relatively little research
may not feel as threatened by younger workers on the nature and content of generational stereo-
as they rarely compete for similar jobs or roles. types in the workplace (Perry et al. 2013).
Additionally, older workers may have children the A generation refers to a group of people who
same age as younger workers and due to their have similar birth years, age, location, and sig-
more frequent exposure to that age group, view nicant life events at critical developmental
younger workers in a more positive light stages (Kupperschmidt 2000, p. 6). Researchers
(Finkelstein et al. 2012). Moreover, older workers also make distinctions between generations and
seem to be unaware that younger workers see cohorts, which generally refer to generations by
them in a positive light due to the evidence that their range of dates in which members were born
suggests their metastereotypes of younger (Parry and Urwin 2011). The three main cohorts
workers are negative (Finkelstein et al. 2012). identied in previous research and theory include:
There are several unanswered questions with (Bal et al. 2011) Baby Boomer (19431960)
respect to the nature of age metastereotypes at (Broadbridge 2001), Generation-X (19611981),
work. For example, it is necessary to understand and (Finkelstein et al. 1995) Generation-Y/
how age metastereotypes affect cross-age group Millennial (1982present). Previous research in
interactions in the workplace. Similar to the bias this domain focuses on the differences between
inherent within age stereotypes, age generational groups in terms of their values, pref-
metastereotypes could similarly affect informa- erences, and behaviors in the workplace (Twenge
tion processing and communication between indi- 2010). Moreover, the majority of scholarship on
viduals of different age groups (Finkelstein generational differences exists in practitioner lit-
et al. 2012; Posthuma and Campion 2009). Addi- erature focusing on the perceived differences in
tionally, more research is needed to examine how beliefs, attitudes, and behaviors. Indeed, there is
these metastereotypes increase the presence of very little compelling evidence to support the
conrmation bias (i.e., the tendency to seek, inter- notion of generational differences across a variety
pret, and/or recall information in a way that serves of work outcomes and research indicates that per-
to egoistically conrm ones beliefs or hypothe- ceived differences between generational cohorts
ses) and its inuence on job performance and likely arise from stereotypes that overgeneralize
interpersonal interactions. There is also a need to characteristics of different generational groups
examine contextual factors that have been previ- (Rudolph and Zacher 2015).
ously considered as boundary conditions to the Recent evidence from systematic examinations
inuence of stereotypes to examine their of the academic and practitioner literatures has
corresponding effects on metastereotypes (e.g., uncovered common stereotypes to describe each
the presence of job-relevant information, generational group (Perry et al. 2013). Evidence
suggests that stereotypes between Generation-X uncover the content of stereotypes towards gener-
and Generation-Y are not clearly differentiated. ations, more evidence is needed to further clarify
However, there are distinct differences in genera- the characteristics with which individuals use to
tional stereotypes between the Generation X and describe generations and how these stereotypes
Baby Boomer cohort as well as between the Mil- affect workplace processes.
lennial and Baby Boomer cohort (Perry
et al. 2013). Evidence suggests that Baby
Boomers are commonly described as hardwork- Conclusions
ing, loyal, not technology savvy, resistant to
change, and valuing monetary rewards from Here, current theories and empirical evidence on
their jobs. Workers from Generation-X were age stereotypes in the workplace were reviewed
most commonly described as lazy, technology and several overarching conclusions were drawn.
savvy, valuing work/life balance, disloyal, hard- Age stereotypes in the workplace are largely con-
working, and well educated. Lastly, recent schol- ceptualized as the overgeneralized beliefs and
arship indicates that common stereotypes towards expectations of the behaviors and characteristics
workers from Generation-Y suggest these of an employee based on his or her age. Addition-
workers are seen as technology savvy, preferring ally, evidence suggests there is a coherent set of
to use technology to communicate, multitaskers, common age stereotypes towards older workers
valuing work/life balance, and entitled (Perry (e.g., poor performers, resistant to change, shorter
et al. 2013). tenure, more costly, dependable) and younger
Lastly, evidence reveals both similarities and workers (e.g., productive, efcient, creative, feed-
differences between the common older worker back oriented, entitled) present in the workplace.
and younger age stereotypes with the above gen- Despite their prevalence and ubiquity, there is
erational stereotypes (Perry et al. 2013). Stereo- very little evidence to suggest that workplace
types towards Baby Boomers overlap the most age stereotypes are valid generalizations. More-
with those towards older workers (e.g., depend- over, evidence suggests that contextual and work-
able, resistant to change, lower ability to learn; place factors can affect the extent to which age
(Posthuma and Campion 2009) although Baby stereotypes are endorsed (e.g., supervisory status,
Boomers are also perceived as career driven, exposure to age groups, in-group bias, job rele-
achievement oriented, hardworking, competitive, vant information, positions with correct
and having a strong work identity (Perry age bias).
et al. 2013). Additionally, stereotypes towards Contemporary perspectives suggest that age
Generation-X are different from younger worker stereotypes are both descriptive (i.e., describing
stereotypes (e.g., feedback seeking, eager, pro- what individuals actually do) and prescriptive
ductive) as workers from Generation-X are seen (i.e., describe what individuals of a certain age
as lazy, self-centered, socially responsible, and should do) in nature and it is likely that both
having more balanced work needs than younger processes can affect the evaluations and judg-
workers (Perry et al. 2013). Lastly, younger ments made of workers (North and Fiske 2013).
worker stereotypes typically focus these workers Recent scholarship on the nature of
ability to do work and openness to learning while metastereotypes (i.e., beliefs that individuals
the content of stereotypes towards Generation-Y expect members of other age groups hold about
seems to focus on technology (e.g., the use tech- their own age group) provides opportunities for
nology and knowledge new technology), impa- further research on the content and effect of work-
tience (e.g., the desire or need for instant place age stereotypes on work-related variables.
gratication and short attention spans), and nega- Lastly, research suggests age stereotypes also
tive traits (e.g., entitlement and arrogance; (Perry exist towards different generational groups
et al. 2013). While recent scholarship helps (Perry et al. 2013). While there exists myriad
research on the topic of age stereotypes in the Hamilton, D. L., & Sherman, S. J. (1996). Perceiving
workplace in general, future research is needed persons and groups. Psychological Review, 103(2),
336355.
to clarify the nature and inuence of age stereo- Hassell, B. L., & Perrewe, P. L. (1995). An examination A
types and the factors that mitigate the effects of of beliefs about older workers: Do stereotypes still
stereotypes on cognitive, affective, and behavioral exist? Journal of Organizational Behavior, 16(5),
outcomes in work contexts. As the workforce 457468.
Hedge, J. W., Borman, W. C., & Lammlein, S. E. (2006).
continues to age and diversify in its age composi- The aging workforce: Realities, myths, and implica-
tion, understanding the mechanisms that prevent tions for organizations. Washington, DC: APA.
workplace age stereotypes from affecting infor- Kite, M. E., Stockdale, G. D., Whitley, B. E., & Johnson,
mation processing, affective reactions, and overt B. T. (2005). Attitudes toward younger and older
behavioral expressions of age bias is integral to Social Issues, 61(2), 241266.
creating and maintaining a workplace environ- Kooij, D., De Lange, A., Jansen, P., & Dikkers, J. (2008).
ment that supports its individuals across the Older workers motivation to continue to work: Five
lifespan. meanings of age: A conceptual review. Journal of
Managerial Psychology, 23(4), 364394.
Kubeck, J. E., Delp, N. D., Haslett, T. K., & McDaniel,
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96 Age Stereotyping and Discrimination
directed toward older people. Compared with

Age Stereotyping and Discrimination research on other types of bigotry (e.g., racism,
sexism), far less research exists on ageism
Alison L. Chasteen, Lindsey A. Cary and (Chasteen et al. 2011; North and Fiske 2012).
Maria Iankilevitch The majority of research that has been done on
Department of Psychology, University of ageism has focused on negative age stereotypes,
Toronto, Toronto, ON, Canada prejudice, and discrimination.
Synonyms Age Stereotypes
Age prejudice; Ageism; Stigma One of the primary features of age stereotypes is
that they are complex, consisting of both positive
and negative elements. This complexity was rst
Definition proposed by Neugarten in 1974 (Neugarten
1974). It was suggested that there are at least
Researchers distinguish between stereotypes, two age groups of older adults: the young-old
prejudice, and discrimination. Stereotypes are and the old-old. The young-old are conceived of
dened as the mental representations people as relatively active, healthy, and educated and the
have about different social groups. Stereotypes old-old as less active and healthy. Since that time,
have been described as beliefs and opinions the complexity of age stereotypes has been further
about the characteristics, attributes, and behaviors characterized by a number of researchers. For
of members of various groups (Whitley and Kite example, Hummert (2011) found a total of seven
2006, p. 6). In contrast, prejudice is depicted as specic age stereotypes of older people that were
the feelings people have toward different social shared by young, middle-aged, and older adults.
groups. Prejudice is an attitude directed toward The seven stereotypes consisted of four
people because they are members of a specic negative severely impaired, despondent,
social group (Whitley and Kite 2006, p. 7). Dis- shrew/curmudgeon, recluse and three
crimination is conceived of as the behavior people positive golden ager, perfect grandparent, and
enact toward members of different social groups. John Wayne conservative. Kornadt and
It has been dened as treating people differently Rothermund (2014) suggest that there is even
from others based primarily on membership in a greater complexity to age stereotypes, such that
social group (Whitley and Kite 2006, p. 8). Note the content and valence vary as a function of
that stereotypes, prejudice, and discrimination can context, specically, the life domain in which
be either positive or negative in valence, as people older people are being considered at that time.
may have positive or negative mental representa- They found evidence that evaluations of older
tions and feelings and act positively or negatively adults could vary across eight different life
toward others based on their social group mem- domains: family, friends, religion, leisure, life-
bership. The majority of research on this topic, style, money, work, and health.
however, has focused on negative stereotypes, Other researchers also contend that stereotypes
prejudices, and discrimination directed at differ- of older adults are not simply negative but consist
ent social groups. of positive and negative components. The stereo-
Ageism was rst dened as age-based type content model (SCM) suggests that most
stereotyping, prejudice, and discrimination groups are evaluated along two fundamental
(Butler 1969). In its original conception, age bias dimensions: warmth and competence (Cuddy
was conceptualized as bias directed at older et al. 2008). Stereotypes about groups are based
adults, but prejudice toward young people also on the degree to which members of those groups
exists. The present entry focuses on ageism are seen as warm and as competent. In the case of
Age Stereotyping and Discrimination 97
older adults, they are viewed as warm but incom- them. A prescriptive stereotype about identity per-
petent. According to the SCM, this combination tains to the expectation that older adults act their
of perceptions can lead to feelings of pity toward age and engage in age-appropriate behavior. For A
older people and to paternalistic prejudice. consumption, the prescriptive stereotype refers to
Most of the research on the content of age concerns that older adults will consume more than
stereotypes has been done in Western cultures their fair share of resources such as health care or
such as the United States and Europe. Studies pensions. The researchers suggest that when older
that have compared Eastern and Western cultural adults violate any of these three prescriptive age
perspectives have produced somewhat inconsis- stereotypes, they are more likely to face hostile
tent ndings. Some research found that individ- prejudice rather than paternalistic prejudice, as
uals from Eastern cultures held more positive posited by the SCM (North and Fiske 2012).
views of older adults, whereas others found that
age stereotypes of older adults were more nega-
tive in Eastern cultures, such as in Asia (Hummert Age Prejudice and Discrimination
2011). Despite these inconsistencies, however,
there has been some agreement across Eastern Several reviews and meta-analyses have been
and Western samples about the general content conducted on attitudes toward older adults. The
of age stereotypes, such that the age stereotypes majority of studies have found that older adults
found in some cultures (e.g., stereotypes about are viewed negatively more often than positively
age-related cognitive and/or physical impairment) (Chasteen et al. 2011; Hummert 2011; Kite
have also been identied in others (North and et al. 2005). The context surrounding the assess-
Fiske 2012; Hummert 2011). Instead, culture ment of age-related attitudes, however, can make
seems to inuence what domains people empha- a difference. For example, within-subject designs
size within the general content of age stereotypes, in which young and older adults are directly com-
such that individuals from Western cultures tend pared tend to produce more negative assessments
to focus more on age stereotypes about mental and of older adults than when a between-subject
physical traits, whereas individuals from Eastern design is used. As well, when older adults are
cultures focus more on social and emotional traits depicted as behaving in stereotypically consistent
(Hummert 2011). Overall, though, there is a great ways, such as being forgetful, they are rated more
deal of convergence between Eastern and Western negatively (Hess 2006).
perspectives on the content of age stereotypes. Consistent with the results for explicit evalua-
As noted earlier, context can determine how tions described above, results of studies that have
older people are stereotyped and perceived. Most used implicit assessments of attitudes toward
of the research on age stereotypes has focused on older adults have also found more negative than
descriptive stereotypes, or depicting the content of positive reactions (Hummert 2011). For example,
peoples beliefs about how older people are. More research using the implicit association test (IAT)
recent work has shown that prescriptive age ste- found that people implicitly preferred younger
reotypes are also applied toward older people. over older adults. Respondents demonstrated
Prescriptive stereotypes refer to beliefs about these preferences not only in Western countries
how older people should behave and involve but in Eastern nations as well (Hummert 2011).
expectations that are used to control what older Although a great deal of research has found
people do (North and Fiske 2012). Three types of negative attitudes toward older adults, expressed
prescriptive age stereotypes have been posited to both explicitly and implicitly, ndings from the
exist: succession, identity, and consumption SCM suggest that there should be instances in
(North and Fiske 2012). For succession, the pre- which attitudes toward older adults are ambiva-
scriptive age stereotype is an expectation that lent. Based on the SCM, Cuddy and colleagues
older adults will relinquish resources such as developed the BIAS (behaviors from intergroup
jobs to younger generations, who wish to succeed affect and stereotypes) map in order to capture the
different types of prejudice and discriminatory distancing oneself from that group. This is
behaviors that various social groups might face achieved by ignoring or socially excluding
(Cuddy et al. 2008). They propose that discrimi- others. An example is choosing not to hire an
natory behaviors can be predicted systematically applicant because of his or her age.
from both the stereotypes and emotions
(prejudices) perceivers hold of various social In order to predict whether individuals will act
groups. In their BIAS map, Cuddy and colleagues in an active or passive manner that is either helpful
contend that two dimensions explain a wide scope or harmful, Cuddy and colleagues argue that the
of discriminatory behaviors toward various perceived warmth and competence of a particular
groups, including older adults: (1) the intensity group must be considered. Importantly, they con-
of the behavior (i.e., active or passive) and tend that the warmth dimension is more important
(2) the valence of the behavior (i.e., facilitative than the competence dimension, because the
or harmful) (Cuddy et al. 2008). The intensity warmth judgment is based on the extent to which
dimension refers to the amount of effort a person people believe that a target groups goals threaten
puts into a behavior. Active behaviors are straight- the self. Thus, the level of warmth attributed to a
forward, explicit, intense, and purposeful, group predicts whether perceivers will act in an
whereas passive behaviors are indirect, implicit, active facilitative or in an active harmful manner
and relatively less intense and purposeful. The toward that group. That is, groups stereotyped as
valence dimension helps to explain whether the high in warmth evoke active helping behavior
intended consequences of active and passive from others and groups stereotyped as low in
behaviors will be positive or negative. Facilitative warmth evoke active harmful behavior from
behaviors are prosocial and help others achieve others. Conversely, competence stereotypes of a
their goals, thus leading to positive outcomes. In group are predictive of whether others will act in a
contrast, harmful behaviors are antisocial and passive facilitative or in a passive harmful manner
impede others from reaching their goals, thus toward members of that group. People will behave
leading to negative outcomes for the target in a passive facilitative way toward groups per-
group. In combination, these two bipolar dimen- ceived as highly competent and in a passive harm-
sions produce four categories of discriminatory ful way toward groups perceived as low in
behaviors: competence. Findings supporting the SCM show
that older adults are stereotyped as warm but
1. Active facilitation. Behaviors that fall under incompetent and are often treated in active facili-
this category are overtly intended to benet tative and passive harmful ways (Cuddy
members of a group. Examples of these are et al. 2008). For instance, institutionalization can
providing aid or offering an older adult a seat be intended to help an older adult; however, it also
on public transportation. isolates that individual from society and can lead
2. Active harm. Behaviors classied in this cate- to neglect.
gory are overtly intended to disadvantage a Emotions mediate the link between combina-
group. Examples include physical or verbal tions of the warmth and competence stereotypes
abuse. and behavior. Admiration, based on the stereotype
3. Passive facilitation. Behaviors categorized this that a target group is high in both competence and
way involve cooperating with another group in warmth, leads to both active and passive facil-
with the intention of benetting the self. Nota- itation. Contempt, based on the stereotype that a
bly, however, both groups benet from this target group is low in both competence and in
behavior. An example would be providing warmth, leads to both active and passive harm.
companionship to an older family member in Envy, based on the stereotype that a target group is
order to receive an inheritance from him or her. high in competence but low in warmth, leads to
4. Passive harm. Behaviors falling under this cat- active harmful and passive facilitative behaviors.
egory involve hurting another group by Pity, based on the stereotype that a target group is
low in competence but high in warmth, leads to intonation when communicating with older adults
active facilitative and passive harmful behaviors. as well as physical behaviors such as patting older
Given that older adults are stereotyped as highly adults on the head (Whitley and Kite 2006; A
warm yet not very competent and are a pitied Bugental and Hehman 2007). Both the verbal
group, they are often treated with paternalistic or and the physical behaviors involved in baby talk
benevolent prejudice (Cuddy et al. 2008). Such convey assumptions about older adults limited
behaviors convey the message that older adults cognitive and hearing abilities as well as situate
are subordinate, weak, and incapable. older adults as subordinate (Whitley and Kite
While pity is the default emotion associated 2006; Bugental and Hehman 2007). Importantly,
with older adults, there are instances in which this form of ageism is used by a variety of com-
they may face other kinds of discriminatory municators such as nurses in nursing homes,
behavior. As noted earlier, when older adults vio- strangers, and family members (Whitley and
late prescriptive age stereotypes, they are more Kite 2006).
likely to face hostile forms of prejudice. For Elder abuse. Hostile ageism, including elder
example, when older adults violate age prescrip- abuse, can often be seen within the family. The
tions about succession (i.e., yielding desired most common forms of elder abuse within fami-
resources like jobs to younger age groups), they lies include physical abuse, neglect, nancial
are more likely to face envious prejudice (North exploitation, and discrimination in the area of
and Fiske 2012). If older people violate the pre- sexuality (Palmore et al. 2005). These forms of
scriptive age stereotype concerning consumption abuse are especially common when older adults
(i.e., using only ones fair share of common live with their children and are seen as a burden
resources such as health care), feelings of con- (Palmore et al. 2005). During physical abuse,
tempt and anger may ensue. But if older adults physical force is used and may result in bodily
violate age prescriptions about identity and do not harm. Neglect involves a lack of attending to older
act their age, they will likely face distancing and adults needs. Financial exploitation includes
rejection. When any of these three prescriptive misusing older adults money, property, and
age stereotypes are perceived to be violated, it is other assets. Finally, when older adults express a
more likely that older people will face some types desire for sexual intimacy, they may face criticism
of hostile ageism (envy, contempt, rejection) than from younger family members because such
paternalistic or benevolent ageism. desires are seen stereotypically as abnormal for
an older population. This can have negative impli-
cations for relationships both within and outside
Examples of Age Discrimination of the family, leaving older adults vulnerable to
social isolation.
Patronizing speech. Benevolent ageism is often Ageism in health care. Medical professionals
manifested through peoples communication pat- may express ageist behaviors and attitudes, which
terns with older adults. Patronizing speech, called can be observed early on in medical professionals
elderspeak, is often used with older adults in order careers. For instance, medical, nursing, and social
to attempt to actively facilitate communication work students have reported that they think more
and is characterized by over-accommodation and positively about the idea of interacting with youn-
baby talk (Whitley and Kite 2006; Bugental and ger adults and more negatively about interacting
Hehman 2007). People unconsciously over- with older adults (Carmel et al. 1992). Conse-
accommodate when communicating with elders quently, these students nd that they are least
by being excessively polite and expressive while likely to want to work with older adults compared
speaking in a loud and slow manner with great to other age groups and compared to other types of
enunciation. Baby talk is an extreme form of patients (such as drug addicts, heart disease
overcompensation in which a person uses simpli- patients, psychiatric patients, etc.) (Palmore
ed language, a higher register, and exaggerated et al. 2005; Carmel et al. 1992). This can have
implications for the quality of service that doctors, magazines which target older adults, such as
nurses, social workers, and other health-care pro- AARPs Modern Maturity, older adults appear in
fessionals provide to older adults. For instance, less than half of the advertisements (Whitley and
believing the stereotype that illness is natural in Kite 2006). When older adults are included in the
old age may lead students and doctors to media, negative images primarily depict them as
misdiagnose physical and psychological ailments unattractive, out-of-date, and having poor health
and can affect communication with older patients (Bugental and Hehman 2007). For instance, in a
(Whitley and Kite 2006; Hess 2006; Palmore number of magazines, such as Time, older adults
et al. 2005). Doctors and other medical profes- primarily appear in pharmaceutical advertise-
sionals may appear to be less respectful, less ments (Whitley and Kite 2006). Magazines and
informative, and less responsive and to afford advertisements illustrate aging as an unwanted
less time to older patients than to young and process and offer a number of solutions to reverse
middle-aged patients (Whitley and Kite 2006; the process, such as Botox injections to smooth
Hess 2006). wrinkles. Other forms of media, such as comedy
Ageism in the workplace. The workplace is shows and birthday cards, insult and make fun of
another area in which people may behave in dis- older adults, thus reinforcing negative age stereo-
criminatory ways toward older adults. Many older types (Palmore et al. 2005). Furthermore, most
workers report experiences of being ignored, people are not aware that such comments may
being excluded from important decisions, and unconsciously intensify peoples negative atti-
being talked down to by coworkers and bosses tudes toward older adults and aging (Palmore
(Blackstone 2013). Additionally, younger et al. 2005).
workers may socially exclude older adults and
make offensive jokes about their age (Blackstone
2013). A strong bias exists in the hiring, promot- Experiences and Effects of Age
ing, and termination processes that favors younger Stereotypes and Discrimination
adults. This bias is driven by the incompetence
stereotype that people tend to hold of older adults. As discussed earlier, older adults are stereotyped
People prefer to hire and to promote younger on negative (incompetent, curmudgeon) and pos-
candidates, perceiving them as more competent itive (warm, perfect grandparent) dimensions.
than older candidates. At the same time, people This complexity of age stereotypes creates multi-
are more likely to terminate jobs lled by older ple ways in which ageism can manifest, as
workers, who are more likely to have higher sal- highlighted in the BIAS model (Cuddy
aries (Whitley and Kite 2006; Palmore et al. 2008). Almost all older adults in Canada
et al. 2005). These decisions are often justied and the United States experience ageism
with the stereotypic view that older adults are (Palmore 2004). In fact, 91% of older adults sur-
unproductive and less capable in the workplace veyed from Canada and 85% of older adults from
(Whitley and Kite 2006). Older adults are often the United States reported experiencing at least
encouraged to retire and some are asked to con- one form of ageism. Ageist experiences range
tinue to perform the same services voluntarily that from severe (e.g., being victimized) to mild (e.g.,
they did when they were being paid (Palmore receiving a birthday card that pokes fun at ones
et al. 2005). age). Encouragingly, the severe forms of ageism
Ageism in the media. Older adults are under- are far less common than milder forms. Only 5%
represented in the media but are portrayed nar- of older adults report experiencing victimization
rowly when they do appear (Whitley and Kite vs. 70% who have experienced jokes based in age
2006; Palmore et al. 2005). Generally, the media stereotypes. However, it is not uncommon for
primarily targets younger audiences and neglects older adults to be patronized (46%), to be ignored
older audiences, thus conveying the message that (43.5%), or to be met with assumptions of incom-
older adults are of low importance. Even in petence (35.5%).
Although we know that most older adults will Over-accommodation is predicated on beliefs of
experience ageism, we know relatively little about lowered competency in older adults. With
the effect of ageism on older adults. There is an repeated exposure, these beliefs are internalized A
imbalance in the extent to which the perspectives by older adults and come to be accepted as valid.
of those who display prejudice are understood Once these beliefs are perceived as valid, older
compared with the perspectives of those who adults expectations about their own abilities are
experience it. Specically, more is known about lowered, leading to lower performance, which
expressions of age stereotypes and prejudice than serves to reinforce the original beliefs of lowered
about what it is like to be the target of those competency (Bugental and Hehman 2007). Thus,
age biases. Of the small amount of research that the behavior of older adults who experience over-
has documented older adults ageism experiences, accommodation may not reect their actual cog-
it has been shown that benevolent ageism, such as nitive abilities, but instead be a reection of the
being patronized, and hostile ageism, such as expectations of their caregivers.
social exclusion, both have negative impacts on Age self-stereotypes and stereotype embodi-
older adults psychological well-being, cognitive ment theory. The extent to which older adults
functioning, and health (Hess 2006; Bugental and internalize and endorse negative age stereotypes
Hehman 2007). Examples of the deleterious predicts a variety of age-related outcomes, such as
impact of age stereotypes and ageism on older for memory function and health. The manner in
adults include research on the provision of which this occurs is explained through stereotype
unwanted help (specically, patronizing speech), embodiment theory (Levy 2009). Stereotype
age self-stereotypes, and stereotype threat. embodiment theory has four main components.
The effects of patronizing speech on older The rst component explains that age stereotypes
adults. It is intuitive that hostile ageism will are internalized throughout a persons lifetime,
have a negative impact on older adults. It is some- forming self-stereotypes among older adults.
what less intuitive why benevolent ageism, This highlights a unique aspect of older adults
manifested in helping behaviors, can also nega- experiences of ageism (vs. other minority
tively affect older people. Patronizing speech, as experiences of prejudice). The age group to
discussed above, is commonly used when people which a person belongs changes over the life
communicate with older adults. The manner in span, with younger adults expecting to age and
which older adults experience and respond to eventually join the age group of older adults.
patronizing speech depends on their cognitive Thus, over time, older adults go from being
and functional abilities. Older adults whose func- outgroup members to ingroup members as people
tional ability is low are responsive to over- grow older. In contrast, other group identities,
accommodating speech. However, this communi- such as race, remain constant and membership is
cation method is often applied to older adults with stable across ones life span. For most of their
little or no cognitive decline and is experienced as lives, people do not perceive older adults as mem-
condescending and patronizing. Specically, bers of their ingroup and are not motivated to
over-accommodation is both insulting and harm- challenge age stereotypes (Levy 2009). Thus,
ful to older adults. It is insulting in that it assumes when people are rst exposed to age stereotypes,
that all older adults have similarly low cognitive often in childhood, they are not motivated to
abilities and is a condescending behavior. It is reject these stereotypes like they would be if the
harmful because it is associated with several neg- stereotypes are applied to an ingroup. Age stereo-
ative outcomes among older adults including a types are consistently reinforced throughout
loss of self-esteem, motivation, and condence adulthood and are internalized after repeated
and a loss of feeling in control (Hess 2006). exposure. This process results in age self-
Stereotype-based helping behaviors like this stereotypes, whereby older adults apply internal-
can lead to dependency in older adults by ized age stereotypes to their own aging expecta-
creating a self-fullling system of expectations. tions and experiences.
The extent to which age stereotypes inuence adults primed with negative age stereotypes dem-
older adults does not rely on explicit activation or onstrate larger cardiovascular responses to a
endorsement of these stereotypes. This is the sec- stressful situation. Thus, stress, a predictor of
ond component of stereotype embodiment theory health, is a more common experience among
(Levy 2009), and it is supported with a large body older adults holding negative views of aging,
of literature demonstrating that subliminal activa- leading to more serious health declines, including
tion of negative age stereotypes inuences older cardiovascular issues.
adults performance on a variety of tasks. Even Stereotype threat. Stereotype embodiment the-
tasks that are not under conscious control can be ory (Levy 2009) emphasizes the unconscious rela-
affected by subtle activation of age stereotypes. tionship between age stereotypes and age-relevant
For example, older adults who complete a writing outcomes. A second theory, stereotype threat,
task after exposure to subliminally presented neg- focuses on the effects of being aware of age ste-
ative age stereotypes have shakier and less steady reotypes (Steele 1997). The extent to which older
handwriting than those exposed to positive age adults have internalized negative age stereotypes
stereotypes. will impact the effect that reminders of their age
The third component of the stereotype embodi- have on their subsequent performance on
ment theory explains that the effects of age ste- age-relevant tasks, including tests of memory
reotypes are only present among people for whom (Chasteen et al. 2011). This phenomenon is
the stereotype is self-relevant. That is, older adults known as stereotype threat (also conceptualized
are impacted by internalized and primed age ste- as social identity threat (Steele et al. 2002)), and it
reotypes but younger adults, for whom the stereo- states that concern about conrming a group-
types are not relevant, are not. relevant stereotype will lead an individual to per-
The fourth component of stereotype embodi- form worse on the associated task, thus conrming
ment theory explains the pathways through which the stereotype (Steele 1997; Steele et al. 2002). Ste-
behavioral assimilation to age stereotypes occurs. reotype threat has been found for memory and
There are three pathways: psychological, behav- cognitive function in tests involving older adults
ioral, and physiological (Levy 2009). The psycho- (Hess 2006). When older adults are given instruc-
logical pathway functions through expectations tions emphasizing the memory component of a task,
founded in age stereotypes. These internalized their subsequent memory performance is reduced
stereotypes guide expectations about the aging compared to those who do not experience instruc-
experience and create self-fullling beliefs about tions with this emphasis and compared to younger
the aging process. These expectations limit older adults who receive the same instructions. Similar
adults ability to perform mental and physical effects are found for recall tasks following a
tasks. A second pathway is the behavioral path- reminder that older adults have poor memory skills.
way. The behavioral pathway functions primarily Stereotype threat functions through multiple
through healthy behaviors. A common stereotype pathways to create performance decits. One
about aging is that it is associated with poor path works through reducing older adults use of
health. Internalizing this stereotype leads to the memory strategies, such as clustering (Chasteen
belief that declining health is inevitable and et al. 2011). A second path functions through
beyond control. This belief prevents older adults reduced performance expectations such that
from engaging in behaviors to minimize health lowered expectations lead to poorer performance.
decline. Thus, the perception that declining health This is similar to what is seen after exposure to
is inevitable prevents older adults from engaging benevolent ageism, although the cause of lowered
in behaviors that would contradict this belief and a expectations varies. Older adults who value the
reinforcing pattern of beliefs and behavior is domain in which they are being evaluated and
formed. The third pathway, through physiology, those who are strongly identied with their age
is founded in the relationship between stress and group experience larger stereotype threat decits
various health outcomes. For example, older (Chasteen et al. 2011).
Overcoming Age Stereotypes Older adults primed with incremental beliefs

outperform older adults primed with entity beliefs
Age stereotypes contain negative and positive on measures of free recall and reading span, both A
content and are internalized by people across measures of memory performance.
their lives. The impact of negative age stereotypes Performance expectations. The priming effects
is demonstrated through stereotype embodiment of exposing older adults to either positive age
theory and stereotype threat; however, there are stereotypes or incremental beliefs operate at an
several methods to alleviate these effects. Priming unconscious level to improve older adults perfor-
positive stereotypes can facilitate positive out- mance on age-relevant tasks. A third means
comes (Palmore 2004; Levy et al. 2014) as can through which the effects of negative age stereo-
priming incremental (vs. entity) beliefs (Plaks and types can be reduced functions by explicitly
Chasteen 2013). Successfully completing an changing older adults expectations about their
age-relevant task can also improve performance performance (Geraci and Miller 2013). As
on subsequent tasks (Geraci and Miller 2013). discussed above, older peoples expectations
Positive age stereotypes. Just as negative ste- about age-related outcomes (e.g., memory, health,
reotypes about aging can lead to poor outcomes etc.) impact the extent to which they engage in
for older adults, so can positive age stereotypes behaviors to achieve the desired outcome, thus
facilitate positive outcomes (Levy 2009; Levy reducing the likelihood of success and ultimately
et al. 2014). Older adults presented with positive supporting the relevant age stereotypes. Changing
age stereotypes implicitly (subliminally) on a older peoples expectations can break this feed-
weekly basis for four weeks experienced a variety back cycle. Performing a cognitive task success-
of positive outcomes. These included increases in fully improves older adults performance on a
the extent to which they endorsed positive age subsequent memory task by reducing the anxiety
stereotypes, the extent to which they applied pos- associated with the memory task (Geraci and
itive age stereotypes to their own aging process Miller 2013). Interestingly, failing a task produces
and their own physical function (Levy the same subsequent performance as not
et al. 2014). performing a prior task: Violating the expectation
Incremental mind-sets. People who endorse of failure, not experiencing failure, inuences
incremental beliefs espouse the view that personal subsequent performance. When older adults
qualities are malleable and that people can expect to succeed, they are more likely to succeed,
improve with effort. In contrast, people who and it is possible to enhance perceptions of future
endorse entity beliefs endorse the view that per- success through an unrelated prior success.
sonal qualities are xed and cannot be improved,
regardless of a persons motivation or effort (Plaks
and Chasteen 2013). Those who endorse entity Conclusion
beliefs tend to rely more on stereotypes than
those who endorse incremental beliefs; they also Age stereotypes consist of the mental representa-
tend to engage in more self-stereotyping. The tions people have about older adults. These ste-
extent to which people self-stereotype is particu- reotypes are complex, consisting of both negative
larly relevant to older adults, given the relation- and positive content and varying across life
ship between self-stereotypes and age-associated domains. Viewing older adults as stereotypically
outcomes discussed in stereotype embodiment warm but incompetent can lead to patronizing
theory (Levy 2009). Older adults who endorse behavior in which older adults face benevolent
incremental beliefs perform better on memory ageism. When older adults violate prescriptive
tasks than do older adults who endorse entity age stereotypes and do not exhibit expected
beliefs (Plaks and Chasteen 2013). Theories on behaviors, they may face hostile ageism. Benev-
change may be successfully applied to improve olent and hostile ageism have been shown to
older adults performance on age-relevant tasks. occur in a variety of life domains for older people
and to worsen older adults emotional, cognitive, Cuddy, A. J. C., Fiske, S. T., & Glick, P. (2008). Warmth
and physical well-being. Moreover, older adults and competence as universal dimensions of social per-
ception: The Stereotype Content Model and the BIAS
may fall prey to aging self-stereotypes because Map. In M. P. Zanna (Ed.), Advances in experimental
they might have internalized negative age stereo- social psychology (Vol. 40, pp. 61149). New York,
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memory performance using prior task success. Psy-
explicitly, can worsen their cognitive and physical chology and Aging, 28, 340345.
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Age Stereotyping and Views of Aging, Theories of 105
specic social groups. In other words, the content

Age Stereotyping and Views of and evaluative components of stereotypes can
Aging, Theories of play an important role in how we perceive and A
respond to others in social situations, which in
Lauren E. Popham1 and Thomas M. Hess2 turn can inuence the nature of social interactions
1
Greenwald & Associates, Washington, DC, USA and the behavior of others. Although most early
2
Department of Psychology, North Carolina State social psychological theory and research focused
University, Raleigh, NC, USA on such effects, more recent work has addressed
self-stereotyping inuences reecting the degree
to which stereotypical beliefs or situational acti-
Synonyms vation of stereotypes affects an individuals
behavior independent of the behavior of others.
Age stereotypes; Ageism; Explicit stereotypes; Research on self-stereotyping effects forms the
Implicit stereotypes; Stereotype threat; Working bulk of much recent aging research and thus is
memory the focus of this section.
Definition Nature of Aging Stereotypes
Stereotypes are beliefs regarding the characteris- Stereotypes can be examined in many different
tics of people within the same demographic, cul- ways, and researchers studying aging have used
tural, or social group. These beliefs inuence a variety of methods. For example, stereotypes
social interactions with and perceptions of others can be examined explicitly by asking people to
based on their membership in a stereotyped group. identify the characteristics associated with a spe-
Such generalizations of a group of people can cic group or implicitly through devices such as
have negative consequences. the Implicit Association Test (Greenwald
et al. 1998). They can also be assessed directly
through the specic assessment of group attri-
The Importance of Stereotypes butes or indirectly through trait sorting or by
examining inferences about individuals and their
Stereotypes are cognitive representations or behavior that are assumed to reect stereotypical
schemata of beliefs regarding the characteristics beliefs. It is important to note that each of these
of a group of people that are typically shared by methods may offer unique insights about stereo-
individuals within a culture or social group. These types and the contexts in which they emerge. For
representations play an important role in social example, consistent with many other studies of
interactions by inuencing our perceptions of stereotypes, research has demonstrated a
others based upon their membership in stereo- mismatch between implicitly and explicitly
typed groups, thereby allowing us to draw infer- assessed attitudes about aging (e.g., Hummert
ences about their behavior. Of course, the et al. 2002).
accuracy of such inferences is dependent upon So, what does research on aging stereotypes
the accuracy of the stereotype and its appropriate tell us? Based upon casual observation and atten-
application to a specic target individual. Given tion to media, one might expect that such stereo-
the relative inaccuracy of many social stereotypes, types will be rather negative. Although there is
however, their inuence often leads to biased much data consistent with such a view, the ulti-
perceptions of others. The information contained mate picture is more complex. This complexity is
in these representations is also evaluative in illustrated in research examining the content and
nature, and thus stereotypes form the basis for structure of age stereotypes in which individuals
attitudes that we may have toward members of sorted pictures, descriptors, or traits into
106 Age Stereotyping and Views of Aging, Theories of
categories (e.g., Brewer et al. 1981; Brewer and of older adults is characterized as high in
Lui 1984; Hummert 1990; Hummert et al. 1994; warmth reecting low competition to the
Schmidt and Boland 1986). Based on the results in-group (i.e., young adults) and low in
of these studies, Hummert (1999, 2015) identied competence reecting low perceptions of status.
specic stereotypes of older adults that were rela- Cuddy and Fiske (Cuddy and Fiske 2002) further
tively consistent across age groups: golden ager, suggest that the shared stereotypes identied by
perfect grandparent, John Wayne conservative, Hummert (1999) and others can also be charac-
severely impaired, recluse, despondent, and terized in terms of these two dimensions with only
shrew/curmudgeon. Whereas the majority of one the golden ager appearing to be high in
these categories do represent somewhat negative both warmth and competence. (Notably, the
depictions of older adults in our society, they also golden ager subcategory is seen primarily in stud-
illustrate two important points. First, aging stereo- ies where the sample generating stereotypes
types are multifaceted, indicating that the super- includes middle-aged and older adults.) Other
ordinate category of older adult does not do a subcategories can be characterized as being low
good job of characterizing peoples cognitive rep- on at least one of the dimensions of competence
resentations. Second, and perhaps more impor- (perfect grandparent, severely impaired, recluse)
tantly, the schemata used for categorizing older or warmth (John Wayne conservative, despon-
adults are not invariably negative. Of further note dent, shrew/curmudgeon). Thus, whereas the
is the nding that increasing age was found to be research on stereotypes does indicate that our
associated with a greater number of subcategories conceptions of older adults are not all negative,
(e.g., Hummert et al. 1994), suggesting that the this structural analysis suggests an underlying
complexity of our representations of aging is negative component to most subcategories of
inuenced by our own experiences as we move older adults.
through the life span. This last point relates to the In addition to examining the perceived charac-
somewhat unique status of old age in that most of teristics of older adults, researchers have also
us will experience this category as both an examined beliefs regarding the nature of change
out-group in young adulthood and as an of specic aspects of behavior across the life span
in-group later in life, perhaps leading to the expec- as another means for understanding aging stereo-
tation that our stereotypes of old age will become types. For example, Heckhausen and colleagues
less severe as we ourselves age. Interestingly, (Heckhausen and Baltes 1991; Heckhausen
whereas there may be some tempering with age, et al. 1989) assessed beliefs about the sensitivity
there is still much consistency in the nature of of personal traits to change along with the timing
such stereotypes across adulthood. and controllability of such change. They found
Although the existence of some positive sub- that, regardless of age, adults expected behavioral
categories suggests a somewhat more positive losses to dominate over gains with increasing age
view of later life, their consideration within the and that desirable, controllable traits were more
context of the stereotype content model (Fiske likely to emerge and cease development earlier in
et al. 2002) may qualify this perspective. This adulthood than were undesirable traits. In other
model proposes that stereotypes of out-groups words, the general characterization of the aging
can be characterized in terms of their placement process is rather negative in terms of the losses of
along the independent dimensions of competence desirable traits, the advent of undesirable ones,
and warmth. The in-group tends to be perceived as and the perceived inability to control the latter.
being high on both dimensions, whereas Similar types of studies that have focused on more
out-groups are viewed as being higher along one specic domains (e.g., memory, language) have
dimension than the other based on perceptions of obtained results consistent with these (e.g., Camp
status and competition relative to the in-group. and Pignatiello 1988; Hertzog et al. 1998; Ryan
Research based on this model (e.g., Cuddy and Kwong See 1993; Ryan et al. 1992). Although
et al. 2009) suggests that the general stereotype the characterization of aging from this research is
rather gloomy, these studies also demonstrated extreme. Of even greater interest are situations
that not all beliefs regarding aging and cognition where stereotypes are incongruent with reality,
are negative, with differences in attitudes being resulting in potentially inappropriate as opposed A
observed as a function of domain. Thus, for exam- to merely condescending responses to older
ple, while old age might be associated with declin- adults in relevant contexts. For example, several
ing physical and cognitive skills, it is also thought investigations of perceptions of older workers
to be associated with growth or maintenance of suggest that aging-related biases are conveyed in
other aspects of functioning, such as those associ- judgments regarding their capabilities. Relative to
ated with expressive behavior or wisdom (e.g., younger workers, older workers are perceived as
Heckhausen et al. 1989; Slotterback and Saarino less physically capable, less healthy, lower in pro-
1996). ductivity, inexible, resistant to new ideas, and
Stereotypes have also been assessed in a some- less capable of being trained. These attitudes are
what indirect fashion using person perception par- subsequently reected in institutional behaviors
adigms that focus on observers responses to the that result in, for example, older workers being
behavior of others. Inferences about aging stereo- given fewer opportunities for training and learn-
types are made based on different interpretations ing of new skills (e.g., Capowski 1994;
of and attributions for this behavior as a function Finkelstein et al. 1995). The disturbing aspect of
of the age of the individual performing the behav- such ndings is that these attitudes typically y in
ior. For example, an identical memory failure is the face of reality. There is little relationship
typically judged as more serious in an older adult between age and job productivity, and absentee-
than in a younger adult (Erber 1989) and is more ism is actually lower in older than in younger
likely to be attributed to internal stable causes workers (McEvoy and Cascio 1989; Schmidt
(e.g., ability) in older adults, whereas attributions and Hunter 1998). What is equally disturbing is
based on internal, unstable causes (e.g., effort) that these negative perceptions of older workers
were more prevalent for younger adults failures occur at an earlier age (e.g., 5065 years) than
(Erber et al. 1990; Parr and Siegert 1993). Another commonly associated with more general aging
example can be seen in the realm of language attitudes, suggesting that the time frame typically
performance, where Kwong See and Heller associated with perceptions regarding the devel-
(2004) examined perceptions of different-aged opment of negative aging-related characteristics is
adults who exhibited high and low levels of lan- compressed in the workplace.
guage performance. They found that poor-quality In summary, several general conclusions can
language performance in older adults was judged be reached about stereotypes of aging and older
less negatively than it was in younger adults, adults. First, our views of aging are multifaceted,
whereas high-quality performance was judged rel- with the notion of a general stereotype of old age
atively more positively. This variability in judg- clearly receiving little support. Second, although
ments across age groups is assumed to reect there are some positive aspects associated with
age-based stereotypic expectations (i.e., good per- these stereotypes, they tend to paint a rather neg-
formance in young adults, poor performance in ative picture of later life. As suggested by the
older adults). Such ndings are consistent with the stereotype content model, this negativity could
shifting standards model of stereotype-based even be seen to underlie some of the more positive
judgments (Biernat 2003). stereotypes of aging. Third, as in many cases, the
These studies of person perception are not only stereotypes that we hold of older adults are not
valuable in examining stereotypes but also in completely accurate. This may bias how we
illustrating how they are translated into actual respond to older adults, with such biases being
responses to other people. Although the stereo- particularly consequential in situations where
typic traits implied in these studies often have a there is a clear disconnect between the stereotype
basis in reality (e.g., impaired memory), the and reality. Fourth, developmental context does
responses to these traits are typically somewhat modify our stereotypes somewhat, with older
adults having more complex views of their group. decrements on cognitive tests (Steele 1997). Per-
However, these differences are not as strong as formance disparities between members of stereo-
one might expect. In a related vein, although there typed and non-stereotyped groups disappear,
is some variation across cultures in views of later however, when the stereotype is de-emphasized
life, a recent review of the literature concluded or made irrelevant in a given situation. This phe-
that there is . . .broad cross-cultural agreement on nomenon is called stereotype threat, and it has
the general nature of age stereotypes that sub- been observed in myriad situations with many
sumes culturally specic beliefs about individual different types of stereotyped groups of people.
components of those stereotypes (Hummert Several studies have examined the possibility
2011, p. 251). For example, although cultures that stereotype threat may be operative in
that value lial piety (e.g., China, Japan, Korea) inuencing older adults behavior, particularly in
may treat older adults with more respect than contexts associated with negative views of aging.
those that do not, individuals in these same cul- For example, Hess and colleagues (Hess
tures often express negative views of aging that et al. 2003) exposed younger and older adults to
are similar to those held in Western cultures (e.g., one of two different articles: one emphasized
Boduroglu et al. 2006; Yun and Lachman 2006). aging stereotypes and the other article
Finally, stereotypes of aging are sensitive to conde-emphasized age differences in memory ability.
text (e.g., type of ability [e.g., Heckhausen They found that the older group who had read the
et al. 1989], domain of functioning [e.g., Kornadt negative aging stereotype article recalled a
and Rothermund 2011]). For example, both smaller proportion of the words than younger
young and older adults perceptions of aging are adults exposed to the same article. This difference
inuenced by the domain of functioning being in performance was dramatically smaller, how-
considered (e.g., health vs. social relationships). ever, in the condition in which participants were
exposed to more positive perspectives on aging.
Moreover, the more highly invested the older
The Impact of Aging Stereotypes on adults were in the stereotyped domain (i.e., mem-
Older Adults ory ability), the worse they experienced threat-
related memory decrements. Related to this,
An important question concerns the extent to older adults who identify strongly with their own
which aging stereotypes affect our behavior. age group are most vulnerable to stereotype threat
A growing body of research in the eld of geron- effects on their memory performance (Kang and
tology has shown that aging-related stereotypes Chasteen 2009). Although in the gerontology eld
have the potential to negatively affect older most stereotype research has focused on the ste-
adults functioning whether the negative stereo- reotyped domain of memory ability, older adults
type is in the air in a performance situation or have also shown threat-related underperformance
becomes internalized over many years. in the math domain (Abrams et al. 2008) and in
Stereotype threat. How do stereotypes get contexts such as the workplace (Buyens
into the air? Stereotypes become salient through et al. 2009; Von Hippel et al. 2013). Importantly,
situational cues, leading to harmful threat effects there have also been demonstrations of enhanced
on the behavior or functioning of the stereotyped functioning in situations where more positive
individual. These situational cues can be blatant, images of old age have been activated.
moderately explicit, or indirect and subtle How does stereotype threat lead to underper-
(Nguyen and Ryan 2008). One way in which formance? Two different mechanisms have been
more explicit inuences have been investigated explored in the literature. The rst relates to the
is through examinations of stereotype threat. idea that self-relevant stereotypes spur evaluative
When reminded of negative, self-relevant stereo- concerns. These concerns lead to self-regulation
types in a performance situation, the targets of processes, including monitoring of ones facial
these stereotypes often experience performance expressions and attempting to tamp down self-
doubt and worry (Schmader et al. 2008). The that older adults under threat were more conser-
cognitive resources required to engage in self- vative in their approach. Popham and Hess (2015)
regulation reduce the availability of resources for also demonstrated that threat led older adults to A
performing the task at hand, thus resulting in respond more slowly but also with greater accu-
performance decrements. This working memory racy than their positively stereotyped peers. In the
mechanism of stereotype threat effects has been same study, younger adults who were exposed to a
observed in younger adults (Schmader and Johns self-relevant stereotype showed a propensity
2003). An alternative perspective has a more toward a similar type of response under threat.
motivational focus, centering on mechanisms However, working memory decrements under
associated with regulatory focus (Higgins 1997). threat seemed to better characterize their response
The idea is that negative stereotypes activate a to the threat manipulation than regulatory focus.
prevention focus, motivating stereotyped individ- Other research from the regulatory focus per-
uals to avoid conrming the stereotype about the spective has suggested that the degree to which
group to which they belong. When in this older adults exhibit decrements in performance
prevention-focused state, threatened individuals under threat depends on the match between task
tend to perform tasks slowly and cautiously. This structure and focus. A prevention focus is most
approach may lead to apparent reductions in per- likely to result in performance decrements in sit-
formance but in fact may represent differences in uations where the task reward structure is focused
the approach to task. Seibt and Frster (2004) on gains, whereas improvements in performance
found support for this mechanism of threat effects will be observed when the avoidance of loss is
in younger adults. important. Research by Barber and Mather (2013)
In research with younger adults, the working has shown that older adults are also sensitive to
memory perspective has dominated much regulatory t, suggesting that the specic task
research. However, there is less evidence that the context in interaction with stereotype activation
same mechanism is operating to degrade older will determine the degree and nature of threat-
adults performance under stereotype threat. For related effects on older adults performance.
example, Hess et al. (2009a) and Popham and The investigation of the mechanisms underly-
Hess (2015) found little evidence of working ing threat is important in better understanding
memory impairments in older adults subjected to how older adults respond to threat. Whereas
threat, whereas the latter study found evidence of there is not much support for diversion of
threat-related working memory impairments in resources from working memory (e.g., worry)
younger adults. Popham and Hess also found accounting for threat inuences on older adults
that emotion regulation abilities play a role in behavior, this does not negate the possibility that
this working memory mechanism in younger such a mechanism may be operative in some
adults. Specically, younger adults with high circumstances. For example, we might expect
emotion regulation abilities were less vulnerable that evaluation concerns will be more likely to
to threat effects on working memory than their occur in important contexts outside the lab (e.g.,
counterparts with lower emotion regulation abili- work settings) and that certain characteristics of
ties. Given that older adults reported high levels of the individual (e.g., high neuroticism) may accen-
emotion regulation ability, it leads to the question tuate such effects.
of whether age differences in the mechanism Implicit stereotype inuences. Research has
through which stereotype threat negatively also shown that aging stereotypes can inuence
impacts performance are rooted in age differences older adults cognitive and physical performance
in reports of emotion regulation abilities. Consis- even when stereotypic cues are more subtle or
tent with this idea, several studies have suggested even operate beneath conscious awareness. Prim-
that performance decrements in older adults under ing is an indirect and subtle way in which stereo-
threat may reect adjustments in their perfor- types become relevant in a situation. For example,
mance. For example, Hess et al. (2009b) found research has shown that implicitly priming
(i.e., activating concepts without the individual when aging stereotypes permeate a context, such
being aware) older adults with aging stereotypes as the workplace, threat-related decrements can
negatively affects their performance on memory start to occur in the stereotyped domain, and this
tasks (Hess et al. 2004; Levy 1996), decreases could have consequences for job performance and
their walking speed (Hausdorff et al. 1999), career longevity. Given these implications, further
reduces balance (Levy and Leifheit-Limson research is needed to develop interventions aimed
2009), and increases physiological reactivity to at mitigating such negative effects. Most promis-
the test situation (Levy et al. 2000). Thus, nega- ing are intervention programs which aim to
tive stereotypes can operate somewhat insidiously improve the cognitive functioning or cardiovas-
in affecting older adults behavior. cular health of older adults through emphasizing
Internalization. Negative stereotypes about positive older age stereotypes (Levy et al. 2000),
older adults may become engrained at an early as positive self-stereotypes can actually override
age, even though the stereotype does not yet implicit reminders of negative old age
apply to oneself (Bennet and Gaines 2010). As stereotypes.
the person grows older, the internalization of Research on stereotype threat and implicit
aging stereotypes manifests itself in way that dam- inuences has important implications for older
ages cognitive and physiological systems, as adults. There are potentially long-term conse-
suggested by Levys (2009) embodiment perspec- quences from exposure to threat in everyday life.
tive on aging stereotypes. Levy et al. (2009) Regardless of the level of awareness, older adults
observed in a longitudinal study that people who exposed to negative aging stereotypes in the
had internalized negative aging stereotypes in workplace may experience unnecessary stress. In
middle adulthood were at increased risk of addition, when activation of negative stereotypes
experiencing a cardiovascular event 20+ years leads to underperformance outside the laboratory
later. The mechanism behind this link may relate in real life, poor performance may be mistakenly
to people who believe aging stereotypes also attributed to an aging-related decline in ability
believing in the intractability of disability and rather than the situational and reversible phenom-
disease with age, leading them to live a less enon that it is. Such inuences may also operate
healthy lifestyle over many decades. Other within the research setting. For example, investi-
research has demonstrated similar long-term gators who study memory ability ought to be
effects of negative stereotypes on mortality aware of subtle, inadvertent aging stereotype
(Levy et al. 2002) and memory (Levy cues, as the test performance of older
et al. 2012). Thus, negative perceptions of aging participants and thus our inferences about
that may be operating relatively early in life may aging-related changes in ability may reect ste-
have long-lasting effects as they can become self- reotype threat effects rather than normative aging
fullling prophecies (Levy 2009). declines.
Conclusions
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Age, Organizational Citizenship Behaviors, and Counterproductive Work Behaviors 113
at work, work attitudes (such as job satisfaction),

Age, Organizational Citizenship and their overall sense of well-being. Numerous
Behaviors, and Counterproductive studies have illustrated the close association A
Work Behaviors between individuals job performance and a raft
of relevant outcomes (Dalal et al. 2009, 2014).
Michael P. ODriscoll and Maree Roche In this literature, frequently work performance
School of Psychology, University of Waikato, is categorized as being either task performance
Hamilton, New Zealand (i.e., enactment of tasks which are core to the
persons job description) or non-task perfor-
mance (additional activities that are important,
Synonyms albeit not central to the job description). The latter
is sometimes referred to as contextual perfor-
Discretionary behaviours; Positive extra-role mance (Bergman et al. 2008). It is generally
behaviours, Prosocial organizational behaviours, recognized, however, that both kinds of job per-
Constructive contextual performance Synonyms formance are highly relevant to the overall pro-
for counterproductive work behaviours; Nega- ductivity and effectiveness, of both the individual
tive work behaviours; Deviant work behaviours worker and his or her organization. In contrast to
task performance, citizenship and counterproduc-
tive actions are viewed as voluntary behaviors
Definition (Fox et al. 2012), that is, they are not prescribed by
the persons job description or formal rules or
This chapter reviews the relationships between regulations within the organization.
age and both positive and negative extra-role This entry summarizes research on the rela-
work behaviors. The basic issue is whether older tionship between worker age and two forms of
workers display more (or less) positive and nega- non-task or contextual performance, namely,
tive discretionary work behaviors. The research organizational citizenship behaviors (OCB) and
evidence suggests that, overall, older workers are counterproductive work behaviors (CWB). OCB
more likely to engage in positive work behaviors are typically dened as behaviors which are help-
(citizenship) and are generally more likely to ful to the organization, such as assisting work
engage in fewer counterproductive behaviors colleagues, performing jobs that are not necessar-
than younger workers. ily required but are advantageous to the rm or
company, positively promoting the organization
In recent years there has been considerable as being a good employer, and so on. Many empir-
discussion of and research on the job performance ical studies of citizenship behaviors in work set-
of workers, along with the factors which contrib- tings have been based upon the typology of OCB
ute, either positively or negatively, to this perfor- dimensions proposed by Organ (1988), who iden-
mance, as well as the consequences of high and tied ve distinct, albeit interrelated, components
low job performance (for a recent review, see of OCB conscientiousness, altruism, civic vir-
Dalal et al. 2014). From an organizational per- tue, sportsmanship, and courtesy. Although Organ
spective, it is clear that worker performance is did not further differentiate between person-
paramount to the overall productivity and effec- oriented and organization-oriented OCB, there is
tiveness of the organization. Managers a conceptual linkage between this distinction and
(in particular) are highly motivated to optimize the ve components which he described. For
worker performance. Performance on the job is instance, conscientiousness and civic virtue are
also important to individual workers, as it is a clearly organization-oriented citizenship behav-
salient contributor to their feelings of achievement iors, whereas altruism and courtesy fall under
114 Age, Organizational Citizenship Behaviors, and Counterproductive Work Behaviors
person-oriented OCB Stereotypes and There have been relatively few direct investi-
threats. Sportsmanship might be viewed as gations of the association of age with OCB and
belonging in both categories. In addition, while CWB. Given the considerable debate over the
some studies have retained the ve-component relationship between age and task performance
distinction, others have merged them into an and effective work, this is surprising altruism
overall or global index of citizenship, probably and prosocial behavior. It would seem logical that
to avoid overcomplicating the data analysis and the links of age with OCB and CWB would be of
theory testing, although this procedure does result considerable interest, both theoretically and prac-
in some loss of information concerning the ve tically. Only recently, however, have researchers
components themselves. probed these associations. Below they summarize
Counterproductive work behaviors (CWB) the major ndings from these lines of research.
aging and psychological well-being, on the The entry is structured as follows. First they
other hand, are typically conceived as deliberate examine the relationship between age and citizen-
and intentional harm inicted on the organization ship (OCB), followed by discussion of the
and/or individuals within the organization (Bruk- age-CWB relationship. They conclude the entry
Lee and Spector 2006; Gruys and Sackett 2003; with an overview of the implications of extant
Jones 2009; Krischer et al. 2010; Mnard research ndings and some suggestions for further
et al. 2011; Penney and Spector 2005; Spector research in this eld.
et al. 2006). CWB are usually classied into two
distinct behaviors: interpersonal deviance and
organizational deviance (Krischer et al. 2010; Age and Citizenship (OCB)
Spector and Fox 2010). Interpersonal deviance
includes undesirable behaviors aimed at other As noted above, research on the relationship
employees and includes gossiping, lying, physical between age and OCB is relatively sparse, and
or verbal abuse, and stealing from other the ndings are not totally conclusive. An impor-
employees (Berry et al. 2007; Robinson and Ben- tant and very relevant meta-analysis was
nett 1995). Organizational deviance refers to conducted by Ng and Feldman (2008), who
transgressions resulting in production losses and included the relationship between age and both
property deviation and includes theft, intentional task performance and contextual performance
absenteeism, sabotage, poor job performance, (organizational citizenship). These authors noted
lack of cooperation, passing out condential that research over the past two decades or more
information, and/or withholding task information has obtained inconsistent ndings on this relation-
(Berry et al. 2007; Mnard et al. 2011; Ones 2002; ship. For instance, several studies have found a
Penney and Spector 2005; Shantz et al. 2014; negative correlation between age and job perfor-
Spector 2012). mance generally, which sometimes has included
Despite the wealth of research which has been contextual performance and prosocial behaviors
conducted on these OCB and CWB, there is con- (OCB). The explanation for this negative associ-
siderable debate about whether they are in fact ation is typically that, as workers grow older, their
polar opposites, and recent articles have suggested physical and (to a lesser extent) cognitive func-
that they are not necessarily negatively correlated tioning declines. In situations where these attri-
with each other (see, e.g., Fox et al. 2012). That is, butes are critical for job performance, it is clear
a person could engage in both OCB and CWB that aging can have some negative impact on task
activities, and under certain circumstances OCB performance. However, this does not necessarily
might be harmful and CWB could be benecial to ow over to contextual performance. Instead,
the organization. Mostly, however, these con- growing older can enhance a persons motivation
structs have been treated separately in research. and willingness to engage in OCB, especially
For this reason, the present entry presents separate toward other people in their work environment
discussions of their relationships with age. (i.e., person-oriented OCB). In addition, older
workers may display more emotional stability and Age. If this happens, it is likely that older workers
conscientiousness, both of which are associated would be more inclined to perform citizenship
with the display of citizenship behaviors (Ng and behaviors, especially in respect to their A
Feldman 2008). coworkers.
In their meta-analysis of 380 empirical studies A more recent meta-analysis of OCB has been
which had incorporated job performance as a cri- reported by Carpenter, Berry, and Houston
terion variable, age demonstrated relatively small (2014), although their focus was not specically
but nevertheless statistically signicant relation- on the relationship between age and OCB, but
ships with OCB, for both self-ratings and other- rather on the connection between self-ratings and
ratings of OCB. Ng and Feldman differentiated other-ratings of citizenship behaviors. Neverthe-
between three forms of OCB: person oriented, less, they did report the correlations between age
task oriented, and organization oriented. Relation- and both self-ratings and other-ratings of OC-
ships between age and OCB were somewhat B. Carpenter et al. found quite low relationships
higher for task-oriented citizenship. Ng and between age and the two ratings of OCB. Age was
Feldman concluded that older adults are more slightly positively related to self-rated OCB
motivated to volunteer in general (p. 4013) and (r = .03) and slightly negatively related to other-
that older workers are good citizens, are more rated OCB (r = .05). The latter correlation
likely to control their emotions at work, and are might reect the impact of stereotyping on
less likely to engage in counterproductive behav- workers perceptions of their colleagues levels
iors (p. 4013). of OCB, but the overall conclusion is that, at
Some caution is needed, however, when least in this meta-analysis, there was virtually no
interpreting the above ndings. For starters, the relationship between age and the two OCB rat-
relationships were quite low, .06 for person- ings. Interestingly, self-ratings were more conver-
oriented OCB, .08 for organization-oriented gent with supervisor ratings than they were with
OCB, and .27 for task-oriented OCB. As coworker ratings of a persons OCB. Overall,
suggested by Ng and Feldman, several other vari- however, the differences between self- and other-
ables might function as moderators (buffers) of ratings were relatively small and not signicant.
these relationships. One of these is the persons Bertolino et al. (2013) explored stereotypes of
physical health status. Put simply, those with both younger and older workers in Italy. They
health difculties might be less able to engage in argued that stereotypes are highly pertinent to
helping and other prosocial behaviors. Secondly, peoples job performance and especially expecta-
and equally important, chronological age might tions of their performance. Given the global aging
not be the most salient attribute to evaluate. Ng of the workforce, the impact of age stereotypes
and Feldman discussed both subjective age will probably increase in the forthcoming years.
(how old the person feels) and relative age These stereotypes are based only partially on
(their age relative to other people in their work actual differences in performance, such as those
environment). As they suggested, in a diverse age described by Ng and Feldman. In addition, peo-
environment, older workers may tend to leave ples perceptions are based on in-group versus
core tasks to their younger colleagues, especially out-group distinctions and a tendency to view
if these tasks involve heavy physical activity or members of ones own in-group as being superior
are more cognitively demanding, and perhaps (for instance, in terms of performance) to
engage in more mentoring and support activities. out-group members. For example, Finkelstein
Similarly, there is evidence that career motiva- et al. (1995) found that younger workers rated
tions among older workers sometimes shift from members of their own age group more highly
a focus on their personal career development to than older workers on several performance-
the enhancement of their younger colleagues related dimensions. Bertolino et al. discussed
careers and progression within the organization these differential perceptions in terms of social
(Lyons and Kuron 2014) Job Attitudes and identity theory (Hewstone and Jaspars 1982),
which posits that favoritism toward ones the organizations best interests and success.
in-group helps individuals to develop a social There is evidence that older workers, particularly
identity and protects them psychologically from those who have been with the organization for a
feelings of inferiority. longer time period, are more likely to display high
As discussed by Bertolino et al., perceptions affective commitment to their organization
and stereotypes can be as important as objectively (Costanza et al. 2012). This form of commitment
assessed performance differences, particularly in can buffer (moderate) the negative effects of age
jobs where the eye of the beholder is highly on work performance. In a hospitality context,
salient. Their research examined the relationship working long hours in difcult circumstances,
between perceptions of personality characteris- rotating shifts, and under high pressure are com-
tics, using the ve-factor model (FFM; Digman mon experiences for employees. Accordingly, Iun
1990; Goldberg 1990) and ratings of organiza- and Huang anticipated that affective commitment
tional citizenship behaviors. They used the mea- would function to alleviate the negative link
sure of OCB developed by Williams and between age and performance (including OCB)
Anderson (1991), which distinguished between in this work context.
person-targeted OCB (known as OCBI) and Their ndings conrmed the interaction
organization-targeted OCB (known as OCBO). (buffering) effect of commitment, particularly in
Overall, the ndings conrmed the researchers relation to altruism, which itself was negatively
expectations. Older workers were generally per- related to age. Older workers who had high affec-
ceived in a more positive light than their younger tive commitment to their organization were more
counterparts, on most of the personality dimen- likely to self-report altruism toward their work
sions and on both measures of OCB (consistent colleagues than older employees with low affec-
with the meta-analytic ndings reported by Ng tive commitment. The moderating effect of com-
and Feldman). However, these relationships mitment was not so pronounced among younger
were moderated, to some extent, by the age of workers however. The authors suggested that their
the rater. Both younger and older workers tended results indicate that affective commitment to the
to rate members of their own age group more organization might be a very salient factor to
positively, and the rater x ratee age interaction consider when endeavoring to increase citizen-
was fairly substantial. ship behaviors among older workers and that
Iun and Huang (2007) examined the relation- management could focus on ways and means to
ship between age and job performance among enhance the levels of affective commitment
hospitality employees in Hong Kong. These among older workers, such as providing training
authors suggested that the nature of work (job opportunities for skill development and more sup-
type) and industry might have an effect on the port for the needs of these workers.
age-OCB relationship. Specically, work in the Other studies have not directly focused on the
hospitality industry (e.g., restaurants, hotels) relationship between age and OCB, although they
tends to be physically demanding and fast-paced, have incidentally reported the association
which may not suit older workers. Under these between these variables. For example, Jain
conditions, Iun and Huang predicted that older (2015) conducted a study of organizational com-
workers would have less energy and motivation mitment and citizenship among public sector
to engage in citizenship behaviors than their youn- managers in India, nding that age negatively
ger colleagues. However, they also suggested that predicted both person-oriented OCB and
this negative relationship would be moderated by organization-oriented OCB. Although the regres-
a highly relevant attitudinal variable, the persons sion coefcients for age were not substantial in
affective commitment to their organization. these analyses, they were higher than coefcients
Affective commitment (Meyer and Allen 1997) for other demographic variables, such as educa-
incorporates identication and belongingness tion and job tenure, suggesting that age may
with the organization plus a desire to promote indeed play some role in citizenship behaviors.
Jain noted, however, that participants in this signicantly related to both work engagement
research were all male managers, which limits and affective organizational commitment, but
the generality of the ndings. Furthermore, Jain hierarchical regression analysis revealed that age A
suggested that the work culture in Indian public did not contribute signicantly to any of the three
sector organizations emphasizes the importance key variables (engagement, commitment, or citi-
of democracy and collaboration; hence, citizen- zenship). In this case, it was clear that the two
ship scores may have been subject to some range personality variables plus feelings of empower-
restriction. The managerial nature of the sample ment were much stronger predictors of these out-
might also have contributed to some lack of var- comes. This may indicate that, while age can be a
iance in citizenship scores. Nevertheless, the nd- factor in relation to organizational citizenship, its
ings from this study conrm some other research inuence is small relative to other potential
using different samples, which has also noted a contributors.
negative relationship between age and OCB. The A third example of positive but nonsignicant
precise reasons for these departures from the linkages is a study reported by Turnipseed and
expectation that age and OCB will be positively Vandewaa (2012) in the USA. These researchers
related are not entirely clear and may well be examined both person-oriented and organization-
linked with sample-specic characteristics oriented OCB, as well as what they referred to as
(as noted above). aggregate OCB (derived from combining
Some other studies have obtained no signi- scores on the two forms of OCB), and reported
cant relationship between age and citizenship. An near-zero correlations between age and all three
example of these ndings is a study conducted by OCB scores. As with the Macsinga et al. research
Lee et al. (2011) of sales representatives in Japan. described above, regression analysis illustrated
The major focus of this research was that age was not a signicant predictor of OCB
performance-based pay, but age was also included in this study. Rather, emotional intelligence
as a predictor variable of altruism, one of the ve emerged as the most substantial predictor vari-
dimensions of OCB postulated by Organ (1988). able. Interestingly, age was negatively associated
However, in this study the correlation between with emotional intelligence, although the authors
age and person-oriented OCB was negligible did not posit possible reasons for this negative
(r = .01). As with the Jain research described relationship, except to say that one of their sam-
above, it is possible that this nding may be due ples (university professors, who were substan-
to characteristics of the participants in the tially older than the other sample, of students)
research. Over 80% of the sample was male, and may have displayed less variability in emotional
the nature of their work may be a contributing intelligence scores.
factor in respect to displaying citizenship behav- Overall, therefore, the jury is still out on
iors. The relatively low standard deviation for whether age is a major contributor to organiza-
altruism scores suggested that there was little var- tional citizenship behaviors, and the evidence is
iance in OCB across the sample. very mixed and inconsistent. One clear implica-
Another recent study which obtained positive, tion is that research on age effects needs to exam-
but nonsignicant, relationships between age and ine the possible reasons for a relationship between
self-reported OCB was reported by Macsinga age and work performance, including citizenship.
et al. (2015), who were concerned with the asso- Even studies which have obtained a signicant
ciation between personality factors (such as extra- relationship (mostly positive) between these vari-
version and conscientiousness) and various ables have concluded that the effects of age are
positive work outcomes (work engagement, affec- likely to be indirect, that is, that there are inter-
tive commitment to the organization, and organi- vening (mediating) variables in the relationship
zational citizenship behavior). This research was between age and citizenship. Rioux and Penner
conducted in three different types of organization (2001) conducted a study which did not focus on
in Romania. As anticipated, OCB was age as a predictor of OCB but nevertheless raised
an interesting possible explanation for this rela- In addition, older workers were signicantly
tionship. Rioux and Penner examined the poten- more likely to rate citizenship behaviors as being
tial motives for enacting citizenship behaviors in a part of their job. The authors attributed these
work context. They suggested three general ndings to Chinese cultural changes over the
motives concern for the organization, prosocial past two decades, with younger workers now
values, and impression management which may more likely to express individualistic rather than
be pertinent to the display of citizenship, along collectivistic values and to place more emphasis
with empathy and helpfulness (which they labeled on self-interest and self-achievement rather than
as prosocial personality factors) and perceptions the more traditional (collectivistic) values of inter-
of distributive and procedural justice in the personal harmony and overriding concern for
organization. their employing organization. Whether these dif-
In their research, the three motives were preferences would be obtained in other cultural set-
dictors of all ve of Organs (1988) citizenship tings is a matter for further empirical research.
dimensions, especially altruism, civic virtue, and So far we have discussed the potential direct
sportsmanship. As noted, Rioux and Penner were relationships between age and organizational cit-
not directly concerned with age as a predictor of izenship, and most studies have focused on this
OCB, but it is reasonable to expect that older direct relationship. It is also possible, however,
workers would score more highly on motives that age may be a moderator of relationships
such as concern for the organization and prosocial between OCB and other variables. Few studies
values. Although other investigators have also have investigated this potential moderation effect.
noted that younger and older workers may differ Wagner and Rush (2000) suggested that older
in terms of their work motivations, further workers typically exhibit greater job satisfaction
research is needed to explore this possibility. than their younger counterparts and tend to have
As well as motivational differences, it is also lower need for achievement and higher need for
possible that younger and older workers have afliation. They argued that these differences
differing perceptions of the nature and importance lead to different salient motives for altruistic
of citizenship behaviors at work. Citizenship is OCB among younger and older employees
typically placed under the rubric contextual per- (p. 382). Specically, older workers may have
formance and is considered to be voluntary more belief in the moral imperative of helping
behavior that is not linked with the organizational other people and hence a greater propensity for
reward system (e.g., pay or promotion), in con- altruism in their work environment. Based on this
trast to task performance, which is mandated by logic, Wagner hypothesized that age would mod-
the individuals job description. That is, citizen- erate relationships between OCB (altruism) and
ship behaviors are not (normally) considered to be various work attitudes, including job satisfaction,
part of the in-role performance of workers. How- organizational commitment, trust in peers and
ever, Wanxian and Weiwu (2007) argued that management, and moral judgment.
older workers may believe that citizenship is For their research, Wagner and Rush adminis-
expected of them, and they may feel some obliga- tered questionnaires to nursing staff from two
tion to enact these behaviors. Wanxian and Weiwu hospitals in the USA. Their results demonstrated
reported an interesting study in North China no direct relationship between age and citizen-
which examined this proposition. They predicted ship, but age signicantly moderated the relation-
differences between the perceptions of younger ship of several predictor variables (including trust
and older workers of the centrality of OCB to in management, job satisfaction, and commit-
job performance, with older workers more likely ment) with OCB (altruism). Specically, older
to view OCB as a component of their in-role workers displayed a stronger relationship between
performance. This expectation was conrmed, moral judgment and self-reported altruistic OCB,
with a signicant positive correlation between whereas relationships of OCB with job satisfac-
age and all ve of Organs OCB dimensions. tion and organizational commitment were
stronger among younger workers. The authors specic personality traits (e.g., anger, anxiety,
concluded that dispositional tendencies to agreeableness, and conscientious) are associated
behave in an altruistic manner may have been with CWB (Fox and Spector 1999; Fox A
better predictors of behavior for the older et al. 2001; Spector 2012). However, far less
workers (p. 388). Furthermore, the inherent research has focused on age as an antecedent to
value of helping behaviors may be more internal- CWB (Ng and Feldman 2008).
ized among older workers. These interpretations The aging workforce has seen an increase in
coincide with the suggestions proposed by Rioux negative stereotypes of older workers (Ng and
and Penner. Feldman 2008; Spector 2012). For example,
there tends to be a belief that older workers lack
motivation, show reluctance to engage in training
Age and Counterproductive Behaviors and development programs, and are resistant to
(CWB) change (Ng and Feldman 2008). However, there is
no empirical evidence to support these
As they noted earlier, there has been relatively stereotypes. In fact, research has indicated that
little research on the relationship between age some of these stereotypes are totally
and both OCB and CWB, and the attention inaccurate (Ng and Feldman 2008). Specically
given to CWB is far less than that accorded to in relation to CWB, empirical research has found
OCB. It is well established that CWB cost orga- that as individuals age, they are less likely to
nizations billions of dollars every year especially engage in deviant behaviors such as poor job
in terms of lost productivity, lost or damaged performance, absenteeism, and theft (Gruys and
property, increased insurance costs, and increased Sackett 2003; Lau et al. 2003; Mangione and
turnover (Krischer et al. 2010; Penney and Quinn 1975; Ng and Feldman 2008; Shantz
Spector 2005). Additionally, CWB result in loss et al. 2014).
of job satisfaction, increased job stress, burnout, In the Ng and Feldman (2008) meta-analysis
increased somatic tension, and fatigue (Spector discussed above, these authors found that age was
and Fox 2002; Penney and Spector 2005). While signicantly and negatively related to CWB, with
there continues to be a lack of empirical under- results indicating that older workers were less
standing of the antecedents of CWB, it has been likely to exhibit workplace aggression, on-the-job
suggested that they may be the result of job con- substance abuse, lack of punctuality, and absen-
ditions such as stressful work, job conict, role teeism. Moreover, Lau et al. (2003) in their meta-
ambiguity, organizational injustice, and perceived analysis found that particular CWB (theft, produc-
lack of job control (Fox et al. 2001; Jones 2009; tion deviance, poor punctuality, and absenteeism)
Spector 2012). These contribute to employee neg- also decreased with age.
ative emotions, and thus, engagement in CWB In a much earlier study, Mangione and Quinn
can be viewed as a way to restore psychological (1975) examined the relationship between job
equilibrium. Some research suggests that engage- satisfaction, CWB, and drug use in the work set-
ment in CWB allows employees to cope with ting. They found that CWB were less prevalent in
work demands (Allen and Greenberger 2013). older employees, than those who were younger
Indeed Spector and Fox (2002) speculated that than 30 years old. This nding was supported by
CWB may reduce negative feelings, enhance pos- Shantz et al. (2014), who examined several work-
itive feelings, and serve no other purpose than to place variables (work engagement, perceived
even the score (p. 274). organizational support, turnover intentions, and
While stressful or unjust organizational and/or deviant behavior). Post hoc analyses found a sig-
job-related experiences contribute to our under- nicant negative relationship (r = .33) between
standing as to why people may engage in CWB, age and deviant behavior, indicating that older
little research has focused on person-centered workers were less likely to engage in CWB than
explanations. Some research has indicated that younger workers.
Typically, research tends to indicate that the Conclusions and Implications

relationship between age and CWB is negatively
related (Hollinger 1983; Lau et al. 2003). While In this entry we have overviewed the link
there is little understanding of the reasons for this, between age and two forms of contextual
it has been suggested that older workers have behavior citizenship and counterproductive
greater satisfaction and commitment toward their work behavior. Overall, the picture which
job than their younger counterparts and are, there- emerges from the (relatively sparse) research is
fore, less likely to engage in CWB (Hollinger that relationships of age with these two contextual
1983; Mangione and Quinn 1975). Hollinger behaviors are somewhat indeterminate, although
(1983) suggested that younger workers have less the research ndings suggest that age may be
commitment to their organizations, are less likely (slightly) positively associated with OCB and
to view CWB negatively in relation to social negatively linked with CWB. Other factors, how-
norms, are less emotionally mature, and feel ever, can also play a major role in the expression
less social risk if detected (Hollinger 1983, of these behaviors, and these need to be taken into
p. 67). On the other hand, even though older account when examining the possible effects of
workers are less likely to engage in CWB, they age. We have highlighted that personality and
tend to be more secure and more socially aware; motivational factors in particular may be espe-
thus, they may see counterproductive behavior as cially relevant to the impact of age on OCB
appropriate action to take if there is a lack of and CWB.
organizational justice (Fox et al. 2001). For Two important implications of the extant
instance, older workers may be more likely to research ndings are that (a) negative stereotypes
engage in retribution or whistle-blowing of older workers need to be counteracted and
(Miceli and Near 2005) if they perceive unfair (b) older workers need appropriate types and
work conditions and procedures. However, this amounts of support to contribute their knowledge,
proposition has not been fully explored to date. skills, and abilities to enhance organizational
Overall, research demonstrates that older performance. The research on OCB and CWB
workers are less likely to engage in CWB (Gruys therefore has signicant implications for organi-
and Sackett 2003; Lau et al. 2003; Mangione and zational managers and HR practitioners, who need
Quinn 1975; Ng and Feldman 2008; Shantz to be aware of the potential for stereotyping to
et al. 2014). While more research is needed in affect older workers performance and well-being
this area to uncover and understand why this is and also of the importance of appropriate forms of
so, researchers have found that older workers are social support for older workers.
more likely to contribute to their organizations Clearly, more systematic research is needed on
and more consciously engage in positive actions these topics, especially longitudinal studies which
(such as OCB), rather than negative work behav- control for the effects of other variables which
iors (Ng and Feldman 2008). Thus, while some contribute to OCB and CWB when examining
negative stereotypes of older workers continue to age relationships with these variables. As the pop-
exist, it is acknowledged that, despite being in its ulation in general and the working population
infancy, research examining older workers and grow older over time, research on the relation-
CWB has uncovered signicant ndings and that ships of age with OCB and CWB will increase
older workers are less likely to engage in counter- in importance.
productive work behavior. These ndings add to
notions that older workers are key to organiza-
tional success and hopefully will encourage References
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Williams, L. J., & Anderson, S. E. (1991). Job satisfaction identity in old age often do not differentiate
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Management, 17, 601617. or maintenance of identity across adulthood.
Age, Self, and Identity: Structure, Stability, and Adaptive Function 123
In this vein, maintaining a sense of personal iden- and gain experiences across adulthood.
tity across adulthood and continuity of identity More importantly, the meaning of what is a
typically involves effort in response to a change gain and loss is malleable. Any loss experience A
or to discontinuity in the aging process. may be subjectively construed as reecting or
involving an experience of gain, or of personal
growth. For example, coping with a severe
Introduction health problem may also entail a sense of mas-
tery and control (Heckhausen 1999).
This entry focuses on two pertinent issues in the Second, there is a multidimensionality of change
literature on self and identity across adulthood. across adulthood. That is, aging-related change
in one domain of functioning may differ from
(A) What is the structure of the aging self? How change in another domain. For example, how
stable is the aging self ? one perceives oneself in professional life may
(B) What are the regulatory functions of the self differ from how one develops in the context of
across adulthood? family life. Such domains of the self may be
differentially interrelated across adulthood
The rst issue addresses the contents and the depending on age. Accordingly, self-
structure of the self across adulthood as an out- representations show considerable domain
come of aging-related challenges. Typically, the specicity, and domain-specic changes in
structure and stability of the aging self involves old age (Diehl et al. 2011; Freund and Ebner
information-processing, temporal, and affective 2005).
components. The second issue addresses the reg- Third, there is much behavioral and cognitive
ulatory self as a process across adulthood. The plasticity across adulthood, even very late in
process of self-regulation pertains to the pursuit life. Individuals are able to learn and develop
of goals, to the accomplishment of developmental new knowledge, skills, and behaviors at all
tasks, and to the maintenance of continuity or phases of adulthood. Consequently, there is
stability. At present, the theoretical and empirical also malleability of the aging self that appears
research on self-regulation in the aging process to respond in exible and adaptive ways to
remains vague with respect to whether the regu- contextual changes in old age (Brandtstdter
latory self is the target (i.e., regulating ones inter- 1999).
nal states), or the origin of regulatory efforts (i.e., Fourth, the course and direction of the aging
producing a cognitive, affective, or behavioral process depends on social and cultural con-
output). Much of the literature pertains to the texts (Baltes 1997). For example, ndings of
regulatory self in the latter perspective, while the research on age differences in interdependent
rst perspective is sometimes referred to as cop- versus independent self-construal in various
ing, or as emotion regulation. There exists a pleth- cultures suggest that with increasing age,
ora of theoretical and empirical work on self- there is an increasing correspondence between
representations across adulthood (Brandtstdter cultural values and an individuals self-
1999; Diehl et al. 2011). Consequently, and for representation as a member of the culture
reasons of parsimony, this entry focuses on the (Diehl et al. 2011). For example, older adults
self across adulthood from a lifespan psychology in China tend to show a more interdependent
perspective with regard to the following ve fun- self-construal, while older adults in the US
damental principles of development (Baltes tend to promote values that reect stronger
1997): independent self-construal (Fung 2013).
Fifth, the human lifespan reects a nitude of
First, the aging process typically entails not only personal resources, and involves a limited
loss but also gains until very late in life. future lifetime. Thus, individual differences in
The aging self entails a changing ratio of loss resources and remaining time in life strongly
impact the course, direction, and outcome reecting domain-specic and contextual con-
of ones development across adulthood tents. These dimensions of the self operate jointly
(Carstensen 2006; Heckhausen 1999; Lang to both stabilize the self and to promote
et al. 2011). Accordingly, the aging self may continuity of personal identity across adulthood
positively adapt to a shrinking of ones (Brandtstdter and Greve 1994; Diehl et al. 2011;
remaining time in life and to limited resources Troll and Skaff 1997). Accordingly, a critical
in old age. Even when experiencing much question is to what extent the stability and change
physical and psychological change, many in content, temporal, and affective dimensions of
older adults manage to maintain a sense of the self reect age-related adaptation processes.
continuity of self and identity throughout the Lastly, although the three dimensions of the aging
aging process, and even into very late life. self are closely connected in the representations
There is robust evidence that when confronted of adults, it is not yet well understood how
with the nitude of life, and with limited these dimensions work together to form an
resources, the regulatory self displays exibil- adaptive, resilient, and proactive self in old age
ity, resilience, and malleability that contributes (Brandtstdter 1999; Freund and Ebner 2005).
to experiences of continuity, or even stability
of the self (Brandtstdter 1999; Carstensen The Content of Self-Representations Across
2006). Adulthood
Representations of the self typically refer to a per-
sons knowledge about his or her attributes that he
or she believes to be relevant or meaningful (Diehl
The Structure of the Aging Self: Stability et al. 2011; Filipp and Klauer 1986). This typically
and Change Across Adulthood involves all aspects of an individuals self-related
knowledge, such as ones physical appearance,
A fundamental distinction in the structure of the personality, behavior, values, attitudes, and
self pertains to the duality of the self as agent motives. The structure of such knowledge is
(I ) versus the self as known (Me ) in the embedded in an individuals developmental con-
tradition of the works by William James (James text, thus reecting individual differences related to
et al. 1890). In the self as agent-perspective, the cohort and chronological age. For example, there
term self typically reects the origin or target of an exist substantive age differences in self views:
individuals conscious thought or action. Exam- Older adults self views as compared to those of
ples of this perspective pertain to concepts such as young adults are typically found to be made up of
self-regulation or self-monitoring. In the self as more issues related to current interests, life circum-
known perspective, the self pertains to contents stances, health, and chronological age. Findings
that account for a persons self-representation. from such studies are corroborated in research on
The terms self, self-concept, views of self, and the contents of self-denitions that found much
self-representation are used interchangeably to similarity in contents of self-denitions between
reect the self-as-known perspective. Mostly, the old and very old adults (Diehl et al. 2011; Freund
structure of the self is described along three major and Ebner 2005). Self-denitions in old age appear
dimensions: (Asendorpf and van Aken 2003) a to reect challenges and contexts of old age
content dimension (e.g., Who am I?), (Baltes that revolve around issues of health, social roles,
1997) a temporal dimension (e.g., How did and meaningful activities in everyday life.
I change? How shall I change?), and (Bluck Accordingly, it is a robust nding that a more
and Alea 2008) an affective or evaluative dimen- exible or multifaceted self-denition is often
sion (e.g., How satised am I with myself?). associated with more adaptive functional outcomes
Such dimensions are strongly interrelated. Evalu- in late life (Brandtstdter 1999; Brandtstdter
ation of the self typically occurs in a temporal and Greve 1994; Diehl et al. 2011; Freund and
frame involving ones past and future, while Ebner 2005).
To date, few studies have examined the change not checked with regard to their veracity.
in the contents of self views in old age from a Objectively testable views of the self (e.g., I
longitudinal perspective, and those that have often am intelligent) may show greater stability A
provide data based on short time intervals only. because they are less context-specic. There
Therefore, ndings on the temporal stability of may be aging-related shifts with regard to
self-descriptions are not consistent and contradic- veracity of self-representations (e.g., becom-
tory. There are several possible explanations to ing more accurate with age; 14).
help explain the inconsistent ndings regarding
the stability and change of the aging self. In sum, ndings on the stability and change of
self-views in old age vary depending on what con-
(a) Findings vary depending on the measurement tents of the self are examined and on how such
approach. For example, methods using a free contents are assessed. More research is needed to
response format show less stability than self- explicitly address issues related to veracity, veri-
descriptive ratings (Diehl et al. 2011). ability, idiosyncrasy, and context- and domain-
(b) Context- or domain-specic self-knowledge specicity of self-representations across adulthood.
(e.g., I am quite amused about this new In addition, multimethod measurement approaches
movie) is different than universal self- are recommended in the assessment of self-
descriptions (e.g., I am a humorous person) representations across adulthood (Diehl et al. 2011).
that are known to be shared by many individ-
uals (Snyder and Shenkel 1975). Conse- The Temporal Dimension of the Aging Self
quently, universal contents of self-denitions The passing of time is a central dimension in
are likely to show greater stability over time. descriptions of the aging self. The temporal dimen-
The self views of older adults may reect sion of the self reects adaptation, maintenance,
greater domain-specicity and context- and continuity of identity across adulthood. The
relatedness, and are thus less stable. passing of time in self has been described with
(c) Core self-representations differ from surface concepts such as personal identity (Troll and
knowledge about self (Asendorpf and van Skaff 1997), autobiographical memory or remem-
Aken 2003). While the core self reects stable bered self (Bluck and Alea 2008), and possible
knowledge about ones personality (e.g., selves (Hooker 1999). For example, an older per-
related to Big Five personality traits), surface sons view of his or her current self may result from
self-representations reect contextual inu- a reection of his or her past (e.g., I am wise now,
ences that may depend on specic tasks or and I learned many lessons in life), his or her
activities. Accordingly, Diehl and colleagues present (e.g., I am as happy today as I was last
(Diehl et al. 2011) report that temporal stabil- year), or from thoughts related to ones future
ity of the self is positively associated with a (e.g., I feel old because there is not much left to
measure of perceived authenticity. do in life for me). There is a paucity of integrative
(d) Veracity and veriability of self-related views on how the temporal components of the
knowledge may also affect stability and aging self relate to the structure and stability of
change. Some contents of self-denition may the self. In general, ndings suggest that the self-
be more objectively testable (e.g., I am a representations of older adults are mostly present-
skilled lawyer) when related to physical oriented, and more likely to refer to the past than to
appearance, health, skills, competence, and the future (Diehl et al. 2011; Filipp and Klauer
cognitive abilities, while some contents of 1986; Freund and Ebner 2005). It has also been
self-denitions are not observable or difcult suggested that this may be reective of the
to verify (e.g., I am trustworthy). This typ- narrowing of future time that results in a process
ically pertains to self-views of internal or past of seeking meaning in those domains and contexts
states of self, to motives, and to preferences. that are of immediate centrality and relevance of
Typically, the contents of self-denition are the self (Brandtstdter 1999; Carstensen 2006).
A critical issue pertains to the adaptive func- self is strongly associated with two psychological
tion of the temporal perspective in views of the constructs, namely self-esteem (Wagner
self. There is agreement in the literature that the et al. 2014) and possible selves (Hooker 1999).
temporal perspective in self-representations Self-esteem is dened as a positive evaluation
serves to stabilize the present view of the self of ones self, and has been shown to decrease over
(Brandtstdter 1999; Staudinger et al. 2003). time with respect to both mean levels, and rank-
Temporal perspectives may contribute to such order stability (Wagner et al. 2014). Currently, it is
stabilization in several ways: an open issue to what extent the expression of
self-esteem in old age depends on age-specic
(a) Comparing ones current self with a less pos- resources, where age-specic resources are not
itive view of the self in the past (e.g., I have fully understood. For example, self-esteem in old
become more wise now). Such downward age may depend more strongly on how well older
temporal comparisons may protect ones cur- adults manage to lower their expectations towards
rent view of his or her self (Staudinger their future self. Developing more modest and
et al. 2003). One implication is that typically, prevention-oriented frames of self-evaluation
with increasing age, the veracity in represen- may protect, and at times even provide a positive
tations of ones past self is difcult to prove. attitude toward the self in old age (Brandtstdter
(b) Anticipating ones future self in humble ways 1999).
provides a positive frame of reference for Possible selves involve an evaluative frame of
views of the self in the future (e.g., My life the self in the aging process. Hoped-for selves and
is much better than I had expected; 14). feared selves reect an individuals strivings and
(c) Focusing on ones present internal state of self goal-pursuits. That is, fears indicate what one
may provide a meaningful experience when wants to preserve and maintain, and hopes pertain
perceiving a narrowing of ones remaining to aspects of the self that one would like to change
time in life (Carstensen 2006). or achieve. In this vein, possible selves constitute
a motivational dimension in the structure of the
In sum, the temporal perspective is critical for aging self (e.g., What am I up for?; 9). While
understanding the adaptivity, the plasticity, and hopes pertain to a striving for growth and goal
the malleability of the aging self. The temporal achievement, feared selves reect a preventive
perspective reects one of the fundamental expe- orientation, and strive to maintain the present
riences that also relates to a exibility of aging state of self. Thus, hoped-for and feared selves
identity in old age (Weiss and Lang 2012). may pertain to distinct processes in the evaluation
Accordingly, there may be two processes respon- of the aging self.
sible for promoting a exible aging identity, Generally, future expectations are robustly
where one process is related to a dissociation of observed to be relatively low and modest among
the self from ones age group, and a second pro- the oldest-old adults. Discrepancies between the
cess pertains to ones identication with his or her ideal self and the current self are reported to be
generation or birth cohort as a resource of social relatively low in old age (Diehl et al. 2011). It
identity. In old age, perceiving ones past self in remains an open question as to what extent
terms of mastery and competence, while age-related changes in discrepancies of possible
expecting ones future in humble ways, and nd- and current selves also reect a positive or nega-
ing meaning in ones current self appears to reect tive evaluation of the self. Theories of positive
a resilient and adaptive self (Lang et al. 2013). versus negative self-perceptions of aging are not
always precise with regard to whether the positive
The Evaluative Dimension of Aging Self or negative affective valence involves a unidimen-
The emotional component of self-representations sional (i.e., bipolar), or a two-dimensional struc-
is reected in positive and negative evaluations of ture. In addition, the time perspective of affective
the self. The evaluative dimension of the aging evaluations of the self is still not well understood.
Positive evaluations of ones past self, ones pre- that require regulatory efforts involve limitations
sent self, and ones future self may have or constraints of the older individuals resources.
age-differential functions (Brandtstdter and In the aging process, there are typically two main A
Greve 1994; Bluck and Alea 2008; Hooker sources for an increased need of self-regulatory
1999; Staudinger et al. 2003). Also, social com- effort.
parisons with other people may age-differently First, limitations of resources in old age, and
inuence ones self-evaluation in old age the nitude of time in life both challenge self-
(Heckhausen 1999). More research is needed to representations in later adulthood. The biology
clarify the age-differential temporal dimensions of of the aging organism typically relates to
self-evaluation in the aging process. Finally, pos- increased loss experience, declining health, and
itive self-evaluation is robustly found to contrib- limited physical or mental functioning (Baltes
ute to positive aging outcomes such as health and 1997). In addition, only humans are capable of
longevity (Wagner et al. 2014). anticipating their future self and to perceive the
ending of their time in life (Carstensen 2006; Lang
et al. 2011). Thus, older adults are typically
The Regulatory Self Across Adulthood: confronted with biological deterioration and with
Adaptive Functions a nearing end of their lives. Taken together, these
objective conditions of human existence can be
In lifespan psychology, the individual is typically expected to threaten or even erode the stability
viewed as a co-producer of his or her own devel- and continuity of the aging self. Surprisingly how-
opment (Baltes 1997). The notion of co-produced ever this is not observed. Consequently, one may
aging implies that there are active processes expect powerful and strong self-regulatory forces
involved that reect responses to age-related chal- that contribute to the maintenance, continuity, and
lenges such as limitation, loss, or environmental stability of the self until very late in life.
change. This implies that individuals engage in Second, in later adulthood compared to earlier
interactive processes between their internal states phases of adulthood, there are fewer social norms
and the external world. Hence, individuals may that structure ones activities, tasks, and social
either bring about a change of their internal self or roles (Heckhausen 1999). At the same time, neg-
a change in the external world. Processes of ative views of aging and age stereotypes prevail.
adapting the aging self as well as processes related However, in old age there is much heterogeneity
to changing ones contexts in the aging process and variability in all domains of functioning,
are typically referred to as self-regulation or including the self (Baltes 1997). Consequently,
developmental self-regulation (Brandtstdter the potentials of the individual reect a wide
1999; Heckhausen 1999). Regulation processes array of biographical, contextual, and biological
may differ depending on chronological age, avail- resources. This implies that there do not exist
able resources, and time limitations remaining in general guidelines or rules on how challenges
life. For example, studies show that individuals related to old age may be mastered in positive
actively choose meaningful contexts and social ways. Generally, there is not one uniform trajec-
roles across adulthood when they perceive to tory of change in old age; on the contrary, the
have limited time left in life (Carstensen 2006; course and direction of an individuals aging pro-
Fung 2013). In this vein, individuals invest cess may strongly reect a life-long history of
resources in activities and goal pursuits that they individual decisions. Again, this involves that
prioritize, while disengaging from other less pri- individuals may have to invest regulatory effort
oritized domains of life. in response to challenges, but there is not one
Regulation of the aging self reects single solution on how to nd an adaptive
age-associated efforts and activities that emerge person-environment t.
in response to age-specic challenges across In sum, both biological and societal constraints
adulthood (Baltes 1997). Typically, challenges challenge the plasticity and the malleability of the
regulatory self in old age. There are several theo- assimilative activities are relinquished when it is
retical perspectives that have elaborated and not in the service of self-continuity (Brandtstdter
advanced assumptions of processes involved in 1999).
the adaptive regulation of the aging self. For rea- Accommodation, in contrast, is activated when
sons of space, two exemplary models of self- assimilative efforts are obstructed and when the
regulation in old age are addressed here: the continuity of self is challenged. Accommodation
dual-process-model of assimilation and accom- involves efforts to restructure and reframe ones
modation of the resilient self (Brandtstdter self-representation and goal pursuits, for example,
1999; Brandtstdter and Greve 1994), and the by lowering expectations and restructuring prior-
model of selective optimization with compensa- ities and preferences. Brandtstdter (Brandtstdter
tion (Baltes 1997; Lang et al. 2011). Descriptions 1999) argued that the accomodative process
of related models such as the life-span theory of once activated overrides assimilative tenden-
primary and secondary control can be found else- cies (Brandtstdter 1999, p. 128) by eliminating
where (Heckhausen 1999). and reinterpreting any prior thought or pursuit that
is in the service of such tendencies. For example,
Dual-Process-Model of Assimilation and when goals are blocked, one may disengage from,
Accommodation devalue, or redene a goal in more exible ways.
Throughout adulthood, individuals are confronted In addition, some depictions of the
with processes of change of internal or external assimilation-accommodation model also refer to
resources. Such aging-related change may result an additional process that has been suggested to
from discrepancies between the desired and the protect the self from realizing any potential dis-
actual self in old age. According to the dual- crepancies between desired and actual states. This
process model, there are two ways of coping that process has been described as immunization
individuals can utilize to reduce, resolve, or elim- (Brandtstdter 1999; Brandtstdter and Greve
inate self-discrepancies in old age. These coping 1994). Immunization involves a preconscious
strategies are referred to as assimilation and and automatic avoidance or neglect of self-
accommodation processes (Brandtstdter 1999; discrepant information. It is not quite clear to
Brandtstdter and Greve 1994), and are assumed what extent such immunization may be separated
to operate antagonistically, that is, when accom- from automatic, unconscious self-regulation
modative processes are activated, assimilative related to either assimilation or accommodation
regulations are inhibited. (Freund and Ebner 2005). Immunization may per-
Assimilation involves intentions that aim to tain to perceptual and attentional cognitive pro-
transform a situation such that the situation is in cesses of the aging self. More empirical evidence
greater accordance with the individuals self- is needed to better understand the specic ways in
representation or personal goals. Assimilative which immunization may be empirical differenti-
activities target the direction and regulation of ated from assimilative and accommodative
ones behavior, and pursuits that are of personal processes.
relevance to ones self concept. Thus, assimilation Overall, the dual-process model posits that
involves activities that stand in the service of assimilation and accommodation contribute in
continuity of ones self and identity. For example, fundamental ways to the continuity and to the
according to the dual-process model, older adults positivity of self-representations in the aging pro-
may engage in assimilative actions that involve cess. While operating in antagonistic ways, all
prevention of future self-discrepancies (e.g., pre- three processes are relevant to successfully adapt
paratory activity), correction of ongoing behav- to the challenges of the aging process. There is
iors (e.g., choosing a more healthy diet or robust empirical evidence that with increasing
engaging in sports), or compensation (e.g., use age, accommodative strategies such as exible
of a hearing aid). However, it is suggested that goal-adjustments prevail over more assimilative
self-regulation strategies (e.g., tenacious goal pur- The principle of compensation involves the
suits). Moreover, it has been shown that a shift substitution, repair, or restoration of resources in
from an assimilative to an accommodative self- response to a loss or a limitation of the self. A
regulation is associated with more positive aging Compensation may occur in response to internal
outcomes and psychological resilience challenges to the self (e.g., memory decline), or in
(Brandtstdter 1999). response to external challenges to the self (e.g.,
widowhood).
Self-Regulation Model of Selection, All together the three principles of selection,
Optimization, and Compensation optimization, and compensation describe ways of
The self-regulation model of selection, optimiza- how the self deals with internal and external chal-
tion, and compensation (SOC) reects the lenges and opportunities in order to minimize loss
multidimensionality of the developmental dynam- while maximizing gains or growth experience.
ics of gains and losses across adulthood (Baltes Thus, the SOC model involves an optimality cri-
1997). According to the model of SOC, any devel- terion in the aging process. Optimality also refers
opmental process reects the joint interplay of to the concept of self-contentment in old age that
three fundamental principles, namely: selection, may involve a focus on maintenance rather than a
optimization, and compensation. These principles focus on personal growth or self-improvement.
operate within and across all domains of behavior The model of selection, optimization, and
and cognition throughout the human life course. compensation is in accordance with assumptions
SOC principles furthermore substantively of the dual-process model of assimilation and
contribute to positive developmental outcomes accommodation. Both models are embedded in a
(Baltes 1997; Lang et al. 2011), including the lifespan theoretical framework and build on fun-
stability, continuity, and resilience of the damental principles of lifespan psychology.
aging self. All three principles (i.e., selection, A difference between these models pertains to
optimization, and compensation) have been what is viewed as the salient motive that drives
shown to be involved in adaptive self-regulatory the regulatory effort of the aging self. The dual-
processes of changing gain-loss dynamics across process model emphasizes the effort of eliminat-
adulthood (Freund and Ebner 2005; Lang ing discrepancies between the desired and the
et al. 2011). actual self. Theories of selection, optimization,
Selection involves choosing meaningful goals, and compensation typically emphasize the ever-
tasks, or contexts in the aging process. This changing dynamics of gains and losses across
implies that any decision to pursue specic adulthood as a central motive of regulatory effort
goals, tasks, or contexts involves gains (in the that involves minimization of losses and maximi-
chosen domain) and losses in not chosen cogni- zation of gains (Baltes 1997; Freund and Ebner
tive or behavioral domains. Generally, selection is 2005). Therefore, the selection, optimization, and
a necessary developmental process because of compensation model is explicit in addressing the
limited life time and the nitude of resources. fundament impact of internal and external
Thus, selection typically involves a narrowing of resources that protect the exibility, resilience,
behavioral options over time. and malleability of the aging self. Once again,
Optimization pertains to the renement, invest- both models should be seen as complementing
ment, or enhancement of resources to accomplish each other at different levels of analysis of self-
a goal or task in specic behavioral or cognitive regulatory processes across adulthood. While the
domains. For example, individuals may invest processes of selection, optimization, and compen-
their time and effort to improve their skills and sation more explicitly address the dynamic trans-
abilities in a specic task. Optimization implies actions between a person and their environment
that costs of self-regulation are minimized while across all domains of functioning (including the
maximizing benets. self), the dual-process model underscores the
steering function of the continuity and consis- Cross-References

tency of the self as a cognitive structure.
Life Span Developmental Psychology
Resilience and Aging
Conclusion Selection, Optimization, and Compensation at
Work in Relation to Age
As people grow old, individuals typically show Self-Theories of the Aging Person
stability and continuity in the structure of their
self-representations. The principles that contrib-
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Age-Friendly Communities 131
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cognition and aging (pp. 97121). San Diego: span the physical and social environment impact
Academic.
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1). Cambridge, MA: Harvard University Press. (Lui et al. 2009). In recent years, the World Health
Lang, F. R., Rohr, M., & Williger, B. (2011). Modeling Organizations (WHO) conceptualization of an
success in life-span psychology: The principles of age-friendly community has been gaining increas-
selection, optimization, and compensation. In
K. L. Fingerman, C. Berg, J. Smith, & T. Antonucci ing traction among both policy makers and
(Eds.), Handbook of life-span development researchers. According to the WHO, an
(pp. 5785). New York: Springer. age-friendly community is one in which policies,
Lang, F. R., Weiss, D., Gerstorf, D., & Wagner, G. G. services, settings and structures support and
(2013). Forecasting life satisfaction across adulthood:
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Snyder, C. R., & Shenkel, R. J. (1975). The P. T. Barnum aging broadly dened in terms of health, partic-
effect. Psychology Today, 8, 5354. ipation, and security (World Health Organization
Staudinger, U. M., Bluck, S., & Herzberg, P. Y. (2003).
Looking back and looking ahead: Adult age differences 2002). Fundamental to the notion of age-friendly
in consistency of diachronous ratings of subjective communities is that older adults must be
well-being. Psychology and Aging, 18, 1324. respected, valued for their contributions, and
Troll, L. E., & Skaff, M. M. (1997). Perceived continuity of included in decisions that affect their lives. More
self in very old age. Psychology and Aging, 12,
162169. specically, the WHO highlights the importance
Wagner, J., Lang, F. R., Neyer, F. J., & Wagner, G. G. of eight domains in making a community
(2014). Self-esteem across adulthood: The role of age-friendly: outdoor spaces and buildings, hous-
resources. European Journal of Ageing, 11, 109119. ing, transportation, respect and inclusion, social
Weiss, D., & Lang, F. R. (2012). Two faces of age identity.
GeroPsych, 25, 514. participation, civic participation and employment,
communication and information, and community
supports and health services (World Health Orga-
nization 2007a).
Age-Friendly Communities
Why the Need for Age-Friendly
Verena H. Menec1 and Michael Sharratt2 Communities?
1
University of Manitoba, Winnipeg, MB, Canada
2
Schlegel-University of Waterloo Research The interest in age-friendly communities on the
Institute for Aging, Kitchener, ON, Canada part of policy makers and researchers in recent
years is, in part, due to several interrelated factors:
Synonyms First, the world is aging. There were approxi-

mately 524 million people aged 65 or older in
Age-friendly communities 2010; this number is expected to increase to
nearly 1.5 billion in 2050 (World Health Orga-
nization 2011). Population aging is occurring
Definition as a result of declining fertility rates, lower
infant mortality, and increasing longevity. Pop-
A variety of denitions of what constitutes an ulation aging is not restricted to developed
age-friendly (or elder-friendly) community countries; indeed, the speed at which
have been proposed over the past decade. populations are aging is particularly rapid in
132 Age-Friendly Communities
less developed countries. From 2010 to 2050, life become important questions to address. Given
the number of older people aged 65 years or its holistic nature, the notion of age-friendliness
older is projected to increase more than 250% provides a community development framework
in less developed countries. In comparison, the for examining these questions.
increase in developed countries is projected to
be 71% (World Health Organization 2011).
Given the lack of supports for older adults, Aspects of an Age-Friendly Community
such as pension systems, in less developed
countries, these demographic trends can be The WHO started to promote the concept of
expected to present major challenges in the age-friendly communities in 2006 with the launch
absence of appropriate policy responses of its Global Age-Friendly Cities project (World
(Bloom et al. 2014). Health Organization 2007a). As part of this pro-
Second, there is growing concern about the sus- ject, focus groups were conducted in 33 cities in
tainability of healthcare and social welfare sys- 22 countries around the world to identify
tems. As people age, the likelihood of health specic aspects of what makes a community
problems increases; consequently, healthcare age-friendly and what barriers and challenges
use also increases with age. Concerns have exist for older adults within each of the eight
also been raised over the effects of a retiring age-friendly domains: outdoor spaces and
workforce on countries productivity and eco- buildings, housing, transportation, respect and
nomic viability. Effective programs and poli- inclusion, social participation, civic participation
cies are, therefore, needed to promote healthy, and employment, communication and
active aging and reduce pressures on information, and community supports and health
healthcare and social systems. services. In each city, eight focus groups were
Third, healthcare needs have shifted from acute conducted: four with older adults (aged 60 or
problems to chronic conditions, such as arthri- older), one with caregivers of seniors, and three
tis, diabetes, and dementia, with the with service providers (e.g., representatives of
co-occurrence of multiple chronic conditions governmental organizations, volunteer organiza-
being common. This means that there is a need tions, and business).
to move away from healthcare systems that This research provided a rich description of a
emphasize acute care for time-limited health wide range of features and barriers to making
problems, reective of a cure approach, to communities age-friendly, with results compiled
systems that focus on care over an extended in an age-friendly guide Global Age-Friendly Cit-
period of time (Chappell and Hollander 2011). ies: A Guide, in order to help communities around
Older people require a continuum of care in the world become more age-friendly (World
appropriate settings, such as at home with sup- Health Organization 2007a). For instance, in
ports to allow them to remain in their homes as terms of outdoor spaces, focus group participants
long as possible, to assisted living where some identied a clean, safe environment and green
services are provided (e.g., meals), and to long- space as assets and, conversely, uneven sidewalks
term care for individuals with extensive care and unsafe pedestrian crossings as barriers. As
needs. another example, within the community
supports and health services domain, issues
Apart from these macro reasons for making identied included the need to have health and
communities more age-friendly, enhancing the social services conveniently located and accessi-
health and quality of life of older adults is a ble by all means of transportation and that the
worthy goal in and of itself. What resources and delivery of services be coordinated and adminis-
opportunities are available to them in their com- tratively simple. Additional examples of
munity, what gaps exist, and how to enhance the age-friendly features identied in the project are
community environment to maximize quality of provided in Table 1.
Age-Friendly Communities, Table 1 Examples of Age-Friendly Communities and Healthy,

age-friendly features Active Aging
Age-friendly domain Examples of features
A
Outdoor spaces and Clean and pleasant public areas Making communities more age-friendly is
buildings Good street lighting to promote expected to promote healthy, active aging and
safety
Good signage on buildings the quality of life of older adults (World Health
Housing Sufcient affordable housing Organization 2007a). The age-friendly domains
Well-constructed housing proposed by the WHO are consistent with
Availability of home existing, established determinants of health and
modication options active aging frameworks. These frameworks
Transportation Reliable and frequent public
highlight the importance of a range of factors
transportation
Availability of specialized within the social and physical environment in
transportation for disabled peoples lives (World Health Organization 2002;
people Evans and Stoddart 1990).
Well-placed and visible trafc
Research evidence also provides support for
signs
Respect and inclusion Helpful and courteous service
specic age-friendly features and their relation-
staff ship to health-related outcomes. For instance, a
Recognizing older adults for large number of studies have examined the rela-
their contributions tionship between specic environmental features
Portraying older adults in the
media in a positive way and
in relation to health-related outcomes such as
without stereotyping physical activity, obesity, disability, and mental
Social participation Affordable activities health (Annear et al. 2014; Saelens and Handy
Conveniently located and 2008). For instance, a recent systematic review
accessible venues for events included 83 quantitative and qualitative studies,
and activities
Wide range of activities to with the authors concluding that a number of
appeal to diverse groups of environmental features show promise in terms of
older adults contributing to health and activity level in older
Civic participation Flexible and diverse volunteer adults, including accessibility of green space,
and employment options for older adults
proximity and density of amenities, and low levels
Workplaces adapted to meet
the needs of disabled workers of pollution and environmental degradation
No discrimination on the basis (Annear et al. 2014).
of age in the work place Evidence regarding the impact of
Communication and Regular and widespread age-friendly policy initiatives on the health and
information distribution of information
quality of life of older adults are not yet
Printed information adapted to
the needs of older adults (e.g., available. This is not surprising given that the
large lettering) age-friendly movement is relatively new, and
Public access to computers and implementing specic projects to make commu-
the Internet
nities more age-friendly would take considerable
Community supports A range of health and
and health services community supports to
time, particularly large projects like developing
promote health housing for older adults. Moreover, health
Home care services that impacts would not be expected to be immediate
include health and personal as there may be a substantial lag time
care and housekeeping
Respectful, well-trained staff
between implementing age-friendly projects and
demonstrating health benets. In the context of
Note: Examples are adapted from Checklist of Essential
Features of Age-Friendly Cities (World Health Organiza- the healthy cities movement, Draper et al. (1993)
tion 2007b) proposed that there is a 510-year time lag
between becoming part of such an initiative and et al. 2013). Canada is at the forefront of the
observing health benets. age-friendly movement, with most provincial
governments having launched age-friendly initia-
tives. Over 800 communities across Canada are
Age-Friendly Initiatives currently part of such provincially led initiatives.
Leadership in Canada is also provided at the
The Global Context national level through the Public Health Agency
The age-friendly communities conceptualization of Canada (PHAC), which has developed national
is fundamentally a community development guidelines to help with implementation of
approach targeted at local governments. The age-friendly community initiatives at the local
WHO Global Age-Friendly Cities project initiated level (e.g., the Pan-Canadian Age-Friendly Com-
in 2006 included 33 cities from 22 countries, munity Milestones and the Pan-Canadian
indicative of a substantial interest in the concept Age-Friendly Community Recognition Frame-
on the part of local decision makers. The number work) and is helping to coordinate knowledge
has, to date, grown to 210 communities from exchange in the area of age-friendliness. Consis-
26 countries that have joined the WHO Global tent with the WHOs Network cycle steps, the
Network of Age-friendly Cities and Communities Pan-Canadian Age-Friendly Community Mile-
(http://agefriendlyworld.org/en/). The network stones focus on the process communities should
was established in 2010 by the WHO to provide ideally use to become more age-friendly Public
a forum for communities to exchange information Health Agency of Canada (n.d.):
and learn from each other. Belonging to the net-
work does not mean a community is certied as Establish an advisory committee that includes
being age-friendly but rather that there is a com- the active engagement of older adults.
mitment to becoming more age-friendly and fol- Secure a local municipal council resolution to
lowing the four steps of the network cycle: actively support, promote, and work toward
(1) establishing a mechanism to involve older becoming age-friendly.
adults, (2) developing a baseline assessment of Establish a robust and concrete plan of action
the age-friendliness of the community, (3) devel- that responds to the needs identied by older
oping a 3-year action plan based on the assess- adults in the community.
ment, and (4) identifying indicators to monitor Demonstrate commitment to action by publicly
progress in relation to the action plan. posting the action plan.
Indicators to assess a communitys age- Commit to measuring activities, reviewing
friendliness are currently being developed and action plan outcomes, and reporting on them
piloted (World Health Organization Center for publicly.
Health Development 2014). Consistent with the
ndings from the Global Age-Friendly Cities pro- Because they are provincially led, the
ject (World Health Organization 2007a), they approaches taken to roll out age-friendly initia-
focus on issues such as accessibility of buildings, tives differ across provinces (Plouffe et al. 2013).
affordability of housing, and positive social atti- By way of example, one of the longest-running
tudes toward older adults. Canadian age-friendly initiatives is the
Age-Friendly Manitoba Initiative which was
Regional Age-Friendly Initiatives launched by the government of Manitoba in
While the WHO Global Network of Age-friendly 2008. In several successive intake rounds, all
Cities and Communities is composed primarily 198 municipalities in the province have been
of local governments that individually join invited to become part of the initiative. To date,
the network, some countries have estab- 100 communities have joined the initiative,
lished countrywide or regional networks of representing over 80% of the population of the
communities (Plouffe and Kalache 2011; Plouffe province. Communities receive a small amount of
funding from the provincial government to help To be sustainable, ongoing promotion of

defray some of the costs associated with planning age-friendliness is important at the community
activities or to implement small projects. They are but also at the provincial level to ensure A
also invited to a 1-day orientation workshop that sustained buy-in at the local level.
provides information on the concept of Taking into account community characteristics
age-friendliness and identies ways to get the is important as the trajectory and timeline of
initiative launched in the community (e.g., the becoming more age-friendly may differ in rural
importance of forming an Age-Friendly Commit- versus urban communities.
tee). Moreover, workshops are held at regular
intervals with representatives from participating A Model of Age-Friendly Housing
communities to share experiences and problem- While the majority of older adults want to age in
solve challenges. place in their own homes, many do eventually
A partnership with university researchers has need some assistance with activities of daily liv-
provided a unique opportunity to underpin the ing. Recently, the Health Minister for the Ontario
Age-Friendly Manitoba Initiative with research. government tabled a 10-point road map to
For example, it led to a formative evaluation, include home care as an integral part of the overall
which was designed to assess the process of how healthcare system. By acknowledging that the
the initiative was being implemented. The evalu- care for thousands of families is currently patchy,
ation, conducted in 2011 (3 years after the initia- uneven, and fragmented, he signaled a need for
tive was rst launched) with 44 participating rural policy changes that have been severely neglected
and urban communities, demonstrated consider- for too long.
able progress (Menec et al. 2013). Virtually all In advanced age, the challenges related to meal
communities had formed an Age-Friendly Com- preparation, personal support, and therapy ses-
mittee to help guide the implementation of the sions grow exponentially. Consequently,
initiative, and most of them had conducted a com- remaining in the home may become impossible,
munity assessment to identify priorities for action. and admission to a long-term care facility may be
The majority of communities had implemented necessary. To accommodate the needs of older
one or more age-friendly projects. Major barriers adults, there was a rapid development in seniors
to becoming age-friendly identied by partici- facilities after 1950, growing to one million resi-
pants included funding; lack of capacity, particu- dents in 36,000 facilities in the USA (ALFA 2009)
larly in small communities; and lack of leadership and 200,000 residents in 2,000 facilities in Can-
or direction. The evaluation further identied sev- ada by the early 2000s (Insight: Current demo-
eral key issues in implementing age-friendly ini- graphics and trends in seniors housing). The
tiatives, including: philosophy has been bigger is better, especially
as it translates not only to larger facilities and
Becoming age-friendly requires strong leader- organizations but also to larger private bedroom
ship at all levels of government (local, provin- suites compared to common spaces. The tendency
cial, national). has been to make the bedroom areas bigger at the
Communities (particularly rural ones) need expense of smaller common spaces.
support, such as resources to assist with plan- A competing philosophy might be to reverse this
ning and funding for projects. relationship so that the common spaces become
Linking the age-friendly community initiative an exciting hub to bring the resident out of
to other initiatives is useful as it creates ef- his/her room.
ciencies in committee structures and planning Signicant progress has been made in the
processes and can facilitate accessing funding. design of long-term care facilities, countering the
It can, thus, help mitigate the two biggest chal- stigma of traditional nursing homes with their
lenges identied, namely, lack of nancial and dozens of residents clustering in wheelchairs with
human resources to implement projects. no discernible engagement or distraction other
than a small television in an otherwise barren emphasis on small-scale homelike settings as

room. In addition, the emergence of CCRCs part of The Eden Alternative. This concept
(continuum of care retirement communities) has extols well-being as a much larger idea than
redened housing alternatives for the growing quality of life and embraces an elder as one
demographic of older adults. who should be seen as an active partner in his/her
Two dominant patterns prevail that can be own case. According to Schlegel, society was
characterized either as a hospitality model or a built around cars, streets, and neighbourhoods.
healthcare model. The hospitality model is The difference now is that the walker has
designed more like a hotel where you would be replaced the car and intentional design can still
delighted to go for a vacation but would not like to emulate the environment a person would have
live there. Meanwhile, the healthcare model is the experienced in past years.
antithesis of the hotel model by virtue of integrat- Inspired by Ron Schlegels thinking, architect
ing as many homelike features as possible. Both Richard Hammond of Cornerstone Architecture
models are necessary, but not mutually exclusive Incorporated has taken the typical functions of
as all residents are looking for both comfort and dining, lounge, and activity spaces and translated
medical safety. However, neither of these models these into an urban village setting to make this
seem to address the signicant social needs of concept come alive in all 15 villages located
individuals who have grown up in more simple across southwestern Ontario in Canada. These
and community-oriented environments where functions are reinterpreted as a variety of store-
everybody knew each other, with a main street front buildings organized along Main Street,
and common meeting places. leading to the Town Square as the social hub of
The quest was to recreate that welcoming envi- the community. Architectural detailing helps to
ronment to the extent possible and produce a reinforce the urban messaging through the use of
paradigm shift in the way older adults interact in traditional streetscape materials and canopies. The
a congregate setting. Leading this charge in 1989 result not only looks like an age-friendly village,
was Dr. Ron Schlegel, academic, entrepreneur, but it also functions that way with social interac-
and philanthropist. Schlegel has a PhD in social tions unfolding naturally.
psychology and that knowledge of the interface A similar urban theme continues past Main
between the environment and social living, com- Street into the residential areas of the community.
bined with growing up in a small rural town in These are conceived as neighborhoods with
Ontario, led to the Schlegel Village Model. their own local common areas appropriate to the
Although conceptualized well in advance of the level of care being provided. Entrances to individ-
current age-friendly movement, the Schlegel Vil- ual resident suites are designed as traditional
lage Model provides an excellent example of an front doors, including a valance, street number,
age-friendly environment for older adults with and mailbox, evoking a local residential street as
care needs that incorporates many of the elements opposed to an institutional corridor.
identied in the WHO model (World Health Orga- Age-friendly design is more than simply
nization 2007a). increasing accessibility by removing barriers.
This paradigm change is based on the simple The real magic is design and function, which
concept of replicating the life experiences that encourages people to take advantage of the easy
people have had throughout their lifespan. The access. For example, en route from the home area
signicant culture change associated with the to the dining room, a person will travel along
Schlegel Village Model is to move away from a Main Street at least three times a day and encoun-
traditional institutional model of care to a social ter common spaces where they might interact
model of living. Thomas (Kaczynski and Sharratt with a fellow traveler. This intentional planning is
2010) captured some of this ambience with analogous to a grocery store where one has to go
to the far end to get milk, passing all kinds of Cross-References

attractive features along the way.
The notion of a Schlegel Village is not a new Aging and Psychological Well-Being A
invention. Precedents have been taken from obser- Aging and Quality of Life
vations about how small towns work and even the Housing Solutions for Older Adults
way urban neighborhoods function within cities. Retirement Villages
Schlegel has adapted the aphorism of a doctor Small-Scale Homelike Care in Nursing Homes
learns from his patients to a congregate housing
innovator who learns from his residents. Concepts
References
are also drawn from the place-making principles
of the New Urbanism (www.cnu.org), such as ALFA (2009) 2008 largest senior living provider. ALFA
walkability, diversity of experience, familiar ele- seniors living executive. March/April
ments, easy orientation, and collective identity, Annear, M., Keeling, S., Wilkinson, T., Cushman, G.,
elements that are also evident in the notion of Gidlow, B., & Hopkins, H. (2014). Environmental
inuences on healthy and active ageing: A systematic
age-friendly communities. Ironically, these princi- review. Ageing and Society, 34, 590622.
ples are part of a larger set that guided development Bloom, D. E., Chatterji, S., Kowal, P., Lloyd-Sherlock, P.,
of an outdoor village (Williamsburg), which was McKee, M., Rechel, B., Rosenberg, L., & Smith, J. P.
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and intentional design strategies of indoor villages, Chappell, N., & Hollander, M. J. (2011). An evidence-
only with an outdoor Main Street, walkable ame- based policy prescription for an aging population.
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(2010)
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on as a global mandate with the launch of the dents perceptions of the building of a walkable com-
Global Age-Friendly Cities project. Ideally, this munity. Int J Behav Nutr Phys Act, 7, 112.
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age friendly: State and municipal initiatives in Canada
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138 Age-Related Changes in Abilities
Public Health Agency of Canada. (2015). How can Cana- controlling for SES) (Salthouse 2012). Cognitive
dian communities become more age-friendly? http:// ability facilitates the execution of an array of tasks
www.phac-aspc.gc.ca/seniors-aines/afc-caa-eng.php
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cities: A guide. Geneva: World Health Organization. changes in abilities are complex. For one, ability
World Health Organization. (2007b). Checklist of essential changes throughout the lifespan vary by person.
features of age-friendly cities. Geneva: World Health For instance, two 50-year-olds may have
Organization. extremely different intellectual proles: one may
World Health Organization. (2011). Global health and
aging. NIH, (n.p). have the same measured cognitive abilities as an
World Health Organization Centre for Health Develop- average 30-year old and the other may resemble
ment. (2014). Measuring the age-friendliness of cities: an average 70-year old. Moreover, within the
A guide to using core indicators. Kobe: World Health same person, different abilities decline and/or
Organization Centre for Health Development.
grow at varying rates. These changes are a func-
tion of the continuous use of some skills, which
serves to preserve skill-related abilities and the
decay of unused skills. As such, there is signi-
Age-Related Changes in Abilities cant between- and within-person variability in age
and abilities. Because of this variability, there is
Margaret E. Beier and Jacqueline M. Gilberto not an agreement on the age at which a person
Department of Psychology, Rice University, becomes an older person. In this review, general
Houston, TX, USA changes in abilities are described. Research sug-
gests that these changes are a function of regular
aging (memory impairment that is a function of
Synonyms psychopathology such as dementia or
Alzheimers disease is not considered). Nonethe-
Aptitudes; Cognitive abilities; Intellectual devel- less, it is important to note that the trends
opment; Intelligence described herein will not occur at the same age
for every person (Hertzog et al. 2008). Moreover,
ability is not a monolithic construct and different
Definition types of abilities have different patterns of growth
and decline throughout the lifespan.
Cognitive abilities are dened as a persons men-
tal capacity to do or act; broadly considered, cog-
nitive abilities include attention, reasoning Cognitive Abilities
abilities, memory, and knowledge (Salthouse
2012). There are two categories of cognitive abilities
Answers to questions about the development most relevant to aging: one related to reasoning
of cognitive abilities with age have implications abilities associated with generating, transforming,
for work performance, socioeconomic success and manipulating information and the other
(i.e., income and education, SES), and even mor- related to knowledge accumulated throughout
tality (the likelihood of mortality at earlier ages the lifespan. These abilities have different names
increases at lower ability levels, even after depending on theoretical orientation; they have
Age-Related Changes in Abilities 139
Knowledge A
Level of Ability
(Crystallized ability)
Reasoning
(Fluid ability)
Younger Middle Older

Age
Age-Related Changes in Abilities, Fig. 1 Hypothetical compilation of research ndings on age-related changes
trajectories of knowledge (crystallized abilities shown with in abilities using an array of measures and both cross-
the dashed line) and reasoning (uid abilities shown with sectional and longitudinal research designs (Ackerman
the solid line) by age group. The gure represents a 2014)
been referred to as uid and crystallized abilities depending on the design of the research study
representing the reasoning and knowledge com- (as discussed below), but both reasoning and
ponents, respectively, and the process (reasoning) knowledge increase up to early adulthood, when
and products (knowledge) associated with cogni- their paths begin to diverge. Reasoning abilities
tion (Carroll 1993; Horn and Cattell 1966). They begin to decline early some studies suggest as
are thought to represent, for example, a persons early as late adolescence or early adulthood and
ability to acquire new information compared to continue the downward trend throughout older
the information already known (Salthouse 2010). ages. The size of the effect varies by study, but
For simplicity, the terms reasoning and knowl- generally research shows a decline of about 1.52
edge are used to denote these different types of sample standard deviation units from when a per-
cognitive abilities. son is in their 20s to when they are in their 70s in
Measures of reasoning and knowledge abilities reasoning and related abilities (e.g., memory,
are positively correlated in the general population; speed, and working memory tests, Salthouse
that is, a person who has relatively higher reason- 2010). By contrast, knowledge levels remain sta-
ing capacity is also likely to acquire more knowl- ble and may even increase, up until age 70 or so
edge. This relationship reects the idea that (Salthouse 2010). Patterns of reasoning and
reasoning ability is a major determinant of learn- knowledge abilities are shown in Fig. 1, which is
ing and knowledge acquisition throughout the derived from research conducted with thousands
lifespan. Indeed, the development of knowledge of participants using an array of measures and
and expertise within a domain is often described study designs (Ackerman 2014; Salthouse 2010).
as a function of the investment of reasoning ability The dashed line represents the growth and stabil-
such as when a student works with full attention to ity of knowledge throughout the lifespan, while
complete a calculus problem in a unit he/she is the solid line represents the growth and subse-
learning or when an accountant learns a new quent decline of reasoning abilities.
spreadsheet program to increase his/her produc- Some theoretical perspectives place a greater
tivity (Ackerman 2014). emphasis on reasoning abilities than knowledge
Despite this positive relationship, however, as representative of intelligence (Spearman 1904).
reasoning and knowledge have different trajecto- These perspectives either consider knowledge
ries over the lifespan. The trends differ slightly to be a product of intelligence, but not an
depending on how the abilities are measured and essential component of it, or they ignore
knowledge completely. Given that reasoning abil- adaptive; that is, people have less need to reason
ities start declining relatively early in life and through difcult problems as they age because
continue a downward trajectory, this perspective they have developed vast stores of knowledge
provides a relatively pessimistic view of intellec- through experience that they can bring to bear on
tual development at middle and older ages. an array of adult situations. A middle-aged or
Furthermore, this view neglects compelling evi- older engineer, for instance, might work on a
dence available through everyday encounters variety of projects during a year learning some-
with smart and successful people that intellec- thing new from each of them and this learning
tual abilities continue to develop throughout life. may not seem very effortful. Nonetheless, it
For instance, the overwhelming majority of CEOs would be more difcult, although probably not
of fortune 500 companies in the United States is impossible given enough time and effort, for the
between the ages of 45 and 70. Similarly, with few middle-aged or older engineer to learn a
exceptions around the globe, heads of states are completely new eld, like psychiatry.
likely to be older versus younger. Given the ability
trajectories shown in Fig. 1, these leaders would
be considered long past their intellectual peak if Assessment
reasoning were the sole or central cognitive ability
important in adult intellect (Salthouse 2012). In There are a variety of methods used to assess
the context of aging, theories that emphasize rea- reasoning and knowledge abilities, and a
soning abilities over knowledge paint a relatively researchers choice of measure will undoubtedly
pessimistic picture of adult intellectual develop- affect the outcome of the research. Reasoning
ment; a picture that is not aligned with lay obser- abilities are typically measured with abstract
vations and common sense. problems such as pattern completion with gures
Theoretical perspectives that consider adult and numbers (e.g., number series tests where test
intellect to be comprised of both reasoning and takers complete a pattern of numbers and Ravens
knowledge give credit to adults for their knowl- advanced progressive matrices) (Raven
edge and expertise (Ackerman 2014). And et al. 1991). These tests are designed such that
although there is little research on the topic of performance is relatively knowledge and context
how adults might continually develop their free (although it is certainly the case performance
knowledge and expertise even with declining rea- is affected by a persons familiarity with test tak-
soning abilities, it seems likely that people typi- ing and that practice in this regard can affect
cally choose environments (i.e., for education, performance). Assessments of working memory
work, home, hobbies) that align with their capacity also shown to be related to reasoning
established knowledge and skills. This strategy ability are relatively free of knowledge and
increases peoples reliance on their vast repertoire focus on a persons ability to simultaneously pro-
of knowledge and expertise and also reduces the cess and store information. Examples of such tests
need for people to reason through every problem are the backward digit span test, which requires
in their environment as if it were new. Indeed, test takers to recall in reverse order a set of
research suggests that even though declining rea- three or more numbers that are read aloud, and the
soning abilities with age can make learning novel operation span test, which requires test takers to
information difcult, domain-specic knowledge make decisions about the veracity of an equation
facilitates the acquisition of new knowledge in while remembering the equations numerical out-
that particular domain (e.g., an extensive under- come (Ackerman et al. 2002).
standing of investment products facilitates learn- Because no individual measure is perfectly
ing about managing investments within a reliable or a perfect reection of a concept as
retirement account) (Ackerman and Beier 2006). complicated as cognitive ability researchers
In this way, the age-related trajectories of abilities typically use a battery of multiple measures
shown in Fig. 1 can be considered somewhat to assess reasoning abilities (e.g., spatial,
numerical, symbolic). Reasoning ability is anything encountered and learned throughout the
then estimated by aggregating or life course (e.g., the length of time a whole
averaging peoples scores on these multiple chicken needs to roast, when a child should be A
measures. This approach is similar in concept to taken to the doctor, how to operate a forklift). As
factor analytic approaches, which derive an ability implied by these examples, capturing the whole of
factor by pooling the common variance among knowledge through the lifespan giving adults
measures (Ackerman et al. 2002; Carroll 1993). credit for what they know would require an
Aggregation helps control for the inuence that impossibly elaborate knowledge battery. Indeed,
the measurement error or content associated with researchers endeavoring to assess knowledge
any one test has on the assessment of reasoning growth with age have measured knowledge across
ability, which can be substantial. For instance, if multiple academic (e.g., 20 academic domains
the only test used to assess reasoning ability is a including natural science, business, social sci-
number series test that is only somewhat reliable, ence, and humanities) and nonacademic (e.g., cur-
a persons score on that test would be a function of rent events, health, nancial, and technology
their reasoning ability, but also a function of their knowledge) domains (Ackerman 2014). In this
numerical ability and the measurement error asso- research, age was positively correlated with
ciated with the particular test used. It would also knowledge possessed across all domains, with
be impossible to separate the amount of variance the exception of those domains most related to
associated with each of these factors (reasoning natural science (e.g., physics and chemistry).
ability, numerical ability, and error). To avoid Nonetheless, these elaborate knowledge assess-
these issues and to get a reliable assessment of ments will still underestimate what adults actually
reasoning ability, scores derived from most com- know because assessments can never account for
mercially available intelligence assessments are a the idiosyncratic nature of adult experiences that
function of an aggregation of individual items and lead to knowledge and expertise.
measures over a range of content (e.g., digit sym-
bol, block design, matrix reasoning, and letter
number series in the Wechsler Adult Intelligence Research Designs
Scale) (Wechsler 1997).
Knowledge is typically measured with vocab- Most research on age and abilities is cross-
ulary tests or general information tests that include sectional in nature, meaning that people of differ-
questions about widely available information ent ages are assessed simultaneously. Inferences
within a cultural context (e.g., What is the capital about age-related changes are made by examining
city of France? Who was Benjamin Franklin?). the test scores for people of different ages (e.g.,
As discussed above, performance on general cul- comparing performance on an ability battery for
tural knowledge tests remains relatively stable 20- versus 70-year-olds or correlating ability
across the lifespan, but performance on these scores with age). Though informative, these stud-
tests does not typically show increases in knowl- ies are limited in that differences between age
edge with age. This is somewhat puzzling given groups may not represent age-related changes
the expectation that knowledge will continue to within a person. A classic anecdote illustrates
grow as a function of professional and life expe- this point (Salthouse 2010). A scientist examining
riences. One reason for this discrepancy is that, age-related changes who nds himself/herself in
because knowledge develops in ways that are Miami in the year 2014 might observe that youn-
unique to a persons experiences, knowledge ger people are more likely to be of Hispanic/
acquisition is idiosyncratic. As such, a complete Latino or African-American descent, while older
picture of what a person knows would include a people are more likely to be of European descent.
lot more than general cultural knowledge; it Based on this observation of an age-diverse cross
would include knowledge about his or her job, section of the population, the researcher might
hobbies, and unique life experiences essentially conclude that people tend to become increasingly
European looking (i.e., white) with age. This is development, particularly as related to millennials
absurd of course, but it is meant to illustrate that versus older generations. It is less clear, however,
cross-sectional studies may lead to erroneous con- how cohort effects might inuence the develop-
clusions about age-related changes because they ment (growth and/or decline) of reasoning ability.
do not actually assess the changes within a person In contrast to cross-sectional studies, longitu-
that are a result of aging; rather, they assess dif- dinal research tracks the development and decline
ferences between people and presume that these of abilities within a person by administering the
differences are a function of age. Moreover, these same (or similar) measures periodically over time.
designs do not control for environmental, societal, Most of these studies include the periodic inclu-
or other extraneous factors that might affect peo- sion of a new sample of younger participants to
ple differently by age group. ensure a continuous sample given attrition and
Cohort effects are an example of a societal mortality. Examples of signicant longitudinal
inuence on cross-sectional studies in aging. studies in cognitive aging include the Seattle Lon-
A cohort is a generational group that presumably gitudinal Study (Schaie 2013), which was started
shares a cultural identity. Factors that affect one in the 1950s with a sample of about 500 people
cohort differently than others can inuence the ages 20 to 69. Participants were assessed on a
development of abilities. For instance, millennials battery of reasoning and knowledge measures on
are generally dened as those people who reached 7-year intervals, and every 7 years until 2005, a
young adulthood around the year 2000 (i.e., they new cohort was added to the study. The Victoria
were born around 1980 or so). In developed and Longitudinal Study (Hultsch et al. 1998) is similar
developing countries, millennials have grown up to the Seattle Longitudinal Study, but the sample
with access to technology that allows them to is somewhat older (5585) with new cohorts
communicate globally in minutes and that pro- starting every 10 years or so. Each of these studies
vides them access to a wealth of information at has assessed the abilities of literally thousands of
the press of a button. In this example, access to participants.
technology would affect the development of Although longitudinal studies are rare because
knowledge differently for millennials relative to of the time and resources involved, they provide
older cohorts. As such, cross-sectional studies on information about within-person change in abili-
aging and knowledge would capture differences ties and can control for cohort or other inuences.
in knowledge that are a function of age and cohort Fortunately, the results of longitudinal studies
and importantly, the variance associated with each tend to echo those of cross-sectional studies; that
could not be separated (a researcher could not is, most of this research shows the growth of
determine what differences between people were both reasoning and knowledge until early adult-
a function of age vs. cohort). In cross-sectional hood, the subsequent decline of reasoning abili-
designs, cohort essentially introduces a third var- ties, and the relative stability of knowledge.
iable (or confound) in the study. For this reason, Longitudinal studies show a more optimistic pic-
there is considerable debate about the value of ture of cognitive aging than do cross-sectional
cross-sectional studies for examining age-related studies, however. That is, the decline of both
changes in abilities, with some researchers taking reasoning abilities and knowledge tends to be
the extreme position that the value of cross- relatively later in longitudinal research (e.g., rea-
sectional research in aging is limited (Salthouse soning abilities begin to decline closer to age 30 in
2010). Rather than discounting all cross-sectional longitudinal studies vs. around age 20 in cross-
studies, however, it is probably important to sectional studies) (Ackerman et al. 2002; Schaie
understand the inuence of cohort vis--vis the 2013). In summary, the age-related trajectories of
constructs and variables in question. For instance, cognitive abilities shown in Fig. 1 reect trends
the discussion above highlights that cohort might found in cross-sectional and longitudinal research
be an important inuence on knowledge designs.
Ability Preservation of online brain training exercises for people of

all ages. Unfortunately, little empirical evidence
Important questions have been raised about the has shown brain training to be effective; meta- A
factors that affect changes in cognitive abilities analytic studies examining training effectiveness
throughout the lifespan, and the answers to such found little benet to using these programs
questions can inform interventions to preserve (Melby-Lervag and Hulme 2013). Some research
abilities. To date, many possibilities have been has shown that direct training on working memory
investigated (e.g., gender, personality traits, initial measures can be effective for increasing cognitive
levels of abilities, and environmental inuences performance. These effects have typically been
such as education and health, Ackerman small, temporary, and limited to already cogni-
et al. 2002), but there is generally little evidence tively healthy individuals, however. Moreover,
that any one factor exerts a strong effect on the these short-term improvements tend to exist only
course of age-related changes in abilities. There is for the specic working memory tasks practiced
some research to suggest that a persons initial in training (or similar tasks), meaning that the
level of ability, overall health, and education will effects of working memory training are relatively
differentiate people by ability level throughout the narrow and have not been found to transfer to
lifespan (Salthouse 2010). For instance, a person more generally complex life tasks
who starts out with signicantly lower scores on (Hertzog et al. 2008). Nonetheless, because of
reasoning ability tests relative to others in the the importance of preserving cognitive abilities
population of the same age will likely continue into older ages, many researchers continue to
to have relatively lower scores compared to the work on developing effective strategies for pre-
same population throughout the lifespan; a person serving mental abilities through brain training.
who is healthier will likely have higher reasoning The bottom line is that current brain training
ability and knowledge scores throughout their life activities are not likely to improve general mem-
compared to someone who is less healthy. ory or mental functioning in a measureable way,
Recent research has focused on the preserva- but they may not do any harm either. Moreover, to
tion of abilities throughout adulthood (into older the extent that remaining cognitively engaged
ages). This preservation is indeed important as leads to learning and skill acquisition (i.e., exper-
most people will tend to experience some form tise in an area), these exercises may increase
of intellectual decline, even in knowledge and levels of knowledge.
expertise, in late life (e.g., age 80 and beyond). Physical exercise. Research on physical exer-
The aging of the global population, coupled with cise has shown promise for its effect on preserving
the daunting prospect of the loss of cognitive cognitive abilities into later life. These ndings
abilities, has increased the urgency of nding extend to both short- and long-term exercise inter-
remedies to age-related cognitive decline. Com- ventions and have been most compelling for aer-
mon ability preservation strategies include both obic exercises (i.e., those that increase heart rate
cognitive (e.g., brain training) and physical (e.g., such as brisk walking/jogging vs. stretching)
exercise) approaches. (Hertzog et al. 2008). The key to cognitive benet
Brain training. Brain training typically appears to be enhancing cardiorespiratory func-
employs cognitive exercises to enhance a persons tions that lead to myriad health benets related to
working memory. Based on models of physical increased tissue oxygenation (healthier muscles,
tness that target exercises to specic muscles for heart, and brain). Studies examining short-term
strengthening, brain training is designed to aerobic and high intensity exercise interventions
strengthen memories or reasoning abilities suggest better performance at simple cognitive
through mental drills. At least in the United States, tests postexercise. Effects are largest for people
brain training is developing into a protable with lower cognitive ability predating exercise
industry, with advertisements extolling the virtues interventions. Long-term effects of exercise are a
bit more complex to study. In younger cohorts, way, researchers are simply responding to the
regular aerobic exercise has been shown to demands of a rapidly aging global population to
predict improvement in various tasks related to stave off pending declines. Although the research
reasoning ability and working memory (Guiney is currently inconclusive, the best evidence sug-
and Machado 2013). For healthy older adults, gests some promise for remaining mentally and
however, regular physical activity does not physically active throughout the lifespan. The
appear to improve cognitive ability, so much as brain, after all, is an organ that benets from
maintain it. That is, people who engage in regular physical activity just as do other organs in the
aerobic exercise across the lifespan are expected body. And although the research on mental exer-
to optimize cognitive ability when young and cise is still inconclusive, brain training activities
maintain ability longer and more effectively as are unlikely to do any harm, especially if people
they age. refrain from spending excessively on unproven
techniques (e.g., brain training software pro-
grams). There are, after all, plenty of relatively
Conclusion inexpensive ways to stay mentally engaged (e.g.,
crossword and other word puzzles, math games,
Medical science has succeeded in expanding life reading a book). For both mental and physical
expectancy across the globe. According to the health, however, cognitive benets are most evi-
World Health Organization, people born in 2012 dent when people start early and remain consis-
can expect to live 6 years more, on average, than tently active.
people born in 1990, and average life expectan-
cies are now around age 80 for developed coun-
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determined and measured. The American Journal of
Psychology, 15, 201293. loss than individuals of Hispanic, Black, or Asian
Wechsler, D. (1997). WAIS III: Administration and scoring races (Schoenborn and Heyman 2008). Occupa-
manual. San Antonio: The Psychological Corporation. tionally, individuals who work in louder environ-
World Health Organization. (2014). World Health Organi- ments, such as transportation or manufacturing,
zation: World health statistics, 2014. http://apps.who.
int/iris/bitstream/10665/112738/1/9789240692671_ are more likely to experience hearing loss (Tak
eng.pdf?ua=1 and Calvert 2008). Military service also increases
an individuals risk for hearing loss, mostly due to
noise exposure. In the USA, hearing loss is the
most common disability related to compensation
and pension benets for WW2 and Korean era
Age-Related Hearing Loss veterans and the second most common among
Vietnam era veterans (Veterans Benets Admin-
Christina Garrison-Diehn istration 2014).
Geriatric Research, Education, and Clinical
Center, VA Palo Alto Health Care System, Palo
Alto, CA, USA Types of Hearing Loss
Department of Psychiatry and Behavioral
Science, Stanford University School of Medicine, Hearing loss is categorized into two main types,
Stanford, CA, USA conductive and sensorineural. Conductive hearing
loss is due to problems in the outer and middle ear
and is often correctable by surgical or medical
interventions. A few examples of causes of con-
Synonyms ductive hearing loss include congenital
malformations of the middle ear structures, uid
Deafness; Hard of hearing; Hearing impairment; in the middle ear from colds, impacted earwax,
Presbycusis benign tumors, and foreign bodies in the ear.
146 Age-Related Hearing Loss
Sensorineural hearing loss is the most common noises, and it is very difcult to hear when there
type of hearing loss in older adults and is caused is background noise. With moderate hearing loss,
by damage to the inner ear and/or the nerve path- individuals often have trouble on the phone.
ways between the inner ear and the brain. Com- When a person has severe hearing loss
mon causes of this type of hearing loss are (7090 dB), one-on-one conversations in quiet
exposure to loud noises, head trauma, viruses, settings need to be conducted loudly, and when
and ototoxic (i.e., ear poisoning) medications. someone has profound hearing loss (90 dB and
Though some causes are reversible, usually sen- louder), only very loud noises are heard.
sorineural hearing loss is irreversible. There is a Hearing loss can occur in the high-frequency
third category, mixed hearing loss, which is a (e.g., birds singing, higher-pitched voices) or the
combination of conductive and sensorineural low-frequency ranges (e.g., hum of the refrigera-
hearing loss. tor, a bass drum). The most common hearing loss
in older adults is in the high frequencies. Much of
human speech patterns fall in the higher fre-
Hearing Loss Health-Care Providers quency, especially consonant sounds S, F, K, T,
Sh, and Th. Often individuals with mild to mod-
Otolaryngology is the branch of medicine focused erate high-frequency loss can hear that someone is
on issues of the ear, nose, throat, head, and neck. speaking to them, but because of their hearing
Otolaryngologists (sometimes called ear, nose, impairment, they are unable to discriminate the
and throat or ENT physicians) diagnose and med- speech sounds. For example, do you think shell
ically/surgically treat diseases and disorders that nd it? may sound like did you see Sauls mind
are causing or contributing to the hearing loss. yet? Understandably, this can lead to problems in
Audiology is the scientic study of hearing communication and frustration in social interac-
loss, balance, and related issues. Audiologists tions. This sound discrimination issue is one of the
have either a Masters degree or Doctorate reasons that speaking louder is not a good com-
(Au.D. or Ph.D.) in Audiology/Communication pensatory strategy when working with an older
Sciences and Disorders. They perform hearing adult with hearing impairment, because saying it
evaluations, diagnosis type, and severity of hear- louder does not necessarily increase the clearness
ing loss, recommend and t hearing aids, and of the sounds. Rather, ensuring that the individual
conduct other clinical activities related to preven- can see the providers face and mouth, slowing
tion, treatment, and management of hearing loss. down speech, and enunciating clearly can help
with this communication problem.
Visual impairment is also a common sensory
Degree and Experience of Hearing Loss decit experienced by older adults. When older
adults have both hearing loss and visual impair-
Hearing loss is categorized as mild, moderate, ment (sometimes referred to as dual sensory
severe, and profound. These descriptors are impairment), this can complicate their experience
based on the decibels (dB), a measurable unit of of hearing loss. Individuals with hearing impair-
volume, the individual is able to hear. Most cases ment often use visual cues to help their under-
of hearing loss are in the mild to moderate range. standing of conversation, such as lipreading,
A person with mild hearing loss (2540 dB) has facial affect, and other environmental informa-
trouble hearing softer noises and often has dif- tion. Visual impairment reduces the individuals
culty hearing speech in a loud environment (e.g., ability to rely on this type of information, which
talking to a dinner partner in a loud restaurant). impacts their hearing functioning. A common
A person with moderate hearing loss (4070 dB) joke that illuminates this experience is I cant
has trouble hearing soft and moderately loud hear you. . . I dont have my glasses on.
Hearing Loss and Health Risks It is notable that untreated hearing loss can
result in an individual appearing as though they
Hearing loss is associated with specic diseases have cognitive impairment when they do not. A
such as diabetes, arthritis, and cardiovascular dis- Also, if an individual has some cognitive decits,
ease (Stam et al. 2014; Helzner et al. 2011). There hearing loss can make them seem more cogni-
is evidence that individuals with hearing loss are tively impaired than they are. Reduced communi-
hospitalized more and are at higher fall and acci- cation abilities or attention abilities are sometimes
dent risk (Genther et al. 2013; Lin and Ferrucci the result of not being able to hear. For example,
2012). Compared to matched samples of older an inaccurate answer may be the result of mis-
adults without hearing loss, individuals with hear- hearing a question, or a lack of attention may be
ing loss are at higher risk of functional impairment because the individual did not hear or realize they
and decreased levels of physical activity (Chen were being spoken to. Sometimes, simple inter-
et al. 2015; Gispen et al. 2014). Some observa- ventions, like using a personal amplier (e.g.,
tional studies have found that hearing loss alone pocket talker) or making sure that hearing aids
was an independent risk factor for mortality are functioning properly (e.g., batteries are
(Fisher et al. 2014; Genther et al. 2015). charged, ear tubes are clean), can make a big
impact on an individuals cognitive ability in the
moment.
Hearing Loss and Cognitive Decline
Individuals with hearing loss are at higher risk of Hearing Loss and Psychosocial Risks
developing dementia and faster decline in the
trajectory of the disease (Lin et al. 2013). This An important area of possible intervention in
risk increases with the severity of the hearing geropsychology is on the impact of hearing loss
loss mild, moderate, and severe hearing loss and psychosocial functioning. Hearing loss is
increases risk two, three, and ve times, respec- associated with social isolation, loneliness, and
tively, compared to individuals without hearing depression (Brink and Stones 2007; Pronk
loss (even after other health problems were con- et al. 2014). The impact of not being able to hear
trolled for). Three possible mechanisms of this in loud groups, such as restaurants or theaters, can
increased risk are (1) reduced social and environ- limit an individuals ability to enjoy these types of
mental engagement due to communication dif- events. In one-on-one or small group conversa-
culties, (2) shared pathology of hearing loss and tion, it can be frustrating or embarrassing to
dementia (e.g., vascular changes), and repeatedly remind conversation partners to speak
(3) increased cognitive load (Lin and Albert up or ask them to repeat themselves. This can lead
2014). Cognitive load describes the amount of to increased withdrawal. Even solitary activities,
mental effort being used in working memory. such as watching television or listening to the
Given the difcultly discriminating speech radio, can lose some of their enjoyment, espe-
sounds and trying to block out background cially if aids such as closed captioning or ampli-
noise, it can be much more effortful to engage in ers are not available.
communication for individuals with hearing loss. Hearing loss can also cause problems in signif-
It is possible that as the brain allocates resources icant relationships, lowering socialization and
to engage in this effort, it depletes resources from relationship satisfaction (Kamil and Lin 2015).
other brain functions. Currently, it is unknown A marked reduction in socialization by a
what mechanism is responsible for this increased hearing-impaired signicant other can lead to
risk, but generally it is hypothesized to be a com- reductions in social opportunities for both parties.
bination of these three mechanisms. For example, if a husband no longer likes to go to
148 Age-Related Hearing Loss
dinner with friends because he cannot hear in that accuracy). Hearing aids increase amplication
setting, his partner might not want to go without and are programmed to pick up different frequen-
him and is also missing that opportunity to social- cies to t the users type of hearing loss. The
ize. Within signicant relationships, benign or human ear has the ability to focus in on individual
neutral interactions can easily escalate to heated sounds and tune out background noise; hearing
moments or conict due to frustration by both the aids are not able to perfectly mimic this ability.
hearing-impaired individual and their partner. It is Though advances have been made in reducing the
common for individuals with hearing loss to background noise amplication in hearing aids, it
blame their signicant other when they cannot still can be difcult for users in louder settings.
hear what is said with comments like she mum- Other hearing aid advances include tele-coil tech-
bles too much or he is always talking to me from nology, which directly links into sound systems in
across the house how is anyone supposed to hear public places like auditoriums and theaters (if the
that? Similarly, it can be frustrating for signi- setting has the corresponding sound system tech-
cant others to repeat themselves, especially when nology), phones, and televisions. Also, some
they need to repeat themselves several times. hearing aids are able to use bluetooth technology
Also, as signicant others repeat themselves, to connect to phones and televisions. Unfortu-
they are often raising their voice to a louder vol- nately, it is estimated that a high percentage of
ume. This can strain the interaction, making the individuals who could benet from hearing aids
hearing-impaired partner feel yelled at and do not use them. Chien and Lin (2012) found that
increasing feelings of frustration on the part of among hearing-impaired individuals, only 4.3%
the speaker. of people aged 5059, 7.3% aged 6069, 17%
Individuals with mild hearing loss sometimes aged 7079, and 22.1% aged 80 and older wear
lack insight to the changes in their hearing abili- hearing aids.
ties. As described above, it can be common for Another, more intensive intervention for sen-
attributions about changes in others or the envi- sorineural hearing loss is a cochlear implant. This
ronment to be made, instead of acknowledging the intervention, which is recommended mostly for
changes in their hearing. For example, my individuals with profound to severe hearing loss,
grandchildren speak too fast and mumble or involves a surgical procedure, and the implanted
the television companies do a poor job with device replaces the functioning of the inner ear.
balancing sound on their programs. While both A sound processor is worn externally and behind
of these statements might have some truth, often, the ear, which captures the sound, turns it into
it is more likely that the individual is experiencing digital code, and sends the information to the
changes in their hearing abilities. Hearing loss is implant. The device then converts the code to
often an insidious process, and changes over time electrical impulses and communicates via the
may go unnoticed. This lack of insight or accep- hearing nerve with the brain. Similar to a hearing
tance of hearing loss can be a challenge for family aid, while it greatly enhances the individuals
members and contribute to reduced quality social ability to hear, it does not correct an individuals
interactions. hearing ability to normal levels. Also, often in
the surgical placement of the cochlear implant, the
inner ear functioning is damaged to the point that
Prosthetics and Rehabilitation what natural hearing abilities the individual had
are not restorable if they change their mind or the
Hearing aids are the most common treatment for cochlear implant does not work.
irreversible sensorineural hearing loss. There have Audiological rehabilitation involves using
been large advancements in hearing aid technol- training or treatment with individuals with hearing
ogy, but a hearing aid does not correct hearing in a loss to improve their hearing abilities and quality
way that glasses can correct vision (to 100% of life. Usually provided by an audiologist,
interventions in audiological rehabilitation somewhat louder can be helpful, but providers

include education about the hearing loss to both should be careful that the patient does not feel
the individual and the family members and edu- like they are being yelled at. Clinics and providers A
cation about using the hearing aid or cochlear who regularly work with older adults should have
implant, improving speech, using visual and con- personal ampliers on hand (e.g., pocket talkers);
textual cues, managing communication, and sim- these devices can greatly improve communica-
ilar other environmental techniques to improve tion. It is also helpful to reduce extraneous noise,
quality of life. meeting in a quiet area. And, nally, use written
material, such as handouts or written instructions
to aid in communication.
Implications for Working with Older
Adults with Hearing Loss
In working with older adults, asking about possi- Cross-References

ble hearing loss and the impact on the individuals
life is an important area to assess. As noted above, Communication with Older Adults
older adults are sometimes not aware of their Disability and Ageing
hearing loss or sometimes shrug it off as just an
inevitable part of aging. This can be an area where
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National Institute on Deafness and Other Communication Aging has long been associated with sadness, fear,
Disorders. (2015). Quick statistics. http://www.nidcd. and loss. From the downtrodden visage of
nih.gov/health/statistics/Pages/quick.aspx Picassos The Old Guitarist to the incompetent
Pronk, M., Deeg, D. J., Smits, C., Twisk, J. W., van Til-
burg, T. G., Festen, J. M., & Kramer, S. E. (2014). shenanigans of TVs Mr. Magoo, older adults
Hearing loss in older persons: Does the rate of decline have been depicted as depressed and cognitively
affect psychosocial health? Journal of Aging and impaired, and negative stereotypes of aging are
Health, 26(5), 702723. ubiquitous. Recent empirical evidence, however,
Schoenborn, C. A., & Heyman, K. (2008). Health dispar-
ities among adults with hearing loss: United States, has revealed that older adults experience more
20002006. http://www.cdc.gov/nchs/data/hestat/ positive and fewer negative emotions in their
hearing00-06/hearing00-06.pdf daily lives compared to younger adults (for a
Stam, M., Kostense, P. J., Lemke, U., Merkus, P., Smit, review, see Charles and Carstensen (2010)).
J. H., Festen, J. M., & Kramer, S. E. (2014). Comor-
bidity in adults with hearing difculties: Which chronic Older adults also appear to favor positive over
medical conditions are related to hearing impairment? negative information in attention and memory
International Journal of Audiology, 52(6), 392401. compared to younger adults, a developmental
Tak, S., & Calvert, G. M. (2008). Hearing difculty attrib- phenomenon known as the age-related positivity
utable to employment by industry and occupation: an
analysis of the National Health Interview effect. This entry provides an overview of the
SurveyUnited States, 1997 to 2003. Journal of Occu- empirical origins and theoretical foundations of
pational and Environmental Medicine, 50(1), 4656. the positivity effect, the debates concerning its
Ventry, I. M., & Weinstein, B. E. (1982). The hearing underlying mechanisms, the moderators of the
handicap inventory for the elderly: A new tool. Ear
and Hearing, 3(3), 128134. effect, and open questions for future research in
Veterans Benet Administration. (2014). Annual Benets this area. Implications of the positivity effect for
Report, Fiscal Year 2013. Department of Veterans social behavior and well-being in later life are
Affairs. discussed.
Age-Related Positivity Effect and Its Implications for Social and Health Gerontology 151
Empirical Origins Theoretical Foundations and Debates
Social scientists have long held that negative stim- Initial evidence for the positivity effect emerged A
uli are more attention grabbing than positive stim- from empirical tests of socioemotional selectivity
uli and that negative information is processed theory (SST; Carstensen 2006), a life-span theory
more deeply than positive (Baumeister of motivation. SST posits that a select group of
et al. 2001). Even though the bulk of research goals operates throughout adulthood. Some goals
showing this preference was based on undergrad- are related to preparing for the future, such as
uate samples of young adults, few questioned its accumulating knowledge and meeting new peo-
universality. When researchers began to study ple. Other goals pertain to optimizing the present,
cognitive processing in older adults, however, it such as savoring close relationships and striving
became clear that bad was not stronger for emotional satisfaction. Though both goal cat-
than good. In fact, several early studies found egories are important across the life span, their
that whereas younger adults showed a negativity relative prioritization is shaped on inter- and
bias, older adults preferentially processed intraindividual levels by future time horizons,
positive over negative information in attention which are inversely associated with chronological
and memory (for a review, see Mather and age. When the future is perceived as long and
Carstensen (2005)). The interaction between age nebulous, as is typical in youth, individuals prior-
and valence in the processing of emotional infor- itize future-oriented goals over emotional grati-
mation constitutes the age-related positivity cation. With advancing age, however, people
effect. perceive their futures as progressively more lim-
Early evidence for the positivity effect ited. As a consequence of these narrowing time
spanned paradigms from memory to attention horizons, motivational priorities shift in favor of
and incorporated a wide variety of stimuli. present-oriented goals related to emotional mean-
The positivity effect initially emerged in studies ing and well-being over goals associated with
of working memory, short-term memory, and long-term rewards. Insofar as positive information
autobiographical memory. Compared to is more emotionally satisfying and meaningful
younger adults, older adults appeared to than negative information, SST maintains that
privilege positive over negative stimuli such as older adults will display a relative preference for
emotionally valenced images and words. Studies the positive. The positivity effect, therefore, rep-
of visual attention likewise showed that older resents controlled cognition operating in the ser-
adults spent more time viewing happy and less vice of chronically activated goals and is
time viewing angry or sad faces compared to presumed to adaptively reect goal-directed
younger adults. behavior (Mather and Carstensen 2005).
As empirical studies accumulated, investiga- SST offers falsiable hypotheses about the
tions of the positivity effect were extended to contours of the positivity effect, that is, the precise
higher-level cognitive processes such as decision conditions under which older adults are expected
making (for a review, see Peters et al. (2011)). to favor positive information and those where age
When asked to make decisions about health- differences are mitigated or even reversed. Theo-
related choices (e.g., doctors and hospitals) or retically, the effect will be evident when individ-
consumer choices (e.g., cars and apartments), uals have sufcient cognitive resources to
older adults focused more on positive than nega- deliberately direct their attention and memory,
tive attributes compared to younger adults, both but not appear when cognitive resources are lim-
when they initially viewed the attributes and when ited or constrained. Second, the effect will emerge
they were asked to subsequently recall the when individuals are afforded the freedom to pur-
information. sue chronically activated goals, but not when
external goals or instructions conict with default Moderators and Mechanisms

priorities. Finally, the effect will appear when
selective attention and memory contribute to In the intervening years since the positivity effect
well-being, but not when it is emotionally risky was initially observed, dozens of studies have
or maladaptive to selectively process positive attempted to clarify the underlying mechanisms
information. As discussed in the following sec- of the positivity effect as well as the contexts
tion, evidence largely supports these predictions. under which it is observed versus not. The accu-
Whereas SST posited that the positivity effect mulating literature ultimately afforded a system-
emerges from top-down and uid processes atic meta-analysis of the research literature to
guided by motivational priorities, alternative determine the reliability, robustness, and modera-
accounts emerged to suggest that the effect is a tors of the positivity effect (Reed et al. 2014).
product of bottom-up and xed processes related Results of the meta-analysis indicated that the
to biological or cognitive aging (for a discussion, positivity effect is evident when cognitive
see Reed and Carstensen (2012)). These decit- resources are readily available, when experimen-
based perspectives contend that older adults pref- tal tasks or stimuli do not activate automatic
erentially process positive information because processing, and when information processing is
processing negative information exceeds cogni- unconstrained by external factors such as task
tive capacity and/or neural degradation. Reason- instructions. Collapsing across the entire research
ing from these positions, the positivity effect is literature indicates that these conditions yield a
expected to be most evident among individuals reliable, medium-sized positivity effect in the
with the most cognitive impairment and is rela- form of a classic crossover interaction between
tively insensitive to contextual factors such as age and valence: Younger adults favor negative
situation-specic goals. Such hypotheses, how- information, while older adults favor positive
ever, have not been supported in empirical stud- information. The positivity effect also appears
ies. On the contrary, as discussed below, the across a wide variety of paradigms. In visual
positivity effect varies systematically in response attention, the effect is evident in looking time as
to situational and methodological factors, and it is indexed by eye-tracking and dot-probe methods.
typically not observed in cognitively impaired Studies observe the positivity effect in working
samples. memory, short-term memory (both true and false),
Not long after the effect was rst identied, long-term memory, and autobiographical mem-
skepticism emerged among researchers who ory. The positivity effect has been shown to inu-
failed to observe the effect using paradigms that ence aspects of decision making from pre-choice
were putatively similar to studies that did observe information processing and gain/loss sensitivity
the effect. Questions soon arose concerning the to risky decisions (for a review, see Peters
consistency and reliability of the positivity effect. et al. (2011)). The positivity effect manifests
In the early years, concrete answers to these ques- across a wide range of stimuli, from basic stimuli
tions proved elusive because the empirical litera- such as words, images, and faces to complex
ture was still nascent and lacking in volume. stimuli such as health messages and videos.
Within less than a decade, however, mounting Consistent with predictions derived from SST,
empirical attention to the positivity effect yielded meta-analysis indicates that the positivity effect is
a literature with over 100 studies. As discussed in signicantly mitigated when experimental tasks
the following section, the sheer volume of evi- impose external constraints on cognitive
dence enabled a systematic meta-analysis that resources and/or goal pursuit. Examples of
resolves much of these questions and the sur- processing constraints include distracter tasks
rounding debate. designed to consume executive control resources
and explicit instructions to attend to or ignore that placed constraints on processing (e.g., via
emotional stimuli. Many of these studies inadver- experimental instructions to attend to all stimuli),
tently constrain processing by, for instance, and meta-analysis afrms that these studies typi- A
informing participants at the outset that their cally observe a mitigated, if any, positivity effect.
memory for experimental stimuli will be tested By contrast, when individuals are simply asked
at the end of the session, thereby prompting to review information without processing instruc-
increased attention across stimulus types. tions (e.g., open-ended visual attention para-
In contexts such as these where individuals are digms), the positivity effect is reliable and fairly
instructed to pursue specic goals other than emo- robust. This pattern underscores the need for a
tionally meaningful ones, older adults process clear theoretical framework. Seemingly minor
positive and negative information comparably, methodological differences across studies, in the-
while younger adults processing preference for oretical context, are meaningful and result in crit-
negative information is substantially weakened. ical changes to experimental paradigms. Taken
The moderating role of experimental constraints together, evidence suggests that the effect reects
is further highlighted by studies that purposefully default cognitive processing that favors informa-
manipulate these factors. For instance, age differ- tion relevant to emotion-regulatory goals. Older
ences in attention and memory for choice attri- people value goals related to emotional meaning
butes are eliminated when individuals are and well-being, and, all else equal, cognitive
explicitly instructed to focus on the specic processing serves such goals.
facts and details or make decisions for other
people rather than for themselves (Lckenhoff
and Carstensen 2008). Close analysis of individ- Neural Signature
ual studies also indicates that the positivity effect
does not appear when experimental tasks target The positivity effect also manifests in distinct
automatic processing and that individuals with age-by-valence interactions in neural responses
habitually poor cognitive control (as indexed by to emotionally valenced stimuli (for a review,
cognitive tests) do not show the positivity effect. see Samanez-Larkin and Carstensen (2011)). At
Emerging evidence also suggests that positivity the subcortical level, older adults show reduced
may be reduced when the stakes are high and activation in the amygdala relative to younger
other goals supersede emotion-related priorities. adults when viewing or evaluating negative
For instance, it appears that older adults in rela- faces (e.g., displaying sad, fearful, or angry
tively poor health pay more attention to negative expressions). Although several researchers have
information than their healthy peers when making interpreted this nding to support age-related dys-
health-related decisions such as selecting a physi- function in the amygdala, it is critical to note that
cian (English and Carstensen 2015). Theoreti- age-related decreases in amygdala activation are
cally, this is because under such circumstances, eliminated or even reversed in response to posi-
the search for personally relevant information out- tive faces (e.g., Mather et al. (2004)). The age-by-
weighs emotional goals. valence interaction suggests that negative (but not
Consistent with the motivational formulation positive) stimuli may be less salient to older ver-
offered by SST, the positivity effect does indeed sus younger brains. At the same time, age differ-
appear sensitive to the experimental context under ences observed in cortical activity suggest that
which it is measured. These ndings also help to older and younger adults differentially engage
explain why the controversy over the existence of emotion-regulatory processes while processing
the positivity effect emerged: Concern about the negative stimuli. When viewing negative faces,
reliability of the effect had been based on studies older adults recruit medial prefrontal regions to a
greater extent than younger adults, indicating that positive stimuli paired with delayed down-
they are actively and effortfully downregulating regulation of emotional responses to negative
negative affect to a greater extent than their youn- stimuli. This pattern of ndings is inconsistent
ger counterparts. Evidence also suggests that age with explanations for the positivity effect based
differences in prefrontal activation while viewing on age-related neural or cognitive degradation,
negative stimuli may underpin downstream age which predicts an immediate and automatic posi-
differences in memory. Relative to younger tivity effect in processing. However, it is consis-
adults, older adults appear to devote fewer sub- tent with the motivational view of SST, which
cortical resources to encoding negative stimuli emphasizes the deliberate allocation of cognitive
and more cortical resources to downregulating resources consistent with a delayed onset.
their affective responses, which yields worse
memory but better emotional outcomes. In addi-
tion to attention and memory, the age-by-valence Cultural Specificity
interaction in brain activation extends to higher-
level cognitive processes such as decision mak- The age-related positivity effect was initially con-
ing. For example, in nancial decision-making ceptualized as a broad developmental pattern
tasks, older adults show increased activation of related to the increasing value placed on emotion-
caudate and insula when anticipating monetary ally meaningful information in later life. Findings
losses but not gains. Thus, the positivity effect from cross-cultural studies suggest that, just as the
and its motivational precursors appear to be denition of emotional meaning varies between
deeply seated within the brain. Western and Eastern cultures, age differences in
preferential emotion processing may likewise dif-
fer across cultures. For instance, East Asian cul-
Temporal Signature tures are less likely to distinguish positive and
negative information relative to American culture.
The rapidly expanding literature on the positivity Consequently, some studies suggest that older
effect not only sheds light on the importance of Hong Kong Chinese do not show positivity in
context but also the temporal signature of the gaze patterns if anything, they appear to dem-
effect, with clear implications for underlying onstrate a stronger preference for negative faces
mechanisms. In general, evidence suggests that relative to younger Chinese (Fung et al. 2008). In
the positivity effect has a delayed onset consistent Western cultures that place great value on positive
with controlled cognitive processing. Close exam- experience, evidence for the positivity effect is
ination of visual gaze patterns using eye-tracking highly reliable. By contrast, the effect is
indicates that older adults preferentially attend mitigated and sometimes eliminated in cultures
toward happy faces only half a second after they that place comparable value on negative and
are presented and that gaze aversion from sad positive experience and stimuli. In a study
faces emerges only 3 s after onset. In fact, older conducted with a Korean sample, and based on
adults immediate visual attention (under 500 ms) memory for emotionally evocative images, a
shows a bias away from positive faces, suggesting positivity effect was observed only when
that positivity may emerge as a response to auto- stimuli were categorized as positive or negative
matic processing biases rather than constituting an based on the Korean participants own ratings.
automatic process itself. Neural evidence pro- Korean participants considered some of the
vides converging support for this view (for a images rated by Westerners as neutral, such as a
review, see Samanez-Larkin and Carstensen teacup, as positive. These ndings indicate that
(2011)). Specically, older adults medial prefron- further research is needed to fully elucidate the
tal brain activity in response to happy and fearful role of culture and emotional values in the posi-
faces shows an initial reduction in processing of tivity effect.
Implications for Social Gerontology reverse pattern. The positivity effect in impression
formation also extends to contexts where
The positivity effect appears to support goal- social partners are both tangible and aversive. A
directed behavior and parallels age-related prefer- For instance, when older adults are asked to col-
ences for everyday social behavior. In general, laborate with a disagreeable stranger on a
older adults appear particularly motivated to problem-solving task, they subsequently rate the
avoid negative social interactions, which presum- task as more enjoyable and the stranger as more
ably contributes to improved emotional experi- likeable relative to younger participants (Luong
ence in daily life (Charles 2010). Selective and Charles 2014). In combination, these ndings
exposure is arguably the most effective way to suggest that older adults devote more resources to
regulate emotional states, and there is consider- processing positive versus negative social infor-
able evidence that older people are more selective mation and may consequently form more favor-
than younger people in their choice of social part- able impressions than younger adults even when
ners and environments (for a review, see Charles their social partners and experiences are negative.
and Carstensen (2010)). Specically, older adults
prefer the company of meaningful social partners
such as close friends and family over novel part- Implications for Well-Being
ners such as recent acquaintances. Age differ-
ences in social partner preferences appear to Emerging evidence suggests that the relationship
reect the same top-down motivational priorities between the age-related positivity effect and
that underlie the age-related positivity effect and health is nuanced, complex, and elusive. As
are likewise susceptible to contextual factors. dened by SST, the positivity effect operates in
Consequently, older and younger adults express the service of goals related to emotional meaning.
comparable partner preferences when future time That is, if a person is seeking meaningful experi-
horizons are experimentally constrained or ence, they tend to see stimuli that are related to
expanded. meaning. A distinct but related issue concerns the
The positivity effect manifests not only in how consequences of attention to positive stimuli. That
older adults selectively seek versus avoid social is, when people attend to positive material, does
interactions but also in how they process and such attention improve mood? To date, this issue
appraise their social partners and experiences. remains unresolved. On the one hand, older
Consistent with theoretical predictions, the posi- adults, who typically display positive preferences,
tivity effect is evident in impression formation. report higher levels of emotional well-being than
For example, in a recent study, participants were younger adults, who typically display preferences
asked to evaluate the positive and negative traits for negative information (Charles and Carstensen
of strangers based solely on neutral facial photo- 2010). Findings based on laboratory studies that
graphs (Zebrowitz et al. 2013). Older adults rated present positive and negative stimuli and subse-
the targets as healthier, more trustworthy, and less quently measure mood are equivocal (Isaacowitz
hostile than their younger counterparts. Comple- and Blanchard-Fields 2012). Whereas some stud-
mentary ndings were observed in a neuroimag- ies do observe improvement in mood, others do
ing study in which individuals formed not. It is possible that stimuli in laboratory studies,
impressions of strangers based on photos paired such as synthetic faces, are insufciently positive
with valenced behavioral attributes (Cassidy or emotionally evocative to elicit changes in
et al. 2013). Older adults selectively recruited mood. It is also possible that the effect does not
brain regions such as the medial prefrontal cortex directly benet mood.
and amygdala to a greater extent when evaluating It is clear that the positivity effect is most
positive versus negative attributes about pronounced in older people who have relatively
strangers, whereas younger adults showed the good cognitive functioning and is weak in those in
poorer cognitive health. Alzheimers disease message frames in alternative domains will be
patients, for example, do not show systematic valuable.
preferences for positive over negative information
(for a review, see Reed and Carstensen (2012)).
Again, the balance of evidence indicates that the Open Questions and Future Directions
positivity effect is a reection of the goal-directed
behavior. Although the literature on the age-related positiv-
Kalokerinos and colleagues (2014) recently ity effect has grown rapidly, its relatively nascent
proposed that the positivity effect may benet status leaves many questions unanswered. For
older adults health by strengthening immune sys- instance, SST maintains that the positivity effect
tem functioning. In one study, older adults posi- represents downstream consequences of
tivity in recall of emotional images predicted age-related shifts in time horizons and the increas-
better immune function (as indexed by t-cell ing valuation of emotional meaning, yet the dis-
counts and activation) at a 1-year follow-up. crete contributions of these factors remain unclear
Though these ndings point to a possible tangible (Reed and Carstensen 2012). Questions about the
benet of positivity for health, they should be role of time horizons in the positivity effect have
interpreted with some caution. Specically, it is not been fully addressed, although some evidence
likely that cognitive control resources, which suggests that younger adults favor positive infor-
were not assessed in this study, predict both the mation when endings are made salient (Ersner-
positivity effect and good health in later life. Fur- Hersheld et al. 2009).
ther research is therefore needed to elucidate the In a similar vein, many if not most empirical
unique contributions of the positivity effect to tests of the positivity effect use stimuli that are
health, above and beyond cognitive status. neither personally meaningful nor affectively
Although the consequences of the positivity evocative. On the one hand, research-specic
effect for emotional, cognitive, and physical materials such as cartoon faces and IAPS images
health have yet to be elaborated, ndings do sug- create a level playing eld for testing attention
gest that the positivity effect can effectively be and memory by ensuring that age groups are
leveraged to improve health-related behavior in equally unfamiliar with the stimuli. On the other
later life. In particular, positively framed health hand, they lack face validity. Research that better
messages may be especially effective in motivat- simulates the emotional worlds people navigate in
ing older adults to engage in healthy behaviors. their daily lives is needed, as well as paradigms
Older adults demonstrate better memory for pos- that measure affective information processing
itive health messages (e.g., emphasizing the ben- outside of the laboratory.
ets of regular cholesterol tests) versus negative Finally, little is known about the potential pit-
messages (e.g., emphasizing the risks of failing to falls of the positivity effect. Two domains are
check cholesterol), and they may be more respon- particularly relevant in this regard. First, older
sive to such messages as well (Shamaskin adults preference for positive and inattention to
et al. 2010). In two recent quasi-experimental negative information may leave them especially
studies, older adults walked signicantly more vulnerable in situations that demand attention to
when exposed to messages that emphasized the negative information, such as potential scams.
benets of walking compared to those who were Some advocates worry that a disproportionate on
exposed to messages warning of the dangers of focus on gains that are too good to be true may
inactivity (Notthoff and Carstensen 2014). By place older people at risk. Such concerns are
contrast, younger adults did not walk more or compounded by the fact that scam artists dispro-
less as a function of messaging. These applica- portionately target older people. A second mal-
tions of the positivity effect to health behavior adaptive consequence of the positivity effect is
change, though scant, represent fertile ground for that it may be detrimental to everyday decision
future research. Future research testing positive making. Beyond nancial scams, there is no
shortage of domains in which negative informa- References

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158 Age-Related Slowing in Response Times, Causes and Consequences
Notthoff, N., & Carstensen, L. L. (2014). Positive messag- Response times of an individual can be character-
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Peters, E., Dieckmann, N. F., & Weller, J. (2011). Age dency (mean or median) is what researchers focus
differences in complex decision making. In on, but the dispersion (variance or standard devi-
K. W. Schaie & S. L. Willis (Eds.), Handbook of the ation) and skew can be of interest as well. In an
psychology of aging (7th ed., pp. 133151). San Diego: aging context, most of the work has focused on
Academic.
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the age-related positivity effect. Frontiers in Psychol- labeled age-related slowing, and what these
ogy, 3, 339339. changes can teach us about aging in different sub-
Reed, A. E., Chan, L., & Mikels, J. A. (2014). Meta- systems of the cognitive substrate.
analysis of the age-related positivity effect: Age differ-
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mation. Psychology and Aging, 29(1), 115.
Samanez-Larkin, G. R., & Carstensen, L. L. (2011). Age-Related Slowing in Basic
Socioemotional functioning and the aging brain. In Response-Time Tasks
J. Decety & J. T. Cacioppo (Eds.), The oxford hand-
book of social neuroscience (pp. 507521). New York:
Oxford University Press. It is no surprise that, generally speaking, older
Shamaskin, A. M., Mikels, J. A., & Reed, A. E. (2010). adults take longer than younger adults to process
Getting the message across: Age differences in the information. The increase in response time
positive and negative framing of health care messages.
Psychology and Aging, 25(3), 746751. (RT) with age is monotonic and quite large. In a
Zebrowitz, L. A., Franklin, R. G., Hillman, S., & Boc, large meta-analysis on studies using continuous
H. (2013). Older and younger adults rst impressions age samples, Verhaeghen and Salthouse (1997)
from faces: Similar in agreement but different in posi- reported an age-speed correlation of 0.52;
tivity. Psychology and Aging, 28(1), 202212.
Welford (1977) estimated that each additional
year of adult age increases two-choice reaction
time by 1.5 ms. The increase accelerates notably
with advancing age (Verhaeghen and Salthouse
Age-Related Slowing in Response 1997; Cerella and Hale 1994). Cerella and Hale
Times, Causes and Consequences (1994) estimated that the average 70-year-old
functions at the speed of the average 8-year-
Paul Verhaeghen old a large effect.
Georgia Institute of Technology, Atlanta, GA, One question that was widely debated in the
USA eld in the 1980s and 1990s was the question
whether or not age-related slowing was monistic
or unitary, that is, whether or not it all goes
Synonyms together when it goes (Rabbitt 1993). The
so-called general slowing hypothesis states that a
Latency; Response single dimension sufces to explain age-related
slowing. The main technique to investigate the
dimensionality of age-related slowing is the
Definition Brinley plot (Brinley 1965): a scatter plot with
mean performance of younger adults on the
Response time refers to the time between an input X-axis and mean performance of older adults on
and an output. In cognitive psychology, this is the Y-axis. Many varieties of Brinley plots exist:
typically the time needed for some task, from the One can plot mean latencies or mean accuracies of
moment the stimulus is presented to the moment a a number of studies, or mean latencies of a num-
response is emitted, measured most often by the ber of tasks or conditions with the same group of
time elapsed between the appearance of the rele- participants. Early research using Brinley plots as
vant stimulus and an appropriate key press. a meta-analytic technique (i.e., gathering results
Age-Related Slowing in Response Times, Causes and Consequences 159
from multiple studies in a single plot) typically (i.e., enumerating 1, 2, or 3 elements), counting
demonstrated not only that older adults are slower (i.e., enumerating 4 or more elements), mental
or less accurate than young adults but that data rotation, feature visual search, conjunction visual A
from multiple studies and conditions could be search, simple reaction time, choice reaction
well described by a single straight line (with a time, P300 (an ERP component in EEG that
small negative intercept), and hence a single linear reects the engagement of attention), and lexical
equation. For instance, the rst published Brinley decision times. The table includes the estimated
analysis was a meta-analysis on 99 data points average response times for younger and older
from 18 studies; the resulting equation was adults for each of these tasks, the number of
RT(old) = 1.36 RT(young) 70 ms; R2 = 0.95 studies used for each estimate, and two measures
(Cerella et al. 1980). This result implies that of age-related slowing: the old-over-young ratio
within broad classes of tasks, performance of a of response times and the slope of the Brinley
group of older subjects can be extremely well function.
predicted simply from knowing the performance Inspection of both the Brinley plot and the data
of a group of young subjects and the linear equa- in the table suggest that there is more than a single
tion from the Brinley plot; information about the dimension at play. It should be noted that, despite
actual tasks is not needed. This in turn strongly the clear fan in the Brinley plot, a single dimen-
suggests that processing differences between sion does t the data impressively, with 96% of
young and older adults are quantitative rather the variance in older adults RT accounted for in a
than qualitative in nature, and that the nature of multilevel regression model. A 15-dimensional
processing (i.e., the type of processes involved model, with a separate regression line for each
and their sequencing) is well preserved through- task, adds only 0.5% to the explained variance;
out adulthood. According to these studies, what this amount, however, was highly signicant. The
happens over the course of aging, in other words, data from this large meta-analytic set thus show
is mainly a general decline in processing ef- that although the general slowing model is a pow-
ciency. The extreme regularity of the Ceralla erful approximation of the data, it is also blatantly
et al. and subsequent data sets thus gave rise to imperfect. Many lower-dimensionality cut-ups of
the notion that all computational processes in the data are possible (see Verhaeghen 2014), but a
older adults are slowed to the same degree, as few regularities can be derived from this and other
indexed by the slope of the Brinley function data sets:
(a slope of 1.36 indicates 36% slowing for older
adults of the indicated age). 1. Spatial tasks yield larger age-related effects
A stronger answer to the question of general than linguistic tasks and, more generally,
slowing, however, demands an approach where tasks involving manipulations of lexical items
age-related effects are rst estimated within spe- (such as memory search).
cic elementary cognitive tasks; in a second step, 2. Within spatial tasks, lower-level or early
the slowing factors of these different tasks are tasks, likely involving occipital brain struc-
compared and tested for statistical differences. tures (such as icker fusion threshold and fea-
One such attempt was made by Verhaeghen ture visual search), generally yield smaller
(2014) in a large-scale meta-analysis; the Brinley age-related effects than more integrative,
plot is provided in Fig. 1. Table 1 provides data for later spatial tasks, likely driven more by
both younger and older adults for each of 15 ele- parietal brain structures (such as subitizing,
mentary tasks/processes, derived from a total of conjunction visual search, and mental
1,014 data points from 307 studies; the tasks or rotation).
processes included were xation duration, 3. When no decision component is involved, sen-
icker fusion threshold, auditory gap detection sorimotor tasks yield small or no age-related
threshold, tapping speed, movement time effects; when a decision component is
towards a target, memory scanning, subitizing involved, a more moderate age-related slowing
Age-Related Slowing in Response Times, Causes and restricted to the 01,400 ms range. The dotted line repre-
Consequences, Fig. 1 Brinley plot of all data included sents the diagonal (Figure used with permission from
in Table 1, grouped by task (1,014 data points); data Verhaeghen (2014))
Age-Related Slowing in Response Times, Causes and large-scale meta-analysis (Verhaeghen 2014), as well as
Consequences, Table 1 Mean response times for young/older ratios and the Brinley slopes derived from
15 tasks for younger and older adults, as derived from a these data
Mean RT (younger) Mean RT (older) k Young/older ratio Brinley slope
Fixation duration 242 ms 280 ms 27 1.16 0.96
Flicker fusion cycle time 29 ms 36 ms 22 1.24 1.25
Gap detection threshold 4.4 ms 8.1 ms 10 1.84 1.33
Tapping speed 105 ms 121 ms 20 1.15 1.16
Movement time 124 ms 179 ms 9 1.44 1.63
Memory scanning 60 ms 72 ms 9 1.20 1.33
Subitizing 40 ms 61 ms 8 1.53 1.11
Counting 330 ms 335 ms 8 1.02 1.03
Mental rotation 4.8 ms 8.6 ms 8 1.79 1.86
Feature visual search 4 ms 6 ms 39 1.50 1.76
Conjunction visual search 28 ms 55 ms 30 1.96 1.80
Single reaction time 246 ms 310 ms 26 1.26 1.40
Two-choice reaction time 283 ms 351 ms 20 1.24 1.60
P300 400 ms 452 ms 38 1.13 0.95
Lexical decision 679 ms 863 ms 33 1.27 1.36
Note. k = number of studies
factor is observed (icker fusion threshold and tasks involving resistance to interference show no
tapping rate vs. movement time, single RT, and age-sensitivity in the control process, neither do
choice RT). tasks measuring task shifting. In contrast, the abil- A
ity to coordinative different tasks (as expressed in
dual-task costs and in the costs of having to prepare
Age-Related Slowing in Tasks for multitasking) does show specic age decits.
of Executive Control At a broad level of generalization, one could con-
clude that tasks of selective attention are mostly
Debate is still ongoing about whether tasks with spared and that reliable age differences emerge in
an added executive control requirement yield tasks that involve divided attention and/or the
larger age-related differences than basic cognitive maintenance of two distinct mental task sets.
tasks such as the ones described in the previous
section (e.g., Braver and West 2008). Executive
control can be loosely dened as the set of Life-Span Trajectory of Age-Related
general-purpose mechanisms that modulate the Changes in Response Times
operation of various cognitive subprocesses and
regulate the dynamics of cognition (Miyake Figure 2 shows meta-analytic data (Verhaeghen
et al. 2000). Factor-analytic work (e.g., Miyake 2014) pertaining to the life-span trajectory of
et al. 2000; Oberauer et al. 2000) suggests that the response times; 1,292 data points from 50 studies
concept of executive control can be split into at that compared younger adults with either children
least four interrelated but distinct aspects: or middle-aged or older adults. The tasks are
(a) resistance to interference (also known as inhi- diverse simple RT, two-choice RT, go/no-go
bition as, for instance, measured by Stroop tasks), RT, a cancelation task, a clock test, abstract
(b) coordinative ability (as, for instance, measured matching, digit symbol substitution, different cat-
in dual-task situations), (c) task shifting egory membership classication tasks, lexical
(measured in task-switching paradigms), and decision, memory search, visual search, mental
(d) memory updating (as measured, for instance, rotation, stroop, task switching, and trail making.
in N-Back tasks). The data are represented in 3D space. The X-axis
Too few studies exist to warrant a meta- represents age. The Y-axis represents response
analysis on updating, but the former types all time at the given age divided by the response
have been analyzed using Brinley plots time of the group of younger adults for that par-
(Verhaeghen 2014). Two conclusions emerged. ticular task in that particular study (data for youn-
First, at the level of absolute age ger adults are data at age 25, real or interpolated
differences the level older adults deal with in from the data); this metric expresses age-related
their daily lives there are indeed near-universal differences in response time as a ratio of speed at
decits: Absolute age differences are typically age 25. (Thus, a score of 1.25 means that this
larger for task versions requiring executive con- particular group of subjects, in this particular
trol (e.g., reading the font color of incompatible task in this particular study, are 1.25 times, or
color words in the Stroop task) than for versions 25%, slower than 25-year-olds in this particular
with minimal control demands (e.g., determining task in this particular study.) The Z-axis represent
the color of color patches). This stands in stark the response time of 25-year-olds for the particu-
contrast to the second level, the level of the under- lar task within the particular study; this time can
lying dimensionality as revealed by Brinley plots: be taken as an index of task difculty or task
Most executive-control tasks do not show decits complexity (i.e., harder or more complex tasks
over and beyond those already present in their typically take longer to perform).
low-control or no-control baseline version. Per- Three ndings stand out. First, the decline in
haps most surprisingly given the attention this speed over the adult life-span is positively accel-
explanation has received in the literature, most erated: The trajectories curve upwards, so that
Age-Related Slowing in
Response Times, Causes
and Consequences,
Fig. 2 3D representation
of life-span response time
data. The X-axis is age; the
Y-axis represents slowing
ratios relative to speed at
age 25 within each task
within each study; the
Z-axis is the reference time,
that is, response time for the
task at age 25. The two
panels show the same data
from a different vantage
point (Figure used with
permission from
Verhaeghen (2014))
decline becomes progressively larger with same point in historical time. This confounds
advancing age. Second, the minimum of the aging with generational and historical differences.
function the apex of processing speed is situ- To have a more precise estimate of changes
ated in early adulthood, at around age 23. Third, related to aging proper, we would also need to
age-related slowing, expressed as an old/young look at longitudinal studies, where a group of
ratio, increases with task difculty, as can be participants is followed over a period of time,
seen in the increasing 3D curvature as age often decades. In longitudinal studies, changes in
increases. scores are due to the aging process itself, as well
The trajectory plotted in Fig. 2 is cross- as to historical change; generation is kept con-
sectional, that is, it depicts age-related differences stant. In eight studies that contained both cross-
between groups of individuals as measured at the sectional and longitudinal data, the average
ratio of cross-sectional over longitudinal slopes is inuences: growth in brain connectivity in the
1.09, suggesting that cross-sectional age early part of the life-span (functional brain con-
differences generally overestimate longitudinal nectivity increases up until age 30; Dosenbach A
age differences by about 10% (Verhaeghen et al. 2010) and loss of connectivity in the second
2014). This, in turn, suggests that some of the part of the life-span (both, directly through
age-related differences in cross-sectional studies decreases in cerebral white matter volume,
are due to generational differences: People born starting at age 40 (Walhovd et al. 2011), and
later in historical time tend to have faster response indirectly through changes in the dopamine sys-
times. tem). Both mechanisms operate in concert to
determine the systems processing speed, with a
buildup of (functional and anatomical) connectiv-
Causes of Age-Related Slowing ity dominating childhood and adolescence, until
the steady decline in the efciency of the dopa-
Proposed causes of age-related slowing range mine system and, later, white matter volume
from the purely psychological to the biological. causes the system to slow down even as
Psychological explanations include increased (functional and anatomical) connectivity is still
caution (i.e., older adults would place higher pri- increasing.
ority on accuracy than on speed; e.g., Ratcliff Some researchers (e.g., Anstey 2008) have
2008) and disuse (i.e., compared to younger gone even deeper and argue that the best predic-
adults, older adults lack recent and/or relevant tors of response times (especially of the simpler
practice; e.g., Baron and Cerella 1993). The for- variety) are low-level measures of basic physio-
mer explanation carries some weight: In a meta- logical health, such as forced expiratory volume,
analysis on 42 studies where data could be grip strength, and vision; under this model,
modeled using the diffusion model, older adults age-related slowing can be conceived as a general
were indeed found to be more cautious, even indicator of the overall intactness of the biological
though they were still slower in their processing substrate.
even when caution was taken into account
(Verhaeghen 2014). The disuse explanation
seems less plausible. That is, this explanation Consequences of Age-Related Slowing
would by necessity imply that older adults should
show larger practice effects than younger adults Age-related differences in processing speed are
when performing speeded tasks repeatedly over likely to have consequences for more complex
an extended period of time. This is, however, not aspects of cognition. In younger adults, speed of
the case: In a meta-analysis of 31 repeated- processing is at least moderately correlated with
practice studies, younger and older adults showed uid intelligence. In one meta-analysis on the
identical learning rates as measured by the expo- subject (which included both age-homogenous
nent in the power law of practice (Verhaeghen and age-heterogeneous samples), Sheppard and
2014). Vernon (2008) estimate the average correlation
On the biological side, age-related slowing has between inspection time (the minimum presenta-
been associated with a loss of brain connectivity tion time needed before a given stimulus becomes
(e.g., Penke et al. 2010); with changes in neuro- identiable, a very basic measure of processing
transmitter systems, notably dopamine (e.g., speed) and uid intelligence at 0.36 and the aver-
Bckman et al. 2000); with changes in brain glu- age correlation between single reaction time and
cose metabolic rate or intracellular pH levels (e.g., uid intelligence at 0.26.
Hoyer 2002); and with the degree of neural Speed of processing indeed turns out to be a
myelinization (e.g., Anderson and Reid 2005). powerful mediator of age-related changes in cog-
The life-span trajectory, with its minimum around nition: Individual differences in speed are associ-
age 23, likely represents the convergence of two ated with 6293% (on average: 78%) of the
age-related variance in more complex aspects of accelerated pattern within the older-adult portion
cognition (viz., episodic memory, spatial ability, of the life-span. Inconsistency is also longitudi-
and reasoning; (Verhaeghen 2014)). The available nally predictive of cognitive outcomes. For
longitudinal evidence (reviewed in Verhaeghen instance, in one large-scale study (the UK Heath
2014) conrms the interdependence of different and Lifestyle Survey (HALS); Shipley
aspects of the cognition over the adult life-span: et al. 2006), higher variability in response times
Individual differences in response time at the signicantly predicted all-cause mortality over the
onset of longitudinal studies are correlated with course of 19 years; inconsistency has also been
changes in higher-order cognition, and vice versa shown to uniquely predict terminal decline (i.e.,
(cross-correlations explain on average 55% of the cognitive decline close to the end of life; Mac-
relevant variance); and within-individual changes Donald et al. 2008).
in speed over the course of a study are correlated
with within-individual changes in higher-order
cognition over the same time course (explaining
on average 16% of the within-subject age-related Can Age-Related Slowing Be
variance). Moreover, in lead-lag analyses, speed Remediated or Reversed?
appears to drive changes in higher-order cogni-
tion, but higher-order cognition has no leading There are at least two ways to improve response
role for changes in speed. time, even in old age. First, performance can be
These ndings all converge on the conclusion improved with repeated exposure to the task.
that age-related changes in speed (and/or other There are, however, two clear limitations to be
basic aspects of processing associated with it) noted here. The rst is that, as stated above, learn-
drive age-related changes in more complex ing rates of older adults are identical to those of
aspects of cognition. This does not, however, nec- younger adults. This suggests that the effect of
essarily imply that speed is causal; it may simply practice is not one of remediation or reversal of
be a biomarker or proxy par excellence. That is, age-related slowing, but simply one of increased
speed might be the most sensitive (in the case of efciency of the processes involved in the partic-
individual differences) or earliest (in the case of ular task and/or the assemblage of these processes
age-related differences) indicator that a more gen- in the service of the task. The second limitation is
eral, low-level underlying suboptimality is creep- that there is no indication whatsoever that the
ing into in the substrate. Speed then acts as the effects of repeated practice generalize beyond
canary, so to speak, in the coal mine of the aging the task at hand: Only four studies have examined
mind. High cognitive speed is then an indicator of transfer effects (i.e., effects of training on
a well-functioning substrate at the peak of its response time that generalize to other cognitive
integrity; decreases in speed are indicative of tasks), but the end result is a zero effect
insults to the system. (Verhaeghen 2014). Second, performance can be
One type of data that suggest that this may be improved with aerobic tness training (Hillman
the case comes from the study of intraindividual et al. 2008). The effects of tness training appear
differences in response times, that is, a persons to be rather large and are already visible after
inconsistency in speed of processing, often con- relatively short training regimens (3 months or
sidered to be an indicator of noise in the even shorter); they also spread throughout the
information-processing system (for an overview, cognitive system, and thus hold better promise
see MacDonald and Stawski 2015). Inconsis- for more general cognitive rehabilitation.
tency, even after controlling for mean perfor- Note that such effects appear to be restricted to
mance, follows the same U-shaped trajectory aerobic tness training strength or exibility
over the life-span as mean RT and shows an training does not yield the same benets.
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166 Aging and Attention
the stove) and accidents (e.g., driving accidents

Aging and Attention while talking on a cell phone) and in disorders
such as ADHD and visual neglect. Furthermore,
Eric Ruthruff1 and Mei-Ching Lien2 attention is a necessary precursor for many other
1
Department of Psychology, University of New cognitive functions to work properly. For
Mexico, Albuquerque, NM, USA instance, the most important aspect of working
2
School of Psychological Science, Oregon State memory best predicting performance in reading,
University, Corvallis, OR, USA reasoning, as well as academic and occupational
pursuits is not storage capacity per se but rather
how well one controls the contents of that store
Synonyms (i.e., attention). Likewise, attention is also critical
for encoding information, so poor attention could
Attention; Cognitive control; Executive control; ultimately lead to poor long-term memory as well.
Multitasking; Spatial attention; Task switching The central questions motivating research on
aging and attention are as follows. Do attentional
abilities decline with normal aging (absent any
Definition pathologies)? Is the decline uniform across varie-
ties of attention, or is there a mixture of preserva-
In everyday life, people often refer to attention as tion and decline? Can a unied theory explain all,
if it were a single, unitary thing, such as a vat of or most, of these attentional problems that occur
energy that can be spread across stimuli or tasks. with old age?
Research suggests otherwise (Nobre and Kastner The rst possibility to consider is that there are
2014). There appear to be many different limited no specic age-related declines in attentional
mental resources associated with different brain functioning, per se, just a general age-related
networks and pertaining to different levels of slowing of all cognitive processes, or at least all
processing (e.g., spatial vs. central) that can be non-peripheral processes (Cerella 1985;
utilized in multiple ways (e.g., activation, inhibi- Salthouse 1996). Regardless of the precise cause
tion, control). For example, one can apply extra of this generalized cognitive slowing slower
mental effort to an important task, as in the synaptic transmission, increased information
oft-heard command pay attention, as opposed loss, longer cycle time per calculation, greater
to performing it automatically. Attention can also neural noise, etc. the end result is that every
refer to selective processing of one thing over task that measures attention by how fast people
another (selective attention), which could be a can respond should show at least some age-related
spatial location, object, feature, thought, or entire slowing. The exact amount of slowing depends on
task. Attention can also be spread among tasks the age ranges of the older adult sample and other
(divided attention), often degrading performance factors (e.g., whether the task is lexical or
on one or all of them. Relatedly, one can shift nonlexical), but the typical response time
attention from one task to another. What all of (RT) increase is about 50%. Performance in an
these varieties have in common is control over attention-demanding condition should be even
how limited mental resources are utilized in the worse than this before researchers argue for a
service of thought and action. specic attentional decit. To rule out general-
slowing explanations, researchers often transform
the data (proportional, log, or z-score) or replot
Introduction the data as Brinley plots or state traces (Faust
et al. 1999; Verhaeghen 2000). Below, references
Attention is critical for everyday performance. Yet to an age effect imply that the researchers found
it is usually taken for granted until it fails, as in age effects that persisted even after correcting for
everyday action slips (e.g., forgetting to turn off generalized cognitive slowing. None of the
Aging and Attention 167
research areas discussed below are entirely with- processes, perhaps to (successfully) compensate
out controversy, in part due to disagreement about for underlying decits in other processes (Madden
how to appropriately account for generalized et al. 2007). A
slowing. Another widely studied example of space-
based selection is the Eriksen anker task, in
which participants respond to a central target char-
Empirical Review acter while ignoring anking distractor characters.
Critically, these ankers can have the same or
This review summarizes research on the impact of different identity as the target. As an example, a
normal cognitive aging on three broad categories participant might see S H S and be asked to report
of attentional function that have been widely stud- whether the central character is an S or an
ied: selective attention, divided attention, and H. Although it is relatively easy to nd the target,
switching attention. Each has been investigated whose location is xed, people nevertheless usu-
using a variety of dependent measures (RT, accu- ally respond more slowly when the anker iden-
racy, neuroimaging) and tasks. However, a proto- tity is incompatible rather than compatible with
typical task will include at least one condition that the target. Here, again, selectivity appears to be
taxes the targeted aspect of attention, to be com- generally well-preserved with age (Salthouse
pared against a control condition that does not. 2010). An electrophysiological study corrobo-
Selective Attention. Selective attention is the rated that conclusion from behavioral data, show-
ability to focus on one thing while ignoring ing similar early visual components of the event-
other things, excluding to-be-ignored information related potential (P1 and N1) across age groups
from deeper processing and control over action. (Wild-Wall et al. 2008). If anything, older adults
Selectivity can be applied to many different showed enhanced target processing relative to
things, such as locations, features, objects, younger adults, perhaps by applying greater
sensory modalities, moments in time, or entire top-down control over spatial attention.
tasks. The selection is often a voluntary choice, The negative priming task also involves inter-
although it can also be involuntary, as when we ference between targets and distractors, except
orient to a blaring police siren that we were not that the key question is not how the distractor
expecting. inuences the current trial but rather how it inu-
Perhaps the most basic form of selectivity is ences the next trial. If the distractor is inhibited to
allocating attention to regions of space. A real- facilitate processing of the current target, then this
world example is watching a stoplight for a color inhibition might slow responses if that inhibited
change. A common approach to studying space- distractor becomes the next target. Researchers
based selective attention is the Posner cuing have examined both inhibition of distractor iden-
paradigm, in which participants use an advance tity and distractor location. For younger adults,
location cue, either peripheral or central, to nd both dimensions have revealed negative priming
the target. When a cue reliably predicts the targets effects. Several studies have reported that older
location, the question is how well people can adults showed smaller negative priming effects
utilize that cue. When a cue is unreliable/irrele- than younger adults, taken as a sign of reduced
vant yet particularly salient (e.g., ashing or mov- inhibition in older adults. However, a recent meta-
ing), the question is whether people can analysis (Verhaeghen 2015) reported that, overall,
successfully ignore it. Many studies have shown negative priming effects are quite similar for
preserved abilities with age in both cases using young (21 ms) and old (18 ms). Negative priming
location cues and resisting capture (Hartley 1993; studies typically show little overall age-related
Lien et al. 2011; Kramer et al. 1999). Interestingly, slowing in the baseline condition, so, from a gen-
whereas behavioral data usually show preserved eralized slowing perspective, one would also not
spatial selective attention, neuroimaging data sug- necessarily expect older adults negative priming
gest that older adults rely more on top-down effects to be much larger.
The Stroop task resembles the Eriksen anker absence of a feature tend to be very inefcient.
task, except that the competing information is This means that RT increases relatively steeply as
(in most variants) located within the same object. the number of items in the visual display increases
In the classic version, a person must indicate the (i.e., the search slope is steep). Many studies of
ink color of a word (typically by saying it out simple feature search have reported only modest
loud) that happens to spell out a potentially effects of age on visual search performance,
conicting color word. Here, selection must be roughly in line with what one would expect from
accomplished by choosing one object feature a general slowing of all cognitive processes.
(ink color) over another (color word name). Ink Researchers have, however, reported age effects
color-naming is slower when word meanings and with especially difcult visual searches with high
ink color mismatch (incongruent) than when they target-distractor similarity, conjunction searches,
match (congruent) or when the word is neutral and also on target-absent trials.
(e.g., a row of Xs). In younger adults, this Stroop Overall, the general trend in studies of selec-
effect is famously robust, suggesting that word tive attention is that age effects are small or non-
reading is an automatic process that cannot easily existent for many relatively easy tasks (e.g.,
be stopped, even when doing so would benet selection by location), but can become relatively
performance. A majority of studies have reported large when the task becomes sufciently difcult
increases in the Stroop effect with age (Hartley (e.g., classic Stroop and particularly challenging
1993). Although one meta-analysis with Brinley visual searches).
plots argued for a general-slowing interpretation Divided Attention. The selective attention
(Verhaeghen 2015), Stroop effects were, on aver- tasks discussed above might present multiple
age, almost twice as large in older adults (480 ms) objects per trial, but there is really only one task:
than younger adults (254 ms). Another study nd the target and report some attribute. In daily
failed to nd age effects in a few alternative life, however, we often attempt to do more than
Stroop-like tasks, such as with color words not one thing at a time, such as texting while walking.
in the response set (e.g., the word NAVY For younger adults, regulating multiple processes
printed in green) or color-associated words simultaneously often results in substantial dual-
(SKY or BLOOD), but did report age effects task costs, possibly because one must spread lim-
with the classic Stroop color word task that pro- ited mental resources across multiple tasks. In
duces the strongest interference (Li and Bosman fact, one popular account (the central bottleneck
1996). One popular interpretation of exaggerated model) asserts that we cannot perform any central
Stroop effects is that older adults have reduced operations those that fall in-between perception
executive attentional control (i.e., impaired inhi- and action, such as response selection on more
bition). The age effect might also reect, in part, than one task at a time (Maquestiaux et al. 2013).
that older adults read more automatically due to a Even highly practiced tasks such as driving and
lifetime of reading (a point discussed in more talking can interfere to a degree, resulting in
detail below). accidents.
In the anker and Stroop paradigms, there are Although dual-tasking is already difcult
typically just a few stimuli (e.g., one or three) and enough for younger adults, it apparently is even
the target location is known and xed. In visual more difcult for older adults. Dual-task costs
search tasks, however, people search for a have often been cited as being particularly sensi-
prespecied target in an unknown location tive to age effects (Verhaeghen 2015; Craik 1977),
among a variable number (possibly quite large) and many authors have argued for a specic def-
of distractors. In younger adults, if the target has a icit in multitasking. One review reported an aver-
simple visual feature not shared by any age dual-task cost of 215 ms for older adults but
distractors, then visual search is usually very ef- only 106 ms for younger adults (Verhaeghen
cient. Meanwhile search for conjunctions of fea- 2015). These age effects have been attributed to
tures (e.g., red and horizontal) and search for the mere slowing of component central processes,
reduced processing resources, or more cautious to explain in terms of mere generalized slowing,
task-coordination strategies by the elderly. so it appears to indicate a genuine age-related
The aforementioned dual-task studies typically decit in the acquisition of new task automaticity. A
present participants with two novel tasks and pro- Nevertheless, it is not simply the case that old
vide a minimal amount of practice during a single adults avoid all automaticity across the board. It
session lasting about an hour. In contrast, many has been argued, in fact, that they actually rely
real-world tasks of interest involve extensive even more heavily on previously automatized
practice, possibly over many years. This observa- routines, while avoiding novel tasks. Studies of
tion raises the question of whether younger and expertise have consistently shown that older
older adults can combat dual-task interference by adults maintain automaticity acquired earlier in
automatizing some or all of the component pro- life. Expert typists, for example, appear to main-
cesses. Automaticity of a mental process can tain their skill well into old age. They can some-
entail many different things, such as being fast, times even maintain their high typing rate,
obligatory, or uncontrollable. In a dual-task con- compensating for general cognitive slowing with
text, though, the main question is whether a men- greater chunking (Salthouse 1984). Language
tal process can operate capacity-free (i.e., not skills and vocabulary are also generally well-
requiring any limited mental resources). There preserved into old age. Some studies have even
are two distinct issues: can older adults acquire found that older adults can access the mental
new automaticity, and can they maintain previ- lexical more automatically than young adults
ously acquired new automaticity? (Lien et al. 2006). A possible exception to the
With regard to acquisition of new automaticity, general rule is that certain motor skills that are
the picture is somewhat bleak. Although older automatic in young and middle age (such as walk-
adults can improve performance on novel tasks ing or writing) are sometimes found to require
with practice (Fisk and Rogers 2000), they often more attention in old age to compensate for
do so more slowly than younger adults. More motoric decits.
importantly, they are in many cases less likely to In summary, older adults have extra difculty
eventually achieve capacity-free automaticity. performing multiple novel tasks at the same time,
Studies of visual search with consistent and this difculty cannot generally be overcome
stimulusresponse mappings, for example, have simply by providing more practice. Although
shown that practice reduces search slopes (the RT older adults typically maintain automaticity
increase per item to be searched) to nearly zero for acquired earlier in life, they have difculty acquir-
younger adults, consistent with parallel display ing new automaticity of novel tasks. This might
processing, but not for older adults (Rogers explain the anecdotal observation that younger
et al. 1994). adults frequently attempt multiple tasks at the
In dual-task practice studies with novel tasks, same time (texting while driving, walking, or
younger adults can under favorable conditions almost anything else), but older adults do not.
(simple tasks, distinct input modalities, distinct A lingering question is whether older adults are
output modalities, etc.) eventually learn to per- merely slow to acquire new automaticity (and
form the two tasks in parallel, bypassing the cen- eventually would if researchers were to invest in
tral bottleneck. It has been reported, however, that much more lengthy training regimens). Relatedly,
older adults typically continue to perform central do the ndings reect a decit in forming new
processes serially despite considerable practice associations (reduced plasticity), a decrease in
levels. One study reported that older adults failed processing resources, or increased cautiousness?
to achieve dual-task automaticity despite receiv- Interestingly, one study successfully induced
ing extra practice on even easier tasks, to the point more automatic memory retrieval in older adults
that they responded just as fast as younger adults by providing monetary rewards for fast responding
on each task in isolation (Maquestiaux (Hertzog and Touron 2011), though it is as yet
et al. 2013). This dual-task nding is very difcult unclear how widely this nding will apply.
Switching Attention. People have a remark- Summary. The ndings reviewed above reveal
able ability to control their minds and recongure age-related deterioration in some attentional func-
themselves to carry out any arbitrary new task tions that cannot easily be explained by mere
rather than reexively repeating the last task or generalized cognitive slowing. Yet age effects in
performing the task most strongly associated with attention tasks are far from universal. The stron-
the current environment. This control, however, gest evidence of age effects have been obtained
comes with a cost. It takes extra time and effort to when holding multiple tasks active (divided atten-
instantiate the new task set, and once instantiated, tion and global task switching), suppressing com-
performance of a new task tends to be slower than peting semantic representations (Stroop), and
performance of an old task. In the terminology when attempting to acquire new automaticity.
used in task-switching experiments, task-switch Meanwhile, the functions that are relatively well-
trials are slower than task-repetition trials. Criti- preserved with age tend to be those involving
cally, this is typically true even given ample time shifts of spatial attention (e.g., using spatial cues,
to prepare for a new task. This residual switch cost resisting capture, ltering out ankers), local task
might be due to carryover of the previous task set switching, and the retention of automaticity
or to an inability to completely recongure a new acquired earlier in life.
task set via mental preparation alone, without A common trend, however, is that even where
actually performing the task. age effects are generally spared, decits begin to
Given that dual-task costs are exaggerated with emerge when the component tasks become more
age, one might naturally expect that task- complex (9). A potentially related recurring nd-
switching costs would as well. Indeed, note that ing is that even when older adults show equivalent
dual-task studies almost always involve task behavioral performance, neuroimaging data often
switching as well. However, the picture is not show greater activation in older adults, especially
quite this simple. When calculating switch costs in prefrontal cortex. This nding inspired the
between task-repetition and task-switch trials CRUNCH (compensation-related utilization of
within a block sometimes called local switch neural circuits) hypothesis, which states that
costs many studies have found little or no effect older adults compensate for emerging cognitive
of age beyond generalized slowing (Verhaeghen decits by utilizing more top-down resources
2015; Lien et al. 2008), especially with pairs of (Reuter-Lorenz and Cappell 2008). This compen-
relatively simple tasks that do not overburden sation might be successful for relatively easy
working memory. Substantial age effects often tasks, allowing older adults performance to
do emerge, however, when comparing task- mimic that of younger adults, yet be insufcient
repetition trials within mixed blocks containing when overwhelmed by sufciently difcult tasks.
both tasks to task-repetition trials in pure blocks Overutilization of top-down control might also
of only one task, called global switch costs explain why older adults sometimes have great
(Verhaeghen 2015; Kray and Lindenberger difculty acquiring new automaticity, which
2000). The cause of this pattern is not yet clear. requires performance of a task with fewer
One speculation, however, is that although task resources rather than more.
repetitions within mixed blocks could theoreti-
cally be performed with minimal executive con-
trol, older adults apply extra top-down control Theories of Age-Related Attentional
anyway. This conservatism by older adults Deficits
would have two consequences: (a) slowing per-
formance in mixed blocks (hence exacerbating It is conceivable that the age-related changes in
global switch costs) and (b) undermining the attention noted above reect a large set of unique
usual benet of task repetition which (perhaps underlying decits. Alternatively, there might be
counterintuitively) reduces measured local switch just a very small set of global attentional decits,
costs (Lien et al. 2008). or perhaps just one, that causes all the attentional
problems observed in old age. Several such frontal lobes are a main target of dopaminergic
accounts have been proposed. pathways. Further research combining behavioral
One inuential account is the inhibitory decit and neuroscientic approaches is needed to A
view, which attributes a wide variety of achieve greater resolution regarding the primary
age-related cognitive declines to a decline in inhi- causes of declines in attention with age.
bition (Hasher and Zacks 1988). This view could
explain the oft-reported age effects in the Stroop
task. It could also conceivably explain difculties
Cross-References
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Age-Related Slowing in Response Times,
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Causes and Consequences
itory decit view has been highly inuential, and
Aging and Inhibition
it is plausible that older adults do sometimes show
Automaticity and Skill in Late Adulthood
reduced inhibition, several lines of evidence now
Cognitive and Brain Plasticity in Old Age
argue against a strong version of the account.
Cognitive Compensation
Several paradigms that would seem to be particu-
Cognitive Control and Self-Regulation
larly sensitive to inhibition such as inhibition of
Common Cause Theory in Aging
return and negative priming actually tend to
Executive Functions
show little or no age effect (Verhaeghen 2015).
Expertise and Ageing
Meanwhile, other paradigms (e.g., acquisition of
Working Memory in Older Age
new automaticity) do show age effects despite not
obviously relating to inhibition.
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McCann, R. S., & Remington, R. W. (2006). Visual Aging and Driving
word recognition without central attention: Evidence
for greater automaticity with advancing age. Psychol- David L. Strayer
ogy and Aging, 21, 431447. The University of Utah, Salt Lake City, UT, USA
Lien, M.-C., Gemperle, A., & Ruthruff, E. (2011). Aging
and involuntary attention capture: Electrophysiological
evidence for preserved attentional control with
advanced age. Psychology and Aging, 26, 188202. Synonyms
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differences in switching between cognitive tasks: Does
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Provenzale, J. M., Cabeza, R., White, L. E., & Huettel, Definition
S. A. (2007). Adult age differences in the
functional neuroanatomy of visual attention:
A combined fMRI and DTI study. Neurobiology of Motorists 65 and older show an increased risk of
Aging, 28, 459476. fatal crashes when turning across trafc.
Maquestiaux, F., Didierjean, A., Ruthruff, E., Chauvel, G., Age-related declines in dual-task processing play
& Hartley, A. A. (2013). Lost ability to automatize task
performance in old age. Psychonomic Bulletin &
an important part in this effect. Several solutions
Review, 20, 12061212. are suggested to mitigate the increased crash risk.
Nobre, K., & Kastner, S. (Eds.). (2014). The Oxford hand-
book of attention. Oxford: Oxford University Press. Operating an automobile is the single riskiest
Reuter-Lorenz, P. A., & Cappell, K. A. (2008).
activity that most readers of this entry engage in
Neurocognitive aging and the compensation hypothe-
sis. Current Directions in Psychological Science, 17, on a regular basis. For example, motor vehicle
177182. crashes are the leading cause of accidental injury
Rogers, W. A., Fisk, A. D., & Hertzog, C. (1994). Do deaths in the United States and are the leading
ability-performance relationships differentiate age and
cause of all deaths for people between the ages
practice effects in visual search? Journal of Experimen-
tal Psychology: Learning, Memory, and Cognition, 20, 133 and 5671 (NSC 2010). Driving is a com-
710738. plex skill that takes years to master. Support for
Salthouse, T. A. (1984). Effects of age and skill in typing. this assertion is provided in Fig. 1, in which are
Journal of Experimental Psychology: General, 113,
plotted fatal crash rates for different age drivers
345371.
Salthouse, T. A. (1996). The processing-speed theory of normalized by million miles driven (FARS 2015;
adult age differences in cognition. Psychological IIHS 2015). In the gure, fatal crash rates steadily
Review, 103, 403428. decline from novice/teen drivers until crash rates
Salthouse, T. A. (2010). Is anker-based inhibition related
asymptote around 30 years of age. Around age
to age? Identifying specic inuences of individual
differences on neurocognitive variables. Brain and 65, fatal crash rates begin to steadily increase
Cognition, 73, 5161. mirroring the fatal crash rates of the teen drivers.
Verhaeghen, P. (2000). The parallels in beautys brow: The U-shaped function depicted in Fig. 1 is
Time-accuracy functions and their implications for
multiply determined. On the one hand, younger
cognitive aging theories. In T. J. Perfect &
E. A. Maylor (Eds.), Models of cognitive aging drivers have less experience, take greater risks,
(pp. 5086). Oxford: Oxford University Press. and have a higher likelihood of being intoxicated
Aging and Driving 173
Aging and Driving, 9
Crash Rate per 100 Million Miles Traveled

Fig. 1 Fatal crash rates as a
function of the age of the 8 Fatal Crash Rate
driver. The miles traveled
7
A
for each age cohort were
used to normalize the data 6
85
16-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
Driver Age
Aging and Driving, 350

Fig. 2 Miles traveled as a
function of the age of the 300 Miles Driven
driver
100 Million Miles Traveled
250
200
150
100
50
0
20-24
16-19
55-59
45-49
70-74
25-29
30-34
35-39
75-79
80-84
40-44
50-54
60-64
65-69
85
Driver Age
from drugs and alcohol as compared to drivers in (as discussed below, older drivers are involved
the 3560-year age range. On the other hand, in more side-impact crashes (i.e., where their
drivers over 65 years of age tend to have more vehicle is hit broadside at an intersection). These
experience, take fewer risks, are less likely to at-fault crashes are often more severe (Farmer
drive at night, are more likely to use seat belts, et al. 1997), making it difcult to determine if
and they have the lowest proportion of intoxica- exposure to serious crashes is really equivalent
tion of all adults. Older drivers are also more across the age range.
likely to succumb to the health complications Interestingly, Fig. 2 shows that driving expo-
associated with a crash than are younger drivers sure, plotted in million miles driven, has an
(NHTSA 2009); however, the U-shaped function inverse relationship with fatal crash rates most
is still present, albeit muted, when considering noticeably, as fatal crash rates increase for older
both fatal and nonfatal police-reported crashes drivers, exposure decreases precipitously
Proportion of Fatal Crashes by Age and Intersection Type

50
MV Intersection
45 MV Non-intersection
SV Intersection
40
Crash Percentage (within Age)
SV Non-intersection
35
30
25
20
15
10
5
0
85
16-19
20-24
25-29
30-34
35-39
40-44
45-49
50-54
55-59
60-64
65-69
70-74
75-79
80-84
Driver Age
Aging and Driving, Fig. 3 The proportion of fatal drivers age; single-vehicle intersection crashes remain
crashes by the age of the driver and intersection type. MV constant, and both non-intersection fatal crashes decrease
multiple vehicle, SV single vehicle. Note that fatal multiple across the age range
intersection accidents increase systematically with the
(FARS 2015; IIHS 2015). This is likely a conse- crashes involving multiple vehicles. Multiple
quence of lifestyle changes (e.g., employment vehicle intersection crashes begin to increase
status) and self-regulation on the part of the from baseline levels as drivers enter their sixth
older driver (e.g., avoiding driving at night or in decade. The other categories are either at or
inclement weather). Indeed, Ross et al. (2009) decline across the lifespan. Intersections with traf-
used a longitudinal analysis and found that the c place high demands on the driver because they
most at-risk drivers limited their driving exposure, require dividing attention between trafc lights,
although this self-regulatory behavior did not ade- pedestrians, and other vehicles on the roadway.
quately compensate for the elevated crash risk. Non-intersections and intersections with a single
Moreover, as the population of older drivers vehicle apparently do not place the same demands
increases, a greater number of older motorists on attention. The patterns in Figs. 1, 2, and 3 are
are projected to be on the road. By the year important because they help to illuminate the sort
2030, one out of ve drivers on the roadway will of cognitive issues that underlie fatal crash rates in
be over the age of 65 in the United States (DOT older drivers.
HS 809 980). The situation is similar in other Older adults are at a particularly elevated risk
countries around the world. Driving therefore proof crashing when making left turns at intersec-
vides an excellent opportunity to examine aging in tions. For example, using Fatality Analysis
this important real-world context, particularly in Reporting System (FARS) data and adjusting for
light of the disproportionate increase in at-fault exposure, Sifrit et al. (2011) found that the risk of
crashes for older adults. at-fault crashes increased strikingly when older
Figure 3 presents another intriguing piece to drivers were turning left at intersections both
the aging and driving puzzle (FARS 2015; IIHS with stop signs or stop lights. These authors
2015). When examining different sections of the reported a similar pattern using a nationally rep-
roadway where fatal crashes occur, only one type resentative sample of police-reported motor
systematically increases with age: Intersection vehicle crashes of all types, from minor to fatal.
Other researchers have found that older drivers categories (and these risk factors also tend to
at-fault crashes increased when making decrease with age).
gap-acceptance maneuvers while crossing trafc Slower perception-reaction time is without A
(Staplin and Lyles 1991). Side impacts associated doubt a contributing factor to the increased crash
with failing to yield the right of way are also more risk. In fact, slower reactions have been shown to
prevalent in older drivers (Evans 2004). Impor- increase both the likelihood and severity of
tantly, side impacts account for approximately crashes (Brown et al. 2001). However, processing
34% of crashes on the roadway and 30% of fatal- speed of an individual should covary with the four
ities (Farmer et al. 1997). These side impacts tend crash categories suggesting that it is not sufcient
to be more severe than front and rear impacts to explain the increased at-fault crashes. The com-
because the side crush space is limited. plexity of an intersection with multiple vehicles
Fisher (2015) recently examined the eye move- places an additional load on the cognitive system
ments of drivers at intersections and found that over and above the baseline differences in
they often make a primary glance to the left and processing speed.
right as they approached the intersection and then
make a secondary glance to the left and right just
before entering the intersection. Importantly, Aging, Vision, and the Useful Field
Fisher (2015) found that older adults were three of View
times less likely to take secondary glances to the
left and right as they entered an intersection. This A variety of physical and psychological factors are
decreased rate of making secondary glances is likely to contribute to multiple vehicle intersec-
critical for avoiding intersection crashes. How- tion crashes. One important factor is the overall
ever, with one hour of simulator training, the rate health of the visual system. Common problems
of secondary glances at intersections doubled for associated with senescence include presbyopia,
older adults thereby reducing crash rates by 50%. cataracts, glaucoma, and macular degeneration
The objective of this entry is to provide an (CDC 2015). Increased glare sensitivity and
account for the age-related differences in at-fault reduced light sensitivity are also more prevalent
crashes. As illustrated in Fig. 3, one category in older populations (Wood 2002). As the visual
stands out above all others as a culprit for the health declines, the quality of the information
increased crash risk of older drivers: Intersection transmitted to the visual cortex is degraded.
crashes involving multiple vehicles, particularly Older drivers are also often restricted with their
those where the driver is turning across trafc. In ability to turn their head and neck, which may
considering what distinguishes this category of limit scanning in the periphery for potential haz-
crashes from the others, it is worth considering ards. However, after controlling for these physio-
the factors that are in common (and hence are not a logical factors, drivers across the age range still
proximal cause in the increased crash risk) (It is differ in the amount of information that they can
often difcult to distinguish causal factors from extract at a glance (Remy et al. 2013).
factors that are simply associated with the ele- The useful eld of view (UFOV) refers to the
vated crash risk. While not causal factors (e.g., area in the visual eld in which a driver can extract
failure to use a seat belt did not cause the crash, useful information without head or eye move-
reduced health reserves of the driver, etc.), in ments (Ball and Owsley 1993). UFOV is most
many instances they heighten the consequences commonly assessed using a computerized pro-
of a crash and, thereby, are associated with fatal gram that has four subtests (Ball et al. 1993;
crashes.). The ability to control the vehicle, per se, Edwards et al. 2006). The rst subtest involves
would seem to be ruled out as a causal factor, as the identication of a centrally presented target
are many of the typical risk factors (e.g., speeding, (a silhouette of a car or truck). The second subtest
alcohol intoxication, seat belt compliance), since measures divided attention by requiring identi-
these should be common in each of the crash cation of both a centrally presented target and a
peripherally presented target at a xed eccentric- processing speed for drivers of all ages, but par-
ity in one of eight radial locations. The third ticularly so for older drivers.
subtest combines these two subtasks but adds
47 visual distractors (triangles) along the eight
radial locations. The fourth subtest adds to the Driving and Multitasking
demands of the third subtest, by presenting two
objects at the center location and requiring a Watson et al. (2011) combined the driving and
same-difference judgment in addition to the local- neuropsychological literatures by suggesting that
ization of the peripheral target. In the UFOV task, the U-shaped function depicting crash rates and
the display duration for each subtest is systemat- age was closely aligned with the rise and decline
ically adjusted so that it is performed accurately in prefrontal cortical (PFC) regions of the brain
on 75% of the trials (i.e., the duration of each (e.g., an inverted U-shaped function across the
subtest ranges from 16 to 500 ms). The UFOV lifespan that reaches apex around 30 years of
score is determined by the sum of the durations of age). The PFC regions are involved in a wide
the four individual subtests. variety of higher-level cognitive functions that
The UFOV tests the speed of both visual and support executive attention. In this context, exec-
higher-order attentional processing (e.g., focused utive attention would be involved in processing
attention, divided attention, visual search, ignor- task-relevant information associated with the safe
ing distractions, etc.). In an examination of over operation of a vehicle (e.g., lane position, speed
2700 adult drivers, the UFOV scores were found management, relation to other vehicles, status of
to be positively correlated with age (r = 0.437). trafc lights, acceptable gap for making a left-
UFOV scores was approximately 800 ms for hand turn, etc.) as well as juggling other task-
drivers less than 70 years of age and averaged irrelevant interactions (e.g., talking or texting on
1200 ms for drivers 85 or older a 50% increase a cell phone). In addition, the increased perceptual
in UFOV processing time (Edwards et al. 2006). load at intersections places an additional burden
In fact, each of the subtests of the UFOV corre- on the executive attention system. For example,
lated with age, with correlations of .209, .353, the effect of secondary-task load increases as the
.399, and .385, for subtests 14, respectively. extraneous perceptual load in the driving environ-
Importantly, UFOV scores are also negative asso- ment increases (e.g., Strayer et al. 2003). Consis-
ciated driving outcomes (for a meta-analysis Clay tent with this interpretation, multiple studies have
et al. 2005). found age-related declines in dual-task processing
The UFOV measures help to shed light on the (e.g., Craik 1977; Hartley 1992; Hartley and Little
increase in multiple vehicle crashes for older 1999; Kramer and Larish 1996; McDowd and
adults. In particular, the time required for older Shaw 2000).
adults to divided attention between spatial loca- When the complexity of driving increases, as is
tions (subtest 2) and ignore distractors (subtests the case with multiple vehicle intersection
3 and 4) systematically increases with increasing crashes, older adults exhibit greater difculties
age. The UFOV task shares many of the dividing attention between the different compo-
processing requirements that confront older nents of the driving task. This is illustrated in
drivers as they approach an intersection with Fig. 4 which compares the performance of
multiple vehicles. In such circumstances, younger-, middle-, and older-age adult drivers
drivers must divide attention between the other when they drove a new car on residential streets
vehicles, pedestrians, trafc lights, and other (i.e., the single-task baseline condition) with a
sources of visual distractions (e.g., signs, condition where they perform the same driving
stopped/parked cars, people waiting at the cross- task and also concurrently used voice commands
walk, etc.). Intersections with multiple vehicles to perform simple operations that were unrelated
represent the perfect storm in terms of the to the task of driving (Strayer et al. in press).
demands placed on visual attention and These in-vehicle information systems (IVIS)
Aging and Driving, Fig. 4 The DRT data plotted for the The right panel reects performance in the in-vehicle
younger adult-aged (solid white pattern), middle-aged information system (IVIS) secondary-task portions of the
(striped pattern), and older-aged (solid black pattern) experiment. Error bars reect 95% condence intervals
adults. The left panel reects single-task performance around the point estimates
when participants are driving without any secondary task.
were cognitive in nature and did not require the processing speed associated with senescence
driver to take their eyes off the road or their hands (Salthouse 1996; but see Ratcliff and Strayer
off the wheel (e.g., using voice commands to 2014). Note that the single-task condition pro-
place an outgoing phone call or changing the vides the standardized baseline upon which to
radio station). evaluate the effects of IVIS secondary-task load.
The data presented in Fig. 4 were obtained Interestingly, the right-hand panel of Fig. 4 shows
using a new international standard for assessing that the costs of IVIS secondary-task interactions
the cognitive demands of driving an automobile increased with the age of the driver (as evidenced
(The DRT task: ISO DIS 17488, 2015). The DRT by an age X condition interaction). When older
task presents a visual probe every 35 s, and adults used these voice-based commands, the cost
drivers are required to press a button attached to of interacting with the IVIS was 55% more than
their nger when they detect the light (i.e., this is a the cost incurred by younger adults performing
simple RT task). The logic behind the DRT task is the same activities.
that RT is inversely related to the mental workload The data presented in Fig. 4 represents a
experienced by the driver. Prior research with superadditive interaction. That is, the RT increase
younger drivers has found that when additional for older adults is more than the simple addition of
cognitive load is added to the driving task either in a constant dual-task cost in RT (i.e., dual-task-
the form of increased demand in the driving task > single-task + constant). The RT cost is also
itself (e.g., with different trafc densities or dif- greater than a proportional increase in RT from
ferent roadway congurations) or by adding a younger adults to older adults (i.e., the dual-task/
concurrent secondary task that is unrelated to single-task ratio for younger adults times the
driving (e.g., talking or engaging in other voice- single-task data for older adults is less than that
based interactions in the vehicle), that RT is observed for older adults in dual-task condi-
increases relative to baseline levels (e.g., Strayer tions). In fact, the actual dual-task cost for older
et al. 2013; Cooper et al. 2014). adults was 40% greater than that predicted by a
The left-hand panel of Fig. 4 presents single- proportional increase. The costs of interacting
task performance in the DRT task. RT increased with the IVIS system were substantially greater
with age and this is likely due to differences in than that predicted by general slowing model.
These ndings are in line with the age- (McGwin and Owsley 2015), suggesting that the
complexity hypothesis (Cerella 1985; Cerella current practice for licensure of older adults is
et al. 1980) that posits that age-related differences currently not supported by the empirical literature.
are amplied as the complexity of the task Based on the literature reviewed above, a more
increases. The pattern of dual-task interference promising test for licensure may be the UFOV.
shown in Fig. 4 should serve as a caution for A recent study by Lambert et al. (2016) added
drivers of all ages who attempt to use these an interesting twist to the aging/driving story. In
in-vehicle systems as they place surprisingly the study, one group of drivers was given infor-
high demands on the driver. The data also suggest mation consistent with the stereotype that older
that older adults, who are the most likely to pur- drivers are impaired in driving performance (e.g.,
chase a new vehicle with voice-based technology the impairments reviewed in Figs. 1, 2, and 3).
(Sivak 2013), will experience a much greater cost The other group was given other driving-related
when required to divide their attention within their information without the stereotype threat. Older
vehicle. participants under stereotype threat exhibited
greater impairment to driving (e.g., slower brake
RT and a greater frequency of rear-end collisions)
Aging and Mobility than did the age-matched controls that did not
receive the stereotype threat. These ndings sug-
Mobility is important for maintaining indepen- gest caution in how the media and public policy
dence and is a critical factor in older adults ability communicate information about older adult driv-
to age in place, maintaining social connections, ing, as this information can impair the driving of
accessing healthcare, and performing daily tasks older motorists (i.e., reading the preceding pas-
(e.g., shopping, meals, work, etc.) (Colello 2007). sages may make older adults perform worse on the
Operating a motor vehicle is often a key compo- driving task).
nent of mobility, particularly in rural communities
where other modes of transportation are
unavailable (Bailey 2004). In fact, twenty percent Conclusions
of adults 65 or older do not drive at all, and half of
these nondrivers do not leave home on a regular At-fault crashes increase with senescence at inter-
basis (Farber et al. 2011). Bailey (2004) found that sections, particularly when the driver is making a
the reduced mobility of senior nondrivers resulted left turn. This pattern is consistent with the
in a 15% decline in trips to healthcare providers, hypothesis that age-related declines in dual-task
59% fewer trips for shopping and dining, and 65% processing play an important part in these fatal
fewer trips for social and religious functions. crash statistics. There are several things that can
The cessation of driving tends to isolate older be done to mitigate the crash risk. First, the crash
adults and has clear negative consequences for risk is lower when there are left-turn arrows to
independent living. At the same time, the control the ow of trafc (e.g., Sifrit et al. 2011).
increased crash rates, particularly multiple vehicle Adding left-turn signals at intersections would
crashes at intersections, is a signicant concern help both younger and older motorists to navigate
for trafc safety. According to the Highway Loss these hazardous sections of the roadway. Round-
Data Institute (2015), approximately 40% of the abouts have also been shown to reduce the sever-
states in the United States have restrictions on ity of intersection crashes. For example, crashes
relicensing of older drivers. Nineteen states cur- decline by 40% and serious injuries decline by
rently require more frequent visual screening of 80% when roundabouts have been installed
older drivers and several do not offer a renew-by- (IIHS 2015). Fisher (2015) also found that train-
mail option for older drivers. Surprisingly, neither ing older drivers to take second glances as they
tests for visual acuity nor tests of contrast sensi- enter an intersection reduced crash rates by 50%.
tivity are predictive of population-based crash risk This simple driver feedback offers a cost-effective
way to reduce fatal crashes for all ages. Moreover, publication http://www.aging.senate.gov/crs/aging15.
these changes were still present in a 2-year follow- pdf. Downloaded on September 24, 2015.
Cooper, J. M., Ingebretsen, H., & Strayer, D. L. (2014).
up of drivers who received training, indicating Measuring cognitive distraction in the automobile IIa: A
that the benets are long-lived. In a similar vein, Mental demands of voice-based vehicle interactions
Horswill et al. (2010) found that training using a with OEM systems. AAA Foundation for Trafc Safety
short video on hazard perception facilitated older https://www.aaafoundation.org
Craik, F. I. M. (1977). Age differences in human memory.
drivers subsequent identication of trafc haz- In J. Birren & K. W. Schaie (Eds.), Handbook of the
ards. Finally, a strategy that could be adopted by psychology of aging (pp. 384420). New York: Van
older drivers is the three rights make a left rule. Nostrand Reinhold.
Motorists can often use this rule (or the compara- DOT HS 809 980. Online publication http://www.nhtsa.gov/
people/injury/airbags/Countermeasures/pages/Chapt7/
ble rule in countries which drive on the left) to 7OlderDrivers.htm. Downloaded on May 29, 2015.
avoid making turns across trafc and to accom- Edwards, J. D., Ross, L. A., Wadley, V. G., Clay, O. J.,
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While taking longer to complete, the procedure useful eld of view test: Normative data for older
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Aging and Inhibition 181
downregulation or inhibition of excessive measure, as inhibitory theory would have

activation is the critical function that works predicted. Recent evidence suggests that success-
together with (3) goals to constrain thought pro- ful inhibition of irrelevant stimuli is associated A
cesses to only (or mostly) relevant information; with activation in a specic set of frontal and
and (4) there are substantial age and individual parietal brain regions that comprise the
differences in the ability to suppress nonrelevant frontoparietal control network (Campbell
stimuli along with minimal differences in auto- et al. 2012). Older adults show less activity in
matic activation. The empirical work on this topic cognitive control regions and less coherence
now covers a wide range of domains within cog- within the frontoparietal control network com-
nitive and social psychology, along with differ- pared to young adults when ignoring distraction
ences tied to mood (e.g., Biss et al. 2012) and to (Campbell et al. 2012).
circadian rhythms (e.g., Anderson et al. 2014). Noisy environments can signicantly impair
Here we review how a reduction in the ability to recognition memory in older adults. In one fMRI
ignore irrelevant information has wide-ranging study, forgetting of face stimuli was predicted by
effects on cognition in late adulthood. decreased activity in brain areas responsible for
successful encoding (e.g., hippocampus) as well
as elevated activity in the auditory cortex (Stevens
Neural Correlates of Inhibitory Deficit et al. 2008). Since the memory task in this study
was purely visual, the auditory cortical activity
Neuroimaging ndings have corroborated the presumably reected distraction from scanner
idea that older adults process more irrelevant noise. The auditory distraction only disrupted the
information than their younger counterparts. memory performance of older but not younger
Using recordings of event-related potentials, adults, consistent with the inhibitory theory
researchers have found that older adults show a assumption that young adults are efcient at l-
larger neural response to unattended auditory tering out irrelevant information.
stimuli played while they are reading a book com- These lines of work suggest that the increase in
pared to young adults, even after many repetitions processing of irrelevant information is at least
of the sounds (Fabiani et al. 2006). Young adults partially driven by a failure of top-down control
quickly suppress their neural response to the networks to exert control over the focus of atten-
repeated tones, showing efcient sensory gating tion, which in turn allows irrelevant items to be
of auditory distraction during reading. These neu- processed. Once irrelevant items are processed,
roimaging results suggest that the age-related def- they can interfere and compete with relevant
icit in ltering out irrelevant information occurs at items, resulting in a general performance reduc-
a low level of sensory processing. tion in older adults and others with inhibitory
Similar low-level processing of irrelevant decits (e.g., Nigg 2000).
visual information has been observed in older
adults using functional magnetic resonance imag-
ing (fMRI). In a study measuring cortical blood Inhibitory Control and Response Times
ow during a selective attention task, older and
younger adults were instructed to attend to face Perhaps the most replicated nding in all of cog-
stimuli and ignore place stimuli (Gazzaley nitive gerontology is the slowing of response
et al. 2005). Older adults showed more activation times with age. Many studies have shown that
in a place-selective brain region to the irrelevant older adults are slower to make speeded responses
stimuli than did young adults, suggesting that the than are young adults and there is evidence that
perceptual qualities of distracters are processed to age-related slowing is exacerbated by the pres-
a greater degree in older adults. In that study, only ence of distraction. Lustig et al. (2006) measured
the degree to which irrelevant stimuli were response time to make a simple similarity
suppressed was correlated with a memory judgment between two sets of letters
(e.g., RXL____RXL) in young and older adults, they read; older adults, who were more slowed by
and they manipulated visual distraction in this task distracting text during reading, also made more
by either presenting only one trial at a time (low intrusions from distractor words compared to
distraction condition) or presenting many stimuli at young adults (Mund et al. 2012), showing that
once (high distraction condition). Older adults older adults memories can be colored by irrele-
were faster to respond in the low distraction condi- vant past experiences.
tion compared to the high distraction condition, but Interference resulting from the encoding of
the manipulation had a smaller effect on young extraneous, never-relevant information not only
adults. Thus speed differences between young inuences recall but can also disrupt later learning.
and older adults may be exaggerated in tasks with Biss, Campbell and Hasher (2013a) asked partici-
a high degree of visual clutter. Furthermore, only pants to perform a picture judgment task in which
speed on the high distraction condition predicted distracting words were superimposed over the pic-
uid intelligence for older adults, consistent with tures; later, in an ostensibly different task, partici-
the suggestion that the regulation of attention in the pants were asked to learn pairs of pictures and
face of distraction is a major determinant of overall words, some of which were comprised of new
cognitive functioning. words and old pictures from the judgment task
A similar effect of distraction has been widely (high-interference condition) and some of which
reported in the literature on reading speed. The were completely new (low-interference condition).
presence of distracting text interspersed through- Older adults showed worse cued recall in the high-
out a written passage in a distinctive font has a interference condition compared to the
dramatic slowing effect on older adults oral read- low-interference condition. Young adults showed
ing times, but does not affect young adults to the no effect of the previously seen distraction. This
same degree (Connelly et al. 1991). The slowing result, consistent with the predictions of inhibitory
effect of distracting text is observed to be greater theory, suggests that older adults retain knowledge
in older adults even when visual acuity is matched of previously encoded distraction and this knowl-
between age groups (Mund et al. 2010). edge can create interference that impacts future
learning episodes. Retention of the recent past
(or failure to suppress it) is also a source of age
Inhibition and Explicit Memory differences in measures of working memory capac-
ity (May et al. 1999).
Another hallmark of cognitive aging is a decrease Conversely, the retention and transfer of irrele-
in explicit memory performance (e.g., Craik and vant information from one task to the next can
Jennings 1992). Attention to distraction can have confer a unique benet to older adults learning if
a profound effect on memory. There are at least the irrelevant items later become relevant (e.g.,
two inhibitory-based functions that have been Amer and Hasher 2014). Weeks and colleagues
identied. The rst is the role inhibition plays at (2016) showed that older adults cued recall of
retrieval when a new task follows an earlier one. face-name pairs can be improved to the level of
According to the theory, the ability to suppress the young adults if the names are previously presented
recent past as tasks and goals change is as distraction alongside the faces earlier in the exper-
compromised by poor inhibitory regulation. In a imental session. This transfer of distraction to a new
previous section, we reviewed the evidence that task appears to be implicit since it occurs without
older adults reading times are slowed by the participants reporting awareness of any connection
presence of distracting text in a different font, between tasks. Together, these studies suggest that
but there is also evidence that distracter text can separate tasks may begin to bleed into one another in
intrude into older adults memory for a written old age, making experiences less distinct and more
passage. Following the reading of a passage inter- interrelated as a result of broader encoding.
spersed with distracting text, young and older The second inhibitory-based role at retrieval
participants were prompted to recall the passage occurs when a retrieval cue activates two
Aging and Inhibition 183
competing memory traces; inhibition of the irrele- is evidence that older adults do not suppress
vant or incorrect trace is required in order for the thoughts as effectively as younger adults do. In
correct trace to be selected. Inhibition during com- the so-called think/no-think paradigm, partici- A
petition resolution was directly tested by Healey pants rst learned word pairs (e.g., BANNER
and colleagues (2013), who found that older adults FOOTBALL) and then, in a second phase, are
do not inhibit irrelevant items at retrieval like cued with one word from the pair (e.g., BANNER)
young adults do (Healey et al. 2013). In this para- to either think about or avoid thinking about the
digm, participants rst incidentally encoded a list second word (Anderson et al. 2011). The no-think
of words that contained pairs of orthographically instruction is similar to the real-world phenome-
similar words (e.g., ALLERGY and ANALOGY); non of suppressing retrieval of unpleasant or
later, they solved a series of word fragments, off-topic thoughts. Anderson and colleagues
some of which could be completed with only one (2011) measured suppression of the no-think
word from the encoded pair (e.g., A_L_ _GY, words by cuing the items with their category
solved by ALLERGY). In order for the word frag- (e.g., Sport F______) and comparing retrieval
ment to be correctly solved, competition between rates between no-think items and baseline (i.e.,
the two activated words would have to be resolved uncued) items. They found that younger but not
by suppressing the incorrect word (e.g., ANAL- older adults had suppressed the no-think items,
OGY). To test this prediction, Healey and col- resulting in more forgetting of the unwanted
leagues (2013) measured naming time of memories (Anderson et al. 2011).
competitor words and found that older adults Similarly, there is also evidence that older adults
showed priming for competitor (i.e., incorrect) fail to inhibit prejudices, even when they intend to
words, while young adults did not. The lack of do so. Older adults were more likely than young
priming for previously seen competitor words in adults to show implicit prejudice in their judgments
young adults suggests that they used inhibition to of an other-race person, even when they were explic-
resolve interference at retrieval. In contrast, older itly instructed not to use a persons background in
adults do not suppress competitors at retrieval and their judgments (von Hippel et al. 2000). Although
instead show facilitated access to these irrelevant older adults in this study also scored higher than
items. In other circumstances, by contrast, older young adults on scales of overt prejudice, the age
adults can totally fail to produce a response, despite difference in implicit use of stereotypes was medi-
a recent exposure to relevant items (Ikier and ated by inhibitory abilities, as measured by the read-
Hasher 2006). In this study, older adults who had ing with distraction task and not by their overt
seen two words (BELLS and BILLS that could com- prejudice scores (von Hippel et al. 2000).
plete a fragment (B_L_S) often gave neither answer. This failure to control social biases may be
Older adults who had seen only one of the two related to older adults inability to suppress previ-
words showed equivalent retrieval to that of young ous interpretations of text. In a study by Hamm
adults. Failure to suppress competing items at and Hasher (1992), young and older adults read
retrieval can compound the effects of attending to passages that were initially biased toward one
distraction, resulting in a situation in which interfer- interpretation (e.g., a hunter on a safari) and either
ence cannot be overcome and retrieval fails alto- took an unexpected turn (e.g., the hunter takes a
gether (Postman and Underwood 1973). shot with a camera and the reader learns it is a
photographic safari) or remained consistent with
the initial interpretation. During the reading of the
Inhibition of Thoughts and Biases passage, participants were asked to indicate
whether certain words were consistent or incon-
In some cases, memory retrieval is actually unde- sistent with their current interpretation of the story.
sirable, as is the case with unpleasant or irrelevant Older adults responses indicated that they contin-
memories. Inhibition is also important in ued to hold onto their initial interpretation of the
suppressing these unwanted thoughts, and there story even after the turning point in the story
demanded a reinterpretation. On the other hand, interference between relevant and irrelevant
young adults showed evidence of suppressing the items. Interference can impact cognition at all
initial interpretation when it became clear that it levels since it occurs as a result of competing
was incorrect. Older adults inability to suppress perceptual stimuli, competing memory traces,
thoughts, once activated, may bias their future and competing thoughts or goals. Interference
thoughts and decision-making. can be either prevented or resolved by top-down
Further, older adults cognition may be heavily control over the contents of attention, and this
inuenced by previous goals, since there is evi- process seems to necessitate cohesive brain activ-
dence that they do not deactivate no longer rele- ity in the regions comprising the frontoparietal
vant goals as young adults do. Scullin et al. (2011) control network (Campbell et al. 2012).
taught a group of young and older adults to respond Decreased connectivity of the frontoparietal con-
with a button press whenever they saw a given trol network has been observed in other
target word during an imageability judgment task. populations with decreased inhibitory abilities,
Later, after the prospective memory task had including those with depression (Kaiser
ended, participants were given a lexical decision et al. 2015) and people at their off-peak time of
task that contained former target words from the day (Anderson et al. 2014). The results reviewed
prospective memory task, and response latencies here in light of inhibitory theory suggest that some
were compared between target and new items. In cognitive and social decits previously associated
keeping with the idea that older adults do not with aging are instead associated with a decrease
inhibit previous goals, older but not younger adults in inhibitory ability and not age per se. If this is the
showed slower response times to targets from the case, it may be possible to prevent or reduce
prospective memory task, despite both age groups impairment in old age by targeting and training
indicating that they knew the prospective memory inhibitory abilities. An alternative approach has
task was complete. Further, the age difference in been successful in improving older adults mem-
slowing to former target words was mediated by ory by capitalizing on the tendency to ignore
age differences in measures of inhibitory control distraction. The benet of helpful distraction has
(Scullin et al. 2011). The tendency to hold on to been demonstrated (a) when information from a
prior thoughts, goals, and biases may impact the previous task becomes relevant to a new task, with
way older adults interact with the world and may some evidence that age differences in memory are
underlie many of the observed age-related changes eliminated under these circumstances (Weeks
in cognition and social behavior. et al. 2016), and (b) when distraction occurs dur-
ing a retention interval and serves as a rehearsal
opportunity for those who attend to it, reducing
Conclusions forgetting in older adults (Biss et al. 2013b).
The presence of distraction is disruptive to most

peoples ability to perform cognitively demanding
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Lustig, C., Hasher, L., & Zacks, R. T. (2007). Inhibitory Synonyms
decit theory: Recent developments in a new view.
In D. S. Gorfein & C. M. MacLeod (Eds.), The place of
inhibition in cognition (pp. 145162). Washington, Geriatric depression; Mental well-being and
DC: American Psychological Association. aging; Neuropsychiatric disorders and aging;
186 Aging and Mental Health in a Longitudinal Study of Elderly Costa Ricans
Old-age dementia; Psychiatric disorders and group. In addition, the number of dementia cases
aging; Psychotropic and antidepressant medica- is growing rapidly worldwide, but particularly in
tions at old age low- and middle-income countries (Yasamy
et al. 2013). Depression is the second most dis-
abling condition, accounting for 1.5% of DALYs
Definition worldwide and 1.4% of DALYs in developing
countries in this age group (authors calculations
Geriatric depression and cognition impairment, based on World Health Organization (2004)).
including memory loss, are common neuropsy- Older adults face specic challenges and
chiatric disorders at old age. Diagnosing these opportunities that may affect their mental well-
conditions in the context of a general population- being. The process of aging simultaneously
based survey conducted by nonmental health spe- includes several opposing forces with regard to
cialists is challenging. The effect of aging on an mental health. Older adults are more likely to face
individuals mental health is not always mirrored increased isolation, declining physical health,
in the prevalence of mental disorders of the pop- changes in cognitive ability, and decreased
ulation by age. Changes over time and across income, which may lead to more mental health
cohorts, as well as survival selection, affect the conditions. At the same time, having more time
comparison of individuals at different ages. Lon- for engaging leisure activities and family interac-
gitudinal studies that follow the same individuals tion may help protect against the onset or remis-
over time allow a better assessment of the effect of sion of mental health conditions. In addition,
age on mental health. The Costa Rican Longevity studies suggest that aging increases ones positive
and Healthy Aging Study (CRELES) includes a affect because of increased emotional regulation
panel of elderly people that provides a rare oppor- (Mather and Carstensen 2005). These increases in
tunity of documenting mental health and aging in positive affect may lead to a more positive out-
a middle-income country. look, keep people engaged in their daily activities,
and therefore buffer against the onset of mental
health conditions.
Introduction Understanding what factors are directly related
to common mental health disorders in older
Worldwide populations are aging. With the excep- populations is therefore difcult because
tion of a few countries, most have had remarkable researchers must disentangle competing forces.
increases in life expectancy coupled with declin- In order to better understand how a change in
ing birthrates in the latter half of the twentieth one factor affects changes in another, longitudinal
century, which has led to aging populations even data enable stronger and richer studies. Longitu-
in low- and middle-income countries. The dinal study designs follow the same individual
increase in older populations worldwide has led over time, which allows researchers to compare
to increased interest in how countries can enable the same individuals before and after life changes,
and ensure healthy aging. and thus account for invariant unmeasured or
A vital aspect of healthy aging is ones mental unobservable factors such as disposition or genet-
health, and older adults have a substantial burden ics. This possibility is particularly important for
of disease from mental health conditions. World- the study of mental health conditions, because
wide, 7.5% of all disability-adjusted life years imperfectly measured individual traits may pre-
(DALYs) for those aged 60+ are due to neuropsy- dict both cognitive and physical disability, as well
chiatric disorders. Alzheimers disease and as mental health-related symptoms, and thus con-
dementia are the most disabling conditions in found inferences in cross-sectional studies.
this age group, accounting for 4.2% of all In an effort to better understand the aging pro-
DALYs worldwide and 2.9% of all DALYs in cess, several countries have invested in detailed,
low- and middle-income countries in this age nationally representative longitudinal health and
retirement surveys of their older populations. This entry exploits the longitudinal informa-
These include the United States Health and tion on mental health collected within CRELES,
Retirement Survey; English Longitudinal Study to sort out the effect of aging from the effects of A
of Ageing; Survey of Health, Ageing and Retire- cohort, period, and survival selection that usually
ment in Europe; Japanese Study of Aging and cloud traditional cross-sectional data by age. The
Retirement; The Irish Longitudinal Study on Age- focus of the analysis is on the effects of aging on
ing; China Health and Retirement Longitudinal mental health, and the entry presents estimates
Study; Mexican Health and Aging Study; and of the prevalence of mental health conditions by
Korean Longitudinal Study of Aging. The Costa age and sex among elderly Costa Ricans from
Rican Longevity and Healthy Aging Study cross-sectional CRELES data, as well as of the
(CRELES) is part of this growing set of health transition (incidence and remission) rates from the
and retirement surveys being conducted and is a longitudinal CRELES data on changes of state
nationally representative longitudinal survey of between waves. Then, these rates are used to
health and life-course experiences of older Costa simulate the pure effect of aging in hypothetical
Ricans. Costa Rica is of particular interest to study cohorts using multiple-decrement life table
given its high longevity: life expectancy is greater methods. The comparison of the age proles of
than that of the United States, despite being a observed and simulated mental health prevalence
middle-income country with about one-fth the provides not only a better picture of the effect of
per capita income and one-tenth the per capita aging on mental health but also hints some of the
health spending. changes under way in Costa Rica.
In this entry, the longitudinal CRELES data are
used to describe the prevalence of common geri-
atric mental health disorders as people age, par- CRELES Indicators of Mental Health
ticularly dementia and depression. To date there
have been few studies that examine changes in Ever Diagnosed with Psychiatric Problems
mental health status for the elderly in middle- Responded yes to the wave 1 question Has a
income countries such as Costa Rica with large physician ever told you that you have a nervous or
aging populations, particularly the eldest of psychiatric problem such as depression? In wave
the old. 3 the question was: In the last 4 years, since the
rst time we visited you, has a physician told you
that you have nervous or psychiatric problems
The CRELES Data such as depression? Therefore, the yes responses
in wave 3 are added to those of wave1; no infor-
The Costa Rican Longevity and Healthy Aging mation was available from wave 2. This variable
Study (CRELES, or Costa Rica Estudio de does not allow transitions back to never diag-
Longevidad y Envejecimiento Saludable) is a lon- nosed nor does it allow us to disentangle barriers
gitudinal study of health and life-course experi- in accessing care that would yield a diagnosis
ences based on a national sample of residents of from the lack of symptoms meeting diagnostic
Costa Rica aged 60 and older in 2005, with criteria.
oversampling of the oldest old. The sample was
selected randomly from the 2000 census database Impaired Cognition
using a multistage sampling design. This entry The CRELES used a short version of the Mini-
uses the information from three waves of inter- Mental State Examination (MMSE) questionnaire
views conducted primarily in 2005, 2007, and (Folstein and Folstein 1975) that had been adapted
2009. Documentation and public-use CRELES and validated for Latin America (Quiroga et al.
data are available from the National Archive of 2004). This version has a maximum score of
Computerized Data on Aging at the University of 15 points instead of the original 30-point MMSE
Michigan (Rosero-Bixby et al. 2010). test. The six cognitive domains included in this
test were time orientation (4 points), primary ver- medications were identied by brand or generic
bal memory (three words, 3 points), attention name to create indicators of whether respondents
(to repeat a ve-digit number backward, were taking antidepressants at the time of each
1 point), secondary verbal memory (three words, survey wave. This indicator has the advantage of
3 points), following instructions (1 point), and identifying those taking antidepressant medica-
reconstruction (to copy two intersected gures, tions regardless of the reason for medications;
1 point). The Cronbach alpha for this series of antidepressants are known to have high rates of
15 items was 0.72, indicating acceptable internal off-label use (Radley et al. 2006). Respondents
validity. The test was administered at the begin- who were prescribed antidepressants but did not
ning of the interview to decide whether to use a ll them and respondents who initiated and then
proxy to help in responding the interview. Indi- discontinued antidepressant therapy between
viduals with a score of <10 were considered to waves could not be identied.
have impaired cognition (needing a proxy respon-
dent) as were individuals who were considered by
trained interviewers to be too impaired to com- Results
plete the test.
Of the 2,827 participants interviewed in the
Depression Screening Symptoms CRELES rst wave, 2,369 (84%) were
The CRELES used the 15-item short-form Geri- interviewed in the second wave and 1,855 (79%)
atric Depression Scale (GDS15) (Sheikh and in the third wave. Loss of follow-up was 6% in
Yesavage 1986). This instrument more accurately wave 2 and 9% in wave 3. The remaining 10% and
assesses depression in older populations because 12% of participants died between waves,
it was developed specically for use with older respectively.
adults, has a simplied yes/no response format, Table 1 shows the prevalence of the four indi-
and contains very few items related to somatic cators of mental health by wave and sex. A simple
symptoms. This scale is an instrument designed way of using data from longitudinal studies is by
for screening purposes, and thus it may lead to an taking each wave as a cross section as shown in
overestimate of clinical depression. A systematic Table 1 and looking for time trends. For example,
review of 42 studies validating this instrument the data for women show a reduction in the prev-
reports an average positive predictive value of alence of depression symptoms from 19% in 2005
only 0.32, whereas the negative predictive value to 17% in 2007 and 15% in 2009 and an increase
is 0.95 and sensitivity and specicity are in the in the proportion using antidepressant medicines
order of 0.8 (Wancata et al. 2006). Most studies in from 9% in the rst wave to 11% in second and
that review used a cutoff value of 7+ to classify an third waves. Because this panel does not have
individual as depressed, which is the same cutoff refreshment cohorts and the effect of age was not
value employed here in the CRELES data. The controlled for in the analysis, these inter-wave
Cronbach alpha for the 15 items in CRELES data changes could be a result of the aging of the
was 0.85, indicating high internal validity of the panel, as well as from period changes. Addition-
scale. Per study protocol, the CRELES did not ally, these changes might be a result of survival
administer the GDS15 questionnaire to approxi- selection. Disentangling these three forces age,
mately 25% of participants with cognitive impair- period, and survival selection is a classic prob-
ment (i.e., needing a proxy respondent). lem in demographic studies, as is sorting out aging
from cohort effects when one compares individ-
Taking Antidepressant Medicines uals at different ages.
As part of the CRELES interview, participants Table 1 also shows the results of the three
were asked to show the interviewer all of the waves pooled together, which yields more reliable
medicines they were currently taking. From the estimates as shown by the smaller standard errors.
database of all recorded medicines, antidepressant Pooling together several waves of interviews is a
Aging and Mental Health in a Longitudinal Study of Elderly Costa Ricans, Table 1 Prevalence of four mental
health conditions investigated in the CRELES by wave and sex
Sex and mental Wave 1 Wave 2 Wave 3 All waves
A
Health indicators 2005 2007 2009 20052009
Sample size 2,827 2,369 1,855 7,051
Both sexes
Ever diagnosed psychiatric disorders Prevalence 19.6% . 24.1% 21.4%
(S.E.) (0.9) . (1.2) (0.9)
Cognitive impairment Prevalence 14.2% 20.6% 17.3% 17.2%
(S.E.) (0.6) (0.9) (0.9) (0.6)
Depression symptoms Prevalence 14.1% 12.3% 11.9% 12.9%
(S.E.) (0.9) (0.9) (1.0) (0.7)
Taking antidepressants Prevalence 6.6% 7.9% 7.8% 7.4%
(S.E.) (0.5) (0.6) (0.7) (0.5)
Males
(S.E.) (1.2) . (1.5) (1.2)
(S.E.) (0.9) (1.3) (1.4) (1.0)
(S.E.) (1.1) (1.0) (1.2) (0.8)
(S.E.) (0.6) (0.8) (0.7) (0.5)
Females
(S.E.) (1.4) . (1.7) (1.4)
(S.E.) (0.9) (1.1) (1.2) (0.8)
(S.E.) (1.4) (1.4) (1.4) (1.1)
(S.E.) (0.9) (1.0) (1.2) (0.8)
S.E. binomial standard error of the proportion per 100
simple way of taking advantage of longitudinal Studying cross-sectional variation by age is a

data, although the researcher must be careful in common procedure in assessing the effect of
using only corrected estimates of the standard aging on mental health or other diseases. Figure 1
errors (as was done in Table 1) that take into shows the cross-sectional age variation in the four
account the clustering of data due to repeated indicators of mental health using the pooled
measurements for the same individual. These esti- CRELES data for the three waves. The prevalence
mates show that depression prevalence among curves in the gure were smoothed out using local
women in this sample is 17%, a gure that is regression procedures; the 95% condence inter-
more than twice that of men (8%). The proportion val for each curve is shown as a shaded area. The
of women ever diagnosed with psychiatric condi- gure conrms that the prevalence of depression,
tions (28%) and the proportion taking antidepres- other psychiatric disorders, and antidepressant use
sant medicines (10%) also more than double the is higher for women, although this gender gap
proportions estimated for men. In contrast, the shrinks or disappears at advanced ages. In con-
prevalence of cognitive impairment (17%) is trast, the indicator of cognition impairment does
about the same for males and females. not differ signicantly by sex at any age.
a Ever diagnosed psychiatric disorders b Cognition impairement

.4
.8
95% CI
Females
Males
.3
Proportion
.6
Proportion
.2
.4
.1
.2
95% CI
Females
Males
0
0
60 70 80 90 100 60 70 80 90 100
Age Age
Depression symptoms Taking antidepressants
.25
c d 95% CI
.02 .04 .06 .08 .1 .12

Females
.1 .15 .2
Males
Proportion
Proportion
95% CI
Females
.05
Males
60 70 80 90 100 60 70 80 90 100
Age Age
Aging and Mental Health in a Longitudinal Study of Elderly Costa Ricans, Fig. 1 Prevalence of four mental health
conditions by age (locally weighted smoothing functions)
Only the prevalence of cognitive impairment period change, the disease has become more
shows a strong increase with age, and there seems widely recognized. A fourth source of variation
to be no difference across sexes. Prevalence of this by age is survival selection. For example, age
impairment is about 10% at age 60 years, increas- declines in the curve of prevalence of depression
ing to about 40% by age 85 years. The other three could occur if women suffering depression die at
indicators suggest that among women, depression substantially higher rates. Longitudinal data allow
declines with age. The result for males is mixed: assessing pure aging effects. It is rare to have
depression symptoms increase with age, the prolong-running longitudinal studies that observe a
portion ever diagnosed is essentially at, and the cohort of, say, 60-year-old individuals at baseline
proportion taking antidepressant medicines until their death after four or ve decades. In the
increases until about age 85 and diminishes case of CRELES, the longitudinal observation
afterward. was only during 4 years. During that period, lon-
The age prole of cross-sectional curves, such gitudinal transition rates were determined with the
as those in Fig. 1, is certainly driven by age data, and then hypothetical cohorts were
effects, but cohort and period effects may also constructed with those rates using multiple-
exert inuence. For example, the higher preva- decrement life table techniques (Wachter 2014).
lence of depression among younger women Table 2 shows the transition rates incidence and
might occur because the disease is less common remission estimated from the data and then used
as a woman get older, but also because, in a to simulate the hypothetical cohorts. Both are
generational change, younger cohorts of women annual rates, which are estimated using Poisson
are more affected by this disease or because, in a regression models with exposure equal to the time
Aging and Mental Health in a Longitudinal Study of The transition rates for depression symptoms
Elderly Costa Ricans, Table 2 Annual transition and for taking antidepressant medicines behave
(incidence and remission) rates for the four mental health
conditions by sex similarly. The incidence rate at age 60 years is A
about three times higher for women than for men
Mental
health (0.067 compared to 0.021 for depression symp-
indicator Males Females toms). Then, while among men the incidence rate
Ever diagnosed psychiatric disorders increases by 3% per year, among women it
Incidence 0.012 0.023 decreases by 2% per year for depression symp-
rate toms and 1% for taking antidepressant medicines.
(S.E.) (0.002) (0.002) By age 85 or 90 years, the incidence rates of men
Cognitive impairment and women are about the same. The remission
Incidence 0.019 0.019 rates for the two conditions are very high at all
rate 1.081x 1.081x
ages: close to 30% of ill individuals leave the
(S.E.) (0.002) (0.005) (0.002) (0.005)
disease state every year.
Remission 0.373 0.373
rate 0.946x 0.946x Figure 2 shows the simulated prevalence in the
(S.E.) (0.043) (0.006) (0.043) (0.006) four conditions under study. The simulations cre-
Depression symptoms ated hypothetical cohorts using as inputs the inci-
Incidence 0.021 0.067 dence and remission rates shown in Table 2 and
rate 1.028x 0.979x initial prevalence at age 60 similar to that
(S.E.) (0.004) (0.014) (0.010) (0.011) observed in Fig. 1. The simulated curves show
Remission 0.279 0.279 the expected age prole of prevalence if aging is
rate
the only change that takes place, i.e., if cohort and
(S.E.) (0.014) (0.014)
period effects are absent.
Taking antidepressants
Incidence 0.011 0.039
The observed and simulated curves of preva-
rate 1.032x 0.991x lence of cognition impairment are similar, which
(S.E.) (0.003) (0.011) (0.006) (0.009) suggests that this population has not been subject
Remission 0.335 0.278 to meaningful changes in this condition over time
rate nor across generations. The same can be said
(S.E.) (0.027) (0.020) about the prevalence of depression symptoms,
x = age 60 whose observed and simulated curves differ little,
Standard errors in parentheses especially for men. For women, the simulated
curve suggests that the age slope of decline in
observed prevalence should be steeper.
(in years) between waves. Because of the A potentially important confounder of this curve
log-linear specication of Poisson regression is the fact that about 50% of the sample aged
models, the effect of age is multiplicative, and 80 years or more were not administered the
age is an exponent. In models where age showed depression screener because they required a
non-statistically signicant effects, age is proxy for responding (a more complex analysis
excluded as a control variable, i.e., the rates are could also include the simulation of a third state in
then modeled as constant for all ages. In models the model: requiring a proxy.)
where the effect of gender was not signicant, the The simulated curves for the proportion taking
same age coefcients were assumed in each sex. antidepressant medicines are not that different
The condition ever diagnosed has no remis- from the observed prevalence curves either,
sion by denition. Its incidence rate does not vary except in two aspects: (1) The simulation for
signicantly with age. The incidence rate of 0.023 women results in a systematically higher than
for women means that, in a year, 23 women are observed curve, which would be consistent with
newly diagnosed out of 1,000 not yet diagnosed. a recent increase in prescription of antidepressant
The rate for women is about double that for men. medicines to women. (2) The simulation for men
a .8 Ever diagnosed psychiatric disorders b Cognition impairment
1
.8
.6
Proportion
Proportion
.6
.4
.4
.2
.2
0
0
60 70 80 90 100 60 70 80 90 100
Age Age
Observed: M F Simulated: M F Observed Simulated
Depression symptoms Taking antidepressants

d
.12
c
.2
.02 .04 .06 .08 .1

Proportion
.15
Proportion
.1
.05
60 70 80 90 100 60 70 80 90 100
Age Age
Observed: M F Simulated: M F Observed: M F Simulated: M F
Aging and Mental Health in a Longitudinal Study of Elderly Costa Ricans, Fig. 2 Hypothetical cohort simulations
and observed prevalence of four mental health conditions by age
older than 80 years results in a growing curve of removing this assumption, Fig. 3 shows simu-
compared to the at or even declining observed lations assuming that mortality among individuals
curve. This discrepancy may result from survival with mental illnesses doubles the mortality of the
selection as noted below. general population, which is an extreme assump-
By contrast, the indicator Ever diagnosed tion of over-mortality of people with mental
with psychiatric disorders differs markedly health problems. Mortality for the general popu-
between the observed and simulated aging curves lation is assumed to follow a Gompertz distribu-
in Fig. 2, panel A. Being cumulative, the cohort tion with the parameters estimated for Costa Rica
proportion of ever diagnosed psychiatric condi- elsewhere (Rosero-Bixby et al. 2014).
tions should increase monotonically with age, as it The new simulations for ever diagnosed
does in the simulated curves. In this case, the depression conrm that the at or declining prev-
decline in the observed curve with age is highly alence curves by age observed in this sample
misleading if interpreted as a pure aging effect; might originate in survival selection, given that
instead, this likely reects cohort or period the simulation curves that included differential
increases in these diagnoses or else elevated mor- mortality stopped growing by age 77 among
tality among people suffering from psychiatric men and age 80 among women and decreased
impairments. afterward. This is speculative, however, pending
The simulations shown so far assumed that further longitudinal analysis to more precisely
mortality is similar among prevalent and estimate the mortality differences by psychiatric
non-prevalent individuals. To illustrate the effect indicator.
A-1) Ever diagnosed psychiatric A-2) Ever diagnosed psychiatric

disordersMales disordersFemales
A
.5
.8
.4
.6
Proportion
Proportion
.3
.4
.2
.2
.1
0
0
60 70 80 90 100 60 70 80 90 100
Age Age
Observed DRR=1 DRR=2 Observed DRR=1 DRR=2
B-1) Depression symptomsMales B-2) Depression symptomsFemales

.08 .1 .12 .14 .16 .18
.2
Proportion
Proportion
.1 .15.05
60 70 80 90 100 60 70 80 90 100
Age Age
C-1) Taking antidepressantsMales C-2) Taking antidepressantsFemales

.12
.1
.08
.1
Proportion
Proportion
.06
.06 .08
.04
.02
.04
60 70 80 90 100 60 70 80 90 100
Age Age
DRR is the death rate ratio of prevalent relative to non-prevalent individuals used in simulations.
Aging and Mental Health in a Longitudinal Study of Elderly Costa Ricans, Fig. 3 Hypothetical cohort simulations
with differential mortality and observed prevalence of three mental health conditions by age and sex
Figure 3, panel C, also shows that the new decreasing for females are consistent with sim-
simulations with differential mortality produce ilar proles in the curves of the proportion taking
simulated prevalence values that are quite close antidepressants, and these are conrmed by the
to the observed values, especially for older men. simulations enabled by the longitudinal data.
Again, this indicates that differential mortality is The cross-sectional pattern for the proportion
plausibly important in driving the observed age ever diagnosed with psychiatric disorders is more
curves of the proportion taking antidepressant complex and on its own would provide a mislead-
medicines, especially for older men. ing description of aging effects. The at and
Simulations with differential mortality of the decreasing cross-sectional patterns by age are
proportions with depression symptoms (plot B in likely a result of survival selection or of recent
Figure 3) result in curves lower than those simu- increases in diagnosis among younger cohorts; the
lated with no differential mortality and, therefore, simulated age proles enabled by the longitudinal
further away of the observed curves, especially at data instead reveal strongly increasing rates with
older ages. This suggests that differential mortal- aging.
ity by depression status may be less extreme than An important limitation of two of the indicators
it is for the other indicators. used (ever diagnosed psychiatric disorders and
For cognitive impairment, simulations with taking antidepressant medicines) is that they are
differential mortality (not shown in Fig. 3) result sensitive to access to care those meeting depres-
in even closer observed and simulated curves than sion criteria but who have poor access to physi-
those already similar in Fig. 2, especially after cian care would not report diagnosis nor would
about age 80. they be taking medicines. In addition, since the
wording of the survey question specically asks
for diagnoses from physicians, respondents may
Discussion not report diagnoses received by other mental
health specialists, such as psychologists, nurse
The data from the CRELES study is a valuable practitioners, or social workers, thus potentially
rst step in assessing the prevalence of mental understanding lifetime diagnosed prevalence.
health problems among elderly Costa Ricans. It is also helpful to compare the different indi-
About 28% of Costa Rican women aged 60 or cators of depression or psychiatric history, as the
more reported being ever diagnosed with psychi- indicators are better understood in their contrasts.
atric disorders, about 17% were screened as suf- Self-reported psychiatric history could cover psy-
fering cognitive impairment or geriatric chiatric conditions beyond depression, such as
depression, and 10% were found taking antide- anxiety or psychotic disorders, as well as condi-
pressant medicines. These female proportions are tions that are no longer symptomatic, such as
twice the rates of males except for cognitive childhood or early adult disorders. This measure
impairment, a condition that does not differ by could undercount depression, however, if there is
gender. perceived stigma in reporting conditions or if
The longitudinal information in CRELES respondents experienced barriers to care. The
allow researchers to disentangle the age, cohort, depression screener will detect current symptoms,
and mortality patterns in mental health rather than but not prior history. Respondents who are
simply observing cross-sectional patterns by age. untreated or inadequately treated, for example,
There is a clear increase with aging in cognitive might meet current symptom criteria but not
impairment for both sexes, as well as for depres- have a prior history of diagnosis. The depression
sion symptoms for males. In contrast, depression screener also has the limitation that it cannot be
symptoms decrease with age among women, and easily administered to individuals with cognitive
this trend is not an artifact of period-cohort effects limitations requiring a proxy to respond, who are
nor survival selection. The aging effects on an important group at older ages, close to 50% at
depression symptoms increasing for males and 85 or more years. Finally, receipt of antidepressant
medication indicates current use of medication for Cognition

either depression or other conditions. Persons English Longitudinal Study of Aging (ELSA)
who are adequately treated by antidepressants Health and Retirement Study, A Longitudinal A
would no longer exhibit psychiatric symptoms Data Resource for Psychologists
and may or may not report a prior psychiatric Irish Longitudinal Study on Ageing (TILDA)
history. The discordance among these measures Korean Longitudinal Study of Ageing
in the CRELES is further described elsewhere (KLoSA): Overview of Research Design and
(Domino et al. 2014). Contents
Mental Health and Aging
Conclusion
References
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ing the effects of mental health policies and inter- Rosero-Bixby, L., Dow, W. H., & Rehkopf, D. H. (2014).
ventions implemented in low-resource settings. The Nicoya region of Costa Rica: A high longevity
island for elderly males. Vienna Yearbook of Popula-
Although only the longitudinal CRELES data tion Research, 2013(11), 109136.
was introduced in this entry, there are increasing Sheikh, J. L., & Yesavage, J. A. (1986). Geriatric depres-
efforts to collect comparable data in other lower- sion scale (Gds): Recent evidence and development of a
and middle-income settings so as to enable further shorter version. Clinical gerontology: A guide to
assessment and intervention. New York: The Haworth
cross-national comparisons over time as well. Press.
Wachter, K. W. (2014). Essential demographic methods.
Cambridge, MA: Harvard University Press.
Cross-References Wancata, J., Alexandrowicz, R., Marquart, B., Weiss, M.,
& Friedrich, F. (2006). The criterion validity of the
geriatric depression scale: A systematic review. Acta
Aging and Psychological Well-Being Psychiatrica Scandinavica, 114(6), 398410.
China Health and Retirement Longitudinal World Health Organization. (2004). The global burden of
Study (CHARLS) disease2004 update. WHO. http://www.who.int/
196 Aging and Psychological Well-Being
healthinfo/global_burden_disease/GBD_report_2004 Socio-Economic Panel Study and the British

update_full.pdf Household Panel Study also show that average
Yasamy, M. T., Dua, T., Harper, M., & Saxena, S. (2013).
Mental health of older adults, addressing a growing levels of life satisfaction remain quite stable
concern. World Health Organization. http://www.who. across adulthood and only decline in very late
int/mental_health/world-mental-health-day/WHO_ life (Baird et al. 2010). These ndings suggest
paper_wmhd_2013.pdf that the majority of older people maintain a high
level of psychological well-being that is equiva-
lent to that experienced by their younger
counterparts.
Aging and Psychological Well-Being When studying psychological well-being over
the life course, Carol Ryffs six dimensions of
Dannii Y. Yeung psychological well-being, life satisfaction, and
Department of Applied Social Sciences, positive and negative affect are often assessed in
City University of Hong Kong, Hong Kong, younger, middle-aged, and older adults (Ryff
China 1989). In this entry, the age-related changes in
these three aspects will rst be reviewed, followed
by discussion on theoretical explanations and
Synonyms future directions.
Positive psychological functioning; Psychologi-

cal health; Subjective well-being Age-Related Changes in Ryffs
Psychological Well-Being
Definition Ryffs (1989) six distinct dimensions of psycho-

logical well-being comprise self-acceptance, pos-
Psychological well-being is dened as a psycho- itive relations with others, autonomy,
logical state with positive functioning and environmental mastery, purpose in life, and per-
absence of mental illnesses. sonal growth. These dimensions are regarded as
the eudaimonic well-being, which is characterized
by purposeful life engagement and realization of
Introduction ones potential. Self-acceptance refers to a per-
sons attitudes toward acceptance of himself/her-
Old age is often associated with declines and self; positive relations with others captures the
losses in physical, cognitive, and social domains, quality of relationships with signicant social
with many older people perceived as unhappy, partners; autonomy is dened as ones own free-
lonely, or depressed as a result. However, recent dom and independence to think and act in partic-
empirical ndings do not support these stereotyp- ular ways; environmental mastery assesses the
ical beliefs. In contrast to the popular belief that sense of mastery and competence in managing
most of older adults are depressed, the statistics of life events; purpose in life concerns the sense of
the 2012 National Survey on Mental Health reveal meaning, purpose, and directedness in life; and
that the 12-month prevalence of major depression personal growth refers to the tendency to develop
declines from young adulthood to old age. In personal talents and actualize potentials.
particular, the percentages of adults aged 1825, Cross-sectional studies showed that compared
2649, and 50 or older who had at least one major with younger and middle-aged adults, older adults
depression episode in the previous year were exhibited higher levels of environmental mastery
8.9%, 7.6%, and 5.5%, respectively, implying and autonomy but lower levels of purpose in life
that the rate of depression is lower in late adult- and personal growth (Ryff 1989; Ryff and Keyes
hood. Moreover, the ndings from the German 1995). No signicant age variation was found in
Aging and Psychological Well-Being 197
self-acceptance and positive relations with others. Age-Related Changes in Life Satisfaction
Using two waves of data from two population-
based longitudinal studies, Midlife in the United Life satisfaction is another core aspect of psycho- A
States (MIDUS) and the Wisconsin Longitudinal logical well-being. It is dened as a persons cog-
Study (WLS), Springer and colleagues (2011) nitive assessment of satisfaction with his/her life.
demonstrated a similar pattern of age-related Life satisfaction is often assessed by a single item
increases in environmental mastery and to measure a persons current happiness with
age-related decreases in personal growth and pur- his/her overall life or the Satisfaction with Life
pose in life over approximately 10 years. However, Scale which comprises ve items (Ryff 1989;
for the other three dimensions of psychological McAdams et al. 2012).
well-being, the age trends are somewhat different Past studies on life satisfaction across adult-
from those reported in the cross-sectional studies. hood have yielded inconclusive results. For exam-
In particular, autonomy declined with age in the ple, a positive linear relationship between age and
WLS younger, middle-aged, and older groups, life satisfaction was shown in a representative
whereas it increased with age in the three MIDUS sample of Americans aged 2574 years (Prenda
age groups. For the three age groups in the WLS and Lachman 2001). A curvilinear relationship
and MIDUS, an age-related increase in positive between age and life satisfaction was demon-
relations with others was observed. Self- strated in a large sample of American men aged
acceptance decreased in the three WLS cohorts, 4085 years who participated in the Veterans
whereas it slightly increased for the middle-aged Affairs Normative Aging Study over a period of
MIDUS cohorts but not the younger and older 22 years (Mroczek and Spiro 2005). Specically,
cohorts (Springer et al. 2011). growth-curve models revealed that life
Age-related changes in psychological well- satisfaction increased from age 40 to 65 years
being vary by cultural context. Karasawa and and then declined. Signicant individual differ-
colleagues (2011) compared the six dimensions ences in rate of change and amount of curvature
of psychological well-being between Japanese were also shown, implying that people vary in
and American adults. The results of their studies their life satisfaction trajectories and not every
revealed that the culture by age interaction was individual changes at the same rate and in the
shown in personal growth and positive relations same way.
with others. In particular, personal growth Mroczek and Spiros (2005) study, however,
increased with age among Japanese adults, included those aged 40 years as the youngest
whereas a reverse pattern was shown in the US participants, making it difcult to get a clear pic-
sample. Concerning interpersonal well-being, ture about changes in life satisfaction across the
younger and middle-aged Japanese adults (aged lifespan. To address this concern, Baird and col-
3554) rated their relations with others better than leagues (2010) analyzed the longitudinal data
their older counterparts (aged 5574), whereas from the German Socio-Economic Panel Study
older US adults reported more positive relations and the British Household Panel Study which
with others than their younger counterparts. comprise nationally representative samples of a
In summary, when people grow older and pro- wide age range (1691 years). Their study dem-
gress through the developmental tasks, the direc- onstrated that average levels of life satisfaction
tion of changes in psychological well-being is remained relatively stable over adulthood and
dependent on the dimensions concerned, with started declining after age 70 when health,
increases in some dimensions and declines in the income, and social support were declining. Even
others. These patterns of age-related changes are though the two samples share some similarities,
indeed in alignment with the emphasis in the the British Household Panel Study revealed a
theory of selective optimization with compensa- moderate increase from the 40s to the early 70s.
tion that adult development is multidirectional In addition to overall life satisfaction,
(Baltes and Baltes 1990). McAdams and colleagues (2012) used data of
the British Household Panel Study to systemati- In summary, the level of overall life satisfac-
cally analyze age-related trajectories of domain tion remains high into the 60s and early 70s and
satisfaction. Eight life domains were investigated, then drops when satisfaction with health, social
including health, income, house, spouse/partner, life, and leisure activities decreases in late life.
job, social life, amount of leisure, and use of
leisure. Among these domains, health satisfaction
declined steadily over the lifespan. Job satisfac- Age-Related Changes in Positive
tion and income satisfaction remained at in and Negative Affect
young adulthood but increased gradually after
mid-40s. Satisfaction with spouse/partner rst Positive and negative affect are important compo-
increased from adolescence to the twenties, nents of psychological well-being. They are
remained stable until mid-40s, and then slightly dened as hedonic well-being. Positive affect
improved until late 70s. For the remaining four refers to subjective experiences of pleasant emo-
domains namely, satisfaction with social life, tions (e.g., happy, excited, enthusiastic), whereas
amount of leisure, use of leisure, and negative affect refers to subjective experiences of
housing all showed a decline from teens to late unpleasant emotions (e.g., sad, angry, worry).
thirties or early forties and then increased until late They are often measured by emotion checklists
70s. When aggregating satisfaction ratings in all to record ones affective experiences at the
these eight domains, the overall trajectory is moment of assessment or over a certain period
largely similar to that in overall life satisfaction. of time.
That is, life satisfaction and aggregated domain Recent research has suggested that affective
satisfaction drop from adolescence to early 40s, well-being improves from early adulthood to old
then increase until mid-70s, and gradually drop age until late 70s and 80s. Both cross-sectional
among the oldest group of participants. Similarly, and longitudinal studies found that older adults in
using four waves of data from 80 countries in the general experience stable levels of positive affect,
World Value Survey, a U-shaped effect of age on lower levels of negative affect, and lower rates of
life satisfaction was demonstrated, with the lowest anxiety and depression (Charles and Carstensen
level of life satisfaction being observed in 2010). When examining positive affect, a longi-
between the mid- and late 40s (Blanchower and tudinal study over two decades found that positive
Oswald 2008). Such a U-shaped pattern is found affect remained quite stable from early to middle
in most Western countries (e.g., Canada, France, adulthood and then decreased slightly from
Germany, Great Britain, the USA), East European mid-60s to late 80s (Charles et al. 2001). More-
countries (e.g., Croatia, the Czech Republic, Hun- over, a longitudinal experience sampling study
gary, Poland, Lithuania), and developing coun- found that positive emotional experiences
tries (e.g., Brazil, China, Iraq, Mexico, Vietnam). improve with age and level off after age
Even though the U-shaped pattern of life satis- 70 (Carstensen et al. 2011). A recent investigation
faction is observed in Western, East European, of high- and low-arousal emotions also reveals
and developing countries (Blanchower and that age-related decreases in positive emotions in
Oswald 2008), other studies suggest that the rela- late life are strongly related to high-intensity pos-
tionship between age and life satisfaction may itive emotions such as excitement and enthusiasm,
vary by culture. For instance, in a study conducted whereas low-intensity positive emotions such as
among Chinese adults residing in ve capital cit- calm and peaceful do not show an age-related
ies in Mainland China, a steady increase in life decrease (Scheibe et al. 2013). The age-related
satisfaction was observed over the life course decreases in negative emotions from early to mid-
(Xing and Huang 2014). On average, Chinese dle adulthood are consistently shown in prior
adults aged 65 years and above are more likely research, including the examination of both
to experience a higher level of life satisfaction high-intensity (e.g., anger, rage, despair) and
than younger and middle-aged adults. low-intensity negative affect (e.g., worry).
Aging and Psychological Well-Being 199
For depressive symptoms, the results of the Balti- Second, the theory of selective optimization
more Longitudinal Study of Aging (Davey with compensation proposes that when physical
et al. 2004) showed an age-related increase. How- and cognitive capacities decline with age, the A
ever, when certain factors such as health and func- individuals allocate their resources more carefully
tional abilities are taken into consideration, these (Baltes and Baltes 1990). They select goals that
age-related increases in depressive symptoms van- are important and realistic, devote effort and
ish, and old age is again associated with lower resources to optimize their performance in the
levels of negative affect (Kunzman et al. 2000). prioritized domains, and make use of external
Karasawa and colleagues (2011) cross- aids and social support to maintain a satisfactory
cultural comparison on hedonic well-being outcome. Applying this theoretical framework to
revealed that both older Japanese and American psychological well-being, older people select the
adults experienced higher levels of positive affect life domains that are important and achievable to
and lower levels of negative affect than their enhance their affective experiences. For instance,
younger counterparts. In a longitudinal study, they focus on goals of maintaining relationships
Hong Kong Chinese adults whose age ranged with emotionally close social partners instead of
from 18 to 86 years were interviewed over the peripheral partners. Their prior knowledge on
phone to report their emotional reactions to the handling emotional situations enables them to
SARS outbreak (Yeung and Fung 2007). Older use the most effective emotion regulatory strate-
respondents experienced less anger than did youn- gies to deal with the contextual demands. They
ger and middle-aged adults during and after the also seek emotional support and instrumental
SARS outbreak. To conclude, past ndings from assistance to compensate their losses in other
both Western and Eastern countries all suggest domains. The use of selection, optimization, and
that older adults often display better emotional compensation thus helps to maintain psychologi-
well-being than younger adults. cal well-being in old age.
Theoretical Explanations Future Directions
The aforementioned review of past research sug- Contrary to the stereotypical beliefs that old age is
gests that individuals enjoy high levels of psycho- linked to sadness and distress, research evidences
logical well-being in old age even though there are reveal that people maintain or even improve their
unavoidable declines in physical and cognitive psychological well-being with age. However,
areas. Two theories of lifespan development can most past studies on aging and psychological
help explain these age-related changes. First, well-being are conducted during typical periods
socioemotional selectivity theory stresses that of daily life, and not in the context of major life
motivation changes when individuals age and per- events. Maintaining a positive psychological
ceive future time as increasingly limited functioning is more challenging during moments
(Carstensen 2006). Relative to younger people, of hardship or adversity. It remains an open ques-
older peoples realization of limited time is accom- tion whether older adults are more able to main-
panied with present-focused awareness, so they are tain a high level of psychological well-being in the
prioritized with goals that can maximize their emo- midst of stressful life events than younger adults.
tional satisfaction in the present. Accordingly, Future studies should compare younger and older
older adults are more likely to pay attention to adults longitudinal changes in affective
emotional information or to use emotion regulatory responses to major life events. In addition, prior
strategies such as reappraisal to reduce the discrep- research mainly assessed the participants current
ancy between their current and ideal states. As a psychological functioning and seldom looked into
result, psychological well-being of older people their anticipated outcomes in the future. Lang and
can be maintained or even improved. colleagues (2013) made use of the data from the
German Socio-Economic Panel Study to investi- Baltes, P. B., & Baltes, M. M. (1990). Psychological per-
gate the effects of current life satisfaction, antici- spectives on successful aging: The model of selective
optimization with compensation. In P. B. Baltes &
pated future life satisfaction in 5 years, and M. M. Baltes (Eds.), Successful aging: Perspectives
accuracy of the anticipated life satisfaction on from the behavioral sciences (pp. 134). Cambridge,
health outcomes. Compared with younger adults, MA: Cambridge University Press.
older adults were more pessimistic about their Blanchower, D. G., & Oswald, A. J. (2008). Is well-being
U-shaped over the life cycle? Social Science & Medi-
future and underestimated their actual life satisfac- cine, 66, 17331749.
tion 5 years later. However, such underestimation Carstensen, L. L. (2006). The inuence of a sense of time
was indeed associated with positive health out- on human development. Science, 312, 19131915.
comes such as lower rates of mortality and disabil- Carstensen, L. L., Turan, B., Scheibe, S., Ram, N., Ersner-
Hersheld, H., Samanez-Larkin, G. R., Brooks, K. P.,
ity. It suggests that anticipating a dark future may & Nesselroade, J. R. (2011). Emotional experience
be adaptive for older people as it can facilitate more improves with age: Evidence based on over 11 years
preventive measures to minimize potential losses of experience sampling. Psychology and Aging, 26,
and cultivate a greater sense of control. Future 2133.
Charles, S., & Carstensen, L. L. (2010). Social and emo-
studies should apply this reasoning to other tional aging. Annual Review of Psychology, 61,
domains of psychological well-being, such as 383409.
anticipated positive affective experiences in Charles, S. T., Reynolds, C. A., & Gatz, M. (2001).
5 years, to develop a more comprehensive picture Age-related differences and change in positive and
negative affect over 23 years. Journal of Personality
of aging and psychological well-being. In addition, and Social Psychology, 80, 136151.
cultural variations are observed in certain dimen- Davey, A., Halverson, C. F. J., Zonderman, A. B., & Costa,
sions of psychological well-being. Future studies P. J. T. (2004). Change in depressive symptoms in the
would benet from making use of the longitudinal Baltimore longitudinal study of aging. The Journals of
Gerontology. Series B, Psychological Sciences and
data from the representative national samples (e.g., Social Sciences, 59, 270277.
MIDUS and Midlife in Japan) to conduct a system- Karasawa, M., Curhan, K. B., Markus, H. R., Kitayama,
atic cultural comparison to unveil the similarities S. S., Love, G. D., Radler, B. T., & Ryff, C. D. (2011).
and differences in psychological well-being trajec- Cultural perspectives on aging and well-being:
A comparison of Japan and the United States. Interna-
tory between Westerners and Easterners. tional Journal of Aging and Human Development, 73,
7398.
Kunzman, U., Little, T. D., & Smith, J. (2000). Is
Cross-References age-related stability of subjective well-being a para-
dox? Cross-sectional and longitudinal evidence from
the Berlin Aging Study. Psychology and Aging, 15,
Age-Related Positivity Effect and Its
511526.
Implications for Social and Health Gerontology Lang, F. R., Weiss, D., Gerstorf, D., & Wagner, G. G.
Aging and Quality of Life (2013). Forecasting life satisfaction across adulthood:
Mental Health and Aging Benets of seeing a dark future? Psychology and
Aging, 28, 249261.
Positive Emotion Processing, Theoretical
McAdams, K. K., Lucas, R. E., & Donnellan, M. B.
Perspectives (2012). The role of domain satisfaction in
Psychological Theories of Successful Aging explaining the paradoxical association between life
Selection, Optimization, and Compensation at satisfaction and age. Social Indicators Research, 109,
295303.
Work in Relation to Age
Mroczek, D. K., & Spiro, A., III. (2005). Change in life
Socioemotional Selectivity Theory satisfaction during adulthood: Findings from the vet-
erans affairs normative aging study. Journal of Person-
ality and Social Psychology, 88, 189202.
References Prenda, K. M., & Lachman, M. E. (2001). Planning for the
future: A life management strategy for increasing con-
Baird, B. M., Lucas, R. E., & Donnellan, M. B. (2010). trol and life satisfaction in adulthood. Psychology and
Life satisfaction across the lifespan: Findings from two Aging, 16, 206216.
nationally representative panel studies. Social Indica- Ryff, C. D. (1989). Happiness is everything, or is it?
tors Research, 99, 183203. Explorations on the meanings of psychological well-
Aging and Quality of Life 201
being. Journal of Personality and Social Psychology, conditions, and perceived health, to psychological
57, 10691081. well-being, as indexed by self-esteem and happi-
Ryff, C. D., & Keyes, C. L. (1995). The structure of
psychological well-being revisited. Journal of Person- ness, or to social well-being, capturing how well A
ality and Social Psychology, 69, 719727. one functions in their social roles, and connec-
Scheibe, S., English, T., Tsai, J. L., & Carstensen, L. L. tions with family and friends. It can also be con-
(2013). Striving to feel good: Ideal affect, actual affect, ceptualized as a sweeping concept that combines
and their correspondence across adulthood. Psychology
and Aging, 28, 160171. some or all of these particular domains; some-
Springer, K. W., Pudrovska, T., & Hauser, R. M. (2011). times referred to as over-all well-being. It can
Does psychological well-being change with age? Lon- refer to either or both the macro (societal, objec-
gitudinal tests of age variations and further exploration tive) and micro (individual, subjective) levels.
of the multidimensionality of Ryffs model of psycho-
logical well-being. Social Science Research, 40, To illustrate, Anderson (2004) denes ve
392398. domains of well-being: physical well-being
Xing, Z., & Huang, L. (2014). The relationship between (health, tness, mobility, etc.); material well-
age and subjective well-being: Evidence from ve cap- being (possessions, transport, security, privacy,
ital cities in Mainland China. Social Indicators
Research, 117, 743756. etc.); social well-being (family, relatives, interper-
Yeung, D. Y., & Fung, H. H. (2007). Age differences in sonal relationships, etc.); emotional well-being
coping and emotional responses to SARS: (trust, self-esteem, satisfaction, etc.); and devel-
A longitudinal study of Hong Kong Chinese. Aging & opment and activity (political freedom, employ-
Mental Health, 11, 579587.
ment, education, economic freedom, etc.).
Bowling (2004) distinguishes between eight
models of quality of life: objective standard of
living; health and longevity; satisfaction of
Aging and Quality of Life human needs; life satisfaction and psychological
well-being; social capital; ecological and neigh-
Neena L. Chappell borhood resources; health and functioning;
Centre on Aging and Department of Sociology, cognitive competence and autonomy and self-
University of Victoria, Victoria, BC, Canada efcacy; and values and interpretations and per-
ceptions. Arun and evik (2011) draw on Allardt
and colleagues (1993) model, an index compris-
Synonyms ing three domains having (material and interper-
sonal needs), loving (social needs), and being
Happiness; Life satisfaction; Quality of life; (needs for personal growth) where each domain
Well-being has both objective and subjective indicators.
Within each domain, there is similarly no
agreement on the conceptualization of the con-
Definitions struct. For example, examining only the subjec-
tive domain, multiple terms and meanings are
Quality of life a multidimensional concept that used that include morale, self-esteem, fulllment,
can refer to physical, psychological, and/or social happiness, subjective well-being, and overall
well-being measured at the societal and/or indi- well-being. Subjective well-being can be studied
vidual level, objectively and/or subjectively. as either or both cognitive evaluations of ones life
and affectivity (ongoing emotional reactions to
ones life) (Chappell 2007). It is often dened in
A Broad Concept terms of valuations of ones life, events in ones
life, their bodies and their minds, and the circum-
Quality of life is both a multidisciplinary and a stance of their lives (Diener 2006). The World
multidimensional concept. It can refer to physical Health Organization (WHO) (1995) has dened
well-being, incorporating medical disease, health quality of life in terms of perceptions of ones
202 Aging and Quality of Life
position in life within the context of their culture of life (though this does not diminish the objective
and in relation to goals, expectations, standards, hardships they experience). The extent to which
and concerns. Cameld and Skevington (2008) the in-group supportiveness results from necessity
argue that the centrality of value judgments in due to a lack of resources to purchase help or lack
denitions of both subjective well-being and qual- of culturally appropriate services, and the extent
ity of life leaves little difference between them. to which it is cultural and preferred, requires more
They further argue that, while subjective well- research.
being and subjective quality of life are virtually Notions of successful aging are closely aligned
synonymous, the related concept of life satisfac- with the concept of quality of life. The 1980s saw
tion is insufcient to explain either. new nomenclature appear within gerontology
Some dene happiness as affect, feeling, expe- with the introduction of terms such as productive
rience, and life satisfaction as an overall evalua- aging; referring to an individual who maintains
tion of your life (Deaton 2008); yet others treat their productivity with age, through work, volun-
them synonymously. Hellliwell and colleagues teerism, family caregiving, or other socially val-
(2013) note that individuals responding to surveys ued contributions. The term successful aging
do not have difculty distinguishing between hap- became popular at this time, incorporating bio-
piness as an emotion and happiness as an evalua- medical, psychosocial and lay denitions. Since
tion of life. Knight and Rosa (2011), nevertheless that time it has been associated with positive
dene happiness as relatively short-term, situation adaptation to growing old, having little disease
dependent expressions of mood whereas self rat- or disability, preservation of physical and cogni-
ing of life satisfaction refers to longer-term more tive functioning, high engagement with life, opti-
stable evaluations. Veenhoven (1999) though mal life expectancy, and greater happiness.
denes happiness as the degree to which an indi- Recently, the WHO (2002) referred to active
vidual judges the overall quality of his or her life aging as the process of optimizing opportunities
favorably and states it can be called life for health, participation and security in order to
satisfaction. enhance quality of life as people age. Other
When reecting on the number of medical terms, often used interchangeably, have captured
conditions one can study, let alone psychological the same concept: robust aging, successful aging,
and emotional states or social circumstances one vitality, maintenance of functioning, and aging
might live in, it is easy to become overwhelmed. well. All of these terms are intended to portray
Researchers typically do not address all of good aging, i.e., aging with a better quality of life.
these areas but focus on particular aspects. As a It should also be noted that those studying a
consequence, inconsistencies or apparent particular domain of quality of life may do so
contradictions between different aspects of qual- considering it an indicator of quality of life, but
ity of life can proliferate. An example comes others may do so without considering it an aspect
from the ethnicity area where objective inequities of quality of life but focusing only on that phe-
often characterize subcultural groups. When nomenon. In the health area, researchers study
quality of life is measured in terms of economic cancer or depression or dementia to learn more
hardship often within the context of about the disease or the health of the individual
broader economic, political, and social without necessarily having an interest in quality of
structures ethnic subgroups often emerge with life. For others, it can represent a partial or total
a low quality of life. However, when measured in focus for their quality of life research. In another
terms of subjective well-being, these same groups example, standard of living or socioeconomic sta-
often emerge as high, if not higher, than host tus are often studied in its own right or as mea-
country populations. This is often explained in sures of the political and economic structures of a
terms of their greater access to social support society. It is also found in quality of life studies as
from their social relationships, especially family, objective measures of the quality of an individ-
which appears to enhance their subjective quality uals life, where the more material goods one has,
the higher the income, the greater the wealth, the individuals quality of life. Mobility disability is
better the quality of life. especially important because being able to ambu-
It might also be noted that the emphasis of the late is critical to so many activities permitting A
research varies depending on the region of the independence, so often related to quality of life.
world. In the USA, an overwhelming emphasis Disability is not a characteristic of the individ-
on life satisfaction has been evident while in ual per se but rather it is a relational concept taking
Europe the focus has been more on declines in the intersection between the individual and the
health and functioning, assuming the worse ones environment into account. For instance, if an indi-
health, the worse ones quality of life. vidual has difculty walking up and down stairs
but lives in an area that is at, with no stairs, they
are not disabled and their difculty is unlikely to
A Focus on Health effect their quality of life. In gerontology, the
disablement process refers to a dynamic interac-
Health receives much attention in gerontology tion that takes into account attitudes, emotions,
because of the decline in physical health as people stigma, accessibility, thus embracing a relational
age. It is no surprise then that many with an concept. However, it is not often measured as
interest in health and aging have an interest in such. Some measures capture bodily function
quality of life. As life expectancy has increased (also referred to as impairment), some activity
in developed countries and increasingly in devel- limitation, some participation restriction. Some
oping nations, chronic conditions tend to domi- ask for self-identication as disabled, some ask
nate. People are living longer but with several about diagnosable conditions, basic activities of
chronic conditions, often requiring complex daily living, instrumental activities of daily living,
care. Common chronic conditions in old age and/or participation. The lowest rates are typically
include: cardiovascular diseases, hypertension, obtained when asking a person whether they have
stroke, diabetes, cancer, chronic obstructive pul- a disability, suggesting impairments per se do not
monary disease, muscular-skeletal conditions necessarily result in perceptions of a lower quality
including arthritis and osteoporosis, mental health of life.
conditions such as dementia, and blindness and When someone experiences multiple declines
visual impairment. Both the number of chronic in physical, mental, and psychological function-
conditions and functional disability increase with ing, there is relative consensus that he or she has
age and continue to do so throughout old age transitioned from independence to dependence,
(Chappell and Penning 2012). and has thereby become frail. There is general
However, the ndings in relation to health- agreement that their quality of life is poor, but no
related life quality, within the same country and consensus on how to dene frailty. Moreover,
between countries, are mixed. The extent to which being dependent does not necessarily mean the
selection effects account for differences between person is frail (Rockwood and Mitnitski 2007).
studies is not known. It is clear that most studies Adding to the complexity, some argue that suc-
exclude those living in long-term care institutions cessful aging does not mean avoiding declines in
who no doubt have a greater number in addition to health but includes adjusting to poor health and
more severe chronic conditions. Typically, our other challenges in old age. That is, someone who
physical health declines gradually. Not all older is sick, has poor health, or is frail can age well and
adults are incapacitated and, among those who have a good quality of life. Supporting this view is
are, there are degrees of disability. Many have a the research documenting that life satisfaction,
chronic condition (some loss of eyesight is an happiness, and well-being tend to be high even
example; diabetes might be another) but that con- among older adults with declining physical health
dition does not interfere with their functioning. and increasing disability. The vast majority of
When the health problem interferes with function- older adults report being happy or very happy
ing, typically it has more consequences for the for example in the USA, Canada, China, Italy,
204 Aging and Quality of Life
Germany, the Netherlands, Luxemburg, Austria, higher subjective well-being leads to healthier,
the UK, and Sweden (Chappell and Cooke 2010). more productive, and social connected lives
Health quality of life, similar to overall quality (Helliwell et al. 2013). That is, there are benets
of life, is measured both objectively and subjec- not only for the individual but also for families,
tively. Declines in objective measures of health, the economy, and community.
however, do not necessarily translate into percep- An added dimension is that correlates of hap-
tions of lower quality of life, pointing to the piness change somewhat as we age. Diener
importance of taking subjectivity into account. (2006), studying adults throughout the life span,
reports that while health satisfaction declines over
the life course, job and income satisfaction are at
Psychosocial/Subjective Well-being for much of life, but increase dramatically in later
life starting in the 60s and 70s and peaks later.
In this area the focus tends to be on specic Relationship satisfaction increases sharply from
domains of quality of life related to family, social the teen years to the 20s and is at until the
relationships, nances, leisure, spirituality, health, mid-40s then increases steadily until the late 70s.
and/or a combination of these domains that are Satisfaction with social life, amount of leisure
summed or weighted to provide an overall global time, and use of leisure time decreases sharply
evaluation of ones life. The subjectivity is espe- from the late teens to the early 40s, and then
cially important because the term quality sug- increases rapidly from the mid-40s to late 70s. In
gests a standard of valuation that many argue is most domains and the overall category, life satis-
necessarily subjective, dened by the individual faction ratings do not decline until very late (80+).
involved. This implies that older adults them- Indeed, when all domains are aggregated, there is
selves must be the deners of their own quality a high correlation with the global life satisfaction
of life (Walker and Mollenkopf, 2007). This argu- scale.
ment is supported by the Easterlin paradox which Furthermore, the salience of specic domains
essentially recognizes that within a society, rich of quality of life changes once we are older
people tend to be much happier than poor people; (speaking here of what we generally consider old
rich societies are no or not much happier than poor age 60+ or 65+). Not surprisingly, health and
countries; and average national happiness does relationships, especially with family, gain impor-
not increase over long spans of time, in spite of tance. The decline in satisfaction with health is not
large increases in per capita income (Helliwell surprising given the objective decline in physical
et al. 2013; Deaton 2008). Additionally, those health with age. While satisfaction with health is
who have a high standard of living and wealth related to objective measures of health, overall
can nevertheless be unhappy. Conversely, there satisfaction with life is not strongly related to
are those living in objectively disadvantaged cir- objective measures of health such as life expec-
cumstances who are happy. Even though much of tancy (Deaton 2008).
the research on the correlates or predictors of Global indices indicate that life satisfaction
quality of life, reports that social class or socio- among older adults is high. The vast majority
economic status is a signicant correlate, it report being very satised or satised with their
explains little of the variance. This accounts for lives and to experience high levels of overall
the apparent (but not real) contradiction with the happiness. Blanchower and Oswald (2008) ana-
fact that many subcultural groups who live in lyzed data from 72 countries, and nd a curvilin-
economic disadvantage also maintain good sub- ear (U-shaped) association between age and
jective quality of life. It also adds support to the psychological well-being across the life course.
argument that quality of life has, at minimum, a Specically, when factors such as gender, educa-
subjective component. Other typical correlates tion, income, and marital status are held constant,
include health and relationships with family and individual life satisfaction and happiness are at a
friends, including social support. Furthermore, minimum in middle age. In contrast, Deaton
(2008) reports that, internationally, age has an Indeed, one of the main paradoxes in this large
inconsistent relation with happiness and that the but inconsistent research literature is the fact that
U-shape is found only in wealthier objective measures of social class and socioeco- A
English-speaking countries. Part of the difculty nomic status often emerge as statistically signi-
in drawing conclusions in this area is the cant correlates of subjective measures of quality
diversity of measures used, making comparisons of life, and at the same time, economically disad-
problematic. vantaged groups can nevertheless experience a
Longitudinal research shows differing results subjective quality of life that is at least equal to,
depending on the country studied, and often dif- if not higher than, those with greater economic or
ferent studies conducted in the same country social class wealth. A challenge for this area is to
report different ndings. Some countries reveal adequately explain these apparent contradictory
curvilinear relationships whereby happiness is ndings. An answer likely lies in an examination
the lowest in middle age. Depending on the of the intersection of multiple facets of life (such
study, some aspects of subjective well-being as social class plus social support and
(such as positive affect) decline in old age while expectations).
others (such as negative affect) remain stable. Still
others nd that life satisfaction remains constant
across the lifespan, even among the oldest old
Cross-References
(Yang 2008; Kunzmann et al. 2000). In many
studies, age differences disappear when control-
Aging, Inequalities, and Health
ling for other factors such as functional limita-
tions, income, and social relationships such as
marital status.
Psychological Theories of Successful Aging
Psychological Theories on Health and Aging
Conclusions
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Aging and Semantic Memory
Gary D. Laver The Contents and Structure of Semantic

Psychology and Child Development Department, Memory
Cal Poly, San Luis Obispo, CA, USA
Copious evidence shows preservation of (if not an
increase in) the information stored in semantic
Synonyms memory such as vocabulary and general knowl-
edge as measured via IQ or similar tests through
Conceptual knowledge; General knowledge base; much of adulthood. Begun in 1988, the Betula
Semantic network Project has involved thousands of adult
Aging and Semantic Memory 207
participants assessed at ve-year intervals. One of Their ndings supported an age-invariant seman-
its primary goals is to study changes in adult tic component to declarative memory with sub-
memory functions through old age. Cross- divisions of knowledge (the contents of semantic A
sectional word comprehension and general memory) and uency the efciency with which
knowledge data reported from this study the knowledge can be accessed. (Additionally, an
(Nilsson 2003) have shown that although the episodic memory component emerged with sub-
best performance for adults was in their late 50s, divisions of recognition and recall.) Their results
there was no signicant difference in performance from vocabulary and knowledge-based tests, in
on semantic memory tasks between the group in particular, showed the same peak performance
their late 30s and the group in their late 70s. This described above in young-old adults with no sig-
corroborated many earlier ndings that substantial nicant differences between middle-aged and
decits in vocabulary do not become common old-old adult age groups. In the uency measures,
until ones 80s. somewhat greater decline was found among the
Rnnlund, Nyberg, Bckman, and Nilsson old-old.
(Rnnlund et al. 2005) performed a cross- Data from another large project in adult aging,
sequential analysis of data from the Betula Project the Seattle Longitudinal Study (SLS) (Schaie
involving a sample of participants from across ten 2013), provide evidence similar to the pattern in
age cohorts ranging from age 30 to 85. For the semantic memory found in the Betula Project.
portion of the study concerned with semantic This study was begun in 1956 and to date has
memory, participants from these ten groups were involved more than 6000 participants aged 22 to
administered general knowledge, vocabulary, and over 100. Compared to many other measures of
word uency tests on two occasions separated by cognitive ability, SLS data show verbal meaning
5 years. Semantic memory performance based on (vocabulary) scores decline the latest not until
the cross-sectional data indicated stable perfor- the late 70s but are then among the steepest. As
mance until age 55 and then a decline in perfor- the seven-year data cycles have progressed over
mance close to two standard deviations by age 85. the decades, peak scores in the latent verbal ability
In contrast, the longitudinal change scores actu- construct have moved from the 50s to the 60s.
ally showed improvement in semantic factors Even into the late 80s, declines in general verbal
through age 60 and then a much milder decline ability are modest. Indeed, because of the rise in
to age 85. Concerned about the possible inuence abilities through middle age, the SLS data show
of cohort effects on the cross-sectional data and essentially no difference in overall verbal abilities
practice effects on the longitudinal data, the between adults in their 20s and 80s.
researchers ran follow-up analyses to account for Yet another large project in adult aging, the
these factors. The adjusted adult age patterns for Victoria Longitudinal Study, has yielded ndings
both the cross-sectional and longitudinal semantic similar to the basic patterns reported above
memory data were remarkably similar to the pat- concerning semantic memory (Small et al.
tern for unadjusted longitudinal data: improve- 2011). Based on two semantic measures (world
ment through age 60 followed by mild decline knowledge questions and vocabulary), data gath-
into the 80s. ered over a period as long as twelve years from
Using participants from the Betula Project and nearly a thousand participants aged 5595 indi-
another sample, respectively, both Nyberg cated mild declines in world knowledge of about a
et al. (2003) and Enmarker et al. (2006) supported quarter of a standard deviation per decade prior to
the basic pattern of semantic performance over age 75 and half a standard deviation per decade
adult age described above through their compre- after that. No signicant changes in vocabulary
hensive examinations of the structure of declara- were found up to age 75; thereafter the declines
tive memory, the invariance of this structure were just shy of a third of a standard deviation per
with advancing adult age, and the nature of decade. Interestingly, for neither metric did
declining performance with advancing adult age. declines accelerate in the 80s.
Older adults semantic performance shows types of information. It is plausible, therefore, that
impressive resilience even when additional any adult age-related performance declines in
stressors are introduced. Situations in which semantic tasks may be attributable to retrieval
diminished performance would be expected due processes rather than changes in the structure or
to factors other than aging often do not produce content of the semantic memory system, per
interactive aging effects in semantic memory se. Consistent with this interpretation are produc-
tasks. For example, if older adults semantic struction decits such as generally increased speech
ture were compromised relative to young adults, disuencies with adult age and even an
one might expect noisy testing conditions to age-related increase in spelling errors when con-
impact older adults performance more severely veying well-formed ideas in writing (MacKay
than young adults. However, neither Enmarker et al. 1999).
(2004) nor Enmarker et al. (2006) found an inter- The assessment of semantic uency provides a
action of noisy test conditions with adult age on good example of how older adults decline in
word comprehension and word uency measures. production processes might mask intact semantic
Marital status is also well known to affect physical processes. Early studies of word uency showed
health and cognitive abilities. Compared to mar- decits in the rapid access of lexical material with
ried adults, declines are found in divorced, adult aging. As well, the Seattle Longitudinal
widowed, or never-married adults on such diverse Study (Schaie 2013) indicated signicant decre-
measures as periodontal disease, depression, gen- ment in word uency by age 60 (unlike its nding
eral cognitive abilities, risk for Alzheimers dis- of preserved vocabulary performance past the
ease, and life span. Yet, Mousavi-Nasab et al. 70s), and uency data from the old-old partici-
(2012) found no interaction of adult age and mar- pants in the Betula Project showed somewhat
ital status on vocabulary or uency tests. The greater declines relative to other semantic mea-
integrity of information in semantic memory sures. Other work suggests that diminished verbal
appears to hold across adult age even in the face uency past middle age may be less the result of
of factors known otherwise to diminish cognitive declines in accessing semantic content than of
performance. declines in executive or language production pro-
cesses. In a longitudinal study involving data col-
lection at two points separated by a three-year
Accessing Semantic Memory interval, Hultsch et al. (1992) found declines in
older adults world knowledge and verbal uency
The above discussion shows that the richness of but not in their vocabulary. These results have
semantic information is well maintained and even been interpreted as support for the culpability of
rises with age. To this may be added many other declining retrieval processes in that both the world
ndings that young and older adults produce com- knowledge and verbal uency tasks make high
parable semantic associations, demonstrate simi- retrieval demands but vocabulary does not.
lar effects of word frequency, and show the same Mayr and Kliegl (2000) used a word uency
inuence of the strength of two items semantic task to demonstrate more directly a dissociation
relatedness. All of the laboratory evidence between semantic processes that remain intact and
supporting the preservation of semantic processes executive retrieval processes that decline with
notwithstanding, age-related memory problems adult age. They had participants in one condition
are reported more frequently among older than generate exemplars from a single category; partic-
young adults, and these differences are conrmed ipants in another condition generated exemplars
in the laboratory in areas such as naming common from two alternating categories. They proposed
objects, producing words from denitions, and the that while executive and semantic search pro-
number of tip-of-the-tongue episodes (Burke cesses would be present in both conditions, addi-
et al. 2000). One clue to explaining this paradox tional executive functions would be present in the
is the robustness of reported decline across many two-category switching task. Their results showed
age effects in the nonsemantic, executive task participants undergoing an fMRI scan judge
elements. However, the rate of semantic access whether two named items shared a particular attri-
did not differ with adult age. Furthermore, the bute (e.g., are a carrot and cucumber the same A
manipulation of category difculty affected color?). While there was an age-group difference
young and older age groups equivalently, evi- on this task, a subset of the older adults performed
dence that adult age did not affect semantic comparably to the young adults. Generally speak-
retrieval. Along with their analyses of the struc- ing, semantic processing was associated with a
ture of semantic information, Nyberg et al. (2003) pattern of activation in the ventral-lateral
and Enmarker et al. (2006) found young-old temporal-occipital cortex for all the participants.
adults uency in producing information from However, the older adults who performed compa-
semantic memory was slightly better than rably to the young showed a different intensity of
middle-aged adults. Consistent with a broader brain activation. Relative to the young adults, the
pattern across adulthood, however, the old-old better-performing older adults showed more
adult age group showed signicant decline. activity bilaterally in the premotor cortex and in
Further support for the distinction between the the left lateral occipital cortex. The authors con-
activation of semantic information and the ability cluded that performance maintenance on this
to report it comes from a study by Shafto semantic task in some older adults was due to a
et al. (2007) of tip-of-the-tongue (TOT) experi- reallocation of the brain areas supporting the abil-
ences. Their work also provides a glimpse at how ity. Gray matter atrophy affected these areas in the
a neurological approach to changes in adult cog- older adults for whom task performance declined.
nition adds a dimension not captured by purely The issue of modied patterns of brain activation
behavioral measures. TOTs produce a frustrating with age is addressed more generally below.
failure to report key information (i.e., the name of
a target word) along with strong semantic activa-
tion of information related to the target. As men- Semantic Priming
tioned above, there is a parallel increase in
semantic knowledge and frequency of TOT epi- In addition to explicit behavioral and neurological
sodes as adults age into their 70s. This suggests a measures of semantic processes, semantic mem-
decit in reporting otherwise intact semantic ory may also be examined using implicit mea-
information. Shafto et al. uncovered evidence of sures. Explicit measures of the content or
the neural underpinnings of these parallel trends. structure of semantic memory or the speed of
Their ndings replicated a positive relationship accessing it based on deliberate, conscious search
between adult age and TOT frequency, but they (e.g., in a uency task or a free-recall paradigm)
also found a positive relationship between the may show age-related decline to the extent that
number of TOTs and the amount of gray matter they rely on executive or speech production pro-
atrophy in the left insula as measured by MRI. The cesses. But implicit measures of semantic pro-
left insula is known to support phonological processes avoid these concerns and provide
duction. What is more, this relationship held with corroborating evidence of preserved function
the effects of age removed, supporting the with adult aging. This is commonly demonstrated
involvement of declining phonological produc- in measures of semantic priming and with the
tion, not semantic impairment, with TOT semantic priming effect in particular. The seman-
frequency. tic priming effect is the empirical nding that
Neurological studies of semantic processes recognition or pronunciation of a target word
also show that equivalent or superior ndings on will take less time or be more accurate when the
cognitive measures in older versus young adults word is preceded by a meaningfully related word
may also suggest different forms of supporting than when preceded by an unrelated word or by no
neural processes in the two groups. Peelle word at all. For example, responding that the
et al. (2013) had young- and older-adult string of letters nail is indeed a word will be faster
if it is presented following the word hammer than all types of cognition (Salthouse 1996). Yet, many
following the unrelated word toast (or following of the ndings described above appear to contra-
no word at all). The semantic priming effect here dict the notion of universal slowing. In response to
would be the difference in reaction times between ndings incongruent with general slowing, a
the primed and unprimed conditions. This effect is modication of the theory emerged, domain-
held to be evidence for spreading activation, a specic slowing, in which tasks within a particular
theoretical (but neurologically informed) con- area of cognition exhibit decline due to slowed
struct by which recognition of a stimulus facili- processes. Pressing questions for domain-specic
tates responding to semantically related concepts. slowing include differences in the onset of
Theories representing semantic memory as a net- slowing in various areas of cognition and the
work of nodes and connections (Collins and rate with which slowing proceeds once begun.
Loftus 1975) attribute the reduced response time Nevertheless, the evidence discussed above is
or increased response accuracy in priming condi- consistent with domain-specic slowing in that
tions to a process of automatic spreading activa- executive and response production processes
tion from the node of a recognized word to the show decline, whereas access to and activation
linked nodes of meaningfully related words. among semantic concepts appear to remain intact
Responding to a related target is facilitated by well into adult age.
the accumulated activation from the node of the Another theory of cognitive aging that has
priming word. been applied to semantic processes is the inhibi-
In a meta-analysis of semantic priming effects, tion decit theory (Zacks and Hasher 1997). The
Laver and Burke (1993) found older adults fundamental premise in this theory is older adults
larger, but nonsignicant priming effects from diminished ability to inhibit task-irrelevant infor-
individual studies provided combined evidence mation. While evidence is found in many corners
that older adults benet more from a semantically of the cognitive aging literature for greater activa-
related prime than do young adults. Not surpris- tion of distracting information in older adults and
ingly, older adults greater priming effects are their reduced ability to inhibit these distractions,
typically associated with longer response laten- this approach does not seem able to explain older
cies than for young adults. To address the concern adults preserved or improved verbal and seman-
that their longer response latencies permitted tic abilities relative to young adults. As summa-
older adults a greater accumulation of spreading rized above, older adults have no trouble with the
activation and thus greater priming, Laver (2009) comprehension or concept generation processes
employed a response deadline procedure to equal- associated with semantic tasks, but their response
ize response times for young- and older-adult production is often impaired. Inhibition decit
participants. With processing times controlled theory does not account for this asymmetry.
across age groups, older adults still showed Even when considering the one aspect of verbal
semantic priming effects at least as large as production that inhibition decit theory does pre-
young adults. This suggests the mechanism by dict, verbosity or off-topic speech, the detailed
which information in the semantic memory sys- evidence is not congruent with inhibitory decits.
tem is accessed is at least as efcient in older than The amount of older adults verbal output varies
young adults. with the kind of topic they are addressing, but
when they are verbose, older adults speech is
denser with topic-relevant information.
Semantic Memory and Theories As an elaboration on earlier network theories
of Cognitive Aging (Collins and Loftus 1975), node structure theory
is able to account for older adults retained com-
Among the oldest theories of cognitive aging is prehension processes and rich semantic networks
general slowing, which holds that speed of execu- as well as their difculties in response production
tion diminishes with advancing adult age across (Burke et al. 2000). This theory organizes nodes
and their connections into hierarchical levels, with connections is easily overcome, and no
phonological and orthographic nodes at the bot- age-related declines are manifest. Because node
tom, lexical nodes above that, and propositional structure theory acknowledges the likelihood of A
nodes forming the uppermost level. The ow of slower cognitive processes (i.e., spreading activa-
activation in perceptual/recognition processes is tion) within the semantic system, in its own way it
bottom up. The multiple feature nodes of a seen or corroborates general slowing theory. But the
spoken stimulus send activation upward along semantic richness of old age and the converging
connections that converge on a lexical node. bottom-up node structure compensate for this
This spreading activation summates at the lexical slowing. This results in a preservation of function
node and may surpass a threshold level resulting not seen in other areas of cognitive aging.
in the recognition of a word. An activated lexical Craik (2000) has written of the possibility that
node, in turn, sends activation across connections the general performance difference between epi-
to related propositional nodes in the level above. sodic and semantic memory in older adults may
Related nodes not receiving activation sufcient stem from the specicity constraining the expres-
to result in conscious recognition nevertheless sion of information from the two domains.
receive a boost toward that threshold. In such a Semantic memory affords a richness or redun-
primed state, these nodes require less additional dancy of information not present in episodic
activation to reach threshold relative to their base memory. As a consequence, much semantic infor-
state. mation is open to various ways of expression,
Activation within the semantic system of lexi- whereas episodic memories concerning time or
cal and propositional nodes is supported by the place must be more specically expressed. Craik
redundancy of connections among its nodes. sees this as a potential explanation of declines in
Along with reduced frequency or recency of use, semantic memory performance involving infor-
node structure theory posits that advancing age mation that leans toward the specic and for
may of itself diminish the ability of individual which there are few if any possibilities for
connections to transmit as much spreading activa- rephrasing, e.g., word nding or recall of names.
tion as quickly as in young adults. In compensa-
tion, however, adult age results in more nodes and
connections in the semantic system reecting a Semantic Memory and Adaptation
greater knowledge base than in younger adults.
The greater number of connections can offset their An important theme that emerges from the work
diminished individual functioning, which on cognitive aging in general and semantic mem-
accounts for the nding that older adults semantic ory in particular is that of adaptation. The process
priming effects are at least as large as young of cognitive adaptation in adult aging is found in
adults. areas of study as distinct as age-related changes in
However, the one-to-many, diverging architec- basic neurological functions and the ability of
ture of top-down pathways (e.g., from concepts to elders to function in the everyday world. In the
phonology) in node structure theory does not rst area, we can juxtapose older adults well-
always provide sufcient activation for responses, preserved semantic functions with the substantial
and this transmission decit (along with older adaptation (relative to young adults) in the brain
adults slower connection speed) can explain tissue that supports those functions. In the second
diminished age-related response production even area, there is the possibility of adapting preserved
though concept recognition and generation are semantic memory to the practical support of other
spared. When summation of priming is supported, cognitive functions that decline sooner or more
as in bottom-up processes or in the spread of rapidly in adulthood.
priming among the copious connections within a The rst form of adaptation involves changing
rich semantic network, the diminished capacity cognitive structures and changing patterns of
for transmission of priming within individual neurological activation with advancing adult age.
Not only may older and younger adults equiva- activation address far more than semantic mem-
lent performance on certain cognitive tasks rely ory. But for all the relative resilience of semantic
on different patterns of brain activation processes through adulthood, it is noteworthy that
(as discussed briey above), but older adults they too are subject to the broad inuence of
may demonstrate generally more distribution of dedifferentiation.
brain activation as well. The proposition that what The second form of adaptation concerns
are distinct neurological or cognitive functions in semantic memorys relative durability and how it
early adulthood merge as adulthood progresses is may serve to support practical aspects of aging. Is
known as dedifferentiation. Support for dediffer- it possible to capitalize on the relative preserva-
entiation comes from two broad, converging tion of semantic memory in older adults to support
sources: analysis of behavioral measures (both or improve other cognitive functions, episodic
cross-sectional and longitudinal) and results memory in particular? It seems intuitive and
from neuroimaging techniques. In tying these has been formally argued that semantic
diverse data together, Cabezas (2002) theory of memories ordinarily begin as forms of episodic
hemispheric asymmetry reduction in older adults memory, but there is preliminary evidence that
(HAROLD) also incorporates evidence of dimin- semantic memory serves to support the formation
ished age-related asymmetry in word recognition of episodic memories as well (Cabeza 2002;
and semantic retrieval tasks. What is more, early Greve et al. 2007). Some recent work has
ndings of increasing age-related correlations explored the question of whether invoking seman-
among cognitive measures as well as their increas- tic aspects of information may improve older
ing correlations with measures of sensory func- adults episodic memory performance (e.g., list
tion suggest that dedifferentiation could occur not learning).
only within a cognitive domain (such as semantic Episodic memory may be tested by having
memory) but also across cognitive domains (such participants study lists with individual words or
as semantic memory and sensory processing). lists with paired words. Memory for lists
Hlr et al. (2015) corroborated this notion with containing unpaired items is commonly tested
data from the Seattle Longitudinal Study, indicat- via free recall, but paired-item lists often involve
ing the consolidation over adulthood of subtest cued recall in which the rst item from a word pair
scores on number ability, verbal meaning, and is presented as a cue for remembering the associ-
word uency within the factor of crystallized, ated second word. Relative to young adults, older
semantic abilities. Their analysis also indicated adults performance in recalling single items from
the coupling of this factor with others such as a study list is impaired, but the decit is even
uid abilities and visualization. greater for paired items. This has been attributed
Copious neurological data complement the to a problem in binding the paired words. Binding
cognitive data that point to dedifferentiation in is considered essential in linking two, often arbi-
showing shrinkage of brain tissue and reallocation trarily paired words for subsequent cued recall.
of brain activity. Park and Reuter-Lorenz (2009) Naveh-Benjamin and his colleagues have investi-
not only provided a review of such ndings from gated whether semantic memory support can alle-
imaging studies, they also offered the scaffolding viate older adults associative decit in recalling
theory of aging and cognition (STAC) to paired items. They examined whether word pairs
account for them. STAC posits that cognitive with existing semantic relationships (e.g., doctor-
scaffolding the use of additional neural nurse) would improve older adults cued recall
resources to bolster declining structures occurs over pairs with no such relationship (e.g., rock-
throughout life in response to cognitive chal- number). Their results were mixed. A prior
lenges. It does, however, become more prevalent semantic relationship between paired words did
over time as adult aging results in more frequent help older adults recall performance relative to
challenges. Of course, theories of age-related the condition in which the paired words had no
changes in cognitive function and neural semantic relationship, but this occurred only for
items in long-term, not short-term memory condi- functioning. Everyday life does not regularly pre-
tions (Brubaker and Naveh-Benjamin 2014). sent the abstract, novel problems found in formal
All else being equal, the mental clustering of assessments. Furthermore, there are multiple A
to-be-remembered information from a list determinants of successful functioning in every-
according to semantically related categories is day life (e.g., motivation, focus, and personality in
well known to improve recall relative to condi- addition to cognitive abilities), and older adults
tions in which no strategy is used, but there are often make accommodations to declining skills by
mixed ndings regarding the benet of this strat- delegating increasingly challenging responsibili-
egy in older adults. At rst thought, it might seem ties to others or avoiding difcult tasks altogether.
that older adults would have an advantage in the But most relevant to the subject of adult age and
ability to organize such information based on the semantic memory is Salthouses point that older
strength of their semantic networks. However, adults promote successful functioning in every-
strategically utilizing semantic information day life by adopting a strategy of shifting from
requires executive resources that are not necessar- novel processing to reliance on their lifetime of
ily resistant to decline over adulthood. Kuhlmann accumulated knowledge. As Salthouse points out,
and Touron (2014) investigated whether the little or no consequence of cognitive declines
semantic clustering of items would improve may be evident when one can draw upon relevant
older adults recall performance on a list-learning knowledge, and older adults greater world
task. Older adults were certainly capable of knowledge and intact ability to draw on it may
forming semantic clusters of list items, but this serve an important role in their success in every-
strategy was effective for them only when the day tasks.
words were presented simultaneously on a single
screen. When the words were presented individu-
ally, the dual task demands of needing to keep the Summary
words in mind along with the strategy of forming
semantic clusters reduced the older adults perfor- In normal adult aging, the rich network of infor-
mance to the level found when no semantic clus- mation in semantic memory is retained, at least
tering was used. (Younger adults recall was through ones mid-80s. Although some studies
superior to the older adults, and they performed suggest that verbal uency in reporting semantic
as well regardless of word presentation format.) information may decline earlier, these ndings
The above discussion suggests that, within the may well be the result of declining executive and
laboratory at least, older adults intact semantic language production processes, not the impair-
processes may be hard pressed to improve the ment of the semantic memory system itself. Fur-
function of episodic processes because using ther evidence for the strong preservation of
them may rely on diminished processing semantic memory into old age comes from studies
resources. of semantic priming, an implicit measure of
Outside of the laboratory, preserved semantic access to semantic information. Using semantic
processes likely serve a critical role in older memorys relative strength in the support of other
adults ability to deal with everyday life. Despite declining cognitive abilities has received limited
copious evidence of adult age-related cognitive support from laboratory studies but seems to be
decline (in areas other than semantic processing), critical in maintaining older adults everyday
everyday functioning appears typically spared in functioning.
older adults. Salthouse (2012) offered several pos-
sible explanations for this incongruity. First, even
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Aging and Slowing of the Neuromotor System 215
Shafto, M. A., Burke, D. M., Stamatakis, E. A., Tam, P. T., movement. There is also an age-related change
& Tyler, L. K. (2007). On the tip-of-the-tongue: Neural in the complexity of output of the human physio-
correlates of increased word-nding failures in normal
aging. Journal of Cognitive Neuroscience, 19, logical and behavioral systems (Lipsitz 2002; A
20602070. Lipsitz and Goldberger 1992; Vaillancourt and
Small, B. J., Dixon, R. A., & McArdle, J. J. (2011). Track- Newell 2002).
ing cognition-health changes from 55 to 95 years of A pervasive phenomenological change with
age. The Journals of Gerontology Series B: Psycholog-
ical Sciences and Social Sciences, 66B, i153i161. aging that has been the subject of considerable
Tulving, E. (1972). Episodic and semantic memory. In experimental investigation is the progressive
E. Tulving & W. Donaldson (Eds.), Organization of slowing of the neuromotor system (Cousins
memory (pp. 382403). New York: Academic. et al. 1998; Moehle and Long 1989; Deary
Zacks, R., & Hasher, L. (1997). Cognitive gerontology and
attentional inhibition: A reply to Burke and McDowd. et al. 2010). The slowing of movement-related
Journal of Gerontology: Psychological Sciences, 52B, properties is found across all levels of analysis of
P274P283. the system (behavioral, neural, chemical, thermal)
and from dynamic analyses of the organization of
subsystems in the control of movement behavior,
such as the muscle, spinal cord, and brain. The
Aging and Slowing slowing of the aging motor system is also apparent
of the Neuromotor System in a range of behavioral movement-related prop-
erties. Indices of slowing in aging have been
Steven Morrison1 and Karl M. Newell2 reported across the spectrum of movement
1
School of Physical Therapy and Athletic actions, from eye movements to ne motor skills
Training, Old Dominion University, Norfolk, involving a small number of joints/muscles such
VA, USA as in laboratory reaction time-movement time and
2
The University of Georgia, Athens, GA, USA nger-tapping tasks and more complex gross
motor activities such as walking that involves
the coordination and control of multiple elements
Synonyms of the skeletal-muscular system. Figure 1 provides
a schematic overview of the predominant qualita-
Neuromuscular system; motor processes; physio- tive changes in movement tasks and properties of
logical declines; loss of complexity with aging motor control with aging.
The slowing of the motor system in aging leads
to a loss of functional capacity, adaptability, and,
Definition in the ultimate expression, death (Birren and
Fisher 1991). The changes in the timescales of
The declines observed across numerous motor motor output and the multiple processes that sup-
functions that develop as a consequence of the port it provide an interdisciplinary window into
natural process of aging can be broadly viewed the motor control of aging. There has been an
within the context of a general slowing of various increasing interest in systems frameworks of ana-
physiological processes. lyses to the timescales of change in aging given
The processes of aging tend to progressively that it is difcult to ascribe a causal relation (as in
degrade the human motor system and reduce the the reductionist agenda) of one particular process
ability of even healthy elderly individuals to move to the performance decrement with aging.
and perform skillfully in the tasks of everyday life
(Spirduso 1985). At the behavioral level of anal-
ysis, these detrimental effects of aging are most Discrete Movement Tasks
typically manifest in the decrement of perfor-
mance outcome, a change in indices of movement Reaction Time. Assessment of reaction time
variability and/or a loss in the efciency of (RT) in discrete movement tasks has been a
216 Aging and Slowing of the Neuromotor System
Slowing of Motor Responses

with Aging
Discrete Movements Continuous Movements
Gait
Slower gait speed, decreased cadence
Reaction Time Decreased step length
Slowing of responses Wider walking pattern
Seen under simple and Implications for falls
complex task conditions
More complex tasks lead to
Older Adult Finger Tapping
Central and peripheral Decreased speed and/or number of
slower reactions
neural changes responses
Increased inter-trial
Changes in motor units
variability of responses with
properties
aging
Declines in strength Physiological Tremor
Different strategies Increased amplitude
Movement Time Transition to lower part of 8-12 Hz range
Slowing of responses Loss of fast time scales?
Consistent with speed-accuracy
tradeoff?
Neural basis for more cautious Isometric Force tremor
approach? Increase in fluctuations
Increased variability
Not purely driven by strength
differences
Aging and Slowing of the Neuromotor System, Fig. 1 Schematic illustration of the various changes in motor
outputs with aging. The general characteristics of the changes within each movement are also outlined
common approach to determining the impact ready signal to the presentation of the go
aging has on cognitive and neuromotor processes signal) is usually varied so the individual cannot
(Bunce et al. 2004; Graveson et al. 2015; Hultsch predict when the stimulus to start the movement
et al. 2002; Spirduso 1980; Spirduso et al. 1988; response is provided (Welford 1971, 1988).
Williams et al. 2005; Welford 1988). Reaction Typically, reaction time tends to progressively
time measures the latency from the presentation increase (i.e., individuals get slower in the latency
of a go signal to the onset of the appropriate of their responses) from their mid-20 years until
movement response (Spirduso 1980, 1985). Typ- the individual passes 70 years of age (Welford
ically, investigators assess the response latency of 1988). Naturally, the changes in age-related RT
the subject under either simple reaction time are more marked when the task response is more
(SRT) or choice reaction time (CRT) conditions. difcult, as where individuals are required to
SRT consists of a single stimulus to begin the respond under CRT situations (Bunce
action that is paired to a single possible response. et al. 2004; Spirduso 1980; Williams
For CRT conditions, more than one stimuli is et al. 2005). The use of EMG to fractionate RT
available to be presented, with each stimuli requir- has shown that the majority of the simple and
ing a different response (e.g., the varying stimuli choice RT age effect is in the pre-motor
may relate to performing the action with a differ- phase that is, the time from the onset of the
ent effector or, when performing the action, mov- stimulus to begin the action to the initiation of
ing to different targets). The time taken to perform muscle activity (Clarkson 1978). Interestingly, the
the movement component of the task is referred to effects of age on both RT and the time it takes to
as movement time (MT). To minimize any antic- perform the desired movement (MT) are not the
ipatory actions, the foreperiod (i.e., time from a same across genders, with males generally
Aging and Slowing 500

of the Neuromotor
System, Fig. 2 Age-
related differences in simple A
reaction time responses.
Data were attained from
Simple Reaction Time (msec)

400
75 healthy adults ranging in
age from 30 to 80 years of
age. The reaction time task
involved depressing a
computer button with the
index nger in response to 300
a light stimulus. Three
individual trial responses
from each person are shown
in this gure
200
30 40 50 60 70 80
Age (years)
exhibiting faster (shorter latency) responses com- range of studies have shown how the complex-
pared to females. However, both males and ity/variability of such diverse physiological time
females are similarly inuenced by condition series such as brain activity (i.e., EEG), neuro-
effects such as complexity of stimulus context muscular function, respiratory and cardiovascular
(Der and Deary 2006). An example of the typical responses, balance, walking ability, physiologi-
pattern of change in simple RT with age is shown cal/pathological tremor, and hormone secretion
in Fig. 2. is systematically affected by increasing age in
The resultant age-related slowing of motor adulthood (Hausdorff et al. 2005; Newell
responses under the various RT situations is not et al. 2006; Peng et al. 1995; Pincus 1994).
simply reected by changes in the average latency Movement Time. Within the context of the
of the persons response. Increases in reaction time discrete movement paradigm, MT
intraindividual variability (i.e., trial-to-trial varia- captures the time from initiation of the selected
tion in RT performance) are also a function of response to the termination of the movement
healthy aging (Graveson et al. 2015; Hultsch (Schmidt and Lee 2011; Spirduso 1985). Similar
et al. 2002; Light and Spirduso 1990). Together, to the results reported for RT changes with aging,
the age-related slowing of RT and increased trial- older adults tend to exhibit a slowing of MT
to-trial RT variability has been linked with a gen- (Sleimen-Malkoun et al. 2013a; Temprado
eral decline in cognitive functioning, including et al. 2013; Birren and Fisher 1991; Heitz and
attentional and/or executive control mechanisms Schall 2012; Ketcham and Stelmach 2004).
(Bunce et al. 2004; Deary et al. 2010). Based upon an understanding of the age-related
Interestingly, the reports of increased intertrial changes in various physiological processes, a
variability with aging are consistent with the gen- number of different explanations such as neural
eral view that the process of aging or the emer- noise theory and the general slowing hypothesis
gence of age-related diseases is reected by were developed to explain the slowing of MT with
changes in the variability and/or complexity of a aging (Schmidt and Lee 2011; Spirduso 1985).
given physiological process (Lipsitz 2002; Lipsitz Aging individuals tend to follow the speed-
and Goldberger 1992; Vaillancourt and Newell accuracy relation described by Fitts (1954) law
2002). Indeed, from this perspective, a diverse in aiming tasks, but the effect of task difculty
(amplitude increase and/or target size decrease) activities, older adults often exhibit reduced con-
tends to slow the movement more than in young trol in force production, as quantied by an
adults (Fitts 1954; Forstmann et al. 2011; Smith increase in the amplitude of these uctuations
and Brewer 1995; Ketcham and Stelmach 2004; (Kinoshita and Francis 1996; Lazarus and Haynes
Sleimen-Malkoun et al. 2013b). 1997). Interestingly, this decrement in force-
producing capacity has been interpreted to reect
changes in motor unit (MU) control and sensori-
Continuous Movement Tasks motor function and not simply in terms of muscle
strength. The consequence of these changes is that
Aging-related effects of the slowing of the elderly adults exhibit greater targeting error and
neuromotor system have also been studied in isometric force variability.
sequential and continuous movement tasks. The Gait. Walking performance is another move-
aging-related slowing of the motor system is ment activity where declines are observed with
observed in both the preferred rhythm and the increasing age in adulthood. The preferred walk-
maximal frequency (or minimal duration) of ing speed of healthy older adults (i.e., over
motor output for a given task. 60 years) tends to be signicantly slower than
Finger-tapping. The pattern and frequency of healthy adults in their 20s, and walking speed
nger-tapping has been widely used to assess how continues to decline as the person ages further
aging or neurological disease impacts on central (Murray et al. 1969). One reason for this decrease
nervous system function (Aoki and Fukuoka in speed appears to be that older persons take a
2010; Arunachalam et al. 2005; Cousins shorter step length in preference to altering (i.e.,
et al. 1998; Moehle and Long 1989). Consistent decreasing) step time (Himann et al. 1988; Winter
with the general trend of the observed slowing of et al. 1990; Owings and Grabiner 2004). Further
movement responses, several studies have adaptions utilized by older adults include increas-
reported a decline in nger-tapping speed (i.e., ing the proportion of time spent in double stance
declines in overall rate and longer inter-tap inter- (i.e., both feet in contact with the surface of sup-
vals) and increased variability of tapping port), taking wider steps, and reducing the propor-
responses in both healthy older adults and persons tion of time spent in the swing phase during
with neurological disorders such as Parkinsons locomotion (Murray et al. 1969; Winter
disease and Alzheimers disease and where dam- et al. 1990). The goal of these adaptations would
age to the cerebrum leads to declines in cognitive appear to ensure an optimal level of dynamic
function (Cousins et al. 1998; Shimoyama balance during locomotion and prevent falls
et al. 1990). The basis for this decline appears to (Maki 1997). Figure 3 illustrates the general pat-
be embedded within neuromotor changes rather tern of change in gait speed as a function of the
than being attributed to decits in peripheral sen- normal process of aging.
sory function or force-producing capacity of the However, these decrements in walking perfor-
muscles involved in the task (Aoki and Fukuoka mance are not the singular product of chronolog-
2010). ical aging per se. Several studies have found no
Isometric Force Control. When grasping an gait differences between healthy young and
object with the hand, there is a requirement to elderly adults when the older individuals have
produce a certain level of (isometric) force in been screened for potential physical impairments
order to hold and manipulate the object (Grabiner et al. 2001; Owings and Grabiner
(Flanagan et al. 1999). In performing these tasks, 2004). These ndings indicate that factors other
the resultant force prole is characterized by a than chronological age such as fear of falling,
series of small uctuations or oscillations referred decline in cognitive processing speed, decreased
to as force steadiness or isometric force tremor leg strength, and/or reduced leg range of motion
(Enoka 1997; Christou and Carlton 2001). Con- are also likely to contribute to the slower walking
sistent with the pattern of ndings for other speeds observed in the average elderly individual
Aging and Slowing 2.0

of the Neuromotor
System, Fig. 3 Pattern
of changes in individual 1.8 A
walking speed as a function
of increasing age. Gait
speed data were attained 1.6
while healthy individuals
(n = 75) walked at their
Gait Speed (m.s)

preferred speed on a 20 f. 1.4
GAITRite pressure-
sensitive walking surface.
Three individual trial 1.2
responses from each person
are shown in this gure
1.0
0.8
0.6
30 40 50 60 70 80
Age (years)
(Maki 1997; Kang and Dingwell 2008). These factor. For example, the slowing of RT, increased
associations of potential causal factors provide trial-to-trial RT variability, and decreases in
indirect evidence that there are multiple contribu- tapping speed have primarily been tied to a gen-
tions to the slowing of neuromotor system with eralized decline in cognitive function. In contrast,
aging. changes in tremor and force production have been
Generalization of Intraindividual Move- attributed to decline in neuromuscular function,
ment Slowing Across Tasks. The ndings on particularly with respect to changes in MU capa-
the behavioral slowing of the aging movement bilities. Many of the reported age-related declines
system in different motor tasks have typically have been linked to structural changes within the
been reported in isolation. This experimental CNS itself that can include decreases in overall
design does not afford an examination of the conduction velocity, age-related losses of white
generalization of intraindividual movement matter and gray matter, and degeneration of neu-
slowing that is assumed to hold in theories of rotransmitter systems (Zimmerman et al. 2006;
aging. The limited studies on intraindividual gen- Soares et al. 2014; Wang and Young 2014; Seidler
eralization have reported modest correlations of et al. 2010). A consequence of these structural
movement slowing over tasks with the effects changes within the CNS is that, when performing
stronger as aging advances (Bielak et al. 2010; the same motor task, older adults demonstrate
Dykiert et al. 2012). increased activity across a wider network of
motor areas within the brain (including the
regions of the prefrontal cortex and basal ganglia)
Physiological Basis for Slowing compared to younger adults (Seidler et al. 2010;
Riecker et al. 2006; Ward 2006).
Physiological Function and Structure. While In addition to the central changes in function,
there seems to be little dispute regarding the gen- there are a number of peripheral physiological
eral slowing of behavioral responses with aging changes that may impact on the ability of the
and age-related diseases, the basis for such older adult to respond quickly and appropriately.
changes cannot be linked to any single dening Central to these changes is the general decline in
skeletal muscle function that leads to an overall High

Young Old
decrease in muscle cross-sectional area, a reduc- 1
tion in muscle mass, and a decline in strength. 2
Specic structural and functional neuromuscular 3
Degree of Accuracy
changes that can arise with aging include
increases in the variability of MU ring, atrophy
of fast-twitch MUs, remodeling of MUs, and a
decline in the number of alpha motor neurons
(Erim et al. 1999). These peripheral changes
have been linked to the slowing of gait responses,
declines in isometric force control, and the altered
dynamical structure of physiological tremor
(Himann et al. 1988; Kang and Dingwell 2007; Low
Morrison and Sosnoff 2009; Enoka 1997). Fast Slow
As an example, changes (slowing) in physiolog- Response Time
ical tremor dynamics have been widely reported in
healthy older individuals. The primary mechanism Aging and Slowing of the Neuromotor System,
Fig. 4 Illustration of the potential differences in the
for this change has been some compromise in the speed-accuracy trade-off as a function of increasing age.
neural output the result of a general decline in the The increased response time for older adults in comparison
functional capacity of the aging system (Elble to young adults may reect that they operate on a different
1998; Morrison et al. 2006; Raethjen et al. 2000). point and/or curve. For example, to achieve a similar
degree of accuracy as the young adults, older persons
Physiological tremor is an intrinsic property of a may operate on a different curve (3), or if they operate on
normal functioning nervous system which reects the same curve (2), they would trade-off accuracy for speed
the aggregated contribution from the mechanical (Adapted from Spirduso 1985)
resonant properties of the limb segment, cardiac
mechanics, central neural mechanisms, and more possibility that older adults select different strate-
peripheral neural contributions from stretch gies when performing movement tasks compared
reexes (Elble and Koller 1990; McAuley to younger adults. Under RT conditions, for exam-
et al. 1997). The oscillations of the central neural ple, there is evidence to indicate the older individ-
component of physiological tremor are typically ual is often more careful and cautious in their
within the 812 Hz range and represent output selection of when to respond in effect trading
from neural oscillatory structures including the speed of movement for accuracy of performance
basal ganglia, thalamus, inferior olive, and alpha (Bunce et al. 2004; Hultsch et al. 2002; Light and
motor neurons within the spinal cord (Elble 2000; Spirduso 1990; Williams et al. 2005; Spirduso
McAuley et al. 1997). For older adults, changes in 1985). Thus, in comparison to younger adults,
this intrinsic, involuntary motor output are reected older persons may prioritize minimizing perfor-
by increases in overall tremor amplitude and/or a mance errors over moving faster, and so the
decrease in frequency, with the tremor responses observed slowing of responses may actually
being observed at the lower range of the 812 Hz reect that they occupy a different criterion posi-
bandwidth (Elble 1998; Morrison and Sosnoff tion on the speed-accuracy continuum (Spirduso
2009; Raethjen et al. 2000). Thus, the general 1985; Welford 1988). Figure 4 illustrates this pat-
slowing of motor responses is also reected by a tern whereby older adults may operate on a differ-
loss of the fast timescale processes inherent in ent point and/or curve with regard to the relation
physiological tremor of postural control. between speed of response and target accuracy
While the predominant view is that the slowing (Salthouse 1979). However, this is not to say that
of movement responses is primarily driven by this trade-off is voluntarily driven and occurs inde-
declines in physiological processes, an alternate pendent of any age-related changes in the underly-
(but related) consideration relates to the ing neurological structures. For example, studies
have reported that the adoption of a more cautious physiological slowing of the neuromotor system
selection strategy in older adults could also be as a function of aging. For the majority, these
reective of alteration in the activation pattern examples rest on the traditional distributional ana- A
and/or impaired neural connectivity between such lyses of temporal components of behavioral
regions as the supplementary motor areas and stri- responses and activities that are driven by the
atum (Bogacz et al. 2010; Forstmann et al. 2011; mean and standard deviation of the dependent
Heitz and Schall 2012). Supporting this view, van variable in question (e.g., RT, MT, nger-tapping
Dyck and colleagues (2008) reported that declines rates, average gait speed, and cadence). This stan-
in dopaminergic function within the basal ganglia dard approach, however, takes out the roles of
can be linked to the progressive slowing of RT in time- and frequency-dependent structure in a
older adults (van Dyck et al. 2008). time series of behavioral output in spite of being
The consequences of the declines across vari- concerned about the role of time in aging and,
ous physiological systems are not simply more generally, developmental processes.
restricted to performance within the context of a Since the early 1990s, there has been a con-
single task. One of the major health concerns for certed effort to introduce a new view to understand-
older adults is the likelihood of suffering a fall ing the problems of aging that is formulated around
(Tideiksaar 1998; Tinetti et al. 1988). The trend of the general umbrella theoretical constructs of self-
a slowing of responses, including decreased organization and the emergent complexity (Lipsitz
strength, slowing of reactions, walking slower, and Goldberger 1992; Vaillancourt and Newell
loss of physiological variability, impaired bal- 2002). The construct of self-organization in behav-
ance, changes in visual and/or sensory function, ior is tied to the emergent dynamics, their change
and declines in cognitive functioning all are fac- over the life span, and the contribution of different
tors that are linked with (and contribute to) timescales to this process. The timescales provide a
increased falls risk for older individuals (Close window into the role of different processes in a
et al. 2005). There is little doubt that the combined systems framework to movement behavior and its
gradual slowing of responses across a range of change over time. In this view, a timescale is not
physiological and behavioral outputs are driving merely the duration of an event as in the typical
factors underlying the increased occurrence of psychological framework, but is an interval that
falls in older adults. However, the consequences arises from the intrinsic dynamics of the system
are not simply limited to the immediate outcomes (growth-decay and/or oscillatory processes).
of suffering a fall (e.g., injury, death), as the long- This approach incorporates the use of
term effects can be just as problematic. Indeed, a nonlinear dynamics, frequency analysis, and
previous fall can be the precursor for a downward time series analysis to provide additional insight
cascade of decline, as many people become less as to process of aging and/or disease. While dis-
physically active, which can lead to further losses tributional analysis of variables through a mean
of muscle strength, adopting a slower, more cau- and SD is still useful, it does not directly address
tious walking pattern, and exhibit increased tired- the time- and frequency-dependent properties of
ness following a fall. All these outcomes can physiological and behavioral data that are often
ultimately lead to a further increased risk of falling more sensitive to age-related change. Moreover,
and are viewed as markers for the descent into Gilden et al. (1995) showed that even the pattern
physical frailty (Fried et al. 2001). of RT responses, rather than exhibiting a normal
distribution, was more appropriately character-
ized by complex frequency and nonlinear tenden-
Aging and the Adaptation of Multiple cies (the pattern was referred to as an example of
Timescales 1/f noise). Subsequently, there have been many
developments around this dynamic theme to tra-
The preceding sections show the pervasive and ditional human performance variables in different
well-established examples of behavioral and experimental paradigms.
Aging and Slowing

of the Neuromotor
System,
Fig. 5 Differences in the
pattern of stride interval
(top, a) during walking in
healthy young and older
adults. Plots of the resultant
differences in signal
complexity (bottom, b)
using detrended uctuation
analysis are also shown
(Figure adapted from
Hausdorff et al. 1997)
Hausdorff and colleagues (1997) studied the structure of the variability of the gait cycle over
increase in the degree of variability of the gait time. An important consequence of this
pattern in aging adults and disease states such as nding is that it shows that the variability of the
Huntingtons and Parkinsons disease (Hausdorff gait cycle is not that of a signal plus noise process,
et al. 1997). They used spectral analysis and as has been viewed traditionally in studies of gait
detrended uctuation analysis to reveal the struc- variability and assumed more generally in
ture in the gait cycle beyond mean and SD of age-related performance decrements. Rather, this
stride length (see Fig. 5). Their central nding result highlights that there is an inherent dynamic
was that the variability of the gait cycle exhibits structure to the variability of movement patterns
properties of a self-similar system. That is, uctu- and that deviations from the typical pattern of
ations of the gait cycle exhibit long-range corre- complexity may reveal insights as to the impact
lations such that the stride properties of any given aging and disease on the selected motor output.
cycle are dependent on a cycle previously at rather Sosnoff and Newell (2008) examined the
remote times, perhaps hundreds of cycles earlier age-related loss of adaptability to fast timescales
in the locomotion sequence. Their analyses in the motor variability of isometric force pro-
showed, as others have since, that the dependence duction (Sosnoff and Newell 2008). The senso-
of the stride interval decays as function of a rimotor outputs to differing time and frequency
power law, suggesting a fractal pattern to the properties (1/f noise structures) of target-force
waveforms were studied. By having force- The challenge is that correlates of the slowing
tracking pathways that followed different fractal of movement speed with aging can be found at
noise structures, the manipulation of timescales many theoretical levels of analysis thereby lend- A
in the task demands could directly be accom- ing support to the veracity and relevance of all
plished (i.e., changing the relative contribution theories of aging although no single unied theory
of long- and short-frequency processes). The has adequately captured the full scope of the
results showed that, when compared to younger declines seen across the various movement
adults, the older persons were progressively less domains. Spirduso (1985, 2005) has proposed
able to approximate the lighter-color noise force that the most compelling hypotheses to explain
targets and utilize information in the higher fre- the age-related behavioral slowing are to be found
quencies of the target signal. in the various manifestations of biological deteri-
The ndings of Sosnoff and Newell (2008) are oration that induce the slowing of movement in
consistent with aging and the loss of complexity action seen in the aging adult. The systems
hypothesis of Lipsitz and Goldberger (1992), approach to the loss of complexity (Lipsitz and
given that there was a declining ability with Goldberger 1992) provides a complementary
aging to use the faster timescales of sensorimotor framework for investigating the array of
control in force output. However, several studies age-related changes found for physiological and
have now shown that the particular directional behavioral processes. Contemporary research on
effect of the loss or gain of complexity of force movement and aging is still focused on hypothe-
is moderated by the differential impact of task ses of network signal and connectivity issues in
demands (Vaillancourt and Newell 2002). This is the aging neuromotor system.
consistent with the general view that behavior is
an emergent property of the conuence of con-
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226 Aging and Strategy Use
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t and healthy elderly. Physical Therapy, 70, 340347. When children and adults of varying ages accom-
Zimmerman, M. E., Brickman, A. M., Paul, R. H., Grieve, plish cognitive tasks, they use a wide variety of
S. M., Tate, D. F., Gunstad, J., Cohen, R. A., Aloia, strategies (Siegler 2007). A strategy can be
M. S., Williams, L. M., Clark, C. R., Whitford, T. J., &
Gordon, E. (2006). The relationship between frontal dened as a procedure or a set of procedures for
gray matter volume and cognition varies across the achieving a higher level goal or task (Lemaire
healthy adult lifespan. The American Journal of Geri- and Reder 1999). When researchers adopt a strat-
atric Psychiatry, 14(10), 823833. egy perspective on cognitive aging, above and
beyond determining what changes and what
remains constant with age in cognitive perfor-
mance, they investigate the following strategy
dimensions (Lemaire and Siegler 1995; (Lemaire
Aging and Strategy Use 2010):
Thomas Hinault and Patrick Lemaire Strategy repertoire includes all available strat-
Aix-Marseille Universit and CNRS, Marseille, egies to accomplish cognitive tasks.
France Strategy distribution refers to how often each
strategy is used.
Strategy selection characterizes how strategies
Synonyms are selected among on each item.
Strategy execution concerns performance (i.e.,
Strategic processing; Strategic variations speed and accuracy) yielded by each strategy.
A strategy perspective is useful to understand

Definition cognitive aging for several reasons. First, it
enables to characterize cognitive changes during
Strategy use refers to the sets of procedures aging, as it helps uncovering mechanisms respon-
employed to accomplish a cognitive task. With sible for age-related changes in cognition. Sec-
aging, changes in every strategy dimensions are ond, a strategy perspective enables to distinguish
observed. cognitive processes that decline with age from
Aging and Strategy Use 227
those not affected during aging. Moreover, the adding 1 + 7 for units), or borrowing units from
strategy perspective is fruitful to understand one operand to increment the other (e.g.,
individual differences during adulthood, as 18 + 50). What is interesting is that both young A
research has found that some people age better and older adults, as a group, used these nine
than others. Finally, a strategy perspective offers a strategies (Lemaire and Arnaud 2008); (Hodzik
deeper understanding of when age-related and Lemaire 2011). However, examining the
declines in cognitive performance result from number of strategies used by each individual
age-related decrease in processing resources like revealed that older individuals used fewer strate-
processing speed and when they result from gies than young individuals. This suggests that
changes in how tasks are accomplished. This strategy repertoire used in a given task can be
article presents age-related changes and smaller in older than in young adults, even if
invariance in strategic variations by examining both age groups know all available strategies.
when young and older participants differ (or not) Changes in strategy repertoire with age have
in strategy repertoire, distribution, selection, been found not only in the number of strategies
and execution when they accomplish cognitive used by individuals but also in the type of strate-
tasks (Lemaire 2010); (Duverne and Lemaire gies. For example, when they want to make a
2005). decision regarding a product to purchase, older
adults tend to adopt simpler strategies (e.g., they
Strategy Repertoire tend to search fewer pieces of information) than
Age-related differences in strategy repertoire are young adults. Note though that older adults do not
seen in differences in the type of strategies used always use simpler strategies. For example, if they
and/or in the number of strategies used by young are asked to verify arithmetic problems like
and older individuals. Age-related differences and 8 + 4 = 19 vs. 8 + 4 = 13, young adults tend
similarities in strategy repertoire have been found to use calculation strategies to determine that the
both when strategies can be observed directly with second equation is false and fast, easy plausibility-
external behavioral evidence (via video record- checking strategies on the rst equation. Older
ings or verbal protocols) and indirectly when no adults tend to use the harder, calculation strate-
external behavioral evidence are available (i.e., gies, even when basic arithmetic skills are com-
via performance variations as a function of task parable in both age groups.
or stimuli parameters). Differences in strategy repertoire have been
To give one example, previous research has found in a number of cognitive domains, ranging
found that both young and older adults strategy from low-level sensorimotor tasks (e.g., Fitts
repertoires include the following nine strategies pointing tasks) to higher-level inferential tasks
when people are asked to solve mentally two-digit (e.g., deductive reasoning tasks). Note though
addition problems like 17 + 51: retrieving the that age changes in strategy repertoires are not
product directly from long-term memory (e.g., always found. Sometimes young and older adults
people retrieve 68 directly from memory as a accomplish cognitive tasks using the same and
correct sum), rounding the rst operand down same number of strategies. For example, in epi-
(or up) to the nearest decade and then adding sodic memory, where participants are asked to
(or subtracting) the units (e.g., doing learn pairs of words like dog basket, both young
10 + 51 + 7 or 20 + 513), rounding the second and older adults use sentence generation (i.e., they
operand down (or up) to the nearest decade and make a sentence with each pair of words like the
then adding (or subtracting) the units (e.g., dog sleeps in her basket), interactive mental
17 + 50 + 1 or 17 + 60 9), rounding both oper- imagery (i.e., constructing a mental image with
ands down (or up) to the nearest decades and then each word of the pairs), or repetition (i.e., contin-
adding (or subtracting) the units (e.g., doing uously repeating pairs of words) strategies, as well
10 + 50 + 7 + 1; 20 + 60 39), using columnar as other or no strategies (Hertzog and Dunlosky
retrieval (e.g., adding 1 + 5 for decades and then 2004).
One fascinating feature of cognitive aging memory) (Geary and Lin 1998) when asked to
regarding strategy repertoire is that both differ- solve simple one-digit addition or multiplication
ences and similarities in young and older adults problems, to use plausibility-checking strategies
strategy repertoires can be found in the same more often to answer comprehension questions
domain and sometimes with the same task. For about a text they had just read, and to use sentence
example, when participants verify arithmetic generation, rote repetition, or interactive imagery
problems like 4 13 = 54 or 4 13 = 57, strategies to judge sources of information in
both young and older adults are faster on the latter source-memory tasks.
than on the former (Hinault et al. 2015). Presum- Note that sometimes, in the same cognitive
ably, both age groups verify the parity rule (i.e., domains, both age- and no age-related differences
when at least one of the two operands is even, the in strategy distributions are found. For example,
product is even; otherwise the product is odd like in episodic memory, some research found that to
in 4 13 = 52) in such arithmetic problem ver- encode pairs of words, young and older adults did
ication tasks. This means that, depending on the not differ in how often they used the sentence
domain, on the task, as well as on the task envi- generation, interactive mental imagery, repetition,
ronment, young and older adults can use the same as well as other or no strategies. Other research
or different strategy repertoires. In order to best (Bouazzaoui et al. 2010) found that young and
characterize participants performance, it is cru- older adults did not use these strategies equally
cial to determine how young and older adults often either when participants encoded pairs of
accomplish cognitive tasks and if they use the words or accomplished other episodic memory
same strategy repertoires. tasks like recognition tasks or like when they
had to determine how they use external aids
Strategy Distribution (e.g., drawing lists of items to purchase) in daily-
Even when both young and older adults know and life memory tasks (like remembering grocery
use the same strategies and the same number of shopping lists).
strategies, they may differ in how often they use It is important to note that there is no general
each available strategy. Indeed, studies in a variety rule that can be stated regarding the contexts in
of domains found that older adults do not use which young and older adults use available strate-
available strategies as equally often as young gies to different extents. Indeed, researchers found
adults. that older adults tend to use sometimes simpler
Differences in mean percentages with which strategies more often than young adults and some-
young and older adults use available strategies times more difcult strategies more often, indepen-
have been found in domains as varied as decision dently of relative strategy performance. Thus,
making, reasoning, memory, problem solving, age-related differences is characterized sometimes
language processing, or numerosity estimation. by older adults using simpler and easier strategies
For example, research has found that, compared more often, sometimes using more complex and
to young adults, older adults tended to use the harder strategies more often, irrespective of which
optimal strategy (i.e., the strategy that consists in strategy is most efcient. The only important thing
asking the most informative question) less often in to remember is that it all depends on a number of
inductive reasoning tasks, to use the less efcient factors, like characteristics of participants (e.g.,
computational estimation strategies or numerosity their level of education, their profession, their
estimation strategies more often when participants health), the domain and tasks in these domains
were asked to nd approximate products to (e.g., nding a solution vs. determining whether a
two-digit problems like 57 89 or to nd the proposed solution is correct or incorrect), the situ-
approximate number of dots in dot collections ations and task instructions (e.g., emphasizing
briey displayed on a computer screen, to use speed vs. accuracy), the type of (easy vs. hard)
more often the retrieval strategy (i.e., retrieving items, and the cognitive costs incurred by available
the correct solutions directly from long-term strategies.
Strategy Selection has found strategy exibility and calibration of

Strategy selection concerns how one strategy is strategy choices to task parameters in both
chosen among available strategies on each item. young and older adults. Previous research has A
Age-related differences in strategy selection can also found both age-related differences and simi-
be assessed by determining how often young and larities in strategy selection. For example, in arith-
older adults are able to calibrate their strategy metic, when participants were asked to select the
choices to task parameters (e.g., instructions, better of two available rounding strategies to nd
items, type of strategies) and how often to select approximate products to two-digit multiplication
the most efcient strategy on each item. Crucial to problems like 62 86 (e.g., rounding both oper-
strategy selection are the abilities to choose strat- ands to the nearest smaller decades, like doing
egies on a trial-by-trial basis. Such trial-by-trial 60 80 and providing 4800 as an estimate),
strategy choice process is in sharp contrast with older participants selected the best strategy on
selecting a given strategy applied on the whole set each problem less often and less systematically
of items, or with selecting a strategy executed on than young adults (Lemaire 2010). Similarly,
the rst half of items and a second strategy used when asked to select encoding strategy to memo-
on the second half of items, or with any other rize lists of words, to search information about
variants of such processes that would dispense items to purchase, to combine premises to make
participants from making strategy choices on inductive inferences, to use linguistic cues to
each item. It also differs from random and incon- understand sentences or texts, and to accomplish
sistent strategy choices across items. Systematic mental rotation and sentence-verication tasks,
trial-by-trial strategy choices require participants older adults were less systematic in selecting the
to be able to exibly switch between different best strategy on each item. Some research recently
strategies on successive items when the best strat- found that, when they selected the best strategy
egy on successive items differs and to use the less often than young adults, older adults adopted
same strategy on successive items when the best an easier, cognitively less-demanding approach.
strategy is the same on these items. They tended to repeat the same strategy on con-
Only in domains where young and older adults secutive items even if the best strategies were not
have reached a high level of expertise do we nd the same on these consecutive items, or to use the
that most participants use a given strategy on easiest strategy to execute even if this easiest
almost all items. For example, in simple arith- strategy was not the most efcient (Lemaire
metic tasks, where participants have to nd solu- 2015).
tions to simple one-digit addition or In many studies, older adults have been found
multiplication problems like 3 4 or 5 + 2, did to be less able than young adults to calibrate their
previous research nd that participants use strategy choices to item or situation characteris-
retrieval strategy (i.e., they retrieve the correct tics. For example, when they were asked to
answer directly from memory) on over 95% of encode lists of words, older adults tended to use
trials. In some studies, most likely due to cohort interactive mental imagery to encode concrete
effects, older adults have been found to use words and sentence generation to encode abstract
retrieval on 100% of trials and young adults on words less systematically than young adults
around 8090% of trials (Geary and Lin 1998). (Hertzog and Dunlosky 2004). Similarly, when
Such lack of trial-by-trial strategy selection in time to encode items in episodic memory tasks
older adults most probably stemmed from high was limited, relative to older adults, young adults
level of expertise in arithmetic that made one tended to more systematically and more ef-
strategy most efcient on all items, rather than ciently adjust their strategy choices relative to an
from strategy inexibility. unlimited encoding time condition.
In most domains, some strategies are more Finally, it is important to note that in a few
efcient on some items and other strategies on experiments where participants were instructed
other items. In such domains, previous research to use a given efcient strategy (e.g., use
interactive mental images to encode as many poorer strategy (e.g., the rounding-up strategy on
words as possible when you memorize this list small-unit problems like 72 34 and the
of words), both young and older adults increased rounding-down strategy on large-unit problems
their use of interactive mental imagery to compa- like 54 69) (Hinault et al. 2015). Similarly, in
rable extents (Hertzog and Dunlosky 2004). episodic memory, age-related differences are
When the best decision-making strategy was larger when participants are asked to execute the
taught to young and older adults, both age groups interactive imagery strategy on concrete words
used it more systematically than when they were than when executing it on abstract words
not taught such strategy. More generally, in sev- (Hertzog and Dunlosky 2004). As another exam-
eral domains, when information about relative ple, as participants had encoded lists of words,
strategy efcacy was provided prior to the exper- age-related differences in participants perfor-
iment, age-related differences in how often young mance were larger after using a deep-encoding
and older adults used the best strategy on each strategy (e.g., nd a synonym of each word) than
item tended to decrease and sometimes to after using a shallow-encoding strategy (e.g.,
disappear. count the number of syllables in each word), and
these differences were magnied in recognition
Strategy Execution compared to recall task. As a nal example, par-
Differences between young and older adults in ticipants are slower when they switch strategy
strategy execution are the strongest and most from one item to the next than when they repeat
robust of all age-related differences in strategic the same strategy, irrespective of which strategy is
variations. Strategy execution refers to relative the best on each item. Such so-called strategy
strategy speed and accuracy. Above and beyond switch costs have been found to be of comparable
general slowing, previous research has found that magnitudes in young and older adults when par-
older adults tend to be slower and less accurate ticipants were allowed to choose among two strat-
when they execute strategies. Age-related differ- egies but to increase in older adults as soon
ences are increased not only when participants strategies could be chosen among three available
execute harder strategies, but also when they exe- strategies on each item (Ardiale and Lemaire
cute strategies in most demanding conditions. 2012). All these ndings showed that age-related
Examples of most demanding conditions include differences in strategy execution are modulated by
harder items, situations with high-speed/high- a wide variety of contextual factors. Note though
accuracy pressures, under stress, or tasks that are that not all contextual factors change age-related
less familiar to participants. differences in strategy execution. For example,
For example, when participants use rote repe- participants tend to execute a strategy on a current
tition, mental imagery, or sentence generation to item more slowly if a harder strategy has been
memorize pairs of words, older adults obtain executed on the previous item. Such so-called
poorer performance with each of these strategies strategy sequential difculty effects seem to inu-
than young adults (Hertzog and Dunlosky 2004). ence strategy execution in young and older adults
When participants are forced to execute rounding- to the same extents (Uittenhove and Lemaire
up strategy (i.e., rounding both operands to the 2012).
nearest larger decades) to nd product estimates to
all two-digit multiplication problems (i.e., doing Sources of Strategic Variations During
80 40 = 3200 to estimate 72 34) of a given Cognitive Aging
set and to use the rounding-down strategy on all In all cognitive domains in which strategic varia-
problems of another, matched set of problems, tions have been adequately investigated,
older adults are slower and less accurate than researchers have found age-related differences
young adults, especially with the most difcult and similarities. These include older adults using
rounding-up strategy. These age differences are fewer strategies, simpler (but sometimes harder)
larger if participants are asked to execute the strategies, and some strategies more often than
others, executing strategies more poorly, selecting with high level of cognitive resources, who often
best strategies less often, and calibrating strategy obtain comparable cognitive performance relative
choices to task constraints less systematically than to young adults, are also older adults with much A
young adults. These age-related differences in less decreased processing resources than other
strategic variations are correlated with age-related older adults (Park and Reuter-Lorenz 2009).
differences in cognitive performance. Crucial to a This enables them, for example, to be more ef-
deeper understanding of cognitive aging, and cient at inhibiting irrelevant information,
age-related changes in cognitive performance, disengaging more quickly from a just-
are the sources of these strategic variations during accomplished task to engage in another task or
aging. Previous research has shown that from a just-executed strategy to activate and exe-
age-related differences in strategic variations are cute a new more efcient strategy, to be able to
modulated by a variety of tasks parameters, such temporarily hold more information in working
as strategy, participants, problems, and situation memory as well as to update content information
characteristics. within working memory, to quickly activate rele-
Strategies differ in the number of processes vant information from long-term memory, and to
they include as well as the nature of these pro- execute cognitive processes more quickly.
cesses. Some processes are harder to trigger and Another participants characteristic that has in
execute. Therefore, relative strategy complexity is some research been found to inuence magni-
rst determined by the number and nature of tudes of strategic variations during aging is
cognitive process strategies included. A strategy age-related differences in metacognitive skills
including more and/or harder processes will be (Hertzog and Dunlosky 2004). Metacognition
taking more time to execute and might be harder refers to cognition about cognition. This includes
to select appropriately. As seen above, aging beliefs as well as knowledge about cognition and
effects are larger on more complex strategies. cognitive processes and monitoring processes.
Relative strategy complexity often does not act Such inuence may include participants belief
in isolation on age-related differences in strategic that the selected strategy is the most efcient
variations. It often interacts with other factors like strategy leading them to not change strategy, inde-
participants characteristics. One such partici- pendently of whether it is the better or poorer
pants characteristic that has recently been greatly strategy, or the belief that they are unable to select
investigated is so-called cognitive reserve (Stern the best strategy on most items leading them to not
2009). Cognitive reserve refers to the ability to devote cognitive efforts to systematically try to
cope with age-related structural and functional select the best strategy on each item. It may also
changes in the brain with larger neural recruitment include lack of knowledge or partial knowledge of
to preserve functional abilities. Proxies of cogni- relative strategy efcacy either for a particular
tive reserve include factors such as education or item or a set of items (e.g., concrete words are
lifestyle, so that older adults with a better educa- better memorized with mental imagery than with
tion have higher levels of cognitive reserve. Older sentence generation). Finally, older adults may be
adults with higher levels of cognitive reserve have poorer than young adults at performance monitor-
been found to be better able to select the best ing, seen in their more poorly determining that
strategies on each problem and to execute strate- they are not executing the selected strategy most
gies more efciently (Barulli et al. 2013). One efciently.
important difference between older adults with Whichever process resources (metacognitive
high- and low-cognitive reserve concerns avail- skills, expertise, processing speed, executive
able processing resources (Salthouse 2010). functions, working memory) enhance age-related
Processing resources include working-memory changes in strategic variations, age-related differ-
capacities, processing speed, and some crucial ences in strategic variations, and as a consequence
executive (e.g., inhibition) and sensory (e.g., on cognitive performance, may be exacerbated in
visual, auditory acuity) functions. Older adults some situations (like when participants are tested
under high-speed pressures). Such situations usu- 2015). These strategic variations during aging are
ally place greater demands in processing exacerbated in some situations (e.g., like when
resources, and these increased demands are larger young and older adults are tested under speed
in older adults because of their age-related pressures) and in some participants (with some
decrease in available processing resources. Of older adults showing patterns of strategic varia-
course, there are individual differences in how tions close to young adults and other older adults
greater demands in processing resources inuence showing poorer strategic behaviors).
strategy use and strategy execution in older adults, One of the crucial underlying features of exac-
as some older adults with larger available erbated poorer strategic behaviors in older adults
processing resources are less detrimentally seems to be how older adults available
affected by these situations than other older processing resources match demands in
adults. Note that some situation characteristics processing resources made by the task environ-
can also be more benecial to older adults per- ment. In some situations, for some items, and for
formance via greater use of most efcient strate- some strategies, the demands in resources will
gies. To take just one example, instructions exceed older adults available resources and
encouraging older adults to try to be the most more so for some older adults who have low
accurate led them to increase their best strategy level of cognitive reserve. This leads older adults
use relative to no accuracy pressure more often to be poorer at selecting the best strategy and at
than young adults in arithmetic problem solving efciently executing strategies, to use fewer strat-
tasks. egies, and/or to use the simpler (though less ef-
cient) strategy most often. In other words,
Conclusions age-related changes in strategic variations seem
to be a consequence of age-related changes in
Age-related changes in cognitive performance are processing resources. At a more general level, if
often accompanied by changes in how young and as often assumed in cognitive sciences, the brain
older adults perform cognitive tasks. When is an optimizing device (i.e., a device that tries to
researchers have tried to understand cognitive optimize deployment of available resources to
aging by determining how young and older adults cope with necessary demands to successfully
accomplish cognitive tasks, they have found accomplish cognitive tasks); age-related changes
age-related differences in what we called strategic in strategic behaviors suggest that the brain
variations (Lemaire 2010). These include strategy remains an optimizing device throughout life.
repertoire (or which strategies people use to
accomplish a task), strategy distribution (or how Cross-References
often they use each available strategies), strategy
selection (or how they choose among strategies on Cognition
each item), and strategy execution (or how they Cognitive Control and Self-Regulation
apply each strategy). Psychological Theories of Successful Aging
In many cognitive domains and tasks, relative
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tion. Oxford: Oxford University Press. is a longitudinal cohort study of community
234 Ageing in a Community Environment Study (ACES) Cohort
dwelling elderly Singaporeans that aims to: Examination (MMSE). The second study visit
(1) study the markers and predictors of healthy involves cognitive tests, mental health, and clini-
and functional aging in a community environ- cal measures: (1) Montreal Cognitive Assessment
ment; (2) describe the trajectories of cognitive (MoCA); (2) Repeatable Battery for the Assess-
and physical function decline in normal and ment of Neuropsychological Status (RBANS);
abnormal aging; (3) identify modiable risk and (3) The Global Mental Health Assessment Tool
protective factors such as diets and life styles for (GMHAT); (4) Brief Informant Screening Test
the prevention of cognitive decline, dementia, (BIST); (5) Pittsburgh Sleep Quality Index
depression, frailty, and disability. (PSQI); (6) Vital Signs: blood pressure, pulse
rate, body temperature; and (7) the collection of
stool sample. Trained medical assessors conduct
Method detailed neurocognitive assessment for all partic-
ipants who obtained a MMSE total score lower
ACES is a community-based longitudinal cohort than education specic cutoff values (27 for
study. Baseline recruitment was started in July subjects without formal education, 28 for pri-
2011 and will be completed by the end of 2016. mary school education level, and 29 for sec-
Subjects are recruited through door-to-door cen- ondary school and above) or a preliminary
sus from Jurong area of Singapore. Inclusion diagnosis of dementia based on GMHAT. This
criteria are: (1) Singaporeans or Permanent Resi- will take place at the third study visit. The assess-
dents aged 60 years and above and (2) able and ment session consists of history taking, brief
willing to provide written informed consent. Inter- physical examination, Clinical Dementia Rating
views and assessments are performed at a (CDR), and a battery of standard neuropsycholog-
community-based study center in Jurong Point ical tests. Qualied medical assessors conduct
Shopping Center: the Training and Research psychiatric assessment on participants who have
Academy at Jurong Point (TaRA@JP). ACES a GDS total score >= 3, or a GAI total score >=
cohort has recruited and assessed over 950 study 5, or a preliminary diagnosis of depression/anxi-
subjects as of 31 December 2015. The rst follow- ety disorder based on GMHAT. This takes place at
up of the cohort was started in July 2015 and will the fourth visit. The assessment session consists
be completed by the end of December 2019. of history taking, and selected modules from the
Structured Clinical Interview for DSM Disorder
(SCID). All participants who are eligible for
Procedures neurocognitive assessment or psychiatric assess-
ment are invited to the study center (the fth study
There are six study visits at ACES baseline. The visit) for blood sample collection. Regular case
rst study visit involves questionnaire interview conferences are held to obtain consensus diagno-
and physical performance assessments: (1) Demo- sis of dementia, mild cognitive impairment,
graphic data; (2) Self-rated overall health and depressive disorders, and anxiety disorders. Sub-
health changes; (3) Medical conditions, medica- jects with mild cognitive impairment and
tions, and supplements; (4) Depression symp- age-gender matched controls are selected for the
toms: the Geriatric Depression Scale (GDS); sixth study visit as a substudy that focuses on the
(5) Anxiety symptoms: the Geriatric Anxiety role of biological markers such as telomere length,
Inventory (GAI); (6) A Food Frequency Ques- oxidative stress, inammatory cytokines, fatty
tionnaire (FFQ); (7) Attitude and knowledge of acids, oxylipins, plant-based bioactive com-
healthy diet; (8) Physical performance: handgrip pounds, etc. A total 19 ml blood sample is col-
strength and 6-m walking speed test; (9) Personal lected from each subject following standard
and Parents Parenting Style; (10) Subjective cog- venipuncture procedure.
nitive impairment: the Perceived Decits Ques- At the rst follow-up of the ACES cohort, each
tionnaire (PDQ); and (11) Mini-Mental State subject has three sessions of assessment with the
study research nurse or research associate/assis- 0 to 3; a global score is obtained by totaling the
tant. The rst session (study visit 1) involves component scores.
questionnaire-based interview on demographics Modied local versions of the Mini-Mental A
and life styles, clinical measurements (weight, State Examination (MMSE) (Feng et al. 2012)
height), screening tests (Geriatric Depression and the Montreal Cognitive Assessment (MoCA)
Scale, Geriatric Anxiety Inventory, Mini-Mental (Liew et al. 2015) are administered as global
State Examination), and physical performance measures of cognitive function. The MMSE con-
assessment (hand grip strength, 6-m walking sists of 11 items across cognitive domains such as
speed test, Timed Up and Go Test). Within orientation, memory, attention, and language. The
2 weeks after the rst visit, venous blood and test has a maximum score of 30 with higher scores
urine are collected from the subjects. Trained corresponding to better cognition. The MoCA is a
research staffs will conduct neurocgontive assess- brief cognitive screening tool that assesses cogni-
ment at the third visit. The assessment session tive functions in the domains of visuo-executive,
consists of Clinical Dementia Rating (CDR) and naming, attention, language, abstraction, delayed
a battery of standard neuropsychological tests. recall, and orientation. The MoCA is scored on a
Brian magnetic resonance imaging (MRI) are pro- 30-point scale and higher scores correspond to
vided to selected subjects who are diagnosed with better cognitive status.
amnestic mild cognitive impairment or early Subjective cognitive complaints (SCC) are
Alzheimers diseases, and age-gender matched assessed using the Perceived Decits Question-
controls. naire (PDQ) (Sullivan et al. 1990). This scale
consists of 20 items making up 4 subscales: atten-
tion/concentration, retrospective memory, pro-
Measures spective memory, and planning/organization.
Subjects are asked to rate on a Likert scale
A brief summary of psychology-related measures (0 never, 1 rarely, 2 sometimes, 3 often,
in the study protocols are provided as follows: 4 almost always) how often they experienced
The 15-item version of the Geriatric Depres- each cognitive problem during the past 4 weeks.
sion Scale (GDS) is used to index the level of Individual item ratings are summed to produce
depression (Sheikh and Yesavage 1986). This four subscale scores ranging from 0 to 20 and a
version of the GDS consists of 15 yes/no total score ranging from 0 to 80, with a larger
questions each worth a point, giving a maximum score indicating higher severity.
possible total score of 15. This version has been The Repeatable Battery for the Assessment of
validated and has demonstrated good psychomet- Neuropsychological Status (RBANS) is adminis-
ric properties in the local context. tered as a short battery of cognitive tests (Lim
The Geriatric Anxiety Inventory (GAI) is used et al. 2010). The battery consists of 12 subtests
to index the level of anxiety (Pachana et al. 2007). across 5 indexes: (1) Immediate memory list
There are 20 agree/disagree items in the GAI, each learning and story memory; (2) Visuospatial/
is worth a point, giving a maximum possible total Constructional gure copy and line orientation;
score of 20. The GAI was validated and has (3) Language picture naming and semantic u-
shown good psychometric properties in a similar ency; (4) Attention digit span and coding; and
Asian population. (5) Delayed memory list recall, list recognition,
Sleep-related variables are assessed by the story memory, and gure recall. The tests thus
Pittsburgh Sleep Quality Index (PSQI) (Buysse yield subtest scores, index scores, and total scaled
et al. 1989). The PSQI, consisting of 19 questions, scores. Individuals were tested with form A of the
assesses sleep components such as sleep duration, RBANS. This battery of tests had previously been
sleep latency, sleep disturbance, sleep efciency, normed on elderly Chinese in Singapore.
quality of sleep, daytime dysfunction, and use of A standard neuropsychological test battery is
sleep medications. Each of these is scored from used to provide more detailed information on
236 Ageing in a Community Environment Study (ACES) Cohort
major cognitive domains that decline in aging the examiner records the numbers spoken by the
(Feng et al. 2006, 2009a, 2010). In the Rey Audi- subjects.
tory Verbal Learning Test (RAVLT), the examiner A local version of the Clinical Dementia Rat-
reads a semantically unrelated word list (list A) to ing (CDR) scale is used to assesses the severity of
the examinee in a series of ve trials. After each dementia (Feng et al. 2009b), with CDR global
learning trial, the examinee is asked to repeat all score 0 = dementia, 0.5 = questionable demen-
the words he or she can remember (RAVLT imme- tia, 1 = mild dementia, 2 = moderate dementia,
diate recall). A second distracter word list (list B) and 3 = severe dementia.
is then presented. In Digit Span Forward, the
examiner reads strings of numbers in series with
increasing length, and the examinee is asked to Results
repeat the string in the exact order. In Digit Span
Backwards, the examinee is asked to say the Table 1 presents a summary of demographic
strings in reverse order. The Color Trails Test and psychological characteristic of the rst
(CTT) uses numbered colored circles and univer- 900 participants from the ACES cohort. There
sal sign language symbols. For the Color Trails are more female subjects in this cohort and the
1 trial, the examinee uses a pencil to rapidly con- years of formal schooling is only 6.06 years.
nect circles numbered 1 through 25 in sequence. The subjects obtained higher scores on MMSE
For the Color Trails 2 trial, the examinee rapidly as compared to MoCA. They reported 1.38
connects numbered circles in sequence, but alter- depressive symptoms and 1.15 anxiety symptoms
nates between pink and yellow colors. For the on average.
Block Design test, the examinee is asked to repli- The study team and collaborators are currently
cate models or pictures of two-color designs with working on over 20 original research articles
blocks. The designs progress in difculty from using data from cohort baseline. Research topics
simple two-block designs to more complex, include sleep problems, mild cognitive impair-
nine-block designs. Rey Auditory Verbal Learn- ment, subjective cognitive complaints, handed-
ing Test (RAVLT)Delayed Recall & Recogni- ness, depression, anxiety, dietary patterns,
tion: The examinee is asked to recall all the nutrients intake, etc. Selected results from current
words he or she can remember from list A again analysis shows:
(RAVLT delayed recall), followed by the
recognition task in which the examiner read 1. Geriatric Depression Scale and Geriatric Anx-
aloud a list of 50 words (this list included iety Inventory scores were both signicantly
words from both list A and B and words phone- correlated with sleep disturbance
mically or semantically related to them) (Yu et al. 2015). Geriatric Depression Scale
from which the participants had been instructed
to identify the words in list A. In the Verbal
Fluency test, the examinee is asked to produce
as many words as possible in 1 min from a dened Ageing in a Community Environment Study (ACES)
category (the category is animal for this study). In Cohort, Table 1 Demographic and psychological char-
acteristics of the study sample
the Boston Naming Test, the examinee is told to
tell the examiner the name of each of a series of Variable Value
pictures. The examiner writes down the patients Age, mean (SD) 68.01 (5.83)
responses in detail, using codes. In the written Female,% 66.9
Years of education 6.06 (4.24)
version of the Symbol Digit Modalities Test
MMSE score 27.9 (2.47)
(SDMT), the examinee is asked to write as many
MoCA score 25.5 (4.01)
numbers as he or she can in the boxes below a
GDS score 1.38 (1.93)
series of symbols according to the key provided at
GAI score 1.15 (2.47)
the top of the page within 90s. In the oral version,
scores were uniquely associated with Ageing in a Community Environment Study (ACES)
daytime dysfunction, and Geriatric Anxiety Cohort, Table 2 The prevalence of MCI, dementia, and
other psychiatric disorders
Inventory scores were uniquely associated A
with perceived sleep quality, sleep latency, Prevalence ratea
Diagnosis N (%)
and global Pittsburgh Sleep Quality Index
Amnestic MCI 46 4.9
scores.
Nonamnesic MCI 65 6.9
2. Subjective Cognitive Complaints (SCC) were
MCI subtype not 10 1.1
associated with older age, lower education speciedb
level, poorer perception of current and past Dementia 20 2.1
health, greater number of medical problems, Depressive disorders 10 1.1
and lower cognitive activity in elderly Anxiety disorders 3 0.3
Chinese Singaporeans. Of these, poorer per- Other psychiatric diagnoses 7 0.7
ception of current health showed the best pre- a
Prevalence rates were calculated using 936 as the denom-
diction. SCC was not found to be related to inator based on the last assessed subject
b
current cognitive impairment, depressive, or Subtype of MCI was not determined because subjects
refused neuropsychological assessments
anxiety status.
3. The accuracy of detecting mild cognitive
impairment was signicantly improved when
results from multiple tools and demographic Future Plan
information were included in the statistical
model. Area Under Curve (AUC) value of the A subgroup of subjects from the ACES cohort
best model was 0.91; the predictors in this nal will join the SG70 Community Ageing Cohort
model were MMSE score, MoCA score, Per- which will be formed in 2017. Deep, longitudinal
ceived Decits Questionnaire (PDQ) score, phenotyping and biosampling will be instituted on
age, gender, race, education, and years of a regular basis. The SG70 Community Ageing
schooling. Cohort will allow the validation of the biological
4. There were 121 MCI cases and 20 dementia signatures of healthy aging identied in an oldest-
cases from the rst 936 subjects (Table 2). The old cohort the SG 90 Longevity Cohort, as
prevalence rate of nonamnestic MCI was well as providing a platform for further discovery
higher than that of amnestic MCI. The in science. Selected subjects will undergo further
relative low rate of dementia reects selection tissue biopsies for nested casecontrol studies.
bias as only those who were able to provide
written informed consent and visit our study
center for interviews and basements were Cross-References
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5. The prevalence rates of psychiatric disorders Mild Cognitive Impairment
were relatively low: 1.1% for depressive disor-
ders, 0.3% for anxiety disorders, and 0.7% for
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Pachana, N. A., Byrne, G. J., Siddle, H., Koloski, N., Aging, according to the Oxford English Dictio-
Harley, E., & Arnold, E. (2007). Development and nary, is dened by the process of getting older, the
validation of the Geriatric Anxiety Inventory. Interna- process of making something appear older than it
tional Psychogeriatrics, 19, 103114. is, or in reference to something that has reached
Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depres-
sion Scale (GDS): Recent evidence and development of the end of its usefulness (Oxford English Dictio-
a shorter version. In Clinical gerontology: A guide to nary n.d.). Ageism refers to discrimination of a
assessment and intervention (pp. 165173). New York: person based on age, and in the context of this
The Haworth Press. chapter, to the discrimination of older adults, this
Sullivan, J., Edgley, K., & Dehoux, E. (1990). A survey of
multiple sclerosis. Part 1. Perceived cognitive problems is also sometimes called, gerontophobia. In
and compensatory strategy use. Canadian Journal of Western society, and especially the United States,
Rehabilitation, 4, 99105. it is commonly accepted that the greater society is
Yu, J., Rawtaer, I., Fam, J., et al. (2015). Sleep correlates of youth oriented, and thus, older adults are less
depression and anxiety in an elderly Asian population.
Psychogeriatrics. doi: 10.1111/psyg.12138. [Epub respected (Hillier and Barrow 2011; Nelson
ahead of print]. 2002). Stereotypes refer to beliefs and opinions
Aging, Inequalities, and Health 239
about people or groups, which may stem from Aging Stereotypes

personal experience or societal beliefs. The act
of stereotyping may come from a basic need for When one thinks of older adults, one is bound to A
categorization important for survival; however, think of grandparents or other older adults who
stereotypes are often inaccurate, oversimplica- have made an impression on his or her life,
tions of individual characteristics, as in the case of whether positive or negative; these experiences
older adults. Stereotypes are often negative and are likely to be the basis of some stereotypes of
harmful, causing discrimination toward older older adults. In addition, pervasive messages in
adults (Hillier and Barrow 2011). Inequality refers popular media promote age reversing products
to a difference between the ways in which people, and send the message that aging is undesirable.
in this case, older adults are treated from other Younger adults who may not have had as many
segments of the population. For older adults, interactions with older adults may often form their
inequalities may be based on stereotypes regard- impressions of older adults based on caricatures of
ing aging but may also be perpetrated between older adults in television, movies, or print. Lim-
groups of older adults (Hillier and Barrow 2011). ited interactions with older adults, coupled with
images presented in the media, may shape a young
adults understanding of older adults completely
Background and may be the difference between an afnity for
and or aversion to older adults.
In modern industrialized nations, humans now Stereotypes of aging begin in childhood as
live longer than ever before. During the early people begin to develop expectations about their
1900s, the average life expectancy was between own aging. These stereotypes can be carried into
47 and 55 years (Stuart-Hamilton 2006). In just adulthood, where the stereotypes are reinforced
100 years, life expectancy has increased on aver- by the predominantly negative stereotypes present
age by 30 years (Aging 2012). This is due, in part, in North American and European cultures (Levy
to a better understanding of sanitation but also due 2003). Older adults still hold these negative ste-
to medical and technological advances. Older reotypes formed in childhood and have been
adults, aged 65 and older, make up an increasing found to hold the same negative views of aging
percentage of the worlds population, yet negative as young- and middle-aged adults (Cavanaugh
attitudes toward and stereotypes surrounding and Blanchard-Fields 2002). Age stereotypes
older adults, their role in society, and the aging often surround how an individual will function
process have sustained. Older adults are more physically, emotionally, and cognitively as an
likely than other age groups to experience older adult. As such, it is possible that chronic
inequalities on a daily basis, including in activation of these stereotypes can affect how an
healthcare, largely due to age stereotypes and older adult actually functions (Levy 2003). Gen-
ageism, an accepted and systemic form of dis- erally, when speaking of stereotypes, negative
crimination (Butler 1969; Hillier and Barrow stereotypes are the rst to come to mind and are
2011; Nelson 2002, 2015; Stuart-Hamilton the most common (Nelson 2002). There are, how-
2006). Although stereotypes, whether positive or ever, some positive stereotypes associated with
negative, may not overtly seem harmful, they can older adults.
negatively impact the way other people interact Three main positive aging stereotypes have
with older adults and subsequently create addi- been identied in younger adults. These include
tional psychological and medical problems the golden ager, who is active, alert, capable,
(Hillier and Barrow 2011; Schaie and Willis and independent; the perfect grandparent, the
2011). older adult who is kind, loving, interesting, wise,
and family-oriented; and the John Wayne con- Douglas 2012). Additionally, some studies have
servative, who is patriotic, religious, conserva- shown that providers believe that caring for older
tive, and proud (Schaie and Willis 2011, p. 250). adults is somehow less technical, less interesting,
While these ideals many not be viewed as inher- or more depressing, even though clinicians who
ently damaging, they may still inuence the way work primarily with older adults overwhelmingly
younger people interact with older adults, never- agree that they are a fullling and rewarding pop-
theless (Hillier and Barrow 2011; Schaie and ulation to work with (Eymard and Douglas 2012;
Willis 2011). Kydd and Wild 2012). On these grounds, many
The same set of studies identied four main medical programs have done away with geriatrics
negative aging stereotypes consistently programs, instead relying upon one or two courses
reported among younger adults: the severely in medical school to provide didactics on older
impaired older adult who is slow, incompetent, adult issues
senile, or feeble; the despondent older adult Inaccurate views of older adults have been
who is depressed, sad, hopeless, and lonely; the suggested to negatively impact their ability to
curmudgeon who complains and is demanding, access care or, at the very least, access equal care
inexible, ill-tempered, or prejudiced; and the (Nelson 2015; Kydd and Wild 2012; Eymard and
recluse who is quiet, keeps to him- or herself, Douglas 2012). Many studies have shown that
and is nave. These stereotypes can negatively older adults receive unequal care when compared
affect not only how others view and interact with to younger adults (Robb et al. 2002). This type of
older adults but how they view themselves (also discrimination occurs across medicine specialties
referred to as stereotype threat). such as oncology, endocrinology, or surgery, to
name a few. In many cases, diagnostic testing is
not provided to adults over the age of 75 (Robb
Impact of Aging Stereotypes et al. 2002). This has been attributed to the belief
on Healthcare that it would be a waste of resources to treat
someone who seems to be near their end of life
Aging stereotypes not only affect the way the (Kydd and Wild 2012; Robb, Chen, and
general public view older adults but also how Haley 2002). Additionally, medical clinicians are
medical and mental healthcare providers and more apt to spend less time with older adults, in
healthcare systems deliver services. Older adults part due to age bias, increasing the risk of over- or
are more apt to be labeled with conditions such as underdiagnosing, which would also lead to an
mild cognitive impairment, dementia, or depres- inadvertent withholding of treatment (Robb,
sion than younger adults, even in the absence of Chen, and Haley 2002).
strong evidence (Hillier and Barrow 2011). These Additionally, research has shown that a lack of
perceptions are likely to affect the way that training in the area of geriatric pharmacology may
healthcare is delivered, sometimes causing more lead to medication errors and adverse medication
harm than good (Robb et al. 2002). interactions (Keijsers et al 2012). This fear may
Effects on Healthcare: Healthcare providers result in physicians withholding medications
are not immune to ageist stereotypes. They often especially in older adults with chronic conditions,
fall into the trap of generalizing older adults to be such as diabetes or emphysema. Older adults with
difcult or noncompliant. This is suggested to be chronic conditions are often denied treatment for
one of the reasons there is a shortage of medical unrelated disorders due to a fear of drug interac-
and nursing students interested in focusing on tions; however, this is often an overreaction and
geriatric medicine (Eymard and Douglas 2012; alternate formulations may usually be found
Kydd and Wild 2012; Nelson 2011). Many stu- (Robb et al. 2002). Furthermore, in an extensive
dents in the medical eld believe that older adults review of geriatric pharmacology training, it was
are more difcult to treat, despite training to found that very little specic training is made in
improve attitudes toward them (Eymard and this area, and even though interest in
Aging, Inequalities, and Health 241
pharmacology has increased, interest in geriatric Aging stereotypes are also apt to inuence the
pharmacology has not (Keijsers et al. 2012). way that psychological researchers design
While there is an overall disparity between care research studies, as well as the way results are A
provided to older adults and that for younger interpreted. For example, many past research
aged adults, this may not be due simply to a studies indicated that older adults were more
negative attitude toward older adults. Lack of prone to depression, causing many mental health
experience with older adults is also a contributor. providers to believe that rates of depression
Some medical programs have attempted to com- among older adults were greater than other age
bat geriatric-related medicine by incorporating groups, a view still commonly held today. How-
didactics aimed at increasing awareness and expo- ever, once factors such as gender and socioeco-
sure to older adults through experiential learning nomic status were adjusted for, older adults had
(Robb et al. 2002). Even when there is a desire to signicantly lower rates of depression than other
work with older adults, there is a paucity of train- age groups (Hillier and Barrow 2011). This is an
ing in geriatric medicine and a lack of opportunity important point because if researchers are subject
to learn about issues that older adults may face. to implicit stereotypes of older adults, they will be
Compounding this problem is the fact that for- unlikely to combat these unsubstantiated points of
merly required courses in geriatric medicine view. Thus, it is important that clinicians and
have been discontinued and the Accreditation researchers are aware of their own biases, to
Council for Graduate Medical Education (the reduce the likelihood of psychiatric misdiagnosis.
governing body which oversees postgraduate However, even when psychiatric symptoms are
medical training) cited geriatric medicine training correctly diagnosed, age stereotypes can contribute
as one of the top ten areas that lack compliance to suboptimal treatment for older adults (Butler
(Bragg and Warshaw 2005). et al. 1998). Mental healthcare providers may
Effects on Mental Healthcare: Medical profes- believe that older adults are more difcult to work
sionals are not the only ones who are susceptible with and have a biased view about their presenting
to age stereotypes; mental health professionals symptoms (Siegel 2004). Older adults are often
may also fall into the same trap (Eymard 2012; viewed as stubborn, set in their ways, and
Nelson 2011). resistant to change. Similarly, they may be
While older adults experience many of the same viewed as unresponsive and incapable of self-
emotions as younger adults, there are unique factors reection (Butler et al. 1998) or unwilling to par-
that generally affect older adults more than other ticipate in psychotherapy (Robb et al. 2002).
age groups. For example, they tend to experience Although adult personality is relatively stable,
more loss than other age groups and are likely to older adults show an ability to change and adapt,
have more comorbid medical diagnoses than youn- and healthy aging has been characterized by exi-
ger adults (Butler et al. 1998; Robb et al. 2012). bility, resourcefulness, and optimism (Butler
Although sadness, grief, and depressive reactions in et al. 1998). Some studies have found that mental
older adults can increase in frequency with the healthcare providers, when presented with
increases in loss (Butler et al. 1998), it has also vignettes of different aged clients, preferred to
been shown that as adults age, they focus more work with younger clients and often had signi-
selectively on positive interactions, relationships, cantly more negative reactions toward the older
and experiences to regulate emotions and compen- adults client (Robb et al. 2002). These implicit
sate for negative experiences (Carstensen, biases are likely to cause a barrier for the provider
Isaacowitz, and Charles 1999). A prevailing stereo- to be open and willing to make a therapeutic bond
type about older adults is that they are more prone to with his or her patient (Eymard 2012). Older adults
grief and depression or are more likely to isolate are, in fact, capable of actively participating and
themselves (Siegel 2004), which may inuence the making meaningful changes in psychotherapy.
way that mental healthcare professionals approach Additionally, chronic medical conditions and
working with older adults. illnesses can also affect psychological
functioning, given the close association between workforce, and legal safeguards, age discrimina-
medical and psychosocial problems (Cavanaugh tion is often difcult to establish and many cases
and Blanchard-Fields 2002; Nelson 2002). Being are not proven (Hillier and Barrow 2011).
the rst point of contact for many older adults, Most older adults, in the United States, utilize
primary care providers are often responsible for government insurance programs such as Medicare
diagnosing older adults with psychological disor- or Medicaid to help pay for medical care. While
ders or syndromes, rather than a mental health this is a helpful service, these programs only cover
professional (Nelson 2002). Accordingly, they a specic dollar amount for very specied ser-
are also responsible for mental healthcare treat- vices and medications. This can cause difculties
ment decisions, and as a result referrals to psy- if specialty services are required. Some reports
chologists or psychiatrists are not regularly made indicate that medical care providers may exagger-
(Nelson 2002). Primary care providers may view ate claims for services or may order more tests
reactive emotional responses as symptoms of a than are needed in an attempt to recoup costs
chronic and untreatable state (Butler et al. 1998), because of the small percentage reimbursed by
causing them to over-pathologize symptoms. For Medicare or Medicaid, for medical services
example, medical providers are more likely to (Hillier and Barrow 2011). However, this misuse
confer diagnoses of dementia or psychosis on of government-subsidized insurance contributes
older adults than on younger adults (Butler to tighter regulations of the types of services that
et al. 1998; Robb et al. 2002). As a consequence, Medicare and Medicaid is willing to pay for,
older adults may not receive the appropriate med- which may reduce the care that older adults can
ical and/or mental health treatment. access, again, putting them at risk. Some older
Finally, inequalities in healthcare also occur adults may be able to afford supplemental insur-
within groups of older adults, with evidence of ance to cover services and medications that are not
gender inequality in particular. Psychological accepted by Medicare or Medicaid. However, the
diagnoses may be informed by gender stereo- cost for supplemental policies is often greater than
types, which can be compounded over a lifetime the benet received. Additionally, the increasing
as one ages (Hillier and Barrow 2011). These number of older adults also taxes this system,
issues are likely to result in misdiagnoses, with again, decreasing the per service fee that is paid
disproportionate numbers of older women being by Medicare or Medicaid and decreasing access
diagnosed with a psychiatric disorder (e.g., psy- for those older adults who cannot afford to pur-
choses), when compared to men of similar age chase supplemental insurance (Hillier and Barrow
(Robb et al. 2002). 2011).
Effects on Health Insurance: Health insurance
fees, which tend to increase with worker age, can
constitute a high cost for retaining older workers. Conclusions
Thus, the older worker can be quite vulnerable in a
tight labor market, particularly during times of It is important to consider the role of how one
recession. However, as more data is collected thinks of older adults, whether implicitly or
and analyzed on health patterns in the work explicitly, as these ideas may interfere with, or
force, the evidence nds that older adults may affect, treatment of ones clients or patients.
cost no more in medical benets than younger Even the most well-meaning stereotypes (e.g.,
employees. Use of sick leave is also more highly the sweet grandparent or the stoic older adult) may
correlated with lifetime patterns developed at a lead to inequalities in care and therefore may lead
young age than with age itself, again not to preventable detrimental effects. Many studies
supporting the stereotypical view of the older have shown the effectiveness of geriatric educa-
adult as subject to illness and absenteeism. How- tion and/or clinical experiences in changing atti-
ever, despite the accumulating evidence to coun- tudes of care providers toward older adults. Often
ter the negative stereotypes of older adults in the times, it is a lack of knowledge or experience with
Agnosia and Related Disorders 243
older adults that creates a reliance upon stereo- Keijsers, C. J. P. W., van Hensbergen, L., Jacobs, L.,
types. Time and again, research focused on this Brouwers, J. R. B. J., de Wildt, D. J., ten Cate, O. T.,
& Jansen, P. A. F. (2012). Geriatric pharmacology and
area has indicated that didactics and experiential pharmacotherapy education for health professionals A
exercises focused on interactions with older adults and students: A systematic review. British Journal of
combat against ageist stereotypes and can change Clinical Pharmacology, 74(5), 762773.
the attitudes of students and clinicians, alike. As a Kydd, A., & Wild, D. (2012). Attitudes towards caring for
older people: Literature review methodology. Nursing
large proportion of the worlds population become Older People, 25(3), 2227.
older adults, focused training on the specic issues Levy, B. R. (2003). Mind matters: Cognitive and physical
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244 Agnosia and Related Disorders
Definition and Background a disconnection syndrome. He posited that recog-

nition involves matching perception input to
Agnosias are relatively rare disorders of recogni- stored knowledge and that agnosia results from
tion that can be described as the brains inability to disconnection between visual (perceptual) and
interpret information received through various verbal processes. Geschwind argued, for example,
sensory channels. By denition, inability to iden- that left mesial occipital lobe damage not only
tify a stimulus occurs in the absence of primary results in right homonymous hemianopia but
sensory decit. Patients with agnosia have intact also prevents visual input perceived by the intact
vision, hearing, etc. In addition, agnosia cannot be right hemisphere from reaching verbal areas.
explained by attentional disturbance, language While disconnection models are compelling,
disturbance, general cognitive impairment/ they cannot explain all agnosia syndromes
dementia, or lack of familiarity with the stimulus. (Catani and Ffytche 2005). The advancement in
The term agnosia was coined by Freud (1891); cognitive neuroscience and neuroimaging tech-
however, recognition decit had been described nology allowed better understanding of
prior to him and referred to as asymbolia processing networks involved in recognition.
(Finkelnburg 1870), imperception (Jackson New data suggest that it is not necessarily a
1876), and mindblindness (Munk 1881). The two-step process but includes parallel processing
conceptualization and interpretation of agnosias at cortical and subcortical levels. For instance,
changed over time as a function on existing Damasio (1989) suggested that perception
models of perception. For example, Lissauer involves activation of specic neural patterns
(1890) described two stages of recognition: apper- combined in convergence zones. He believed
ception, which involves constructing visual attri- that recognition results from activation of neural
butes into a whole, and association, which patterns in a time-locked fashion in response to a
involves linking the content of perception to specic stimulus.
semantic knowledge. Based on this model, he
distinguished between apperceptive and associa-
tive agnosias. In the former, failure in recognition Agnosia Types
results from some impairment in perceptual rep-
resentation of the stimulus, although at a higher Agnosias can occur in all sensory systems but are
level than sensation. In other words, patients can- typically modality specic, meaning that while
not synthesize what they see into a whole. As a recognition through a particularly sensory modal-
result, they are unable to copy a stimulus or match ity is impaired, recognition through other sensory
a sample. Associative agnosia, in contrast, is char- channels is intact. For example, patients with
acterized by failure in recognition despite pre- visual agnosia would not be able to recognize an
served perceptual representation due to inability object placed in front of them. However, they
to attribute meaning to the correctly perceived would be able to pick it up and to identify it
stimulus. Patients with associative visual agnosia through the tactile modality, the sense of touch,
are able to copy a stimulus but not identify what once they are holding it. Within each modality,
they copied. Despite preserved copy, there is evi- recognition decits can be general or specic,
dence that perception is not entirely normal in involving a whole semantic class or individual
patients with associative agnosia (Farah 2004). items within a class.
Patients often present with visual eld decits, Visual agnosias are the most common agnosia
most commonly right homonymous hemianopia. type dened as inability to identify visually
Lissauer also posited that focal lesions and com- presented material. The impairment can be spe-
binations of focal lesions could impair visual, cic to objects (object agnosia), colors (color
auditory, or somatosensory perception or recogni- agnosia), faces (prosopagnosia), or words (pure
tion without affecting these abilities in other word blindness). Each of these conditions may
modalities. Geschwind (1965) dened agnosia as occur in isolation or in various combinations.
The distinction between apperceptive and associa- beings and inanimate objects (Borenstein
tive visual agnosias remains useful. Apperceptive et al. 1969). Prosopagnosia is typically acquired
visual agnosia usually results from diffuse poste- and involves bilateral lesions to fusiform gyrus at A
rior damage to occipital lobes and surrounding the junction of occipital and temporal areas. Cases
areas, while associative visual agnosia involves of unilateral lesions to both dominant and
left or bilateral inferior occipitotemporal lesions. nondominant hemisphere have also been
Both have been associated with carbon monoxide described, with greater impairment in right-sided
poisoning, mercury intoxication, cardiac arrest, lesions. Developmental/inherited cases have also
bilateral cerebrovascular accident (CVA), basilar been reported. Prosopagnosia has been interpreted
artery occlusion, or bilateral posterior cortical as a visual-limbic disconnection syndrome.
atrophy. Supporting it is the fact that patients with
Patients with color agnosia are unable to iden- prosopagnosia appear to have reduced emotional
tify colors by naming or pointing to colors named responsiveness to visual stimuli.
by the examiner. Several color disturbance Another agnostic syndrome is agnosia for
syndromes have been described. Central words, also known as pure alexia, alexia without
achromatopsia refers to the loss of color vision agraphia, or pure word blindness. While it can be
and is associated with lesion in the optic nerve or considered a linguistic impairment, most patients
chiasm or unilateral or bilateral lesions in the do not show impairment in other aspects of lan-
inferior ventromedial sector of the occipital lobe. guage. Alexia without agraphia is another exam-
Color anomia refers to inability to name colors ple of a disconnection syndrome, wherein the left
despite intact color perception. Another of visual- hemisphere is deprived of the visual input. It
verbal disconnection syndromes originally involves lesions in the dominant occipital lobe
described by Geschwind (1965), this decit usu- and the splenium of the corpus callosum.
ally results from a lesion interrupting communi- Visual agnosia syndromes demonstrate that
cation between visual cortex and language areas different brain structures and pathways are
such as infarction in the left posterior cerebral involved in processing of various aspects of visual
artery. Specic color aphasia is seen in the context stimuli. They also support the distinction into
of aphasia, with disproportionate decit in color ventral and dorsal visual pathways (Ungerleider
naming. It usually results from left (dominant) and Mishkin 1982) that involve different types of
parietal lobe lesions. visual information. The ventral (what, how)
The term prosopagnosia, or face blindness, stream projects to the inferotemporal cortex; is
describes inability to recognize familiar faces, involved in the processing of color, texture, etc.;
including ones own. While individuals with and plays a major role in constructing a perceptual
prosopagnosia are able to recognize that a face is representation of the visual world. Object and
a face and to describe some of its characteristics color agnosias and prosopagnosia result from
(e.g., beard), they are unable to identify a face by damage to this pathway. The dorsal stream pro-
visual input alone. The decit cannot be attributed jects to the posterior parietal cortex and is
to memory loss/dementia or Capgras syndrome, involved in processing location, orientation,
in which the patient believes that familiar persons movement, and object parameters important for
have been replaced by imposters. Because visual guidance of movement. Damage to the
patients can compensate by relying on voice and dorsal visual stream results in decits in visual
other non-facial characteristics, prosopagnosia spatial processing. Simultanagnosia is often
can be unrecognized for a while and may not be discussed among agnosias and refers to inability
revealed until a family member is encountered in a to process more than one object or aspect of
different context, in the absence of familiar cues. objects at a time and consequently to integrate
Prosopagnosia can also be more broadly charac- objects into coherent visual scenes (Kinsbourne
terized by difculty identifying objects within a and Warrington 1962). Other disorders of the dor-
semantic category, which can include both living sal visual stream include hemispatial visual
neglect, dressing apraxia, optic apraxia, and optic often seen in bilateral cerebrovascular disease
ataxia. The latter two and simultanagnosia are affecting the primary auditory cortex.
collectively known as Balints syndrome. Phonagnosia refers to the loss of ability to recog-
Auditory agnosias involve impairment in rec- nize familiar persons by voice and is associated
ognition of sounds in the presence of adequate with right parietal lesions (Van Lancker
hearing. Verbal auditory agnosia, also known as et al. 1989).
pure word deafness, describes decits specic to Tactile or somatosensory agnosias include a
speech processing. Patients with this rare condi- less well-understood group of disorders that
tion are unable to understand speech, while rec- involve impairment in object recognition through
ognition of other sounds is preserved. The term touch that cannot be explained by sensory-motor
pure refers to the freedom of aphasic symp- disturbance. Similarly to visual and auditory
toms, as reading, writing, and speech are rela- agnosias, apperceptive (astereognosis) and asso-
tively preserved. The disorder is typically ciative dichotomy has been described (Wernicke
associated with bitemporal lesions involving pri- 1895). Subtypes based on the specic features
mary and secondary auditory association cortices have been proposed. Thus, cortical tactile disor-
but has also been documented in unilateral lesions ders involve decits appreciating distinct attri-
of the dominant temporal lobe. Both lesions result butes such as size or shape. There is no evidence
in disconnection of auditory input from language of hemispheric lateralization, although spatial
areas of the left perisylvian cortex. While signs of attributes are usually impacted in right hemi-
aphasia might be present, the patients are able to sphere lesions. Lesions in the contralateral
recognize linguistic information when audition is postcentral gyrus produce the most severe disor-
not required (written language). Some patients ders of cortical tactile sensation, particularly when
may recognize foreign language and the person lesions occur in the hand area. Tactile agnosia
speaking but not the semantic content. Paralin- refers to inability to identify objects placed in
guistic aspects of speech (prosody, intonation) hand. It typically results from lesions to the pari-
can be preserved. Auditory agnosia or environ- etal lobe, particularly primary somatosensory cor-
mental sound agnosia is a very rare condition tex (postcentral gyrus) and somatosensory
characterized by inability to identify nonspeech association cortex. In the last decade, patients
sounds. Perceptive-discriminative and semantic- who would meet criteria for olfactory and gusta-
associative forms have been described (Vignolo tory agnosia have been described in the context of
1969), characterized by acoustic and semantic temporal resection for seizure control. The discus-
errors, respectively. Amusia describes agnosia sion of agnosia syndromes usually includes
specic to music perception and refers to inability anosognosia, which refers to lack of awareness
to appreciate characteristics of heard into ones decit and is common in all sensory
music. Oftentimes, patients are no longer able to agnosias. Another similarity is that despite dis-
enjoy music. Specic decits such as vocal ability in direct object identication, many
amusia, loss of instrumental ability, or the ability patients with agnosia demonstrate some knowl-
to read and write music (musical alexia and edge about the stimulus, thus demonstrating
agraphia) have been described (Midorikawa and implicit or covert recognition.
Kawamura 2000). Interestingly, cerebral organi-
zation of musical ability depends on degree of
experience and skill, with skilled and musically Assessment of Agnosia
trained individuals more likely to rely on the
dominant hemisphere and perceive music analyt- When examining a patient with agnosia, it is
ically. The term cortical deafness has been important to rule out alternative explanations to
applied to patients with extreme lack of aware- a recognition decit such as primary sensory def-
ness of auditory stimuli of any kind. It is most icit, inattention, aphasia or anomia, memory loss
or dementia, and lack of familiarity with the association cortex. Mendez and colleagues
stimulus. Neuropsychological evaluation/ (1990) found that 43% of community-based AD
neurobehavioral exam to assess general intellect, patients had visual complaints. Despite pre- A
memory, linguistic competence, and sensory- served visual acuity, patients showed impairment
perceptual processing is important. To rule out in recognition of objects (57%), famous faces,
aphasia, it would be important to demonstrate spatial locations, and complex gures. More
comprehension of commands not requiring severe dementia was associated with more com-
objects and the use of objects. Drawing might be plex visual disturbances.
impacted by constructional and visuomotor de- Apperceptive visual agnosia is a core symptom
cits. The possibility of confabulation may need to of posterior cortical atrophy (PCA), neurodegen-
be considered. Referrals for sensory-perceptual erative disease characterized by disproportionate
testing (ophthalmologic, audiometric) may be atrophy or parieto-occipital cortex (Benson
needed. In the tactile domain, each hand should et al. 1988). The disorder is sometimes considered
be assessed separately in the performance of basic a variant of AD, and AD pathology is present in
somatosensory function and discrimination of approximately 80% of cases. Other etiologies
weight, texture, shape, and substance. Once the include Lewy body disease, subcortical gliosis,
presence of agnosia is determined, it is important corticobasal degeneration, and prior disease.
to assess the nature and extent of the recognition PCA is characterized by complex visual distur-
impairment. The process of recognition is com- bances, including object agnosia,
plex and includes a wide range of skills. Recog- simultanagnosia, alexia without agraphia, and
nition can be assessed at different levels including environmental agnosia. Basic vision remains
the ability to overtly identify a stimulus, semantic intact, although visual eld decits may be pre-
knowledge about the object, and covert recogni- sent. Memory and other cognitive areas are usu-
tion, which can be shown by correct use in the ally preserved until later in the disease when
absence of direct object identication. As symptoms of various dementia syndromes over-
discussed earlier, agnosias are usually modality lap. Early common symptoms include reading
specic. Thus, multimodal decits are more likely difculty or difculty reading an analogue clock.
to be due to other causes (Bauer 2009). Associative visual agnosia can be observed in
semantic dementia before disturbance in semantic
memory. Visual spatial decits can also be
Agnosia and Neurodegenerative Illness observed in other neurodegenerative disorders,
as the disease process advances and impacts rele-
The most common etiologies of agnosia are cere- vant brain structures and networks. Visual symp-
brovascular accidents and traumatic brain injury toms can occur in the absence of other cognitive
followed by herpes simplex encephalitis decits but are usually associated with greater
(auditory agnosia), carbon monoxide poisoning dementia severity and contribute to functional
(visual agnosia), and hypoxia. Progressive visual impairment.
agnosia has also been associated with neurode- Patients with visual agnosia may not recognize
generative disorders. Agnosia together with and misuse common objects (e.g., use detergent
aphasia and apraxia is sometimes referred to as instead of shampoo, not be able to use a key).
the A triad of decits in Alzheimers disease They may misrecognize their surroundings and
(AD). Disturbances in basic visual, complex get lost, particularly in the context of any
visual, and oculomotor functions have all been changes such as road construction or a new bill-
described in AD, and visuospatial difculties are board sign. Driving for someone with visual
often reported by caregivers. Not surprisingly, agnosia presents signicant safety concerns.
visual system disorders have been associated Simultanagnosia is also associated with signi-
with concentration of neuropathology in visual cant impairment. Patients are often functionally
blind and unable to navigate their environment. objects that are safe to use. Verbal descriptions
Simultanagnosia also impacts reading ability. may help patients with visual agnosia and
Complex visual hallucinations are common in simultanagnosia to recognize their surroundings
neurodenegerative disorders and usually such as a particular room in the home. Audio
suggest Lewy body pathology. Patients vary in books might substitute reading for a patient with
the extent of visual system pathology and symp- pure alexia.
toms, and a comprehension interview and assess- Organizational strategies include any tech-
ment are important both for characterization of niques aimed at organizing the patients living
specic challenges and for compensation environment to increase their independence. For
strategies. example, to organize closets, matching garments
may be placed on the same hanger. Organizational
strategies may be used in combination with alter-
Recommendations nate cues. For example, organizing clothing by
different hangers may provide tactile cues. Color
While therapeutic success in treating agnosias is or tactile cues may be used to mark drawer con-
often limited by anosognosia, targeted recommen- tents. Pantry/refrigerator may be organized so that
dations may improve the quality of life and alle- a patient learns the specic location of certain
viate some of the difculties and caregiver foods (e.g., fruits are always kept on the bottom
burden. Burns (2004) offered three categories of shelf). For dementia patients, these strategies
recommendations for agnosia, including alternate might need to be implemented by caregivers.
cues, verbal, and organizational strategies. Alter- Learning paradigms such as spaced retrieval train-
nate cueing uses cues from other modalities. The ing might be helpful to teach association between
rationale for using alternate cues is that agnosias, cues. Our search did not reveal any currently
as discussed above, are modality specic. As available commercial programs or applications
such, relaying on preserved information pathways for remediation of agnosia; however, this is cer-
may be benecial. For example, for a patient with tainly an area that might see development in the
visual agnosia, feeling an object by touch may future.
assist with recognition. Patients with pure alexia To summarize, agnosias are rare disorders of
can learn to read through letter tracing tactually. recognition resulting from brain damage. Agno-
Many patients with agnosia discover this strategy sias can be found in all sensory systems but are
instinctively. For example, patients with typically modality specic. While cerebrovascu-
prosopagnosia learn to recognize family members lar accidents are the most common etiology, agno-
by the sound of their voice and other non-facial sias can also be a symptom of neurodegeneration.
characteristics. Patients with pure word deafness No disease-modifying therapies are available;
may learn lipreading and rely on pragmatic however, compensatory strategies might improve
(intonation, gestures) and contextual cues. Tactile patients quality of life and alleviate caregiver
cues, such as a piece of Velcro attached to the stress.
stove or the doorframe of an area the patient may
wish to avoid, can be used to indicate danger.
Similarly, soft fabric may be used to mark
friendly objects, such as a telephone. Preserved Cross-References
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affected modality may also be used. For example, Alzheimers Disease, Advances in Clinical
if color recognition is preserved, color cues may Diagnosis and Treatment
assist patients with object visual agnosia. For Cognition
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(e.g., stove), while green cues might signify Dementia and Neurocognitive Disorders
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250 Altruism and Prosocial Behavior
Imagine the following scenario: For the past motivated by a genuine desire to benet another
38 years, Charlie, a consumer protection lawyer, person, without any expectation of benets to
has made pro bono work an important part of his oneself (Feigin et al. 2014; Eisenberg and Miller
law practice, working with disadvantaged clients 1987). Coming back to the above hypothetical
making claims against large corporations. Early in scenario, Charlie may be motivated to engage in
his career, Charlies track record of winning these pro bono work out of compassion for disadvan-
pro bono cases earned him much prestige and was taged clients who particularly need his support.
central to his success as an emerging professional. There is ongoing debate among psychologists
Although career building is no longer a concern over whether purely altruistic behavior does in
for him, Charlie has continued providing free fact exist (Feigin et al. 2014), and most
legal counsel to people who could not otherwise researchers agree that prosocial behavior tends to
afford it and also to his extended family and also be driven by egoistic (non-altruistic) motiva-
friends. Being retired now, he gives legal aid to tions. These can include a desire to feel good
the people he feels close to and cares about, such about oneself, to improve ones social standing
as his grandson, who recently sought his counsel (such as Charlie wanting to build a reputation at
when suing a fraudulent credit union. the beginning of his career), or to avoid uncom-
Prosocial behavior can come in many different fortable feelings of sadness, anxiety, or guilt
forms, ranging from small acts of kindness, such (Feigin et al. 2014; Penner et al. 2005).
as letting someone in a rush go ahead at the Research seeking to disentangle altruistic from
cashier, to more sustained acts, such as egoistic motivations of prosocial behavior typi-
volunteering for a charitable organization, and cally uses experimental paradigms that manipu-
even to things one might take for granted, such late aversive arousal, social evaluation, or rewards
as looking after ones grandchildren. However, and link them to prosocial intentions, prosocial
the above example clearly illustrates that motiva- responses to hypothetical scenarios, or actual
tions for engaging in prosocial behavior may prosocial behavior (Penner et al. 2005). Further-
change across the lifespan. more, survey methods have been used to explore
volunteering motivations including egoism and
altruism (Konrath et al. 2012; Midlarsky and
Antecedents of Prosocial Behavior Kahana 2007).
There is strong evidence for systematic changes in Empathy

prosocial behavior across the adult lifespan, An alternative approach to examining antecedents
suggesting that older adults behave more of prosocial behavior is to delineate the specic
prosocially than young adults (Midlarsky and skills that enable individuals to understand com-
Kahana 2007; Sze et al. 2012). The next section plex social situations and behave prosocially. For
reviews a spectrum of possible motivations for example, individuals may be empathic (de Waal
engaging in prosocial behavior, from genuinely 2008) independently of whether their prosocial
psychological mechanisms to evolutionary behavior is primarily altruistically or egoistically
accounts, examines potential age-related differ- motivated. Hence, Charlie might have offered pro
ences in these mechanisms, and reviews fre- bono services over the years because he is the kind
quently chosen methodological approaches for of person who has a very sensitive radar for other
studying them. peoples needs.
A large body of research has investigated the
Altruism empathy-altruism link across species, including
Social psychological theories often distinguish humans (Feigin et al. 2014), suggesting that
between altruistic and egoistic motivations for there may be an evolutionary basis for this ability
prosocial behavior. Altruistic behavior is typically (de Waal 2008). In humans, emotional empathy,
thought of as the type of prosocial behavior that is dened as a merging of emotional contagion and
compassion, seems to be particularly closely asso- their grandchildren (Coall and Hertwig 2010).
ciated with prosocial behavior (Eisenberg and This idea is also in line with the grandmother
Miller 1987). Unlike cognitive empathy (the abil- hypothesis, which explains the relatively long A
ity to engage in perspective-taking), emotional post-reproductive period of women based on the
empathy has been shown, in cross-sectional but survival benets for not just their own children but
not in longitudinal research, to be higher in older also for their grandchildren (Coall and Hertwig
adults than in younger adults and seems to 2010). Although particular attention has been paid
account for age-related differences in prosocial to the role of grandmothers, evolutionary-based
behavior (Grhn et al. 2008; Sze et al. 2012). theories of grandparental investment also apply to
This increased emotional empathy in todays grandfathers, although this depends on paternity
cohort of older adults, as compared to young certainty (how sure the grandfather is that the
adults, may reect older adults desire to help child in fact carries his genes; Coall and Hertwig
others and engage in emotionally meaningful 2010). Going back to the example of Charlie, the
experiences or age-graded cultural expectations help he devotes to protect his grandson could be
to recognize and fulll others needs (Sze an illustration of kin selection. This is assuming
et al. 2012). Emotional empathy is frequently that Charlie believes that his grandson is biologi-
assessed via physiological arousal (skin conduc- cally related to him; kin selection theory would
tance, heart rate), nonverbal emotional cues not apply to adopted grandchildren. One could
(facial movements, gestures, vocalizations), or make a stronger case for kin selection if Charlie
self-reports of empathy (de Waal 2008; Eisenberg were a woman because the maternal grandmother,
and Miller 1987). for example, is certain of her relationship with her
daughter and her daughters relationship with her
Kin Selection grandchildren. Regardless of Charlies gender,
Unlike the psychological theories described however, kin selection theory cannot account for
above, evolutionary accounts of prosocial behav- the time Charlie spends with other young pro
ior have focused on the survival benets of bono clients to whom he is not biologically
prosocial behavior. For example, kin selection related. To explain this, one would need to invoke
theory (Feigin et al. 2014; Penner et al. 2005) other, more psychological mechanisms.
holds that individuals are particularly motivated It is not possible to directly test or falsify evo-
to help members of their own family because this lutionary theories of prosocial behavior in human
ultimately helps their own genes survive. Linking beings. However, in line with kin selection pre-
this back to the altruism-egoism distinction, kin dictions, experimental work has found that people
selection then becomes, in a sense, both altruistic are more likely to help those to whom they think
and egoistic. It is altruistic to the extent that an they are more genetically related (Penner
individual may sacrice his or her own well-being et al. 2005). Animal models and research in the
to help a blood relative; at the same time, kin area of genetics have supplemented these ndings
selection may also be seen as egoistic because it to provide more support for the overall concept of
serves to propagate ones own genes (Feigin kin selection (de Waal 2008; Penner et al. 2005).
et al. 2014). Several studies have documented
preferential helping for kin over unrelated indi- Age- and Future Time Perspective-Related
viduals, even when this contradicts social norms Differences in Prosocial Motivations
(Penner et al. 2005). There is solid evidence for age-related differences
Of note, kin selection theory can be extended in prosocial behavior in the literature (Wilson
to apply to prosocial behavior directed toward 2000). Below, the authors introduce two promi-
grandchildren. In other words, post-reproductive nent lifespan theoretical models that provide
adults can still improve their inclusive tness (the potential explanations for why this may be the
likelihood that others who share some of their case. The model of generativity is built on the
genes will survive) by investing resources in idea that adults have to master distinct challenges
as they move across different life phases, with the may have come to the conclusion that his limited
mastery of earlier challenges predicting the likeli- time left is too valuable to be spent on anything
hood of succeeding with later challenges (Erikson but the people he really cares about and feels close
1982). Generativity, which is thought to peak in to, like his grandson. Predictions originating from
mid-life and continue until later in life, may be socioemotional selectivity theory have frequently
dened as the need to make a contribution to the been tested using cross-sectional survey methods
well-being of the next generation, along with a and experimental methods (Carstensen
sense of responsibility for those younger in age et al. 2003). For example, hypotheses derived
(McAdams et al. 1998). Hence, by virtue of their from this theory have been tested directly in a
position in the life course, middle-aged and older study of volunteering motivations (Okun and
adults may be particularly motivated to engage in Schultz 2003). Although socioemotional selectiv-
behaviors that help younger individuals thrive ity seems to be a very relevant framework for
(Schoklitsch and Baumann 2012). Going back to understanding prosocial behavior across the
the legal aid example, Charlie may indeed be lifespan, to our knowledge, no research has yet
driven by generative goals when he assists youn- directly investigated the effects of changing future
ger clients does he perhaps wish to bestow a time horizons on prosocial behavior; correlational
tradition of social justice-oriented legal action that and experimental work is needed to ll this gap.
will inspire generations to come? Generativity
may also reect a desire to leave a lasting legacy,
thus combining altruistic with egoistic connota- Consequences of Prosocial Behavior
tions (Maxeld et al. 2014). Nevertheless, the end
result is that society reaps the benets of older When one thinks of prosocial behavior, the impli-
adults generative investments. Survey methods cation typically is that this kind of behavior ben-
have been used to investigate associations ets the recipient, whether emotionally,
between generativity and prosocial behavior nancially, or otherwise (Penner et al. 2005).
across the lifespan, indicating that both tend to Importantly, however, behaving prosocially may
peak in mid-life and continue to be high in older also benet the actor the person who is helping
age (Keyes and Ryff 1998), although cohort or giving to others. Indeed, prosocial behavior has
effects cannot be ruled out because age differ- well-documented physical health, cognitive, and
ences in generativity have been found mainly psychological well-being benets, particularly in
cross-sectionally, not longitudinally (Schoklitsch old age (Midlarsky and Kahana 2007; Van
and Baumann 2012). Generative motivations Willigen 2000; Wilson 2000). The benets of
have typically been investigated through autobio- prosocial behavior for the giver, if known, may
graphical methods, self-reported motivations and also drive motivation to engage in such behavior,
behavior, and personal goal analysis (Schoklitsch thereby reinforcing a positive cycle that builds
and Baumann 2012). both prosocial behavior and health and well-
According to socioemotional selectivity the- being. The following section describes some of
ory, the recognition of future time becoming the key benets of prosocial behavior that have
more limited prompts motivational shifts away been documented in experimental, experience-
from autonomy or knowledge acquisition goals sampling, and longitudinal work, using
typically found in young adults and toward emo- volunteering as a case study for prosocial
tionally meaningful social goals that focus on behavior.
close others, possibly including generative themes
(Carstensen et al. 2003; Lang and Carstensen Volunteering, Health, and Well-Being
2002). Coming back to the illustrative scenario, The majority of research on prosocial behavior in
Charlies motivation to provide pro bono services older adults looks specically at volunteering,
may have been guided by knowledge acquisition which can be dened as any activity in which
goals early in his career, whereas later in life, he time is given freely to benet another person,
group, or organization (Wilson 2000, p. 215). more people to whom they could turn for help
Typically, volunteering involves some commit- (Fried et al. 2004). It seems that a key benet of
ment of time and effort (not just a single act of volunteering is that it facilitates building high- A
kindness) and serves to benet people outside of quality social relationships that may serve as
ones family. Hence, volunteering is a special, but social support resources in old age (Fried
readily recognized, form of prosocial behavior. et al. 2004). Furthermore, participating in volun-
Volunteering is especially relevant for todays teer work can make older adults feel needed and
aging population as it may be a vehicle to stay appreciated, which can improve their overall
connected and make an active contribution to the sense of well-being (Midlarsky and Kahana
functioning of society past retirement (Fried 2007). For instance, ndings from the Americans
et al. 2004; Midlarsky and Kahana 2007). Further- Changing Lives study demonstrate positive asso-
more, volunteering has recently attracted a lot of ciations between volunteering and both life satis-
attention for its health-promotion potential in old faction and perceived health (Van Willigen 2000).
age (Midlarsky and Kahana 2007; Wilson 2000). Importantly, this study revealed that participating
This section will discuss some of the key in volunteer work had greater well-being benets
documented benets for physical health, cogni- for adults over age 60 years than for their younger
tive functioning, and social integration and well- counterparts, which further speaks to protective
being. effects of prosocial behavior in old age speci-
A well-known volunteering program for older cally (Van Willigen 2000). With few exceptions
adults is the Experience Corps (Fried et al. 2004), (Fried et al. 2004; Midlarsky and Kahana 2007),
which successfully integrated older volunteers the vast majority of research on the social and
into public elementary school programs to help psychological well-being benets of volunteering
vulnerable children improve their reading, prob- has employed cross-sectional and longitudinal
lem solving, and other social-cognitive skills. survey methods.
Findings from this program document a host of
benets for the older adult volunteers themselves, Other Forms of Prosocial Behavior and Links
including but not limited to physical health bene- with Well-Being
ts such as increased physical activity and In line with the research on volunteering
reduced declines in measures of physical strength described above, recent longitudinal and experi-
and health (Fried et al. 2004). mental work has also demonstrated the benets of
Volunteering has also been linked to reduced other, more discrete forms of prosocial behavior.
cognitive decline in old age. For example, nd- For example, spending money on others has been
ings from the Georgia Centenarian Study reveal shown to have a more positive impact on happi-
that, among the oldest old, leading an engaged ness than spending money on oneself in cross-
lifestyle (which involves volunteer work) is asso- cultural samples across the lifespan (Dunn
ciated with higher cognitive functioning in et al. 2008). Other experimental work looking at
domains that typically have a strong age gradient, young adult samples has revealed that engaging in
namely, orientation skills, attention, memory, small acts of kindness can increase positive emo-
arithmetic, motor skills, and language abilities tions in individuals who are socially anxious
(Martin et al. 2009). This is in line with the idea (Alden and Trew 2013), and dyadic studies con-
that volunteering encourages people to learn and rm that short-term prosocial behaviors give an
adapt to new situations and to make use of their emotional boost to the helper as well as the recip-
knowledge and skills, thereby helping to maintain ient (Weinstein and Ryan 2010). The benets of
cognitive abilities. small or short-term prosocial behaviors on well-
Volunteer activities also have well- being continues to be a hot topic, and these recent
documented social and well-being benets. For trends in social psychology could be fruitfully
example, participants in the Experience Corps extended to older samples. Further research is
program, compared to controls, reported having needed to also explore potential cognitive and
physical health benets of small, short-term Lifespan Development Knowledge Gaps

prosocial behaviors. In order to understand lifespan developmental
changes in prosocial behavior, its antecedents,
and its consequences, it is important to include
Future Directions participants of varying ages in a given study.
However, the current literature tends to use differ-
The literature on motivations and consequences of ent approaches when investigating prosocial
prosocial behavior is rich in ndings and in impli- behavior in young adult samples as compared to
cations for social engagement and well-being older adult samples. Specically, the vast majority
across the lifespan. This next section will selec- of experimental work in psychology relies on the
tively focus on some avenues that may be worth recruitment of university student samples, who
pursuing. also tend to be WEIRD: from Western, Educated,
Industrialized, Rich, and Democratic societies
Methodological Directions (Henrich et al. 2010). Experimental investigations
While experimental paradigms are typically used of older adult volunteers in the Experience Corps
to study discrete prosocial acts, such as donating (Fried et al. 2004) and eld studies of older adults
to charity or helping a confederate (Dunn helping behavior (Midlarsky and Kahana 2007)
et al. 2008; Weinstein and Ryan 2010), more are notable exceptions to this trend. Further inter-
sustained prosocial behavior, such as formal vention studies (with appropriate controls) in this
volunteering, is more often studied using cross- vein are needed to look at long-term outcomes of
sectional and longitudinal designs that incorpo- sustained volunteerism in older adults. Further-
rate a variety of data sources (Wilson 2000). There more, such studies should include middle-aged
are challenges and limitations to each of the above adults in order to better understand what will
research designs, for example, laboratory and motivate them to be active volunteers by the
eld experiments are limited with respect to the time they leave the labor force and to what extent
conclusions that can be drawn regarding how and the benets of volunteering might extend to this
to what extent people behave prosocially in their age group.
everyday lives. Prosocial behavior has been Many studies of volunteering in older adults
found, in fact, to be very situation specic and also investigate underlying motivations (Wilson
hence can vary from day to day or from hour to 2000). However, although much is known about
hour. The use of methods such as experience the benets of volunteering, less is known regard-
sampling can help resolve this issue; a key advan- ing whether achieving these benets depends on
tage of experience sampling is that it allows volunteers motivations for their work. For exam-
researchers to investigate behavior and associated ple, it might be interesting to determine whether
cognitions and emotions as they arise naturally in volunteering that is driven by generativity or that
participants daily lives (Bolger and Laurenceau which is driven by socioemotional selectivity pro-
2013). An experience-sampling study could be duces greater benets or if perhaps both sources
used, for example, to investigate the short-term, of motivation need to be there in order for
dynamic emotional antecedents and conse- volunteering to be maximally satisfying for older
quences of lawyers engagement in different adults. There are a few intriguing studies in this
kinds of pro bono work over the course of a 2- area showing, for example, that volunteering may
week period. A promising avenue of research reduce mortality in old age, but only when volun-
involves combining experience-sampling and teers are driven by other-oriented (more altruistic)
experimental methods, in order to assess prosocial reasons for volunteering (Konrath et al. 2012).
behavior (and its antecedents and consequences)
in the most scientically rigorous manner while Emotion Regulation and Cognitive Decline
taking into account the daily life context in which Behaving prosocially is potentially an effective
it occurs. means of regulating ones emotions, as it can
activate neural pathways related to reward (Moll explored the antecedents or motivations of
et al. 2006), reduce the emotional distress of see- prosocial behavior and how these may shift over
ing a person in need (Feigin et al. 2014), and help the lifespan, and has discussed various health and A
solidify positive relationships with others. How- well-being benets of behaving prosocially. Fur-
ever, effective emotion regulation (such as the ther research in this area needs to directly examine
ability to deal with emotional complexity and developmental trajectories and outcomes of
high-arousal negative emotion) relies on cognitive prosocial motivation and behavior by including
resources that decline with age (Charles 2010; older, middle-aged, and young adults in the same
Labouvie-Vief 2003). As a result, older adults study, making use of longitudinal methods when-
might nd it more difcult to put their emotion- ever possible. It will also be interesting to expand
regulation skills into action (Charles 2010). our current knowledge by looking at a variety of
Hence, despite their great capacity for empathy short-term as well as sustained kinds of prosocial
and altruism, age-normative cognitive decline behavior in the context of adults daily lives. This
could become an obstacle to older adults pursuing area of inquiry promises to inform a social model
and reaping the emotional rewards of prosocial of health promotion that fosters active social
behavior. Further research is needed to investigate engagement throughout adulthood and into old
the possibility of direct linkages between age and that at the same time benets society.
emotion-regulation abilities and prosocial behav-
ior as people age.
Cross-References
Implications for Policy and Practice
Given what is known about the health and well-
Aging and Psychological Well-Being
being benets of volunteering and other forms of
Intergenerational Relationships
sustained prosocial behavior in old age, what can
Loneliness and Social Embeddedness in Old
be done to encourage these kinds of behavior in an
Age
aging society? From a public policy perspective,
Psychological Theories of Successful Aging
society might do well to offer more opportunities
for volunteering, as well as leisure activities with a
generative focus, for older adults. Businesses,
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Definition
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How and why we care for the next generation Alzheimers disease (AD) is a progressive, irre-
(pp. 743). Washington: APA. versible brain disorder that is the most common
Midlarsky, E., & Kahana, E. (2007). Altruism, well-being,
cause of dementia in later life. It is characterized
and mental health in late life. In Altruism and health:
Perspectives from empirical research (pp. 5669). New clinically by a profound impairment in new learn-
York, NY: Oxford University Press. ing and memory recall along with decits
Alzheimers Disease, Advances in Clinical Diagnosis and Treatment 257
commonly in expressive language, complex heart disease, cancer, lower respiratory disease,
problem-solving, and visuospatial functions. accidents, and stroke. At present, the disease is
Neuropathologically the signature of the disease estimated to affect nearly 5.4 million Americans A
includes abnormal processing and aggregation of and over 36 million individuals globally
two proteins: b-amyloid and tau protein, which (G8 Dementia Summit 2013). As the world pop-
leads to the formation of amyloid plaques and ulation continues to age, the numbers are expected
intraneuronal brillary tangles. Fluid and imaging to climb dramatically over the next 40 years. By
biomarker tests are now available to measure the year 2020, over 76 million individuals will
these abnormalities to facilitate reliable AD diag- have AD globally, and this number will nearly
nosis and staging across the disease continuum. double to over 135 million by 2050, a number
which does not include individuals in the milder
stages of disease. The annual costs for medical
Introduction care will be staggering. In the USA alone, the
healthcare costs (Medicare and Medicaid) for
Alzheimers disease (AD) is a progressive, irre- AD are currently estimated at 148 billion dollars
versible brain disorder that is the most common (Alzheimers Association Facts and Fig-
cause of dementia in later life. Although typically ures 2015). Absent a treatment to slow the trend,
conceptualized as a disorder of old age with symp- these numbers will exceed 1.1 trillion dollars
tom onset commonly in the eighth decade of life, annually by the year 2050.
AD is now recognized to be a chronic disease in Despite considerable advances in understand-
which the underlying neuropathology begins to ing the basic biology of the disease, there is cur-
accrue decades before memory problems are rently no cure for the disease nor are there any
appreciated. Clinically the disease begins insidi- disease modifying treatments available that can
ously, generally when the individual is in their alter the inevitable course of the disease. Without
mid-60s or older. The earliest signs typically a way to mute the effects of the disease, the public
include impaired recent memory function and health outlook is grim. Families will bear the
trouble in word retrieval. These problems become greatest burden for care and costs, providing
increasingly more pronounced as the disease pro- informal care to those affected by the disease,
gresses, leading to decits in complex problem- often at personal expense as they exit the work
solving, spatial judgment, and motor perfor- force early to respond to the around the clock
mance. Ultimately, as the neural destruction care needs. In anticipation of the growing eco-
evolves, increasing levels of disability result, cul- nomic and social impact of this disease as the
minating in total dependence on others for basic population ages, national plans addressing
needs related to nourishment, toileting, and self- Alzheimers disease have been enacted by the
care. Individuals who survive to the late stages of G8 countries in Europe and by the USA. Each
AD eventually are bedbound and in a vegetative plan is aimed to reduce the numbers of individuals
state. They typically succumb to the disease due to affected by Alzheimers disease with stated goals
complications related to severe brain compro- of developing effective therapeutics by the year
mise, such as aspiration pneumonia. 2025 that could limit the impact of the dementia
With advances in healthcare, more and more by either halting Alzheimers disease altogether or
people are living into old age (after age 65) and slowing its inexorable progression.
late old age (after age 80). This increase in lon- This entry provides a conceptual overview of
gevity brings with it a concomitant rise in the clinical, neuropsychological, and neuropatho-
age-associated illnesses. As a result, Alzheimers logical features of Alzheimers disease. In this
disease is now the leading cause of late-life context, we discuss the advances in understanding
dementias globally, and it is overall the sixth the genetics and underlying pathogenesis of dis-
leading cause of death in the USA, following ease which have resulted in the development of
antemortem biomarkers to facilitate diagnostic of neurons called neurobrillary tangles; and

reliability across the continuum of disease. The (3) a loss of synaptic connections between neu-
last section of the entry then turns to consider rons. These changes are not uniformly distributed
treatments, summarizing the currently available across the brain but rather are regionally conned
medications and the continuing efforts to identify to specic cellular laminar areas within the medial
disease modifying therapies that will delay the temporal lobe area and throughout the associa-
onset and progression of disease once it has tional cortices of the frontal, temporal, and parie-
begun. tal lobes (Arnold et al. 1991). Essentially spared,
even into the late stages of the disease, are the
sensory and motor cortices.
Characteristic Features of Alzheimers Although the disease follows a fairly predict-
Disease able course, there can be some variability in the
clinical expression of symptoms, depending on
Alzheimers disease (AD) was rst described in the regions of the brain affected. Regardless of
1906 by Dr. Alois Alzheimer who reported the the prole of impairments expressed, the clinical
clinical characteristics and the underlying brain course of disease is one of the inexorable progres-
pathology in his patient, a 51-year-old woman sion which passes through essentially three iden-
who progressed to end-stage dementia and even- tiable stages of disease (see Fig. 1), dened on
tually succumbed to the disease (see Ballard the basis of a combination of both clinical and
et al. 2011 for review). Initially believed to be a biological features. These stages include a latent
rare problem, AD is now recognized as a common or preclinical stage (Sperling et al. 2011), a
disorder of late-life that involves the slow, indo- prodromal or mild cognitive impairment stage
lent progression of neuropathological change over (Albert et al. 2011), and the full symptomatic
the course of decades in the brain. Beginning with stage of AD dementia (McKhann et al. 2011).
subtle memory problems, the fully expressed clin- Each of these stages is described below along
ical syndrome includes prototypical impairments with the role of biomarkers in enhancing diagno-
in four key cognitive domains, referred to as the sis reliability at each stage (Jack et al. 2010).
4 As of Alzheimers disease: Amnesia, Apha-
sia, Agnosia, and Apraxia. The memory disor-
der, or the amnesia of AD, is characteristically a Preclinical AD
pronounced anterograde memory disorder involv-
ing difculties in the learning and retention of new The preclinical stage of the disease is the clinically
information. This problem is consistently one of silent stage of the disease, in which the affected
the earliest and most distinguishing features of individual appears cognitively healthy despite the
AD throughout the disease course, with decits appearance of cortical b-amyloid (Ab) deposition
detectable in the presymptomatic stages. Later, within discrete regions of the cerebral cortices
expressive aphasia emerges along with difculties along with tau pathology and tangle formation in
in form vision and recognition (agnosia) and the trans-entorhinal cortices, brain circuits respon-
impairments in problem-solving and the execu- sible for learning and memory function (Hyman
tion of common tasks involving motor integration et al. 2012, for review). Prospective, longitudinal
(apraxia). data collections within large epidemiological
At postmortem examination, the disease is cohorts and clinical series indicate that subtle
characterized by three pathological hallmarks, changes in neurocognition may be observed for
appreciated since the early descriptions of nearly a decade before a diagnosis of AD is made,
Alzheimer in 1906. They include (1) an abnormal even though the individuals performance may
aggregation of a viscous small peptide, b amyloid, remain within the normal range (Vos
surrounding by cellular debris outside the neuron, et al. 2015). Analysis of cognitive trajectories
termed the amyloid plaque; (2) tangled bundles across a number of studies suggests that the
A
Neural Substrate of Cognition
Latent Stage (preclinical)
Prodromal AD/ Mild
cognitive impairment
(MCI)
Threshold
Symptomatic Stage
(Dementia)
Age
Alzheimers Disease, Advances in Clinical Diagnosis intervention. Prior to the silent stage, there is an opportu-
and Treatment, Fig. 1 Alzheimers disease chronic nity for primary prevention in subjects at risk for the
disease model. Alzheimers disease is now recognized as disease. As symptoms or pathology express, secondary
a chronic disease developing over decades in brain and prevention approaches are aimed at stopping, reversing,
divided into three stages: preclinical stage where disease is or slowing disease progression. At the symptomatic stages,
latent, prodromal disease where mild cognitive symptoms typically the target for therapies is to delay or slow
are apparent, and a fully symptomatic stage when dementia progression
is evident. Each stage provides avenues for therapeutic
earliest changes are typically in episodic memory bolster function (Albert et al. 2011). Clinically,
performance and aspects of higher executive func- the symptoms can be highly variable early in the
tion, occurring on the order of 79 years prior to process, and hence MCI may be confused on
receiving a clear AD diagnosis. Other cognitive routine screening for the more common experi-
domains, including verbal uency, change more ence of age-associated forgetfulness. However,
proximally to dementia onset, within approxi- more detailed clinical evaluation with the inclu-
mately 3 years, whereas simple attention and sion of neuropsychological assessment permits
speed domains remain relatively unchanged until the detection and discrimination of mild cognitive
dementia is diagnosed (see Attix and Welsh- impairments from the more benign effects of nor-
Bohmer 2006, for review). mative aging. The recent introduction of new AD
diagnostic criteria (see Table 1) facilitates diag-
nostic reliability through a consideration of the
Prodromal AD/Mild Cognitive clinical signature specic to AD and the incorpo-
Impairment ration of available uid and imaging biomarker
information. Depending on the criteria used, the
The prodromal stage of AD or mild cognitive early symptomatic stage of the disease is either
impairment (MCI) is the early symptomatic referred to as the prodromal AD (Dubois
phase of the disease at which time the memory et al. 2007), mild cognitive impairment due to
impairment for recent events or other cognitive AD (Albert et al. 2011), or a mild neurocognitive
disorders are particularly prominent but function disorder due to AD (American Psychiatric Asso-
remains fairly to normal. The individual is able to ciation 2013). The criteria differ in some aspects
attend to their usual activities unassisted but may from one another as can be seen in Table 1, with
be less efcient and is often more reliant on aux- the DSM-5 capturing a broader spectrum of tran-
iliary aids, such as reminders and calendars, to sitional disorders, whereas both the NIA-AA
Alzheimers Disease, Advances in Clinical Diagnosis and Treatment, Table 1 Diagnostic criteria for mild
pre-dementia stage of Alzheimers disease
NIA-ALZ Association Mild
IWG-criteria Prodromal AD (Dubois Cognitive Impairment (Albert DSM-5 Mild Neurocognitive
et al. 2007) et al. 2011) Disorder (APA DSM5 Manual 2013)
Presence of early and signicant Cognitive concern reecting a Evidence of modest cognitive decline
episodic memory impairment (alone change in cognition from usual from previous level of performance
or with other cognitive/behavioral baseline reported by the individual, a in one or more cognitive domains
problems) and includes both knowledgeable informant (such as a based on either an informant report or
(i) a gradual and progressive course family member) or the clinicians objective evidence such as
from family or patient report own observation. This can be based neuropsychological testing
over > 6 months and on historical information from Capacity to perform everyday
(ii) there is objective evidence of subject and/or informant or it activities (instrumental activities of
impaired memory on memory tests includes actual observed evidence of daily living) is maintained although
such as cued recall or encoding tests decline greater effort or compensatory
strategies may be needed
In vivo evidence of AD pathology, Objective evidence of impairment in Not occurring exclusively in the
from either: one or more cognitive domains, context of delirium
(i) CSF tau/AB levels studies typically including episodic memory Not explained by another mental
(ii) Amyloid PET imaging early in the course. This can be disorder such as major depression of
(iii) AD autosomal dominant genetic established by formal or bedside schizophrenia
mutations testing of multiple domains
No sudden onset or early occurrence Preservation of function in abilities to The disorder is not better explained
of gait disturbance, seizures, or major carry out instrumental activities of by cerebrovascular disease, another
or minor prevalent behavior changes daily living although greater effort, neurodegenerative disorder, or
time, and/or compensatory strategies another medical explanation
are needed
No focal neurological signs, no early Etiology is consistent with AD Probable AD as cause of the mild
extrapyramidal signs, and no early pathophysiological process with neurocognitive disorder is supported
hallucinations or cognitive evidence of longitudinal decline if there is a genetic mutation from
uctuations when possible and history of AD family history or genetic testing
genetic factors when relevant
No other medical condition that is Vascular, traumatic, and other Mild neurocognitive disorder due to
severe enough to account for the medical causes responsible for possible AD is diagnosed in the
presentation cognitive decline are excluded absence of a causative gene and all
three of the following are met:
(i) Clear evidence of decline in
learning/memory and one other
domain based on history or serial
neuropsychological testing
(ii) Slow and indolent decline in
cognition without extended plateaus
(iii) No evidence of mixed etiology
Biomarkers indicating a high
likelihood that the MCI is due to AD
include a positive biomarker of Ab
deposition (CSF Ab42, PET amyloid
imaging) and a positive biomarker of
neuronal injury (CSF
tau/phosphorylated tau; hippocampal
volume or medial temporal atrophy
by volumetric measures or visual
rating; FDG-PET imaging)
criteria of MCI and the Dubois criteria for prodro- score is more sensitive than categorical ratings of
mal AD are focused on diagnosing early symp- dementia (mild, moderate, severe) in detecting
tomatic disorders due specically to Alzheimers changes in function over time and is useful in A
disease. staging the disease in practice, research, and clin-
ical trials.
Fully Symptomatic AD Dementia

Clinical Variants of AD
At the fully symptomatic, dementia stage of the
disease, the memory problems remain prominent; It should be noted that AD can present in an
however, there are also pervasive impairments atypical fashion, where memory is not the prom-
across areas of problem-solving, language expres- inent early feature. Although less common, visual,
sion, visuospatial function, and other aspects of language, and frontal variants of AD have been
intellectual ability (Attix and Welsh-Bohmer described. In these instances, the initial presenting
2006, for review). These cognitive issues, symptoms may consist of a complex visual system
superimposed on the episodic memory disorder, disturbance, such as Balints syndrome, a uent
make it increasingly difcult for the patient to aphasia, or a notable dysexecutive disorder,
function normally in everyday life (McKhann respectively. These variants of AD are very rare
et al. 2011). Patients become increasingly reliant and typically have an earlier age of onset than the
on others to assist in daily routines, including common form of the disease. Determining the true
meal preparation, transportation, bill paying and prevalence of these unusual forms of AD has been
nancial decision-making. By denition, the indi- difcult due to very few neuropathological studies
vidual has progressed to dementia when the which permit rm conclusions as to causation of
ability to function independently is no longer what is presumed to be atypical AD (see Attix and
possible. Welsh-Bohmer 2006 for review). However, on
This stage of the disease typically lasts for both imaging and postmortem evaluation, the
810 years and covers a broad range of functional brain areas affected by the pathology tend to par-
disability, from mild disruption in instrumental allel the abnormal symptoms such as involvement
activities of daily living (e.g., bill paying) to of left hemisphere language areas in instances of
some dependence on others for self-care, to aphasia and parietal/occipital involvement in con-
end-stage total care. To assist in tracking disease ditions with complex visual system disorders.
course, the severity of the dementia is often parsed
using different methods, such as the Clinical
Dementia Rating Scale (CDR; see Attix and Neuropsychological Characterization
Welsh-Bohmer 2006). The CDR breaks the
dementia of AD into severity stages, ranging Neuropsychological evaluation is an important
from very mild (CDR = 0.5), mild rst step in the characterization of memory disor-
(CDR = 1.0), moderate (CDR = 2), and severe ders occurring in normal aging and AD. This
(CDR = 3), depending on functional abilities assessment permits the systematic documentation
within six different domains (memory, communi- of decits across multiple cognitive processing
cation, independence in self-care, interest in home domains which can then be mapped to their asso-
and hobbies, bladder and bowel function, and ciated brain systems. AD and other common
overall awareness with the environment). causes of dementia in later life, including vascular
A global composite score, referred to as the sum disease, Parkinsons disease, and depression, have
of boxes (CDR-SB), can be generated by sum- unique cognitive signatures reecting differing
ming ratings across each of the six domains, per- underlying neurobiology and neural systems
mitting a continuous measure of observed involvement. Consequently, based on both
cognition and functional abilities. This composite the pattern and extent to which a patients
performance deviates from age- and education- diagnosis and to facilitate treatment and medical
based normative values, the clinician can draw management efforts. Acquired problems in
inferences as to the likely explanation for the expressive language often emerge early in the
cognitive disorder and the degree of impairment. disease course and leads to blocking on words or
The characteristic neuropsychological prole anomia. As the problem becomes more acute,
of AD dementia is among the best understood of the patient will often resort to circumlocution, a
the neurodegenerative conditions of aging (Attix tendency to describe the word eluding recall. To
and Welsh-Bohmer 2006). The memory assess language expression, tests of visual naming
processing problem of AD is one involving and word uency are commonly used (Attix and
impaired consolidation of new information Welsh-Bohmer 2006). Typically, patients with the
from a limited capacity, short-term memory store anomia of AD will do poorly on tests of visual
into a more permanent, longer-term memory store memory and category uency where they are
for later use and retrieval. Problems in consolidat- required to generate examples of items in the
ing information can be demonstrated on verbal category of interest (e.g., animals). Curiously,
episodic learning measures, such as story recall word generation to a letter such as the commonly
and supra-span word list learning tests, with rapid used F-A-S task remains intact, suggesting that
forgetting of the verbal information over a span of the problem is not in language retrieval but rather
30 min or less (Attix and Welsh-Bohmer 2006, for in retrieval of specic examples from semantic
review). knowledge stores. Comprehension and repetition
Contrasting the memory disorder of AD, for- also remain preserved at this point in the illness.
getfulness in cognitive aging is ascribed to inef- However, these abilities also change as the disease
ciencies in encoding new information (learning) progresses. Ultimately, decits in speech expres-
and retrieval of this information from a more sion become more extreme and the burden of
permanent memory store. Tests such as the Free conversation falls increasingly on the listener.
and Cued Selective Reminding Test (FCSRT) as Impairments in verbal comprehension begin to
well as other memory procedures that have built in emerge during the later stages of dementia, mak-
prompts or recognition procedures are clinically ing it increasingly difcult for patients to process
useful in distinguishing between AD and other more than one task at time. These problems in
disorders. These procedures permit distinctions performing single and multistep commands can
between recall decits due to AD, encoding/ be established with tests of verbal comprehension
retrieval inefciencies observed in normal aging, such as the Token Test.
and attentional decits that can occur in situations Subtle issues with visuospatial function often
of anxiety or depression. Cognitively normal sub- surface early in the disease leading to issues in
jects are able to demonstrate recall of newly spatial navigation even in familiar territory. Later
learned information when retrieval and encoding in the disease these problems become more pro-
supports are applied, whereas the use of these nounced, and difculties involve impaired vision
same techniques does not appreciably change rec- perception difculties in well coordinating motor
ollection in AD subjects (Dubois et al. 2007). movements. The problems in perception can con-
Building on these observations, some of the tribute to agnosia which refers to the ability to
newly emerging diagnostic criteria for AD now understand the environment. And the decits in
include recommendations for specic memory spatial and motor coordination lead to apraxia,
techniques to include in the standard assessment the ability to complete common motor tasks such
of early staged AD to facilitate diagnostic cer- as manipulating utensils, dressing correctly, and
tainty (Dubois et al. 2007). navigating effectively in a familiar environment.
As mentioned, although memory impairment While at the later stages of the disease, when the
is the cornerstone of the AD diagnosis, many full syndrome of AD dementia is expressed, neu-
other aspects of cognition are affected in the dis- ropsychological testing may not be required for
ease and need to be assessed, both to secure the documenting and characterizing these obvious
problems. Within the early stage of disease, neu- The hypothesis essentially proposes that there is a
ropsychological testing of visuospatial, construc- chain of cellular events in predisposed individuals
tion, and perceptual functions can be quite useful which results in an abnormal processing of the A
in documenting subtle processing problems that amyloid precursor protein (APP) leading to an
are not at all obvious in conversation or on mental incorrectly cleaved peptide product, amyloid-b
status screening. Decits in visuospatial function (Ab). The increased production and impaired
can be elicited using tests of constructional copy, clearance of Ab, particularly the oligomeric form
involving simple and more complex designs. of the peptide, proves neurotoxic. As a conse-
Other tests examine judgments of spatial align- quence, this abnormal Ab deposition initiates a
ment, form vision, or visual conceptualization and pathogenic cascade which results in tau phosphor-
abstraction. ylation, neurobrillary tangle development, cell
death, and the concomitant emergence of clinical
symptoms. Support for the amyloid hypothesis of
Neuropathological Signature AD pathogenesis has come from the eld of
genetics. Known mutations in genes encoding
Biological Basis of Alzheimers Disease APP accelerate amyloid-b production in gene car-
Although the cognitive signature of AD is now riers and result inevitably in an early onset form of
very well understood, the biological causes under- AD. Other gene mutations have been identied in
lying this complex condition are not completely two other genes, presenilin 1 (PSEN 1) and
resolved. Three dominant hypotheses of disease presenilin 2 (PSEN 2), each of which has a pri-
causation include what are called the cholinergic, mary effect on Ab processing and plaque forma-
amyloid cascade, and tau hypotheses. The rst of tion and also leads to an early onset form of the
these hypotheses, the cholinergic hypothesis, con- disease (Vos et al. 2015, for review).
ceptualized AD as a disease involving the cholin- Although the amyloid hypothesis is well
ergic system, the main neurotransmitter system accepted as an explanation of the plaque forma-
innervating the hippocampal memory system. tion occurring in AD subjects (Jack et al. 2010),
The hypothesis was supported by two fundamen- this hypothesis is a source of debate as an
tal observations. First, age-dependent memory explanation that can fully explain the
change had been shown to be closely related to neurodegeneration occurring in the disease. By
cholinergic system integrity. Second, the pathol- denition, amyloid plaque formation is present
ogy of AD was correlated with the extent of cell in all cases of AD, but aggregation of Ab is also
loss in the nucleus basalis of Meynert, the source observed in aged individuals who do not manifest
of cholinergic afferents to the hippocampal mem- any clinical signs of the disease. There also is poor
ory system. The cholinergic hypothesis drove ini- correlation between the level of overall aggrega-
tial drug development in the 1980s1990s tion of Ab and both the extent of clinical impair-
(Schneider et al. 2014, for review), but was ment and apparent neurodegeneration upon which
found to be an incomplete explanation of the the dementia rests (Small and Duff 2008; Ballard
aggregation of amyloid and tau pathology seen et al. 2011, for review). Further, if Ab accumula-
in the disease. tion is an essential upstream event in AD, it is
More recent hypotheses focus around the unclear how this aggregation incites intracellular
abnormal processing of amyloid and tau, as the hyper-phosphorylation of tau, a key cellular event
key constituent proteins involved in amyloid observed in AD. The failure of a number of recent
plaque formation and neurobrillary tangles, clinical trials using Ab lowering agents gives fur-
respectively (Ballard et al. 2011). The amyloid ther pause to the amyloid hypothesis (Cummings
hypothesis has been the most inuential of the et al. 2014). In these trials, there was no clinical
hypotheses in the last decade, leading to the iden- improvement in patients with mild to moderately
tication of drug treatment targets, and is the basis severe staged disease, despite an overall reduction
of many of the current drug development efforts. in Ab deposition indicating appropriate target
engagement. Although it is argued that the com- Understanding the pathophysiological pathways
pounds were aimed at the wrong stage of the involved in AD and the interactions between
disease and should be implemented in the preclin- these pathways to cause the disease is crucial for
ical stage to be effective, an alternative interpre- the development of effective treatments.
tation is that amyloid dysregulation alone may
be an insufcient explanation for the
neurodegeneration occurring in AD. Other mech- Genetics of Alzheimers Disease
anisms may need to be considered to explain the
emergence of clinical dementia. Whatever its role in AD pathogenesis, it is now
The tau hypothesis has generated considerable well understood that genetics has a fundamental
attention and is focused around abnormal effect in AD risk and symptom onset. As already
processing of tau protein within neurons resulting described, gene mutations in APP, PSEN1, and
in tangle formations. Tau protein is an important PSEN2 are causal linked to both an
constitutional protein within the neuron, playing a overproduction of Ab and an early onset form of
role in microtubule stabilization and cellular AD. However, these genes account for less than
transport (see Small and Duff 2008, for review). 5% of all cases of AD, leaving the vast majority of
In its abnormal phosphorylated state, as occurs in AD cases unexplained by genetic mutations. In
AD, the protein forms cross-linkages leading to the more common late-onset form of AD, com-
microtubule instability, impaired axonal transport, mon variations in several other genes have been
loss of synaptic connections, and cell death. Sup- identied as increasing risk of disease and leading
port of this hypothesis is a tight correlation to an earlier symptom onset (see Ballard
between the extent and distribution of tangle for- et al. 2011; Lambert et al. 2013 for review). The
mations, loss of synapses, and the cognitive dis- most consistently associated risk gene is ApoE, a
order of AD. For this reason, tau is considered gene that is important in cholesterol metabolism
crucial to AD pathogenesis. However, as in the and also plays a role in immunity, inammation,
other hypothesis, it remains unresolved as to how and endosomal vesicle recycling. The gene also
tau processing and amyloid aggregation are linked appears to have an effect on APP trafcking and
together (Small and Duff 2008). AB production.
Other hypotheses under investigation include For nearly 15 years, this gene was the only
(1) a role of genetics in driving both tau phosphor- established risk factor for late-onset AD. With
ylation and Ab clearance, (2) impaired homeosta- the advent of new genome-wide sequencing
sis of cerebral iron and problems with myelin approaches, other gene loci have been identied.
repair, (3) environmental inuences altering In a recent meta-analysis involving over 74,000
bloodbrain barrier permeability to opportunistic cases of AD and controls, 19 loci including APOE
pathogens, and (4) altered immune response and were identied as reaching genome-wide signi-
an unresolved inammatory response or some cance as associated with AD (Lambert
combination of these and other mechanisms. et al. 2013). Interestingly, the second strongest
While each explanation has some support for signal to date is within the SORL1 gene, a gene
observed cellular abnormalities in AD, none of that is associated with increased risk of both auto-
these explanations are considered mutually exclu- somal dominant and sporadic forms of AD. It is
sive. Rather, the pathogenesis of AD is now con- the rst gene related to late-onset forms of AD that
ceptualized as involving a number of complex directly connects abnormal trafcking of APP to
events mediated by unique cellular pathways the late-onset form of AD. Other genes identied
that ultimately involve amyloid aggregation, tan- have roles in amyloid and tau processing and in
gle formation, synapse loss, and cell death. Trig- inammation and immune function. Some new
gering events, while not completely known, are genes were identied with roles in other funda-
likely inuenced by a number of host risk condi- mental cellular functions, including hippocampal
tions including genetic factors as mentioned. synaptic function, cytoskeletal function, and
axonal transport. This now provides new mecha- of disease get underway, these biomarkers are
nistic insights into late-onset disease and possibly being used to improve subject identication
some new target pathways for drug development. (Sperling et al. 2011). Change in these markers A
in response to therapy may also serve as indicators
of target engagement as well as surrogates track-
Biomarkers of Alzheimers Disease ing disease progression.
Based on a better understanding of the underlying

biology of AD, biomarkers are identied which Treatments for Alzheimers Disease
track the disease and can be applied to facilitate
diagnostic decision-making and disease staging. Treatment trials leverage genetic risk factors and
The ve scientically established biomarkers evidence of AD biomarkers as interventions move
included in the new diagnostic criteria for AD to earlier stages in the disease course (Reiman
are (1) cerebrospinal uid (CSF) measures of et al. 2016). Currently approved medications
Ab42, (2) CSF level of total tau (t-tau) and phos- were developed in symptomatic disease and are
phorylated tau (p-tau), (3) position emission prescribed in mild AD and in MCI. All four com-
tomography (PET) amyloid imaging, (4) structural pounds are considered symptomatic treatments,
magnetic resonance imaging (MRI) measures of improving attentional focus but not altering the
hippocampal volume loss and cerebral atrophy, underlying neuropathology of the illness
and (5) regional hypometabolism on uoro- (Schneider et al. 2014). Each has demonstrated
deoxyglucose (FDG) PET. The use of these modest effects on cognition over the course of
biomarkers in clinical diagnosis is based on a 6 months in patients with mild to moderate
theoretical model of how AD unfolds pathologi- AD. The cholinesterase compounds include
cally over time (Jack et al. 2010; Fig. 2). donepezil, introduced in 1996 (1997 in the UK),
According to the initial model, Ab deposition rivastigmine approved in 2000 (1998 in Europe),
is an early initiating event in the pathogenic cas- and galantamine made available in 2001 (2000 in
cade, measured by low levels of CSF Ab42 or Europe). Later, in 2002 in Europe and 2003 in the
high uptake of amyloid PET tracers. Shortly there- USA, the N-methyl-D-aspartate (NMDA) recep-
after, once amyloidogenesis has commenced, tor antagonist, memantine, was approved for use
there are detectable elevations in levels of CSF in moderate to severe AD (Schneider et al. 2014).
t-tau and p-tau, markers correlated with postmor- No other new compounds have been approved for
tem neurobrillary tangle burden and neuronal AD over the last 13 years, despite a number of
degeneration at autopsy. Later, as neuronal dys- promising agents that have effectively engaged
function becomes more pervasive and therapeutic targets.
neurodegeneration ensues, there are measurable The reasons for the lack of recent AD clinical
changes in memory, brain volume on MR imag- trial successes are likely complex and involve a
ing, and glucose utilization on FDG-PET imag- combination of (1) imperfect study designs, such
ing. Validation of the model is based on as heterogeneous patient populations with an
accumulating evidence that the biomarkers mirror admixture of diagnoses, (2) focus on compounds
the pathophysiological progression of the disease. that are targeted on wrong disease mechanisms,
Although the relative temporal emergence of the and (3) attempt to implement therapies that alter
biomarkers is still debated, the presence of these the pathological targets but are introduced at the
biomarkers in the context of clinical disease helps wrong stage of disease. In overcoming these chal-
afrm a diagnosis of MCI or AD dementia. Their lenges, the current generation of trials uses AD
presence in cognitively healthy subjects suggests biomarker evidence to improve patient selection,
preclinical disease and provides a testable frame- focuses on a broad array of disease targets, and
work for in vivo staging of asymptomatic illness attempts to match the right treatment to the right
(Vos et al. 2015). As clinical trials in earlier stages stage of disease, based on current models of the
Abnormal A
Tau-meditated neuronal injury and dysfunction
Brain structure
Memory
Clinical function
Biomarker magnitude
Normal
Cognitively normal MCI Dementia
Clinical disease stage
Alzheimers Disease, Advances in Clinical Diagnosis structural MRI (Republished with permission of Lancet
and Treatment, Fig. 2 Original dynamic biomarkers Neurology from article entitled Hypothetical model of
of the AD pathological cascade model. Ab amyloid is dynamic biomarkers of the Alzheimers pathological cas-
identied by CSF Ab42 or PET amyloid imaging. Neuro- cade Author: Clifford R. Jack Jr et al., Lancet Neurology
nal injury and dysfunction are identied by CSF tau or 9:119128, 2010; permission conveyed through Copyright
FDG-PET. Neurodegenerative atrophy is measured by Clearance Center, Inc., April 13, 2016, # 11555434)
unfolding of the disease pathophysiological cas- The Dominantly Inherited Alzheimer Network
cade over time. Trials Unit (DIAN-TU) is examining promising
Many of the current therapeutic efforts are now treatments in individuals with known causative
positioned earlier in the disease continuum to test mutations for AD in the PSEN1, PSEN2, or APP
the efcacy of therapeutic compounds in postpon- genes. All three clinical trial programs described
ing, reducing risk, or completely preventing the are supported through publicprivate partnerships
clinical onset of AD (Reiman et al. 2016). These positioned between the US National Institute of
so-called secondary prevention trials include Health and industry partners. Another global
the Anti-Amyloid Treatment in Asymptomatic trial to delay the onset of clinical signs of MCI
Alzheimers A4 study which is testing due to AD is the TOMMORROW study. This
amyloid-based therapeutics for the sporadic form investigation, unlike the others summarized, is
of the disease in individuals with high amyloid entirely industry sponsored. It is designed with
deposition visualized on functional brain imaging. two goals. The rst of these is to qualify a
The Alzheimers Prevention Initiative (API) of the genetic biomarker risk algorithm comprised of
Alzheimers Disease Cooperative Study (ADCS) two AD risk genes (APOE, TOMM40) for
is a program that includes cognitively healthy assigning 5 year risk of developing MCI due
participants who are at high risk of AD based on to AD. The second concurrent goal is to evaluate
their genetic background and age. The a novel agent which acts on cellular bioenergetics,
API-ADAD study examines large families or a low-dose pioglitazone, in delaying the onset
kindreds with evidence of autosomal dominant of MCI due to AD in cognitively normal, high
AD transmission; the API-APOE4 study exam- risk individuals based on the genetic risk
ines subjects who have at least one e4 allele. algorithm.
Non-pharmaceutical Approaches: lifestyle interventions involving diet, exercise,

Modifiable Risk Factors of Alzheimers cognitive training, and vascular risk monitoring
Disease showed signicant neuropsychological improve- A
ments over 2 years compared to those who
Beyond pharmaceutical trials, large-scale epide- received regular health monitoring and informa-
miological studies have suggested a host of both tion about healthy lifestyle (Ngandu et al. 2015).
modiable and unmodiable factors that contrib- Future studies are needed to determine the impact
ute to the lifetime risk of AD and different mech- of behavioral approaches such as these on indi-
anistic aspects of the disease. The most consistent viduals with either mild memory disorders or with
behavioral health factors tied to AD risk include brain evidence of preclinical disease. However,
(1) smoking, (2) poor diet (high saturated fat and the current data suggest that attention to modi-
low vegetable intake), (3) cognitive inactivity, able health conditions may serve to preserve opti-
(4) diabetes, (5) physical inactivity, and (6) depres- mal brain health in aging and may be important in
sion (Xu et al. 2015). Because these factors rep- forestalling dementia in patients who are at risk of
resent treatable conditions, the implication is that AD and related conditions.
by addressing these factors when present, it may
be possible to reverse some of the adverse health
trends and, when done on a large scale, could have Conclusions
a substantial impact on global public health.
Recent public health statistical models support AD is a highly complex, chronic disease evolving
this premise (Norton et al. 2014). A modest theo- over decades in the brain and involving not only
retical reduction (1020% over the next several multiple pathological mechanisms but a broad
decades) in the prevalence of the seven major risk network of interconnected brain systems. Pro-
factors associated with AD (low education, diabe- gress in understanding the neuropsychological
tes, smoking, midlife hypertension, obesity, phys- expression of disease and the neurobiology of
ical inactivity, and depression) could have a the disease now permits early detection of true
remarkable impact on the future prevalence of cases of disease and more condent diagnoses.
AD in 2050, amounting to potentially 815% The early identication of silent preclinical dis-
fewer cases worldwide or 916 million fewer ease provides a strategy for drug development
affected individuals (Norton et al. 2014). during a point in the illness when intervention is
At the individual patient level, the ultimate test most likely to have an impact. Success in treating
of the clinical effectiveness of these interventions AD will likely require a range of therapeutic
in reducing AD risk rests on the results of ran- agents which are applied strategically either
domized clinical trials. To this end, a number of alone or in combinations at different points in
trials are underway examining individual behav- the illness. Additionally, it is likely that the thera-
ioral interventions involving diet, exercise, cogni- pies applied will not be conned to pharmaceuti-
tive interventions, or their combination. Recent cals. Rather, optimal approaches will likely need
ndings from a large clinical trial in Finland, the to use a personalized approach that considers the
FINGER study, are particularly encouraging. This entire patient, existing health conditions, lifestyle,
study examined the impact of modifying and other variables. Treatments will need to be
unhealthy lifestyle behaviors with a multimodal and involve both drug compounds
multicomponent approach. Preliminary data after and behavioral lifestyle approaches. The chal-
2 years of observation suggests that such intensive lenges ahead will be in determining the optimal
interventions can have a measurable inuence on combinations and how to personalize these thera-
cognitive and vascular health (Ngandu pies to each patient at differing stages of disease.
et al. 2015). In this trial of over 600 cognitively Tools developed through neuropsychology and
healthy individuals at high risk for vascular dis- brain imaging will continue to be fundamental to
ease, those individuals who were randomized to patient care and will likely provide the optimal
metrics both for tracking response to treatment as G8 Dementia Summit. (2013). Global action against demen-
well as for gauging overall function and quality of tia. https://www.gov.uk/government/uploads/system/
uploads/attachment_data//le/265868/2901669_G8_De
life in the various stages of this chronic progres- mentiaSummitCommunique_acc.pdf
sive disease. Hyman, B. T., Phelps, C. H., Beach, T. G., et al. (2012).
National Institute on Aging-Alzheimers Association
guidelines for the neuropathologic assessment of
Alzheimers disease. Alzheimers & Dementia, 8, 113.
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Aisen, P. S., Weiner, M. W., et al. (2010). Hypothetical
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Dementia ological cascade. Lancet Neurology, 9, 119128.
Lambert, J. C., Ibrahim-Verbaas, C. A., Harold, D.,
Dementia and Neurocognitive Disorders et al. (2013). Meta-analysis of 74,046 individuals iden-
Frontotemporal Dementia (FTD) ties 11 new susceptibility loci for Alzheimers disease.
Person-Centered Care and Dementia Care Nature Genetics, 45, 14521458.
Mapping McKhann, G. M., Knopman, D. S., Chertkow, H.,
et al. (2011). The diagnosis of dementia due to
Semantic Dementia Alzheimers disease: Recommendations from the
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Andropause, Understanding the Role of Male Hormones in the Aging Process 269
these are more common causes of low T than

Andropause, Understanding the Role chronological age.
of Male Hormones in the Aging In addition to the impact on health factors, A
Process there is some evidence of an association between
low T and low mood or depression (Khosravi
Monique M. Cherrier et al. 2015) as well as impaired cognition
Department of Psychiatry and Behavioral (Cherrier 2009) although ndings are equivocal.
Sciences, University of Washington School of Several epidemiological, cross-sectional studies
Medicine, Seattle, WA, USA involving large groups of healthy older males
have reported bioavailable or free T to be signif-
icantly and positively correlated with tests of
global cognitive functioning (Yaffe et al. 2002;
Synonyms
Barrett-Connor et al. 1999) and measures of atten-
tion (Hogervorst et al. 2004) and measures of
Late-onset hypogonadism (LOH); Partial andro-
visuospatial ability and semantic and episodic
gen deciency of the aging male (PADAM)
memory (Moffat et al. 2002; Thilers et al. 2006).
Older hypogonadal men evidence signicantly
poorer performance for visual memory, verbal
Definition memory, divided attention, and visuospatial rota-
tion compared to eugonadal men and are at greater
Andropause or late-onset hypogonadism (LOH) is risk for developing dementia (Moffat et al. 2004).
frequently dened as low serum testosterone Indications, and consideration for treating
(T) accompanied with symptoms. Symptoms andropause with T supplementation, can include
may include reduced sexual function, loss of patient motivation to improve symptoms and pre-
vigor, muscle weakness, osteoporosis, low mood vention or reduction of risk for frailty, immobility,
or depression, weight gain, insulin resistance, and and improvement of cognition. Several studies
potential cognitive symptoms. have revealed a benecial impact of T treatment
Serum levels of total testosterone and bioavail- in older men for sexual functioning, muscle
able T (T that is not bound to sex hormone- strength, and quality of life (Srinivas-Shankar
binding globulin) decrease with age in men et al. 2010; Kunelius et al. 2002).
(Moffat et al. 2002; Tenover et al. 1987; Tenover In addition, there is some indication of bene-
1992). While there is some variability with regard cial effects on cognition for older men with low or
to the criteria for andropause, there is general low normal T levels and with mild cognitive
consensus that a diagnosis of andropause in dementia and/or Alzheimers disease (Cherrier
older men requires the presence of low et al. 2005, 2015) although not all studies have
T accompanied by the presence of symptoms of shown a benecial effect (Maki et al. 2007; Kenny
low testosterone (Matsumoto 2002). The Euro- et al. 2004).
pean Male Ageing Study (EMAS) dened the T treatment, like all interventions, includes
diagnostic criteria for LOH to include the simul- medication-related effects which may include
taneous presence of reproducibly low serum acne, polycythemia (increased red blood cells),
T (total T <11 nmol l-1 and free T <220 pmol possible increase in prostate-specic antigen or
l-1) and three sexual symptoms (erectile dysfunc- prostate growth, edema, gynecomastia, and sleep
tion, reduced frequency of sexual thoughts, and apnea. Consideration of treatment for andropause
morning erections). By these criteria, only 2% of or LOH should be discussed with the medical
40- to 80-year-old men have LOH (Huhtaniemi provider with consideration given to the treatment
2014). Common causes of LOH in older men goal and all the important health factors of the
include obesity and impaired general health, and patient (Cunningham 2013).
270 Andropause, Understanding the Role of Male Hormones in the Aging Process
Cross-References randomized, double blind study. The Journal of Clinical

Endocrinology and Metabolism, 87, 14671472.
Maki, P. M., Ernst, M., London, E. D., Mordecai, K. L.,
Gender Differences in Memory and Cognition Perschler, P., Durso, S. C., Brandt, J., Dobs, A., &
Resnick, S. M. (2007). Intramuscular testosterone
treatment in elderly men: Evidence of memory
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in older men with low testosterone levels. Endocrine muscle strength, physical function, body
Practice, 19, 847852. composition, and quality of life in intermediate-frail
Hogervorst, E., Bandelow, S., Combrinck, M., & Smith, and frail elderly men: A randomized, double-
A. D. (2004). Low free testosterone is an independent blind, placebo-controlled study. The Journal
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Anxiety and Cognition 271
Global Cognitive Performance

Anxiety and Cognition Scientic evidence bridging late-life anxiety and
cognitive performance has focused primarily on A
Sherry A. Beaudreau1,2,3, Andrew J. Petkus4, nonclinical older samples without cognitive
Nathan Hantke1,6 and Christine E. Gould1,5 impairment (Beaudreau and OHara 2008). Even
1
Department of Psychiatry and Behavioral among older adults with no psychiatric diagnosis,
Sciences, Stanford University School of greater severity of self-reported anxiety symp-
Medicine, Stanford, CA, USA toms correlates with worse global cognitive func-
2
Sierra Pacic Mental Illness Research Education tioning in most cross-sectional studies (Beaudreau
and Clinical Center, VA Palo Alto Health Care et al. 2016). Further, clinical levels of anxiety
System, Palo Alto, CA, USA were found to increase the risk of global cognitive
3
School of Psychology, The University of decline 15 years after baseline testing in one
Queensland, Brisbane, QLD, Australia study (Sinoff and Werner 2003). Other longitudi-
4
Department of Psychology, University of nal studies did not nd an effect of anxiety on
Southern California, Los Angeles, CA, USA global cognitive decline (DeLuca et al. 2005;
5
Geriatric Research, Education, and Clinical Okereke and Grodstein 2013). Thus, while ele-
Center (GRECC), VA Palo Alto Health Care vated anxiety may be associated with worse
System, Palo Alto, CA, USA global cognitive performance, ndings regarding
6
Sierra Pacic Mental Illness Research, anxiety severity and global cognitive trajectories
Education, and Clinical Centers (MIRECC), are mixed.
VA Palo Alto Health Care System, Palo Alto,
CA, USA Attention and Information Processing Speed
Studies on specic cognitive abilities suggest that
older adults with elevated anxiety perform worse
Synonyms in some cognitive domains relative to older adults
reporting minimal anxiety (Beaudreau and
Neurocognitive functioning in late-life anxiety OHara 2008). Community-dwelling older adults
disorders; Neurocognitive functioning in the con- who report more severe anxiety symptoms have
text of late-life anxiety symptoms been noted to have slower information processing
speed (Beaudreau et al. 2016) and greater declines
over time (Petkus et al. in press), with some evi-
Definition dence that more anxiety and depressive symptoms
together impact speed of processing in commu-
Older adults reporting elevated anxiety symptoms nity samples (Beaudreau and OHara 2009).
have been shown to exhibit lower global cognitive Poorer divided attention and simple attention for
functioning and lower performance in specic spatial information also have been reported in
cognitive domains, namely, speed of information older adults with higher anxiety (Beaudreau and
processing, memory, and effortful cognitive abil- OHara 2008; Derousene et al. 2004). Elevated
ities known collectively as cognitive control anxiety, however, was not signicantly associated
(Beaudreau and OHara 2008). Anxiety is also with simple attention for repeating digits aloud
frequently observed in older individuals with cog- (Derousene et al. 2004; Wetherell et al. 2002) or
nitive impairments, such as dementia (Beaudreau sequencing digits by connecting the dots on a
and OHara 2008). trail-making task (Mantella et al. 2007).
272 Anxiety and Cognition
Thus, performance on tasks that are more complex (Beaudreau and OHara 2008; Beaudreau
or require more effortful attention might be lower et al. 2016). Nonclinical older samples have dem-
with elevated anxiety, but there is limited evidence onstrated worse learning and delayed memory for
that anxiety inuences simple tasks of attention. verbal information in the context of more severe
anxiety symptoms (Booth et al. 2006), though the
Cognitive Control association might not be linear. Specically, mild
Complex cognitive processes, collectively referred and severe anxiety could both be detrimental to
to as executive functioning or cognitive control, memory performance, and moderate levels could
have been of increasing interest with regard to be facilitative in older adults potentially best
late-life anxiety (Beaudreau et al. 2013). Though represented as an inverted U-shaped relationship
many denitions for these abilities exist, the most (Bierman et al. 2005). Other nonpsychiatric older
recent conceptualization includes tasks that require adult studies have also found an association, inde-
a person to maintain a goal or switch goals. This pendent of depressive symptoms, between higher
conceptualization of cognitive control has been state anxiety and greater declines in visual recog-
examined using the Stroop task, which requires nition memory over time (Petkus et al. in press). In
the person to say the ink color of color words that psychiatric samples, general memory performance
are purposely incongruent (i.e., the word blue has been shown to decline faster in older individ-
written in red ink). In older nonpsychiatric com- uals with MDD and a co-occurring anxiety disor-
munity samples, inhibitory ability appears to be der (GAD or panic disorder) than MDD alone
lower in those with more severe anxiety symptoms (DeLuca et al. 2005). In an investigation compar-
(Beaudreau and OHara 2008). This association is ing older individuals with GAD, MDD, and
not attributable to depressive symptoms as an inde- nonpsychiatric controls, Mantella and colleagues
pendent predictor or in interaction with anxiety (2007) found that both GAD and MDD groups had
symptoms in community elders, suggesting that poorer delayed memory performance compared
anxiety may be uniquely related to inhibition. Abil- with controls; thus, memory issues may not be
ity to shift set (i.e., alternating between numbers specic to anxiety. Only the GAD group (and not
and letters sequentially) is worse in individuals those with MDD), however, had signicantly
with generalized anxiety disorder (GAD) than in poorer immediate memory recall compared with
nonpsychiatric controls (Mantella et al. 2007) and controls. This could be due to older persons with
also poorer in elders with more anxiety symptoms GAD having trouble encoding new information
(Booth et al. 2006; Yochim et al. 2013). Neverthe- due to attentional problems, or because they lose
less, poorer set shifting was also found in individ- recent information more quickly, possibly due to
uals carrying a diagnosis of major depressive inefcient learning strategies related to poorer cog-
disorder (MDD; Mantella et al. 2007) or with nitive control abilities. The latter hypothesis of
greater depressive symptoms (Yochim et al. 2013) inefcient learning strategies being unique to anx-
suggesting that these ndings are not anxiety iety is posited from recent evidence showing that in
specic. Further, in the Mantella et al. study nonpsychiatric elders, elevated anxiety and depres-
(2007), the MDD group performed worse than the sion were both associated with more difculty in
GAD and nonpsychiatric control groups on a very learning new information; however, anxiety alone
basic cognitive control battery. This nding sug- was associated with less efcient categorization
gests that the nature of cognitive control difculties strategies (Yochim et al. 2013). Future studies that
in anxiety compared with depression is distinct and examine the underlying memory processes in GAD
likely more global in late-life depression than in would help determine mechanisms behind the nd-
anxiety. ings regarding memory performance in GAD.
Memory Other Cognitive Abilities

Memory is another complex cognitive ability that Less research has focused on other cognitive abil-
might be compromised with elevated anxiety ities such as language and visuospatial abilities.
Though one investigation found that the ability to cognitive processes, namely, divided attention
generate synonyms for words was poorer in the and information processing, cognitive control,
context of greater state anxiety (Wetherell and memory. Late-life anxiety and depression A
et al. 2002), other studies found that confrontational overlap in some areas identied as reduced for
naming of objects based on line drawings was not cognitive control ability, such as set shifting.
associated with anxiety severity in nonpsychiatric Other areas of reduced cognitive control perfor-
(Beaudreau and OHara 2009) or psychiatric older mance appear unique to anxiety, for instance,
samples (i.e., Mantella et al. 2007). Thus, generally inhibitory ability and categorization. These damp-
speaking, there is no clear evidence that anxiety ened cognitive control abilities in late-life anxiety
impacts language in older adults. could potentially drive lowered performance in
Visuospatial ability may potentially be other complex cognitive processes, such as mem-
compromised in the presence of elevated anxiety, ory. Evidence for associations of anxiety with
although only one study has reported on this to other cognitive abilities, including simple atten-
date. Older adults with higher state anxiety dem- tion, language, and visuospatial ability, derives
onstrated poorer visuospatial skills based on a from few studies and less theoretical support.
block design task (Petkus et al. in press). Prelim- Continued development of a framework that com-
inary ndings from an investigation of bines theoretical work regarding anxiety grabbing
community-residing older adults, however, attentional resources and cognitive decline due to
found no associations between anxiety symptom normal aging is most salient to understanding
severity and visual-spatial abilities based on a line these associations.
orientation task (Beaudreau et al. 2015).
Cognitive Models Anxiety in Individuals with Cognitive

Eysencks processing efciency and attentional Impairment
control theories are broadly applicable to late-life
cognitive performance in individuals with both A second line of inquiry with regard to anxiety
nonpsychiatric and psychiatric anxiety. Eysenck and cognition in older adults has been to deter-
proposed that anxious states divert cognitive mine if anxiety is more common in older individ-
resources to threatening stimuli and away from uals with cognitive impairment and more recently
cognitive tasks. He postulates that this overtaking whether anxiety increases the likelihood of inci-
of cognitive resources interferes with attentional dent cognitive impairment. This research has
control during inhibition, task shifting, and working mostly focused on dementia, but mild cognitive
memory monitoring or updates (Eysenck impairment (MCI) has been studied as well.
et al. 2007). Marchant and Howard (2015) extended Higher rates of anxiety symptoms are observed
Eysencks theory to hypothesize that worry or anx- with more severe cognitive impairment, i.e.,
iety incurs a cognitive debt with regard to compen- dementia (Beaudreau and OHara 2008). In par-
satory strategies. Specically, a persons ability to ticular, the likelihood of clinically signicant anx-
compensate for cognitive losses due to neurodegen- iety triples in MCI compared with older adults
erative disease diminishes in the presence of anxiety with no cognitive impairment (Geda et al. 2008).
because it taxes cognitive resources. This tendency The presence of anxiety in MCI and dementia has
for anxiety to usurp precious cognitive resources, been reported as high as 43% and 80%, respec-
combined with normal, age-related cognitive loss, tively (Lyketsos et al. 2002). Both amnestic and
has been proposed as a double jeopardy in anxious, non-amnestic subtypes of MCI have been linked
older individuals (Beaudreau et al. 2013). to chronic and severe anxiety (Andreescu
et al. 2014).
Summary The presence of anxiety symptoms also
Late-life anxiety has associations with global cog- increases over time in dementia (Brodaty
nitive performance and with more complex et al. 2015), and these symptoms have been
274 Anxiety and Cognition
shown to lead to additional behavioral and cogni- Apolipoprotein E e4 variant (Michels et al. 2012;
tive issues (Ferretti et al. 2001), which can create Reynolds et al. 2006), have been identied as
further challenges to the person with dementia, the potential contributors to both anxiety and cogni-
caregiver, or both. In addition, anxiety symptoms tive impairment. These and other genetic vulner-
double the risk of Alzheimers disease in persons abilities likely interact with environmental risk
with MCI over a 3-year time frame (Palmer factors, particularly early life stress or abuse
et al. 2007). Anxiety emerged as an independent (Heim and Nemeroff 2001), setting the stage for
risk factor for Alzheimers disease (AD) in partic- both anxiety and cognitive impairment.
ipants with amnestic MCI enrolled in the Chronic medical conditions, such as cardiovas-
Alzheimers Disease Neuroimaging Initiative cular disease (Mozaffarian et al. 2015) and high
(ADNI), a longitudinal investigation with recruit- blood pressure (Carmichael 2014), are also asso-
ment sites around the world (Mah et al. 2015). The ciated with elevated anxiety and poorer cognitive
median follow-up was 3 years. Anxiety remained performance. Both of these medical conditions
signicant after accounting for memory loss, have been associated with white matter changes
depression, and baseline volume for areas of the in the brain that have been implicated in reduced
brain typically associated with AD pathology and cognitive control abilities (Carmichael 2014). In
neurodegeneration (hippocampus and, within it, addition, thyroid disease has been linked to both
the entorhinal cortex). Remarkably, anxiety anxiety and cognitive functioning. Thyrotoxicosis
predicted faster atrophy of the entorhinal cortex. and Graves disease, diseases with hyperthyroid-
Results suggest that anxiety exerts an effect on the ism, have been associated with more severe levels
entorhinal cortex both directly and indirectly. The of anxiety symptoms in younger (Gulseren et al.
authors contend that these results argue for anxi- 2006) and older adults (Brandt et al. 2014).
ety as a risk factor for dementia rather than a Hyperthyroidism may also produce cognitive
prodromal stage of dementia. problems, although the results have been mixed
(Yudiatro 2006; Lilesvant-Johansen 2014).
Biological Models Though not a medical condition per se, it is
Neurotoxic effects of habitual stress on the brain worth noting that amyloid beta deposits, common
have been a popular model linking late-life anxiety in AD, may be moderated by anxiety symptoms
and cognitive impairment (Carlson 2004). In partic- (Pietrzak et al. 2015). In particular, older individ-
ular, the hypothalamic-pituitary-adrenal (HPA) axis uals with no cognitive impairment demonstrated
produces the stress hormone cortisol. Chronic eleva- faster cognitive decline in the presence of high
tion of cortisol due to stress anxiety can have dam- amyloid beta concentration and high anxiety.
aging effects on the brain, especially the Thus, biological models suggest that the etiology
hippocampus (Lupien et al. 1998), a critical area for underlying association between anxiety and cog-
learning and memory, and the prefrontal cortex nitive decline is multifactorial including, but not
(Kremen et al. 2010), important for cognitive control. limited to, the neuronal, environmental, genetic
Genetic factors are also implicated in the asso- factors and specic chronic medical conditions.
ciation between anxiety and cognitive dysfunc-
tion. Shared genetic vulnerabilities have been
shown to explain as much as 3680% of the Conclusion
correlation between anxiety and cognitive perfor-
mance (Petkus 2014). Genetic factors common to To date, there is overwhelming support for associ-
anxiety and dementia partially explain the ations between elevated anxiety and reduced cog-
increased risk of developing dementia in older nitive ability in older individuals. Further, the
adults with elevated anxiety (Petkus et al. under higher frequency of anxiety among cognitively
review). Gene polymorphisms, particularly impaired individuals is now substantiated with pro-
Val66Met polymorphism of the BDNF gene spective investigations showing anxiety as a risk
(Suliman et al. 2013; Ward et al. 2014) and the factor for developing dementia. While anxiety
shares some cognitive characteristics with depres- Bierman, E. J. M, Comijs, H. C., Jonker, C., & Beekman,
sion, the evidence base clearly shows that aspects of A. T. F. (2005). Effects of anxiety versus depression on
cognition in later life. American Journal of Geriatric
reduced cognitive performance and risk for cogni- Psychiatry, 13, 686693. A
tive impairment have unique associations with anx- Booth, J. E., Schinka, J. A., Brown, L. M., Mortimer, J. A.,
iety not otherwise explained by depression. Further & Borenstein, A. R. (2006). Five-factor personality
delineation of these associations could lead to iden- dimensions, mood states, and cognitive performance
in older adults. Journal of Clinical and Experimental
tication of different anxiety subphenotypes distin- Neuropsychology, 28, 676683.
guished by distinct cognitive proles, which could Brandt, F., Thvilum, M., Almind, D., Christensen, K.,
have implications for treatment as well as preven- Green, A., Hegeds, L., & Brix, T. H. (2014). Hyper-
tion of cognitive impairment. thyroidism and psychiatric morbidity: Evidence from a
Danish nationwide register study. European Journal of
Endocrinology/European Federation of the
Endocrological Society, 170, 341348.
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K. A., Harrington, K., . . . & Villemagne, V. L. (2015). ety disorders
Anxiety Disorders in Later Life 277
Definition anxiety tend to be underdiagnosed and

undertreated. These disorders may go unnoticed
Anxiety disorders are generally characterized by due to the chronicity of their course, the overlap of A
both excessive fear and irrational, fearful thoughts anxiety symptoms with other common comorbid
that are difcult to control and negatively affect psychiatric and medication issues, and the misin-
daily functioning. Additionally, avoidance behav- terpretation of avoidance behaviors as age appro-
iors are often used as a strategy to reduce those priate rather than a sign of a psychiatric disorder.
excessive feelings of fear and anxiety. Anxiety First, anxiety into late adulthood may go
disorders are the most common mental disorders undetected because of their chronic course that
across the life span. With the introduction of starts often early in life. This is in contrast to
DSM-5 in 2013 (American Psychiatric Associa- depression or dementia, which may be easier to
tion 2013), obsessive-compulsive disorder, post- detect due to a marked appearance at a later age.
traumatic stress disorder, and acute stress disorder Specically, depression has a median age at
moved from the anxiety disorder section into two onset of 32 years, and 27% of individuals
separate sections: obsessive-compulsive and have their rst depressive episode at 65 years or
related disorders, and trauma- and stressor-related older, and most dementias appear for the rst time
disorders. DSM-5 anxiety disorders seen in older after age 60. Second, with regard to comorbidity,
adults include panic disorder, agoraphobia, social other disorders (e.g., depression) may mask the
anxiety disorder, generalized anxiety disorder, existing anxiety symptoms, increasing the likeli-
and specic phobia. hood that the anxiety disorder goes unrecognized.
This becomes especially difcult when chronic
medical conditions like pulmonary or cardiovas-
Introduction cular diseases are also present, might fully or
partly explain the origin of anxiety. Third, age-
Several epidemiologic studies have revealed that ism, which in this context refers to the misinter-
anxiety disorders are the most prevalent mental pretation of abnormal behaviors as age
disorders in later life. Most of these studies are appropriate, may hinder the diagnosis and thus
limited to European and North American proper treatment of late-life anxiety
populations. As a result of conceptual and meth- disorders. Avoidance behaviors after a heart attack
odological differences between studies, preva- are, for instance, often deemed understandable
lence rates differ widely. Most studies showed a and an adequate, adaptive response, but could
prevalence of late-life anxiety disorders between underlie a larger issue with anxiety. In addition,
6% and 10% (Bryant et al. 2008). These disorders being retired and often receiving support in
have a chronic life course that often begins early and around the home, elderly people may
in life with a median age of onset of 11 years increasingly and successfully avoid anxiety-
(Kessler et al. 2005). An onset of anxiety disor- provoking situations, like traveling by car or vis-
ders in older adulthood is less common with only iting crowded shopping malls unattended, without
1% appearing for the rst time at age 65 years or raising suspicions of a more serious afiction.
older (Kessler et al. 2005). Although research into These aforementioned issues contribute to
late-life anxiety disorders has grown in recent differences in late-life anxiety presentation in
years, it is still in its infancy, and there still is a older adults compared to younger adults, which
large gap to bridge compared to, for example, may hinder proper recognition and diagnosis.
studies on late-life depression. Studies examining Underdiagnosis of anxiety disorders could lead
how anxiety presents differently in young versus to the assumption that they are a minor health
older adults are limited, and well-conducted treat- problem in later life. The following sections chal-
ment studies in elderly patients are still scarce. lenge this presumption and provide an overview
Despite the frequent appearance of anxiety dis- of the empirical research on late-life anxiety
orders in later life, older adults suffering from disorders.
Epidemiology Clinical Features and Diagnostic Issues
Recently a systematic review and meta-analysis Underdiagnosis and Undertreatment

provided data on the global prevalence of anxiety in Late-Life Anxiety
disorders (Baxter et al. 2013). These data showed Underdiagnosis and undertreatment of late-life
substantial variation across different regions in the anxiety are reected in the available epidemiolog-
world. The mean current prevalence of anxiety ical data. A longitudinal epidemiological study in
disorders was 7.3% and ranged from 5.3% in the Netherlands showed that a mere 2.6% of
African countries to 10.4% in Western countries. elderly patients reporting anxiety symptoms
The global 12-month prevalence ranged from consulted a psychiatrist, and only 3.8% were
7.6% to 17.7%. Prevalence rates on specic anx- seen by health professionals at a mental health
iety disorders were not provided. Overall anxiety outpatient clinic. In this sample of older adults
disorders were twice as common among women reporting anxiety symptoms, the use of antide-
compared to men. Compared to pressants was also extremely low (3.8%),
Western countries, the risk for experiencing anx- although 25% were prescribed benzodiazepines.
iety disorders was 2050% lower in non-Western Six years later the use of benzodiazepines had
countries. Older age (>55 years) was associated increased to 43%. The prescription of antidepres-
with a 20% lower prevalence of anxiety disorders sants had doubled to 7%, and referral to mental
compared with younger age groups. Additionally, health facilities raised to 14% (Schuurmans
a recent meta-analysis of late-life mental et al. 2005). The ndings are important because
disorders in Western countries showed current benzodiazepines are, relative to antidepressants,
and lifetime prevalence rates for specic late- not the rst-line agents for the management of
life anxiety disorders: 0.88% and 2.63% for anxiety disorders and are associated with serious
panic disorder, 0.53% and 1.00% for drug-related hazards such as a possible aggrava-
agoraphobia (with and without panic), 4.52% tion of cognitive difculties (e.g., memory prob-
and 6.66% for specic phobia, 1.31% and 5.07% lems), becoming dependant, and an increased risk
for social phobia, and 2.30% and 6.36% for gen- of falls and fractures.
eralized anxiety disorder (Volkert et al. 2013). The National Comorbidity Survey Revised
Studies of the global burden of disease reveal (NCS-R), conducted in the United States, has also
that mental and substance use disorders are the conrmed the increased overall risk of elderly
fth leading disease category of global people (aged over 60 years) going untreated for
disability-adjusted life years (DALYs) accounting mental disorders in general relative to their youn-
for 7.4% of total disease burden (Whiteford ger counterparts: compared to younger adults
et al. 2013). Within this category anxiety disorders between, respectively, 1829 years, 3044 years,
account for the second most common cause of and 4559 years, older adults were, respectively,
DALYs (overall 14.6%), whereas depression is 4.8, 3.8, and 2.4 more times likely of being
the rst cause accounting for 40.6% of DALYs untreated for a mental health disorder (Wang
among almost all countries (except Eastern et al. 2005).
Europe where alcohol use disorders were the sec-
ond cause) and among almost all age categories Although Partially Overlapping, Later-Life
(except drug use disorders between 20 and Anxiety Disorders and Depression Need to Be
35 years). The burden for anxiety disorders rises Distinguished
rapidly in childhood, peaks between 15 and The widespread assumption that depression
25 years, and declines with increasing age almost always accompanies late-life anxiety
afterward. could lead some clinicians to prefer a diagnosis
of mixed anxiety-depression syndrome over a
diagnosis of an anxiety disorder in an older adult populations (1865 years) gauging the clin-
patient. Nevertheless, this concern may not be ical course of anxiety disorders for 10 or more
warranted given that mixed anxiety-depression years are scarce, existing evidence reveals the A
syndrome has a prevalence of only 1.8% in older chronicity of symptoms and relative high relapse
adults (Bryant et al. 2013). Although there is a risk for anxiety disorders in general (Lenze and
clear evidence of a large overlap in anxiety and Wetherell 2011). The recovery rate for anxiety
depression in older adults, studies have uncovered disorders following treatment varied from 40%
more differences than similarities between late- to 60%, and relapse rates during a several-year
life anxiety and depression. Whereas a quarter of follow-up period remained high. Given that the
the elderly participants diagnosed with an anxiety greater majority of adults suffering from anxiety
disorder also met the DSM-IV criteria for a disorders do not receive adequate treatment, it can
comorbid major depression; approximately half safely be concluded that anxiety disorders tend to
of those diagnosed with major depression satised start at a young age and are highly likely to be
the criteria for a comorbid anxiety disorder. chronic, with a uctuating course into late adult-
Although anxiety and depressive symptoms par- hood and thus contributing to a relatively high
tially overlapped, they could also be distinguished prevalence in later life.
from each other. Whereas late-life depression was
associated with an older age at onset and an exter- Late-Life Anxiety Disorders Should Not Be
nal locus of control (i.e., attributing success or Regarded as a Minor Health Problem
failure to outside inuences or believing that Clinicians and researchers are often inclined to
events in ones life are caused by uncontrollable consider anxiety disorders in older adults a
factors), the risk prole for late-life anxiety disor- minor health problem that does not seriously
ders was more complex, consisting of a combina- impair their quality of life, but the opposite is
tion of vulnerability factors, daily stressors (e.g., true (Lenze and Wetherell 2011). Firstly, as men-
chronic medical comorbidity, functional limita- tioned earlier, empirical ndings show that late-
tions), life events (e.g., recent losses), and social life anxiety disorders are frequently associated
problems (e.g., smaller social network, less emo- with psychiatric (e.g., with major depression and
tional support). These differences in comorbidity other anxiety disorders) and medical comorbidity
patterns and risk factors suggest that late-life anx- (e.g., cardiovascular disease). Secondly, the qual-
iety and depression are distinguishable diagnostic ity of life is affected in older people with anxiety
entities. to levels that are comparable to what has been
observed in older adults suffering from major
Age of Onset and Course of Late-Life Anxiety depression; they experience signicantly more
Disorders decline in physical health, general well-being,
The NCS-R data showed that when compared to and social and overall functioning and more
mood disorders, anxiety disorders generally have health-care utilization compared to asymptomatic
the youngest age at onset (Kessler et al. 2005). As elderly. Finally, late-life anxiety is associated with
noted in the previous section, the median age of an increased risk of mortality and for dementia.
onset was 11 years, with 75% of all anxiety disor-
ders starting before the age of 21 years and only The Diagnosis of Late-Life Anxiety Disorders
1% starting after the age of 65 years. These gures May Be Complicated by Age-Related Variables
correspond with an observed global rapid increase Medical and cognitive comorbidity can pose a
in the burden of disease of anxiety disorders challenge to accurate diagnosis and treatment of
before the age of 15 and a peak between the age late-life anxiety disorders. Most elderly people
range 1525 (Whiteford et al. 2013). Although with anxiety problems tend to attribute their
prospective posttreatment follow-up studies in symptoms to physical causes and existing medical
conditions (Wolitzky-Taylor et al. 2010). More- based their differentiation on analyzing epidemi-
over, the process of aging is often associated with ological data calculating a best tting cutoff age
more physical illness and other physical symp- between 25 and 30 years (Tibi et al. 2013). Epi-
toms. Overall, more than 80% of the older adults demiologically based studies showed that a later
are diagnosed with one of more chronic physical onset of anxiety disorders was associated with less
illnesses (Wolitzky-Taylor et al. 2010). Symptoms severity and a better outcome. Other studies used
of anxiety and depression in older adults often a threshold age of 5565 years (Ritchie
coincide with serious somatic conditions, espe- et al. 2013) to differentiate between early and
cially cardiovascular involvement, chronic late onset. Also, in these studies an onset at older
obstructive pulmonary diseases (COPD), hyper- age was associated with less severity and better
thyroidism, and vestibular problems. Thus, sepa- outcome. An unambiguous, proper, and valid def-
rating anxiety disorders from normal anxiety inition of early- and late-onset anxiety disorders is
induced by medical problems and procedures as yet not available.
may be difcult. In addition, cognitive decline Differences in cognitive (i.e., worry), emo-
and dementia seem to be interrelated with anxiety tional (i.e., feeling keyed up), and physical symp-
in later life in a bidirectional way, which can also toms (i.e., heart palpitations) between younger
complicate or obscure the presence of an anxiety and older adults with anxiety problems have
disorder in an older patient. mainly been studied in undiagnosed or outpatient
Further, receptiveness to sharing personal populations with elevated anxiety or mixed symp-
information with a provider can also pose a chal- toms (Gould and Edelstein 2010). It is demon-
lenge to treating anxiety in older patients. The strated in these populations that, relative to the
current generation of elderly may be less open in values obtained in younger individuals, older
sharing psychological problems than the younger age, and especially onset at an older age, is asso-
generations and may therefore have been strug- ciated with fewer cognitive and emotional symp-
gling with anxiety symptoms for many years with- toms of anxiety, as well as a decrease in
out ever receiving adequate treatment. physiological arousal. Additionally, older adults
A prospective cohort study showed that less than may experience more tolerance of uncertainty. In
5% of the elderly patients confronted with psy- general, the experience of negative feelings and
chological problems consulted their general prac- the intensity of emotional responses appeared to
titioners (Shah et al. 2001). The question whether decrease with progressing age. This may be attrib-
they are reluctant in communicating their personal utable to a natural, age-related decrease in emo-
problems or whether they lack the necessary ver- tional responsiveness, i.e., a dampening of
balizing skills to do so remains. affective reactivity. Additionally, elderly people
Finally, it is plausible that aging may lead to tend to be more in control of their emotional life
phenomenological differences with younger and better able to cope with stressful life events.
adults suffering from similar anxiety disorders So far, however, these factors have never been
and therefore possibly making an accurate diag- systematically examined, and mentioned assump-
nosis more difcult. tions are hypotheses at the present time.
Most studies are conducted in older adults with
Phenomenological Age-Related Differences generalized anxiety disorder. It was observed that
The main arguments to differentiate between anx- older adults with generalized anxiety disorder
iety disorders in young and middle-aged individ- showed fewer symptoms compared to younger
uals and older adults are the supposed differences adults (Miloyan et al. 2014b). Compared to the
in phenomenology and outcome in the two age younger age categories trouble in concentrating,
bands. However, the criteria for the differentiation feeling dizzy/lightheaded and gastrointestinal
of early and late-onset anxiety seem fairly arbi- symptoms like nausea and upset stomach are
trary, and the threshold age range in previous more prevalent in late-life generalized anxiety
studies varied from 25 to 60 years. Some studies disorder. Also the worry content differs in later
life. Older GAD patients worry more about health Assessment of Anxiety in Older Adults
and the well-being of loved ones, whereas their The use of semi-structured clinical interviews,
younger counterparts worry more about work, like the Anxiety Disorders Interview Schedule or A
nances, and social relations. the Structured Clinical Interview for DSM disor-
Phenomenological age-related differences ders, is the gold standard in diagnosing anxiety
were also studied in elderly patients diagnosed disorders in the general population. In general,
suffering from panic disorder with/without agora- self-report instruments are used to assess severity
phobia. Furthermore, the phenomenology of of symptoms of anxiety disorders and to evaluate
panic attacks in younger and older adults has treatment effects. A major limitation of the avail-
also been investigated in nonclinical populations able instruments, especially instruments for the
and populations with mixed anxiety disorders. It specic anxiety disorders, is both the absence of
was demonstrated that, relative to the values validation studies of these instruments in older
obtained in younger individuals, aging and onset adults and the lack of research on the assessment
at an older age are associated with a decrease in of late-life anxiety. Psychometric evidence is suf-
both cognitive and affective anxiety, as well as in cient for the use of the Penn State Worry Ques-
physiological arousal. It is suggested that normal tionnaire to assess severity of worry in older
age-related psychophysiological changes and the adults (Crittendon and Hopko 2006). Addition-
latter symptom onset are responsible for these ally, the Beck Anxiety Inventory, the Geriatric
differences, which would explain why panic dis- Mental Status Examination, and the Geriatric
order with/without agoraphobia has been consid- Anxiety Inventory are also valid instruments for
ered to be a less severe disorder later in life assessing general anxiety symptoms in older
(Flint et al. 1998; Hendriks et al. 2010; Segui adults (Therrien and Hunsley 2012). Finally, the
et al. 2000; Sheikh et al. 2004). These ndings short version of the Geriatric Anxiety Inventory,
could explain a declining severity of physiologi- consisting of 5 items, may be a psychometrically
cal (e.g., lower increase in the heart rate frequency sound instrument for use in large-scaled epidemi-
during panic attacks) and cognitive symptoms of ological studies or for screening purposes in older
anxiety (e.g., agoraphobic cognitions like the fear adults in primary care (Byrne and Pachana 2011).
of going crazy or losing control) in late-life panic
disorder. However, differences in age-related dif-
ferences in agoraphobic avoidance, a core symp- Treatment
tom in panic disorder with agoraphobia, were not
found. For young and middle-aged adults, powerful,
Also in social phobia, an age-related reduction evidence-based, and guideline-recommended
in number of symptoms was observed. However, treatments are available for all anxiety disorders.
a core symptom prole accounting for the diag- Numerous meta-analytic studies conrmed the
nosis of social phobia and consisting of both efcacy of both cognitive behavioral therapy
social phobic cognitions and social phobic avoid- (CBT) and antidepressants (selective serotonin
ance behaviors remains the same across all age reuptake inhibitors (SSRIs) or tricyclic antide-
categories (Miloyan et al. 2014a). pressants (TCAs)) or the combination. Recent
It may also be important to differentiate meta-analytic ndings showed that both treat-
between an early and a late onset of the complaints ments improved also quality of life (Hofmann
in older patients with social phobia, and other late- et al. 2014a, b). CBT and SSRIs/TCAs are also
life anxiety disorders, because age of onset may assumed to be effective in older adults diagnosed
likewise have a differential impact on the presence with anxiety disorders (Pinquart and Duberstein
and severity of specic symptoms. Nonetheless, 2007). However, to date empirical evidence on the
insufcient information about age of onset in efcacy of these two treatments in adults aged
older adults with social phobia symptoms are 65-plus years is scarce since randomized con-
available at this time. trolled trials (RCTs) testing both CBT and
SSRIs/TCAs and direct comparisons of the two It is suggested that CBT protocols originally
treatment arms in older and younger adults are developed for younger adults should be adapted to
lacking. In older adults reporting anxiety-related the specic needs and preferences of older adults.
complaints, the symptoms may often not be rec- Proposed adaptations are focusing on education,
ognized as serious, and the possibility of a psy- frequently repeating treatment rationale, frequent
chological disorder is hence most often use of reminders, offering help in practicing
overlooked, leaving many patients undiagnosed homework, and adherence enhancement.
and undertreated. The diagnostic focus often pri- Although the very few studies have demonstrated
marily concerns the patients physical problems that adaptations in CBT improved treatment out-
and the reassurance that no physical abnormalities comes for late-life anxiety, these studies were
have been found. Even if diagnosed adequately, small, and ndings are preliminary. Generalized
the older patient is seldom offered a targeted and anxiety disorder is by far the most studied anxiety
evidence-based treatment. Thus, rather than anti- disorder in older adults. Studies on the treatment
depressants, CBT, or both, the two treatments of of panic disorder with/without agoraphobia are
choice for anxiety disorders, benzodiazepines are scarce and absent in as well late-life social phobia,
often prescribed. agoraphobia as specic phobias.
The extensive research into the treatment of
anxiety disorders in younger adults is in stark
contrast to the small number of randomized con- Cross-References
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from studies focusing exclusively on elderly Comorbidity
patients is analyzed in several meta-analytic Depression in Later Life
reviews. Both CBT and antidepressants (SSRIs Psychological and Personality Testing
or TCAs) may also be the optimal treatments for Worry in Later Life
the management of anxiety disorders in older
adults, although it is suggested that the efcacy
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284 Aphasia in Later Life
Wetherell, J. L., Petkus, A. J., Thorp, S. R., Stein, M. B., commonly accepted denitions of aphasia. Apha-
Chavira, D. A., Campbell-Sills, L., &, Roy-Byrne, sia is an acquired disorder, not a developmental
P. (2013a). Age differences in treatment response to a
collaborative care intervention for anxiety disorders. disorder. It is selective to the language pathways
The British Journal of Psychiatry, 203(1), 6572. doi: of the brain. Aphasia results when there is damage
10.1192/bjp.bp.112.118547. to the language-dominant hemisphere, usually the
Wetherell, J. L., Petkus, A. J., White, K. S., Nguyen, H., left hemisphere, and the most common cause of
Kornblith, S., Andreescu, C., &, Lenze, E. J.
(2013b). Antidepressant medication augmented with aphasia is stroke. Focal lesions that cause aphasia
cognitive-behavioral therapy for generalized anxiety may also include brain tumor and head trauma, such
disorder in older adults. The American Journal of Psy- as gunshot wounds. However, as Papathanasiou
chiatry, 170(7), 782789. doi: 10.1176/appi. and colleagues (Papathanasiou et al. 2013) point
ajp.2013.12081104.
Whiteford, H. A., Degenhardt, L., Rehm, J., Baxter, A. J., out, the language difculties sustained after a head
Ferrari, A. J., Erskine, H. E., &, Vos, T. (2013). injury may be intrinsically bound to cognitive dif-
Global burden of disease attributable to mental and culties. This is also the case in more generalized
substance use disorders: ndings from the Global Bur- language decits that occur in dementias. To distin-
den of Disease Study 2010. Lancet, 382(9904),
15751586. doi: 10.1016/S0140-6736(13)61611-6. guish aphasia from other language impairments,
Wolitzky-Taylor, K. B., Castriotta, N., Lenze, E. J., Stan- Code (1989) highlights that aphasia can be
ley, M. A., & Craske, M. G. (2010). Anxiety disorders described as impacting on core linguistic compo-
in older adults: A comprehensive review. Depression nents including lexical semantics, syntax, morphol-
and Anxiety, 27(2), 190211. doi:10.1002/da.20653.
ogy, and phonology. Put simply, aphasia is a
problem with talking, understanding, reading,
and/or writing. The provided denition also extends
beyond the person with aphasia to describe the
Aphasia in Later Life impact of aphasia on those around them.
Linda Worrall1, Tanya Rose1,

Caitlin Brandenburg1, Alexia Rohde1, Karianne Introduction
Berg2 and Sarah J. Wallace1
1
The University of Queensland, St Lucia, The word aphasia originates from the Greek a
Brisbane, QLD, Australia (without) and phsis (speech), literally meaning
2
Norwegian University of Science and speechless. While the prex a indicates a
Technology, Trondheim, Norway complete loss, the term aphasia is commonly
used to describe both the total loss and partial
impairment of language. Hallowell and Chapey
Synonyms (2008) describe four principles important to
include in a denition of aphasia:
Aphemia; Dysphasia
1. Aphasia is neurogenic in that there is some
form of damage to the brain.
Definition 2. Aphasia is acquired in that there is a partial or
complete loss of language function in a person
Aphasia is an acquired selective impairment of who had previously developed some language
language modalities and functions resulting from ability.
a focal brain lesion in the language-dominant 3. Aphasia involves language problems in that the
hemisphere that affects the persons communica- individual with aphasia may have a problem
tive and social functioning, quality of life, and the with formulation and interpretation of linguistic
quality of life of his or her relatives and care- symbols, i.e., aphasia is multimodal.
givers (Papathanasiou et al. 2013). This deni- 4. Aphasia is not a problem of sensation, motor
tion incorporates the main components of function, or intellect (p. 3).
Aphasia in Later Life 285
The denition of aphasia has evolved in who compared the everyday communication
parallel with treatment philosophies and health activities in healthy older people and older people
frameworks, shifting from a sole focus on with aphasia. This study showed that there were A
impaired language modalities to incorporate the both similarities and differences between these
broader impacts of the condition on the person two groups. People with aphasia engaged in the
and their signicant others. The World Health same type of communication activities but had
Organizations International Classication of fewer communication partners and less engage-
Functioning, Disability, and Health (World ment in social interactions than their healthy
Health Organization 2001) is a conceptual counterparts. Communication situations that
framework that is often used to describe the were affected by aphasia were information
impact of aphasia. In reference to this framework, sharing, maintaining and establishing relation-
the health condition is the stroke or brain ships, and telling ones story. All of these
injury that has caused the aphasia. The impair- situations are important to maintaining a persons
ment is the language impairment that results feeling of belonging and having a chance to
from the loss of functioning to the language share ones wisdom and life experiences, feelings,
pathways of the brain. This may have a broad and opportunities which are related to aging
effect on activities and participation in life (Birren and Schroots 2000). In another study
roles. For example, when communication activi- by Davidson et al. (2006), the same results
ties such as conversing, telephoning, writing were evident. People with aphasia were shown
letters, and reading books are limited, participa- to have fewer friends than healthy older
tion in education, work, and leisure roles may be people, something that may lead to isolation and
restricted. Both personal and environmental loneliness and more dependence on family and
factors may impact the persons ability to friends.
communicate, with the major environmental
factor being the communicative ability and
support of key conversational partners such as Classifying Aphasia
family and friends.
The majority of people living with aphasia are Aphasia impacts individuals differently, and var-
above the age of 65. This is due to the increased ious classications have been devised to help
incidence and prevalence of stroke in the older categorize these differences. The most commonly
population (Go et al. 2014), with stroke being the used dichotomy for describing and grouping types
main cause of aphasia. Approximately 65% of all of aphasia is between nonuent and uent aphasia.
strokes occur in individuals 65 years or older People with nonuent aphasia have halting,
(Go et al. 2014; Rothwell et al. 2005). Incidence effortful language, often producing few words
refers to the new cases identied in a given period with no connecting words or grammatical ele-
of time and prevalence to the number of people ments (e.g., Dog. . .feed). In contrast, people
living with the condition in a given period of time. with uent aphasia have a ow of language
Relating this to aphasia, Engelter et al. (2006) which sounds similar to a speaker without apha-
studied the incidence of aphasia in rst-ever ische- sia, but that often lacks meaning (e.g., Well see
mic strokes (i.e., strokes caused by a blockage of he came and did that, but then the other happened
blood ow to the brain). The number of people so I left). Another commonly used dichotomy is
diagnosed with aphasia in this study increased based on level of comprehension decit. Expres-
from 15% for people below the age of 65 to 43% sive aphasia is a term used to describe impaired
in people above the age of 85 years. This is an expressive abilities (i.e., difculty speaking/writ-
increased risk of aphasia of 3% for each year of ing) when the individual has relatively intact com-
the stroke patients age. prehension abilities (i.e., understands spoken/
The impact of aphasia in older people has been written language). In contrast, receptive aphasia
described by Davidson and colleagues (2003) is a term used to describe impaired
comprehension abilities, regardless of the individ- difculties. Anomic aphasia is an aphasia type
uals expressive abilities. characterized by word-nding difculties, with
More detailed subclassications of aphasia minimal impairment in grammar or receptive lan-
exist as a way of grouping the various presenta- guage. Global aphasia refers to a severe impair-
tions of this communication difculty, helping to ment of both expressive and receptive language
guide treatment. A commonly used classication and is associated with extensive damage to the
system is the Bostonian or Connectionist classi- language-dominant hemisphere (usually the left).
cation system (Murray and Clark 2005). This It should be noted that while formal classications
classication system contrasts language charac- provide a common language for describing apha-
teristics, specically language uency (i.e., sia, not all cases will t exactly into a single
nonuent versus uent language), naming ability, aphasia type. Furthermore, aphasic language
comprehension ability, and repetition skills to impairments can change over time, for example,
form different aphasia subtypes, each associated if people with global aphasia are able to recover a
with a specic brain location. Aphasia subtypes in substantial amount of their language skills, their
this classication system are Wernickes, Brocas, aphasia may resolve into a Brocas or transcortical
transcortical sensory, transcortical motor, motor type.
transcortical mixed, anomic, conduction, and Types of aphasia also exist outside of the
global aphasia (Murray and Clark 2005). standard Bostonian/Connectionist classication
The language characteristics observed in an system. For example, primary progressive apha-
individual with Wernickes aphasia include uent sia is a type of aphasia which results from
language and poor comprehension skills, with the progressive neurological disease, rather than
individual producing owing but empty speech, stroke or traumatic brain injury (Murray and
sometimes producing jargon or nonsense words. Clark 2005). Thus, this type of aphasia is unique,
These difculties are proposed to occur as a result as language decits worsen over time, unlike
of damage to Wernickes area of the brain (i.e., the other types of aphasia where the individuals
posterior section of the superior temporal gyrus). language abilities remain stable or improve over
Transcortical sensory aphasia presents similarly time. In order for aphasia to be classied as
to Wernickes aphasia, except that a strong ability primary progressive aphasia, rather than
to repeat words or phrases is retained, and a per- dementia, the impact on language must be inde-
son may exhibit echolalia. In contrast, a classic pendent of impairments in cognitive functions.
presentation of Brocas aphasia would be halting There are also types of aphasia classied
speech consisting mainly of content words according to an alternate site of lesion in the
(nouns, verbs) but with few grammatical elements brain. Subcortical aphasia occurs when language
(agrammatism). Comprehension is Brocas apha- decits result from injury to the subcortical areas
sia is relatively intact. This type of aphasia is of the brain (e.g., thalamus, internal capsule, basal
linked with damage to Brocas area of the brain ganglia), which are not typically associated with
(i.e., the anterior portion of left hemisphere). language processing (Murray and Clark 2005).
Transcortical motor aphasia is similar to Brocas This type of aphasia is considered to be rare.
aphasia, but again with preserved repetition and Crossed aphasia describes language impairments
possible echolalia. Mixed transcortical aphasia is that are present following injury to the right hemi-
a combination of both sensory and motor sphere, which is considered to be uncommon as
transcortical aphasias, where both expressive and language is usually lateralized to the left side of
receptive language abilities are poor, but repeti- the brain in both right- and left-handed people
tion remains intact. Conduction aphasia is asso- (Murray and Clark 2005). Crossed aphasia does
ciated with damage to the arcuate fasciculus not follow any particular pattern of impairment
(or parietal lobe in general) and is characterized and can co-occur with the cognitive-
by impairments in repetition of words or phrases communication decits usually associated with
which exceed any expressive or receptive right hemisphere damage.
Assessing Aphasia thorough knowledge not only of current lan-

guage functioning but also the patients medi-
Aphasia is a complex and multifaceted communi- cal, social, and communicative history to A
cation disorder. Assessment of aphasia involves ensure the individuals presentation is correctly
evaluating several aspects of language function- attributed to the right condition (Chapey 2008).
ing and potential social consequences. A thorough 2. Nature of aphasia: After the presence of apha-
assessment should determine the following: pres- sia has been ascertained, the nature of the lan-
ence of aphasia, nature of aphasia, and social guage decits may be explored. This may
consequences of aphasia: involve a diagnosis of aphasia type, based on
the classication systems described earlier.
1. Presence of aphasia: The acquired nature of Aphasia varies widely in its clinical presenta-
aphasia onset is one of the key clinical features tion, and individual patient performance across
instrumental in assisting the assessment and different language modalities can vary signi-
identication of the condition. As stroke is cantly. Comprehensive and multimodal assess-
the predominant etiology for aphasia, the iden- ment of language performance is required to
tication of aphasia is often intrinsically linked identify areas of decit as aspects of language
with the onset of stroke symptoms. Like other may appear unimpaired unless specic atten-
acquired neurological injuries, the site and tion is paid to investigate them (Spreen and
extent of brain lesion inuences the character- Risser 2003).
istics of the condition and the likelihood of Six different areas of language functioning
aphasia diagnosis. The characterization of are typically examined in the assessment of
lesion site through medical imaging is there- aphasia. Spontaneous speech tasks examine
fore a key element in guiding the identication expressive language functioning which often
and providing preliminary diagnostic evidence include picture description tasks or an evalua-
in which to guide clinical decision-making. tion of general conversational interaction. Rep-
In addition to underlying etiology, an etition tasks can vary in complexity from
assessment must consider other explanations single-phoneme repetition to repetition of
for language decit. Aphasia is dened as a multisyllabic words or phrases. Comprehen-
selective impairment of language sion of spoken language assesses a patients
(Papathanasiou et al. 2013) where decits can ability to follow simple commands or answer
be directly attributable to impaired expression yes or no questions of varying levels of
or understanding of spoken or written language abstraction and difculty. Assessment of word-
alone. In practice, however, poor language test nding ability can examine the ability to name
performance does not automatically imply pictures or different objects. Reading and writ-
presence of aphasia. Other conditions such as ing abilities are also assessed which include
hearing decits, motor or sensorimotor limita- evaluation of the comprehension of written
tions, visual impairment, cognitive decits, words or phrases as well as writing abilities,
and even vocalization difculties may all result such as a patients ability write their own name
in poor language test scores (Spreen and Risser (Spreen and Risser 2003; LaPointe 2011).
2003). Accurate identication of aphasia and Comprehensive aphasia assessments are useful
the process of differential diagnosis can be to provide multimodal examinations of lan-
complex and multifaceted. The prevalence of guage functioning with tasks of varying length
neurological conditions such as dementia, neu- and complexity. Often other clinically relevant
romuscular conditions such as Parkinsons dis- factors such as attention, orientation, and
ease, and age-related cognitive decline in older patient alertness are also noted during these
populations adds increased complexity to examinations (Brookshire 2003). Such evalua-
accurate disease identication. Identication tions enable an estimation of overall severity as
of and assessment of aphasia therefore require well as a sense of the patients communicative
strengths and weaknesses (LaPointe 2011). In the question: What is aphasia? Firstly, aphasia
addition to assisting with diagnosis, such can affect different aspects of language: When the
assessments assist with guiding the selection ability to put ideas into language is very impaired,
of treatment goals and planning intervention. people with aphasia may rely on using words such
3. Social consequences of aphasia: Aphasia is a as yes and no and communicate through their
condition which can have detrimental impact facial expressions, gestures, and tone of voice.
upon a patients functioning and quality of life, Nearly all people with aphasia have wording-
and it is important to assess these impacts in nding difculties, like the experience of having
addition to traditional language assessment a word at the tip of your tongue. Some people
(Lam and Wodchis 2010). The social and psy- with aphasia speak in very short phrases, while
chosocial inuence of aphasia extends across others may speak in sentences. However, putting
the continuum of recovery from hospital to the words into grammatical sentences may be prob-
community. People with communication dif- lematic due to difculty organizing the way words
culties have been found to be six times more should go together. The ability to spell, write, and
likely to experience an adverse event while read can also be difcult. Less obvious may be the
they are in the hospital (Bartlett et al. 2008). difculty in understanding others, despite being
Evaluation of the impact on a patients com- able to hear. Many people with aphasia nd it
municative and social functioning in this acute more difcult to follow what is being said when
phase is an important element in the assess- they are stressed, tired, or when there is back-
ment of aphasia. Further into the recovery, ground noise and distractions. Secondly, aphasia
people with aphasia can experience signicant is different for different people: Some people with
depression and anxiety (Shehata et al. 2014). aphasia may be hesitant when talking and use only
A study of over 66,000 hospital-based resi- the key words. Others may have an outpouring
dents in Ontario found that aphasia diagnosis of words and nd it challenging to be specic and
demonstrated the largest negative relationship to convey information precisely. Thirdly, the
to health-related quality of life when compared severity of aphasia varies for different people:
with 75 other diseases and conditions (Lam Some people living with aphasia may have occa-
and Wodchis 2010). Assessment of aphasia sional difculties with their language, for exam-
should endeavor to provide a comprehensive ple, nding the right word to use or having
evaluation of aphasia beyond the physical and problems reading complex information, while
behavioral features of the condition to include others may only be able to say a few phrases. As
the social and psychosocial functioning of the Parr and colleagues (1997) state, Aphasia is not
individual and their social environment. straightforward or simple (p. 5). Fourthly, apha-
sia changes with time: The type of language dif-
culties can change and the severity and impact
Aphasia from the Point of View of People can also change. For example, in words of a
with Aphasia gentleman with aphasia, The stroke took my
language. I was left with only two words. . .
When dening a complex, chronic condition like I knew Id had a stroke but I couldnt tell anyone
aphasia, it is important to consider to perspective that I knew. I didnt have the words to say any-
of the person with aphasia and their families. Parr thing (Green and Waks 2008). Eight years later
et al. (1997) completed in-depth interviews with the same gentleman stated, I now have many
50 adults with aphasia which explored their thousands of words and I can write hundreds,
understanding of aphasia, based on the lived expe- though not always completely. I am happy phon-
rience. The adults interviewed had been living ing anyone. . .I still have some trouble with the
with aphasia for approximately 5 years or more. subtlety of language, particularly with jokes. But
Analysis of the interview information revealed my language allows me to be completely
ve primary considerations when responding to independent. . . (Green and Waks 2008).
Some people may regain language skills soon Cross-References

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intelligence: In the words of a lady living with Dementia and Neurocognitive Disorders
aphasia, My mind is one hundred per Disability and Ageing
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describing aphasia, Parr and colleagues (1997) Language, Discourse Production and
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language is not working. Aphasia damages the Primary Progressive Aphasia
lines of communication going in and Semantic Dementia
out. . .not. . .intelligence (p. 5). Traumatic Brain Injury
Due to the many different types of aphasia and
impacts, aphasia can be difcult to describe and
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Green, C., & Waks, L. (2008). A second chance: Recover-
schemes are described. The link between the con- ing language with aphasia. International Journal of
ceptualization of aphasia is demonstrated by how Speech-Language Pathology, 10(3), 127131.
aphasia is assessed. Finally, the true experts, peo- Hallowell, B., & Chapey, R. (2008). Delivering language
ple with aphasia themselves, describe aphasia in intervention services to adults with neurogenic com-
munication disorders. In R. Chapey (Ed.), Language
their own words.
290 Apraxia
intervention strategies in aphasia and related neurogenic movements. It is important to note that the dis-
communication disorders (5th ed., pp. 203228). Balti- ability in the apraxic patient is not explained by
more: Lippincott Williams & Wilkins.
Lam, J. M., & Wodchis, W. P. (2010). The relationship of impairment in gait, tremor, weakness, intellectual
60 disease diagnoses and 15 conditions to preference- or verbal comprehension, and motor and/or sen-
based health-related quality of life in Ontario hospital- sorial decits. Among the core symptoms in
based long-term care residents. Medical Care, 49(4), apraxia are the incapacity to perform motor acts
380387.
LaPointe, L. L. (Ed.). (2011). Handbook of aphasia and on verbal command, mimics, use of tools, and to
brain-based cognitive-language disorders. New York: organize the sequence of movements to conclude
Thieme Medical Publishers. an action. Nonetheless, apraxia comprises several
Murray, L. L., & Clark, H. M. (2005). Neurogenic disor- subtypes and its heterogeneous clinical manifes-
ders of language: Theory driven clinical practice. New
York: Thomson Delmar Learning. tation affects the severity and specicity of the
Papathanasiou, L., Coppens, P., & Constantin, P. (2013). decits.
Aphasia and related neurogenic communication disor- The term apraxia derives from the greek
ders. Burlington: Jones & Bartlett Learning. a (absence of) + prassein (ability to perform).
Parr, S., Byng, S., Gilpin, S., & Ireland, C. (1997). Talking
about aphasia: Living with loss of language after The disorder has been described previously by
stroke. Buckingham: Open University Press. another neurologist. The German philosopher
Rothwell, P. M., et al. (2005). Population-based study of and philologue Heymann Steinthal (1871) was
event-rate, incidence, case fatality, and mortality for all probably the rst to use the term to refer to a
acute vascular events in all arterial territories (Oxford
Vascular Study). The Lancet, 366(9499), 17731783. clinical manifestation frequently observed in
Shehata, G. A., El Mistakawi, T., Risha, A. S., & Hassan, aphasic patients (e.g., impairment in use of tools
J. S. (2014). The effect of aphasia upon personality previously used in everyday life, such as a fork or
traits, depression and anxiety among stroke patients. a pencil). An in-depth description of apraxia was
Journal of Affective Disorders, 22(172C), 312314.
Spreen, O., & Risser, A. H. (2003). Assessment of aphasia. provided some years later in the pivotal work of
New York: Oxford University Press. the German physician, Hugo Karl Liepmann.
World Health Organization. (2001). International classi- Liepmann described in 1900 the clinical case of
cation of functioning, disability and health. Geneva: the patient MT who presented impairment in
World Health Organization.
performing gestures using the right hand and
head (including face and tongue) in the absence
of decits in the left hand. But his key nding was
Apraxia reported in 1908, with the comparison between
two groups of brain damaged patients classied
Lafaiete Guimares Moreira1, Jonas Jardim de according to the hemisphere affected. In this
Paula2 and Malloy-Diniz Leandro Fernandes3 study, Liepmann described the independence
1
Universidade Fundao Mineira de Educao e between aphasia and apraxia, as some patients
Cultura - FUMEC, Belo Horizonte, Minas Gerais, suffered from this disorder without the former.
Brazil Furthermore, Liepmann argued that the left hemi-
2
Faculdade de Cincias Mdicas de Minas Gerais, sphere was dominant both for language and motor
Intituto Nacional de Cincia e Tecnologia em control (Liepmann 1900, 1908).
Medicina Molecular, Federal University of Minas Another important contribution derived from
Gerais, Belo Horizonte, Minas Gerais, Brazil Liepmanns work was the idea that apraxia is not a
3
Department of Mental Health, Instituto Nacional unitary syndrome. Furthermore, Liepmann pro-
de Cincia e Tecnologia em Medicina Molecular, posed a neuropsychological model describing
Federal University of Minas Gerais, Belo how we plan movement including its form and
Horizonte, Minas Gerais, Brazil spatiotemporal properties. According to this
model, the sequence from plan to action involves
several regions in the left brain hemisphere
Apraxia is a neurological disorder which affects including the recovery of the movement and its
the ability to perform skilled and purposeful meaning (related to the left parietal lobe), the
Apraxia 291
association of this information to sensorimotor of the actions and motor learning program,
(which contains the innervatory pattern of the processing the meaning and the known gestures,
movement) areas, and nally the transmission of be it transitive or intransitive) and another A
the appropriate information to primary motor non-lexical route for unfamiliar gestures (which
areas (responsible for the movement execution). allows playback of gestures perceived by a motor
These processes were related to the movement of visual conversion mechanism, central to the
the right limb. Considering the left limb, informa- processing of new or meaningless gestures).
tion had to be conducted from the left hemisphere Despite its wide pragmatic value, the model of
to the right motor areas via corpus callosum. Rothi et al. had difculty explaining the selection
According to Pearce (2009), Liepmann of a tactile route (The handling tool is not
described three types of apraxia: compromised, even when gestures started by ver-
bal or visual stimuli are), as well as the imitation
1. Ideational apraxia incapacity to perform of meaningless gestures (Petreska et al. 2007).
movements in their ideal form and spatiotem- Cubelli et al. (2000) reviewed the model of
poral characteristics and consequent decits in Roth et al. and reinforced the conception that the
use (and simulation to use) of tools. processing of gesture information occurs follow-
2. Ideomotor apraxia even with preservation of ing a set of steps, ranging from the input
retrieval process of the form and spatiotempo- (recognition) to the output (production) of ges-
ral characteristics of a movement, it is discon- tures. They added the module of direct
nected from the innervation pattern related to transcoding for visual stimulus (responsible for
movement generation. In this case, the patient suitable motor programming) and the gesture
will present the understanding of what has to buffer module (responsible for representing the
be performed but there will be an incapacity to short-term memory of gestures as a whole).
perform or imitate meaningful movements on The model described by Cubelli et al. (2000)
verbal command due to the lack of synergy presents a hierarchical organization according to
between the knowledge and the sensorimotor the following steps:
pattern to generate the movement.
3. Motor, innervatory, or limb-kinetic Step I: there is the identication of the nature
apraxia the sensorimotor representation of of the stimulus (auditory/verbal or visual).
movement is not sufcient to activate the pri- Step II: the information undergoes a stage of
mary motor components of the movement. gesture of identication; there is a search for
This disorder affects the speed, coordination, the appropriate motor action knowledge based
and performance of ne motor movements. on prior experiences of the individual in the use
of the tool or object. The posterior parietal
Some of contemporary models of apraxia were cortex seems to be responsible for the ability
based on the work of Liepmann and his concep- to properly position hands to use tools, based
tion of gesture formulation in time and space (for a on motor representations already known about
good review we suggest Petreska et al. 2007). this tool.
Among these models, we will highlight two that Step III: there is the implementation of knowl-
have received more attention and have been more edge, save in a kind of motor formula, that
frequently used in later works. represents intended actions. The connection
In the 1990s, building on the cognitive between the parietal and premotor areas are
processing model of language of the time, Rothi responsible for coding vision-for-action, and
et al. (1991) described an updated version of the they are involved in abstract knowledge
model initially proposed by Liepmann. They pro- motor required for proper control of the ges-
posed the existence of different routes of ture, depending on the context. The connection
processing: a route of lexical semantic nature to of the parietal lobe with the supplementary
the familiar gestures (which stores the knowledge motor area is associated with the beginning of
292 Apraxia
the movement in the specic sequence of mul- specialized regions representing well-dened fea-
tiple combined movements. Subcortical structures of motor act. In a revision about limb apraxia
tures, such as the basal ganglia, are involved in in Alzheimers disease, Lesourd and colleagues
the initial learning of motor actions. If the (2013) suggested that the superior parietal lobe is
gesture is already known, the parietal premotor involved in the production phase of the move-
circuitry is activated. In the case of use or ment, the inferior parietal lobe supports both
imitation of a new tool, subcortical structures the mechanical and sensorimotor knowledge
mediate the process. involved in the action, and the anterior temporal
Step IV: Finally, the motor command would be lobe stores the semantic knowledge about
executed by the motor cortex. tool use.
This hypothesis would account for the most
More recent theoretical models of cognition traditional concept of apraxia as a disorder
argue that our representational capacity is based on which involves a conceptual mechanism
the brains sensorimotor system, which also sup- (to form a representation of the action) and an
ports the semantic content of these representations executive mechanism (which implements the
in terms of the way we interact with our bodies in the motor commands). These mechanisms interact in
environment (Gallese and Lakoff 2005). According a dynamic way: the environmental feedback in
to this embodied cognition model, motor plan response to action changes the conceptual system
actions would be a consequence of our prior expe- and then the executive system. The constant com-
rience with objects and its manipulation and also by munication between the three brain regions
employing compensatory strategies that change the involved with the conceptual-executive system
motor act, especially in the use of tools according to and their connection with the basal ganglia and
sensory feedback (Osiurak et al. 2015). thalamus seem essential for adequate gesture
Rounis and Humphreys (2015) argue that limb production.
apraxia can be explained by the model of Although initially conceptualized as lateralized
affordance competition. According to this model, system in the left hemisphere, more recent studies
objects elicit some prototypical and prepotent suggest involvement of both hemispheres,
actions. For example, a pen affords to be held to according to the task specicities and complexity
write. A motor behavior is generated by parallel involved in the gesture. The premotor cortex
and competitive processes involving both available would be the main responsible area for transfor-
outcomes and demands for a specic gesture. In mation of a general gesture concept in a specic
ideational apraxia, the affordance of some specic gesture conception that nally would be
characteristic of an object could lead to the activa- implemented by the motor cortex (Johnson-Frey
tion of a wrong pattern of gesture. In ideomotor 2004; Wheaton and Hallet 2007; Goldenberg
apraxia the selection of movements to perform a 2009; Peeters et al. 2013). An incipient literature
gesture could be inuenced by this competition. has suggested that different categories of action
Some effectors (response to a stimulus), less impor- are distinctively coded in distributed and
tant or effective to a specic action, can be selected overlapping patterns of neural responses that sub-
instead of a more appropriate effector (e.g., utiliza- serve a higher-level and more abstract representa-
tion behavior, wherein the person automatically tion of distinct nalized motor action categories as
uses objects placed in his front by examiner, even transitive, intransitive, and tool-mediated
when asked to do another action). (Handjaras et al. 2015).
Brain Systems Related to Apraxias Apraxias: Subtypes for Clinical Practice
As to regions or brain structures activated during In the clinical neuropsychological literature, there
the motor act, there is a vast literature highlighting are many descriptions of apraxia subtypes
Apraxia 293
(Osiurak and Le Gall 2012). The classical differ- copying) or construct objects using small pieces
entiation between ideomotor and ideational like cubes or puzzles.
apraxias remains useful even nowadays. Ideomo- In some cases, apraxia can be the outcome of A
tor apraxia is related to the capacity to regulate abnormal brain development. This disorder is fre-
the motor programming of a gesture. This patient quently referred to as dyspraxia or developmental
knows the meaning of a gesture and the tools apraxia. It is important to note that this is different
involved and knows how to use them. Nonethe- from adult apraxia, as in the case, the disorder
less, the motor gesture fails in terms of timing, leads to the loss of a previously skilled gesture.
coordination, and organization of the gesture in Dyspraxia involves impairment in learning or
space. Patients suffering from ideational apraxia performing motor gestures during childhood
present impairment in the performance of a (Vaivre-Douret 2014).
sequence of motor acts to execute a complex
task. For example, the patient may fail to use
objects in a correct sequence to conclude a task Apraxia in Pathological Aging and Its
which demands multiple steps. According to Clinical Assessment
Gross and Grossman (2008), conceptual
apraxia is related to the decit in knowledge of In pathological aging, such as in Alzheimers
the meaning of the action and its relation to disease (AD) and other dementias, apraxia is a
objects. For example, a patient might fail to very frequent decit, but it is often neglected in
know the meaning of a hammer or the action clinical assessment (Lesourd et al. 2013). Apraxia
required to use this tool. is relatively common in neurocognitive disorders,
Other types of apraxias are frequently including AD, Lewy body dementia (DLB), vas-
described in neuropsychology and can be dened cular dementia (VD), frontotemporal dementia
in terms of selectively affected effectors or a spe- (FTD), Huntingtons disease dementia (HD), and
cic motor ability impaired Petreska et al. (2007). even mild cognitive impairment (MCI)
One example of apraxia related to specic effec- (Smits et al. 2014; Johnen et al. 2014; Nagahama
tors is buccofacial apraxia in which a patient fails et al. 2015). Nagahama and colleagues (2015)
to produce movements involving the face, mouth, analyzed the ability of patients with dementia to
tongue, or even larynx and pharynx. The decit imitate a series of gestures and found impairment
can be evidenced in simple tasks like blowing a in different types of dementia, especially when
candle. Another example is the limb kinetic performing bimanual gestures, with worse perfor-
apraxia. In this disorder, patients cannot perform mance observed in patients with LBD, followed
precisely acts using upper or lower limbs. by subcortical VD and AD. Ozkan and colleagues
According to Rounis and Humphreys (2015), (2013) reported a different pattern in which
limb apraxia is a very heterogeneous disorder apraxia was more frequent in AD than subcortical
and can affect the planning of a sequence of ges- VD, but in both conditions the syndrome was
tures, its conceptual representation, or even its more common than in MCI patients.
implementation. Therefore, this disorder can also Apraxia can also be used in the differential
be classied in terms of the dichotomy ideational diagnosis of the behavioral variant of FTD from
versus ideomotor. Considering apraxias related to other types of dementia, even in mild stages of
specic abilities, the main example is the dressing dementia, according to Johnen and colleagues
apraxia. In this disorder, patients fail to dress in a (2014). More interestingly, their study suggests a
correct way. specic pattern of impairment, in which panto-
Finally, constructional apraxia is a disease mime of object-use is lower in AD when com-
which affects the capacity of coordinate sensorial pared to FDT but pantomime of signs shows the
and motor information to construct elements in opposite pattern. Imitation of nger postures more
two or three dimensions. Patients suffering from impaired in AD than in FDT, but this latter group
this disorder often fail to make a drawing (even by showed pronounced difculties in the imitation of
294 Apraxia
face postures, where AD patients do not. A study study and achieved a high percentage of correct
compared the ideomotor apraxia prole of AD classications between different types of demen-
and HD and found more prominent symptoms in tia and normal aging. In a previous review
the latter (Holl et al. 2011). Not only do the sub- (Leiguarda and Marsden 2000), the authors
types of apraxia or its specic symptoms vary described a series of steps for the assessment of
according to each dementia subtype, but also the both cognitive systems involved in apraxia, con-
clinical progression may be different depending ceptual and production, and suggested a useful
on the etiological mechanism of the dementia, as classication of errors (temporal, spatial, content,
seen in Chandra et al. (2015). Signs of apraxia are and others) which can be clinically observed in
also a strong predictor of impairment in activities patients behavior.
of daily living in pathological aging (Farias
et al. 2009).
Structured batteries for the assessment of Conclusion
apraxia in dementia and MCI are still scarce and
often suffer from lack of psychometric validity Apraxia is a broad concept which encompasses
and reliability. Although motor tests which can several types of diseases that in turn have in com-
be used to assess apraxia may be found in different mon specic decits in motor action. Although it
neuropsychological batteries for dementia (e.g., is often neglected in neuropsychological assess-
Mattis Dementia Rating Scale (Mattis 1988) and ment, it has a fundamental role in the differential
Mini-Mental State Examination (Folstein diagnosis of some diseases and shed light on the
et al. 1975)), they are often too brief or designed organization and functioning of motor behavior in
for screening. In that sense, they do not allow the healthy individuals. Is apraxia a concept, a dis-
clinician a more detailed analysis, including the ease, a symptom of other diseases? Please clarify.
subtype/classication of apraxia. On the other
hand, several independent tests for apraxia were
developed in the last decades, yet most of them References
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296 Assessment of Functional Abilities in Older Adults (BADLs, IADLs)
The Importance of Being Active social activities, having an extensive social net-
in Healthy Aging work and a socially integrated lifestyle may also
reduce the risk of dementia (Srensen et al. 2008).
Due to the ongoing growth of elderly populations
in modern societies, the issue of how to maintain
and improve the functional abilities of aging peo- The Definition of Functional Abilities
ple has become a matter of urgency, in order to and Functional Status
help to live independently in the community and,
furthermore, to enhance the quality of their lives The WHO has dened functional status as a per-
(Glass et al. 1999). sons ability to carry out the activities necessary to
The traditional focus of research on aging has ensure well-being. The integration of three
been on general health, but the idea of functional domains of function is at work here: biological,
capacity has recently gained more attention. It was psychological (cognitive and affective), and
not until the 1950s that the signicance of func- social. Consequently, functional assessment is
tion in health and illness was given its proper drawn from a model which looks at how the
recognition, as the numbers of older and disabled interrelationship of these domains contributes to
persons grew and the prevalence of chronic dis- overall behavior and function.
ease increased. In 2001, the current International Classica-
For people to lead fullling social lives, health tion of Functioning, Disability, and Health (ICF)
and functional ability are crucially important: the (WHO 2001) was published. It shifted the rela-
level of functional ability determines the extent to tionship of health and functioning from the con-
which they can cope in the community indepen- sequences of a disease or condition to the result of
dently, take part in events, visit other people, use complex interactions among the individual, the
the services and facilities provided by organiza- environment, and the disease or condition. The
tions and society, and generally enrich their own new ICF was designed taking into consideration
lives and those of the people closest to them. An this biopsychosocial/integrative approach. This
active lifestyle is widely accepted as being closely system is comprised of three main components:
linked with better health and longer life (Mendes body functions and structures, activities and par-
de Leon 2003). ticipation, and contextual factors (environmental
A growing body of evidence suggests that the and personal factors). Further theoretical research
extent to which older people are engaged in their and instrument development examined key con-
social environment (visits to theaters, sporting structs of functional health: activities of daily
events; shopping; gardening; meal preparation; living (ADLs), instrumental activities of daily
card, game playing; day or overnight trips; paid living (IADLs), and psychological and social vari-
community work; and unpaid community work) is ables. The functional ability of elderly people is
associated with a clear survival benet, irrespective central to how well they cope with activities of
of whether this engagement is dened by specic daily living, which in turn affects their quality of
social or productive activities or by the nature and life. In this chapter, focus will be given on basic
quality of their social relationships. Moreover, par- and instrumental activities of daily living (BADLs
ticipation in leisure activities unconnected to t- and IADLs), one of the key aspects encompassed
ness can also increase longevity and has other in functional abilities.
positive health effects for older adults (Glass
et al. 1999), as recent studies have suggested
(Mendes de Leon 2003; Strout and Howard 2012). Functional Decline Associated
As such, lack of social engagement, as well as with Aging
social isolation, and infrequent participation in
social activities may be risk factors for cognitive Impairment in ADLs, to a certain extent, is part of
impairment in aging. Taking part in stimulating normal aging. There is a progressive slow decline
in functional abilities, which accompany the aging internal control mechanisms (i.e., self-initiated
of the body, and is therefore considered normal. retrieval), which depend heavily on prefrontal
Healthy older adults will often undergo subtle systems, that are often affected in older adults A
declines in their independent management of (Woods et al. 2012).
instrumental activities of daily living (IADLs). Given the global nature of the decline in speed
While the rates of IADL dependence have fallen of processing and working memory that occurs
among older adults in recent years, the prevalence with age, one might expect that older adults would
of these same declines and their negative impact have substantial difculties in managing the
on individuals, caregivers, and the healthcare sys- affairs of everyday life or maintaining a good
tem are still considerable and highlight how level of performance on the job. Decline in tests
important it is to identify clinically useful predic- of executive function (e.g., complex attention,
tors of everyday functioning that may play a part verbal uency, and planning) is expected to a
in psychological interventions. Among the recog- certain extent, and these, when present, have
nized risk factors for IADL disability among shown to be associated with a natural decline in
healthy older adults are demographics (e.g., sex), ADL performance (Piguet et al. 2002). This is
depression, medical comorbidities, and certain however not a consensus: there is considerable
psychosocial factors (Kiosses and Alexopoulos evidence that older adults function well and that
2005). Neurocognitive impairment is another cognitive declines documented in the lab might
independent risk factor for concurrent IADL prob- not have as negative an effect as one would expect
lems among older adults. Functional disability on everyday domains of behavior. In a similar
due to age-related chronic or debilitating condi- vein, it has been noted that a question that fre-
tions is therefore common among older adults, quently arises when evidence for aging-related
and its prevalence is expected to increase as the neurocognitive decline is presented is why are
population ages, particularly among the oldest old the effects not more noticeable in everyday life?.
(Gitlin et al. 2009). Moreover, the DSM-IV-TR (American Psychiat-
ric Association) directs that in order for a diagno-
sis of dementia to be warranted, cognitive decits
Cognitive Factors Contributing must result in a decline from previously higher
to Functional Decline in Old Age levels of occupational or social functioning. This
instruction to exclude from dementia diagnosis
Among the strongest and most reliable cognitive adults who exhibit cognitive decits absent of
predictor of IADL problems in older adults is decline in occupational or social functioning sug-
decit in episodic memory (EM). Episodic mem- gests a perspective that normal aging often leads
ory involves conscious gathering of information to some cognitive decline without accompanying
acquired in a particular place and at a particular decline in everyday functions (Tucker-Drob
time, and a decit in EM was especially associated 2011).
with problems in regard to older adults managing Another common problem in older adults is
their own medication (Koehler et al. 2011). apathy, which is associated with cognitive and
Consequently, one might postulate that functional impairment in the elderly with pre-
age-related declines in prospective memory served cognition. Apathy is a disorder of will,
(PM) would also increase the risk of IADL prob- i.e., the human power, potency or faculty to
lems. PM is the complex cognitive process of initiate action. A reduction of this capacity
successfully carrying out a delayed intention, or sees affected individuals manifest diminished
remembering to remember. When compared to desire, goal formulation, and voluntary
their younger counterparts, older adults can expe- behavior characteristics central to an operational
rience mild-to-moderate declines on laboratory denition of apathy proposed by Marin 25 years
tests of PM. Aging may have a signicant effect ago (Marin 1991). Apathy can lead to
on PM because of the latters strong reliance on cognitive impairment and functional disability in
older adults. In the Cache County Study, elders and IADL, originally developed for general geri-
without cognitive impairment and presenting with atric assessment. Several scales were later devel-
apathy scored lower in cognitive tests and oped for Alzheimers disease, and they are
reported a decrease in the level of their daily normally used in other dementias.
functioning (Onyike et al. 2007). This section will address the most common
ADL scales used in clinical and research settings
involving healthy aging and dementia patients.
The Emergence of Standardized
Functional Assessment in Older Adults
The ADL Index (Katz 1963)
For the past 20 years, research has been dedicated
to achieving an objective and comprehensive The Katz Index of Independence in Activities of
direct measure of the functional performance of Daily Living (Katz ADL) assesses functional sta-
the elderly. tus as a measurement of the persons ability to
The historical context of the increased life span perform activities of daily living independently
prompted specialists to ask the following ques- (Katz et al. 1963). The Index identies the quality
tions regarding the older adults independence: of performance in the six functions: bathing,
Can the person perform activities as previously? dressing, toileting, transferring, continence, and
Does the person require direct assistance or spe- feeding. People are scored yes/no for indepen-
cialist equipment to independently and safely dence in each of the six functions. A score of
carry out their daily activities? For this reason, 6 indicates full function, 4 indicates moderate
assessment of functional ability often includes an impairment, and 2 or less indicates severe func-
evaluation of the individuals ability to carry out tional impairment.
various activities of daily living (ADLs). Score ratings should be based on the current
ADLs can be further categorized as basic ADLs state and not on the ability to carry them out; the
(BADLs) or instrumental ADLs (IADLs). BADL scale is usually completed by a professional. It is
refers to various self-care activities such as eating, considered that a patient who refuses to perform a
dressing, personal hygiene, and mobility in and function is considered incapable of carrying out
outside the house, while IADL functions are related that function with regard to the scoring on the item
to more complex tasks such as household manage- in question.
ment, carrying out activities outside the home, use Validity and Reliability: No formal reliability
of public transport, cooking meals, etc. As such, and validity reports could be found in the
functional rating scales aid in the identication of literature.
impairments, functional limitations, and participa-
tion and can serve as tools that monitor changes
over time as well as in response to interventions The Lawton Instrumental Activities
(e.g., outcome measures). of Daily Living (Lawton and Brody 1969)
Still, when selecting ADL tools, one needs to
consider their measurement characteristics and The Lawton Instrumental Activities of Daily Liv-
psychometric properties (reliability, validity, sen- ing (IADL) Scale is an instrument used to assess
sitivity, and specicity) to avoid or reduce independent living skills among older adults and
observer bias. may be used in the community setting, clinic, or
hospital (Lawton and Brody 1969). The type of
tasks evaluated are more complex than the basic
Functional Scales for Older Adults activities of daily living as measured by the Katz
ADL Index or the Barthel Index. It takes 510 min
There are many instruments for ADL assessment, for a trained interviewer to assess ability in eight
including widely used scales for ratings of BADL complex daily living tasks such as using the
phone, grocery shopping, preparing meals, house- The ADCS-ADL inventory offers a detailed
keeping, laundering, using transportation, taking outline of each activity and asks the carer to
medications, and managing nances. The assess- describe observed actions or behaviors. The nec- A
ment can be delivered with a written questionnaire essary information is taken from the past 4 weeks.
or via an interview with the informant. The clini- If a person did attempt to perform the ADL, the
cian can complete the scale using information informant is asked to pick the single most accurate
about the patient, from an informant (persons denition of the patients level of performance
family member or carer), the patient himself/her- from a list of descriptions of alternative methods
self, or recent notes. of doing the ADL. For an ADL in which different
The main purpose of the instrument is to iden- methods of performance do not apply, the infor-
tify how a person is functioning at the present time mant is asked if the subject usually carries out the
and to identify improvement or deterioration over ADL independently (the highest level), with
time. Persons are rated according to their highest supervision (needing verbal instructions during
level of functioning in that category. A summary ADL performance, an intermediate level of abil-
score ranges from 0 (low function, dependent) to ity), or with physical help (a lower level of
8 (high function, independent). performance).
Validity and Reliability: Inter-rater reliability Validity and Reliability: Good test-retest reli-
was established at 0.85. Of note, inter-rater reliability (ranging from 0.41 to 0.70) over 12
ability was determined with a small sample of months. Correlations between the ADCS items
12 subjects (Lawton et al. 1982). and the MMSE total score range from 0.28 to
Advantages and Disadvantages: There are 0.70.
three fundamental issues: low sensitivity, does
not address all IADLs, and is gender biased. His-
torically, women were scored on all eight areas of Disability Assessment for Dementia
function; men were not scored in the domains of (DAD) (Gelinas and Gauthier 1999)
food preparation, housekeeping, and laundering.
However, current recommendations are to assess The Disability Assessment for Dementia (DAD)
all domains for both genders. Scale is targeted at individuals living in the com-
munity who have cognitive decits such as
Functional Assessment in Dementia Alzheimers disease and other dementias
Some assessments of function have been speci- (Gelinas et al. 1999). Tasks include basic
cally designed to detect changes due to dementia. (dressing, hygiene, continence, and eating) and
This section presents the most common functional instrumental ADLs (meal preparation, telephon-
tools used in dementia. ing, housework, taking care of nance and corre-
spondence, going on an outing, taking
medications, and ability to stay safely at home),
Alzheimers Disease Cooperative Study as well as leisure activities (activities that
Activities of Daily Living Inventory are beyond self-maintenance and are for the
(ADCS-ADL) (Galasko 1997) purpose of recreation). The DAD helps delineat-
ing areas of cognitive decits which may
The ADCS-ADL scale is an informant-based impair performance in ADL. Scores can be broken
inventory consisting of 23 items that assess both down in regard to initiation, planning, and
basic and instrumental activities of daily living, execution.
i.e., functional performance, of people with The DAD is administered through an interview
Alzheimers disease (Galasko et al. 1997). It with the caregiver, taking 15 min, and is a measure
takes 15 min to administer, and it can be com- of the actual performance in ADL of the individ-
pleted by someone who spends at least 2 days a ual as observed over a period of a fortnight prior to
week with the person. the time of the interview.
Each item is scored: 1 point = able to, informants may not be able to provide responses
0 point = not able, or non-applicable = N/A. on certain items, either because the subject never
Validity and Reliability: Internal consistency performed them prior to developing cognitive
coefcient is reported at 0.96, the intraclass cor- impairment or because the informant had insuf-
relation reported at 0.96, and the test-retest reli- cient information to rate the subjects current
ability also has excellent ratings (Gelinas performance.
et al. 1999). The convergent validity for the
DAD is supported through the instruments corre-
lation with the Global Deterioration Scale. The Activities of Daily Living Questionnaire
usefulness of this scale has been demonstrated in (ADLQ) (Johnson 2004)
numerous clinical trials.
The Activities of Daily Living Questionnaire
(ADLQ) Scale is an informant-based instrument
Functional Activities Questionnaire used to measure functional abilities in people with
(FAQ) (Pfeffer 1982) dementia. It takes 510 min to be completed
(Johnson et al. 2004).
The Functional Activities Questionnaire (FAQ) The scale is divided into six sections (self-care,
measures instrumental activities of daily living household care, employment and recreation,
(IADLs), such as preparing balanced meals and shopping and money, travel, and communication)
managing personal nances (Pfeffer et al. 1982). addressing different areas of activity, and each
It is an informant-based questionnaire that can be section has between three and six items. Each of
given to either patient or carer, and it takes the items is rated on a 4-point scale from
approximately 510 min to be completed. The 0 (no problem) to 3 (no longer capable of
individual answers 10 items relating to daily performing the activity). For each item, there is
tasks which are needed to live independently. also a rating (9) provided for instances in which
A scale ranging from independence (0) to depen- the patient may never have performed that activity
dence (3) is used for responses. in the past (Never did this activity), stopped the
The total score ranges from 0, reecting the activity prior to the onset of dementia (e.g.,
fully preserved capacity, to 30, indicating maxi- stopped working before dementia symptoms
mum functional dependency. A cutoff point of were apparent), or for which the rater, for a variety
9 (dependent in 3 or more activities) is of reasons, may not have information (Dont
recommended to indicate impaired function and know).
possible cognitive impairment. The total score, which has a range of 0100, is
Validity and Reliability: The FAQ is a consis- calculated using the formula below:
tently accurate instrument with good sensitivity Functional impairment: (Sum of all ratings/3
(85%) to identify an individuals functional total number of items rated) 100
impairment. The FAQ demonstrates high reliabil- The denominator represents the score that
ity (exceeding 0.80). Tests of validity have been would have been obtained if the most severe level
performed on the FAQ, establishing it as an instru- of impairment had been indicated for all items rated
ment for the bedside and research being able to (excluding those rated 9). The numerator repre-
discriminate among different functional levels of sents the total of the actual ratings for all items rated
individuals and being able to predict neurological (excluding those rated 9). The resultant score
exam ratings and mental status scores such as the represents the level of severity of impairment in
Folstein Mini-Mental Status Examination ADL. The amount of functional impairment is then
(MMSE). rated as none to mild (033%), moderate
Advantages and Disadvantages: The FAQ is (3466%), or severe (66100%).
very sensitive in detecting individuals with Validity and Reliability: This scale has high
dementia. A limitation of the FAQ is that test-retest and concurrent validity and has been
shown to accurately detect decline in individuals Informant-based dementia screens provide an

with probable Alzheimers disease. Total ADLQ estimate of change over the long time periods
score is highly reproducible, with concordance typically seen in evolving dementias, evaluate A
coefcients of 0.86 or higher (Johnson cognitive abilities related to everyday function,
et al. 2004). and appear minimally affected by cultural, educa-
tional, and language biases.
Performance-based ADL instruments require
Bristol Activities of Daily Living Scale the person to carry out real tasks in a structured
(BADLS) (Bucks 1996) setting using accessories. Scoring is standardized
and can encompass elements of performance such
The Bristol Activities of Daily Living Scale as sequencing, initiation, and motivation. The
(BADLS) was designed specically for use in main disadvantages of such assessments is the
patients with dementia and covers 20 daily living length of time taken to administer, need of spe-
activities (Bucks et al. 1996). A professional or cialist training, and also the potential requirement
family can complete it in about 510 min. It is of an ecological setting in the clinical environ-
sensitive to change in dementia and short enough ment, which is not always available.
to use in clinical practice. It is regularly used as an
outcome measure in clinical trials. This outcome
is among those recommended by a consensus Direct Assessment of Functional Status
recommendation of outcome scales for nondrug (DAFS) (Loewenstein et al. 1989)
interventional studies in dementia (Moniz-Cook
et al. 2008). The DAFS is a performance-based (ADL) task
Validity and Reliability: The BADLS has good that assesses seven specic functional areas:
test-retest reliability and good content validity time orientation, communication, transportation,
(Bucks et al. 1996). nancial skills, shopping ability, grooming, and
Advantages and Disadvantages: Patients can eating (Loewenstein et al. 1989). The time ori-
be evaluated over a full range of ADL and abilities entation subtask examines (a) the ability to tell
despite communication difculties, and it is sen- time using a clock and (b) orientation as to person,
sitive to detect change over time. However, over place, and time. The communication subtask
half of the items (13 of 22) on the scale rate basic includes (a) ability to use a telephone and
ADLs (e.g., selecting food, eating food, selecting (b) send a letter, while (c) transportation task,
drink, drinking), making the total score heavily (a) identication of driving signs and (b) driving
determined by these tasks. Most individuals with rules. The nancial subtask assesses participants
dementia would not experience a decline in these ability to (a) identify and (b) count currency, as
areas until the later stages of illness, and this scale well as (c) write a check and (d) balance a check-
is unlikely to be sensitive to early decline in higher book. The shopping subtask assesses participants
level cognitive activities. ability to learn a list of shopping items and then
(a) freely and (b) with cueing select the items from
Informant-Based Versus Performance-Based a mock grocery store after a 10 min delay, (c) shop
Functional Assessments with a list, and (d) getting the correct change.
Informant-based tools can be as effective as cog- Scores are obtained by computing individually
nitive tools for dementia screening and have completed correct responses in each domain.
many advantages: they can measure change Validity and Reliability: This instrument has
longitudinally, they can be used for subjects high inter-rater and test-retest reliabilities. Con-
unable to do cognitive testing for any reason, vergent validity is evidenced by signicant corre-
they are relevant to everyday cognitive activities, lations between the scale and established
and they can be used cross-culturally (Lorentz measures of functional status (Loewenstein
et al. 2002). et al. 1989).
The Assessments of Motor and Process four cognitive operations related to EF: ability to
Skills (AMPS) (Fisher 2003) formulate the goal, plan the task, execute it, and
verify the attainment of the goal. For each opera-
The AMPS is a well-validated performance-based tion, the persons level of independence is scored
tool. It has been used extensively with a number of on a ve-level ordinal scale ranging from depen-
populations (Fisher 2003). The person has to per- dent (score of 0) to independent without difculty
form two everyday tasks chosen from a set of over (score of 4). In addition to the independence score,
100 standardized tasks. The assessment of the two this test also allows clinicians to understand the
tasks simultaneously measures 16 motor (e.g., types of errors committed by the individual, the
coordination, grip, transportation, etc.) and type and amount of cues required to perform the
20 mental process skills (e.g., searching, choos- task, and the time to complete the task.
ing, organizing, sequencing, etc.) and their effect Validity and Reliability: This revealed high to
on the ability of the person to perform familiar very high internal consistency for all factors rang-
ADL tasks. Both tasks scores are used in con- ing from 0.81 to 0.98; internal consistency of the
junction with the AMPS score. Raw scores from total scale was very high (0.94). Hence, a total
each motor and process skill are converted into score can be calculated, providing a reliable
logits, using a Rasch model approach. A software global indicator of IADL independence and indi-
program compares a patient score against age- and cating where on a continuum from totally depen-
sex-matched controls; scores lower than cutoffs dent (total score, 0) to totally independent (total
denote impairment. score, 116) the ability of an individual is located
One of the disadvantages of the AMPS is its (Bottari et al. 2009).
cost for the training; however, this ensures greater
reliability for the trained assessor. The AMPS is Limitations and Advantages of Functional
also limited to OTs, which may pose a challenge Assessments
depending on staff availability. Finally, the AMPS A key limitation of functional assessments relates
does not measure initiation. to its high sensitivity to change. Changes in ADLs
can be due to physical symptoms or frailty, cog-
nitive decits, neuropsychiatric symptoms, or a
The Instrumental Activities of Daily combination of these, which could confound the
Living (IADL) Profile (Bottari 2009) decline related to cognitive decits.
However, for the same above reason, ADL
The IADL Prole was originally developed for scales are very useful in clinical care planning
people post-brain traumatic injury (Bottari and psychosocial interventions and are also sen-
et al. 2009). However, it is currently being vali- sitive to detect improvement post pharmacologi-
dated for aging populations and dementia cal and non-pharmacological trials.
patients. The assessment evaluates independence Of note, to date, most scales are unable to
in complex everyday activities. This tool is differentiate the exact factors underlying ADL
administered in the persons home and commu- change. This is a eld with growing research
nity environment and aims to establish whether interest, and it will not be long before a novel
the subjects main difculties in everyday life ADL can also address factors behind the mea-
relates to executive function (EF) decits. Partic- sured disability.
ipants are asked to simultaneously plan the full
series of embedded tasks necessary to attain the
ultimate goal of hosting a meal for unexpected Summary
guests. Two other tasks, obtaining the daily bus
schedule for a long-distance trip between two The evaluation of functional performance in older
large urban cities and making an annual budget, adults is essential for planning support needed in
are also tested. Tasks are scored on the basis of older age. Changes related to normal aging, acute
illnesses, worsening chronic illnesses, and hospi- in dementia: Development of the bristol activities of
talization can contribute to a decline in the ability daily living scale. Age and Ageing, 25, 113120.
Fisher, A. G. (2003). Assessment of motor and process
to perform tasks necessary to live independently skills volume 1: Development, standardization, and A
in the community. The information generated administration manual. Three Star Press, Fort Collins,
from a well-conducted functional assessment can CO.
provide objective data to assist with targeting Galasko, D., et al. (1997). An inventory to assess activities
of daily living for clinical trials in Alzheimers disease.
individualized rehabilitation needs or to plan for The Alzheimers Disease Cooperative Study.
specic in-home services (such as meal prepara- Alzheimer Disease & Associated Disorders, 11, 3339.
tion, nursing and personal care, homemaker ser- Gelinas, I., Gauthier, L., McIntyre, M., & Gauthier,
vices, nancial and medication management), or S. (1999). The disability assessment for dementia. The
American Journal of Occupational Therapy, 53,
the need to involve other people for continuous 471481.
supervision. Gitlin, L. N., Hauck, W. W., Dennis, M. P., Winter, L.,
Functional assessment can also help clinicians Hodgson, N., & Schinfeld, S. (2009). Long-term effect
to understand a persons baseline capabilities, on mortality of a home intervention that reduces func-
tional difculties in older adults: Results from a ran-
facilitating early recognition of changes that may domized trial. Journal of the American Geriatrics
lead to an early diagnosis of dementia. Monitoring Society, 57(3), 476818.
ADL function can also provide key information Glass, T. A., de Leon, C. M., Marottoli, R. A., & Berkman,
on the progression of the disease. For this reason, L. F. (1999). Population based study of social and
productive activities as predictors of survival among
functional disability tools are commonly used as elderly Americans. BMJ, 319, 478483.
outcome measures in pharmacological and Johnson, N., Barion, A., Rademaker, A., Rehkemper, G., &
non-pharmacological trials and should be part of Weintraub, S. (2004). The activities of daily living
any set of assessments involving the elderly and questionnaire: A validation study in patients with
dementia. Alzheimer Disease and Associated Disor-
people with dementia. ders, 18, 223230.
Acknowledgments We are very grateful to Martin Boon Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., &
for his help in editing the manuscript. Jaffe, M. W. (1963). ,Studies of illness in the aged:
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Bucks, R. S. (2012). Memory for intentions is uniquely This entry has three aims, to describe the main
associated with instrumental activities of daily living in methods and features of assessment of older peo-
healthy older adults. Journal of the International Neuro- ple in primary care, drawing on examples from
psychological Society. doi:10.1017/S1355617711001263.
around the world; to describe in some detail the
EASYCare assessment method, whose develop-
ment over the last 25 years as an assessment tool
Assessment of Older People for use in primary care for older people has been
in Primary Care led by one of the authors; and to provide a number
of recommendations for international develop-
H. C. Moorey, S. K. Bradshaw and I. Philp
ment in this area.
Heart of England Foundation Trust, Birmingham,
UK
Methods
Synonyms
An electronic search of all HDAS journals was
Community care; Comprehensive geriatric carried out to prepare materials for this entry, we
assessment; Needs assessment undertook an electronic search of all HDAS
Assessment of Older People in Primary Care 305
journals (http://www.library.nhs.uk/hdas) carried feedback on their risk factors. The feedback was
out through the OpenAthens portal on 24 Novem- also incorporated into the primary care IT system
ber 2015. We searched for the following words in so that it could also be used by GPs for reinforce- A
the abstract and title elds, Primary Care AND ment of health behavior. This tool appears to be
Assessment AND Older People. The time frame effective at identifying risk factors, has been val-
was set from 01 January 2015 to 24 November idated in the USA and in a number of European
2015. This produced 1,063 results, which were countries, and has a high acceptability among
reviewed. We selected 30 articles were selected patients and providers in primary care. However,
for detailed review based on conrming that the this study found the HRA-O had a limited impact
tool was used in the assessment of older people in on health behaviors, excluding a small increase in
a primary care setting, was not a single disease- physical activity and an increased uptake of the
specic screening tool, and included mental pneumococcal vaccine. Previous studies that
health within a holistic assessment. Studies were included face-to-face encounters with participants
selected case studies for this entry to cover the have had more positive outcomes, suggesting
main purposes of assessment where there was the direct contact may be important in the assessment
strongest evidence base for their use. of older people in primary care.
The literature study identied a small number Eichler et al. (2007) also used risk assessment
of assessment methods that fulll the criteria. to assess older people (70 years of age) in pri-
These can be divide into three main groups: mary care in Austria; however, they used the
those that are used to screen for risk, those that Standardized Assessment Tool for Elderly People
form a single assessment in primary care, and in Primary Care (STEP) tool. This tool was devel-
those that can form part of a stepped approach oped in a collaboration between 7 different Euro-
toward more comprehensive assessment. These in pean countries and involves 33 possible health
turn will then be discussed, drawing on a number problems and risk factors for health decline.
of case studies. Again, this took the form of a self-completed
questionnaire but also included a memory and
mobility assessment by the general practitioner.
Risk Screening Assessment If there was a positive result, the general practi-
tioner and the patient would make decisions
Health risk appraisal (HRA) is an example of a together about further management. Eichler
risk screening assessment that can be used in et al. (2007) found the assessment inuenced fur-
primary care. HRA is an approach that has devel- ther management in four domains: hearing impair-
oped from the US-based insurance system. It ment, mobility and falls, depression, and urinary
involves a systematic approach, to collect infor- continence. In contrast, GPs were unlikely to act
mation from individuals and to identify poten- on positive cognitive results, a nding repeated
tially modiable risk factors (Eichler elsewhere in the literature. Again, this demon-
et al. 2007). Within the assessment of older peo- strates that risk assessment may be an effective
ple, the aim of HRA is to identify risk factors for way of assessing older people to identify risk
decline in status that can then be used to modify factors and may be used to affect management in
management and improve quality of life (Eichler primary care. However, the impact of these man-
et al. 2007). Harari et al. (2008) used the health agement changes on long-term outcomes is not
risk appraisal for older persons (HRA-O) as a clear.
self-completed questionnaire assessing medical
conditions, function, social support, depressive
conditions, memory impairment, and health Primary Care Assessment
measurements. A sample of people over 65 living
in their own homes in London returned the ques- Assessment of older people in primary care can
tionnaire and received individualized written also involve a more thorough assessment than that
of risk alone. Often this assessment will be an The EASYCare Assessment

assessment of need and unmet need.
The Camberwell Needs Assessment for the Over the last 25 years, one of the authors (IP) has
Elderly (CANE) was developed in the UK, spe- led an international project, EASYCare Health, to
cically for older people with mental disorders develop and implement an assessment system for
(Reynolds et al. 2000). It assesses four categories older people in primary care. The approach has
of need: environmental, physical, psychological, been validated (Philp et al. 2001) in 44 poor,
and social. Its validity, reliability, and acceptabil- middle income, and rich countries around the
ity have been assessed in the UK with good world (Olde-Rikkert et al. 2013) and reported in
results. Stein et al. (2014) have also developed a 80 peer-reviewed publications. The key insight
German version which identied met and unmet from this work is that all older people and their
need in older people in primary care, and results family circumstances are unique. Therefore, older
were consistent with other tools and scores. people need to be assessed for their perceptions
CANE has also been validated in a number of about their health and care needs and mobilize a
other countries. Although we found no evidence response based of their priorities and that of their
of association of the use of CANE and improved family carers. Local systems also need to be
outcomes for older people, the use of CANE in understood, both voluntary and statutory, from
both research and clinical setting and the valida- which support can be mobilized. The EASYCare
tion in a number of countries suggests it may be a experience has shown that older people and their
useful tool in the assessment of older people in families are most concerned about maintaining
primary care, particularly those with mental dis- independence, being able to do what is important
orders such as dementia. to them, not being a burden and not suffering at
Another needs assessment tool that has been the end of their lives. We have identied the top 49
used in the assessment of older people in primary top concerns of older people have been identied
care is the Brief Assessment in General Practice relating to their health and care, which fall into
Health Tool (BRIGHT). Wilkinson-Meyers seven domains: communication, daily living
et al. (2014) used this tool to identify met and activities, mobility, safety, accommodation and
unmet need in a sample of older people (>75) living nance, mental health, and staying healthy. In
in the community in New Zealand. They found recent studies, the top concerns reported have
81% of people needed assistance with at least one been about pain, loneliness, accommodation,
instrument of daily living, and there was signicant nancial difculties, memory, and sleep. This
unmet need with regard to housework. However, heavy weighting toward concerns about mental
this study was limited to personal assistance needs. health and environmental factors suggests that
Kerse et al. (2014) have published further work with policy and practice should give greater priority
the same sample where BRIGHT was used to per- to these issues to promote better health in old age.
form a more comprehensive assessment through The EASYCare approach has strong evidence
telephone interviews in primary care. They found for validity for use in primary care, with a variety
that this method was effective at identifying older of methods of implementation, including incorpo-
people in the community with increased disability. ration into frontline assessments by professionals
Those who undertook the BRIGHT assessment had such as primary and community nurses (Philip
a smaller decline in quality of life during the follow- et al. 2014), allied health professionals, social
up period. They also had an increased rate of place- care staff, and care assistants. Voluntary sector
ment in residential care, suggesting BRIGHT was staffs, such as those working for NGOs, have
able to identify need in the community that could been particularly effective in using the EASYCare
not be met with older people remaining in their own assessments to underpin their work with older
homes, or the community support was not available people. Evidence also suggests that many older
to allow this. There was no difference in hospitali- people can have a satisfactory and efcient
zation and service use between the two groups. telephone-based assessment by call center staff.
Assessment of Older People in Primary Care 307
Assessors from statutory, voluntary, and indepen- The assessment begins with a frailty screening,
dent sectors do however need to be trained in using U-PRIM, of older people in the community
person-centered assessment, including under- that is applied to primary care records. This is then A
standing issues about mental capacity. Self- followed by U-CARE, a nurse-led, multidis-
assessment is possible but older people derive ciplinary assessment and intervention.
more benet from a guided conversation with a A further frailty assessment using the Groningen
trained assessor. Prior to offering an assessment Frailty Indicator (GFI) questionnaire and further
service, local resources which could address identi- supplementary tools to ensure a holistic assessment
ed concerns need to be mapped, and agreement is undertaken. Frail older people in the community
must be reached about how to share summary then undergo a comprehensive geriatric assessment
assessment information at both an individual and at home conducted by a practice nurse. The nal
population level, with due consideration to issues of step is then to create a tailor-made care plan in
condentiality, security, and consent. In countries collaboration with the GP. Results suggest that this
with well-developed primary care systems, we have approach is acceptable to health-care professionals
found that it is useful for contact with the older and may have positive outcomes (Metzelthin
person to be initiated by their primary care physi- et al. 2014). There was better preservation of phys-
cian and for the summary of the assessment and ical functioning in the U-CARE group; however, no
response to be held within the persons individual effect was seen on quality of life. Furthermore, there
primary care record. Following an assessment and is evidence to suggest the U-CARE method is likely
mobilization of support, a follow-up assessment is to be cost-effective compared to usual care
undertaken to document what happened as a result (Metzelthin et al. 2014).
and the persons satisfaction with the outcome. In Another example of stepped assessment was the
RCTs have shown that the process mobilizes an use by Vass et al. (2005) of an educational program
increase in support from community and voluntary to enable health visitors and GPs to provide vali-
sector services, balanced by a reduction in hospital dated short geriatric assessments to older people.
admission. Levels of independence and well-being Older people were rst assessed by a health visitor
in the older person improve. One RCT evaluated the in their own homes, as part of a nationwide pro-
cost per quality-adjusted life year gained, with the gram in Denmark. However, this was modied to
intervention found to be highly cost-effective include an assessment to select older people who
(Melis et al. 2008) at less than 2000 per QUALY. were showing early signs of disability. Depending
An EASYCare assessment can be triggered by on the results of the rst assessment, older people
screening tools to identify at-risk older people and were then asked to see their GP for a short geriatric
can also itself identify people who are likely to assessment, focusing on the ve Ds: delirium,
benet from comprehensive geriatric assessment depression, dementia, drugs, and drinks. Vass
by specialist multidisciplinary teams. However, et al. (2005) observed that those receiving the
the unique feature of the approach is that its use modied home visit program and GP assessment
can be contained for the most part within the pri- had less of a decline in their functional ability over
mary care system and can help deliver appropriate 3 years. This result was more notable in the 80-year
care and support to older people in their own homes. olds compared to the 75-year olds. Improved out-
comes were also associated with more regular
home visits. No differences in mortality or rates
Stepped Approach of nursing home admission were seen.
Another approach identied from the literature is a

stepped approach, where assessments move toward Summary of Assessment Instrument
more comprehensive assessment. The U-CARE
method (Bleijenberg et al. 2013), developed in The key properties of the instruments we have
the Netherlands, is a prime example of this. described are summarized in the Table 1.
Assessment of Older People in Primary Care, Table 1 Properties of the assessment instruments
HRA-O STEP CANE BRIGHT U-CARE EASYCare
Holistic
Good coverage of mental health
Valid for use in primary care
Cross-cultural validity
Supports stepped care
Cost-effective
Conclusion health. This has been given added impetus in

older people with recognition of the benets of
Research of the literature for this entry demon- early intervention for including specialist assess-
strated a relative paucity of recent published work ment for people with dementia.
about primary care-based assessment of older Health systems should be developed to harness
people, in contrast to the large amount of the use of these assessment methods. How they
published work on identifying frail older people are implemented will depend on local factors. It is
and meeting their needs through specialist ser- important to mobilize all available resources,
vices. However, the search terms were limited including those from the third sector. The respon-
and we know that there is much published work sibility for assessment and care navigation should
and a long academic tradition focussed on devel- ideally be independent of the provision of care to
oping better primary and community-based care avert the risk of assessors skewing the mobiliza-
for older people. tion of support toward their own services. There is
Nevertheless, there are some excellent, vali- a strong policy and professional rhetoric for
dated methods for primary care-based holistic person-centered care, but it is impossible to under-
assessment of older peoples health and care estimate the capacity for providers to pursue pro-
needs. The methods fall into three main catego- fessional and organizational objectives, rather
ries: assessment to screen for risk, single assess- than working across organizations for the benet
ment for primary care management, and stepped of recipients of services. To have sustainable and
assessment. Patterns of need appear to have strong effective care for aging populations, commis-
commonalities across health systems and are well sioners and policy-makers need to promote a cul-
covered among the instruments we reviewed. ture of empowerment and capability, rather than
Mental health needs feature strongly in them all. one based on passive receipt of welfare and care,
It is no surprise that mental health is a key with genuine attention to the concerns of older
feature in assessment tools, which have been val- people and their families for their health and
idated for use in primary health care. Poor mental care. The adoption of any of the assessment
health is a strong predictor of poor outcomes and approaches we have reviewed would be encour-
will therefore feature in screening tools for risk. aged, to strengthen primary care for older people
Mental health problems, including depression and and help change culture and systems to improve
anxiety, are common in older people, as are wider older peoples lives.
aspects of poor mental well-being such as loneli-
ness, pain, and sleeping problems, and should
therefore form a major component of any holistic Cross-References
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Assisted living facilities (ALFs) are a long-term
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310 Assisted Living
setting (Brodie and Blendon 2001; Grabowski Residents

et al. 2012).
ALFs are able to serve residents with a wide range
of physical and mental health ailments. Some
Services Provided residents are in relatively good health, require
minimal assistance, and can function with little
Residents are provided with living amenities, to no limitation. These residents typically choose
daily meals, activities, and basic medical care. to live in an ALF to have assistance with taxing
Living arrangements are offered as apartment chores such as cleaning and meal preparation.
style housing units, creating a community in Others choose to move to an ALF with a spouse
which residents live nearby one another. Within who has declining health to have extra assistance
the same facility, ALFs provide dining halls, with taking care of them. Other residents have a
shared facilities, and common spaces such as liv- variety of physical disabilities due to chronic pain
ing rooms and patios. In addition to the provided or being wheelchair ridden that limit them from
space, many residencies offer activities and events accomplishing ADLs. These residents require
to engage individuals and provide entertainment assistance with mobility within their private living
(Howe 2014). Encouraging residents to engage in space and transporting to the dining hall, common
social events is an effective way to help older areas within the ALF, or to off-site locations.
adults in their transition to an ALF. These activi- Furthermore, some residents are physically able
ties may also help them cope with difcult life but require assistance to compensate for their cog-
events such as the bereavement of a spouse or nitive decline. Such residents may require assis-
loved one. Additionally, engagement in activities tance with remembering to take medication and
may reduce depressive symptoms that are com- other ADLs such as bathing and dressing. Addi-
monly seen in older adults (Brody and Semel tionally, residents with health problems such as
2006). hypertension, diabetes, heart problems, and joint
The aspect that typically attracts older adults to pain also benet from medication management
move into ALFs is the on-site, 24 7 support and and call systems to staff members in case of emer-
health services. Such assistance includes help gency. Many residents have a combination of
with activities of daily living (ADL) such as bath- limitations and health problems requiring individ-
ing, eating, dressing, medication assistance and ualized assistance to address their specic needs
management, using the toilet, and walking. Spe- (Zimmerman et al. 2001).
cically, residents can receive assistance with
daily showers and morning routines with getting
out of bed and getting dressed. Assistance can also Unique to Independent Living
be provided to those who need help in going from and Skilled Nursing
their rooms to the dining room for meals. Addi-
tionally, help is provided with chores such as The services provided at an ALF are at a higher
cleaning, laundry, and transportation. This care level than within an independent living facility but
is provided on an as-needed basis and can increase less intense than what is offered within a skilled
as health declines and need for support increases. nursing facility. An independent living facility
Residents have access to a 24-h emergency call offers fewer services and is considered the rst
system typically near their bed, in the bathroom, step in the spectrum of care for elder adults. Inde-
and sometimes even around their neck on a neck- pendent living is sometimes referred to as a retire-
lace (Howe 2014). Overall, the philosophy of ment community in which adults are generally in
service within ALFs is to increase residents inde- good health and require minimal supervision.
pendence and dignity while emphasizing exible, Residents are responsible for taking their own
individualized supportive services and health care medication and setting up doctors appointments,
(Allen 2004). as well as requesting extra assistance when
Assisted Living 311
needed. These facilities offer smaller condomin- Safety

iums and apartments as housing options to reduce
housekeeping tasks for residents when Since many residents have physical and/or mental A
transitioning from their larger homes. Many disabilities that prevent them from living indepen-
older adults are drawn to independent living facil- dently, safety is an increased concern within
ities for the sense of community and activities AFLs. Older adults are at a higher risk of falling
offered to maintain stimulation and enjoyment in due to increased fragility and decreased sensory
life. Safety is always taken into account with well- perception (Chang et al. 2004). In order to create
lit walkways to reduce falling and emergency call an adequately safe environment for disabled
systems to quickly alert the staff if assistance is elders, many AFLs are designed to accommodate
needed. The staff typically keeps note of resi- the specic needs of the residents. For instance,
dents health status in order to consider when facilities have wide hallways to t wheelchairs
health decline is signicant enough to require and well-lit sturdy handrails for assistance with
increased assistance or a transition into assisted walking. All bathrooms and walkways throughout
living (Howe 2014). the building are also handicap accessible. Bed-
When health declines to the extent that a resi- rooms are typically equipped with a call cord or
dent needs more support than is offered in an ALF, switch so that patients can have immediate contact
the resident is typically transitioned to a skilled with nurses in an emergency or if they need imme-
nursing facility. While independent living pro- diate assistance. Additionally, some AFLs pro-
vides less support than in an ALF, skilled nursing vide a pendant or wristband for patients to wear
provides the highest level of intensive services for for easier access to communicate with staff mem-
residents who need more individualized and bers (Howe 2014).
advanced care. Within skilled nursing facilities,
assistance is typically provided by registered
nurses due to the increased care needed by resi- Facility Amenities
dents. On the other hand, the staff members at
ALFs are not required to be registered nurses Assisted living facilities typically provide apart-
and instead are commonly referred to as personal ment style housing to residents in the form of a
care assistants (PCAs). Staff members in ALF are studio, 1-bedroom, or 2-bedroom. Units also typ-
mostly responsible for assistance with ADLs ically include a kitchenette and a private bath-
rather than trained to provide advanced medical room. Residents tend to either live alone or with
care. A registered nurse typically acts as the med- their spouse or partner. Some single residents may
ical director in ALFs to supervise the PCAs and choose to live in a unit with another resident for
the residents medical needs. While PCAs assist companionship (Howe 2014). The ample space
residents in an ALF on an as-needed basis with allows residents to create a homelike environment
ADLs, skilled nursing facilities provide services and incorporate their belongings to maintain their
for individuals who have signicant difculty individuality within the facility.
completing daily activities and require 24-h assis- In addition to the individual units, ALFs also
tance (Howe 2014). provide many common spaces throughout the
Assisted living can be an attractive and more building to facilitate a community atmosphere
affordable intermediate option between indepen- for the residents. Such spaces include living
dent living and skilled nursing. ALFs are best rooms, meeting spaces/multipurpose rooms, din-
designed for individuals who do not yet need a ing halls, and patio areas for socializing and
high level of intensive care but can benet from events. Many assisted living facilities also have
assistance with ADLs and medication manage- amenities on-site that are shared by residents such
ment. Many residents may transition from one as central laundry, hair and nail salons, movie
level of care to another as they age, their health theaters, convenient stores, and restaurant dining.
declines, and need for assistance becomes greater. These additional conveniences and luxuries create
312 Assisted Living
a comfortable living environment for the older of depression and further lowering food intake.
residents. Additionally, studies have shown that people tend
To further create a comfortable atmosphere to eat more when sharing a meal with others than
within the assisted living facilities, many also when eating alone (Edwards and Hartwell 2004).
provide a calendar of events and outings to engage Therefore, the psychological aspects of the eating
residents and keep them active. For instance, environment have been suggested to play a large
transportation services are provided for off-site role in increasing residents nutritional intake and
needs such as grocery shopping, pharmacy visits, thus increasing quality of life. Overall, the dining
shopping, and doctors appointments. Addition- experience provided within AFLs is meant to
ally, transportation is also provided for off-site create a comfortable homelike environment for
recreational activities such as museums visits, residents to mimic distinctive patterns of family
food tastings, and farmer markets. Such activities life. Creating an environment that encourages and
and entertainment are also planned at the facility enables residents to eat together induces feelings
to promote socialization among resident and to of togetherness, security, and happiness
increase quality of life. Such events include (Mahadevan et al. 2014).
guest speakers, musicians, performances, arts
and crafts, and movie nights (Howe 2014). Some
ALFs may also offer a reminiscing group in Choosing the Right ALF
which residents are encouraged to discuss and
recall pleasant memories from their pasts (Howe In order to choose a high quality t between a
2014). Not only does recalling pleasant memories resident and a facility, there are many components
increase mood but doing so can also have cogni- that must be taken into account. Finding a strong
tive benets for older adults by exercising their match is essential to ensure the resident feels
memory (Brody and Semel 2006). These activities comfortable and is satised with their environ-
promote engagement among residents to encour- ment to feel at home. There must be a balance
age them to get out of their rooms and socialize between the residents proles, their needs, and
with others. preferences with the staff and services offered at
an ALF. For instance, some residents may prefer a
smaller-scale ALF with a quiet and calm living
Importance of Dining Experience environment, while others seek a hustle and bus-
tle environment that provides many activities to
A critical component of ALFs that contributes to encourage engagement. When all of these compo-
the quality of life of the residents is the dining hall nents are taken into account, it becomes quickly
for communal meals. Many ALFs provide all apparent that a one-size-ts-all mentality is
meals for residents in buffet style or restaurant inadequate when choosing the right ALF for
style dining areas. Therefore, the facilities must each individual (Morgan 2012).
provide quality food to meet the nutritional needs There are a variety of ways in which residents
of elder adults. This older population commonly determine the quality of an ALF. First, quality is
has deciencies in nutritional intake due to not an abstract concept but comprised of specic
decreased appetite and thus a reduction in food components that are valued by the resident. Indi-
consumption. Additionally, reduced food intake viduals move into ALFs coming from specic
also commonly occurs due to limited food options backgrounds, familial lifestyles, and cultures that
in some ALFs. Eating meals in a designated din- drive their preferences for their new home. These
ing area within the ALF encourages residents to preferences may or may not coincide with the
be more active and social within an otherwise specic brand advertised by the ALF and thus
inactive lifestyle. Without a communal dining make the qualities of an ALF distinctly positive or
area, residents are more likely to eat alone, negative to individuals. Second, the perceived
increasing their isolation, thus creating feelings quality of an ALF may also change over time for
Assisted Living 313
an individual depending on their specic needs. enhances older adults independence, as they no
For instance, the quality of an ALF may be more longer feel like a burden to their family mem-
dependent on the quality of life or the quality of bers. They may also have the opportunity to do A
health care services depending on the needs of a more activities with the aid of transportation and
resident. In a nursing home, the answer may be staff members. However, some residents have
clearer that the quality of health care is more concerns of limited autonomy due to the rules
essential considering the increased need for assis- and regulations of ALFs. Therefore, many facili-
tance from the patients; however, in an ALF, this ties must strike a balance between preserving the
distinction is less clear and likely a combination of autonomy of residents while ensuring that they
both quality of life and quality of health care due are safe.
to the mixed needs of residents. Therefore, ALFs With the added care of staff members within an
experience a challenge to ensure the highest qual- ALF, some privacy must be compromised to pre-
ity considering that the needs and preferences of serve the safety of residents. For instance, staff
residents are broad and ever changing (Morgan members must have access to residents rooms to
2012). enter freely in case of an emergency. Therefore,
The third way to determine the quality of an residents need to adjust to this limited privacy
ALF extends beyond the building and staff mem- that was not present in their personal homes
bers but to consider the additional characteristics before moving to an ALF. They may also have
of the facility that make it unique. For instance, limited freedoms on how to decorate or furnish
the quality of an ALF should also encompass their rooms in order to minimize clutter and
location, culture of the community, staff manage- reduce the likelihood of falling. Minimal clutter
ment, and provided activities. The combination of also increases the staffs ability to easily move
these additional qualities creates an idiosyncratic about the room to provide services within the
community that may feel like home to some private quarters.
but not others. Therefore, some residents may be Residents also must adjust to decreased auton-
particularly attracted to certain ALFs that best t omy in their ability to come and go from the
their needs and preferences. Lastly, the reference facility. Many ALFs request that residents sign
point of the individual judging the ALF can out and inform the staff when they leave the
drastically affect how the quality of an ALF is grounds. Due to the frequency of confused elders
determined. For instance, the resident compared to wander, it is important that the staff keeps track
to the residents adult child may evaluate the of the residents whereabouts. Additionally,
quality differently. These perspectives can also declining memory might also cause older adults
change when touring the facility versus to get lost easily and not be able to nd their way
when residing in the facility. Therefore, when back to the facility. While this limitation can be
accounting for the priorities of the person evalu- frustrating for older adults who are accustomed to
ating the quality of an ALF, the ways in which coming and going as they please, these rules and
quality is determined can drastically vary regulations are put in place to maintain the safety
(Morgan 2012). of residents. Some ALFs do attempt to curb lim-
itations for individuals depending on the level of
their required supervision based on their degree of
Autonomy in an ALF cognitive impairment. However, this aspiration
becomes an ongoing challenge as cognitive abil-
Choosing to move to an ALF can be a difcult ities are always changing and at different rates.
decision for both the individual and their family. Therefore, since such a large proportion of people
Most facilities do its best to create an environment in ALFs do have some degree of cognitive impair-
that is homey and comfortable with the core value ment, many residents must accept these limita-
to preserve as much autonomy as possible for tions as default despite varying levels in ability
residents. For some, merely moving into an ALF (Morgan 2012).
314 Assisted Living
Maintaining Well-Being Residents are provided with private rooms and

assistance with activities of daily living (ADLs).
Overall, adjusting to life in an ALF can be difcult Activities and shared common rooms promote
for some adults and affect their well-being during socialization and engagement in the community
the transition. Research suggests that the best way to increase their quality of life. Additionally, shared
to maintain well-being during this transition is to dining areas encourage residents to leave their pri-
establish a sense of home at the ALF to increase vate rooms to meet other residents. Although lim-
feelings of belongingness and comfort (Cutchin itations are put in place to prioritize safety, ALFs
et al. 2003). There are many ways in which this attempt to create a homelike environment that
feeling can be achieved, such as through auton- maintains the autonomy and dignity of residents.
omy. Although some autonomy is limited as pre-
viously discussed, other types of autonomy
should be purposefully persevered in order to
Cross-References
increase the feeling that the ALF is home for
residents. For example, the freedom to decorate
Comorbidity
ones room and bring personal belonging is an
Small-Scale Homelike Care in Nursing Homes
essential component during the transition to an
ALF that help makes the new facility feel like
home. Additionally, the freedom to maintain the References
same level of contact with family and friends also
contributes to a smooth transition. Maintaining Allen, J. E. (2004). Assisted living administration: The
knowledge base. New York: Springer.
well-being during the transition can also be Brodie, M., & Blendon, R. (2001). National survey on
achieved through developing close social rela- nursing homes. Menlo Park: Kaiser Family
tionships with other residents within the ALF. This Foundation.
can be done through the shared dining spaces and Brody, C., & Semel, V. (2006). Strategies for therapy with
the elderly: Living with hope and meaning. New York:
variety of activities offered at the facility. When Springer.
residents become involved in their new environ- Chang, J. T., Morton, S. C., Rubenstein, L. Z., Mojica,
ment and participate in the events, they are able to W. A., Maglione, M., Suttorp, M. J., . . . Shekelle, P. G.
meet others and form relationships. Creating these (2004). Interventions for the prevention of falls in older
adults: Systematic review and meta-analysis of ran-
relationships is an essential component of feeling domized clinical trials. BMJ, 328(7441), 680.
secure and can generate feelings of belonging to a Cutchin, M. P., Owen, S. V., & Chang, P. J. (2003).
new community. Other essential components to Becoming at home in assisted living residences:
maintain well-being during the transition to an Exploring place integration processes. The Journals of
ALF is having mutual respect with the staff mem- Social Sciences, 58B(4), S234S243.
bers and developing a sense of security within the Edwards, J., & Hartwell, H. (2004). A comparison of
facility. When residents can successfully adjust to energy intake between eating positions in a NHS
life in an ALF, they are able to feel comforted with hospital A pilot study. Appetite, 43, 323325.
Grabowski, D. C., Stevenson, D. G., & Cornell, P. Y.
the amenities and services offered to improve their (2012). Assisted living expansion and the market for
quality of life (Cutchin et al. 2003; Hammer 1999). nursing home care. Health Services Research, 47(6),
22962315.
Hammer, R. M. (1999). The lived experience of being at
home: A phenomenological investigation. Journal of
Summary Gerontological Nursing, 25, 1018.
Howe, B. L. (2014). The gerontology nurses guide to
In summary, assisted living facilities (ALFs) are a the community-based health network. New York:
desirable option for intermediate care during the Springer.
Mahadevan, M., Hartwell, H. J., Feldman, C. H., Ruzsilla,
aging process. Facilities offer individualized assis- J. A., & Raines, E. R. (2014). Assisted-living elderly
tance for residents with a variety of ailments and the mealtime experience. Journal of Human Nutri-
including physical, mental, and health limitations. tion and Dietetics, 27(2), 152161.
Attitudes and Self-Perceptions of Aging 315
Morgan, L. A. (2012). Quality assisted living: Informing attitudes and information about the attitude object,
practice through research. New York: Springer. which they then appraise within their own belief
Zimmerman, S., Sloane, P. D., & Eckert, J. K. (2001).
Assisted living: Needs, practices, and policies in resi- systems (and those held within society and salient A
dential care for the elderly. Baltimore: Johns Hopkins in-groups) to form and update their own opinions
University Press. and attitudes.
Second, attitudes are predispositions. Attitudes
are inclinations and tendencies for action; thus, an
attitude and its direction contain motivational
Attitudes and Self-Perceptions of qualities. If the attitude is such that the salience
Aging towards the attitude object is high and the object is
encountered, then be it negative or positive, as
Paul Nash long as the conative response is satised, an indi-
Centre for Innovative Ageing, Swansea vidual will act upon his or her held beliefs. How-
University, Wales, UK ever, this is a predisposition and the association
with behavior is not a causal one.
Third, attitudes are consistent. This does not
Synonyms mean that attitudes cannot be changed
(as discussed later), just that they have a consis-
Ageism; Discrimination; Internalized ageism; tency in expression and measurement over time
Prejudice; Stereotypes and across contexts. The way in which the atti-
tudes are expressed may however change,
depending on the social situation and on the per-
Definition vasive attitudes of any salient others in the same
social setting.
An attitude may be dened as an internal affective There are two subsets of the overarching atti-
orientation explaining an individuals action tude: these are those of the implicit and explicit.
(Reber 1995). They comprise four components: Implicit attitudes are introspectively unidentied
cognitive, affective, evaluative, and conative. The (or inaccurately identied) traces of past experi-
cognitive component refers to the opinions or ence that mediate favourable or unfavourable feel-
schema held about an object. The affective coming, thought or action toward social objects.
ponent refers to the emotion or salience towards Conversely, explicit attitudes are dened as con-
the attitude object. The evaluative component sciously expressed actions, thoughts or feelings
refers to the direction of the feeling, whether the under the performers control (Greenwald and
object evokes a positive or negative emotion. Banaji 1995). Research has further demonstrated
Finally, the conative component of the attitude is that implicit attitudes are stable and enduring,
the disposition for action (Maio et al. 2000). It is allowing prediction of spontaneous behavior
the combination of these components that deter- after exposure to unexpected stimuli. Research
mines the attitude held by an individual. has also shown that explicit attitudes are less
enduring and more malleable and predict only
planned behavior (Perugini 2005). It is widely
Attitudes: Explicit and Implicit understood that because the two attitude types
predict behavior at different times, they may in
There are several characteristics that dene an fact be manifestations of a single root attitude.
attitude within the 4-tier framework. First, an atti- Where explicit attitudes are consciously
tude is learned. Attitudes can be learned in many expressed by the performer, implicit attitudes
ways, the most prominent being personal experi- reveal information which is not available to the
ence, observation of salient others, and societal individual through introspection however moti-
inuence. Each method exposes the individual to vated or able a person. A prime example of this
316 Attitudes and Self-Perceptions of Aging
is ageism. Where individuals genuinely believe Allport (1954) identied some key ways in
they are not ageist and outwardly express which stereotypes were formed simply through
accepting explicit attitudes, they may harbor neg- the way in which we are raised within our cul-
ative implicit attitudes based on subtle reinforce- ture and environment. Family socialization and
ment from their social interactions and exposure to images in books, television, and
environments. newspapers were highlighted as key contribut-
ing sources for potential prejudicial stereotypes.
Obviously in todays world, the Internet and
Formation of Attitudes seemingly barrier-less technology all feed into
the process of stereotype formation. Further to
There are several theories of attitude formation, this, it has also been shown that stereotypes can
but two have become prominent. These are the be formed from a cognitive bias, resulting in a
summation (Fishbein and Ajzen 1974) and aver- perception-based correlation between minority
aged (Anderson 1971) models. The summation groups and infrequently occurring attributes.
approach argues that an attitude is the sum of The reason for this being adopted as a stereo-
evaluations associated with salient outcomes of typical attribute of the minority group is due to
observed behaviors. Thus, the attitude (either both a categorical distinctiveness process,
positive or negative) is the result of the total enhancing the similarities to the group an indi-
exposure to an attitude object or target. Using vidual belongs while simultaneously maximiz-
this approach, an attitude can be equally strong if ing the differences with the minority other
the salience and outcome are high but observed (increasing the in-group/out-group difference),
infrequently or if the salience and outcome are and the distinctiveness of the attribute
low but the frequency of observation is high. occurring.
In contrast, the averaged model proposes that Unlike other prejudices, ageist attitudes are
attitudes are subject to a process of normalization. still openly prevalent in society. In television com-
Thus, the attitude is formed from the average edies, elderly people are depicted, dened by ste-
evaluations of the attributes associated with an reotyped negativities regarding physical decline
attitude object. Rather than the summation theory and both physical and mental incompetency.
that simply adds together all of the experiences, When the age stereotypes have been acquired,
this theory posits that the direction of the they will be easily activated by the presence of
attitude is a reasoned average based on evalua- an elderly person, resulting in the generalization
tions from each exposure. This theory, unlike the of the stereotyped schema to elderly people. Once
summation approach, would incorporate outlier acquired, these attitudes are maintained and
responses or opinions and dilute them into the strengthened when encountering elderly people
previously held knowledge about a certain atti- even if they do not exhibit characteristics associ-
tude object. ated with the stereotypes held.
In a review, Betsch et al. (2004) argue that both
models are only applicable in certain circum-
stances, and an integrated model is more appro- Population Attitudes Towards Older
priate. This is called the value-account model, Adults
which argues that implicit attitudes are formed
by summation and explicit attitudes by the aver- Although attitudes are central to the formation of
aged procedure. The model also takes into con- prejudicial thoughts and ultimately treatment, it is
sideration the four components of attitudes, arguably the stereotypes derived from attitudes
explaining the salience and motivational aspects that are the key factor in shaping behavior.
of attitudes while centering on the cognitive eval- Research highlights role incongruity as the basis
uations made by the individual and their aware- for prejudicial behavior. It is proposed that preju-
ness of the process. dice itself derives from the dissonance between
beliefs about the stereotyped attributes associated out further information. It is in the absence of
with a group and the beliefs about the attributes additional information that we apply these stereo-
that allow success in valued social roles. types; however hesitantly we may do this. It has A
Aging prejudice, in a similar manner to that of an been shown that the use of stereotypes (especially
attitude, can be broken into component parts: cogni- gender) affects peoples judgments even when
tive, affective, and conative. Cognitive prejudice additional information is presented about the indi-
refers to the belief that an individual holds about an vidual character of the person being judged. Peo-
older person and that a certain opinion or attitude is ple tend to use (age) schemata as a platform on
correct and true. Affective prejudice describes what which to base their assumptions of an older per-
stereotyped characteristics of older people the indi- son. However, rather than seeking information
vidual likes or dislikes. Conative prejudice is similar generally about the person, information is sought
to the conative component of attitude, in that it refers to conrm the stereotype, rather than to cast doubt
to the propensity of the individual to act on their on it. There is still the ability, however, for indi-
ageist prejudice. It is the inclination or predisposition viduals to search for information to contradict the
and direction of action that are aimed to measure ageist preconceptions. Stereotypes, as with other
when assessing the attitudes held by an individual. heuristic techniques, allow for increased
It is fundamental for people to categorize and processing capacity of other information
create stereotypes due to the size and complexity of presented simultaneously. Linked to this, it has
the daily information processed. Stereotypes are also to be considered that stereotype use will
the belief that members of the same group indeed also increase if people are cognitively or emotion-
also share a certain attribute, for example, all old ally preoccupied with other concerns. In elds
people are frail or all old people are wise. This such as medicine where workloads are high,
assumption arises directly from the categorization hours are long, and stressors are ever present,
process through the assimilation of in-group differ- questions should be posed regarding the underly-
ences and as such the promotion of out-group ing stereotypes activated. If not, there is potential
homogeneity. One outcome of this categorization for this to lead to misdiagnosis (Duerson
process is the accentuation of intergroup differ- et al. 1992) or refusal to treat (Filipp and Schmitt
ences and the reduction of intragroup differences, 1995).
both of which affect evaluation of the out-group When these negative attitudes have been inter-
and intergroup perceptions, attitudes, and behavior. nalized and become implicit, the attitude holder
Within ageism, this is essentially maximizing the may indeed no longer be immediately aware that
differences between younger people (the group to they hold these attitudes. It is with the lack of
which you belong) and older people (the conscious awareness that the negative attitude
out-group), ascribing negative characteristics to now becomes the basis for unplanned responses
the group you do not belong. to the attitude target. This phenomenon can be
Levy and Banaji (2002) conducted a review on observed with ageism in that the explicit bias is
implicit ageism, illustrating a pervasive and wide- not expressed; however, behavior and language
reaching proliferation of negative ageist attitudes. used precipitate the negative stereotypes assimi-
This is not something conned to one social or lated. This has been highlighted as a more dan-
ethnic grouping but prevalent across the gamut of gerous form of prejudice as even those outwardly
society, resulting in a range of consequences for expressing the best of intentions have difculty
both older people and society at large. trying to avoid negative responses that are gener-
ated by implicit processes.
Despite prejudice often being largely irratio-
Impacts of Negative Aging Attitudes nal, with regard to older people, some of the
prejudice can be based on biological and observ-
Stereotypes are not applied indiscriminately but able declines. There are both physical and psy-
rather used to create a platform from which to seek chological losses associated with aging, a fact that
is universally accepted. The problem with aging is anxiety among those who hold these negative
that societally it is seen as being simultaneously a stereotypes.
time of wisdom and a time of physical and cogni- When addressing the prevalence of all forms of
tive decline. Looked at more closely, what is being ageism, it becomes clear that it now surpasses
said is that people believe older adults are wiser those of sexism and racism (Kite and Wagner
and more knowledgeable but that they are slower 2002), although it is typically harder to measure
and less efcient in dealing with the new and/or due to the implicit ways it is conducted. Ageism is
when they have to think on their feet. Ageism prominent in advertising, media, and comedy and
appears to have a base in physiological and psy- in the way in which older people are generally
chological fact; however, little or no account is viewed. It is due to this prominence that accep-
taken of the compensation method adopted by tance surrounding ageism has occurred. It is often
older people to minimize the effects of seen as humorous, and based on some degree of
age-related loss. Similarly little importance is fact, this negating any negative effects or out-
placed on the positive aspects of aging which are comes. Due to the humorous nature of ageism,
equally integral to an older person but counter the the negative effects on the older person (self-
existing accepted heuristics and as such are often esteem, disablement, self-isolation) are generally
overlooked or cast aside. From these disparate ignored by the wider public. A problem arises,
viewpoints, a legitimate question arises in however, when trying to measure the colloqui-
whether the objective views of aging (which are ally clear prevalence. On explicit measures, peo-
generally negative) are therefore likely to cue ple will present themselves in what they see as the
negative attitudes in those who work directly or most socially acceptable light. Because of this self-
indirectly with older adults. presentational bias, the explicit measure of ageism
Common forms of modern ageism include (unless very subtle) does not truly capture the full
devaluing the contributions made by older people extent of ageism.
and viewing the pathologic processes sometimes This negative approach is also ever present
associated with later life as normal components of even within the healthcare settings where older
the aging process. Angus and Reeve (2006) have adults are at their most vulnerable. Research indi-
further identied that this socially ingrained age- cates that the care of these older adults may indeed
ism actively promotes stereotypes of social isola- be less than that given to a younger person. Atti-
tion, physical and cognitive decline, lack of tudes held by staff can affect the treatment
physical activity, and economic burden. received and the way in which elderly people are
Gerontophobia is a narrower band of ageism that treated. This has been demonstrated where older
specically refers to a phobia of older people. people were not receiving the same diagnosis
Lynch (2000) identied aging anxiety as a major based on the same symptoms as younger people
component of gerontophobia and more widely where the only differentiating feature was that of
ageism, explaining this as the combination of the patients age (James and Haley 1995). Simi-
peoples concerns or fears about getting larly, research has highlighted that in some
older. These fears are based on concerns over instances, medical professionals were refraining
loss of social contact, reduction in cognitive abil- from treating patients with mental impairments
ity, changes in physical appearance, declines in because due to their age the conditions were con-
overall health, and nancial hardships that are sidered irreversible (Filipp and Schmitt 1995).
themselves stereotyped characteristics of the This is not something as an artifact of previous
aging process. In addition to these somewhat generations as medical student scores on ageism
irrational fears, it is the knowledge that measures were no better than those reported in the
simply by living life we will become a member general population, and no real increase in accep-
of this out-group, a process and transition whose tance was measured from pre- to post-educational
path cannot be altered or avoided. The inevitabil- training. It can be concluded that this was a reec-
ity of the transition itself is stressful and causes tion on the lack of specic geriatric training. It has
been suggested that in order to improve this There are negative consequences for elderly
knowledge and sensitize students in health people as a result of the ageist attitudes held as
professions to the growing needs of the older they are not only subjected to ageist prejudices A
population, they require more specic from others but also internalize these implicit
gerontological training, not simply training that biases. As people progress through the life span,
focuses on the losses associated with aging. It is their age schema becomes more elaborate as more
further posited that this training should include information both about others and themselves
direct contact with older people and patients as becomes incorporated. As they age, the number
this would help student clinicians improve their of traits, categories, and subcategories they have
perceptions. within the schema grows; however, core elements
are still retained. Research supports this develop-
mental approach, nding that despite having a
Self-Perceptions of Aging more complex picture of aging, older people do
not necessarily hold more positive views. Some
A racist will never change skin color, a misogynist research has suggested that older people judge
will never change sex, but an ageist person will their age category more favorably than younger
become that which they hate should they live long people, but both groups have generally negative
enough. As such, every person should be con- attitudes towards older age. Levy (1996) found
scious of the fact that if discrimination against that elderly people who exhibited higher negative
older people is tolerated, one day it could be implicit attitudes also performed signicantly
directed towards them. This internalization of worse on memory tasks. Further, it was identied
negative concepts and the experience of prejudi- that the perceptions of older adults could also be
cial behavior cause issues around self-esteem and affected by implicit self-stereotyping. It is now
well-being in older adults, as well as resulting in largely accepted that implicit age stereotypes can
costs to both the individual and the wider society inuence the views of older adults both towards
at large. others and upon themselves. In addition to mem-
The practice of discrimination has been shown ory tasks it is established that when older adults
to cause lowered self-efcacy, decreased produc- adopt these societal stereotypes, they see decline
tivity, and cardiovascular stress (Levy et al. 2000). as inevitable and becoming a less active member
This is costly to individuals and, in workers, to the of society as the only option. Similarly, when
company they work for as these symptoms lead to adopted, these stereotypes became a self-fullling
decreased productivity and may lead to the per- prophecy, reinforcing stereotypes through the
petuation of ageist attitudes. Especially in the inaction and decits resulting from their initial
workplace, research has demonstrated a clear belief and internalization.
link between perceived credibility of older adults
and ageist attitudes.
Despite there being apparently equal amounts Challenging Negative Perceptions
of positive and negative stereotypes pertaining to
older people, the pervasive attitudes present in Weakly held and less salient attitudes are easier to
research suggest higher negative attitudes than change than strongly held attitudes, and as such,
positive ones. These ndings were not only in stronger attitudes are developed in areas that an
the young. Negative implicit ageist attitudes are individual (or in-group to which they belong)
held by older people themselves (Levy and Banaji considers to be of higher salience. These strongly
2002). The reasoning given for this is that elderly held attitudes can be either positive or negative
people have acquired the same implicit prejudices but are usually polar. In areas of limited or ques-
throughout their lives and have not had sufcient tionable importance, attitudes tend to be weakly
time or opportunity to develop the mechanisms to held, ambivalent, or neutral which means that they
defend against this. are more susceptible to change. Challenging these
negative attitudes also proves harder for ageism Each of the attitudinal modication strategies
than other forms of prejudice due to the underly- can be used in an educational setting to impart
ing nature of the attitude and the duration of time knowledge and cause disequilibrium in the cur-
over which they are formed and reinforced. rent schema held to force a reassessment of
Stereotypes can be changed through the preexisting attributes and evaluations to modify the
sentation of contradictory information, but how existing ageist attitude. This has been shown to be
that information is presented (concentrated exam- effective to differing levels across the globe. It has
ples or sporadic) and the affective nature (positive been shown that these attitudes (implicit and
or negative) of the stereotype undergoing change explicit) can be altered in the favor of older peo-
are integral factors to the extent and level of suc- ple. Westmoreland et al. (2009) demonstrated that
cess of the modication. A growing body of through a well-structured education based on the
research has shown that contact between groups psychological principles above, attitudes towards
can alter stereotypes and reduce prejudice, pro- older people can be changed. It is in the utilization
vided that it takes place under certain conditions. of these strategies in the training of medical pro-
Prestwich et al. (2008) demonstrated that in fessionals and people involved in the care of older
terms of racist attitudes, exposure to the target people that the pervasive negative attitudes can be
group did indeed alter the attitudes held. The challenged. In challenging these stereotypes and
quantity of the contact improved an individuals commonly held misconceptions, the inequalities
implicit attitude, and the quality of the said contact in care can also be addressed, and on a societal
affected the explicitly expressed attitudes. This has level, we can look to challenge the internalization
also been shown to be the case more specically in of the said implicit and explicit ageist attitudes.
the eld of aging. With an intergenerational study,
Tam et al. (2006) illustrated the same pattern of
implicit and explicit attitude change based on qual-
ity and quantity of contact. Cross-References
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planned quality exposure and contact time. Aging and Quality of Life
Research has demonstrated that even when Social Cognition and Aging
encountering contradictory evidence, attitudes Stereotype Threat and Aging in the Workplace
towards older people were resistant to change
and in most cases did not alter. As with most
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attitudes towards older patients through a council of The study has maintained a multidisciplinary
elders and reective writing experience. Journal of the biopsychosocial emphasis throughout, with a
American Geriatrics Society, 57, 315320. broad focus on how economic, environmental,
322 Australian Longitudinal Study of Aging (ALSA)
biomedical, behavioral, and social factors relate to with the ALSA sample showing some advantages
aging. More specic aims of the ALSA were in education, health, and cognition consistent with
concerned with (i) assessing changes in health patterns of sample selectivity typically observed
and functional status over time, (ii) identifying in cohort studies (Luszcz et al. 2014).
risk factors for chronic diseases and normative ALSA participants have provided data on up to
aging-related changes, (iii) assessing effects of 13 occasions across several modes of assessment,
disease processes and lifestyle on functioning over a 20-year period. Much of the key ALSA
and aged care service use, and (iv) examining content has been obtained through face-to-face
predictors of mortality. Following an extensive structured household interviews with participants,
pilot, the ALSA Wave 1 (baseline) assessment conducted at the major waves in 1992 (Wave
commenced in 1992. 1, n = 2,087), 1994 (Wave 3, n = 1,679), 2000
(Wave 6, n = 791), 2003 (Wave 7, n = 487),
2007 (Wave 9, n = 213), 2010 (Wave
Participants and Procedures 11, n = 168), and 2013 (Wave 12, n = 111).
Unequal time intervals between the major assess-
ALSA participants consist of a population-based ments reect changes in the levels of funding
cohort of adults aged 70 and older at baseline, available over the study interval. Shorter inter-
who resided in the Adelaide Statistical Division views focusing on major life events since the
in 1992. The South Australian Electoral Roll was previous wave were conducted at additional
used as a sampling frame (voting is compulsory waves (Waves 2, 4, 5, and 8 by telephone and
for Australian citizens with some rare exceptions) Waves 10 and 13 face to face). At the major
with the sample stratied by age group (7074, waves, participants also undertook clinical assess-
7579, 8084, 85 and older), sex, and local gov- ments and completed leave-behind
ernment area. Older adults living in the commu- questionnaires.
nity and in residential care were eligible to
participate. Prospective participants were sent let-
ters of introduction and invitations to participate. Measures
After exclusion of ineligible participants
(e.g., those deceased, not contactable, out of geo- Details of the various measures included in the
graphical scope), a total of 1,477 of 2,703 eligible ALSA are available in Luszcz et al. (2014) and
persons (a response fraction of 54.6%) consented from the ALSA website www.inders.edu.au/
to take part in the study. sabs/fcas/alsa/. Face-to-face interviews with par-
In addition to the 1,477 primary respondents, ticipants were used to assess a range of character-
spouses and other household members were also istics including sociodemographic variables, self-
invited to participate, with the age inclusion crite- reported health, depressive symptoms, hospitali-
rion for spouses relaxed to 65 years. This resulted zation, carer role, activities of daily living, life-
in recruitment of an additional 597 spouses and style activities, social network characteristics,
13 household members, providing a total of exercise, driving, and income.
2,087 individuals in the baseline ALSA sample. The clinical assessments conducted at the
The mean age of the baseline sample was 78.3 major waves included various cognitive tests,
(SD = 6.7), and the sample included similar pro- including measures of memory, processing
portions of men (51%) and women (49%). speed, verbal uency, and vocabulary. Also
Around two-thirds of the sample (65%) was included were anthropometric assessments (e.g.,
partnered, and just over half of participants left height, weight, skinfold thickness), blood pres-
school aged 14 years or younger (55%). Charac- sure, grip strength, and tests of sensory function-
teristics of the ALSA sample in terms of ing (audiometry and visual acuity). Ancillary
sociodemographic characteristics were similar to clinical studies conducted at Waves 1, 3, 9, and
those of older adults residing in the community, 12 tested bone density and obtained fasting blood
samples from which basic hematology measures Social network members can also alleviate stress
and lipid proles have been extracted and through providing support and creating opportu-
20-channel biochemical analysis conducted. nities for the experience of positive emotions A
Domains assessed in the leave-behind ques- (Berkman et al. 2000; Cohen 2004; Thoits
tionnaires included nutrition, oral health, sexual 2011). Remaining socially engaged has also
activity, and psychological variables (control been identied as a potential mechanism for
beliefs, morale, self-esteem, and metamemory). delaying cognitive aging and dementia
Finally, supplementary qualitative interviews (Fratiglioni et al. 2004; Hertzog et al. 2009).
have been conducted with subsets of participants The particular relevance of social relationships
to obtain in-depth information related to sleep, to aging well is reected in a number of ALSA
widowhood, and characteristics that could pro- studies that have examined associations of social
mote late-life resilience. network characteristics with health and well-
being. Social network characteristics were
assessed at baseline using a range of items related
Accessing the ALSA Data to both social network structure (i.e., objective
network characteristics such as size and contact
The ALSA data are held at the Flinders Centre for frequency) and network function (i.e., the extent
Ageing Studies (FCAS) at the Flinders University to which network members provide support). Spe-
of South Australia. The FCAS team welcomes cic items asked about the number of children;
inquiries regarding the use of the data for specic proximity and frequency of personal and tele-
projects. Information on processes for requesting phone contact with children, relatives, and
the data, current collaborations, and additional friends; size of supportive networks; and the
project details are available from the project availability of condants (Giles et al. 2002).
website. A subset of the social network items concerned
with contact with children and condant availabil-
ity has been retained across all waves.
Social Relationships, Health, and Well- Researchers have also used items related to par-
Being: Findings from the ALSA ticipation in socially oriented activities taken from
the Adelaide Activities Prole (Clark and Bond
To date, ALSA-based research has addressed 1995) and available across all major waves to
numerous topics related to late-life health and create composite measures of social activity
well-being, ranging from characteristics of suc- engagement (Isherwood et al. 2012; Kiely
cessful aging to predictors of cognitive decline, et al. 2013).
prevalence of late-life depression, and correlates Several studies based on ALSA have used
of objective and subjective measures of health social network information obtained at baseline
(see Luszcz et al. 2014 for an overview). Because to predict healthy aging outcomes. Giles
a broad review of the ALSA ndings is beyond et al. (2004) used measures representing networks
the scope of this entry, the following section with children, relatives, friends, and condants,
focuses on ALSA ndings related to the specic along with a composite total network measure, to
domain of social relationships. predict disability over the rst six waves of ALSA
Supportive social relationships are recognized (9 years). Results indicated that social networks
as an important resource for health and well-being with relatives (but not friends, children, or con-
over the life span. Social networks are believed to dants) protected against the development of
promote physical and mental health through a mobility disability after controlling for
range of processes including positive social inu- sociodemographic characteristics, self-rated
ence (e.g., encouraging health behaviors or med- health, chronic morbidities, depressive symp-
ication adherence) and reducing negative toms, global cognition, and lifestyle variables
appraisals of potentially stress-provoking events. (smoking, alcohol, and exercise). The authors
speculated that the absence of protective effects Research from ALSA has also revealed asso-
from children and condants could have arisen ciations between social network characteristics
from a particular reliance on these networks dur- and mortality. Giles et al. (2005) examined social
ing times of experienced or anticipated health networks with children, relatives, friends, and
declines negating benecial effects of social sup- condants as predictors of 10-year mortality in
port from these same sources. Giles and col- the ALSA primary sample. Cox proportional haz-
leagues (Giles et al. 2007) used a similar ard models adjusted for a range of
approach to examine associations of social net- sociodemographic, health, and lifestyle variables
work characteristics with the use of residential revealed that total networks, friend networks, and
aged care facilities. The most robust ndings condant networks were associated with
were evident in relation to availability of con- increased survival. This study added to previous
dants. Specically, participants who had more mortality research using general indicators of
people to conde in were less likely to use nursing social support by demonstrating that some net-
homes over 5 waves post-baseline relative to work attributes (friends and condants) may be
those without condants, after adjustment for of greater signicance to longevity than others
health, demographic, and lifestyle characteristics. (children and relatives). In a separate analysis
In contrast, use of lower-level residential care based on the total ALSA sample, Anstey
facilities (e.g., respite care) was not reliably asso- et al. (2002) showed that membership of a social
ciated with different social network group was associated with delayed mortality
characteristics. among women (but not men) over 9 years after
Additional ndings from ALSA indicate that adjustment for age, self-rated health, functional
social network attributes could have implications capacity, and several psychological variables
for cognitive aging. Giles et al. (2012) modeled (perceived control, self-esteem, subjective life
trajectories of memory performance over 15 years expectancy, and life satisfaction).
in a subset of 706 ALSA participants who pro- In addition to projects concerned with the role
vided memory data and were cognitively intact at of social resources in predicting long-term health
baseline. Growth models revealed a linear decline and well-being outcomes, studies using ALSA
in memory over time and a main effect of a com- have also examined how different social network
posite social network variable, whereby partici- attributes are implicated in processes of late-life
pants classied into upper and middle tertiles (i.e., development. Chan et al. (2011) used baseline
indicating larger and more supportive networks) data to examine the extent to which received
showed better memory performance relative to social support from formal sources (e.g., care
those classied into a lower network tertile indi- organizations) and informal sources (e.g., friends
cating smaller, less supportive networks. Rates of and family) moderated the association of disabil-
change in memory did not vary as a function of ity with depressive symptoms. The results indi-
total network characteristics; however, an interac- cated that the association between higher levels of
tion of friend networks with time emerged. The disability and higher levels of depressive symp-
interaction indicated steeper rates of decline in toms was weaker among participants receiving
memory among those with smaller friend net- support from informal sources or support from
works relative to those with larger friend net- both informal and formal sources. Importantly,
works. The ndings are broadly consistent with formal support alone was not protective against
recent perspectives suggesting that social activity depressive symptoms, highlighting the impor-
could help to preserve brain functioning through tance of informal social relationships for
cognitive stimulation (Hertzog et al. 2009); how- maintaining mental health in the context of
ever, it is also possible that reverse causal mech- aging-related declines. Using 16-year longitudi-
anisms are at play whereby declining cognitive nal ALSA data, a recent study by Kiely
abilities result in withdrawal from wider social et al. (2013) examined the role of social engage-
networks (Stoykova et al. 2011). ment in mediating the relationship between losses
in vision and hearing and depressive symptoms. which there was correspondence between hus-
Findings showed that depressive symptoms were bands and wives levels and rates of change in
higher among participants with hearing loss and social activity over 11 years by treating the spou- A
dual sensory loss (impaired hearing and vision) sal couple as the unit of analysis and tting growth
and that rates of increase in depression became curves to simultaneously model change in hus-
steeper after onset of hearing or dual sensory loss. bands and wives. Results indicated correlated
Importantly, associations between sensory loss levels of social activity between husbands and
and depressive symptoms became nonsignicant wives, indicating that husbands activity levels
after adjustment for social engagement. These were more similar to those of their wives (and
ndings support the possibility of a specic causal vice versa) than they were to those of unrelated
process underlying increases in depressive symp- spouses in the sample. More activities among
toms in late life, whereby sensory losses result in wives were also associated with steeper decline
decreasing social engagement which in turn in activities among husbands. Additional analyses
results in increased experience of depressive including a measure of perceptual speed also
symptoms. revealed a positive association of levels of it for
Whereas Kiely et al. (2013) focused on the role husbands and wives again suggesting interrelated
of social engagement as a mediator, Isherwood development; however, the association was
et al. (2012) treated social engagement as an out- weaker than the corresponding association
come variable, examining the extent to which between husbands and wives social activity
becoming widowed was associated with longitu- levels.
dinal changes in social engagement over 16 years. Additional studies have examined the interre-
Changes in levels of contact with children were lated development of spouses by using contempo-
also examined. Results showed a rise in social rary, dynamic longitudinal methods to examine
engagement over the transition to widowhood, gender asymmetries in the ways in which the
indicating that the loss of a spouse could characteristics of one spouse appear to affect the
prompt broader compensatory network engage- corresponding characteristics of the other over
ment. This nding was consistent with several time. Gerstorf et al. (2009) used bivariate dual
previous studies that have examined changes in change score models to examine time-lagged
social contact following widowhood. The amount spousal interrelations in older couples cognitive
of face-to-face contact with children was test performance. The results indicated that hus-
similar for those who were widowed and those bands perceptual speed reliably and positively
who were not; however, being widowed was asso- predicted wives perceptual speed at subsequent
ciated with more frequent telephone contact with assessments. However, the models did not pro-
children. vide support for the opposite unidirectional effect
One of the unique strengths of ALSA is the of wives perceptual speed predicting husbands
availability of data from a subset of 597 spousal subsequent perceptual speed or for a bidirectional
couples. The spousal dyad represents a central association between husbands and wives speed
social context for aging and development, with performance. A similar pattern was evident in
husbands and wives who remain together over an models used to analyze memory performance,
extended period of time developing a long shared although the unidirectional effect was not as
history of joint experiences and often developing strong and was no longer statistically reliable
effective collaborative methods of coping with after adjustment for functional limitations. The
aging-related losses (Berg and Upchurch 2007; authors speculate that cognitively t husbands
Hoppmann and Gerstorf 2009). Researchers may afford more opportunities for their wives to
have used data from the ALSA couples to exam- maintain broad engagement in intellectually
ine spousal interrelationships in social activity, enriching activities, whereas cognitively chal-
cognition, and well-being (morale) over time. lenged husbands may require a lifestyle with
Hoppmann et al. (2008) examined the extent to wives restricted to less cognitively stimulating
home and caring duties as one possible explana- relations using the ALSA data. One promising
tion for the observed gender differences. avenue concerns the use of prole-based methods
Walker et al. (2011) applied a similar analytical to studying social networks. Approaches of this
approach using dynamic models with 11-year type use statistical methods to identify subtypes of
ALSA data, to examine spousal interrelations in participants characterized by different combina-
morale. The ndings showed an opposite pattern tions of social network characteristics (e.g., Fiori
of gender effects to the one reported by Gerstorf et al. 2006). Previous studies have typically iden-
et al. (2009) in relation to cognitive changes, with tied diverse (i.e., extensive networks), family-
wives morale scores related to subsequent focused, friend-focused, or restricted (i.e., few
changes in husbands morale. Specically, hus- social ties) networks. Extending this approach to
bands whose wives reported higher initial morale ALSA could be used to identify similar network
showed shallower decline in morale over time proles, and to examine changes in prole mem-
relative to husbands whose wives reported lower bership over time, or the extent to which
initial morale. Converse patterns of husbands multidimensional network characteristics are
predicting wives morale were not evident. related to trajectories of change in health, cogni-
Taken together, the various ndings related to tion, and well-being. The spousal dyad data might
social networks and aging that have arisen from also be used with a reorientation to focus on
the ALSA support the importance of social con- differences, rather than similarities between
text in inuencing critical aspects of development spouses on key variables. Gerstorf et al. (2013)
in older adulthood. The existing studies indicate recently demonstrated that despite husbands and
that specic aspects of social networks are differ- wives being more similar to each other in mental
entially related to health, well-being, mortality, health than they are to unrelated others (as is
and cognition. Informal social networks may be typically demonstrated when taking a between-
a key resource for coping with disability, and it couple focus), considerable differences between
may be losses in social engagement that account husbands and wives (and sizeable heterogeneity
for links between declines in sensory capacities in these differences) are evident when taking a
and depressive symptoms. Finally, older couples within-couple perspective. Considering whether
develop in interrelated ways, with gender differ- husbands and wives who are more or less similar
ences apparent in the extent to which husbands to each other on key variables adapt more or less
and wives inuence different aspects of each effectively to aging-related changes could repre-
others psychosocial functioning. sent a fruitful avenue for future examination of
social relations and aging well using the ALSA.
Social Relations in the ALSA: Future

Directions
Cross-References
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active and socially integrated lifestyle in late life might The Australian longitudinal study of ageing: 15 years
328 Australian Longitudinal Study of Womens Health (ALSWH)
of ageing in South Australia. Adelaide: South Austra- researchers to incorporate novel variables, vali-
lian Department of Families and Communities. date participant reports, and evaluate womens
Luszcz, M. A., Giles, L. C., Anstey, K. J., Browne-Yung,
K. C., Walker, R. A., & Windsor, T. D. (2014). Cohort access to, and use of, various healthcare services.
prole: The Australian Longitudinal Study of Ageing
(ALSA). International Journal of Epidemiology,
Advance Access, 110. Background to the ALSWH
Stoykova, R., Matharan, F., Dartigues, J.-F., & Amieva,
H. (2011). Impact of social network on cognitive per-
formances and age-related cognitive decline across a In 1989, the Australian Department of Commu-
20-year follow-up. International Psychogeriatrics, 23, nity Services and Health (ADCSH) released its
14051412. landmark National Womens Health Policy
Thoits, P. (2011). Mechanisms linking social ties and sup-
port to physical and mental health. Journal of Health (Australian Department of Community Services
and Social Behavior, 52, 145161. and Health 1989), reviewing the body of knowl-
Walker, R. A., Luszcz, M. A., Gerstorf, D., & Hoppmann, edge on Australian womens health and outlining
C. A. (2011). Subjective well-being dynamics in cou- recommendations for the course of future
ples from the Australian Longitudinal Study of Aging.
Gerontology, 57, 153160. research. Following a lengthy period of consulta-
tion with womens advocacy organizations and
researchers, the ADCSH (now Australian Depart-
ment of Health) agreed to fund a long-term longi-
Australian Longitudinal Study tudinal study of Australian womens health and
of Womens Health (ALSWH) well-being, and in 1995, the Australian Longitu-
dinal Study on Womens Health (ALSWH) was
Michelle Steffens and MyNhi Nguyen founded (Dobson et al. 2015; Lee et al. 2005;
School of Psychology, The University of Brown et al. 1996).
Queensland, Brisbane, QLD, Australia The ALSWH is a multidisciplinary joint
project of the Universities of Queensland and
Newcastle. The project has two overarching
goals: rst, to investigate the inuences of biolog-
Synonyms ical, psychological, social, environmental, and
lifestyle variables on womens physical and men-
Womens Health Australia tal health (referred to here together as health),
with a view to guiding future Australian health
policy and practice; second, to assess the inu-
Definition ence of any recent changes in Australian health
policy and practice on womens health (Womens
The Australian Longitudinal Study of Womens Health Australia 2016b).
Health (ALSWH; also known as Womens Health To address these aims, ALSWH surveys were
Australia, WHA) is a prospective longitudinal developed around ve key themes: (1) how
population-based survey of more than 40,000 women spend their time in terms of employ-
Australian women across three generations. The ment, unpaid caregiving, motherhood, socializ-
project collects quantitative and qualitative data to ing, and leisure and what impact this has on
investigate the epidemiology of Australian health; (2) how self-rated health, specic diagno-
womens physical and mental health across the ses, weight, exercise, and diet affect health out-
life-span; that is, how biopsychosocial and behav- comes; (3) the prevalence and characteristics of
ioral factors enhance or compromise womens violence and abuse against women across the life-
health, and how these effects might vary at differ- span; (4) how to best help women maintain health
ent life stages. A key feature of the ALSWH is its during and beyond signicant life events (e.g.,
extensive record linkage with Australian Medi- childbirth, menopause, and divorce) and through-
care, Census, and other databases, which allow out their older years; and (5) the availability,
Australian Longitudinal Study of Womens Health (ALSWH) 329
usage, and appropriateness of healthcare options, contains the most complete and up-to-date
implications for governmental costs, and record of Australian citizens and permanent
womens experiences of accessing the healthcare residents. Women in rural and remote commu- A
system (Brown et al. 1996). Twenty years on, nities were intentionally oversampled to ensure
emerging technologies can now provide highly that these subsamples were large enough for
specic location data, enabling researchers to statistically valid comparisons with urban
add a sixth theme: Examining the impact of geo- women (Brown et al. 1999). Comparison to
graphical and climate factors such as drought 1996 Census data conrmed that all three
and pollution on womens health (Dobson cohorts approximated the underlying
et al. 2015). populations (Brown et al. 1996).
By mid-2014, the ALSWH project had pro- In longitudinal research, attrition (participant
duced almost 500 peer-reviewed journal articles withdrawal, death, or nonresponse) is an inev-
involving at least 780 researchers. ALSWH nd- itable challenge. If there is even slight bias in
ings formed the cornerstone of evidence used to the manner in which participants are lost, the
develop the Australian Governments 2010 sample characteristics diverge from those of the
National Womens Health Policy and several population it represents. When differences are
other governmental and organizational health- large, insights from the study might no longer
related policies (Dobson et al. 2015). apply to the population of interest. As ALSWH
ALSWH data have also been used in a number participants who missed one survey have often
of national and international studies and system- completed subsequent surveys, it is not possible
atic reviews, most notably the Dynamic Analyses to determine precise attrition rates, but approx-
to Optimise Ageing (DYNOPTA) project. imations can be made (Dobson et al. 2015).
DYNOPTA pools participants from the ALSWH From Surveys 1 (1996) to 6 (2011), there was
and other major Australian longitudinal work to a 43% drop in the number of surveys returned
study the health determinants and outcomes of by the younger cohort, a 27% drop for
over almost 80,000 Australian men and women mid-aged women, and a 67% drop for the
(Dobson et al. 2015). older cohort. Record linkage with the National
Death Index database showed that around 40%
of the older cohort died over this period. Sur-
Participants and Procedures vey data and researcher contact reveal that a
primary reason for withdrawal by older partic-
At its 1995 inception, the ALSWH established ipants is their increasing frailty. Thus, to max-
three main cohorts, dened by age: young imize the data acquired from older women
women, born in the period 19731978 (aged while limiting their participation burden,
1823 years in 1996); the mid-aged, born researchers now send a shortened survey every
19461951 (aged 4550 years); and older 6 months.
women, born 19211926 (aged 7075 years).
Recruitment and subsequent surveys were
conducted via mail, with an online survey option Measures
now available.
A critical feature of the ALSWH is its Numerous measures are employed across the for-
population-sampling approach, intended to mal ALSWH surveys (S1: 1996; S2: 1999; S3:
broadly represent all Australian women, as all 2002; S4: 2005; S5: 2008; S6: 2011) and
previous Australian longitudinal studies cen- approved substudies (in which participants are
tered on specic subpopulations (Brown invited to partake in related surveys in between
et al. 1996). To establish the 1995 cohorts, the formal ALSWH surveys). All surveys are
the ALSWH researchers took a stratied ran- available on the ALSWH website (Womens
dom sample of the Medicare database, which Health Australia 2016a). The surveys include a
range of established psychometric scales and The ALSWH also includes several objectively
novel items to assess numerous variables (Lee assessed variables, providing validation and
et al. 2005) on demographics, physical and mental expansion of participant reports. This is achieved
health, quality of life, day-to-day functioning, life- primarily via electronic record linking, in which
style, environmental factors, experiences with the each participants ALSWH dataset is matched
healthcare system, and topics of relevance to spe- with records kept by Medicare, Australian Depart-
cic cohorts (e.g., contraception, menopause, and ment of Veterans Affairs, and Pharmaceutical
age-related health problems). Most items are quan- Benets Scheme programs. Linkage allows
titative, but several open-text items have been researchers to corroborate self-reported health
included, allowing deeper qualitative analysis of diagnoses and medications, track government
complex topics. This entry describes the main healthcare costs, and identify patterns of access
types of quantitative measures used with the older to healthcare services across the socioeconomic
cohort. Except where otherwise noted, information and geographical landscapes (Dobson et al. 2015;
is sourced from two reports by ALSWH investiga- Lee et al. 2005). Importantly, linkage has recently
tors, which summarize the projects main methods been established with databases held by aged-care
and ndings (up to publication dates) for the older services and facilities. This will permit future
cohort (Byles et al. 2010) and the mental health of ALSWH work to incorporate data from formal
all cohorts (Holden et al. 2013). assessments of older womens physical and cog-
Demographic items address age, area of resi- nitive capabilities, such as those completed during
dence, country of birth, language spoken at home, application to support services and admission to
marital status, and education. Behavioral and life- residential aged-care facilities (Dobson
style items assess body mass index, height, phys- et al. 2015).
ical activity and restrictions, cigarette and alcohol The ALSWH team has recently expanded their
consumption, transport options, and ability to per- record linkage capabilities in a new direction, now
form activities of daily living. Health-related incorporating geocoded data to pinpoint each par-
items ask women to report their overall physical ticipants location of residence. This allows
and mental health, medical and psychological researchers to assess how climate and weather
health diagnoses, common symptoms of later life events such as drought, natural disasters, and
(e.g., vision or hearing loss, back pain, and height air pollution might affect womens physical and
loss), signicant medical events (e.g., falls and mental health (Womens Health Australia 2016a).
surgeries), medication use, number of GP and
specialist doctor appointments, number of hospi-
talizations, and whether they live in the commu- Accessing the ALSWH Data
nity or in a residential aged care facility. Items
exploring social engagement and support focus on Researchers wishing to work with ALSWH data,
the number, type, and supportiveness of social propose a substudy, or access its linked external
contacts (e.g., spouse, family, and friends); satis- databases must apply to the ALSWH Publica-
faction with their social relationships; whether a tions, Analyses, and Substudies Committee.
loved one was experiencing health problems or Information on eligibility and the application pro-
had recently died; and nancial constraints on cess are available on the ALSWH website
social activities (e.g., whether they have difculty (Womens Health Australia 2016b).
managing on their income).
A number of established self-report psycho-
metric measures are included to assess aspects of ALSWH Findings on Older Australian
older womens health and experiences. Details of Women
these are beyond the scope of this entry but can be
sourced from the ALSWH website (Womens The core ALSWH team has, thus far, released
Health Australia 2016a). three relevant reports of key ndings: Byles and
colleagues review of older womens physical and long-term behavioral patterns. Alcohol consump-
social health (Byles et al. 2010), Holden and col- tion was inversely related to mortality: non- and
leagues review of mental health across all cohorts rare-drinkers were up to twice as likely to die over A
(Holden et al. 2013), and Byles and colleagues a 6-year period as moderate drinkers and also
review of medication and healthcare costs (Byles tended to report poorer mental health and social
et al. 2008). This entry summarizes these ndings functioning, even after accounting for smoking,
and refers the reader to the full reports for health diagnoses, BMI, and demographics. No
citations. survival benets were observed for women who
drank more than the moderate rate. ALSWH
Physical Health in Older Australian Women investigators note that there is insufcient evi-
Aging brings inevitable declines in physical dence to suggest that non- or rare-drinkers should
health, ability to perform activities of daily living, increase their intake to reap health benets.
and health-related quality of life (health QoL). Falls are a common concern for older women,
The ALSWH has explored numerous demo- and for good reason. In a subsample of the older
graphic, biological, medical, and social predictors cohort, around 20% had fallen in the past 6 months
of these outcomes. and over half feared falling in the next year. On
average, womens homes had 9 of 25 listed fall
Physical and Lifestyle Predictors of Health hazards, though hazard incidence differed little
Outcomes between women who and had not fallen. Across
A similar pattern of risk factors was observed the full older cohort, women with moderate to
when investigating health outcomes beyond qual- very high levels of physical activity were less
ity of life: height loss, body mass index (BMI), likely to fall than those with no or very low levels,
falls, smoking, and alcohol use were all identied and much of this benet persisted for at least
as predicting broadly aversive health outcomes. 6 years. Women with very high levels of physical
Both underweight and overweight/obese women activity reduced their risk of sustaining a fracture
had higher risk of hospitalization than those with by half. It is interesting to note, however, that
healthy BMI, especially if they smoked; however, greater physical activity was not signicantly
slightly overweight women (2527 kg/m2) had related to another indicator of bone health: height
the lowest mortality risk, with current smokers at loss. Women lost an average of 0.19 cm height per
greatest risk across all BMIs. Overweight and year, with more severe losses associated with
obese women were at lower risk of osteoporosis, reduced self-rated health. Women were at greatest
but higher risk of hypertension, heart disease, risk for height loss when underweight, born in a
diabetes, and heart disease, with the latter effect European country, diagnosed with osteoporosis,
again amplied in smokers. and taking both sleep and anxiety medications.
Smoking was inversely related to longevity,
with a clear doseresponse relationship. At Sur- Medical Diagnoses as Risk Factors for Poor Health
vey 1, women reported their smoking status and Outcomes
their responses later cross-referenced with 2006 Among the strongest predictors of older womens
national mortality data. Results were striking: health outcomes were the number and types of
81% of those who had never smoked and 75% chronic health conditions and experience. Cancer
of ex-smokers had survived, but smokers mortal- and Alzheimers disease were most predictive of
ity rate rose steeply with the more cigarettes con- disablement and death, while cancer, heart dis-
sumed per day. Just 43% of women who smoked ease, and stroke were predictive of high health
at least 25 cigarettes per day survived to at system usage. More than any other disease,
least 2006. Alzheimers was associated with diminished
Results were less clear-cut for alcohol use. At social functioning and general health. The preva-
Survey 1, 35% of women were nondrinkers and lence of chronic illness increased over time, and
29% drank less than weekly; for many, these were the more conditions a woman experienced, the
greater her likelihood of experiencing poor health compared with around 5 per year for younger and
QoL, physical disablement, and death. mid-aged women. The most commonly used PBS
medications among older women were those used
Predictors of Health-Related Quality of Life to treat conditions of the cardiovascular system
On average, health-related quality of life (health (75%), nervous system (61%), alimentary
QoL) declined at each survey (Surveys 15). This (gastrointestinal) tract (57%), musculoskeletal
trend encompassed four patterns: (a) 50% of system (43%), and respiratory system (20%).
women held relatively stable scores of high health Women taking at least one of these medications
QoL; (b) 27% had high health QoL at Survey were more likely than their peers to visit their GP
1 that declined over subsequent surveys; (c) 20% and specialist doctors often, as were overweight/
began with low health QoL that further deterio- obese women and diabetics (Byles et al. 2008).
rated over time; and (d) 3% reported low health For many older women, poor availability and
QoL at Survey 1 but showed improvement at each affordability of doctor visits limit their access to
survey and reported high health QoL by Survey 5. medical care. From 1995 (Young et al. 2000) to
Compared with women with consistently high 2005 (Walkom et al. 2013), a signicant minority
health QoL, those with poor or declining scores of older women reported that needing to visit a
tended to be poorly educated, widowed, a smoker, non-bulk-billing GP caused nancial strain, with
overweight or obese, and physically inactive. some unable to seek medical care at times.
These women were more likely to have a range Women in rural and remote areas experienced
of chronic health conditions (e.g., heart disease, the greatest nancial burden: with specialist doc-
stroke), general physical symptoms (e.g., back tors, major hospitals, and sometimes GPs
pain, vision problems), and a history of falls. unavailable outside of main cities, these women
They were also more likely to have had specic face travel and accommodation costs on top of
surgeries, take several medications, and fre- consultation fees. For some of these women,
quently access GP and specialist care. becoming unable to drive themselves to distant
appointments has made seeking medical care
Patterns of Healthcare System Usage impossible.
Australians on a low income such as Many older women have also identied medi-
age-pensioners, war widows, and low-income cation costs as a signicant nancial burden
self-funded retirees qualify to receive a Medi- (Walkom et al. 2013), and this was particularly
care subsidy that covers either the full cost of a GP true of those requiring multiple medications. In an
visit (bulk-billing GPs) or the great majority of the evaluation of womens 20032005 PBS subsidy
cost (non-bulk-billing GPs). Likewise, they claims (Byles et al. 2008), older women made
receive a government subsidy on most prescribed more PBS claims and took a greater number of
medications, via the national Pharmaceutical Ben- medications than did younger and mid-aged
ets Scheme (PBS). With record linkage women. Thus, despite receiving a higher PBS
established for around half of older ALSWH subsidy per medication than many young and
women, it is possible to get independent snapshots mid-aged women, older women incurred the
their healthcare system usage and out-of-pocket greatest cumulative out-of-pocket medication
costs. To date, there has been limited review of expenses. This took a serious nancial toll, with
older womens usage of healthcare services. many feeling a substantial impact on their ability
An early ALSWH substudy of New South to live on their income, and some even forced at
Wales women (Young et al. 2000) found that times to choose between buying food or essential
98.8% of older women (6,464 of 6,542) had medication.
seen a GP in the 19951996 calendar period. Dental work, too, is unaffordable for many
Older women claimed the Medicare subsidy for older women. Dentistry receives little govern-
a total of 110,482 GP consultations over this time: mental funding compared with medical services,
an average of 8 appointments per woman per year, leaving considerable patient costs, as well as
limited access for those in rural and remote areas. which an individual realizes his or her own abili-
Across Surveys 24 (Sibbritt et al. 2010), around ties, can cope with the normal stresses of life, can
36% of older women visited a dentist; however, it work productively and is able to make a contribu- A
was not necessarily the same women accessing tion to his or her community. [It is] fundamental to
care at each time point. Of women who had visited our collective and individual ability as humans to
a dentist, just 21% reported a consultation on all think, emote, interact with each other, earn a liv-
three surveys, 15% on two surveys, and 19% on ing and enjoy life. Mental illness, then, is most
just one survey. In Survey 4, 5% of women completely viewed as encompassing both psychi-
reported not consulting a dentist despite needing atric diagnoses and subclinical psychological dis-
to. Reasons typically cited were a shortage of local tress that interferes with a realistic view of the self
dentists, lack of transport, high costs, and/or a or the ability to cope with day-to-day life, employ-
long waiting period for an appointment. Com- ment or study, or community participation.
pared with those reporting no dentist visits,
women who accessed dental care at least once The Prevalence of Psychological Distress
tended to live in urban regions, be married or in Although psychological distress was less com-
a de facto relationship, be non-smokers, have mon in older women than in younger and
better physical functioning, live easily on their mid-aged women, a signicant portion of older
income, and have attained higher education. women reported high distress in at least one sur-
In recent years, Australia has experienced sub- vey. At Survey 1, roughly 6% of older women
stantial growth in the complementary and alter- reported signicant psychological distress and
native medicine (CAM) industry, which includes this gradually increased over time, hitting 8% at
non-evidence-based elds such as naturopathy, Survey 6. It is important to note, however, that this
homeopathy, acupuncture, and chiropractics. The was a dynamic effect, with around half of older
Medicare/PBS systems cover neither consulta- women distressed at Survey 1 becoming mentally
tions with CAM practitioners nor the purchase of well by Survey 2 and a portion of previously well
CAM products, such as herbal preparations and women reporting distress in Survey 2. This trend
detox pills. Roughly 40% of women reported was mirrored across Surveys 36, with the
visiting a CAM practitioner at least once over greatest contribution to prevalence at each survey
Surveys 14, with most reporting usage on just coming from women who had not previously
one survey and none reporting CAM use at all reported distress. A subset of older women did,
four surveys. Despite the overall rise in CAM however, experience chronic or recurrent psycho-
popularity, older womens usage declined at each logical distress. Women were at a ninefold greater
survey, dropping from around 15% at Survey 1 to risk of reporting signicant distress at any given
just 10% at Survey 4. Those most likely to visit a survey when they had reported distress at the
CAM practitioner lived in rural/remote regions, previous survey and a fourfold greater risk when
had poorer physical health, and more frequently they had reported distress at the survey
visited their GP, specialist doctors, and hospital. before that.
Importantly, this suggests that older women were In the younger and mid-aged cohorts, the prev-
not using CAM practitioners as an alternative to alence of psychological distress fell consistently
modern medicine but as a transient complement to across the measured 5-year period, but in a
their usual medical practitioners and treatments concerning trend, distress began climbing again
(Adams et al. 2009). in the older cohort, from 4% at age 75 years to
around 7% at age 87. Likewise, the prevalence of
Mental Health of Older Australian Women diagnosed clinical depression or anxiety increased
Mental health is not merely the absence of a as older women aged: from age 75 to 87 years,
psychiatric diagnosis. Rather, the World Health depression rose from 4% to 7% and anxiety dis-
Organization (World Health Organization 2014) orders from 3% to 5%. It appears, then, that the
refers to mental health as a state of well-being in rate of mental illness in older women is increasing
but so is its detection and treatment. Yet these Social Factors: The Importance of Social Support
mental illnesses were not entirely remediated by for Mental Health
treatment, with depressed women of all ages con- The ALSWH project has also explored how
tinuing to experience greater psychological dis- numerous social factors are linked with mental
tress than those without the diagnosis (3648% health outcomes. Important social factors fall
vs. 516%, averaged across all cohorts). roughly into six categories: (1) building and
Much ALSWH work has focused on identify- receiving social support, (2) accessing the com-
ing and understanding the individual and social munity, (3) contributing to the community,
factors that inuence, and are inuenced by, men- (4) caregiving, (5) navigating widowhood, and
tal health in women. (6) experiencing elder abuse.
Individual Factors: Demographic, Lifestyle, Building and Receiving Social Support Older
and Medical Predictors of Distress persons are at high risk for shrinking social sup-
Several demographic, lifestyle, and medical fac- port, particularly via the death of friends and fam-
tors have been associated with psychological dis- ily members, retirement from the workplace, and
tress in older women. It remains unclear to what declines in their physical mobility. This can result
degree (a) these individual factors might impact in a vicious cycle in which reduced social sup-
mental health, (b) mental health might inuence port worsens mental health, and poor mental
these individual factors, or (c) the individual fac- health impedes women in engaging with their
tors and mental health are reciprocally related. community and making new friends.
Most notable in demographics, women were Unsurprisingly, women with a broader social
more likely to report distress if they had lower network at Survey 1 tended to be those with good
education levels, experienced difculty managing physical and mental health, those born in Austra-
on available income, had been born in a lia or another English-speaking country, and those
non-English-speaking country, or spoke a undergoing a social hardship, such as serious
non-English language at home. In terms of life- health decline in a loved one or being a widow.
style/health factors, older women were more likely Over Surveys 24, womens networks typically
to report distress if they were underweight, a cur- decreased slightly. Smaller networks were more
rent or ex-smoker, or a nondrinker. Interestingly, associated with having been born in another coun-
overweight and obese older women were less try, having impaired vision or physical function-
likely than those of healthy or low weight to report ing, and having moved house (often away from a
psychological distress. There was no signicant long-time home to a retirement village or closer to
association between distress and any relationship family). Women with small social networks
status for older women, which the ALSWH team tended to report poorer mental health than those
suggests might be due to widowhood becoming with more larger networks, which the ALSWH
common in womens social networks by this stage. authors tentatively suggest might reect a poorer
A number of chronic medical conditions were ability of distressed and depressed individuals to
also related to mental health. Older women who connect with, maintain, and benet from their
reported high stress at Survey 1 were more likely social network.
than their peers to report coronary heart disease or Women reporting greater satisfaction with the
stroke for the rst time at Survey 2, while women quality of their social contacts were more likely to
with poor mental health at Survey 1 were at not be impaired in mobility, hearing, sight, or
increased risk of reporting diabetes for the rst continence; not have experienced a recent major
time at Survey 2 (Strodl and Kenardy 2006). Sim- illness; have been born in Australia or another
ilarly, older women with arthritis were more likely English-speaking country; not have recently
than peers to be experiencing depression and/or moved house or suffered a drop in income; and
anxiety (Byles et al. 2010). either have a partner or be a widow, rather than be
separated, divorced, or never married. More
socially satised women also reported better over- system as needed, tending to have private health
all mental health, though, again, the direction of insurance, visiting healthcare professionals more
causality (if any) is undetermined. often, and reporting better physical and mental A
health-related quality of life.
Accessing the Community Physical and cogni- Compared with women who had never
tive signs of aging can reduce older persons volunteered (non-volunteers), those reporting vol-
access to their community, particularly when unteer work at all four time points (continuing
they are no longer able to drive. Often, substantial volunteers) and those volunteering at Surveys
barriers in accessing public transport, such as high 3 and 4 (new volunteers) were more likely to
cost, limited availability, inconvenience, or poor report superior physical and mental health at all
disability access, compound the reduced commu- surveys. Those who reported volunteer work in at
nity access of persons who have ceased driving. least one survey (intermittent volunteers) also
At Survey 3, roughly half of all older women displayed better physical/mental health at Survey
living in urban areas reported driving themselves 2, but showed decline in all measures over time,
as their primary mode of transport, compared with and by Survey 4 had become indistinguishable
around 70% of rural/remote women. Public trans- from non-volunteers. Across Surveys 24, con-
port was rarely used in rural and remote areas, tinuing volunteers had the greatest social support,
likely due to poor availability. Of women driving non-volunteers the poorest, and intermittent and
at Survey 3, 86% were still driving at Survey new volunteers moderate support.
4, while 10% relied on someone else to drive
them; only a minority reported using public Becoming a Caregiver Across Surveys 25,
transport. around 40% of older women reported for at least
Ceased drivers tended to have limited mobility, one time point that they were acting as informal
vision, or hearing; have impairments due to caregivers through their husbands later years or
chronic medical conditions such as stroke or for other family members. However, the great
arthritis; or take at least ve medications. Com- majority (95%) of these women did not act as
pared with continuing drivers, ceased drivers were caregivers permanently, instead transitioning into
more likely to later report poorer self-rated health, or out of the role over the 12-year period sampled.
greater physical disability, and decreased access Compared with older women who had never pro-
to leisure and social activities outside of their vided care, caregivers reported lower perceived
home. One in ve older women reported being quality of life, and poorer physical and mental
unable to venture beyond their own neighbor- health. Those with more intense duties and those
hood, which can have a particularly heavy impact who lived with their care-recipient were particu-
on their ability to access critical facilities such as larly vulnerable to these challenges. At all levels
shops and healthcare service providers. of caregiving intensity, both short- and long-term
carers reported adequate social support.
Contributing to the Community Volunteering
with a community organization is one common Navigating Widowhood With Australian
way to stay physically, mentally, and socially women typically living longer than men, widow-
active. Over Surveys 14, between 8% and 25% hood is a common experience for older women.
of women reported undertaking volunteer work in At Survey 1, 35% of older women were widowed,
at least one survey, whereas 35% reported never with an additional 2,494 women widowed by
volunteering. Across Surveys 24, volunteers Survey 3.
were more likely than their non-volunteer peers Compared with that of their married peers, the
to be well-educated, speak English, live in rural mental health of widows typically showed a slow
areas, live alone, driving their own car as primary decline in the 4 years preceding spousal death,
transport, and having greater social support. They possibly indicating anticipatory grief or the grow-
appeared better positioned to access the healthcare ing burden of caregiving. The greatest decline was
observed at the point of spousal death and over the number of chronic medical conditions such as
subsequent 12 months before beginning to diabetes and stroke, though it remains unclear
recover. By womens fourth year post-loss, their whether there is any causal effect.
mental health had returned to the level prior to the
initial years of decline. Qualitative analysis has Mental Healthcare Usage by Older Australian
shown that, despite the grief of spousal death, Women
older womens quality of life often rapidly In 2006, the Australian government introduced the
improves as the physical and emotional strain of Better Access Scheme (BAS), allowing GPs to refer
caring for a seriously ill husband is relieved. patients for up to 10 subsidized sessions per year
Many widows reported that maintaining or with a mental health professional. The scheme is
increasing social contact and participation in greatly underused by older women: 4 years on from
activities smoothed adjustment to widowhood. its introduction, just 3% of older women had used
Most belonged to a local organization such as a the BAS in treating their diagnosed anxiety or
church or RSL club, and more than one-half depression. Compared with diagnosed women
engaged in enjoyed hobbies (e.g., gardening, who did not use the BAS, the BAS users were less
handiwork, and eating out) most or every day of likely to have private health insurance or a pensioner
the week. Widowhood was, in fact, associated concession card. At each of Surveys 15, BAS users
with greater social connectedness, despite the reported better mental health than non-BAS anxious
loss of the womans primary source of practical or depressed women, though both groups reported
and emotional support. Analyses suggest that in consistently poorer mental health than those diag-
the bereavement period and beyond, friends, nosed with neither anxiety nor depression.
grown children, and other family members step
up to ll the gap in support.
Future Directions for ALSWH
The Experience of Elder Abuse The term elder
abuse encompasses physical, verbal, psychologi- To date, ALSWH investigations with older
cal, sexual, and nancial abuse directed toward women have centered on those living in the com-
older people, typically perpetrated by family munity. With record linkage now expanded to
member(s). Survey 1 revealed an alarming preva- databases held by these aged-care facilities, future
lence of abusive behaviors against older women. work might compare the health and quality of life
Roughly 8% of older women were categorized as of women in residential aged care those living in
vulnerable to elder abuse; these women reported the community. Extending demographic measures
fearing their family member(s) or experiencing at to explore the community living arrangements of
least one episode of verbal or emotional abuse. women (e.g., living independently vs. living with
Over 6% of women reported at least one incident grown children) may yield further insights into
of coercion, while 18% rated highly on depen- factors related to health and well-being, particu-
dence, receiving inadequate privacy, feeling dis- larly regarding elder abuse.
trustful of family, or being reliant upon family A second direction of interest is to include in
members for critical aspects of life. Around 15% upcoming surveys an updated measure of social
were classed as dejected, feeling often sad, lonely, support, as those used to date have not assessed
unwanted, or uncomfortable around at least one the impact of what has become a major source of
family member. social support for individuals of all ages: the
Compared with women who felt safe, abused world of Internet forums, Facebook, and social
women were more likely to be current or media. In particular, it would be interesting to
ex-smokers, be single or widowed, have lower compare the level of support received from net-
education and social support, and have greater works online versus in real life, and whether
difculty managing on their income. They also online support might be more accessible and life
tended to report poorer mental health and a greater enhancing for older women with limited mobility.
Finally, it would be useful to compare ALSWH impact of such measures, as well as further explor-
data with that currently being acquired in a sepa- ing factors contributing to older womens health
rate longitudinal study of Aboriginal and Torres and quality of life. A
Strait Islander (ATSI) Australians health. While a
small number of ALSWH participants were of
ATSI background, they cannot represent the References
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Powers, J., Loxton, D., Baker, J., Rich, J., & Dobson, A.
(2012). Empirical evidence suggests adverse climate Autism spectrum disorder is a neurodeve-
events have not affected Australian womens health lopmental disorder that is both high in prevalence
and well-being. Australian and New Zealand Journal and most commonly lifelong in nature. Despite
of Public Health, 36, 452457. this, there is a dearth of available information
Sibbritt, D., Byles, J., & Tavener, M. (2010). Older Aus-
tralian womens use of dentists: A longitudinal analysis regarding the disorder in later life. Existing evi-
over 6 years. Australasian Journal on Ageing, 29, dence indicates poor outcomes in adult life in a
1420. range of areas of health and wellbeing, though
Strodl, E., & Kenardy, J. (2006). Psychosocial and more information is needed to create a more com-
non-psychosocial risk factors for the new diagnosis of
diabetes in elderly women. Diabetes Research and prehensive understanding of the circumstances
Clinical Practice, 74, 5765. and needs of autistic adults as they age.
Walkom, E., Loxton, D., & Robertson, J. (2013). Costs of
medicines and health care: A concern for Australian
women across the ages. BMC Health Services
Research, 13, 484. Introduction
Womens Health Australia. (2016a). For researchers. Sur-
veys. Source: http://www.alswh.org.au/for-researchers/ The lifelong nature of autism spectrum disorders
surveys (ASD) attests to the need for a thorough under-
Womens Health Australia. (2016b). How to access the
data. ALSWH data. Source: http://www.alswh.org.au/ standing of the condition throughout the lifespan.
how-to-access-the-data/alswh-data This entry will summarize the extant knowledge
World Health Organization. (2014). Mental health: regarding ASD in later life. It will begin with a
Strengthening our response. Fact sheet No220. Source: brief discussion of the conceptual and diagnostic
http://www.who.int/mediacentre/factsheets/fs220/en/
Young, A., Dobson, A., & Byles, J. (2000). Access and background of ASD and evidence of its persis-
equity in the provision of general practitioner services tence into adulthood. Overviews of several key
for women in Australia. Australian and New Zealand areas of health and wellbeing in later life for this
Journal of Public Health, 24, 474480. population follow. These areas include physical
health, mental health and cognition, participation
and lifestyle and supports. In particular, these
sections highlight the knowledge gaps regarding
Autism Spectrum Disorder ASD in later life and make suggestions for future
work in the area. Finally, challenges and future
Ye In (Jane) Hwang1,2, Kitty-Rose Foley1,2 and directions for work on this topic are presented.
Julian Trollor1,2
1
Department of Developmental Disability
Neuropsychiatry, School of Psychiatry, Background
University of New South Wales, Sydney, NSW,
Australia Autism spectrum disorders (ASD) are a heteroge-
2
Cooperative Research Centre for Living with neous group of neurodevelopmental disorders
Autism (Autism CRC), Long Pocket, Brisbane, characterized by persistent decits in social com-
QLD, Australia munication and interaction, as well as restricted,
repetitive, or stereotyped behaviors or interests
(American Psychiatric Association 2013). The
Synonyms Diagnostic and Statistical Manual of Mental Dis-
orders (DSM-V) species that these symptoms
Adulthood; Ageing; ASD; Aspergers syndrome; must be present during the childs early develop-
Autism; Autism spectrum disorder; Autistic dis- mental period and should not be better explained
order; Intellectual disability; Neurodevelopmental by global developmental or intellectual delay
disability; Pervasive developmental disorders (American Psychiatric Association 2013).
Autism Spectrum Disorder 339
Symptoms must also cause clinically signicant criteria (DSM V), autistic disorder, Aspergers
impairments in key functional domains such as disorder, and PDD-NOS were merged under the
social or occupational functioning. umbrella term of Autism Spectrum Disorder A
ASD has undergone several signicant con- (American Psychiatric Association 2013).
ceptual revisions over time, and these are reected The reported prevalence of ASD has varied
in the evolution of terminology and diagnostic widely among studies, though a general increase
criteria. The rst diagnosis of ASD, termed in prevalence has been observed over time. Esti-
early infantile autism, was made by the mates from the mid to late twentieth century lay
Austrian-American psychiatrist and physician between 4 and 12 per 10,000 persons, whereas
Leo Kanner in 1943 (Kanner 1943). In Kanners more recent estimates report the prevalence of
view, autistic children were socially cut off from ASD to be between 30 and 90 per 10,000 persons
the world and experienced particular trouble deal- (Baird et al. 2006). This increase may reect the
ing with change. In some cases, the diagnosis was broadening of diagnostic criteria, increased avail-
confused with schizophrenia. In addition to this, ability of diagnostic services and funded supports,
poor parenting practices and poor parentchild increased public and clinical awareness, differ-
relationships were considered as key precipitators ences in study methodology or a true increase in
of ASD. This resulted in parents, especially prevalence of ASD. The best available data on
mothers, being blamed for their childs ASD. By prevalence of ASD in adults is from a 2011
the 1960s, advancements in scientic research study from the United Kingdom, which found a
methods shifted the focus away from environmen- prevalence of 9.8 per 1000 persons (Brugha
tal inuences to neurological and genetic expla- et al. 2011), a gure similar to that observed in
nations. By the following decade, the rise of the children. This nding suggests substantial reten-
cognitive movement saw language and communi- tion of the diagnosis into later life.
cation difculties become the dening feature of The widening of diagnostic criteria and the
autism. During this time, Wing and Gould (1979) observed increase in prevalence suggests the pos-
framed autism as a triad of social behavioral sibility that a large number of autistic adults live
impairments that originate in specic areas of the without a formal diagnosis of ASD. The complex-
childs brain. Infantile autism was rst ofcially ity of rst diagnosing a developmental disorder in
recognized in the DSM-III in 1980 within the adulthood also raises the possibility that some
class of pervasive developmental disorders, autistic adults may be misdiagnosed with other
alongside Aspergers disorder, Rett syndrome, mental disorders (Stuart Hamilton and Morgan
childhood disintegrative disorder, and pervasive 2011). The hidden nature of this population
developmental disorder not otherwise specied also presents challenges for research, especially
(PDD-NOS) (3rd ed., DSM-III, American Psychi- when determining inclusion criteria for adults
atric Association 1980). Its key criteria included without an ofcial diagnosis. Lack of clarity of
pervasive lack of social responsiveness, decits, diagnosis in adults also creates clinical chal-
and peculiarities in language and bizarre lenges, as assessment and management of addi-
responses to certain environmental cues, but it tional mental or physical health conditions may
was distinguished from schizophrenia based on not be appropriately tailored to the persons needs.
schizophrenia-specic symptoms such as halluci- The most appropriate terminology for referring
nations. After a major revision in the DSM-III-R, to those with a diagnosis of ASD has been subject
infantile autism was renamed autistic disorder, to much debate, with different groups expressing
acknowledging the developmental nature of the their preference for different terms. Person-rst
condition and its persistence beyond early child- language (e.g., adult with autism) has been
hood (Volkmar and McPartland 2014). found to be preferred by health professionals
A polythetic approach was implemented in this and parents of individuals (Kenny et al. 2016).
revision, allowing for greater diagnostic exibil- On the other hand, adults with a diagnosis of
ity. In the most recent revision of diagnostic autism themselves have been found to prefer
identity-rst language (e.g., autistic adult), a com- Autistic children have high rates of co-occurring
mon reason for this preference being the idea that medical conditions, and this co-occurrence has
autism is a positive and inseparable part of their also been observed in adulthood (Croen
identity (Kenny et al. 2016). We acknowledge and et al. 2015). In particular, markers of differential
respect the range of opinions present in this debate health status are evident for autistic adults relative
and have been mindful of this in using the terms to the general population, both in terms of the
with ASD, autism, and autistic adult presence of common medical conditions and med-
interchangeably throughout this entry. ical conditions associated with genetic disorders
(Croen et al. 2015).
Perhaps the most obvious indicator of differ-
ASD in Later Life ential health status for autistic adults is the
observed mortality rate. Compared to the general
Research which follows children with ASD into population, autistic adults experience 25.6 times
younger adulthood and beyond nds evidence of higher mortality rates (Mouridsen et al. 2008).
both improvement and stability in the core social This rate appears slightly higher in females, indi-
and behavioral phenotype of ASD. In a review of viduals with more severe intellectual disability,
25 prospective, retrospective, and cross-sectional and those who also have epilepsy. There is also
studies, Seltzer and colleagues (Seltzer some indication that the causes of death for this
et al. 2004) concluded that despite the small vol- population in childhood and adolescence differ to
ume of work and some methodological limita- those in adulthood, with the most common causes
tions, modest improvements in ASD symptoms of death in adults reported to be epileptic events
are apparent from childhood through to adult- (e.g., seizures), respiratory events (e.g., respira-
hood. These improvements are signicantly less tory arrest), and cardiovascular events (e.g.,
for those who also have intellectual disability. arrhythmia) (Bilder et al. 2013). Unnatural events,
Importantly, these improvements are seldom such as accidents and suicide, are also notable
large enough to place the individual within the causes of death in autistic adults (Hirvikoski
normal range of functioning, indicating that in et al. 2015). Specic unnatural causes of death
most cases, ASD is a lifelong condition. The may have an association with intellectual ability,
progressive increase in the prevalence of ASD, such that people with ASD and intellectual dis-
coupled with global population ageing including ability are more at risk of accidental death whereas
increased longevity for those with developmental suicides are associated with people with ASD and
disorders, highlights the need to ensure the devel- normal intelligence (Mouridsen et al. 2008;
opment of age-specic supports for older adults Hirvikoski et al., 2015). Taken together, mortality
with ASD. Although there has been a notable data suggests that the heightened mortality risk in
increase in research focusing on autistic adults, ASD is associated with the presence of additional
more information is needed regarding the health medical conditions, specic genetic syndromes,
and wellbeing circumstances and lifespan trajec- and intellectual disability, rather than the ASD
tories of this population. itself (Bilder et al. 2013). In light of such evi-
dence, the authors have argued for the need for
more in-depth examinations of the potential medi-
Physical Health ating role of comorbid conditions in the increased
mortality risk for autistic adults using larger,
Physical health is an area of critical importance for population-based samples (Schendel et al. 2016).
both the general population and for autistic adults Studies investigating medical conditions in
as they age. The ageing population of autistic autistic adults report high rates of bowel disorders,
adults and their need for appropriate health ser- sleep disturbance, seizures, diabetes, neurologic
vices presents a signicant challenge to health disorders, and auto-immune diseases (Croen
care systems, health professionals, and to society. et al. 2015; Jones et al. 2015). Reports of obesity
rates have been less consistent. The medical mor- population of developing a mental health condi-
bidity patterns share some similarities to those tion. Robust estimates regarding the rate of psy-
found in autistic children. However, age-related chiatric disorders from population-based studies A
disorders such as hypertension and diabetes of adults with ASD are lacking, though clinic-
mellitus type I (Jones et al. 2015) are also based studies of children suggest that between
observed. More cross-sectional studies of the 50% and 70% suffer psychiatric disorders.
physical health of autistic adults are needed to A recent examination of a sample of insured autis-
elucidate the extent of physical health issues fac- tic adults in the United States reported that 54% of
ing this population and how these compare to their 1507 participants had a clinical diagnosis of
control populations. Further, longitudinal studies a psychiatric disorder according to records from
are needed in order to examine the trajectories of outpatient and inpatient clinical databases for the
health as people with ASD age and the factors that period of 20082012 (Croen et al. 2015). Avail-
determine health outcomes. A particular focus on able evidence from a clinical study indicates anx-
how preexisting conditions interact with the age- iety and mood disorders to be the most common
ing process to produce secondary conditions or psychiatric disorders in autistic adults with life-
disabilities is also required. time rates reported at 50% and 53%, respectively
(Hofvander et al. 2009). Also considerable are the
reported lifetime rates of attention-decit/
Mental and Psychological Health hyperactivity disorder (43%) and obsessive com-
pulsive disorder (24%) (Croen et al. 2015;
The mental health of autistic adults presents Hofvander et al. 2009). As with the general pop-
another area which requires further study. High ulation, there is some evidence from cross-
rates of psychopathology are well documented in sectional investigations to suggest that prevalence
autistic children (Simonoff et al. 2008). The evi- of mental disorders (other than the dementias)
dence base for the association in adulthood is may decline as autistic adults get older (Totsika
smaller and it is unclear whether the comorbidity et al. 2010). However, the extent of this decline is
patterns in children are mirrored in older unclear and an over-representation of mental dis-
populations. There is also limited knowledge orders compared to age-matched non-autistic
concerning age-related changes in prevalence of populations is likely to persist.
mental disorders in autistic adults and the preva- The presence of multiple comorbidities as well
lence of age-specic mental health conditions. as the substantial overlap between the symptom
One study tracing 135 autistic children who had prole of ASD and other mental health disorders
previously been referred to a British outpatient can make it difcult to identify the precise nature
clinic before the age of 16 found about 16% of of psychiatric conditions in autistic adults
the sample developed a denite new psychiatric (Ghaziuddin and Zafar 2008). Similarly, psychi-
condition within the follow-up period (ranging atric disorders may manifest in atypical ways in
from 23 to 58 years). In this work, the authors those adults with low IQ and/or intellectual dis-
emphasize the large variation in individual out- ability, including self-injurious behavior and irri-
comes and in the disabling effects of the psychi- tability (Ghaziuddin and Zafar 2008). Therefore,
atric condition (Hutton et al. 2008). Such ndings misdiagnosis and diagnostic overshadowing,
point to the complexity of the relationship where clinicians fail to diagnose comorbid psy-
between ASD symptoms and the subsequent chopathology in individuals as a result of attrib-
development of psychiatric disorders. uting their symptoms to their ASD, are key issues
The prevalence of psychiatric disorders in for this population.
autistic adults has been examined in a limited Studies have found the majority of autistic
number of studies (Croen et al. 2015; Hofvander adults to be taking one or more psychotropic
et al. 2009; Totsika et al. 2010). These suggest that medications, with some longitudinal evidence
autistic adults are at higher risk than the general suggesting a signicant increase in the
proportion of medicated autistic adults over time Cognition and Perception

(Esbensen et al. 2009). There has been
longstanding concern regarding inappropriate The cognitive functioning of adults in late life is a
prescribing of psychotropic drugs in people matter of substantial research interest in the gen-
with intellectual disability, including those with eral population. In the case of autistic adults, there
ASD in association with intellectual disability. is very little information available regarding their
Studies suggest that rates of psychotropic drug cognitive strengths and weaknesses relative to the
prescription exceed recorded rates of psychiatric general population. Studies examining cognitive
diagnoses with a recent population-based cohort decits in autistic individuals have particularly
study in the United Kingdom reporting that 26% focused on executive functioning. Executive
of their sample who had been prescribed antipsy- functioning has a key role in ageing, since the
chotic drugs to have no record of severe mental deterioration of executive functioning is largely
illness or challenging behavior (Sheehan accepted to be the underlying factor in declines in
et al. 2015). The issue of inappropriate drug cognitive ability as adults get older. Executive
prescription is one with implications both at the functioning also has a particular relationship
individual and system levels. It is a particularly with ASD, with cross-sectional investigations
pertinent issue for those individuals with intel- consistently nding evidence of decits of exec-
lectual disability who are also older and autistic, utive functioning in autistic individuals across the
for whom new prescriptions of antipsychotics are lifespan and both for those with and without intel-
shown to be signicantly more common lectual disability (Hill 2004). Related to this, a
(Sheehan et al. 2015). popular idea in the literature has been that decits
The role of psychological factors in the health in executive functioning may underlie a range of
and wellbeing of autistic adults is another area that social and behavioral characteristics evident in
is poorly understood. Psychological factors ASD (Hill 2004). As with other areas of function-
including coping, resilience, self-esteem, and ing, the vast majority of the available literature in
emotion regulation have been increasingly recog- this area is restricted to childhood and early
nized in gerontology as key adaptive mechanisms adolescence.
for all adults as they age (Bowling and Iliffe There is limited evidence available regarding
2011). However, there is little extant information the developmental trajectory of executive func-
examining such psychological factors specically tioning in autistic individuals. Cross-sectional
in autistic adults. studies have provided some insight into the devel-
Overall, as with physical health, the mental and opment of executive functioning across the
psychological health of autistic adults is a eld lifespan. One study examining performance on
that would benet from further detailed studies. executive functioning tasks of autistic boys with
Robust descriptive and longitudinal examinations no intellectual disability found them to display
of the presentation, correlates, and trajectory of decits in inhibition, exibility, and planning
different conditions in autistic adults across the compared to their non-autistic peers, but also
full spectrum would be valuable. In particular, that the older group (mean age = 13.2)
specic studies of age-specic and ageing- outperformed the younger group (mean
related mental health conditions and related age = 9.2) on these tasks (Geurts and Vissers
interventions are needed. Additional investiga- 2012). Similarly, a 3-year longitudinal study
tions are also needed into the extent and reasons suggested improvement in the planning domain
for different drug-prescription practices. of executive functioning in autistic children
Finally, more concentrated efforts are needed (Pellicano 2010). These ndings are consistent
to investigate the function and predictive value with longitudinal reports showing the lessening
of adaptive psychological mechanisms in of ASD symptoms over time (Shattuck
health and wellbeing outcomes for this adult et al. 2007). However, executive functioning def-
population. icits are still found in adults. One study of older
(mean age, 64 years) autistic adults without intel- reported that sensory experiences can be both
lectual disability found impairments in sustained problematic and enjoyable for autistic adults and
attention, working memory, and uency (Geurts span visual, auditory, tactile, olfactory, and ves- A
and Vissers 2012). Taken together, these cross- tibular stimuli (Robertson and Simmons 2015).
sectional and longitudinal studies suggest that A dening feature as to whether the sensory expe-
decits in executive functioning are apparent rience is positive or negative depends on whether
across the lifespan. However, the precise devel- the autistic adult has control, or perceived control,
opmental trajectory of executive function across over the sensory stimuli. Different sensory stimuli
the lifespan and the interaction with age, intellec- and environments can have extremely debilitating
tual ability, lifestyle, and health related variables effects on autistic adults and can evoke nausea,
require detailed and very long-term study. physical pain, cause the adult to become immo-
Considering the prevalence of dementia in bile, and negatively affect the adults ability to
older adults throughout Western countries, we concentrate or attend to a task. This has signicant
may assume that a substantial number of autistic implications for an adults participation in
adults also develop dementia. However, there is employment and leisure activities, functioning
very little research examining the prevalence, pre- appropriately in social situations, and attending
sentation, and trajectory of dementia in this pop- health care appointment/services and other
ulation. There are two conicting possibilities age-specic activities. Further exploration of the
regarding the representation of dementia in autistic prevalence and changes in sensory processing in
populations. The rst is that there may be an under- autistic adults as they age is required, as well as
representation of dementia in autistic adults. Some further investigations of specic triggers and
researchers believe hyperplasticity (Oberman potential coping strategies.
and Pascual-Leone 2014) of the ASD brain may
be protective against age-related cognitive decline
and dementia. Another possibility is that develop- Participation and Lifestyle
mental effects interact with environmental and
medical risk factors to result in an overrepresenta- For autistic adults who are ageing, little is known
tion of dementia in autistic adults. Recent reports of about participation (e.g., employment, ongoing
thinning in the tempo-parietal cortex in young education, leisure, volunteering, etc.) and lifestyle
autistic adults raise questions about whether such factors (e.g., exercise, diet, smoking, alcohol,
effects may give rise to premature ageing, cogni- drug use, etc.) and how they affect health and
tive decline, and dementia (Mukaetova-Ladinska quality of life. Achieving and maintaining social
et al. 2012). The exact nature of the relationship participation and other lifestyle activities present
between dementia and ASD awaits discovery. Nev- unique challenges for autistic adults due to their
ertheless, dementia has a signicant impact on the social, communication, and behavioral chal-
individual, family, and society, including in people lenges. Exploration of social factors in autistic
with ASD. adults indicates that this population tends to do
A key feature which is now listed in the poorly on objective indicators of social function-
DSM-V criteria for ASD is hyper- or hypo- ing (Howlin et al. 2013) and many report feelings
reactivity to sensory input or unusual interests in of loneliness and isolation (Tobin et al. 2014). In
sensory aspects of the environment (American terms of broader lifestyle factors, autistic adults
Psychiatric Association 2013). Unusual sensory are reported to attain low levels of employment,
processing has been found to occur in 30100% of education, and independence, which have led to
autistic individuals, with one study reporting 95% most extant outcome studies concluding that
of autistic adults self-reporting extreme levels of autistic individuals attain poor overall outcomes
sensory processing on at least one quadrant of the in adulthood (Henninger and Taylor 2013). There
Adult/Adolescents Sensory Prole (Dawson and has been discussion regarding the role of IQ in
Watling 2000; Crane et al. 2009). Research has determining such outcomes, though studies
conducted with a range of samples have indicated and developing treatments for autistic individuals
that autistic adults experience poor social integra- by allowing a holistic prole of their health and
tion regardless of their IQ (Henninger and Taylor wellbeing to be constructed (Burgess and Gutstein
2013). 2007). Further investigation of QoL for ageing
In regards to life style factors, autistic adults autistic adults and identication of factors which
have been reported as using alcohol and drugs less positively or adversely inuence QoL is needed,
than the general population (Croen et al. 2015). given the lack of a solid evidence base.
Participation of adults in physical activities is
relatively unknown, though studies in children
with ASD indicate that they appear to be less Informal and Formal Supports
active than their non-autistic counterparts (Pan
2008). In addition, studies indicate that health Supports and services are central aspects of the
problems resulting from sedentary or minimal- lives of autistic individuals throughout their
activity lifestyles such as obesity and cardiovas- lifespan, regardless of their level of functioning
cular disease are more common in adults with and symptom severity. These supports include
intellectual and developmental disabilities such informal supports such as supportive social rela-
as ASD (Yamaki 2005). This has signicant tionships and more formal supports for participa-
implications during ageing as maintenance of tion in society and everyday activities. The
physical activity is largely accepted to have a positive relationship between social support and
protective effect on overall health and cognitive quality of life (QoL) is well established for the
function. Investigation of participation and life- general population. A substantial number of stud-
style factors which autistic adults are engaged ies have investigated social support and its effects
with as they age is required. This investigation for autistic adolescents and younger adults, but
needs to rstly gain an understanding of ageing there is a paucity of evidence for adults beyond
effects on such activities, and then to identify the the post-secondary school transition period. Infor-
best ways to improve participation which may mal social support has been identied as an impor-
then inuence overall health and quality of life tant predictor of QoL in a systematic review of
of ageing autistic adults. fourteen studies investigating the relationships
Some research has focused on quality of life between social participation, social support, and
(QoL) as an overall indicator of wellbeing for this QoL in autistic adults (Tobin et al. 2014). Evi-
population. These studies have relied on a select dence suggests that perceived, rather than actual,
range of measures that assess QoL as a informal support is a strong predictor of QoL but
multidimensional construct including a range of also that unmet formal support needs contribute to
dimensions: physical and mental functioning, poorer QoL in autistic adults (Renty and Roeyers
relationships and social inclusion, personal devel- 2006). The importance of person-centered
opment, family and wider environments, recrea- approaches to support intervention was also iden-
tion and leisure, safety and security, and tied in this review as important in increasing
subjective wellbeing (Burgess and Gutstein complex skill sets (Tobin et al. 2014). It would
2007). A meta-analysis of 10 QoL studies across be particularly useful to investigate how the rela-
the lifespan demonstrated QoL to be lower in tionship between social support and QoL may be
autistic populations compared to their different for adults with different levels of func-
non-autistic counterparts, and no associations tioning and how this relationship may change
between the individuals QoL and their age, IQ, with age. This would inform the development of
or autism symptom severity (van Heijst and targeted interventions and support solutions
Geurts 2014). Notably, only one of these studies across the lifespan.
examined QoL in an adult sample over the age of Reviews of the availability, quality, and acces-
50. QoL has been argued to be a suitable and sibility of services for autistic adults within each
advantageous construct for examining outcomes region or country are needed to provide important
insight to the service needs and circumstances of large number of autistic adults are ageing either
autistic adults. Existing reviews and reports from unaware of their condition, without a formal diag-
the United States, the United Kingdom, and Aus- nosis or with a misdiagnosis of a different condi- A
tralia report a general lack of supports available tion. The hidden nature of this population
for autistic adults (Freedman 2014; Shattuck presents some difculties for research, which
et al. 2012; Roth 2013). This is unsurprising include identifying recruitment pathways and
given the overall lack of available information determining inclusion criteria for adults who do
regarding the needs and circumstances of autistic not have an ofcial diagnosis. Such issues must be
adults. In order to ensure the effectiveness of carefully considered when conducting research,
services, the evidence base on which existing especially during stages of recruitment and in the
services have been developed should be surveyed. interpretation of ndings.
Accessibility of services is another key issue to be Overall, several key recommendations may be
addressed, especially for those for whom ASD made for future research regarding ASD in later
symptoms may affect access, those living in life. A common thread throughout this discussion
rural areas, those who are time and resource- has been the lack of robust research evidence for
poor, and those from culturally and linguistically the years beyond the post-school transition phase
diverse backgrounds. Furthermore, some qualita- in virtually all areas of health and wellbeing.
tive evidence from the United Kingdom suggests Research focusing on this period of life is urgently
that autistic adults, particularly those considered needed, considering the substantial prevalence of
higher functioning due to their higher IQ and/or ASD, global trends in population ageing, and that
less severe symptoms, are prone to falling the rst cohorts of diagnosed adults are now enter-
through the gaps of services and supports ing middle age and older adulthood.
(Grifth et al. 2012). Being a spectrum disorder, Considerable research efforts are required to
service and support needs will range widely improve the understanding of the circumstances,
between individuals and this must be considered needs, and challenges of autistic adults in later
when developing and reviewing services for this life. Such efforts should include both cross-
population. In addition, reviews of existing health sectional and longitudinal examinations of health
and disability services in terms of their coverage and wellbeing. Importantly, our understanding of
of autistic adults would be useful. autism in later life should be informed not only by
quantitative interrogations but also by qualitative
research that examines the lived experience and
Challenges and Future Directions subjective perspectives of autistic adults and other
relevant parties such as their families and health
There are unique challenges in studying ASD in care providers. Such mixed-methods interroga-
later life. The rst is the heterogeneity of the tions allow for the creation of a more complete
spectrum itself. Being a spectrum disorder, indi- picture of autism in later life.
viduals with ASD vary widely in their level of Findings from the detailed investigations of
intellectual and communicative functioning, ASD in adulthood should be interpreted in the
severity of symptomatology, and presence of context of the wealth of information available
additional conditions. This makes it difcult to regarding ASD in childhood, in order to develop
generalize ndings beyond each study sample a whole lifespan understanding of ASD. Also, the
and its unique characteristics. It may be useful to well-documented presentation of ageing-specic
investigate suitable ways of grouping autistic health conditions in the general population can be
individuals based on certain factors such as IQ a useful source for developing specic research
or gender to make more generalizable and useful questions and for assessing the relative state of
interpretations of research ndings. autistic adults compared to the general population.
A second issue is the hidden nature of adult It should also be noted that our present under-
autistic populations. It is likely that a potentially standing of ASD in later life and consequently
also the discussion throughout this entry relies outcomes exist for this population in adulthood.
heavily on studies from the United States and the While other areas such as cognitive functioning,
United Kingdom. Keeping in mind the inuence participation, lifestyle, and supports have not been
of wider contextual factors on the health and entirely unexamined, the quality and quantity of
wellbeing of populations in general, efforts are this evidence is limited. This topic area would
needed to develop a deeper understanding of the benet from more robust investigations that exam-
specic circumstances facing autistic adults ine not only the presentation and correlates of ASD
across different geographical and cultural con- in later life but examine the lifespan trajectory of
texts including lower- and middle-income such indicators as individuals get older.
countries.
Without a thorough understanding of the
unique circumstances and challenges of ASD in Acknowledgments
later life, it is difcult to develop adequate and
effective services for this population. Such issues The authors acknowledge the nancial support of the
have been illustrated in studies that nd a clear Cooperative Research Centre for Living with Autism
lack of knowledge and training on the part of (Autism CRC), established and supported under the
health professionals in providing care for autistic Australian Governments Cooperative Research
adults (Wareld et al. 2015). Related to this, there Centres Program. The candidate also acknowledges
is the need for future researchers to consider the the nancial support of the Autism CRC.
translational components that may arise from their
ndings and to maximize the utility of their
research in this sense.
Cross-References
In addition to more applied research, there is
also the opportunity and need for the development
Advocacy with Older Adults
of theories specic to ageing and ageing on the
Aging, Inequalities, and Health
autism spectrum. For example, successful age-
ing (Rowe and Kahn 1987) is an emerging theory
Aging and Quality of Life
in the social gerontology literature being devel-
Age-Related Changes in Abilities
oped to understand desirable ageing standards for
Comorbidity
older adults. However, the present theoretical and
Clinical Issues in Working with Older Adults
empirical literature on the concept is largely
Disability and Ageing
exclusive of disabled individuals. Given the high
Healthy aging
rates of disability in old age, it would be useful
Life Span Developmental Psychology
from both personal and societal level to develop
theories of ageing that consider those ageing with
Medication-Related Issues in Later Life
a lifelong disability such as ASD.
Psychological Theories on Health and Aging
Quality of life in older people
Social Policies for Aging Societies
Summary
Social Support and Aging, Theories of
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Automaticity and Skill in Late Adulthood 349
Definition attentional resources. From a descriptive stand-

point, task performance might be considered auto-
Automaticity refers to cognitive processing that matic when it is fast, effortless, obligatory, A
requires few mental resources and describes both autonomous, and occurs without conscious
processes that are innately or spontaneously awareness (Logan 1988). Automaticity is an
effortless as well as those that engage fewer inherent property of some tasks but develops
resources following practice or training. Skill with practice for other tasks, as distinguished by
refers to cognitive processing that has reached a seminal theories of automatic processing
high level of competence and mastery as a result advanced by Hasher and Zacks (1979) and
of experience and investment. Schnieder and Shiffrin (1977).
Perspectives on Automaticity
Automaticity and Skill in Late Adulthood Cognitive processes may be conceptualized as fall-
ing on a continuum, from those that are relatively
This entry will review theoretical perspectives, effortful and require substantial processing
historical ndings, and recent developments in resources, such as performing complex mental
the study of automaticity and skill in older adult- arithmetic, to those that are relatively automatic
hood. This topic is of particular interest for the and require fewer or minimal processing resources,
present volume because automaticity and skill such as navigating the familiar route from ones
represent a critical dissociation in the study of work to home (e.g., Cohen et al. 1990). Some
cognition and cognitive aging. Whereas older tasks appear to be innately automatic, often requir-
adults often show reduced competency in novel ing few resources from very early in development
and unfamiliar tasks, performance is typically and universally across life experiences (Hasher and
spared for the performance of well-practiced Zacks 1979). From the perspective of cognitive
tasks, or tasks that are inherently automatic. This aging, the standard nding is that such tasks rarely
distinction accounts in part for one of the most show age-related declines, as is the case for atten-
notable paradoxes in the study of cognitive tional orienting (Hartley et al. 1990; Jennings
aging that healthy older adults generally func- et al. 2007), implicit memory (Hasher and Zacks
tion quite successfully in their everyday lives, 1984; Amer and Hasher 2014; but also see Howard
despite the marked declines that are seen in labo- and Howard 2013), familiarity-based recognition
ratory assessments of cognitive ability. Indeed, the (Jacoby 1992; Yonelinas 2002), and the processing
empirical study of cognition depends in large part of emotional cues (e.g., Johnson and Whiting
on tasks that are novel, controlled, and reduction- 2013). Other tasks are not inherently automatic
ist, whereas older adults daily lives involve com- and instead involve a shift from effortful to auto-
plex encapsulated domains and opportunities for matic processing but are also largely unaffected by
compensation. This dissociation in the outcomes aging because the learning underlying the automa-
of cognitive aging highlights the distinction ticity was acquired in early life, as with the lexical
between effortful and automatic processing that prociency that underlies performance in the Stroop
occurs in persons of all ages, with unfamiliar tasks task (e.g., Verhaeghen and De Meersman 1998).
often requiring substantial cognitive resources In terms of the mechanisms that underlie auto-
and well-practiced tasks proceeding in a more maticity development, several possibilities have
uent manner. been advanced, including strength-based (Cohen
et al. 1990), memory-based (Logan 1988; Rickard
1997), and process-based (Fitts 1964; Ackerman
Automaticity 1988; Anderson 1987; EPIC Meyer and Kieras
1999) perspectives. These different perspectives
Automaticity is often dened in contrast to cog- shed light on diverse but overlapping classes
nition that involves effort or the involvement of of automatic processing and development
(Fisk et al. 1996). For the most part, these models When considering memory-based automatic-
have been developed and rened by examining ity, older adults transition more slowly compared
performance on laboratory tasks of automaticity to younger adults, in part due to slower learning
development. (Jenkins and Hoyer 2000). Indeed, for some tasks,
Strength-based models of automaticity con- older adults learning is not simply slower but
ceptualize learning as occurring as a result of fails to reach automatic levels even following
attention training, describing a transition from extensive training (e.g., Maquestiaux et al. 2010,
controlled search for information to automatic 2013). In contrast, memory-based automaticity
detection by contrasting associated responses to has been found to develop rapidly for older adults
target stimuli versus distractors in visual search in the well-practiced domain of reading (Rawson
domains following considerable exposure and Touron 2009, 2015).
(Schneider and Shiffrin 1977). Beyond the cognitive changes that can slow
In contrast, memory-based theories of automa- learning in older adulthood, age differences in
ticity propose that skill development is driven by a automaticity development have also impacted an
shift from responding based on an algorithmic aversion by older adults to utilize memory strate-
strategy to responding based on retrieval from gies after learning has occurred (Touron 2015).
memory. In Logans instance theory account Memory avoidance by older adults appears to be
(1988), exposures during practice lead to the accu- driven by a number of different factors, including
mulation of instances in memory. Strategy is deter- low condence in memory ability (Touron and
mined by a race between the algorithmic and Hertzog, 2004a,b; Frank et al. 2013; Hertzog
memory alternatives with an increasing distribu- and Touron 2011) and a failure to understand the
tion of completion times for each. After sufcient costs and benets of memory use relative to the
exposures, instance retrieval is expected to occur algorithmic strategy (Hertzog et al. 2007; Touron
more rapidly than the algorithm can be executed. and Hertzog 2014). Older adults strategy use
Process-based theories also involve increasing during learning is also inuenced by age-related
reliance on memory systems but also increasingly decreases in task-switching preferences (Hines
incorporate reliance on sensory-motor (e.g., et al. 2012) that are likely linked to reduced task-
Ackerman 1988) and procedural (e.g., Anderson switching ability (Kray and Lindenberger 2000;
1987) skills. These models are able to account for Reimers and Maylor 2005), particularly in situa-
a wide swath of both elemental and complex tions where the optimal task strategy is not appar-
human cognition (e.g., see the modeling of simple ent (Kray et al. 2002). Older adults are able to use
digit data entry and the complex radar ghter external cues as an aid to strategy decisions but
pilot task; Fornberg et al. 2012). also might overutilize these cues beyond their
practical applicability (Spieler et al. 2006;
Age Differences in Automaticity Lindenberger and Mayr 2014). Older adults
Research examining age differences in automatic- avoidance of the less demanding memory strategy
ity from the perspective of attentional strength has can be seen as volitional, given that instructions
primarily demonstrated age differences by exam- and modest incentives increase memory use to
ining performance in visual and memory search levels consistent with older adults memory abil-
paradigms, with older adults showing reduced ities and similar to memory use by younger adults
activation of associated responses to target stimuli (Touron et al. 2007; Touron and Hertzog 2009).
even following extensive training (Fisk These ndings are consistent with the perspective
et al. 1996). However, some aspects of automatic- that older adults tend to be more conservative in
ity in visual search performance do show stability decisional elements of cognitive tasks (Ratcliff
with aging. For example, older adults do not show et al. 2000, 2006) and indicate that memory-
impairments in the top-down guidance of visual based models of automaticity should allow for
search (Madden et al. 2004, 2005). strategy choice processes (Rickard 1997).
Research taking a process-based approach to of skill often breaks studied tasks down in order to
automaticity demonstrates that older adults can examine their component operations and abilities.
develop automaticity in some but not all compo- As with the study of automaticity, age differences A
nents of cognitive tasks. For example, when in skill development and skilled performance vary
searching a set of information held in memory, depending on the particular focus of study.
older adults are able to develop automaticity in Research on the establishment of skill, compo-
memory-based components but not attentional nents of skill, and outcomes of skill have taken
components of the task (Fisk et al. 1995). various approaches, from the study of skill develop-
Expanded process models are also able to account ment using novel tasks in a laboratory environment
for older adults slower transitions to automatic (ranging from simple reaction time tasks to com-
task approaches by incorporating age-related plex video game tasks) to the examination of more
declines in the cognitive abilities that underlie complex skills in real-life domains (such as tech-
the task, as well as age differences in strategic nology use), to the study of skills with extended
choices (e.g., Meyer et al. 2001). When consider- training and exceptional populations within
ing the changing roles of knowledge, perceptual- expert domains (such as chess or bridge). For a
motor ability, and memory capacities over the few tasks, older adults performance appears to be
course of training on a task, older adults have similar to younger adults in terms of both the
been shown to have qualitatively similar patterns development and execution of skills (as for simple
to those of young adults (Hertzog et al. 1996; perceptual motor tasks, Salthouse and Somberg
Rogers et al. 2000). 1982). For other tasks, older adults are slower to
Although older adults are slower to acquire acquire skills but then perform at levels compara-
automaticity in new skills, they frequently utilize ble to younger adults (as in the mental arithmetic
already acquired knowledge and automatized training by Charness and Campbell (1988)). For a
skills in everyday life and in this manner may third class of tasks, older adults differ in both the
compensate for declines in cognitive abilities. development and asymptotic performance of skilled
Indeed, interventions that capitalize on automatic activities, even when the task approach is qualita-
processes can improve older adults everyday tively similar (as in a video game interface that
functioning. For example, medical self-care aggregates several simple tasks described by
adherence can be improved by requiring partici- Salthouse and Somberg (1982) and the vigilance
pants to form implementation intentions of the learning studied by Parasuraman and Giambra
critical health behavior, so that these detailed (1991)).
plans can later be automatically available when
the behavior is required (Liu and Park 2004). In a Elements of Skilled Performance
similar manner, age-related increases in Skill domains rely on the coordination of and
established knowledge in relevant domains can support from relevant component cognitive oper-
benet automaticity development for complex ations. Typically, skilled performance integrates
task skills, such as nancial planning, in the lab- uid and crystallized intellectual abilities (e.g.,
oratory (Ackerman and Beier 2006; Beier and Ackerman 1992). Declines in uid abilities, such
Ackerman 2005), particularly in the early stages as processing speed, can present obstacles to skill
of learning. development and performance, whereas crystal-
lized abilities such as vocabulary knowledge are
typically retained or augmented with aging and
Skill can therefore support new skills (Salthouse 2004;
Schaie 1996). Memory involvement is often key
In comparison to many of the automatic processes to expert performance (Ericsson and Chase 1982),
and tasks discussed above, domains of cognitive as in the chunking of complex representations to
skill are often quite complex. Given this, the study more streamlined semantic concepts (Chase and
Simon 1973). This chunking is particularly criti- to experience, which might discourage investment
cal given age-related declines in working memory in developing new skills (Kanfer and Ackerman
capacity (Bopp and Verhaeghen 2005) and the 2004). Older adults also commonly have a lesser
substantial requirements for coordinating infor- interest in pursuing new knowledge and skills due
mation in complex skill performance. Skills also to an increased motivation towards interpersonal
rely heavily on speeded information processing, and emotional goals (Carstensen 1995).
and declines in processing speed contribute sub- Metacognitive beliefs are likely to also play a
stantially to age-related differences in many dif- role, including general and task-specic self-
ferent areas of cognitive performance efcacy and performance monitoring that might
(Salthouse 1996). encourage continued performance or shifts in task
Several large-scale studies of cognitive train- approach or strategy (see Hertzog and Hultsch
ing and interventions have examined whether (2000) for a review). Positive beliefs regarding
older adults skilled performance may be opti- memory control and ability, and monitoring that
mized with extensive exposure to related task highlights the performance success, can lead to
components. Due in part to the recent widespread more optimal strategies and outcomes for
availability and popularity of computerized cog- performance.
nitive training programs, such as Brain Age and Compensatory and strategic factors often inu-
Lumosity, there is considerable interest in evalu- ence older adults performance within skilled
ating the efcacy of cognitive training, as well as domains, both in everyday skills and expert per-
the breadth of any benets that arise from training. formance. Healthy older adults typically retain
Available research typically shows fairly narrow high levels of functioning in everyday tasks, in
ability-specic benets from training for older part due to a tendency to perform familiar tasks in
adults (e.g., Stine-Morrow et al. 2014; Willis and highly routinized domains. These pockets of abil-
Nesselroade 1990), with improved performance ity represent encapsulated regions that do not
on the trained tasks but not for intelligence or typically show the age-related cognitive decre-
cognition more broadly. These ndings are con- ments present in more novel and unpracticed
sistent with the broader literature on cognitive task domains. This encapsulation can be an inci-
training (e.g., Redick et al. 2013). This pattern dental outcome of pursuing personal interests and
has been obtained across a variety of basic cogni- vocations or can also be more purposeful; the
tive abilities, such as memory, reasoning, and selective optimization with compensation model
processing speed (e.g., mnemonic training by (Baltes and Baltes 1990) describes the tendency of
Verhaeghen et al. (1992) and Willis older adults to select activities more narrowly and
et al. (2006)). However, some promising evidence alter task approaches in order to optimize their
for transfer has been obtained, such as benets for performance in skilled domains. For example, in
general health and well-being (i.e., Wolinsky later life an expert auto mechanic might choose to
et al. 2006, 2009, 2015). With a broader invention selectively repair those car models or systems that
approach, research by Park and colleagues has they have the most prior experience, in order to
demonstrated that an engaged cognitive and per- rely on established knowledge and minimize the
haps social lifestyle can also benet older adults cognitive resources needed for the diagnosis and
performance in memory and uid intelligence solving of unfamiliar problems. From the perspec-
(Park et al. 2014; Stine-Morrow et al. 2008; also tive of metacognitive training benets, research
see Hultsch et al. 1999). has demonstrated that cognitive training can be
enhanced with concurrent interventions aimed at
Other Influences on Skilled Performance boosting cognitive self-efcacy (West et al. 2008).
Noncognitive characteristics also play a role in Specic interventions that enhance metacognitive
skilled performance, including those related to monitoring and strategy updating also allow
personal interests, motivation, and personality. older adults to improve cognitive performance
Older adulthood sees a shift towards less openness (Bottiroli et al. 2013).
Everyday Skills cognitive declines (for a review, see Bowen

Other research has examined older adults devel- et al. 2011). From the perspective of both self-
opment and retention of skills in everyday and supervisor ratings, older workers are gener- A
domains such as driving, technology adoption, ally shown to fare quite well in terms of perfor-
and the work context. For many older adults, the mance as well as indices such as attendance
preservation of driving skill is particularly critical, and other personal contributions. In addition, the
given the implications for continued maintenance work environment can provide older adults with
of an active and autonomous lifestyle. Although mental challenge and social support that can
cognitive, sensory, and physical declines can facilitate more positive aging outcomes, particu-
impair driving ability, older adults tend to revise larly when the job requires the processing of
driving patterns in order to compensate for these novel information and completion of varied and
changes. Older adults often have considerable stimulating tasks (Andel et al. 2007). Research
experience and familiarity with driving, but nor- examining exceptional achievements and
mative declines in sensory, physical, and atten- productivity in the work domain has demonstrated
tional abilities can make driving more hazardous that quality work can occur throughout the
for older adults (e.g., Emerson et al. 2012). For lifespan, although there is substantial variability
example, older drivers often avoid periods of busy depending on the particular occupation (Simonton
trafc, night driving, and routes that require left- 1991).
hand turns. Due to these patterns, rates of acci-
dents are not higher for the older adult population, Expertise
although injury from trafc incidents is more fre- The ndings for work domains exemplify the
quent (NHTSA 2014). broader literature on expertise and aging. Older
Although adoption and reliance on technology adults who are experts in a particular skill often
is lower among older adults, use of electronic typify patterns of encapsulation. Substantial liter-
devices can also be benecial to older adults atures on expert performance by master typists,
functioning and independence. Computers and chess players, crossword puzzle solvers (e.g.,
smartphones enable older adults to engage in cog- Hambrick et al. 1999), and bridge players demon-
nitively and socially stimulating activities, and strate that age differences are often eliminated
electronic medical devices can enable the tracking with substantial expertise in a domain. Despite
of health conditions, communications, and out- these ndings, age differences are typically
comes. Older adults are slower to adopt new tech- obtained when the component abilities are exam-
nologies, although historical trends show ined outside of the familiar domain of expertise.
increases in use and competence. In particular, For example, those with expertise that relies upon
those older adults who have minority status, mental imagery (professional graphic designers)
lower education, and lesser nancial resources are no better when implementing a new mental
are less likely to use new technologies, with addi- imagery task, the method of loci mnemonic
tional predictive factors such as cognitive abili- (Lindenberger et al. 1992). Similarly, chess
ties, concerns, comfort, and personal condence experts retain the ability to recall complex spatial
(Czaja et al. 2006). congurations in late life, but only when these
Everyday skill has also been examined within congurations represent meaningful gameplay
the context of changes in work for older adults. for chess pieces, and can therefore rely on
Most people can work productively until fairly established memories. Research focusing on the
late life, although this varies by domain and can role of deliberate practice notes that considerable
be affected by institutional pressures. For individ- investment is required to reach expert levels of
uals who continue to work within a particular performance (e.g., the 10,000 hour rule, Ericsson,
occupation throughout adulthood, the work con- 2006). Other researchers point out that additional
text can become an encapsulated domain that factors must also inuence the establishment of
shows preserved abilities despite general expertise, including intelligence and cognitive
capacities, inherent talent in the domain, and dis- Andel, R., Kreholt, I., Parker, M. G., Thorslund, M., &
positional inuences (Hambrick et al. 2014). Gatz, M. (2007). Complexity of primary lifetime occu-
pation and cognition in advanced old age. Journal of
Aging and Health, 19(3), 397415.
Anderson, J. R. (1987). Skill acquisition: Compilation of
Conclusions and Future Directions weak-method problem situations. Psychological
Review, 94(2), 192210.
Baltes, P. B., & Baltes, M. M. (1990). Psychological per-
This entry has reviewed evidence for both spectives on successful aging: The model of selective
age-related declines and preservation in automa- optimization with compensation. In P. B. Baltes, M. M.
ticity and skill. In general, older adults are most Baltes, P. B. Baltes, & M. M. Baltes (Eds.), Successful
able to maintain functional levels of performance aging: Perspectives from the behavioral sciences (pp.
134). New York: Cambridge University Press.
when tasks rely on abilities that are inherently Beier, M. E., & Ackerman, P. L. (2005). Age, ability, and
automatic, have been automatized early in life, the role of prior knowledge on the acquisition of new
or involve familiar and well-practiced routines. domain knowledge: Promising results in a real-world
In addition to the underlying cognitive capacities, learning environment. Psychology and Aging, 20(2),
341355.
tasks often also involve strategic choices, as with Bopp, K. L., & Verhaeghen, P. (2005). Aging and verbal
the reliance on acquired information for memory- memory span: A meta-analysis. The Journals of Ger-
based automaticity, or the willingness to persist in ontology Series B: Psychological Sciences and Social
the learning of new technologies. Based on these Sciences, 60B(5), P223P233.
Bottiroli, S., Cavallini, E., Dunlosky, J., Vecchi, T., &
ndings, we might support skill acquisition and Hertzog, C. (2013). The importance of training strategy
functioning in older adulthood by structuring adaptation: A learner-oriented approach for improving
tasks in such a way that reliance on established older adults memory and transfer. Journal of Experi-
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Bowen, C. E., Noack, M. G., & Staudinger, U. M. (2011).
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B
Behavior Modification better adherence to medication regimes; behavior

modication and long-term maintenance are cru-
Jennifer Inauen1 and Urte Scholz2 cial at any time during the lifespan, even though
1
Department of Psychology, Columbia the goal of behavior modication may differ
University, New York, NY, USA depending on age. Whereas increasing health
2
Department of Psychology, University of Zurich, and well-being or preventing disease may be
Zurich, Switzerland more achievable goals for younger persons, stabi-
lization is often the more realistic goal in older
age. Irrespective of this, however, behavior mod-
Synonyms ication is usually a prerequisite. The following
sections introduce the key principles of behavior
Behavior change; Behavioral change modication. An overview is given of the behav-
ioral determinants, the techniques by which
behavior modication can be engendered, and
Definition how these can be selected for interventions. The
entry ends with concluding remarks and direc-
Behavior modication means the change of a tions for future research.
current behavior by adopting a new behavior or
by increasing or decreasing the current behavior.
Understanding, predicting, and evoking A Social Cognitive Approach to Behavior
behavior modication is a key topic in all areas Modification
of psychology. It is a crucial means to reaching
personal, organizational, and societal goals across Before the cognitive revolution in the second part
the lifespan, including the major goal to stay of the twentieth century, behavior modication
healthy and well. With chronic disease on the was mostly understood as the learning process
rise, partly due to an increasing aging population, termed operant conditioning (learning by rein-
promoting and stabilizing health and well-being is forcement or punishment), which is associated
more topical than ever (cf. Scholz et al. 2015). most notably with the works of behaviorist
Behavior modication is a major factor to prevent B.F. Skinner. The processes by which behavior
and manage chronic diseases, such as diabetes and modication occurs were considered a black
cardiovascular diseases (e.g., Ornish et al. 1998), box, as they were deemed unobservable and
be it, for example, to normalize blood pressure could therefore not be empirically studied. The
levels by exercising or eating more healthily or by cognitive revolution changed this understanding
DOI 10.1007/978-981-287-082-7
360 Behavior Modification
Behavior Modification,
Fig. 1 Schematic display
of the principles of behavior
modication (Adapted from
Michie et al. (2008))
and led to the social cognitive approach to behav- redirect causal processes that regulate behaviour
ior modication. (Michie et al. 2013, p. 82). There are a great num-
In contrast to the simplistic stimulusresponse ber of BCTs with which researchers and practi-
view of behaviorists, social cognitive theories of tioners aim at modifying behavioral determinants
behavior modication assume that social behav- and behavior. Recent efforts have been directed at
iour is best understood as a function of peoples standardizing denitions of BCTs in order to accu-
perceptions of reality, rather than as a function of mulate evidence on their efcacy (Michie
an objective description of the stimulus environ- et al. 2008, 2013) and to link BCTs to specic
ment (Conner and Norman 2005, p. 5). To illus- behavioral determinants (Abraham 2012). Figure 1
trate this, imagine elderly persons who have summarizes the elements of theory-based behavior
difculties to walk. The objective description modication.
would predict that these difculties will impair
them from getting enough physical activity. The
social cognitive approach, in turn, would assume Determinants of Behavior Modification
that whether or not these persons nd a way to
overcome this barrier and engage in physical There are essentially two types of social cognitive
activity despite their walking impairments (e.g., theories that have been proposed to understand
by doing yoga exercises at home) depends on the and predict behavior modication: continuum
persons perception of this barrier, for example, theories and stage theories. Continuum theories
on their motivation to exercise and on their belief assume that persons can be characterized on a
that they can exercise, even when this is difcult continuum from action readiness to actual behav-
(a behavioral determinant known as self-efcacy, ior modication (Abraham 2012). Stage theories,
Bandura 1999). Various theories have developed on the other hand, assume that the process of
from this social cognitive approach. These theo- behavior change comprises a discrete number of
ries have identied several behavioral determi- stages an individual has to pass through to modify
nants, with the theory of planned behavior a behavior from adoption to long-term behavioral
(Ajzen 1991) and the health action process maintenance. A representative of each type of
approach (Schwarzer 2008) as a classic and a behavior theory is presented next.
more recent example, respectively. A classic continuum model is the theory of
A further principle of the approach is that the planned behavior (Ajzen 1991). At the theorys
behavioral determinants (or causal processes) are core are behavioral intentions. They reect . . .
modiable and that they can be specically tack- peoples decisions to perform particular actions
led with behavior change techniques (BCTs, (Sheeran 2002, p. 2). The theory of planned
Michie et al. 2008). Behavior change techniques behavior predicts that when people form an inten-
are . . .an observable, replicable, and irreducible tion to perform a behavior, they are more likely to
component of an intervention designed to alter or carry out this behavior. Behavioral intentions, in
Behavior Modification 361
turn, are predicted by attitudes toward the behavior transitional variables (e.g., the decision to take
(i.e., persons valuations of the behavior and its action) that move persons from one stage into
consequences and the expected likelihood that the next (e.g., from the pre-action to the action
these will occur), the subjective norm (i.e., beliefs stage, cf. Schwarzer 2008). Each stage transition
about others expectations regarding the behavior is predicted by a specic set of stage determinants B
and a persons willingness to comply with these), that are causally related in some theories (e.g., the
and perceived behavioral control (i.e., beliefs about HAPA, Schwarzer 2008). Stage theories are com-
facilitating and hindering factors and their subjec- monly considered more comprehensive than con-
tive power to impede behavior performance). The tinuum theories, but also more complex. One of
latter is also assumed to have direct effects on the earlier and possibly the most prominent stage
behavior (Ajzen 1991). In summary, the theory of theory is the transtheoretical model of behavior
planned behavior predicts that persons are most change (Prochaska and DiClemente 1983). In its
likely to perform or modify a behavior when they most frequently used version, the transtheoretical
are highly motivated (i.e., have strong intentions as model proposes ve stages of change:
determined by their attitudes, subjective norms, precontemplation, contemplation, preparation,
and perceived behavioral control) and have high action, and maintenance. Stage progression is
perceived behavioral control. The TPB has been specied by decisional balance (pros and cons of
widely researched and proven useful to explain and behavior), self-efcacy (condence and tempta-
predict several health behaviors (Conner and tion), and ten processes of change: ve cognitive
Sparks 2005). However, a major criticism is the (e.g., consciousness raising) and ve behavioral
nding that while intentions are usually well (e.g., stimulus control). While the idea of separat-
explained by its predictors, behavior is not. This ing the behavior change process into distinct
phenomenon is commonly referred to as the phases may seem appealing, empirical tests of
intentionbehavior gap and indicates that, contrary the transtheoretical model and other stage theories
to many behavior theories assumptions, people have generally yielded mixed evidence for the
who have stronger intentions than others are only distinction of stages (e.g., Sutton 2005). Never-
moderately more likely to perform a specic theless, they remain particularly popular among
behavior than others (Sheeran 2002). This has led practitioners, perhaps because of their clear-cut
to fruitful research on self-regulatory (or volitional) directions for intervention development that is a
factors that may explain how intentions translate consequence of the stage assumption: if persons in
into actions (Schwarzer 2008) and how to over- different stages of behavior change are qualita-
come the gap (Sheeran 2002). Timely health tively distinct, they would require different BCTs
behavior models have incorporated these factors to promote their transitions between the stages.
to mediate intentionbehavior relations. The health This point will be further touched upon in a sub-
action process approach (HAPA, Schwarzer 2008), sequent section. But, rst, an overview of BCTs is
for example, includes volitional mediators such as given.
action planning, coping planning, and action con-
trol (Sniehotta et al. 2005). According to
Schwarzer, the HAPA is a hybrid model, meaning Behavior Change Techniques (BCTs)
that it can be applied as both a continuum model
and a stage theory. There are a vast number of techniques that have
Stage theories have traditionally put more been proposed and applied to modify behavior,
emphasis on factors that can translate intentions with the abovementioned operant conditioning
into actions than continuum theories. As men- being one of the rst of what is now termed a
tioned above, stage theories assume that the BCT. A major challenge in behavior modication
behavior change process can be divided into a research is the fact that the same BCTs are often
xed sequence of qualitatively distinct stages termed differently by behavior change profes-
(or phases). At the core of these theories are sionals from different elds. Or the same term is
used, but different techniques are meant by it. This This will help selecting specic BCTs to target
consequently limits the potential of intervention behavioral determinants that are particularly
research to produce evidence on the effectiveness important to change a specic behavior.
of specic BCTs. In an effort to address this issue,
several research groups have recently focused on
creating taxonomies of BCTs with standardized Selecting BCTs
denitions. This work is crucial to building a
cumulative science of behavior modication. Social cognitive theories and empirical evidence
The most widely accepted, systematic, and com- provide guidance which determinants to focus on
prehensive taxonomy that has emerged from these to achieve behavior modication. BCT taxon-
efforts is the BCT taxonomy v1 by Michie and omies and empirical research provide an overview
colleagues (2013). In its rst version, the taxon- of techniques available to modify behaviors. But
omy comprises 93 distinct BCTs that were col- behavior change researchers and practitioners also
lected through extensive reviews of the scientic need knowledge about the link of BCTs and
and applied behavior modication literature from behavioral determinants, so BCTs can be speci-
various elds, such as clinical psychology, social cally selected to tackle the intended determinants.
psychology, and health psychology. The BCTs are Also, when evaluating behavior change interven-
grouped into 16 clusters. These include clusters of tions, the mechanisms of the intervention can be
socialpsychological BCTs, e.g., goals and plan- ascertained by assessing the behavioral determi-
ning, which comprise BCTs such as problem solv- nants assumed to be modied by the administered
ing and action planning, or the BCT cluster BCTs and performing mediation analysis. This
feedback and monitoring. Other clusters not only offers a tool to test social cognitive
contain BCTs to foster social support, making behavioral theories but can also deliver important
contextual changes of antecedents (e.g., BCTs information as to why an intervention was suc-
restructuring the physical environment and cessful (what were its active ingredients?) or not
adding objects to the environment) or providing (did the intervention fail to enhance the behavioral
reward and threats. determinants?). For example, in an intervention
The taxonomy should potentially be applicable study on physical exercise in cardiac rehabilita-
to behavior modication in any eld of interest, tion patients, two intervention groups were com-
from clinical to health psychology and pared to a standard-treatment control group
pro-environmental behavior modication to (Scholz et al. 2007). The rst intervention group
changing workplace behavior. There are, how- received an action planning intervention, that is,
ever, also behavior-specic taxonomies that may participants were asked to plan when, where, and
be helpful in providing a subset of these BCTs, as how to implement their physical exercise. The
not all of the abovementioned techniques are rel- second intervention group received a combined
evant to all behaviors. This can be especially action plus coping planning intervention. The
useful when such taxonomies also include infor- coping planning part comprised asking partici-
mation on the effectiveness of the BCTs for mod- pants to think about barriers to their physical
ifying a particular behavior. exercise and to subsequently form detailed plans,
The BCT taxonomy v1 was a vital rst step when, where, and how they will overcome these
toward standardization of BCT research and prac- barriers. Two months later, the combined planning
tice. Still, it can be expected that this taxonomy group was the most successful in increasing their
will further develop in the coming years, as it will physical exercise levels. This effect was indepen-
be rened by researchers in psychology and other dent of the age of participants. However, a closer
elds as well as practitioners. Another topic that look at the behavioral determinants revealed
also needs to be addressed is the mapping of BCTs age-differential effects: older individuals reported
onto specic behavioral determinants, i.e., what the highest levels of coping planning already at
BCTs can modify which behavioral determinant. the baseline assessment compared to young and
Behavior Modification 363
middle-aged participants. The latter two age one could jump into the causal chain (Sutton
groups increased their coping planning after the 2008, p. 73) and aim at directly altering proximal
intervention whereas the older participants determinants. In addition, some approaches, such
reported relative stability of coping planning as intervention mapping (Bartholomew
across the two months. Self-reported action plan- et al. 2011) or the RANAS (Risk, Attitude, B
ning in contrast was not changed by the interven- Norms, Ability, Self-Regulation) approach
tion, nor were there age-differential effects over (Mosler 2012), suggest procedures to target
time (Scholz et al. 2007). Thus, not only analyzing behavioral determinants that are of particular
the direct effects of BCTs on behavior modica- importance to the target population and context
tion but also examining the effects on the behav- (Mosler 2012; Bartholomew et al. 2011). In the
ioral determinants provides important information intervention mapping approach, this step is
on what the active ingredient of an intervention is referred to as needs assessment (Bartholomew
and whether or not this applies, for example, to et al. 2011). It entails a detailed literature review
people of all ages. and survey in the target population to carefully
Unfortunately, with few exceptions (Mosler adapt the intervention to the context.
2012), behavior theories provide little guidance A criticism of the one-size-ts-all approach is
on which BCTs can modify which behavioral that individual particularities are not taken into
determinants, and empirical research on the account. Tailored interventions seek to overcome
BCTbehavioral determinantbehavior link is this. They are dened as . . .any combination of
still rare. There are, however, some expert groups strategies and information intended to reach one
that have proposed links (Michie et al. 2008; specic person, based on characteristics that are
Abraham 2012) or are currently working on this. unique to that person, related to the outcome of
Abraham (2012), for example, provided a menu of interest, and derived from an individual assess-
40 BCTs linked to behavioral determinants. In any ment (Kreuter et al. 2000, p. 277). One form of
case, much empirical research is needed to test tailoring is stage tailoring. As discussed above,
these proposed links. stage theories assume qualitatively distinct behav-
When planning an intervention, another ques- ior change stages. Consequently, different inter-
tion is which behavioral determinant to target. On ventions result for persons who are in different
the one hand, this depends on the goal of the stages of change. Following a stage theory
endeavor, e.g., testing a particular theory or the approach, the stage of change of each person
more applied goal of evoking greatest possible needs to be assessed beforehand, and everyone
behavior modication. It also depends on the the- receives the intervention that is tailored to their
ory that the intervention is based on. Continuum current stage. By stage theories rationale, inter-
theories and stage theories have different implica- ventions matching individuals present stage of
tions for selecting behavioral determinants for change should allow transition to the next stage,
interventions. As discussed above, continuum whereas mismatched interventions should have
theories assume that their behavioral determinants nil or possibly adverse effects. The prerequisite
increase the likelihood of peoples behavior per- to perform stage-tailored intervention is a staging
formance. This implies that behavior can be mod- algorithm that can reliably assess individuals
ied by changing any of the behavioral stage of change prior to the intervention. The
determinants of the theory and that this holds for transtheoretical model, for example, assumes
all individuals, wherefore this approach is some- time-based criteria to determine individuals
times termed one size ts all. If it is a causal stage of change. This has been frequently criti-
theory, the most distal behavioral determinants cized, because the time criteria seem arbitrary.
should be targeted, as it is assumed that they will More recent theories, such as the HAPA, therefore
work their way through to behavior change by developed psychological staging algorithms that
modifying the more proximal behavioral determi- characterize persons regarding their current inten-
nants of the theory (Sutton 2008). Alternatively, tions and behavior.
An advantage of stage-tailored interventions into at least three stages: pre-intention/motivation,

should be that they take into account the charac- pre-action/volition, and action.
teristics of the target persons and may therefore be In contrast to the behavioral determinant
potentially more effective than not-tailored inter- behavior change link, BCTs and their mechanisms
ventions. However, evidence on this is mixed, to modify behavior require much further research.
which may be due to the lack of reliable staging Important groundwork has been done by produc-
algorithms, and the lack of clear denitions of and ing standardized denitions of the BCTs (Michie
evidence for the predictors of each stage transi- et al. 2013) and by hypothesizing their links to
tion. In particular, it has been criticized that behavioral determinants (Abraham 2012). Now,
stage-tailored interventions usually only use few these denitions require large-scale adoption by
behavioral determinants for assessing stages researchers and practitioners, and empirical inves-
(Abraham 2008). The menu-based approach, in tigations need to test the mechanisms by which
contrast, considers many social cognitive factors, their BCTs modify behavior.
possibly from a compilation of behavioral theo- Regarding environmental factors, the social
ries (Abraham 2008). Each individuals character- cognitive approach makes the argument that
istics are considered, wherefore this approach their inuence on behavior is mediated through
may lead to a menu of as many BCTs as behav- individuals perceptions thereof. However, other
ioral determinants that were considered. elds of research, e.g., environmental psychology,
A disadvantage of this approach is the increased suggest that behavior is best understood as an
effort and complexity for developing and interaction of person by environment. Following
implementing the great number of interventions this viewpoint, it could be helpful to consider
required to meet the needs of all participants. environmental factors that may hinder or facilitate
behavior modication.
Finally, a further line of future behavior change
Conclusions and Outlook research concerns the mode of delivery of inter-
ventions. Whether an intervention is delivered
In summary, behavior modication is related to personally (e.g., by a health professional), by
behavioral determinants that can be modied by mass media (e.g., leaets or television), and by
BCTs. In the health behavior modication eld, the Internet or smartphone should make a differ-
which is of particular importance to the aging ence in its efcacy. But little is known on this
population, theory and research on the behavioral subject yet. Also, the ideal mode of the delivery
determinantbehavior modication link is much could differ for different populations, e.g., for
advanced. Despite an ongoing discussion whether different age groups.
behavior modication is best understood as a con-
tinual process or as divided into discrete stages,
the behavioral determinants of importance are
now, in principal, understood. A behavior change Cross-References
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model (Schwarzer 2008). It species causal Cognitive Control and Self-Regulation
pathways to behavior change, similar to the Decision Making
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latter by volitional factors (action planning and Behavior, Theories of
coping planning, phase-specic self-efcacy, and Health Promotion
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366 Behavioral Analysis
Theoretical Foundations of Behavior and social conditions. In order to understand why

Analysis a particular behavior is occurring, a behavior ana-
lyst attempts to identify patterns in the conditions
Behavior analysis involves the systematic appli- and events that surround the behavior, i.e.,
cation of learning theory to explain why behavior whether events or stimuli (called antecedents)
is occurring. Within this model behavior encom- reliably precede and follow (called consequences)
passes everything a person does including observ- the occurrence of the behavior. The continuous
able behavior as well as what the person thinks interaction of antecedent, behavior, and conse-
and feels (Ramnero and Torneke 2008). Learning quence over time is called the operant contin-
theory posits that an individuals behavioral rep- gency (Skinner 1938/1991). A contingent
ertoire is a product of their genetic and learning relationship between antecedents and conse-
histories (Skinner 1938/1991). The signicant quences is said to occur if systematic observation
heterogeneity of psychological functioning within of behavior reveals that an antecedent reliably
the population of older adults is both predicted increases the probability that a behavior will be
and explained by the models assumption that emitted and the occurrence of the behavior
each human being is unique by virtue of their increases the probability that a consequence will
idiosyncratic genetic and learning histories. The be delivered. Antecedents are environmental
utility of behavior analysis for explaining behav- events or stimuli that are reliably present in the
ior in late life and prescribing interventions to setting in which a behavior occurs. Antecedents
promote behavioral health is signicant as the can be verbal or nonverbal. Verbal antecedents
majority of evidence-based behavioral health may be either the verbal behavior of another per-
interventions share roots in learning theory. son or the individuals own verbal behavior, for
Within learning theory genetic history encom- instance, I know how to do this or This isnt
passes factors that inuence the individuals phys- safe. When an antecedent gains the property of
iology and is reected in the individuals current signaling the availability of reinforcement for cer-
physiological status (e.g., health status, sensory tain behaviors, the behaviors are said to be under
functioning, physical conditioning) as well as in stimulus control in that the presence of the ante-
responses that are natural, biologically driven, and cedent stimulus increases the probability of the
not learned (e.g., salivating at the smell of food, behaviors occurring.
blinking at a bright light). Behavior that is the Within the operant model, consequences are
product of an individuals learning history dened based on their effect on behavior, i.e.,
encompasses responses that are inuenced by whether the consequence results in an increase
environmental experience. or decrease in the probability that the behavior
Learning is conceptualized as occurring within will be emitted in the presence of similar anteced-
two processes: operant conditioning and respon- ents. If it is determined that the probability of a
dent conditioning. Behavior analysis assumes that behavior occurring over time has increased, i.e.,
to the extent that behavior, including both devel- its frequency increased, the consequence is
opmentally normal and dysfunctional behav- labeled a reinforcer; if it is observed that the
iors, is learned it can be unlearned (Krasner and probability of the behavior decreased over time,
Ullman 1965). The assumption of behavioral then the consequence is considered a punisher.
plasticity is the raison d etre for the systematic The adjectives positive and negative distin-
application of learning principles to produce guish different types of reinforcers: if a behavior
behavior change at any point in the life span results in access to a stimulus (e.g., smiling is
(Bijou 1961/1995; Baltes and Barton 1977). reliably followed by a hug from a friend), the
Operant conditioning and functional rela- reinforcer is considered positive. If behavior is
tions. The unit of analysis within operant condi- followed by a reduction in the quantity of a con-
tioning is behavior in context. Context includes sequence (e.g., the intensity of painful emotion
both historical and current physiological, cultural, declines immediately following suicidal ideation;
physical pain is reduced following the ingestion of important to determine if a behavior serves more
an analgesic), the consequence is considered a than one function in order to design an interven-
negative reinforcer. Reinforcement contingen- tion that will effectively address all functions of
cies are identied based on their effect on the the problem behavior.
quantity of behavior, i.e., whether behavior fre- The function of a behavior is determined B
quency increases, is stable, or decreases over time. through a variety of assessment methods:
The identication of the reinforcement contin-
gencies controlling a behavior is a central goal of (a) Experimental functional analysis during
behavior analysis and directly informs the identi- which hypothesized controlling variables,
cation of interventions that would be effective specically the antecedents and conse-
for increasing or decreasing the behavior. Points quences, are directly manipulated while the
of intervention to break the contingency may behavior analyst carefully monitors whether
include: (1) altering the antecedent stimuli to pre- there are changes in frequency of the behavior
vent or increase the probability of the occurrence (Skinner 1938/1991; Bijou 1961/1995).
of behavior (e.g., removing electronic devices and Experimental functional analysis is the most
reading material from a bedroom to promote direct and accurate method of identifying the
sleep, placing medicine containers by the coffee function of a behavior.
pot to increase the probability medication will be (b) Descriptive analysis or assessment involves
taken in the morning as prescribed, camouaging less direct, but often more practical methods
a door to prevent a person with dementia from for generating but not directly testing hypoth-
trying to exit) or (2) discontinuing the reinforce- eses about the function of a behavior. Descrip-
ment of a behavior (known as extinction) (e.g., tive assessment can involve a variety of
discontinuing negative reinforcement of escape methods, such as direct observation, self-
from emotionally painful private events through report methods involving interviews, or
in vivo exposure, instructing family members to paper and pencil questionnaires. Descriptive
stop attending to maladaptive sick role behav- analysis can also include a variety of sources
iors), delivering a reinforcer contingent on behav- of information from clients or collateral
ior that is incompatible with a dysfunctional sources, for instance, a client monitoring and
behavior, or both (Ramnero and Torneke 2008; recording the environmental and private
Skinner 1938/1991). Examples of differential events that precede and follow the problem
reinforcement of behavior include praising a cli- behavior, having the client or an informant
ents problem solving when emotionally dis- (e.g., a caregiver) complete a paper and pencil
tressed rather than his engaging in escape of questionnaire designed to assess the contex-
avoidance behavior or praising a caregiver of a tual variables reliably associated with the
person with dementia for engaging in empathic behavior, or having an informant directly
verbal responses rather than corrective feedback observe and record the problem behavior
with their family member. and events or stimuli that precede and follow
Within the behavior-analytic model, it is the behavior (Haynes and OBrien 2000).
assumed that a behavior may serve more than
one function or purpose. For example,
complaining about poor health or pain may result Classical Conditioning
in an individual escaping from household tasks
(i.e., the behavior is negatively reinforced in that it Classical or respondent conditioning involves
results in the removal of aversive stimuli) and also learning by association. Classical conditioning
being consistently followed by hugs and has been applied to explain the development of
comforting statements by family members (i.e., many physiological and emotional responses
the behavior is positively reinforced in that it is including conditioned fear, sexual arousal,
consistently followed by social attention). It is trauma-related anxiety, and responses associated
with substance abuse. For example, an individual health-interfering and health-promoting behaviors
who has experienced a traumatic event may later are described below.
experience anxiety when they have contact with Depression. The behavior-analytic model of
environmental stimuli, such as the smells, images, depression considers the interaction of the per-
or sounds similar to those present during the initial sons repertoire within its historical and current
traumatic event. environmental context. The model posits that the
Classical conditioning provides the theoreti- risk of depression increases when individuals
cal foundation for several evidence-based thera- experience low rates of positive reinforcement,
pies such as exposure therapy for anxiety. high rates of aversive events (punishment), or
Classical conditioning was rst described by both in their lives (Ferster 1973). Further, the
the Russian physiologist Ivan Pavlov model assumes that an individuals repertoire,
(18491936). In studying the salivary and gastric which may include high-frequency negative self-
secretions of dogs, Pavlov would place a bowl of statements, low frequency of eye contact or smil-
meat powder in front of a dog and measure the ing during interactions, or evidence of a low fre-
amount of secretions naturally produced. During quency of instrumental problem-solving skills,
his studies Pavlov observed that over time the may further limit their access to positive rein-
dogs would start salivating when he entered the forcement in day-to-day life or increase the prob-
room, regardless of whether meat powder was ability of experiencing aversive consequences
presented. Pavlovs serendipitous, yet astute, (Ferster 1973; Lewinsohn and Graf 1973). In
observation of this phenomenon led to a series addition, behaviors commonly exhibited by per-
of experiments in which he systematically sons who meet diagnostic criteria for depression,
manipulated the presentation of a neutral stimu- such as excessive sleeping, social withdrawal and
lus, the sound of a bell or tuning fork, prior to isolation, and alcohol consumption, may be neg-
presenting meat powder in order to better under- atively reinforced by escape from or avoidance of
stand this learning by association. Pavlov potentially aversive consequences such as feeling
observed that by repeatedly pairing the sound, a anxious, ashamed, lonely, or rejected (Martell
neutral stimulus, with the presentation of the et al. 2001). The low rates of behavior commonly
meat powder, an unconditioned stimulus because observed when an individual behaves in a manner
it naturally elicited a response, the dogs would typically described as depressed, in turn, further
start to salivate at the sound of the neutral stim- limit opportunities for the person to contact pleas-
ulus, demonstrating that the neutral stimulus had ant experiences that would elevate his mood.
obtained functional properties similar to the More stable behaviors in the persons repertoire,
food. The bell had become a conditioned stimu- such as social skill decits involving low rates of
lus (CS) in that it elicited a learned reaction or eye contact or smiling and high rates of vocalizing
conditioned response similar to the natural reac- negative and pessimistic statements during social
tion or unconditioned response of salivating to interactions, may increase the likelihood of con-
the food (an unconditioned stimulus). tact with aversive consequences, which could
Behavior analysis of functioning in late life. include negative affect and withdrawal by others.
Behavior-analytic strategies have been applied to In addition, these social skill decits could further
promote the health and quality of life of older limit opportunities for contacting pleasant experi-
adults in a variety of ways. Treatment goals have ences and hence increase the likelihood of contin-
ranged from increasing health-related behaviors ued depressed mood. Behavioral approaches to
such as exercise, sleep, nutrition, and medication the treatment of depression typically target both
adherence to decreasing behaviors that restrict or the depressogenic repertoire and contextual
prevent access to positive and valued outcomes, factors.
(for instance, social withdrawal and isolation, sub- In regard to age-associated considerations, sen-
stance abuse, and suicidal behaviors). Examples sory changes, medical conditions that result in
of behavior-analytic conceptualizations of chronic pain or fatigue, and medication side
effects may reduce or altogether preclude pleasure the emotion regulation benets of intimate inter-
during activities that had been historically pre- actions with close friends and family (Carstensen
ferred. Further, a large proportion of elderly per- 1992).
sons judged to be depressed are prescribed
antidepressant medication although over 50% of B
older adults who meet criteria for major depres- Suicide
sive disorder do not respond to rst-line treatment
with antidepressant medication (Joel et al. 2014). Globally, the elderly are at higher risk of suicide
In many cases, pharmacological intervention for than any other age group, with elderly men
depression may be contraindicated as accounting for the largest proportion of suicides.
polypharmacy increases the risk of adverse Older adults tend to use lethal means and are less
medication effects (American Geriatrics likely to report suicidal ideation prior to
Society 2015). In contrast, evidence-based attempting suicide (World Health Organization
non-pharmacological treatments for depression 2014). Further, the current cohort of older adults
including behavioral activation (BA) (Martell is more likely to report somatic symptoms rather
et al. 2001) and cognitive behavior therapy than emotional distress when experiencing
(CBT) have been found to be highly effective for depressed mood or anxiety (Hinton et al. 2006).
the treatment of depression in older adults A behavior-analytic conceptualization of
(Gallagher-Thompson et al. 1990; Ayers suicidality considers suicidal thoughts and actions
et al. 2007) and have no side effects. to be learned behaviors that function to allow the
BA is designed to improve mood by targeting individual to avoid or escape overwhelmingly
the individuals inactivity, avoidance, and with- distressing and aversive feelings (Chiles and
drawal behaviors. Specically, the BA treatment Strosahl 2005; Linehan 1993). Experiencing
process involves three main steps: activity moni- physical or emotional pain is a normative event
toring (monitoring the actions that preclude and at some point in the course of a long life but the
follow depressive behaviors), activity scheduling ways in which individuals cope with physical pain
(replacing prior maladaptive behaviors with pos- and distressing emotions vary signicantly. For
itive, productive behaviors that increase contact individuals with a limited repertoire for coping
with pleasant consequences), and modifying activ- with painful private events and weak social
ities based on client feedback (continually attachments, suicidal thoughts and actions may
adjusting the treatment plan until the desired out- provide an immediate escape from or avoidance
come is reached) (Martell et al. 2001). During of physical pain and distressing feelings of loss,
treatment it is important to consider how an indi- loneliness, or emptiness.
viduals skill repertoire, sensory functioning, and A behavior-analytic conceptualization of
health may inuence their experience of activities, suicidality focuses on the context of suicidal
for example, individuals with sensory decits may behaviors, both private thoughts and emotions
prefer activities that involve fewer sensory chal- and overt actions, including the circumstances
lenges. It is also important to consider an individ- that tend to precede the occurrence of the behav-
uals socialization history when identifying iors and the consequences that reliably follow the
potentially gratifying experiences. For example, suicidal behavior. To illustrate, suicidal ideation
an individual with a history of enjoying solitary would be conceptualized as being negatively
activity may nd physical activities more reward- reinforced if it produces the consequence of tem-
ing than those involving social interaction. Fur- porarily alleviating painful emotion and the fre-
ther, while it is commonly suggested that quency of suicidal ideation following painful
depressed clients increase social contact by emotions has increased or is maintained over
attending community or other organized events, time. Alternatively, suicidal behavior would be
socializing with strangers may be less preferred by conceptualized as being positively reinforced if
older adults who have a history of experiencing it is consistently followed by a consequence
such as access to social attention and comfort with neurocognitive disorders (Buchanan
from friends and family and the frequency of the et al. 2011; Fisher et al. 2007; Hussian 1981).
behavior increases over time. The behavior-analytic or contextual model
Dialectical behavior therapy (DBT), developed of neurocognitive disorders assumes that a person
by Marsha Linehan (1993) as a treatment for who is experiencing progressive cognitive decline
chronically suicidal individuals, focuses on will develop strategies to compensate for the
replacing harmful behavior patterns (including impairment (Hussian 1981) and that the context
thought patterns) with skillful alternatives. in which they are experiencing the neurological
A behavior-analytic interpretation of the thera- changes can have a profound effect on their and
peutic process within DBT considers the contin- their family members behavioral health and qual-
gency between suicidality, private events (e.g., ity of life (Schulz and Sherwood 2008). In this
distressing thoughts of abandonment), and envi- regard, the contextual model treats the interac-
ronmental events (e.g., attention from or rejection tions between affected persons and their family
by others). This contingency is broken by building as essential to well-being.
a repertoire of behaviors (e.g., emotion regulation An important implication of the age-associated
skills, distress tolerance skills, interpersonal risk of neurocognitive disorders is that they affect
skills) that are incompatible with suicidality. the functioning of individuals with decades-long
Although the primary population Linehan studied genetic and learning histories and hence highly
when developing DBT was young and female, the complex verbal, emotional, and interpersonal rep-
behavioral principles underlying the treatment are ertoires. Given the current lack of treatments for
applicable throughout the life span. DBT has been these disorders, behavior-analytic approaches to
found to be effective with older adults (Lynch the support of persons with neurocognitive disor-
et al. 2006). ders tend to focus on three primary goals: (1) pre-
serving functional repertoires, (2) preventing
excess disability, and (3) preventing behaviors
Neurocognitive Disorders that lead to negative outcomes for persons and
their families (commonly referred to as
Neurocognitive disorders such as Alzheimers noncognitive neuropsychiatric symptoms,
disease and vascular dementia are among the behavioral disturbances, or challenging behav-
most debilitating conditions affecting older iors). The behavior of family and professional
adults. Behavior analysis has been applied to caregivers is considered to be a critical feature of
both support the maintenance of adaptive behav- the context in which persons with neurocognitive
iors (e.g., activities of daily living, speech, etc.) experience changes and therefore the responding
and prevent, decrease, or reverse excess disability of caregivers is commonly targeted within
and promote the behavioral health of elderly per- behavior-analytic support services. Support of
sons with neurocognitive disorders (Buchanan caregivers tends to focus on (1) increasing care-
et al. 2011; Fisher et al. 2007). Within this popu- givers knowledge of neurocognitive disorders
lation, excess disability is said to occur when a and the effects of neurological changes on behav-
person is more disabled than expected based on ior in order to promote perspective taking rather
the underlying neurodegeneration (Fisher than pathologizing behavior, make the behavior of
et al. 2007). Within the behavior-analytic model, care recipients predictable, and reduce the likeli-
excess disability in persons with neurocognitive hood that caregivers will respond to the care recip-
disorders is evident in the premature decline of ient with negative consequences, such as negative
functional behaviors that will eventually be lost affect and corrective feedback that may inadver-
due to neurodegeneration. Designing environ- tently or intentionally punish behaviors within the
ments that support functional behaviors is a fun- already vulnerable repertoire of the care recipient;
damental goal of behavior-analytic approaches to (2) promoting the ability of caregivers to cope
enhancing the health and quality of life of persons with the emotional and instrumental challenges
that commonly emerge when caring for someone likelihood of the emergence of behavior changes
with a neurocognitive disorder; and (3) assisting that are misattributed to neurodegeneration. The
families in preserving the meaningful and default attribution of behavior change to neuropa-
rewarding qualities of their relationship with thology is a leading threat to the behavior health
their family member (Fisher et al. 2007; Nichols and quality of life of persons with neurocognitive B
et al. 2011). disorders. Knowledge of the distinction between
Persons with dementia experience an array of normal or expected behavior change or decline
neurological changes that impact their ability to versus unusual behavior changes and careful
perform activities of daily life such as personal examination of the context in which behavior
care and more complex tasks such as changes occurred are critical for understanding
managing nances and medications and driving. the behavioral health of an individual who has a
The behavior changes that accompany neurocognitive disorder and detecting adverse
neurocognitive disorders are often experienced medical or environmental events. Because neuro-
as confusing, out of character, or intentional degenerative disorders inevitably produce signif-
and aversive by family members. In addition, icant declines in behavioral repertoires, there is a
declines in verbal abilities increasingly lead to risk that all observed behavior changes will be
communication problems within relationships attributed to neurodegeneration, including behav-
that involve behaviors that have been under pow- iors that are a response to acute, treatable condi-
erful stimulus control, for example, responses tions such as pain, infection, or medication side
that have reliably followed an antecedent effects. Through education and guided practice,
stimulus such as a family members request or family and professional caregivers can learn to
effort to initiate a conversation by inquiring understand and better predict the behavior of per-
about how the family member is doing and sons with neurocognitive disorders and hence
were reliably reinforced for decades. The conu- respond in a more empathic and supportive man-
ence of communication decits and perceived ner (Nichols et al. 2011).
intentional and unpredictable behavior changes Given the current lack of a cure or effective
(i.e., reecting the breakdown in the stimulus treatment for neurocognitive disorders, geriatric
control of behavior) that occur during the course healthcare advocacy groups have identied the
of neurodegenerative diseases typically lead to development of support services that promote
high rates of conict between affected persons the quality of life of affected persons and their
and their family members (Fisher et al. 2007). families as a priority (Odenheimer et al. 2014).
From a behavior-analytic perspective, intra- The variable nature of the symptom presentation
familial conicts may be due, in part, to the and trajectory of these disorders can limit the
discontinuation of reinforcement contingencies utility of traditional medical population-based
(i.e., extinction) which is typically experi- approaches to disease management. In contrast,
enced as emotionally painful by family members. the idiographic nature of behavior analysis can
Within the behavior-analytic or contextual readily accommodate the heterogeneous symptom
model, the behavior changes that accompany neu- presentation and the inuence of idiosyncratic
ropathology represent a natural response to personal histories and contextual factors on the
increasingly overwhelming environmental functioning of persons with neurocognitive disor-
demands (Hussian 1981). Declines in verbal abil- ders. An increasing body of literature demon-
ities, including the ability to verbally label and strates that behavior-analytic strategies are
respond to private events (e.g., pain, discomfort, effective for both preventing and reducing excess
fear, boredom, etc.), are a leading risk factor for disability and what are commonly described as
excess disability in persons with neurocognitive noncognitive psychiatric symptoms, including
disorders. This is due to the fact that the lack of resistance to care, wandering, and disruptive
ability to label, report, and respond to private vocalizations exhibited by persons with dementia
events such as pain or discomfort increases the (Fisher et al. 2007; Hussian 1981).
Behavior Analysis of Health-Related promotion tend to address the differential effects

Behaviors of immediate versus delayed reinforcement by
incorporating goal setting that focuses on increas-
Chronic illness and disability disproportionately ing specic, concrete behaviors that are achiev-
affect older adults relative to other age groups. able in a short amount of time (Roane et al. 2015;
Numerous studies have documented the effective- King 2001). Consideration of age-associated bar-
ness of behavior-analytic strategies for promoting riers that may interfere with goal attainment is also
behavioral health and adaptive functioning in important. Potential barriers may include chronic
order to prevent or delay the onset of morbidity pain conditions, access to transportation and
in healthy adults and prevent excess disability in resources such as affordable nutritious food and
persons with chronic illnesses. Domains targeted tness facilities and equipment, and reduced
have included lifestyle factors that are known risk mobility or endurance.
factors for chronic illnesses including exercise, Self-monitoring of specic behaviors is incor-
diet, and smoking (LeBlanc et al. 2011; Roane porated within many behavior-analytic health pro-
et al. 2015). The following discussion focuses on motion programs as it allows the individual to
how the principles of behavior analysis have been assess the occurrence of desired behaviors, com-
applied to foster health-promoting behaviors. peting health-interfering behaviors, and progress
Behavior analysis of health-related behaviors toward goals in real time. Self-monitoring also
considers the complex interaction of an enables individuals to identify barriers that require
individuals repertoire and contextual variables manipulation by providing detailed information
(antecedent and consequent stimuli) that promote about antecedents in instances when the individ-
or interfere with the occurrence of desired behav- ual deviated from their goals or lapsed. Social
ior(s). Analysis of the temporal relationship support in the form of praise for health behavior
between a behavior (e.g., eating calorie-dense adherence has also been found to be effective in
food or sedentary watching of television) and its promoting health-promoting behaviors in older
consequence(s) (e.g., immediate access to plea- adults as it can function as an immediate, second-
surable sensation or escape from physical discom- ary reinforcement of behaviors that compete with
fort vs. delay of benets) is particularly important maladaptive behaviors that have been historically
for understanding the probability of the maintained by powerful primary reinforcers
occurrence of health-promoting versus health- including food or escape from discomfort by stop-
interfering behaviors. The more powerful effect ping exercise (Roane et al. 2015; King 2001;
of immediate reinforcement relative to delayed Penedo and Dahn 2005; Killgore et al. 2013).
consequences can be a signicant barrier to Stimulus control or antecedent-based strategies
behavior change. Further, many health-interfering involve arranging the individuals environment in
behaviors are maintained by primary reinforcers order to increase the probability that a health-
(i.e., stimuli that do not require conditioning to promoting behavior will occur while reduce the
function as a reinforcer such as food or the reduc- probability of the occurrence of health-interfering
tion of pain or discomfort) while health- behaviors. Strategies include removing anteced-
promoting behaviors are often maintained by ents for undesired behavior while increasing the
delayed consequences and/or secondary (i.e., salience of antecedents associated with the health-
conditioned) reinforcers such as praise, a number promoting behavior. For example, in promoting
appearing on a scale, or tting into smaller-size physical activity, an antecedent-based interven-
clothing. The inherent delay in the consequences tion might involve placing exercise shoes by the
of many health-promoting behaviors can limit the front door, laying out exercise clothes on the bed,
effectiveness of setting long-term and abstract or installing a stand-up desk in an ofce. The
verbal goals such as losing weight or getting promotion of nutritious eating might involve
in shape. Behavior-analytic strategies of health removing unhealthy foods from the home and
following a structured meal plan with restricted Cross-References

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Odenheimer, G., Borson, S., Sanders, A. S., Swain-Eng, a number of symptom groups or syndromes; cur-
R. J., Kyomen, H. H., Tierney, S., Gitlin, L., Forciea, rently, there is limited agreement about syndrome
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Quality improvement in neurology: Dementia manage-
ment quality measures. Journal of the American Geri- psychosis feature prominently. It is likely that
atrics Society, 62(3), 558561. BPSD syndromes have a different prevalence,
Behavioral and Psychological Symptoms of Dementia 375
etiological factors (biological, psychosocial, envi- with symptoms being rated in clusters such as
ronmental), prognosis, and hence management delusions, hallucinations, mood disturbance, and
implications. sleep disturbance, while the CMAI is more
descriptive of individual behaviors such as biting,
scratching, screaming, and pacing. Hence, the B
Introduction choice of rating scale might depend on the pur-
pose. There is also a scale that focuses specically
In the historical descriptions of dementia by on depression, the Cornell Scale for Depression in
Esquirol in 1838 and by Alzheimer in 1907, Dementia (CSDD).
behavioral and psychological symptoms were rec- BPSD occur in almost all people with demen-
ognized as features of the dementia syndrome tia, with the community-based Cache County
(Draper et al. 2012a). For example, Alzheimers Study reporting a 97% 5-year prevalence of any
description of his patient Auguste Deter included type of BPSD as measured by the NPI. Many
symptoms of paranoia, delusions, vocal disrup- types of BPSD tend to persist, with 18-month
tion, and hallucinations in addition to cognitive follow-ups in the Cache County Study reporting
impairment. Despite this, for many years the focus that delusions persisted in 66% of individuals,
of clinical dementia research was on the cognitive depression in 58%, and aberrant motor behavior
features, and it was only in the 1980s that an in 56%. However, it is noteworthy that
increase in research into the noncognitive symp- population-based studies of BPSD have shown
toms occurred (Draper et al. 2012a). variability of types of BPSD in different countries;
One of the difculties in establishing BPSD for example, apathy is less prevalent in China and
syndromes has been the term agitation, which Nigeria than in Japan, the United States, Spain,
has been used in a variety of ways by clinicians and the UK (Wang et al. 2012). BPSD are partic-
and researchers. An Agitation Denition Working ularly common in nursing homes with the point
Group recently used a survey and consensus prevalence ranging from 69% to 92% in studies
process to form an agitation denition for from Australia, Norway, the Netherlands, and the
dementia and cognitive impairment that has four United States (Draper et al. 2012a).
components: the behavior is consistent with emo- There has been a paucity of research that has
tional distress; there is excessive motor activity, explored the relative prevalence of BPSD in dif-
verbal or physical aggression; the behaviors cause ferent types of dementia (Ford 2014). However,
excess disability; and the behaviors are not solely high rates of hallucinations and disinhibition have
attributable to another disorder (Cummings been reported in Lewy body dementia, consistent
et al. 2015). with visual hallucinations being one of the core
Another difculty in establishing BPSD syn- diagnostic criteria for the disorder. Similarly, early
dromes has been the lack of consensus about behavioral disinhibition is a diagnostic criterion
measurement. Numerous rating scales have been for frontotemporal dementia, which is distin-
developed to measure BPSD, and there is no guished from other types of dementia in most
single gold standard, with one recent overview studies by the presence of disinhibition, apathy,
article listing 35 scales (Ford 2014). Some of the and aberrant motor behavior. Comparisons of
more commonly used scales are the Neuropsychi- vascular dementia and Alzheimers disease have
atric Inventory (NPI), the Cohen-Manseld Agi- had inconsistent ndings, with some studies
tation Inventory (CMAI), and the Behavioral reporting few differences and others showing
Pathology in Alzheimers disease rating scale higher rates of apathy, depression, and emotional
(BEHAVE-AD). Each relies on the observations lability in vascular dementia and higher rates of
of a person who has been in close contact with the psychosis (most commonly delusions) in
person with dementia over the previous 24 Alzheimers disease. Depression is more strongly
weeks (depending on the scale used). The NPI associated with Parkinsons dementia than
and BEHAVE-AD have a neuropsychiatric focus Alzheimers disease.
Etiology of BPSD associated acute psychosis, particularly visual

hallucinations and paranoid ideation, which
Research into the etiology of BPSD is in its develops over a few days. There are often features
infancy and has mainly focused on Alzheimers of agitation present. From a clinical perspective,
disease. There is a growing body of research, but this is a critically important diagnosis to make due
much of it is unreplicated. Current models suggest to the high morbidity and mortality associated
an interaction of a broad range of factors including with delirium.
neurobiological substrates (such as genetic poly- Psychosis otherwise has a more gradual onset
morphisms, neurotransmitter changes, neuropa- and is more common in females, declining cogni-
thology, medical comorbidity), premorbid tion and increasing severity of neuropathology in
personality, psychological reactions, and social Alzheimers disease. There is preferential
aspects including caregiver and environmental involvement of the frontal lobe and/or limbic
issues (Draper et al. 2012b). regions, although visual hallucinations tend to
There are three main explanatory models of involve the occipital lobes (Draper et al. 2012b).
how caregiver interactions might contribute to On functional imaging, psychosis is associated
BPSD. The stress threshold model is based on with hypoperfusion in frontal and temporal
the observation that people with dementia have a lobes. Some delusions may be explained by mem-
lower threshold to coping with stress, with behav- ory decits (e.g., misplacing items and
ioral disturbances occurring when this threshold is interpreting this as theft) and misidentication of
exceeded. The learning theory model empha- people and place. Although inappropriate care-
sizes the importance of inadvertent reinforcement giver strategies are also reported to be associated
of inappropriate behaviors; for example, care- with delusions, it is unclear whether these are
givers might only respond to a noisy person etiological or reactive to the psychosis.
when they are calling out and not when they are There is an increased familial risk of psychosis
quiet. The unmet needs model recognizes that in Alzheimers disease as suggested in a study
people with more severe dementia cannot always involving the combination of samples from the
communicate their needs, such as social interac- United States and the UK that found a signicant
tion, pain relief, hunger, or physical activity; association between proband psychosis status and
hence, caregivers have the challenge of working the occurrence of psychosis in Alzheimers dis-
out what unmet needs the behavior might repre- ease in siblings with linkage peaks occurring on
sent. The models are not mutually exclusive; it is chromosomes 7 and 15. A meta-analysis of sero-
likely that elements of each might operate simul- tonergic system genes concluded that the HTR2A
taneously with the individual circumstances of the T102C polymorphism is a signicant risk factor
person with dementia perhaps indicating which for psychosis in Alzheimers disease. These
factors might be more relevant in their situation receptors may also modulate antipsychotic
(Draper et al. 2012b). response. Polymorphisms in dopamine receptors
It is likely that the relative contribution of each have also been associated with psychosis in most
of these etiological factors varies according to the studies, particularly D3 genes, where two studies
specic behavior and type of dementia. Here, we found homozygous (i.e., having identical pairs of
cover some of the more prominent types of BPSD genes) carriers of the 1 allele to be at increased
and outline the key etiological factors that have risk (Draper et al. 2012b).
been identied for each. In Lewy body dementia, in contrast to
Alzheimers disease, visual hallucinations, but
Psychosis (Delusions and Hallucinations) not delusions, are associated with less tangle bur-
In general, psychosis is mainly associated with den but more cortical Lewy body pathology and
neurobiological substrates. This includes medical may be related to cholinergic decits in the tem-
comorbidity, such as infection, hypoxia, or drug poral cortex. Further, visual hallucinations are
toxicity, which may result in delirium with associated with hypometabolism in visual
association areas rather than the primary visual noradrenaline with a lower concentration of nor-
cortex. However, delusions in Lewy body demen- adrenaline producing an amplied effect. Locus
tia have a similar substrate to psychosis in coeruleus neuronal loss, upregulated expression
Alzheimers disease. levels of tyrosine hydroxylase mRNA, and an
increase in noradrenaline synthetic capacity in B
Aggression and Agitation residual cells may account for the increased post-
Aggression and agitation are often associated with synaptic sensitivity to noradrenaline. The dopa-
other frontal symptoms such as disinhibition and minergic system has also been implicated in
may be a reection of executive dysfunction. aggression and agitation in frontotemporal
Aggression is more common in males and vocally dementia, a type of dementia that has frontal and
disruptive agitated behavior more common in temporal lobe neurodegeneration, with increased
females. The etiology may be complex, multifac- activity and altered serotonergic modulation of
torial, and include medical comorbidities, history dopamine neurotransmission (Ford 2014; Draper
of head injury, alcohol and substance misuse, et al. 2012b).
neurobiological substrates of dementia, and
social, psychological, or environmental factors. Depression
Premorbid personality may also interact with Depression tends to occur earlier in the course of
these factors. Verbal and physical aggression dementia, and for many, it can be the presenting
may be secondary to pain, physical discomforts problem. In some individuals, this represents a
(e.g., constipation, thirst, overheating), depres- psychological reaction to self-awareness of early
sion, and other health issues. These behaviors cognitive decline, while in others it appears to be
are often best interpreted as a form of communi- associated with neurobiological changes associated
cation of distress. Consequently, patients with with the evolving dementia, with frontal symptoms
agitation and aggression have diverse reactions such as apathy being associated with more severe
to caregiver intrusion into their personal space, depression. Depression is more common in young-
with some improving and others worsening onset dementia with some evidence of an increased
depending on the type of interaction, indicating a risk of suicide in the 3 months post diagnosis.
need for training of caregivers and tailored A history of depression is also a risk factor for
interventions. dementia, and so in many there is likely to be a
Neurobiological substrates of aggression and predisposition to further depressive episodes and,
agitation in Alzheimers disease are multiple and as in cognitively intact people, those with dementia
complex. Genetic factors include polymorphic may become depressed in the context of stressful
variations in serotonergic and dopaminergic life events such as the death of a partner, admission
genes. Dopaminergic, cholinergic, serotonergic, into institutional care, pain, and other physical
and noradrenergic neurotransmitter changes have discomforts. Frustration from impaired communi-
been reported in the brain. For example, in cation skills, particularly in those with aphasia
Alzheimers disease, aggression is linked with disproportionate to impairment in other cognitive
choline acyltransferase (ChAT) activity in the domains, can also precipitate depression.
frontal and temporal cortices, with reduced ratios Neurobiological substrates to depression
of ChAT activity to dopamine D1 receptor binding include abnormalities in the serotonergic neuro-
and dopamine concentration in the temporal cor- transmitter system including polymorphisms of
tex. Consistent with this is the nding that on serotonergic genes, reduced noradrenaline levels,
functional neuroimaging, aggression is associated and polymorphisms in dopaminergic genes. Neu-
with hypoperfusion of the temporal cortex. Fur- roimaging studies show hypoperfusion (i.e.,
ther, dopamine-blocking agents improve aggres- decreased cerebral blood ow) in frontal, tempo-
sive behavior in dementia. Aggression in ral, and parietal lobes to be associated with
Alzheimers disease is also associated with depression in Alzheimers disease (Ford 2014;
an increased postsynaptic sensitivity to Draper et al. 2012b).
Apathy rummaging, restlessness or purposeless activity,

In the absence of depression, apathy is generally a repetitive movements or mannerisms, hiding
reection of neurobiological changes. Apathy is things, and inappropriate dressing or disrobing.
associated with frontal-subcortical dysfunction People with poor social relationships are more
irrespective of the type of dementia. In likely to be aggressive. Unsurprisingly, aggres-
Alzheimers disease, neuroimaging studies show sion and agitation are associated with admission
hypoperfusion in frontosubcortical structures, to residential care.
especially the anterior cingulate, while in
frontotemporal dementia there is disruption of Disorders of Sexual Expression
cortical-basal ganglia circuits. Neurotransmitter Sexual disinhibition may be verbal or physical
changes in Alzheimers disease include choliner- and directed at self or others. These behaviors
gic deciency and a blunted dopaminergic brain may be particularly confronting for caregivers
reward system (Ford 2014; Draper et al. 2012b). and pose logistical problems in residential care.
Sexually inappropriate behaviors may range from
requests for unnecessary assistance in changing/
Clinical Features of BPSD bathing and genital care to suggestive gestures,
disrobing, exposing, or masturbating in public,
The hallmarks of dementia are deterioration in sexually explicit language, remarks or recounts
aspects of cognition and social and physical func- of sexual experiences, and unwanted physical
tioning. The term BPSD is not a diagnosis in itself contact (e.g., kissing, inappropriate touching/fon-
but refers broadly to various clinical presentations dling/grabbing, sexual advances, and attempts to
seen in people with dementia. BPSD is an impor- have intercourse without consent).
tant development in a person with dementia as it is These behaviors may relate to lack of an inti-
associated with longer hospital admissions and mate partner, lack of privacy, misinterpretation of
more complications, more disability, greater like- cues (e.g., caregivers touching them when
lihood of placement in a residential aged care assisting with personal care), an unfamiliar or
home, more rapid rate of decline, greater nancial understimulating environment, predementia sex-
costs, reduced quality of life, greater mortality, ual behavior, medication (e.g., dopaminergic
and signicant stress for carers and staff in resi- drugs), mood disorders, or psychotic symptoms
dential facilities (Draper et al. 2012a). From a (Royal Australian and New Zealand College of
clinical perspective, BPSD can be subdivided Psychiatrists 2013).
into behavioral and psychological symptoms.
Sleep Dysfunction
Behavioral Symptoms Disturbed circadian rhythm may complicate the
progression of dementia and cause considerable
Aggression and Agitation (Verbal or Physical) carer stress. In dementia with Lewy bodies (a type
Agitation is common in people with dementia, of dementia characterized by uctuation in mental
and the prevalence increases with the progression state and intermittent confusion, parkinsonism,
of cognitive impairment. Agitated behaviors visual hallucinations, and falls), REM sleep
may be divided into four subtypes, aggressive, behavioral disorder (which involves the person
nonaggressive, verbal, or physical. Aggressive acting out their vivid dreams while asleep) may
behaviors include swearing, screaming, occur early and even precede the formal diagnosis
scratching, pushing, grabbing, hitting, kicking, of dementia. Sundowning is a term for the onset or
and biting. Nonaggressive behaviors include call- worsening of BPSD symptoms in the afternoon or
ing out/repeated requests for attention, being ver- evening. It may also relate to disturbed circadian
bally demanding, complaining, excessive/ rhythms. Sleep dysfunction may also relate to
unrealistic anxiety, repetitive questions, phrases, comorbid medical conditions (e.g., sleep apnea,
concerns, or sounds, pacing and wandering, congestive cardiac failure, pain, depression),
environmental conditions (e.g., room tempera- in real time around them. Misidentication
ture, lighting, changes in the environment), and includes the dened syndromes Capgras, Fregoli
medication (e.g., diuretics). (i.e., believing that a person is someone else in
disguise), and intermetamorphosis (i.e., believing
Wandering that familiar people in their lives have switched B
Wandering is a symptom particularly burdensome identities).
for carers, which may lead to placement in resi-
dential care. It may include exit seeking and Anxiety Anxiety may occur on its own or in
repeated attempts to leave home and aimless conjunction with another type of BPSD. Themes
walking. Under stimulation, boredom, anxiety, may relate to health, the future, nances, and
and cognitive decits in navigation may be activities or events not previously considered
contributory. stressful. A common anxious cognition in demen-
tia is fear of being left alone, which may reach
Psychological Symptoms phobic proportions. Godot syndrome may also
occur, where the person repeatedly asks questions
Psychosis about an upcoming event.
Delusions Persecutory or paranoid delusions are Depression The spectrum of depressive symp-
the most widespread type in dementia. Common toms is common in dementia, with depressed
delusional beliefs include theft, that a spouse/ mood being most common (4050%), followed
caregiver has been replaced by an impostor by subsyndromal depression and major depres-
(Capgras syndrome), that the persons residence sion (1020%) (Grossberg et al. 2012). It can be
is not their home, indelity, and abandonment difcult to diagnose depression due to the overlap
(Grossberg et al. 2012). Delusions may also be with somatic symptoms of dementia (such as
distressing for caregivers and increase the risk of weight loss, agitation, apathy, disturbed sleep)
violence toward them, particularly with delusions and the increasing communication and language
of indelity and of impostors. Delusions in difculties as dementia progresses. A depressive
dementia are a risk factor for physical aggression. illness should be considered if there is a rapid
deterioration in cognition, a family or personal
Hallucinations Visual hallucinations are the history of depression, pervasive low mood and
most common type in dementia, followed by audi- anhedonia, unexplained acute behavioral change,
tory hallucinations, with other sensory modalities or if the family is concerned about depression.
rare. A common hallucination is of phantom
boarders, where the person sees people in the Apathy Apathy is a lack of interest, interactivity,
home who are not actually there. Visual misper- emotion, concern, motivation, and initiation of
ceptions also occur, when there is a visual stimulus activities. It is a common symptom, which may
but it is misinterpreted. This may relate to visual occur in up to 50% of patients with mild to mod-
agnosias (impaired recognition of items presented erate dementia. Symptoms of apathy and major
visually) or problems with contrast sensitivity. depression may overlap, including reduced inter-
est, lack of energy, psychomotor slowing, and
Misidentication External stimuli may be poor motivation. Apathy may be distinguished
misinterpreted leading to misperceptions, which from a depressive illness when amotivation
may be held with delusional intensity. The com- occurs without the somatic and mood symptoms
mon types of misidentications are of self (not of depression (sadness and psychological dis-
recognizing ones own image), phantom boarders tress). The following case demonstrates how a
(people being in the persons home), of other carer may interpret apathy in a loved one with
people (e.g., a spouse or family member), and of dementia and the commonality with features of
events on television being interpreted as occurring depression.
Case 1 Sidney is a 91-year-old man living at state or behavior. Dementia is a strong risk factor
home with his wife. He was diagnosed with for delirium. The hallmarks of delirium are sud-
mixed vascular/Alzheimers dementia 6 years den onset of or new confusion, uctuation in
ago. His wife refers him for assessment of depres- cognition and level of consciousness, and inatten-
sion. She complains that for the last year he just tion. The etiology may be multifactorial and
sits in his chair and stares at the wall. He no longer include medications, pain, and physical illness.
waters the plants and even seems to have lost Anesthetics, drug intoxication or withdrawal,
interest in cricket as he does not even turn on the and drug interactions, adverse effects, and
television when sitting in front of it. She is frus- polypharmacy may be relevant. Drugs of particu-
trated by how lazy he is and that he no longer lar concern include psychotropics and those with
even helps with the gardening. He does not strike cholinergic properties. Pain is a prevalent symp-
up conversation with her but responds if she talks tom in people with dementia but often
to him. When their great-grandchildren visit, he unrecognized and undertreated. Common causes
smiles and watches them play. of pain include wounds, fractures, urinary reten-
tion, poor dentition, constipation, and surgery.
This case is illustrative of apathy with pro- Any acute medical illness may precipitate a delir-
found lack of motivation, self-initiated activities, ium, so broad potential causes should be consid-
and indifference but the retention of warmth and ered and treated accordingly. It may take days to
reactivity when caregivers take the initiative to several weeks for delirium to resolve, even after
provide enjoyable activities and interactions. the underlying cause is treated.
Nonpharmacological
Principles of Management Nonpharmacological interventions are rst-line
treatment for BPSD. A person-centered approach
BPSD may arise for numerous reasons, thus there emphasizes the importance of understanding the
is no single approach to management. The envi- individual- what their interests, past experiences,
ronmental, biological, psychological, and inter- and preferences are- and how this may inform the
personal factors should be considered when management of their BPSD (Royal Australian and
assessing someone. BPSD may be considered a New Zealand College of Psychiatrists 2013). For
form of communication, whereby unmet needs are example, past negative experiences of institution-
expressed through behavior (Royal Australian alization may be unwittingly reenacted in residen-
and New Zealand College of Psychiatrists 2013). tial care, or knowledge of a persons hobbies may
Aspects of the individuals personality, culture, be used to divert them from the behavior or to
and personal experiences may also inuence address unmet needs for stimulation and social
their presentation. The rst step is to have a clear contact.
description of the behavior and to evaluate
whether intervention is needed. It may help Environment
to have caregivers/residential care staff keep Environmental factors may contribute to BPSD.
a behavior diary prior to formal assessment. A change to the environment, including the inter-
The ABC (antecedent, behavior, consequences) personal mix of residents or staff at a facility, may
approach may be used to comprehensively precipitate BPSD. It is important to evaluate
describe behavioral problems. Using this method, whether there are extremes of temperature, light-
the clinician records the antecedent events leading ing, stimulation, noise, or clutter. There is good
to the behavior (the context and any precipitant), evidence for unobtrusive safety features improv-
the particular behavior, and the consequences of ing resident well-being and depression (Fleming
the behavior (for the patient, staff, others). et al. 2009). Exit seeking may be reduced by
Delirium must rst be excluded in a person minimizing the number of locked doors or obscur-
with dementia who has an acute change in mental ing door handles, so as not to attract attention, and
Behavioral and Psychological Symptoms of Dementia, Table 1 Effective non-pharmacological treatments for
BPSD
Treatment Outcome
Essential oils: lavender and lemon balm Limited evidence for reducing agitation when used as a
sprayed mist and in facial/arm massage, respectively.
Lemon balm also improves social engagement and
B
constructive activity
Recordings of family voices (15 min) Reduced agitated behaviours when audiotape of a family
member talking was played through headphones.
However, low level of evidence
Music: matched to persons taste Reduced agitated behaviours more than generic classical
Soothing sounds of water (ocean, stream) music. When used during baths reduced rates of physical
and verbal aggression
Reduced verbally disruptive behaviour
One-to-one interaction with a clinician (active Reduced verbally disruptive behaviours
engagement in conversation, sensory kit, gentle exercise,
or manual activities matched to their skills and interests)
Daily physical activity (30-min) Improved mood more effectively than a gentle walking
group or conversation group
Sleep hygiene program (encouraging daytime activity, Major reduction in time spent sleeping during the day and
set-personalised bedtime routine, minimising minor reduction in the time spent awake at night
interruptions at night, minimal light and noise at night)
Snoezelen room (multisensory stimulation) Moderate evidence for reducing depression, aggressive
behaviour and apathy and improves wellbeing during
morning care, but benets only apparent for a short time
after the session
Animal-assisted therapy (pets) Promotes social behaviour, improves nutrition, and
reduces agitation and/or aggression
Therapeutic activities (a heterogeneous group including Some benet for apathy, especially if individually tailored
stimulation, cooking, Montessori methods, behavioural (Brodaty and Burns 2012)
elements, creative activities)
when doors do not have glass panels. An environ- of outside space is only benecial if combined
ment that provides a variety of spaces may reduce with staff interaction. A number of other
depression and anxiety, improve social interac- nonpharmacological treatments may confer bene-
tion, and help the person nd their way around. t in BPSD (OConnor et al. 2012, see Table 1).
Single rooms are also benecial in residential Sensory impairment is associated with BPSD
care. Optimization of levels of stimulation is and may be reversible. A thorough visual or audi-
effective, by both reducing unhelpful stimulation tory examination should be part of the assessment
(e.g., noise or busy doors) and increasing lighting of hallucinations and the environment optimized
(e.g., good visual access to toilets). A homelike to improve visual contrast and lighting. Inability
environment reduces aggression, but it is not pos- to speak the local language may act as a sensory
sible to disentangle the effects of small unit size, impairment by impeding communication. Inter-
staff skills, and care philosophy or familiar phys- preters should be used to optimize the likelihood
ical environment (Fleming et al. 2009). Similarly, of effective communication.
there is moderate evidence for providing opportu-
nities to engage in ordinary activities of daily Psychological Approaches
living (ADLs), but the effects are hard to distin- Psychoeducation for caregivers about how to
guish from staff factors and the contribution of the manage BPSD is an effective strategy, with
environment (Fleming et al. 2009). The provision benets lasting months (Livingston et al. 2005).
There is also evidence for behavioral management Pharmacological

strategies, which target behaviors of the individ- Overall, there is only modest evidence for the use
ual or caregiver. Individual sessions are more of pharmacotherapy in BPSD and risk of clini-
effective than groups (Livingston et al. 2005). cally signicant adverse effects (Royal Australian
There are a few types of psychotherapy, which and New Zealand College of Psychiatrists 2013).
have been evaluated in people with dementia. Any Most pharmacotherapy trials, although methodo-
intervention should be based upon a person- logically sound, are often limited by their short
centered framework, which incorporates the duration and follow-up period and exclusion of
unique experiences and preferences of the indi- non-Alzheimers dementias. Nonetheless, medi-
vidual. Overall, evidence is poor, and the method- cation may be indicated in conjunction with
ological quality of studies is weak (Livingston nonpharmacological measures when the BPSD is
et al. 2005). Cognitive stimulation therapy uses moderate to severe, poses safety concerns,
information processing rather than knowledge of nonpharmacological interventions have failed, or
facts to stimulate and engage people with the BPSD is affecting function or the quality of
mild to moderate dementia in an optimal learning life of the patient or carer. Informed consent from
environment. It may reduce depression and the patient and their substitute decision-maker is
improve quality of life, during treatment and essential.
for some months afterward. A small pilot random- Key issues to be considered before initiating a
ized controlled trial of a cognitive behavioral trial of pharmacotherapy for BPSD are whether
therapy-based intervention for people with drug treatment is warranted and why; whether the
dementia and anxiety, Peaceful Mind, showed particular target symptom is likely to respond to
short-term benets in terms of improved quality medication; which class of drug is most appropri-
of life and reduced anxiety in participants as well ate/evidence based; adverse effects of the drug;
as reduced related distress in carers (Stanley the duration of drug treatment, and planned
et al. 2013). review and monitoring of response and adverse
A number of other psychotherapeutic effects. Other general principles of prescribing
approaches have been studied but have low or include slow and careful titration from a low
no evidence (Livingston et al. 2005). Validation dose, consideration of the individuals medical
therapy emphasizes a persons current feelings as comorbidities, which may affect drug metabolism
real regardless of the reality of the situation. It and excretion, and avoiding polypharmacy. Par-
encourages and validates expression of feelings. ticular care must be taken with people with
For example, if a person is agitated because they dementia with Lewy bodies or Parkinsons dis-
cannot be with a loved one, the therapist using a ease, who have greater sensitivity to antipsychotic
validation approach will acknowledge their feel- medication.
ings and engage them in a discussion about the
relationship. Reminiscence therapy focuses on
stimulating memory as it relates to an individuals Pharmacological Cognitive Enhancers
life history, e.g., past signicant events. Materials
such as old newspapers or personal items may be Cholinesterase inhibitors are not currently indi-
used to stimulate memories and enable sharing of cated for BPSD. Meta-analyses of cholinesterase
their experiences. Reality orientation therapy inhibitors in BPSD have found statistically signif-
involves presenting information about place, icant differences in global neuropsychiatric scores
time, and important others using visual prompts compared to placebo, but clinical signicance is
(e.g., calendars, clocks, personal items, regular doubtful (Campbell et al. 2008). Subgroup ana-
family visits, lighting appropriate to time of lyses show cholinesterase inhibitors may be use-
day). The rationale is that reminders, which ful when targeting specic BPSD symptoms,
improve orientation, improve functioning. This including apathy and indifference, hallucinations
therapy also has low-level evidence. and delusions, anxiety and depression, and
aberrant motor behavior (Setz and Lawlor 2012). and a history of anxiety. She is unable to walk
Rivastigmine is signicantly benecial in demen- and stays in her room. The staff ask for assistance
tia with Lewy bodies, particularly for agitation to manage her constantly calling out help. The
and visual hallucinations. Withdrawal of cholin- vocalization has been present for years but has
esterase inhibitors may lead to worsening of become more frequent and associated with dis- B
BPSD within 6 weeks. Adverse effects such as tress in recent months. The general practitioner
diarrhea, gastrointestinal upset, agitation, started risperidone (2 mg nocte), with little effect.
bradyarrhythmia, and anorexia may limit use. The staff complete a behavioral diary which
Memantine, an NMDA glutamate receptor shows that the calling out is greatest in the eve-
antagonist may be useful for BPSD. Although it nings and does not occur during bathing or meal
was found to modestly reduce scores on the neu- times (when she is fed). Sometimes, she grabs at
ropsychiatric inventory, the clinical signicance is her throat and looks distressed. When her son sits
uncertain. It may be most useful for target behav- holding her hand, the vocalization reduces. There
iors such as agitation, aggression, delusions, hal- are no abnormalities on physical examination or
lucinations, and irritability. It may delay the pathology tests. The staff have moved her to a
emergence of agitation in people with dementia. room near their station so they can reassure her
Side effects include dizziness, drowsiness, consti- frequently. This works for a brief time, then she
pation, hypertension, anorexia, headache, anxiety, calls out again when they leave. During the
delirium, and psychosis (in dementia with Lewy assessment, Mary has no spontaneous speech
bodies). other than calling out help. She does not main-
tain eye contact. Tone is mildly increased in her
arms. Her affect is fearful. She nods in agreement
Antidepressants when asked about feeling worried and later about
breathlessness. The vocalization becomes louder
Evidence is lacking for the use of antidepres- and more frequent as the psychiatrist leaves. Fur-
sants in depression with dementia. Nonpharma- ther discussion with staff reveals she used to feed
cological strategies should be used rst and the pet rabbits and sit out in the garden area but
antidepressants reserved for when these are has not done so in several weeks due to short
unsuccessful or in more severe cases with suicidal stafng. She now shares a room with a
ideation. Selective serotonin reuptake inhibitors non-English-speaking resident. Marys son con-
are rst-line agents. Tricyclic antidepressants rms a history of signicant anxiety and depres-
should be avoided due to the risk of delirium sion, with several hospitalizations.
conferred by the high anticholinergic burden. The psychiatrist concludes that Mary has a
Citalopram, a selective serotonin reuptake inhibi- relapse of her anxiety disorder with probable panic
tor, may be effective for agitation/aggression and attacks. She is likely to be understimulated and
comparable in efcacy to risperidone and more lonely. Following discussions with staff, efforts
effective than perphenazine (an antipsychotic). are made to bring her into the dayroom beside
Adverse effects may include gastrointestinal English-speaking residents and for her to resume
symptoms, hyponatremia, falls, and, in citalopram, her role of feeding the rabbits. The risperidone is
prolonged QTc interval (an abnormality on electro- stopped due to lack of efcacy. With consent from
cardiograph which may predispose to cardiac Marys son, she is recommenced on sertraline,
arrhythmias) at doses 40 mg or greater. which she responded to previously. The vocaliza-
The following case demonstrates the assess- tions reduce over a few weeks; she smiles occasion-
ment and multimodal management of verbal agi- ally at staff and appears less worried. Further review
tation due to an untreated anxiety disorder. is scheduled to monitor progress.
This vignette demonstrates the importance of
Case 2 Mary is an 83-year-old nursing home comprehensively describing the behavior using
resident with advanced Alzheimers dementia the ABC approach while taking into account
individual historical factors, the environment, and Use should be time limited, and short-acting
nonverbal communication. Psychotropic medica- benzodiazepines like lorazepam are preferred to
tion may be indicated and useful but should be reduce the risk of accumulation. Sleep hygiene
ceased if ineffective. strategies should be rst-line treatment for
insomnia and, only if unsuccessful, short-term
use of temazepam. Falls, delirium, drowsiness,
Antipsychotics and ataxia are the main adverse effects.
There is modest evidence for the use of either

haloperidol or risperidone for aggression but lim- Anticonvulsants
ited evidence for other agitated behaviors in
dementia (Schneider et al. 2006). Aripiprazole Meta-analyses have shown that carbamazepine is
may be useful for agitation and aggression in modestly effective for agitation (Schneider
Alzheimers disease. Risperidone also confers et al. 2006) but inadequate evidence for sodium
modest benet for psychosis in Alzheimers dis- valproate (Konovalov et al. 2008). Side effects
ease (Schneider et al. 2006). Quetiapine has been include falls, cognitive impairment, ataxia, blood
shown not to be of benet in studies of agitation in dyscrasias, and hepatic dysfunction.
dementia with Lewy bodies and Alzheimers and
may be associated with greater cognitive decline
in Alzheimers (Royal Australian and New Analgesics
Zealand College of Psychiatrists 2013).
Antipsychotics are associated with several Systematic, effective treatment of pain may sig-
risks warranting consideration. There is an ele- nicantly reduce agitation in nursing home resi-
vated risk of stroke, neurological symptoms dents with moderate to advanced dementia.
(e.g., headache, dizziness, transient ischemic Regular paracetamol may be sufcient for the
attacks), and mortality, the latter higher in typical majority of this population and buprenorphine
antipsychotics. The extrapyramidal side effects patches required for some.
are well recognized, more common with typical
antipsychotics, and include parkinsonism (tremor,
rigidity, bradykinesia), falls, akathisia, and neuro- Electroconvulsive Therapy
leptic malignant syndrome. Metabolic side effects
include hyperglycemia, hypercholesterolemia, Although electroconvulsive therapy may be used
and weight gain. Antipsychotics can also cause for depression, psychosis, and agitation in demen-
delirium and cognitive decline, especially those tia, especially in life-threatening situations or with
with prominent anticholinergic side effects, such symptoms nonresponsive to medication, evidence
as olanzapine and quetiapine. Ventricular tachy- is restricted to case reports and series. Transient
cardia, torsade de pointes, and sudden cardiac delirium is common after a treatment.
death may be associated with some antipsy-
chotics. Importantly, several studies have shown
that BPSD remain unchanged or improve when Conclusion
typical antipsychotics are discontinued (Ballard
et al. 2009). BPSD syndromes are an important and common
development in dementia occurring at all stages in
the illness. They have signicant and far-reaching
Benzodiazepines implications for the person with dementia and
their family and caregivers. As well as consider-
Benzodiazepines may be used for agitation; how- ing the particular type of dementia, the behaviors
ever, there are no good studies in BPSD. or psychological symptoms should be carefully
observed and described as part of a thorough Draper, B., Finkel, S. I., & Tune, L. (2012a). Module 1
assessment. Careful evaluation of the individuals An introduction to BPSD. In B. Draper, H. Brodaty, &
S. I. Finkel (Eds.), The IPA complete guides to BPSD-
social circumstances, experiences, personal his- specialists guide (pp. 1.11.16). Northeld: Interna-
tory, and their medical, psychiatric, and functional tional Psychogeriatric Association.
history is essential to understanding the potential Draper, B., Haupt, M., & Zaudig, M. (2012b). Module 3 B
contributing factors. Management must similarly Etiology. In B. Draper, H. Brodaty, & S. I. Finkel
(Eds.), The IPA complete guides to BPSD- specialists
be tailored to the individual addressing the com- guide (pp. 3.13.21). Northeld: International
ponent causes in a collaborative approach with Psychogeriatric Association.
signicant others and carers. Pharmacotherapy Fleming, R., Crookes, P., & Sum, S. (2009). A review of the
should be reserved for situations where other mea- empirical literature on the design of physical environ-
ments for people with dementia. Kensington: University
sures have failed and to target particular symp- of NSW. http://www.dementiaresearch.org.au/images/
toms known to be responsive to specic dcrc/output-les/147-summary_of_a_review_of_the_
medication. A plan for review and ongoing mon- empirical_literature_on_the_design_on_physical_envi
itoring is essential. Further research that integrates ronments_for_people_with_dementia.pdf. Accessed
21 Jan 2015.
neurobiological, psychosocial, and environmental Ford, A. H. (2014). Neuropsychiatric aspects of dementia.
domains will better develop understanding of the Maturitas, 79, 209215.
etiological factors underlying these clinical Grossberg, G., Luxenberg, J., & Tune, L. (2012). Module
syndromes. 2 Clinical issues. In B. Draper, H. Brodaty, &
S. I. Finkel (Eds.), The IPA complete guides to BPSD-
specialists guide (pp. 2.12.23). Northeld: Interna-
tional Psychogeriatric Association.
Konovalov, S., Muralee, S., Tampi, R. R., et al. (2008).
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research denition. International Psychogeriatrics, intervention for anxious patients with dementia. Jour-
27(1), 717. nal of Geriatric Psychiatry, 21, 696708.
386 Berlin Aging Studies (BASE and BASE-II)
Wang, H., Faison, W., & Homma, A. (2012). Module 7 assessments of surviving participants who had
Cross cultural and transnational considerations. In agreed to take part again were carried out until
B. Draper, H. Brodaty, & S. I. Finkel (Eds.), The IPA
complete guides to BPSD- specialists guide 2008/2009. In addition, mortality information was
(pp. 7.17.40). Northeld: International obtained regularly from the city registry. This
Psychogeriatric Association. allowed the examination of age- and death-related
changes in old age. In 2011, a new study was
launched, the Berlin Aging Study II (BASE-II),
which focuses on many of the constructs exam-
ined in BASE as well as new constructs, but
Berlin Aging Studies (BASE and follows a larger group of old participants as well
BASE-II) as a group of young adults for comparison.
In the following, BASE and BASE-II are
Julia A. M. Delius1, Sandra Dzel1, Denis presented in depth, rst focusing on BASE, and
Gerstorf2 and Ulman Lindenberger1 then drawing attention to select features of
1
Center for Lifespan Psychology, Max Planck BASE-II.
Institute for Human Development, Berlin,
Germany
2
Institute of Psychology, Humboldt University, The Berlin Aging Study (BASE)
Berlin, Germany
Institutional Background and Organization
of BASE
Synonyms The rst study was initiated in 1989 by the West
Berlin Academy of Sciences interdisciplinary
Longitudinal studies of old age and aging working group Aging and Societal Develop-
ment. It was initially directed by the late
Paul B. Baltes, psychologist, and Karl Ulrich
Definition Mayer, sociologist (Baltes and Mayer 2001;
Lindenberger et al. 2010; Mayer and Baltes
The Berlin Aging Studies (BASE and BASE-II) 1999). From 1994 to 1999 the working group
are two consecutive studies of old age and aging and BASE were continued by the newly founded
with an interdisciplinary focus. The disciplines Berlin-Brandenburg Academy of Sciences. BASE
involved include psychology, psychiatry, geriat- was carried out as a collaboration among several
rics and internal medicine, genetics, sociology, institutions including the psychology and sociol-
and economics. The initial BASE data collection ogy research centers at the Max Planck Institute
involved 14 sessions and took place in 19901993 (MPI) for Human Development, the Department
with 516 men and women aged 70 to over of Psychiatry at the Freie Universitt Berlin, insti-
100 years. BASE-II currently involves ve ses- tutes and research groups at the Virchow Clinic of
sions with 1,600 older adults aged 6080 years as the Humboldt-Universitt zu Berlin, and the
well as 600 younger adults aged 2035 years, who Evangelisches Geriatriezentrum Berlin. Over
were assessed for the rst time in 20112014. time, the study was funded by various German
The initial Berlin Aging Study (BASE) was federal ministries (Federal Ministry for Research
launched in 1989. In 19901993, 516 women and Technology, Federal Ministry for the Family
and men aged 70 to 100+ years and living in the and Senior Citizens, and nally until 1998 Federal
former West Berlin completed an intensive Ministry for the Family, Senior Citizens, Women,
protocol of 14 sessions that exhaustively assessed and Youth). The Max Planck Society for the
their physical and mental health, life histories, Advancement of Science currently supports the
living conditions, and psychological status. study. The study also received additional support
Subsequently, seven longitudinal follow-up from the Berlin-Brandenburg Academy of
Berlin Aging Studies (BASE and BASE-II) 387
Sciences and the cooperating institutes and cohort differences in education, consequences of
research groups. war and epidemics, etc.) on old age, social
The multidisciplinary nature of BASE is inequality and aging, and differences between
reected in four research units: internal medi- older men and women were analyzed. The ques-
cine/geriatrics (Elisabeth Steinhagen-Thiessen), tion whether dementia represents discontinuity or B
psychiatry (Hanfried Helmchen), psychology continuity in the course of aging was one of the
(Paul B. Baltes, succeeded by Ulman main research topics of the BASE psychiatry unit.
Lindenberger and Jacqui Smith), and sociology/ Issues related to reserve capacity and plasticity in
social policy (Karl Ulrich Mayer). At the begin- old age were important for the analyses of the
ning of the study (19901993), the project group geriatrics unit and the psychology unit. The con-
consisted of about 60 scientists from different sideration of aging as a systemic phenomenon has
disciplines. In 2015, about ten scientists are still always been a key focus in BASE. Here, connec-
regularly involved in the analysis of the longitu- tions were made across domains such as sensori-
dinal data. Since 2004, Ulman Lindenberger motor functioning and cognition or health and
heads the current BASE core group at the MPI well-being, and in a holistic person-oriented
for Human Development. From the outset, young approach, subgroups of older adults were identi-
scientists were heavily involved in BASE. By ed based on their proles of functioning.
2014, 25 diploma and masters theses and 22 doc-
toral theses analyzing BASE data were com- Sample
pleted. In many cases, the ndings were The initial focus of BASE (19901993) was to
subsequently published in peer-reviewed interna- obtain a heterogeneous sample, stratied by age
tional journals. and sex, of individuals aged 70 to 100+ years who
As mentioned above, the study involves eight completed a 14-session intensive protocol that
measurement occasions spaced over 18 years. In involved detailed measures from each of the four
addition, several subsamples have been recruited participating disciplines at the rst occasion of
for intensive study. The key features of BASE measurement. The stratied sample participating
include (1) a focus on the very old (70 to 100+ in this intensive protocol consisted of 258 men
years); (2) a locally representative sample, and 258 women from the former West Berlin
stratied by age and sex; (3) a broadly based aged 7074, 7579, 8084, 8589, 9094, and
interdisciplinarity; and (4) an emphasis on meth- 95+ years. The parent sample was drawn from the
odological issues, such as selective attrition and obligatory city register. A standardized intake
the measurement of change. assessment was also used to collect multidis-
ciplinary data at early stages and as a repeat instru-
Theoretical Orientations ment at each later occasion of measurement. For a
In addition to discipline-specic topics, four inte- detailed documentation of sampling procedures
grative theoretical orientations have guided the and sample selectivity, see Lindenberger
study: (1) differential aging, (2) continuity versus et al. (2001).
discontinuity of aging, (3) range and limits of
plasticity and reserve capacity, and (4) aging as a Longitudinal Continuation
systemic phenomenon. In order to focus on the theoretical orientations
The theoretical orientations led the selection that actually emphasize the processes of aging as
and analysis of the central topics of BASE that well as the dynamics and consequences for differ-
were presented in the initial monographs on the ential aging, a longitudinal continuation of the
study (Baltes and Mayer 2001; Lindenberger study was put in place. With longitudinal data,
et al. 2010; Mayer and Baltes 1999). The concept decisive information can be gained on all four
of differential aging covers a broad range of ques- theoretical orientations. In particular, longitudinal
tions. For example, the cumulative effects of early data allow the identication of interindividual
life experience (such as historically explainable differences in intraindividual change, provide
insights into the determinants of change, and the Third to the Fourth Age and the characteristics
enable analyses of systemic linkages among of the Fourth Age.
behavioral changes. Seven longitudinal follow- Data from the Berlin Aging Study continue to
ups of the survivors from the initial sample provide the basis for new original publications on
involving different depths of assessment were individual differences in late-life development.
completed at approximately 2-yearly intervals. Furthermore, DNA specimens, derived from
A single-session multidisciplinary assessment blood samples frozen at the rst occasion of mea-
was collected in 19931994 (N = 361), reduced surement to allow later analyses, have been
versions of the intensive protocol (six sessions) retrieved and analyzed for about 380 BASE par-
were collected in the periods 19951996 (N = ticipants. Adding genetic information to the
206) and 19971998 (N = 132), and repeats of BASE data set allows researchers to explore and
parts of the psychology battery together with test genetic contributions to individual differences
multidisciplinary outcome variables (e. g., screen- in late-life development.
ing for dementia, assessment of well-being) were The initial sample of 516 individuals formed
collected in 2000 (N = 82), 2004 (N = 46), and the basis of the cross-sectional analyses reported
2005 (N = 37). In addition, mortality information in two monographs (Baltes and Mayer 2001;
about the entire BASE sample is updated at regu- Mayer and Baltes 1999). Current interests
lar intervals. At the eighth (and probably nal) of the BASE core group include issues of
measurement occasion in 20082009, 22 surviv- sample selectivity and representativeness;
ing participants were reexamined, concentrating intraindividual variability and change; terminal
on psychological, geriatric, and dental decline; cognitive aging; mortality prediction;
assessments. self-related change, well-being, and antecedents
An additional focus that also inuenced the of successful aging; and genetic predictors of
design of the longitudinal study deals with the individual differences in cognitive and self-
transition of the Third Age to the Fourth Age. related change in old age.
Within the last phase of the life span, in old age, The BASE data set is rich: For the rst cross-
scientists differentiate between the Third and sectional data collection alone, there are already
Fourth Age or between the young old and old 10,000 variables available per participant. Exter-
old (Baltes and Smith 2003). This differentiation nal scientists can apply for access to parts of the
is based on the heterogeneity within the elderly BASE data set. Data can then be made available in
population with respect to important characteris- accordance with the German data protection laws.
tics such as morbidity, the need for care, cognitive In the interest of scientic exchange, BASE
functioning, well-being, social participation, and researchers have invested much effort and time
mortality. The precise denitions of the determi- into the documentation and archiving of the data
nants of membership in the one or the other group set. This is in line with endeavors in the USA to
or that characterize the transition from the Third to make central data bases of important studies avail-
the Fourth Age still need to be identied. Based able to the scientic community. The data of
on theory, the Third Age can be described as a BASE are described in an extensive and detailed
phase of positive quality of life, whereas the documentation that can be provided on a compact
Fourth Age is characterized by dysfunction, ill- disc. Copies of the questionnaires used in BASE
ness, and death. Some demographers have identi- can also be requested, and some are already part of
ed the age of 85 as the average entrance criterion the documentation. The BASE website (www.
into the Fourth Age (Suzman et al. 1992). How- base-berlin.mpg.de) provides an overview of the
ever, the question remains open whether this age study and includes a searchable catalog of the
is a xed or mobile criterion for the end of the numerous BASE publications. It is updated regu-
Third and beginning of the Fourth Age. Therefore, larly and includes a contact e-mail address
the analysis of the longitudinal BASE data also (basempi@mpi-berlin.mpg.de) for reprint or
focuses on the investigation of the transition from information requests.
Trajectories of Change: Age Versus Time to dementia were excluded from the analysis. This
Death nding is in line with the hypothesis that normal
One example of the kinds of analyses possible aging magnies the effects of common genetic
with the BASE data was published by Denis variation on cognitive functioning.
Gerstorf et al. (2013). Mortality-related processes B
are known to modulate late-life changes in cogni-
tive abilities, but it is an open question whether The Berlin Aging Study II (BASE-II):
precipitous declines with impending death gener- Understanding Heterogeneity in Aging
alize to other domains of functioning. The authors
used 13-year longitudinal data from 439 deceased BASE ndings conrmed that heterogeneity is
BASE participants to compare changes as a func- one of the most salient aspects of aging. Some
tion of time since birth (i.e., age models) with individuals maintain their health and preserve
changes as a function of time to death (i.e., mor- their cognitive abilities into advanced ages,
tality models). Across a large range of functional whereas others show precipitous and early
domains such as subjective health, emotional decline. To understand the mechanisms that pro-
loneliness, grip strength, perceived control, and duce this diversity of outcomes and trajectories of
the score in the Digit Letter Test (a marker of aging, individuals need to be followed over time.
perceptual speed), mortality models revealed reli- With this goal in mind, researchers from Berlin
ably steeper average rates of change than age and Tbingen initiated the Berlin Aging Study II
models. These ndings underscore the pervasive (Bertram et al. 2014). Like BASE, BASE-II was
presence of processes leading toward death in old set up as a multidisciplinary and multi-
age. Multivariate analyses with more closely institutional longitudinal study that captures a
spaced multi-domain measurements are needed wide range of different functional domains. Geri-
to identify the temporal dynamics and dimension- atrics and internal medicine, psychology, sociol-
ality of this end-of-life cascade. ogy, and economics are again among the
disciplines involved, moreover, immunology and
Genetic Contributions to Individual genetics were additionally included. Thus, the
Differences in Late-Life Cognitive BASE-II steering committee represents a wide
Development range of these disciplines and involves many of
Another example of BASE ndings highlights the the scientists who also collaborated in BASE.
importance of the genetic analyses that have Elisabeth Steinhagen-Thiessen, Evangelisches
become possible. The brain-derived neurotrophic Geriatriezentrum Berlin, was the rst BASE-II
factor (BDNF) promotes activity-dependent syn- speaker from 2010 to 2014. In 2015, she was
aptic plasticity and contributes to learning and succeeded by Denis Gerstorf, Humboldt-
memory. Paolo Ghisletta et al. (2014) investigated Universitt zu Berlin. The study received nancial
whether a common Val66Met missense polymor- support from the Federal Ministry of Education
phism (rs6265) of the BDNF gene is associated and Research, the Max Planck Society for the
with individual differences in cognitive decline in Advancement of Science, and other participating
old age. A total of 376 BASE participants with a institutions.
mean age of 84 years at the rst occasion of
measurement were assessed longitudinally up to The BASE-II Sample
11 times (due to multiple testing at several occa- The recruitment of the BASE-II cohort resulted in
sions of measurement) across more than 13 years a consolidated baseline sample of 1,600 older
on the Digit Letter Test. Met carriers (n = adults aged 6075 years and of 600 younger
123, 34%) showed steeper linear decline than adults aged 2035 years (Bertram et al. 2014).
Val homozygotes (n = 239, 66%). This effect Potential participants were drawn from a pool of
was not moderated by sex or socioeconomic status individuals originally recruited at the MPI for
and was also observed when individuals at risk for Human Development for a number of earlier
projects with a focus on neural correlates of interactions among genetic, psychosocial, demo-
cognition. graphic, and lifestyle factors that shape individual
Briey, participant recruitment was based on pathways into old age (Lindenberger 2014).
advertisements in local newspapers and the public Multidisciplinary approaches are required to
transport system of Berlin. Interested individuals understand how individual differences in cogni-
of the greater metropolitan area of Berlin were tive and psychosocial domains of functioning
further screened to meet the inclusion criteria of relate to the wide range of genetic, somatic, and
BASE-II (either in-house or by telephone) leading sociological markers and constructs assessed in
to 2,262 healthy individuals who were eligible for BASE-II and how these associations change
inclusion in BASE-II. Individuals were included over time. Additionally, socioeconomic data and
if they were not taking medication that could data about life satisfaction and habits, the social
affect memory function and did not report a his- environment, and attitudes in life were collected
tory of head injuries or neurological or psychiatric and can be taken into account as explaining fac-
disorders. Finally, 2,200 individuals were selected tors. The BASE-II design allows younger and
to represent the BASE-II baseline cohort. older participants to be directly compared on all
It is well known that some age-related func- dimensions assessed.
tional and cognitive changes, such as decline in An overarching goal of BASE-II is to follow
perceptual speed, evolve in early adulthood. At up the trajectories and the strengths of the
the same time, recent longitudinal studies indicate multidisciplinary associations revealed in the
that other cognitive abilities, such as episodic rst wave of BASE-II. Repeated investigations
memory (EM), are relatively stable until about after a certain time will allow more specic obser-
60 years of age and start declining thereafter. In vation and classication of individual trajectories
order to identify and follow associations of mul- of aging. Longitudinal ndings may contribute
tiple factors inuencing age-related changes, the toward bolstering action strategies for demo-
decision was taken to start observing healthy older graphic change and increasing knowledge of the
adults at an age of relative health and stability, but conditions necessary for independent living.
where most would be at risk of subsequent age-
related changes on multi-dimensional variables of Assessing Cognitive Functioning
interest. Thus, a total of 1,600 participants were A major aim of the psychology subproject is to
assigned to an older subgroup aged between obtain a detailed and comprehensive picture of
60 and 80 years, and 600 individuals were cognitive abilities and psychosocial characteris-
assigned to a younger subgroup (serving as a tics that can serve as a solid baseline for subse-
reference population) aged between 20 and quent longitudinal observations (Fig. 1).
35 years. By design, each age subgroup contains Throughout all analyses, structural equation
an approximately equal number of men and modeling was used (McArdle 2009) in order to
women. To estimate sample selectivity, data establish latent constructs and examine associa-
from this baseline sample are linked to the Ger- tions among them. Thus, by relating individual
man Socio-Economic Panel (SOEP) study, a lon- differences in cognitive abilities to variations in
gitudinal panel survey that is representative of the lifestyle, environmental factors, and personality, it
German population. To date, BASE-II only is possible to identify different patterns and psy-
includes cross-sectional variables but is planned chosocial contexts of cognitive aging and to
as a longitudinal study. investigate links to multiple domains within
BASE-II (Fig. 1).
Interdisciplinary Research in BASE-II After extensive piloting, a comprehensive bat-
In many countries around the world, current tery of cognitive tests and a psychological ques-
cohorts of adults are living longer than earlier tionnaire were added to the baseline protocol in
cohorts and are reaching old age in better health. 2013. The cognitive battery of BASE-II covers
There is a growing need to investigate the key cognitive abilities such as episodic memory
Berlin Aging Studies (BASE and BASE-II), Fig. 1 Overview of cognitive domains with associated tasks within the
baseline assessment of BASE-II
(EM) as well as measures of working memory Data collection takes place between the rst and
(WM), cognitive control, uid intelligence (FI), second cognitive session at the participants place
reading skills, and decision making. The assess- of residence (i.e., private household or institu-
ment is distributed across two testing sessions that tion). Overarching constructs include well-being,
last three hours each and are seven days apart. affect, perceived stress, motivation and control,
The Digit Symbol Substitution Test (WAIS-II; personality, perceptions of time and aging, social
paper-and-pencil version) was applied to relate embedding, and perception of neighborhood char-
performance levels observed in BASE-II to other acteristics. The selection of psychosocial mea-
studies, including BASE (cf. Gerstorf et al. 2015). sures was based on conceptual considerations
In summary, the psychometric space of human and empirical evidence to permit the investigation
cognitive abilities is represented more broadly of links to physical health and cognitive function-
than in most other comparable studies. ing (e.g., Diener et al. 2006). Selection of (sub)
scales and items for the constructs was based on
Assessing Psychosocial Functioning empirical reports attesting that psychometric
To cover a broad range of key psychosocial cor- properties were acceptable. To allow for direct
relates of health and cognition in old age, a com- empirical comparison across studies, several
prehensive psychosocial assessment battery was (sub)scales and items that were also applied in
compiled for BASE-II. A total of eight domains closely related studies, including SOEP (Headey
of psychosocial functioning are assessed. et al. 2010), BASE (Baltes and Mayer 2001;
Lindenberger et al. 2010; Mayer and Baltes 1999), their life and feel socially integrated and young?
and the COGITO study (Schmiedek et al. 2010), To examine these questions, Hlr and colleagues
were chosen. This design strategy allows compar- (in press) compared data obtained in BASE
ison of individuals from the later-born cohorts of (in 199093) and BASE-II (in 20132014) and
BASE-II with their age peers from earlier cohorts applied a case-matched control design based on
in BASE (e.g., comparing 75-year-olds born in age, gender, education, comorbidities, and cogni-
1915 with 75-year-olds born in 1938). The strat- tion. Results revealed evidence for considerable
egy also makes it possible to analyze longitudinal secular changes in peoples perceptions of their
data from participants who were previously part lives. For example, 75-year-olds nowadays hold
of the SOEP and COGITO studies. fewer external control beliefs and report less lone-
liness. Possible correlates underlying such cohort
Developing New Measures of Active Aging differences are being examined at the time of
Maintaining cognitive abilities in aging is impor- writing.
tant for everyday competence and an independent Cognitive functioning. Using conrmatory fac-
lifestyle. A lifestyle associated with exposure to tor analysis (CFA), it was possible to validate a
novel and varied information (enriched environ- three-factor model of memory for both age
ment) is considered benecial for healthy cogni- groups. This latent approach is important to fur-
tive aging (Lindenberger 2014; Hertzog ther investigate the associations between cogni-
et al. 2008). Psychological concepts of motivation tive functioning and other psychosocial, medical,
postulate that the subjective appraisal of the time genetic, and socioeconomic indicators assessed in
left to life affects individuals goal- and activity- BASE-II.
related motivations (Lang and Carstensen 2002). Associations between health and cognition.
Hence the Subjective Health Horizon Question- Being physically active and having a higher over-
naire (SHH-Q) was developed and validated. all health status have protective effects on brain
This novel questionnaire captures individuals structure and function and are associated with
expectations regarding their ability to explore later onset or lower degree of age-related cogni-
and engage with novel information in the future tive decline (Hertzog et al. 2008; Maass
alongside their expectations concerning bodily et al. 2015). The examination of associations of
health and tness. The SHH-Q is administered health- and tness-related measures to global
within the cognitive session by means of a com- measures of cognitive functioning using CFA is
puter. The SHH-Q forms four correlated but dis- in planning. Medical data are used to generate
tinct subscales: (1) novelty-oriented exploration, global measures of health (e.g., grip strength)
(2) bodily tness, (3) occupational goals, and and tness (e.g., lung functioning). Initial multi-
(4) goals in life (cf. Dzel et al. under review). ple hierarchical regression analyses with the sam-
ple of older BASE-II adults showed that grip
Summary of Initial Results from BASE-II strength predicts performance in all memory
Changes in psychosocial functioning across domains (FI, WM, and EM) beyond age, gender,
cohorts. Initial analyses of the psychosocial mea- and years of education. In the younger BASE-II
sures focused on secular changes in aspects of subsample, neither of these health and tness
motivation and control, social embedding, and measures was associated with any of the three
perceptions of time and aging. As mentioned cognitive abilities. Future analyses will investi-
above, levels of functioning in more objective gate age group differences in the associations
and performance-based measures assessed in between somatic health and cognition.
BASE and BASE-II such as physical health and Establishing metabolic status as a latent con-
cognition were higher in more recent cohorts of struct. Epidemiological studies have linked fea-
older people. Does this mean that they also per- tures of the metabolic syndrome (MetS; a
ceive themselves as having more control over clustering of several frequent medical disorders
such as abdominal obesity, hypertriglyceridemia, generalizability when exploring links to genetic

and hypertension) to cognitive decline in old age. variation (e.g., Papenberg et al. 2014). Further
However, it is not clear to what extent each indi- analyses will explore across-domain associations
cator of MetS contributes to pathophysiology and between aspects of physical health, cognitive
how single or combined MetS features affect cog- functioning, and psychosocial characteristics. B
nitive functioning. Additionally, little is known Additional analyses will focus on identifying psy-
about associations among vascular risk, metabolic chosocial variables that may serve as protective or
status, and cognition in healthy aging. The under- risk factors for dealing with health challenges. To
lying hypothesis is that memory functions are move toward a better understanding of whether
moderated by metabolic and vascular factors. Bio- and how contextual factors shape individual func-
markers were collected within the medical tioning and development, geo-coded information
subproject of BASE-II and include systolic and (e.g., to index distance to green spaces) will be
diastolic blood pressure, glucose and insulin area linked to psychosocial characteristics (e.g.,
under the curve, triglycerides, HDL cholesterol, chronic stress) and to health information (e.g.,
body mass index (BMI), waist circumference, and biomarkers of stress).
trunk fat. To investigate the aforementioned
links between MetS and cognition, MetS was Synergies between BASE and BASE-II
established as a latent construct, again using One way to explore the malleability of the human
CFA. A one-factor model of MetS provided life course is to directly compare different cohorts
acceptable model t, with three measures loading of the same age across historical time (Baltes
adequately on the MetS factor (triglyceridemia, 1968; Schaie 1965). The similarities between
trunk fat, fasting glucose level). This factor is in BASE and BASE-II offer excellent opportunities
line with medical descriptions of MetS. Initial for comparisons of this kind. In a recent study,
analyses suggest reliable associations among Gerstorf and colleagues (2015) quantied secular
MetS, cognition, and subjective measures of increases in uid intelligence in old age favoring
future time horizon. later-born cohorts. They compared data obtained
Psychosocial functioning. With the validation 20 years apart in BASE and BASE-II, applied a
of SHH-Q, the new self-report measure of distinct case-matched control design, and quantied sam-
future time perspectives, within the healthy older ple selection using a nationally representative
sample of BASE-II, the SHH was shown to sample as the reference (Fig. 2; see also Hlr
account for a signicant proportion of memory et al. in press). The later cohort performed better
performance variability. Initial analyses indicate on the uid intelligence measure and reported
that greater self-reported novelty orientation is higher morale, less negative affect, and more pos-
associated with higher EM performance and itive affect than the earlier cohort. The authors
greater self-reported bodily tness with better concluded that secular advances have resulted in
metabolic status (Dzel et al. under review). better cognitive performance and perceived qual-
These initial results pave the way to a better ity of life among older adults. To the extent that
understanding of the connections between subjec- BASE-II will be continued as a longitudinal study,
tive activity-related motivation and health it will permit researchers to study the ways in
behavior. which longitudinal trajectories of adult develop-
ment evolve over historical time.
Outlook
The psychometric validation of the BASE-II cog-
nitive battery is an important starting point toward Summary
investigating associations with other functional
domains. In particular, analyses at the latent Taken together, the combination of ndings from
level will enhance statistical power and BASE and BASE-II and the possibility to analyze
Berlin Aging Studies (BASE and BASE-II), standard errors for each cohort are displayed separately.
Fig. 2 Average cohort differences and individual differ- Participants in the BASE-II cohort (data obtained in
ences in cognitive performance. The dots represent partic- 20132014) showed higher levels of cognitive perfor-
ipants scores in the matched BASE (open circles) and mance (d = 0.85) than the BASE cohort (data obtained in
BASE-II (gray circles) samples. Sample means and 19901993). For details, see Fig. 2 in Gerstorf et al. (2015)
BASE-II data in conjunction with BASE data References

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Ghisletta, P., Bckman, L., Bertram, L., Brandmaier,

A. M., Gerstorf, D., Liu, T., & Lindenberger, U. Bibliotherapy and Other
(2014). The Val/Met polymorphism of the brain-
derived neurotrophic factor (BDNF) gene predicts Self-Administered Treatment
decline in perceptual speed in older adults. Psychology
and Aging, 29, 384392. Lisa Mieskowski and Forrest Scogin B
Headey, B., Muffels, R., & Wagner, G. G. (2010). Long- University of Alabama, Tuscaloosa, AL, USA
running German panel survey shows that personal and
economic choices, not just genes, matter for happiness.
Proceedings of the National Academy of Sciences, 42,
1792217926. Synonyms
Hertzog, C., Kramer, A., Wilson, R., & Lindenberger,
U. (2008). Enrichment effects on adult cognitive devel- Bibliotherapy; Self-administered treatment;
opment: Can the functional capacity of older adults be
preserved and enhanced? Psychological Science in the
Self-help
Public Interest, 9, 165.
Hlr, G., Drewelies, J., Eibich, P., Dzel, S., Demuth, I.,
Ghisletta, P., . . . Gerstorf, D. (in press). Cohort differ- Definition
ences in psychosocial function over 20 years: Current
older adults feel less lonely and less dependent on
The formal implementation of written or digital
external circumstances. Gerontology.
Lang, F. R., & Carstensen, L. L. (2002). Time counts: materials to facilitate understanding or assist in
Future time perspective, goals, and social relationships. efforts relevant to a persons developmental or
Psychology and Aging, 5, 125139. therapeutic needs.
Lindenberger, U. (2014). Human cognitive aging: Corriger
la fortune? Science, 346(6209), 572578.
Lindenberger, U., Gilberg, R., Little, T. D., Nuthmann, R.,
Ptter, U., & Baltes, P. B. (2001). Sample selectivity General Overview
and generalizability of the results of the Berlin Aging
Study. In P. B. Baltes & K. U. Mayer (Eds.), The Berlin In its simplest form, bibliotherapy uses literature
Aging study: Aging from 70 to 100 (pp. 5682). New
to facilitate improvements in the well-being or
York: Cambridge University Press.
Lindenberger, U., Smith, J., Mayer, K. U., & Baltes, P. B. functioning of an individual or group of individ-
(Eds.). (2010). Die Berliner Altersstudie (3rd ed.). Ber- uals. The literature may be instructional in nature
lin: Akademie Verlag. (i.e., a therapeutic manual written in narrative to
Maass, A., Dzel, S., Goerke, M., Becke, A., Sobieray, U.,
aid the client in self-administered treatment) or
Neumann, K., . . . Dzel, E. (2015). Vascular hippo-
campal plasticity after aerobic exercise in older adults. conceptual (i.e., a ctional or autobiographical
Molecular Psychiatry, 20, 585593. piece which illustrates issues and/or dealings
Mayer, K. U., & Baltes, P. B. (Eds.). (1999). Die Berliner related to the readers problem of interest).
Altersstudie. Berlin: Akademie Verlag.
Through the years, the media of bibliotherapy
McArdle, J. J. (2009). Latent variable modeling of differ-
ences and changes with longitudinal data. Annual has broadened. Electronic and auditory formats
Review of Psychology, 60, 577605. are often available to the public; websites, hand-
Papenberg, G., Li, S.-C., Nagel, I. E., Nietfeld, W., outs, and even smartphone applications have been
Schjeide, B.-M., Schrder, J., . . . Bckman, L. (2014).
developed to present material. The role of the
Dopamine and glutamate receptor genes interactively
inuence episodic memory in old age. Neurobiology of psychotherapist in bibliotherapy may vary as
Aging, 35, 1213.e31213.e8. well (i.e., completely self-administered, therapist
Schaie, K. W. (1965). A general model for the study of guided, therapist administered). The following
developmental problems. Psychological Bulletin, 64,
entry will outline the basic principles and con-
92107.
Schmiedek, F., Lvdn, M., & Lindenberger, U. (2010). cepts associated with bibliotherapy and related
Hundred days of cognitive training enhance broad cog- forms of self-help, discuss current modes of
nitive abilities in adulthood: Findings from the COGITO distribution and application, and, nally, review
study. Frontiers in Aging Neuroscience, 2, 27.
the general state of bibliotherapeutic endeavors in
Suzman, R. M., Willis, D. P., & Manton, K. G. (Eds.).
(1992). The oldest old. New York: Oxford University older adult populations and outline future
Press. directions.
396 Bibliotherapy and Other Self-Administered Treatment
The general purpose has remained the same Openness to psychotherapy varies as a func-
despite the varied formats in which bibliotherapy tion of many factors, including ones cohort. The
may appear and be administered: to facilitate the issues faced by older adults may also vary, and
participants consideration and understanding physical and geographical access to individuals
of the problem of interest and to encourage struggling through similar situations may be lim-
benecial change in knowledge, perspective, and ited. In summary, bibliotherapy presents a form of
application of skills. Bibliotherapy has been psychological treatment that is easily distributed
dened as the use of written material: . . .for the and is often more nancially accessible. It can be
purpose of gaining understanding or solving prob- retained as a useful resource to refer back to, can
lems relevant to a persons developmental or ther- help connect older adults with others who share
apeutic needs (Marrs 1995). In current similar experiences, and allows the individual to
application, and for the purposes of this entry, dictate the pace and frequency in which they
this denition can be extended to include media- approach psychological change.
based products (e.g., DVDs, audio les, commu-
nity websites). Varying Levels of Administration
The overarching principle of psychologically
based self-help programs such as bibliotherapy is
Concepts, Principles, and Modalities that, for some problems, consumers may be able
of Self-Help to implement treatments with little or no profes-
sional assistance. The goals of psychotherapy and
In many cases in which bibliotherapy is bibliotherapy are generally the same. The differ-
recommended, it provides a portable venue in ence is largely in the degree to which professional
which therapeutic change may occur both inside involvement is included in treatment. One
and outside the therapeutic setting. Difcult to conceptualization has been that professional
access populations (e.g., mobility-restricted per- involvement exists on a continuum. This contin-
sons, prison populations) may benet from this uum ranges from traditional psychotherapist-
more transportable and time-exible approach. administered psychotherapy (with no self-help
Furthermore, bibliotherapy may provide a foot in augmentation) to entirely self-administered treat-
the door technique to facilitate a change in ones ment (typied by the purchase of written or DVD
attitude toward seeking mental health treatment. materials that are implemented with no therapist
Those who are unsure of the merits of psycholog- assistance). Most of the evidence-bases exist
ical treatment or hold negative or ambivalent feel- around the midpoint of this continuum and are
ings toward mental health treatment may nd concerned with the effects of minimal-contact or
themselves more open to seeking treatment if guided self-help and therapist-administered self-
given a tangible medium of treatment that they help (dened further below).
can evaluate and reevaluate at their leisure. This, Though the categorical denitions of self-help
of course, assumes the recommended self-help can vary, three broad categories are likely the most
material is sound and plausible. Bibliotherapy common descriptive derivations in use today
may also provide anecdotal material to stimulate (Glasgow and Rosen 1978). Varying in the degree
and direct discussion in group or social settings. of professional, or colloquially stated, therapist
For instance, it may be less threatening to talk assistance, these three categories outline impor-
about an issue embedded in the struggles of a tant aspects of bibliotherapeutic delivery and are
literary character or relevant problem portrayed therefore useful keywords to implement when
by the interaction of individuals in a written, spo- searching for, or publishing, research in this
ken, or lmed illustrative example. Reading about area. In therapist-administered self-help, the psy-
others with similar experiences may also decrease chotherapist or trained professional plays their
feelings of social isolation and promote healthy most active role in treatment process. For exam-
perspective taking. ple, clarication of and elaboration on materials
by the psychotherapist would be administered in person, the role of clinical judgment where trained
conjunction with self-delivered administration of professionals are involved, and the accessibility of
bibliotherapy to facilitate and guide treatment the self-help materials.
throughout. The second category, minimal-
contact self-help, refers to the psychotherapist or Modalities of Self-Help B
trained professional primarily playing a role in The term bibliotherapy evokes images of written
familiarizing the client with materials at the outset or printed materials. However, as time progresses
and subsequently minimizing their involvement and technology with it, self-help materials con-
to monitoring the clients ongoing experience tinue to adapt to t the currently preferred audio
with intermittent check-ins. These rst two cate- formats (i.e., from cassette tapes, to CDs, to
gories fall into guided self-help, which may be podcasts). Visual materials have also been devel-
delivered in person, over the phone, or via com- oped to accompany treatment or serve as stand-
puterized communication (e.g., e-mail communi- alone applications (e.g., workbooks, videos,
cation, website or computer program-delivered DVDs). Existing printed materials have been
guidance, or smartphone applications). Con- modied to t our ever increasingly technology-
versely, self-administered self-help refers to inter- savvy population by transforming workbook
ventions which rely on client or patient pages to online tablets or client workbooks to an
administration, without the benet of a trained audio format (e.g., Shah et al. 2014). Internet-
professional or psychotherapists introduction to based interventions have arisen and evidence for
self-help materials. The evaluation of treatment their efcacy is continuing to grow in the research
effectiveness is then, most often, limited to literature. Even commercially available games
assessment-driven contact. This category of self- (i.e., the Nintendo DS version of Brain Age)
help is the type that is most often commercially have been evaluated for their efcacy as a self-
distributed and is the least scientically evaluated. help memory training application (Presnell and
Other useful categorizations include Scogin 2015). Future directions in research
didactic versus imaginative materials (Riordan should consider the efcacy of available phone
et al. 1996) and individually delivered versus apps aimed at preventative care (e.g., phone apps
group administration. In some instances, the use aimed at preventing the onset of clinically signif-
of self-help materials may play a role in a stepped- icant depressive symptoms).
care approach, or approach where a clients rst Clinicians initiating treatment with new clients
introduction to treatment efforts begins with self- should consider the self-help methods currently
administered self-help materials. An individuals used by their clients, as well as those implemented
treatment and care is then stepped up as needed before they rst sought professional psychothera-
into increasingly more direct forms of treatment peutic treatment. Clinicians and clients alike will
(e.g., check-in calls, telephone-based sessions, need to keep in mind the broad range of self-help
in-person sessions). Inversely, self-help programs modalities (e.g., books, videos, websites), as both
may be applied in a form of stepped-down care. may neglect recognizing and categorizing readily
In other words, guided or minimal-contact biblio- available materials as self-help (e.g., Weight
therapy could be utilized as psychotherapists Watchers, various websites providing psycho-
move toward termination and progressively extin- education on depression). With the advent of the
guish a clients reliance on in-person sessions and smartphone, the varying levels of administration
encourage self-efcacy in self-care. In this sce- (i.e., client-administered, therapist-guided, and
nario, bibliotherapy could provide personalized therapist-administered self-help) can likewise
evidence that consumers have the skill to select, take on a more uid and nuanced role in mental
maintain, and direct positive change indepen- health treatment and the tracking of treatment
dently. In addition to the varying levels of admin- progress. Moreover, the speed at which these
istration, the delivery of self-help materials will resources become available to the public sur-
likewise vary depending on the preferences of the passes the research bases ability to evaluate
their efcacy. With the ready accessibility and and literacy or reading skills should be consid-
near-universal adoption of personal electronic ered, especially when the material is presented in
communication devices (e.g., smartphones, tab- written form.
lets), the rate of creation and distribution of self- None of these contraindications preclude a
help materials is expected to be exponential. The person from pursuing a purely self-administered
following section will discuss current clinical program. As Lehane (2005), a community psychi-
applications of self-help. atric nurse in Cardiff, succinctly points out, Book
prescriptions are on the increase and general opin-
ion appears to favor this change. Whether a men-
Clinical Application of Self-Help tal health professional actively incorporates
bibliotherapy and self-help techniques into their
The programs with the greatest evidentiary corpus service repertoire is beside the point. Self-help
tend to be those which lend themselves best to programs are available, and clients/patients,
self-administration, such as cognitive behavioral co-workers, and family members will use them.
approaches (Anderson et al. 2005). The range of Unfortunately, there is practically no evidence on
self-help applications across the lifespan is quite the efcacy of entirely self-administered pro-
large and covers much of the territory deemed grams. This is due in part to the logistics involved
appropriate for traditional therapist-administered and the understandable reluctance of university
treatments. Materials created and implemented to IRBs to approve such research. Similarly, selec-
address issues related to depression and anxiety tion of evidence-based minimal-contact and
have received the most extensive review, but areas psychotherapist-administered programs remains
such as weight-control, sexual dysfunctions, limited, but continues to grow as those in the
addictive behaviors (e.g., substance abuse, eld turn their interest toward selecting
smoking), and less obvious targets such as nail- evidence-based treatments (those with random-
biting also carve out a place in the literature. ized control trials establishing the effectiveness
Contraindications for self-help and bibliotherapy, of the self-help program in treating or addressing
primarily based on clinical intuition and not the problem of interest). As a subset of the general
empirical fact, include conditions such as schizo- population, the evidence for self-help programs
phrenia, psychotic depression, and bipolar disor- targeted toward older adults is similarly limited.
der. Other questionable candidates for self- Thus, practitioners will need to base their recom-
administered intervention include those with a mendations largely on what is known to work
personality diagnosis, typied by ego-syntonic with younger adults.
disorder, who may fail to see the applicability of Individuals will continue to use self-help mate-
the materials or have otherwise impeded ability to rials. Thus, psychologists in particular have a
adhere to a self-directed regimen. For example, a continued interest in evaluating the evidence for,
person with narcissistic personality disorder will selection of, and guidance of self-administered
often perceive their behaviors, feelings, and treatments, no matter their form and degree of
values as ego aligned (in support of the goals professional involvement. Psychologists are in
and needs of their ideal self-image) and may see a unique position to contribute to the self-help
little to no utility for changing their behaviors, movement. No other professional group combines
feelings, or values. Conversely, a person with a the clinical and research experiences that are part
depression disorder (an ego-dystonic disorder) of the clinical psychologists educational back-
often has a poor self-image and behaviors, feel- ground. Clinical psychologists are skilled in cur-
ings, and values that are not aligned with their rent therapeutic techniques, they have clinical
ideal self and may predispose to attempt the experience and sensitivity, and they have the train-
changes and activities outlined in self-help pro- ing to assess empirically the efcacy of the pro-
tocols. Client characteristics may also contraindi- grams they develop. This would represent a most
cate the use of self-help programs. Visual ability signicant and new development in the area of
self-help approaches to self-management (Rosen Depression

1982). As such, familiarizing oneself with the As previously discussed, the methods and inter-
benets, limitations, and varied administration of ventions used in self-help largely span the same
self-help therapies is of import to beginning and domains as seen in traditional psychotherapy, and
established psychologists alike. cognitive behavioral models (widely dened) B
Used in conjunction with other treatment tend to be most frequent (a trend also seen in
options, bibliotherapy and related self-help efforts face-to-face delivery of psychotherapy). With
offer cost-benet opportunities. A plethora of respect to older adult clientele and the self-help
extant self-help materials are commercially avail- materials for depression, there are several
able at relatively low cost and may be sifted well-known self-help books that have been
through in pursuit of extending the reach of the marketed and evaluated. Examples include self-
clinician past the therapy room. Non-exhaustive administered self-help books with CBT-based
resources (e.g., Norcross et al. 2003, 2013) have models (e.g., Feeling Good, by Burns) as well as
been compiled over time in an effort to guide the those that are more behaviorally based (e.g., Con-
selection and implementation of bibliotherapy, trol Your Depression, by Lewinsohn) and
but selection of material remains largely dictated therapist-administered client manuals (e.g., Dick
by the clinicians own familiarity with the material et al. 1996). Additionally, CBT-based models of
or, by extension, at the recommendation of their self-help have also been adapted or newly gener-
peers. ated to be distributed specically within research
contexts to address issues experienced by older
Evidence Base for the Use of Bibliotherapy adults (e.g., improving self-care management in
with Older Adults the frail elderly, improving sleep and preventing
In the early 2000s, several systematic reviews depression in rural older adults). Though further
were carried out evaluating evidence-based treat- materials may be indicated in treatment of late-life
ments for older adults. Several of these reviews depression, relatively few have received adequate
found promising evidence for the continued use scientic scrutiny to promote their recommenda-
and further development and evaluation of biblio- tion beyond that which can be obtained through
therapies in this context. The review led by Scogin careful clinical judgment and solicitation of
and colleagues was the only review team in a knowledgeable peers.
multi-team effort to establish evidence-based
treatments in older adults to nd bibliotherapy to Anxiety
meet evidence-based treatment criteria (Scogin Meta-analyses suggest that self-help for common
et al. 2005). Specically, though behavioral bib- mental health disorders (e.g., depression, anxiety)
liotherapy and Internet-based cognitive behav- can be just as effective as face-to-face therapy
ioral therapy were deemed as promising (e.g., (e.g., Cuijpers et al. 2010). In addition to their
awaiting a second conrmatory controlled exper- documented efcacy, self-help treatments of anx-
iment), cognitive bibliotherapy was the only form iety, such as exposure and relaxation, have been
of self-help with enough research for its establish- applied in digital formats. Specically, Internet-
ment as an evidence-based treatment for depres- based treatments such as therapist-guided admin-
sion. The systematic review led by the evidence- istrations with in vivo exposure (Andersson
based treatment search for anxiety also found et al. 2006) and live versus Internet treatment of
promising evidence for bibliotherapy treatment, panic disorder (Carlbring et al. 2005) are on the
but was unable to establish its effectiveness due rise. Instances that tender prime candidates for
to limited, controlled-experiment research in this self-help treatments include situations where
eld. These ndings highlight the need for con- motivation to seek, or accessibility of, services is
tinued efforts to establish and evaluate bibliother- especially impacted. With the rising frequency in
apy treatments in the population as a whole and which computers, tablets, and smartphones are
within older adult populations specically. readily available and pre-existing in a clients
accessible environment, the applicability of pro- instruction in several mnemonic techniques and
viding in-home treatments (e.g., exposure and has been evaluated in several experiments (Scogin
guided meditation from an off-site location) like- et al. 1985; Woolverton et al. 2001). Techniques
wise increases. Problematic issues with a presented in this bibliotherapy approach include
depression-related lack of motivation and clini- categorization and chunking strategies, the
cally elevated worry or panic related to leaving method of loci, and novel interacting images for
ones home (e.g., panic disorder, agoraphobia) remembering names. Self-administered memory
may be especially indicated for self-administered training capitalizes on the nding that self-paced
or therapist-guided administration. Individuals learning is optimal for older adults. Given the
suffering from these conditions may look to concern that many elders have for changes they
stepped-care approaches and consider self- experience in cognition, it is desirable to have
administered treatment as at their own initiative multiple modes of training delivery including
or at the recommendation of their clinician or self-administered versions and variations on pres-
concerned family member. Truthfully, many indi- ently available technology. Examples of the latter
viduals with varying levels of symptom severity include the brain training programs available
may look no further than these commercially or through the Internet or digital means. Presnell
electronically available treatments due to scarcity and Scogin (2015) conducted an experiment on
of, low trust in, or nancial inaccessibility of local the Brain Age program and found that it produced
mental health resources. direct effects on a speed of processing task but had
no evidence of transfer effects to skills not directly
Sleep Problems trained. This is a nding often reported in the
Sleep problems, which can be treated with cogni- memory and cognitive training arena but serves
tive behavioral interventions, require the individ- as a caution that we should be circumspect in
ual to apply what they have learned in a clinical claims for the efcacy of these interventions.
setting to their sleeping environment. As such, it
could be argued that a major aspect of insomnia- Other Areas
related problems lends itself well to various forms In addition to the disorders and psychological
of self-help treatments. Specically, CBT for well-being areas discussed above, self-help mate-
insomnia (CBT-I) has been evaluated in pure, rials have been developed and evaluated by the
self-help formats. Comparisons to therapist- psychological community. Unfortunately, the evi-
guided versions yield favorable outcomes as dence base specic to older adults is quite limited
well. Though therapist-guided methods tend to in these other areas (e.g., assertiveness, death and
produce greater positive change, CBT-I self-help grieving, sex) and will not be discussed at length
methods serve as a viable rst-line treatment (e.g., here. Clinicians and other medical professionals
Rybarczyk et al. 2011). Self-administered and in the position of recommending self-help mate-
minimal therapist-contact CBT-I have also been rials are encouraged to solicit guidance from the
shown to be effective in older adult populations existing evidence base for adults and cautiously
(e.g., Morgan et al. 2012; Riedel et al. 1995), even extend their recommendations to older adults
in the context of chronic health conditions that while being ever mindful that some mediums of
likely acerbate the formation and endurance of self-help may better match the needs and style of
sleep problems. younger cohorts.
Memory Training
Memory or cognitive training is a good t for Conclusion
various forms of self-administration. The material
is largely didactic in nature and involves learning Self-help resources should be considered, both for
and practicing various techniques. One version of their clinical application and for their obvious
self-administered memory training involves continued appeal in community settings.
One need not look further than their local book- manual. Palo Alto: VA Palo Alto Health Care System
store to nd evidence of self-helps popularity. and Stanford University.
Glasgow, R. E., & Rosen, G. M. (1978). Behavioral bib-
Conversely, one must look a bit further before liotherapy: A review of self-help behavior therapy
one nds clinically relevant resources guiding manuals. Psychological Bulletin, 85(1), 1.
the hand of the psychotherapist or other mental Lehane, M. (2005). Treatment by the book. Nursing Stan- B
health workers, in selecting and recommending dard, 19, 24.
Marrs, R. W. (1995). A meta-analysis of bibliotherapy
these resources to those we serve. Consequently, studies. American Journal of Community Psychology,
the responsibility is upon us to continue the eval- 23, 843870.
uation of the utility, applicability, and efcacy of Morgan, K., Gregory, P., Tomeny, M., David, B. M., &
self-help materials, in their various formats of Gascoigne, C. (2012). Self-help treatment for insomnia
symptoms associated with chronic conditions in older
administration. We must ask ourselves, if we do adults: A randomized controlled trial. Journal of the
not take it upon ourselves to apply our training, American Geriatrics Society, 60(10), 18031810.
expertise, and clinical knowledge to the assessment Norcross, J. C., Santrock, J. W., Campbell, L. F., Smith,
of these materials, which qualied other will? T. P., Sommer, R., & Zuckerman, E. L. (2003). The
authoritative guide to self-help resources in mental
health (Revised ed.). New York: The Guilford Press.
Norcross, J. C., Campbell, L. F., Grohol, J. M., Santrock,
J. W., Selagea, F., & Sommer, R. (2013). Self-help that
Cross-References works: resources to improve emotional health and
strengthen relationships. New York: Oxford University
Press.
Anxiety Disorders in Later Life Presnell, A., & Scogin, F. (2015) An examination of the
Behavior Modication effect of a commercially available cognitive training
Cognition program on speed-of-processing. Manuscript submit-
ted for publication.
Riedel, B. W., Lichstein, K. L., & Dwyer, W. O. (1995).
Insomnia and Clinical Sleep Disturbance Sleep compression and sleep education for older
insomniacs: Self-help versus therapist guidance. Psy-
chology and Aging, 10(1), 54.
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402 Bipolar Disorder in Later Life
The World Health Organization (WHO) estimates

Bipolar Disorder in Later Life that BD is the sixth leading cause of disability
worldwide, making it a serious public health con-
David B. King1 and Norm ORourke2 cern in the USA and abroad. For instance, up to
1
IRMACS Centre, Simon Fraser University, 15% of people with BD will commit suicide
Burnaby, BC, Canada (Goodwin and Jamison 2007). Even optimal med-
2
Department of Public Health, Ben-Gurion ication management fails to forestall all mood
University of the Negev, Beer Sheva, Israel episodes; the course of BD is typically character-
ized by high rates of relapse. Longitudinal study
ndings suggest that 37% of persons with BD
Synonyms prescribed mood stabilizers will relapse within
1 year, 60% in 2 years, and 73% over 5+ years;
Bipolar affective disorder; Manic depression moreover, psychosocial functioning often remains
compromised even when individuals are
euthymic (i.e., in neither depressed nor manic
Definition state; (Goodwin and Jamison 2007)).
Given its debilitating effects, BD has been
A chronic affective disorder characterized by deemed the most expensive mental health
major depressive episodes, mild elation (i.e., diagnosis in the USA (Peele et al. 2003). The
hypomania), irritability, or extreme elation (i.e., estimated annual cost of BD is over $45 billion
mania). in the USA, with treatment alone costing approx-
imately $5000 per patient (Hirschfeld and Vornik
2005); however, the majority of the economic
Bipolar Disorder burden typically arises from indirect costs such
as lost productivity and absenteeism. Compared
Bipolar disorder (BD; previously known as bipo- to those with unipolar depression, the relative
lar affective disorder and manic depression) is a impact of BD versus unipolar depression indicates
chronic affective disorder that affects nearly six that persons with BD have lower income levels,
million American adults. Classied as a mental higher mental health disability days, and self-
disorder by the American Psychiatric Association reported job insecurity (McIntyre et al. 2008).
(APA), BD is characterized by extremes of mood. Despite these difculties, there is also evidence
Although nearly everyone experiences mood var- demonstrating that people with BD can identify
iability, people with BD experience very profound ways to live well and experience good quality of
shifts in mood (e.g., periods of clinical depression, life. Generally, this requires more than pharma-
mild elation [hypomania], or extreme elation cology alone (Suto et al. 2010).
[mania] or irritability). The condition is both com- Psychosocial research on BD is nascent
plex and heterogeneous; an individual with BD (Thomas 2010). Although many persons with
can experience symptoms of depression, mania BD are living to older adulthood for the rst
(elated mood), hypomania, or psychosis, or time in human history, there is a paucity of knowl-
indeed experience combinations of each in vary- edge about the course of BD in later life. There is
ing sequences. Moreover, those with BD may some evidence suggesting that BD becomes less
rapidly cycle between these states. prevalent with age yet still accounts for the same
Despite advances in treatment and manage- percentage of psychiatric admissions. Existing
ment, BD remains highly debilitating and can research on symptom intensity and variability
have a profound and deleterious effect on health with older adults with BD has been conducted
and quality of life (Murray and Lopez 1997). largely with small samples.
Bipolar Disorder in Later Life 403
Prevalence of BD in Later Life life have gone undiagnosed or misdiagnosed for

years or decades.
Community surveys have suggested that the Existing research suggests that older adults
prevalence of BD among adults 65+ years of age may experience less severe symptoms of mania
is between 0.1% and 0.5% (Hirschfeld and Vornik compared to younger adults (Young and Falk B
2005), yet these percentages are 1989). There is also evidence that community-
likely underestimates. For instance, older adults dwelling older adults experience more symptom-
residing in assisted living were not included. free days (Calabrese et al. 2003). Despite this
Within mental health settings, however, bipolar limited evidence for reduced symptoms, older
disorder remains a common diagnosis for adults with BD often have additional medical
older adults accounting for between 8% and costs, which might, in turn, complicate BD care
10% of all psychiatric diagnoses (Depp and Jeste management in later life. For example, older
2004). adults with BD are at higher risk of both diabetes
There are a number of reasons that BD may and cardiovascular disease compared to those
appear less prevalent in later life. Higher rates of without a mental health condition (Kilbourne
suicide among younger individuals with BD may et al. 2004). Moreover, poor health habits such
reduce the number of persons surviving into older as smoking and physical inactivity are common
adulthood. among older adults with BD. Research also sug-
gests that approximately half of older adults (60+
years of age) with BD display signicant cogni-
Characteristics of BD in Later Life tive impairment when euthymic (Gildengers
et al. 2004). This may further complicate care
Some have suggested that BD symptoms decrease management and treatment adherence. What
in intensity over the life span (Kraepelin 1921) yet remains unknown, however, is whether cognitive
intervals between depressive and manic episodes impairments such as dementia progress at an
may shorten with age. As the age of BD onset is increased rate for individuals with BD. Other
generally between 20 and 25 years, the majority of medical conditions common to later life such as
older adults with BD have lived with the disorder stroke, brain tumors, and multiple sclerosis may
for many years. The impact of BD may change mimic symptoms of bipolar disorder.
over time as individuals develop effective self- One important nding that appears to distin-
care behaviors; however, kindling theory pro- guish older adults with BD is a reduced likelihood
poses that with each mood episode, the brain of substance use disorders. Substance misuse with
becomes more decient in its ability to manage BD is a common means of self-medication.
shifts in mood, increasing the frequency and Whereas the prevalence of substance use disor-
intensity of BD symptoms over time (Post ders may be as high as 60% for younger adults
et al. 1986). with BD, substance misuse may be as low as
A small percentage of those with BD experi- 2030% with older adults (Cassidy et al. 2001).
ence their rst manic or depressive episode after Substance use disorders exacerbate BD-related
the age of 50. There are important differences disability.
between those with early-onset versus late-onset
BD. For instance, persons with late-onset BD are
more likely to have a history of sustained employ- Treatment of BD in Later Life
ment or be in a relationship at the time of diagno-
sis increasing the likelihood of successful The efcacy of BD treatments in the second
functioning across domains. More commonly, half of life has not been widely studied
however, those rst diagnosed with BD in later (Thomas 2010). In clinical settings, treatment
404 Bipolar Disorder in Later Life
recommendations for older adults with BD are on the course and characteristics of BD in later
derived largely from studies of younger and life, particularly the potential interference of other
middle-aged adults. Yet there are important phys- medical conditions. As little knowledge has been
iological and psychological changes that occur accumulated regarding treatment of BD in old age
over a persons lifetime that may limit the effec- specically, this is an additional area that requires
tiveness of various BD treatments. attention in both research and clinical domains.
Pharmacotherapy is the primary treatment for Alternatively, more research is needed on the pos-
older adults with BD, yet some medications pose itive aspects of aging that may contribute to BD
challenges for this population. Although anticon- management. Our understanding of BD would be
vulsant medications are commonly prescribed, greatly enhanced by a more complete life-span
lithium carbonate remains a common mood perspective on this mental illness.
stabilizer. Yet age-related decline in kidney
functioning reduces the rate of elimination from
the body, and lithium has been shown to nega-
Cross-References
tively affect kidney functioning. Moreover, other
medications commonly prescribed in later adult-
Comorbidity
hood can interfere with the bodys ability to pro-
Depression in Later Life
cess lithium.
Schizophrenia and Other Psychotic Disorders
Antidepressants are also commonly prescribed
in Older Adults
for older adults with BD as well as anxiolytics for
Suicide in Late Life
those with comorbid anxiety disorders. Antipsy-
chotic medications are commonly prescribed for
those with BD who experience psychosis. For References
older adults with cognitive loss, however, these
medications increase the risk of stroke. Calabrese, J. R., Hirschfeld, R. M., Reed, M., Davies,
M. A., Frye, M. A., Keck, P. E., et al. (2003). Impact
Beyond pharmacological treatments, electro- of bipolar disorder on a U.S. community sample. The
convulsive therapy (ECT) has also been used Journal of Clinical Psychiatry, 64, 425432.
effectively with older adults whose mood epi- Cassidy, F., Aheam, E. P., & Carroll, B. J. (2001). Sub-
sodes are mostly depression. Given that memory stance abuse in bipolar disorder. Bipolar Disorders, 3,
181188.
loss is a common side effect, special consideration Depp, C., & Jeste, D. V. (2004). Bipolar disorder in older
must be taken for older adults with cognitive loss. adults: A critical review. Bipolar Disorders, 6,
Psychotherapy can be used in conjunction with 343367.
the above methods, yet few psychosocial inter- Gildengers, A., Butters, M., Seligman, K., McShea, M.,
Miller, M., Mulsant, B., et al. (2004). Cognitive func-
ventions for BD have been adapted or validated tioning in late-life bipolar disorder. American Journal
for older adults. of Psychiatry, 161, 736738.
Goodwin, F. K., & Jamison, K. R. (2007). Manic-
depressive illness: Bipolar disorders and recurrent
depression (2nd ed.). Oxford: Oxford University Press.
Conclusions Hirschfeld, R. M. A., & Vornik, L. A. (2005). Bipolar
disorder: Costs and comorbidity. The American Jour-
It is clear that aging with bipolar disorder presents nal of Managed Care, 11, 585590.
many unique challenges. As the aging population Kilbourne, A. M., Cornelius, J. R., Han, X., Pincus, H. A.,
Shad, M., Sailoum, I., et al. (2004). Burden of general
continues to grow, these challenges will pose medical conditions among individuals with bipolar dis-
greater burdens on individuals and the medical order. Bipolar Disorders, 6, 368373.
community at large. Despite its highly debilitating Kraepelin, E. (1921). Manic-depressive insanity (trans:
and costly nature, little is understood about BD in Barclay, R.M.). New York: Amo Press.
McIntyre, R. S., Muzina, D. J., Kemp, D. E., Blank, D.,
later life. As a result, the management of BD Woldeyohannes, H. Q., Lofchy, J., et al. (2008). Bipolar
symptoms for older adults remains decient. In disorder and suicide: Research synthesis and clinical
order to ll this gap, additional research is needed translation. Current Psychiatry Reports, 10, 6672.
Blue Zones 405
Murray, C. J. L., & Lopez, A. D. (1997). Global mortality, identied around the world as possessing the
disability, and the contribution of risk factors: Global requirements to achieve Blue Zone status. They
Burden of Disease Study. Lancet, 349, 14361442.
Peele, P. B., Xu, Y., & Kupfer, D. J. (2003). Insurance are located in Okinawa, Sardinia, Costa Rica, and
expenditures on bipolar disorder: Clinical and parity Greece.
concerns. American Journal of Psychiatry, 160, Blue Zone or, to be precise, Longevity Blue B
12861290. Zone (LBZ) is a term coined in 2000 by the
Post, R., Rubinow, D., & Ballenger, J. (1986). Condition-
ing and sensitisation in the longitudinal course of affec- Belgian demographer Michel Poulain and the Ital-
tive illness. British Journal of Psychiatry, 149, ian physician Gianni Pes in the context of age
191201. validation of centenarians in Sardinia, and it was
Suto, M., Murray, G., & Hale, S. (2010). What works for used for the rst time in 2004 in an article
people with bipolar disorder? Tips from the experts.
Journal of Affective Disorders, 124, 7684. published in Experimental Gerontology (Poulain
Thomas, A. J. (2010). Special populations: The elderly. In et al. 2004). Initially the term was given to a
A. H. Young, I. N. Ferrier, & E. E. Michalak (Eds.), mountainous area located in the central-eastern
Practical management of bipolar disorder (pp. 8492). part of the Mediterranean island of Sardinia,
Cambridge: Cambridge University Press.
Young, R. C., & Falk, J. (1989). Age, manic psychopathol- where the two scholars had found a population
ogy, and treatment response. International Journal of with exceptional longevity. Although longevous
Geriatric Psychiatry, 4, 7378. individuals exist in all parts of the world, in this
area Poulain and Pes identied a cluster of vil-
lages with an outstanding number of centenarians
and they named it Blue Zone simply because a
Blue Zones blue felt-tip pen was used to draw the rst longev-
ity map. The LBZ concept dened above is related
Giovanni Mario Pes1,2 and Michel Poulain3,4 to population longevity and contributes to den-
1
Department of Clinical and Experimental ing a new paradigm in the research on longevity
Medicine, University of Sassari, Sassari, Sardinia, determinants. By studying a population that
Italy shares the same lifestyle within the same environ-
2
National Institute of Biostructures and ment and enjoys an extraordinary life-span, the
Biosystems, University of Sassari, Sassari, Italy search for longevity determinants could be facili-
3
IACCHOS Institute of Analysis of Change in tated. The LBZ concept was later popularized by
Contemporary and Historical Societies, the American journalist Dan Buettner through the
Universit catholique de Louvain, article he published in the National Geographic
LouvainLaNeuve, Belgium on exceptional longevity in Okinawa, Sardinia,
4
Estonian Institute for Population Studies, Tallinn and Loma Linda (USA) (Buettner 2005). Since
University, Tallinn, Estonia 2006, Buettner has collaborated with the two
scholars and organized expeditions to Costa Rica
and Greece where they identied the existence
Synonyms of two other LBZs (Buettner 2008). At present,
four LBZs have been validated worldwide:
Longevity Blue Zone (LBZ) (i) Okinawa, the southernmost island of Japan;
(ii) an area covering 14 villages in Ogliastra and
Barbagia in the mountainous zone of Sardinia;
Definition (iii) an area including ve cantons within the
Nicoya Peninsula of Costa Rica; and (iv) the
The term Blue Zone (BZ) refers to a rather island of Ikaria in Greece.
small, homogenous geographical area where the The rst and most important problem that must
population shares the same lifestyle and environ- be faced with regard to these LBZs is to ascertain
ment and its exceptional longevity has been sci- age authenticity of the oldest members of these
entically proven. To date, four regions have been exceptionally longevous populations. In actual
406 Blue Zones
fact, in the past the existence of longevous By studying the various LBZ populations,
populations stimulated the collective imagination therefore, identication of the causal factors of
but belonged far more to folklore than to longevity might be enhanced. As a rule, aging
documented history and stringent validation successfully is a multifactorial achievement that
rules, and none of these early alleged longevous implies avoiding diseases and maintaining a high
communities were conrmed after thorough sci- standard of functional and cognitive performance.
entic investigation (Mazess and Forman 1979). In the following paragraphs, the main characteris-
The oldest members of these populations were tics of these areas, in terms of genetic structure,
often the subject of misreporting or exaggeration ethnicity, and lifestyle, are briey described and a
of their age. Many alleged cases of exceptional summary given of the features shared by these
longevity examined in Russia, the Caucasus, populations.
China, Pakistan, and the Andes were later
invalidated through careful demographic investi- Okinawa
gation (Garson 1991). To be specic, the valida- Okinawa is a group of some 160 islands which
tion of populations with a longevity level that can form the southwesternmost part of Japans 47 pre-
be statistically shown as higher than the values fectures. There are currently 934 centenarians in
usually found elsewhere requires the availability Okinawa out of a total population of 1.37 million
of historical registers, such as birth and death inhabitants (2015). In Japan, women of Okinawa
records which can prove, with the greatest accu- show the highest life expectancy at birth among
racy and completeness, the age of the members of all prefectures (87.15 years in 20102013). Spe-
the populations under investigation. Validation of cial attention has been devoted to validation of the
the exceptional population longevity characteriz- individual ages of the oldest people in order to
ing an LBZ is based on conventional individual ascertain exceptional longevity in Okinawa
age validation, as well as on a careful choice of (Willcox et al. 2008; Poulain 2011). Since 1976,
demographic indices that reliably reect the the Okinawa Centenarian Study has investigated
remarkable survival of community members as a the causes of the exceptional longevity of the
whole (population longevity). To meet these islanders, attributing an essential role to genetic,
requirements is often challenging, and this may dietary, climatic, cultural, and social factors,
explain why research on longevous populations although it is likely that the real explanation lies
has only progressed recently and solely where the in a combination of all of these. Okinawans are
required documental sources do exist. It is crucial genetically distinct from the Japanese, and even
that age be accurately veried before any attempt show some of the features of a genetic isolate, a
is made to ascertain the possible determinants of condition that may have reduced their genetic
such exceptional longevity. pool variability and favored life extension
Currently, the populations of each of these four (Bendjilali et al. 2014). Moreover, traditionally,
LBZs are being studied by several groups of Okinawans practiced a high rate of endogamy
researchers aiming to trace the determinants of (i.e., marrying within the limits of ones local
this phenomenon. When seeking population lon- community); this would have increased the
gevity determinants, the relevant characteristics or inbreeding coefcient and may possibly have
behaviors are those shared by a large part of the caused the genetic variant related to longevity to
population. By considering these common char- be selected. A study revealed that siblings of
acteristics, the chance of nding more powerful Okinawan centenarians have 2.58 times
explanatory variables is increased as most of the (females) and 5.43 times (males) more likelihood
people concerned were born and live in the same of reaching the age of 90 compared with their
place and are thus more likely to share genetic age-matched birth cohort of the same area
makeup and early life conditions, as well as tradi- (Willcox et al. 2006). Specic HLA DR1 poly-
tional behaviors and habits, including the con- morphisms have been found in Okinawan cente-
sumption of the same locally produced food. narians that may reduce the risk of inammatory
Blue Zones 407
and autoimmune diseases (Takata et al. 1987). Villagrande Strisaili, where men have been found
Apart from the inuence of genetic factors, the to live as long as women (Poulain et al. 2011).
role of environmental (e.g., low level of pollution) Various hypotheses have been put forward to
and lifestyle factors has also been explored. explain exceptional longevity in the Sardinian
Sociocultural and psychological factors, in partic- LBZ (Poulain et al. 2011; Pes et al. 2013). This B
ular the degree of social integration of elderly population remained isolated for centuries, which
people and the excellent quality of contributed to the stabilization of its gene pool
intergenerational relationships, physical and cog- (Cavalli-Sforza 2000) and the respective preser-
nitive functions, and sleep habits, especially the vation of sociocultural and anthropological fea-
frequency of naps (Uezu et al. 2000), have been tures throughout its history. Considering the
considered benecial. In addition, environmental characteristics of this genetic isolate, as well as
conditions seem to be important, such as climate, the low gender ratio among Sardinian oldest peo-
agriculture, and other occupational activities ple, several genetic association studies have been
(Robine et al. 2012). A considerable amount of performed on Sardinian centenarians, using
research has addressed the relationship between markers already known to be associated with lon-
diet and longevity in Okinawa. A reduced calorie gevity in a gender-sensitive manner. They include
intake (60% of the average Japanese diet) has Y chromosome SNP (Passarino et al. 2001),
been claimed to be responsible for longer survival genetic markers associated with cardiovascular
of Okinawans, probably due to reduced mortality mortality, cancer, and inammation (Pes
from cardiovascular diseases, diabetes, and cancer et al. 2004; Lio et al. 2003). However, in terms
(Willcox and Willcox 2014). The lower calorie of frequency, none of these markers have been
intake is believed to be at the origin of the lower shown to diverge signicantly from that of the
body mass index and shorter stature of general population, thus the relative importance
Okinawans. Traditionally sweet potato, a good of genetic factors in Sardinian longevity still
source of trace elements and vitamins, accounted remains unknown. Among the non-genetic factors
for up to 93% of the staple diet, a percentage far that might be important to account for the excep-
superior to that of the rest of Japan. Other alleg- tional longevity recorded in central Sardinia and
edly longevity-promoting foods are green and the low female/male ratio among the oldest peo-
yellow vegetables, soy products, sh, and moder- ple, the role of physical activity and nutrition has
ate amounts of meat, usually goat and pork been the subject of recent research (Pes
(Willcox et al. 2014). However, it is clear that in et al. 2013). The role of traditional foods,
Okinawa, the post-war generations have largely inuenced by the widespread practice of cattle
modied their diet, replacing sweet potato soup breeding, typical of a society centered on pasto-
with rice and meat under the inuence of main- ralism, was investigated by means of historical
land Japan and US cultures (Todoriki et al. 2004). studies (Pes et al. 2014). In addition to any hered-
Due to globalization, these post-war generations itary factor, growing interest has emerged in the
have largely westernized their lifestyle, thus role of behavioral factors and the sociocultural
recently causing a drop in Okinawas ranking context in successful aging of the Ogliastra popu-
among the Japanese prefectures in terms of life lation. These studies, based on measuring self-
expectancy. referent metacognitive efciency, subjective well-
ness, and depression, have revealed that the
Sardinia elderly in central Sardinia self-rated lower levels
Validation of the age of Sardinian centenarians of depression and cognitive impairment and had
(Poulain et al. 2006) revealed exceptional longev- greater levels of emotional competence (Fastame
ity and unexpected gender equality and resulted in and Penna 2014). It will be necessary to await the
the identication of the Sardinian LBZ, a cluster results of further research to better understand the
of 14 villages nestled around the highest mountain role of geneenvironment interactions as well as
of the island, with their epicenter in the village of epigenetics.
408 Blue Zones
Nicoya noted that current longevity in Nicoya is also

The population of the Nicoya Peninsula in the related to improved socioeconomic conditions,
northwestern region of Costa Rica shows an over- an efcient social security system, and free
all mortality rate 20% lower than that of the rest of healthcare guaranteed by the government
the country, whereas life expectancy at age 60 is (Rosero-Bixby et al. 2013).
24.3 years for men and 24.2 years for women,
compared with 23.6 years for both genders com- Ikaria
bined in the rest of Costa Rica. This remarkable Ikaria, an island in the Aegean Sea inhabited by
situation, pointed out by Rosero-Bixby (Rosero- just over 8,000 inhabitants, has one of the highest
Bixby 2008), aroused some suspicion among life expectancy in Greece and a female/male ratio
demographers as it is usually assumed that lon- among the oldest people that is also close to
gevity increases with economic development, and 1. Most of the inhabitants of Ikaria follow a tradi-
Costa Rica is still a developing country. Among tional lifestyle involving a local version of the
centenarians, the female/male ratio is close to Mediterranean diet, vigorous physical activity,
1, whereas in most developed countries, it is usu- and lack of stress (Siasos et al. 2013). The Ikarian
ally higher. The results of the Costa Rican diet includes vegetables, olives, moderate con-
Longevity and Healthy Aging Study (CRELES, sumption of cheese, and goat milk, with two fea-
or Costa Rica Estudio de Longevidad y tures curiously reminiscent of those of the
Envejecimiento Saludable), which took into Sardinian LBZ: an abundant traditional use of
account some biomedical markers, showed that potatoes and relatively low consumption of sh.
the average height of the inhabitants of Nicoya is Perhaps the most striking feature of Ikarians is
greater than that of the general population of their widespread lack of stress, as evidenced by
Costa Rica, and their body mass index is lower, their proverbial indifference to money and the
as is the prevalence of physical and mental dis- accumulation of material goods; their habit of
ability (Rosero-Bixby et al. 2013). From the bio- taking naps in the afternoon is also widespread,
logical and genetic point of view, telomere length and according to some research, it might reduce
was found to be greater in the inhabitants of the risk of coronary death (Panagiotakos
Nicoya than in the general population of Costa et al. 2011). As Ikaria is the last LBZ to have
Rica (Rehkopf et al. 2013), which, however, as been identied, investigations are still ongoing
reported by Cassidy in 2010 (Cassidy et al. 2010), to disentangle the role of possible factors under-
could also depend on lifestyle-related factors, lying its longevity.
such as stress and daily physical activity, and not
merely reect the individuals genetic makeup. Lessons from the Longevity Blue Zones
The diet of the Costa Rica Blue Zone inhabitants and Directions for Future Research
is based on low-glycemic-index traditional foods The various LBZs offer an example of how suc-
including rice, beans, sh, beef, pork, and chicken cessful aging can be achieved by a signicant
and is high in ber (Rosero-Bixby et al. 2013). number of members of a community. The criteria
Some environmental factors may also be relevant for any candidate LBZ population must, however,
for the longevity of Nicoya: drinking water in the be very stringent and not merely based on the
region has a high calcium content that might have emergence of some sporadic cases of exceptional
exerted a protective effect against cardiovascular longevity. Genuine LBZ represent indeed a new
disease and age-related osteoporosis. Further- scientic paradigm that may prove to be particu-
more, the elderly population residing in the pen- larly fruitful in testing the association between
insula experiences a particularly low level of longevity and various potential explanatory fac-
stress: this nding seems to be conrmed by cer- tors. At the present state of the research, the num-
tain social indicators like the rate of suicide in ber of potential factors behind a complex trait like
Nicoya, with the lowest value in the whole of population longevity is from the start very large,
Costa Rica recorded here. Finally, it should be although it is hoped that a core of major longevity
Blue Zones 409
determinants present in these populations may be psychological solidarity observed in most LBZ
identied more efciently. As for the genetic inhabitants: these people show a strong sense of
aspect, it should be noted that some LBZ their role within the community and strong self-
populations have undergone long periods of iso- esteem, which might help them to feel a part of
lation due to their geographical location or for society until the end of their existence (Poulain B
cultural-historical reasons. Thus, through mecha- et al. 2013). This has undoubtedly contributed to
nisms such as inbreeding and genetic drift, spe- reinforcing family ties and to the awareness of the
cic genetic variants causing longer survival most fragile members of the community that they
could have been selected. Moreover, the insularity can rely on a network of social support that is still
or near-insularity of most LBZs could explain the efcient. In the LBZ, the elderly are generally well
delay in socioeconomic development at the begin- integrated into the community and cared for by
ning of the capitalist era and may have been the close family relatives (usually a spouse and chil-
cause of the lower per capita income compared dren) until late in life, thereby experiencing mean-
with the reference population. This economic ingful emotional contacts across generations.
insecurity mostly disappeared during the last cen- LBZ research is still developing, and a
tury when all LBZs experienced relative high- multidisciplinary strategy alone will help to dis-
quality life and improved availability of health entangle the complex phenomenon of exceptional
services without losing the benets of their tradi- longevity, and in particular to address the classic
tional lifestyle. This is particularly evident in the nature-nurture dilemma. From a biomedical per-
case of diet, which until recently was dependent spective, genetic and epigenetic research must be
on local production and favored foods with increased, although the relatively small number of
low-calorie-density but higher in nutrients LBZ inhabitants makes this strategy difcult.
(Willcox and Willcox 2014). Besides, although More attention should be devoted to possible
Calorie Restriction with Optimal Nutrition gene-environment and gene-nutrition interac-
(CRON) currently considered the only diet that tions. From a demographic standpoint, a possible
promotes longevity was hypothetically included extension of the number of LBZ and in-depth
among the longevity-associated factors in some of analysis of each of them, also including the gene-
the LBZ populations like Okinawa, in other LBZs alogical reconstruction of large longevous com-
there is no compelling evidence that it has been a munities, may increase understanding of the
constant feature in the history of these characteristics of these rare populations and may
populations. It is probable that the quality of enable longevity theories to be tested with greater
foods, rather than the amount of food itself, has statistical power (Poulain et al. 2013). It can be
exerted a role in maintaining high health standards concluded that LBZ have gradually changed from
in these populations. Moreover, the traditional being the focus of simple anthropological curios-
diet could have acquired more positive aspects ity to being an effective model of healthy aging
during nutrition transition (Pes et al. 2014). The that could be followed by the post-industrial soci-
delay of economic development in the LBZ, eties of the twenty-rst century, too, to meet the
implying low mechanization in agriculture, challenge of the growing elderly population and
could have promoted a more active lifestyle in consequent substantial healthcare costs.
the population, stimulating considerable energy Finally, a theoretical issue that concerns the
expenditure during outdoor activities and occupa- nature of LBZ is their temporal evolution. Since
tional work. The prevailing attitude observed in some of the factors supposedly involved in LBZ
the LBZ is of collectivist and egalitarian commu- emergence tend to disappear, it might arise that the
nities rather than individualistic, which in the past phenomenon of population longevity be transitory
may have reduced competitiveness between in itself. In fact, there is some evidence that atten-
social classes and limited average stress levels, uation of the phenomenon is underway in Oki-
and may have delayed the onset of age-related nawa (Willcox et al. 2014), and the same tendency
diseases. This attitude is reected in the may occur in other LBZ in the future. Besides, the
410 Blue Zones
survival advantage disappears in out-migrants Garson, L. K. (1991). The centenarian question: Old-age
from Nicoya, indicating a stronger inuence of mortality in the Soviet Union, 1897 to 1970. Popula-
tion Studies, 45, 265278.
non-genetic environmental factors (Rosero- Lio, D., Pes, G. M., Carru, C., List, F., Ferlazzo, V.,
Bixby et al. 2013). An interesting aspect is that Candore, G., Colonna-Romano, G., Ferrucci, L.,
what LBZ have achieved on a small scale could be Deiana, L., Baggio, G., Franceschi, C., & Caruso,
transferred to larger human aggregates. It is plau- C. (2003). Association between the HLA-DR alleles
and longevity: A study in Sardinian population. Exper-
sible that the geographic clustering of long-livers imental Gerontology, 38, 313317.
currently representing the most salient feature of Mazess, R., & Forman, S. (1979). Longevity and age
the LBZ will disappear, leaving average-level, exaggeration in Vilcabamba, Ecuador. Journal of Ger-
widespread longevity. Future trends will reveal ontology, 34, 9498.
Panagiotakos, D. B., Chrysohoou, C., Siasos, G., Zisimos,
whether what is observed today in the LBZ will K., Skoumas, J., Pitsavos, C., & Stefanadis, C. (2011).
persist and even become commonplace (Appel Sociodemographic and lifestyle statistics of oldest old
2008). people (>80 years) living in Ikaria island: The Ikaria
study. Cardiology Research and Practice, 679187.
doi:10.4061/2011/679187.
Passarino, G., Underhill, P. A., Cavalli-Sforza, L. L.,
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Crivello, A., Candore, G., Colonna-Romano, G., &
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doi:10.4061/2011/153756. Healthy aging diets other than the Mediterranean:
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cyte telomere length in Costa Ricas Nicoya Peninsula:
A population-based study. Experimental Gerontology,
48, 12661273. Gail A. Robinson
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Gondo, Y., Hirose, N., Suzuki, M., & Saito, Y. (2012). Psychology, The University of Queensland,
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Rosero-Bixby, L. (2008). The exceptionally high life Neuropsychology, Department of Neurology,
expectancy of Costa Rican nonagenarians. Demogra- Royal Brisbane and Womens Hospital, Brisbane,
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lial function in middle-aged and elderly subjects: The
Ikaria study. Hellenic Journal of Cardiology, 54, Definition
94101.
Takata, H., Suzuki, M., Ishii, T., Sekiguchi, S., & Iri,
H. (1987). Inuence of major histocompatibility com- A brain tumor is a mass of abnormal cells. There
plex region genes on human longevity among are two broad categories of brain tumors. Primary
Okinawan-Japanese centenarians and nonagenarians. brain tumors arise from an abnormal proliferation
Lancet, 2, 824826.
Todoriki, H., Willcox, D. C., & Willcox, B. J. (2004). The of cells within the central nervous system (CNS).
effects of post-war dietary change on longevity and In contrast, metastatic tumors originate elsewhere
health in Okinawa. Okinawan Journal of American in the body and spread to the brain and are therefore
Studies, 1, 5564. malignant (Blumenfeld 2010). Brain tumors that
Uezu, E., Taira, K., Tanaka, H., Arakawa, M., Urasakii, C.,
Toguchi, H., Yamamoto, Y., Hamakawa, E., & Shira- are malignant usually grow rapidly, are life
kawa, S. (2000). Survey of sleep-health and lifestyle of threatening, and have the potential to spread and
the elderly in Okinawa. Psychiatry and Clinical Neu- inltrate the CNS (Blumenfeld 2010). Brain
rosciences, 54, 311313. tumors are thought to be benign if they are slow
Willcox, B. J., & Willcox, D. C. (2014). Caloric restriction,
caloric restriction mimetics, and healthy aging in Oki- growing, have distinct borders, and do not inltrate
nawa: Controversies and clinical implications. Current or disseminate widely within the CNS (Blumenfeld
Opinion in Clinical Nutrition and Metabolic Care, 17, 2010). This entry will focus on primary brain
5158. tumors and will overview classication, types, inci-
Willcox, B. J., Willcox, D. C., He, Q., Curb, J. D., &
Suzuki, M. (2006). Siblings of Okinawan centenarians dence, etiology, symptoms (including cognitive
share lifelong mortality advantages. The Journals of disorders), treatments, and prognosis, with partic-
Gerontology Series A: Biological Sciences and Medi- ular reference to older adults.
cal Sciences, 61, 345354.
Willcox, D. C., Willcox, B. J., He, Q., Wang, N. C., &
Suzuki, M. (2008). They really are that old: Classification of Brain Tumors
A validation study of centenarian prevalence in
Okinawa. The Journals of Gerontology Series A:
Biological Sciences and Medical Sciences, 63, The World Health Organization (WHO) classi-
338349. cation of tumors of the central nervous system
412 Brain Tumors in Older Adults
(Louis et al. 2007a) is a way of grading the bio- Brain Tumors in Older Adults, Table 1 Abridged sum-
logical behavior or malignancy. The WHO mary of the main categories of WHO Classification System
(2007) for central nervous system tumors. The most com-
grading system is based on the microscopic mon types in older age groups (>55 years) are indicated in
appearance. WHO grade can be a key factor bold (Dolecek et al. 2012)
inuencing the choice of therapies, particularly Tumors of the neuroepithelial tissue
the use of specic chemotherapy and radiation Astrocytic tumors
protocols (Louis et al. 2007b; Du Plessis 2005). Oligodendroglial tumors
Grade I applies to tumors with low proliferation Oligoastrocytic tumors
potential and the possibility of cure following Ependymal tumors
surgical resection alone. Grade II usually applies Choroid plexus tumors
to tumors that are generally inltrative and can Other neuroepithelial tumors
recur, despite low-level proliferation, and some Neuronal and mixed neuronal-glial tumors
progress to higher grades of malignancy. Grade Pineal tumors
III tumors are actively reproducing abnormal Embryonal tumors
cells; they inltrate adjacent normal brain tissue Tumors of the cranial and paraspinal nerves
and tend to recur, often as a higher grade. Grade Tumors of the meninges
IV tumors are very abnormal and reproduce rap- Tumors of the meningothelial cells
Mesenchymal tumors
idly, forming new blood vessels to maintain rapid
Lymphomas and hematopoietic neoplasms
growth (Louis et al. 2007a, b).
Germ cell tumors
Tumors of the sellar region
Metastatic tumors
Box 1: Overview of World Health
Organization (WHO) Tumor Classification
System and other rarer forms (as summarized in Table 1).
Astrocytomas grow from glial cells and
Grade I: Tumors with low proliferation grow slowly or rapidly. Oligodendrogliomas
potential grow from cells that insulate the nerves
Grade II: Inltrative tumors with poten- (oligodendrocytes). Glioblastoma multiforme or
tial for low-level proliferation GBM (also astrocytoma Grade IV) commonly
Grade III: Inltrative and actively contains a mix of cell types and is highly malig-
growing tumors that tend to recur nant. At present, with the advent of new technol-
Grade IV: Highly abnormal and rapidly ogies such as next-generation sequencing and
growing tumor proteomics, the classication of malignant glio-
mas is changing as more information about the
molecular changes occurring at each step of the
tumorigenesis process comes to light (McKay
2014).
Types of Brain Tumor Meningiomas are often WHO Grade I and
benign. However, meningiomas can also be
The most common type of primary malignant malignant, the latter tending to be of a higher
brain tumor, accounting for around 7080% of WHO Grade (II or III) (Dolecek et al. 2012).
patients, is malignant glioma (Omuro and
DeAngelis 2013; Cancer Council of Australia
2011). Within the malignant glioma group, the Incidence and Age
following types and WHO grades have been iden-
tied: astrocytoma (WHO Grade I-IV), oligoden- The median age at diagnosis for all primary brain
droglioma (WHO Grade II-III), ependymomas and CNS tumors is 59 years, according to the
(WHO Grade I-II), mixed oligoastrocytomas, 20052009 CBTRUS statistical report for the
United States (Dolecek et al. 2012). With increas- Headaches are relatively frequent, presenting
ing age, meningiomas are the most common type in about 50% of patients at diagnosis, but usu-
of brain tumor diagnosed, followed by gliomas ally with a nonspecic pain pattern, progressive
which peak in incidence at age 6574 years severity, and unilateral localization. In an indi-
(Dolecek et al. 2012; Wrensch et al. 2002). vidual older than 50 years, a new-onset head- B
Meningiomas have a signicantly higher inci- ache may be indicative of a tumor-associated
dence (3.5 times) in individuals >70 years, com- headache from a benign headache. However,
pared to <70 years. the likelihood of a brain tumor being the under-
lying cause of headaches is less than 1 in 1000,
and new-onset seizures also has extremely low
Etiology predictive value for indicating the presence of a
tumor, being <2% (McKay 2014). Neverthe-
The causes of brain tumors remain elusive. How- less, as one example, the current Australian
ever, there is a slightly higher risk with increasing guidelines recommend that a patient with
age, being male rather than female and with new-onset seizures or recurrent headache
exposure to ionizing radiation (Cancer Council uncharacteristic for that patient should undergo
of Australia 2011). Individuals with rare genetic brain imaging to establish the cause, particularly
conditions such as neurobromatosis type 1 or if focal neurological symptoms such as dyspha-
2 have a higher risk of developing a brain tumor sia, hemiparesis, or hemianopia are present
than the general population (Cancer Council of (McKay 2014).
Australia 2011). The molecular causes of
malignant glioma are highly variable between Neurological Signs
individual patients, even within each subset Changes or disturbance to cognitive functions, or
(Omuro and DeAngelis 2013). In the case of thinking skills, may develop as a result of brain
malignant gliomas, such as astrocytomas and tumors. Cognitive functions allow an individual
oligodendrogliomas, it is characteristic for multi- to respond to both the demands of the environ-
ple cell changes to be present at the molecular or ment and also to their own internal desires and
DNA level. These may include chromosomal needs. Cognitive skills include the ability to
aberrations, single DNA base substitutions speak, concentrate, remember, reason, reect, per-
of mutations, DNA methylation, or epigenetic ceive, and understand. Cognitive disorders can
modications. Recently, changes in gene occur when the brain is damaged or disrupted,
activity that are not caused by changes in the for example, with growth of a brain tumor.
DNA sequence, or epigenetic alterations, have Changes in cognitive functions can be interpreted
been linked to the formation of cancer (McKay as personality changes or can be mistaken for
2014). psychiatric disorders or dementia, particularly in
older adults (Cancer Council of Australia 2011;
McKay 2014). Cognitive difculties may be a
Symptoms and Diagnosis presenting symptom or they may arise during or
after treatments such as surgery, radiation, or che-
The presenting symptoms of a primary brain motherapy (see below for further details of cogni-
tumor are determined by several factors including tive changes).
the tumors size, location, and rate of growth. Focal neurological signs such as hemiparesis,
Common symptoms include headache sensory loss, or visual eld disturbances are com-
nausea/vomiting, changes in cognition and per- mon and typically indicate the tumor location in
sonality, gait imbalance, urinary incontinence, the brain. Other neurological signs that arise usu-
hemiparesis, aphasia, hemi-neglect, visual eld ally in larger tumors that cause mass effect or
defect, and seizures (Omuro and DeAngelis displacement within the brain include gait imbal-
2013; McKay 2014). ance and incontinence.
Brain Imaging and grade, location of tumor within the brain,

Imaging of brain tumors is rst to diagnose or gross total tumor resection, age, and general
conrm a suspected diagnosis. Secondary to this health preoperatively, which is often indicated
is precise localization and characterization to by the Karnofsky Performance Status score
inform further treatment and/or management (Chaudhry et al. 2013). However, negative pre-
(Cancer Council of Australia 2011). Computed dictors and generally poorer prognosis are indi-
tomography (CT) and magnetic resonance imag- cated if an individual is older (>60 years), the
ing (MRI) are currently the main brain tumor tumor is high-grade, resection is incomplete, and
diagnostic imaging techniques. the tumor location is crossing the midline or is
MRI has largely replaced CT scanning in the within the periventricular region of the brain
management of patients with brain tumors, with (Cancer Council of Australia 2011). Although
CT only used in initial imaging and in monitoring recent advances in treatments using combined
acutely changing neurological symptoms. When chemotherapy and radiation, post-resection
evaluating non-enhancing tumors, MRI has the (Stupp et al. 2005), suggest increased survival,
benet of being more specic and sensitive than in general, glioblastoma multiforme (GBM) has
CT. MRI imaging modalities include MR spectros- the poorest survival in all age groups. Further,
copy, perfusion imaging, and diffusion scanning. within any brain tumor type, older adults have
These MRI techniques are benecial in differential poorer survival rates than younger individuals
diagnosis of high-grade gliomas, such as anaplastic (Wrensch et al. 2002).
astrocytoma and anaplastic ependymoma, primary
CNS lymphoma, metastatic tumors, brain abscess,
and other neurologic processes (McKay 2014). Treatments
Although both MRI and CT imaging techniques
reveal structural information, they are limited in The approaches to primary and metastatic brain
providing information about the tumor itself in tumor treatment are based on the histology
terms of biology and activity. and grade of the tumor, as well as the age and
Molecular imaging with positron emission medical condition of the patient. The options for
tomography (PET) has recently been used in brain treatment include surgical resection, radiation,
tumors. PET provides the ability to ascertain addi- and chemotherapy either alone or in combination.
tional metabolic information that can be helpful for In addition, for some tumor types or depending on
patient management as well as for evaluating the a patients general condition and age, a conserva-
indication of other therapeutics (McKay 2014). For tive approach of watch and wait is taken
example, there are several benets to using PETwith (Rosenfeld and Pruitt 2012). Although not yet a
radiolabeled glucose and amino acid analogues such standard practice, increased knowledge about the
as MET or 11C-methionine. In particular, this form molecular biology of tumors, the microenviron-
of PETcan help with the following: tumor diagnosis, ment of tumors, and immunologic interactions
differentiation between recurrent tumors and tissue and how these relate to treatment response will
death due to radiation, and guiding a biopsy or lead to new personalized treatment regimes
treatment. In recent years, uorinated amino acid (Omuro and DeAngelis 2013; Rosenfeld and
tracers such as FET, or [18 F] Fluoroethyl-l-tyrosine, Pruitt 2012).
have also been used to guide treatments including An important factor in improving brain tumor
surgery in patients with primary brain tumors. patient outcomes is receiving centralized care
with a team of specialized health professionals
(McKay 2014), which is similar to the benet of
Prognosis care in an organized and centralized stroke unit
when compared to a decentralized team. For pri-
The survival time after treatment can vary and mary brain tumors, analysis of surgical resections
depends on several factors including tumor type or biopsies identied that large-volume centers
had lower postoperative mortality rates than cen- until the last decade during which time the use of
ters with smaller numbers of patients. stereotactic radiosurgery (SRS) has become
increasingly common. The advantage of stereo-
Surgery tactic radiosurgery is that, via this image-guided
Surgical resection is often the rst line of medical method, a precise radiation dose can be delivered, B
management for benign and malignant tumors, which has the potential to reduce treatment
including meningiomas and gliomas that are the time and toxicity. Moreover, preservation of
most common types in older adults. Thus, for neurocognitive function is more likely with
benign meningiomas tumor, resection is standard, targeted rather than whole brain radiation.
and for higher WHO grade II and III meningio- As noted above, the current standard of care for
mas, surgical resection and postoperative radia- the medical management of primary brain tumors
tion therapy are recommended to increase the and in specically glioblastoma includes radiation
likelihood of reducing recurrence rates. For more treatment combined with the alkylating agent
aggressive high-grade gliomas, resection with temozolomide (TMZ), followed by 6 months of
combined radiation and chemotherapy has adjuvant TMZ (McKay 2014; Stupp et al. 2005).
become a standard care. In a 2005 clinical trial, this regime was found to
In adults over the age of 60 years, surgical signicantly prolong survival (Stupp et al. 2005).
resection of meningiomas carries with it a higher However, the benet of TMZ is fairly modest with a
risk of mortality and morbidity compared to intra- median overall survival 12.1 months for radiation
cranial tumor surgery in general (Konglund treatment alone compared to 14.6 months for radia-
et al. 2013). Specically, a large study of inpa- tion combined with TMZ (Stupp et al. 2005; Quant
tients following tumor resection (N = 8861; 26% and Wen 2010). New therapies, including immuno-
older persons >70 years) revealed a marked effect therapy, vaccines, and the use of nanoparticles, are
of older age on each of the primary outcomes. emerging methods of medical management.
Thus, inpatient mortality rate was higher in the
older patients, as well as discharge rates to a Immunotherapy
facility other than home, and older persons were A relatively recent therapy is based on the role of
more likely to have a longer inpatient hospital stay immune cells in regulating tumor progression.
(Bateman et al. 2005). In addition, postsurgical Each tumor has its own unique set of genomic
complications in older adults have been reported and epigenomic changes, which can inuence the
to include hematomas, deep vein thrombosis, and host immune response to tumor. Active immuno-
neurological symptoms. Although the medical therapy relies on stimulation of the patients
management for patients with life-threatening immune system to increase the immune response
tumors is clear in that surgical resection is neces- to target tumor cells. To this end either the entire
sary, the increased risk of complications for indi- immune system can be boosted or the immune
viduals >70 years must be weighed against the system can be trained to attack the tumor
expected positive outcomes (Bateman (McKay 2014). McKay and Hadeld recently
et al. 2005). The benets of meningioma resection summarized the three broad categories of immu-
can be measured in terms of improved cognitive notherapy strategies:
function on neuropsychological tests and ade-
quate quality of life, as measured by functional (i) Immune priming (active immunotherapy), or
independence scales like the Karnofsy perfor- sensitization of immune cells to tumor anti-
mance scale (Konglund et al. 2013). gens using various vaccination protocols
(ii) Immunomodulation (passive immunother-
Radiation and Chemotherapy apy), which involves targeting cytokines in
For malignant brain tumors such as glioblastoma, the tumor microenvironment or using
radiation therapy is the treatment of choice. immune molecules to specically target
Whole brain radiation has been commonly used tumor cells
(iii) Adoptive immunotherapy, which involves particularly to the frontal regions of the brain
harvesting the patients immune cells, (Resnick et al. 2003). The frontal cortex is asso-
followed by activation and expansion in the ciated with complex thinking and adaptive behav-
laboratory prior to reinfusion ior also known as executive functions. In
addition, age has been found to exacerbate exec-
Although this line of treatment is potentially utive dysfunction in patients with focal frontal
valuable, it has been hampered by factors such as lesions, such as a brain tumor in the frontal cortex
the bloodbrain barrier and lack of lymphatic (Cipolotti et al. 2015).
drainage in the brain (McKay 2014).
Overview of Cognitive Disorders
Aphasia and language: A disorder of language
Cognitive Disorders: Detection, that can affect speaking (expressive aphasia) or
Assessment, and Management understanding (receptive aphasia) or both
(global aphasia). The most common language
Changes in thinking, behavior, or emotion are disorder affects the ability to retrieve words or
quite common in primary and metastatic brain names of objects, people, or places (nominal
tumors. This section will give an overview of the aphasia). In subtle forms of aphasia, an indi-
importance, causes, and types of cognitive disor- vidual may have difculty thinking of what
ders and current methods for detection, with they want to say (dynamic aphasia). Literacy
examples of practical tips for managing cognitive and numeracy disorders are termed dyslexia
difculties. when the problem is with reading, dysgraphia
Cognitive function is an independent prognos- when the problem is with spelling, and
tic factor in the survival of glioma patients dyscalculia when arithmetic difculties are
(Taphoorn and Klein 2004). Moreover, cognitive present.
assessment is useful for several reasons: to inform Amnesia: This is a disorder of memory that can
clinicians of areas to target for neuroreh- affect personal memories (autobiographical
abilitation; to monitor progress and facilitate memory), learning new information (episodic
decision-making about further intervention; if memory) or general knowledge about the
there has been a decline in cognitive function, to world (semantic memory). Amnesia can affect
ask whether the tumor has recurred or progressed; verbal or visual information (selective amne-
and if there are subtle alterations in cognitive sia) or both (global amnesia).
function, to address whether these are signicant Agnosia: This is a disorder of perception and
or not, particularly when monitoring slow- can be present in any form of sensation (e.g.,
growing low-grade gliomas (Robinson touch, taste, hearing, smell, and vision). The
et al. 2015). most common form is visual agnosia, that is,
Disturbance to cognitive function in the con- when someone does not recognize what they
text of a brain tumor can be due to the location and are looking at with their eyes or they have
size of the tumor, prognosis (benign or malignant difculty knowing exactly where something
and WHO grade), treatment (surgery, radiation, is in the surrounding environment.
chemotherapy), secondary medical complications Attention and concentration: Disorders of
of treatments, and also an individuals psychology attention and concentration are common in
response (anxiety, depression) (Cancer Council of any condition affecting the brain. Difculties
Australia 2011). can be in focusing attention or in sustaining
attention over time. Problems can manifest as
Cognition and Aging distractibility or impulsivity.
An additional factor in older adults is the nature of Executive dysfunction: Executive functions
aging itself. With increasing age, there is a dispro- are comprised of many different abilities,
portionate loss of both white and gray matter including problem solving, reasoning,
decision-making, judgment, initiation of

behaviors, monitoring and self-regulation of information to be processed. For exam-
behaviors, abstract thinking, and strategic ple, turn off the television or radio unless
thinking. These skills can be disturbed sepa- watching or listening to a program.
rately or several executive functions may be Memory: Use technological supports B
affected. These are the abilities that enable an like a smartphone, calendar, or notebook
individual to adapt their behavior in order to to remember appointments and impor-
respond and interact appropriately in any situa- tant information.
tion. The executive abilities are uniquely human Fatigue: If easily fatigued, plan activity
and especially vulnerable to the aging process. in intervals, i.e., activity interspersed
Speed of information processing: When infor- with rest throughout the day.
mation processing is disturbed, thinking can be Words: If names of people or things are
slowed down and other cognitive skills can be difcult, ask someone to give the name
affected as the amount of information (rather than guess), repeat it aloud,
processed may be limited. and/or write down important names.
Problem solving: When planning an
Detection and Management of Cognitive activity or how to complete a complex
Disorders task, break it down into steps and then
A signicant issue in brain tumors is the method order the steps and complete these.
for detection of cognitive disorders. The most
widely used method is cognitive screening tools
such as the mini-mental state examination
(MMSE) or the Montreal Cognitive Assessment General Summary
(MoCA). However, recent studies have shown
that, although the MoCA is better at detecting Age poses an increased risk of developing a pri-
cognitive decits than the MMSE, the MoCA mary brain tumor, from the age of 55 years but
fails to detect mild and/or focal cognitive decits particularly for those over 65 years of age. The
in patients with brain tumors (Robinson most common types of tumors in older adults are
et al. 2015). This is particularly for attention, meningiomas and gliomas. Moreover, prognosis
language, and executive functions. Thus, best for survival is poorer if an individual is older than
practice is to assess cognitive disorders with a 60 years. In the context of aging, this is associated
brief cognitive assessment that is tailored to a with an increased loss of brain volume in the
patient based on tumor location and presenting frontal region, impacting complex thinking and
neurological and neuropsychological symptoms adaptive behavior. Older adults are particularly
(Robinson et al. 2015). vulnerable for tumors disrupting the frontal cor-
Simple strategies can help minimize the impact tex. Thus, despite the rarity of primary brain
of cognitive disorders. Detailed strategies can be tumors, older adults may experience more post-
obtained from specialists in neuropsychological surgical complications, and they have a poorer
rehabilitation. However, see Box 2 for simple prognosis for survival.
handy tips when experiencing thinking problems.
Box 2: Examples of Handy Tips for Thinking

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D., Helseth, E., & Meling, T. R. (2013). Outcome
following surgery for intracranial meningiomas in the
aging. Acta Neurologica Scandinavica, 127, 161169.
Louis, D. N., Ohgaki, H., Wiestler, O. D., & Cavanee, Definition
W. K. (Eds.). (2007a). WHO classication of tumors
of the central nervous system. Lyon: IARC. Henkens and van Solinge (2014) note that deni-
Louis, D. N., Ohgaki, H., Wiestler, O. D., Cavanee, W. K., tions of bridge employment vary along a number
Burger, P. C., Jouvet, A., Scheithauer, B. W., &
Kleihues, P. (2007b). WHO classication of tumors of of dimensions. It has been dened as participation
the central nervous system. Acta Neuropathologica, in the labor force between retirement from full-
114, 97109. time work and complete workforce withdrawal
McKay, S., & Hadeld, R. (2014) Current knowledge in (Shultz 2003; Topa et al. 2014). Alcover
brain cancer research. Cure Brain Cancer Foundation.
Sydney, Australia. https://www.curebraincancer.org. et al. (2014) suggest that as such bridge employ-
au/page/89/literature-review ment can be conceptualized as forms of retire-
Omuro, A., & DeAngelis, L. M. (2013). Glioblastoma and ment that prolong working life (p. 7). As Topa
other malignant gliomas: A clinical review. JAMA, et al. (2014) note, this type of paid employment
310(17), 18421850.
Quant, E. C., & Wen, P. Y. (2010). Novel medical thera- can be in the same occupation or different occu-
peutics in glioblastomas, including targeted molecular pations, on a part-time, temporary or full-time
therapies, current and future clinical trials. Neuroimag- basis (p. 226). Henkens and van Solonge
ing Clinics of North America, 20(3), 425448. (2014) note that bridge employment can be for
Resnick, S. M., Pham, D. L., Kraut, M. A., Zonderman,
A. B., & Davatzikos, C. (2003). Longitudinal magnetic an employer or include self-employment. In sum,
resonance imaging studies of older adults: A shrinking bridge employment is paid work undertaken after
brain. Journal of Neuroscience, 23(8), 32953301. retirement from the main career job but before
Robinson, G. A., Biggs, V., & Walker, D. G. (2015). exiting the labor force completely (Topa
Cognitive screening in brain tumors: Short but sensitive
enough? Frontiers in Oncology, 5(60), 17. et al. 2014).
Rosenfeld, M. R., & Pruitt, A. A. (2012). Management of
malignant gliomas and primary CNS lymphoma: Stan-
dard of care and future directions. Continuum Introduction
(Minneap Minn), 18(2), 406415.
Stupp, R., Warren, P., & Maston, M. D. (2005). Radiother-
apy plus concomitant and adjuvant temozolomide for The rapid change to the nature of work and work-
glioblastoma. NEJM, 352, 987996. ing lives in the past few decades has seen a
Bridge Employment 419
concomitant transformation of the pathways to employment can be seen as a career development

workforce exit. Retirement is no longer necessar- stage where employees use bridging opportunities
ily a clean break characterized by an abrupt to pursue career goals. Bridge employment may
departure from the workforce. The transition offer the exibility and autonomy to pursue
from work to retirement is now blurred and generativity goals or to fulll ambitions of self- B
fuzzy retirement is no longer a single discrete employment (Zhan and Wang 2015). Third,
event but can be viewed as a dynamic and indi- bridge employment may be regarded as an adjust-
vidual process that may occur over a short period ment process where those intending to retire use
of time in ones life or may include an extensive bridge employment as a mechanism to adapt to
period of withdrawal and reentry to the paid work- future retirement, both nancially and psycholog-
force (Beehr and Bennett 2007; Bowlby 2007). ically. Finally, Zhan and Wang (2015) conceptu-
Individuals may reduce their work responsibilities alize bridge employment from the employers
or hours of employment or take on some form of point of view as a function of human resource
temporary work or limited contract position. Thus management processes to attract, motivate, and
bridge employment can be characterized as a retain older workers.
transition into some part-time, self-employment
or temporary work after full-time employment
ends and permanent retirement begins Types of Bridge Employment
(Feldman 1994, p. 286).
Bridge employment can be categorized into two
types career consistent bridge employment and
Conceptualizing Bridge Employment noncareer bridge employment. In the rst, indi-
viduals may stay within the same organization or
One way to conceptualize bridge employment is move to a different organization but will remain in
through a life course perspective. Dingemans the same occupation. In the second, individuals
et al. (2015) argue that life transitions, such as move to a different eld where exibility is a key
those incurred through bridge employment, do criterion and status and pay may be reduced to
not operate within a vacuum. Rather, individuals reect this (Alcover et al. 2014). This type of
are embedded within personal and social environ- bridge employment is thought to be the more
ments that shape their life histories and these may common and often involves self-employment as
hinder or facilitate late-life career choices. Thus, it provides greater exibility and autonomy com-
the life course approach suggests that many fac- pared to salaried positions (Alcover et al. 2014).
tors, such as socioeconomic, psychosocial, and Zhan and Wang (2015) note that this typology
health factors, interact to inuence the participa- may not be sufcient to accurately capture the
tion in bridge employment. nature of bridge employment and suggest four
In their recent work, Zhan and Wang (2015) key criteria that can assist in understanding the
provide another organizational framework for complexity of patterns of participation in bridge
conceptualizing and theorizing bridge employ- employment. The rst criterion is working eld.
ment. First, bridge employment can be viewed This reects the typology described above in that
within a decision-making framework as rational individuals may undertake bridge employment in
planned behavior. That is, employees choose to the same eld as their career jobs, or in a different
engage in bridge employment (for numerous rea- eld. Reecting the decision making conceptual-
sons) voluntarily. The decision to participate in ization proposed earlier by Zhan and Wang
bridge employment may be made multiple times (2015), individuals assess the information of
once the retirement process has been embarked their personal characteristics and work-related
upon, and these decisions may be inuenced by characteristics to determine which working eld
personal and contextual factors (Wang and Chan to choose for bridge employment (p. 209). These
2011; Zhan and Wang 2015). Second, bridge factors can be related to the individuals nancial
situation (Wang et al. 2008) or work attributes Determinants and Outcomes of Bridge
such as job strain, job-related skills, and job char- Employment
acteristics (Gobeski and Beehr 2009).
The second criterion suggested by Zhan and Dingemans et al. (2015) propose a number of life
Wang (2015), related to their Human Resource course determinants of bridge employment such
Management conceptualization of bridge employ- as socioeconomic and health factors, work and
ment, is the organization or employer. Organiza- retirement context, and family commitments.
tions are increasingly striving to attract, motivate, First, socioeconomic factors and health are
and retain older employees. Thus they may inu- determinants of work force participation. Finan-
ence the choice between same versus different cial circumstances may be a strong determinant of
organizations by providing exible work environ- whether individuals engage in bridge employment
ments that meet the changing needs and abilities in the transition to retirement. Bridge employment
of older workers seeking to engage in bridge may offer the opportunity of boosting pension or
employment. Along with the notion of same ver- superannuation payments for some (Doeringer
sus different organizations in which to undertake 1990), where for others it may be the only source
bridge employment, a third option is that of self- of income before becoming eligible for such ben-
employment. Zhan and Wang (2015) note that ets (Atchley and Barusch 2004; Zhan
self-employment increases with age and is one et al. 2009). Dingemans and Henkens (2014)
of the most common pathways through bridge found that those who engaged in involuntary
employment to full retirement for older workers. bridge employment reported lower levels of life
This is reected in the conceptualization of bridge satisfaction than those who were motivated to
employment as a career development stage, pro- engage in bridge employment for intrinsic enjoy-
viding arguably the greatest exibility and auton- ment. However, engagement in bridge employ-
omy for the adjustment process to retirement. ment after involuntary retirement partially
The third criterion suggested by Zhan and mitigated the negative effects of involuntary
Wang (2015) is that of the time commitment retirement on life satisfaction.
toward bridge employment and reects the con- Poor health may result in involuntary bridge
ceptualization of adjustment outlined earlier. employment as it dictates the commitment indi-
Operationalizing bridge employment as the time viduals can make to work with reduced hours or
committed to work-related activities highlights responsibilities, often the result of decreased
the dynamic process of adjusting to full-time physical and mental capacity. On the other hand,
retirement and underscores the fact that most good health can enhance the individuals capacity
bridge employment is undertaken on a part-time to continue in some form of paid employment well
basis. Thinking of bridge employment from a beyond socionormative expectations (Zhan
temporal perspective also allows investigation of et al. 2009). Work attributes such as occupational
the transitional nature of the process where indi- status and level are also related to the probability
viduals may move in and out of part-time employ- of undertaking bridge employment (Dingemans
ment over a period of time as they move toward et al. 2015). Bridging employment can also help
full-time retirement. to maintain the sense of structure and worth that
The nal criterion suggested by Zhan and full-time employment may have provided (Kim
Wang (2015) is that of motive. Citing Mor-Banks and Feldman 1998; Wang et al. 2008) even though
(1995) typology of work-motivation factors for bridging jobs tend to be at a lower status and lower
older adults (nancial, personal, social, and the rate of pay than the individuals previous full-time
generativity factor), the authors argue that differ- job (Atchley and Barusch 2004).
ent motivations for bridge employment have con- The context in which retirement occurs also
sequences for outcomes. That is, motivations will inuences whether bridge employment is under-
work differentially on job and career satisfaction taken (Zhan and Wang 2015). Involuntary or early
and retirement adjustment. retirement through organizational restructuring or
personal circumstances may push retirees toward Flexible work arrangements are often cited as
seeking bridge employment in order to gain a important to older workers, but are often not
sense of control or to comply with societal offered by employers (Alpass et al. 2015).
norms surrounding work roles (Dingemans Finally, macro- or societal-level factors, such
et al. 2015). Organizations themselves may facil- as government policies, the employment rate, and B
itate or hinder opportunities for bridge employ- the economy can also impact on the likelihood of
ment. That is, organizations in an effort to attract the availability of opportunities for bridge
or maintain older workers may provide more ex- employment (Wang et al. 2014). As Dingemans
ibility and design the workplace to accommodate and Henkens (2014) note, the impact of
the needs of older workers (Zhan and Wang these factors on the availability of bridge employ-
2015). ment opportunities is not under the individuals
Family factors are also important contextual control.
considerations in the retirement process, although The potential consequences of engagement in
the impact of these may be more distal than bridge employment are many and varied with
job-related factors (Wang et al. 2008). The work evidence for improved health, quality of life, life
situation of a spouse may determine the timing satisfaction, and retirement satisfaction for those
and extent of workforce disengagement for indi- who engage in bridge employment compared to
viduals, as do caring commitments for family those who retire completely from the workforce
members including spouse, parents, children, (Dingemans and Henkens 2014; Topa et al. 2014;
and grandchildren. Wang 2007; Zhan et al. 2009). Two theoretical
Wang et al. (2014) distinguish between micro-, perspectives that provide insight into the potential
meso-, and macro-levels of bridge employment benets of bridge employment for the individual
antecedents. Similar to Dingemans et al.s (2015) are continuity and role theory.
life course perspective, micro- or individual fac- Continuity theory contends that as people age,
tors include nancial status and health plus other they strive to preserve internal and external behav-
demographic factors such as age, education, and ior and circumstances in order to maintain and
gender. Older workers are less likely to take up improve well-being (Atchley 1993). Older adults
bridge employment, while those with higher edu- beliefs about self and identity are tied to their roles
cation levels are more likely to engage in bridge and activities. Continuity theory would suggest
employment (Wang et al. 2014). Henkens and van that any new activities will be in the general area
Solinge (2014) found that men were more work- of former activities. Thus, based on this theory we
oriented postretirement than women, although would expect retirees that continue some form of
this was dependent on education level. They also employment after exiting their career job to expe-
found that married people were more likely to rience better health and well-being, and this would
engage in bridge employment than single or be more so for those who continue in bridge
divorced older workers. employment in same eld of work (Zhan
Meso- or job-related factors include the work et al. 2009). There is some evidence to suggest
environment, work role, and attitudes (Wang this is the case. Kim and Feldman (2000) found in
et al. 2014) and highlight the role of organiza- a sample of early retirees that those more involved
tional context in facilitating the uptake of bridge in bridge employment (both within and outside
employment (Dingemans et al. 2015). Do organi- their previous employer) were more satised with
zations put in place practices to encourage bridge both retirement and life in general. Zhan
employment for older workers such as exible et al. (2009) in a longitudinal investigation using
working hours, improved work design, and Health and Retirement Study (HRS) data found
reduced workloads? Can organizations provide similar results for the benets of career and
opportunities for recognition of skills and experi- noncareer bridge employment on physical health
ence while meeting both organizational goals and and functional limitations while controlling for
employees desire for bridge employment? baseline health and demographics, although only
career bridge employment was benecial for men- Future Directions

tal health. Consistent with continuity theory,
Wang (2007) found, again in longitudinal ana- What are the promising future directions for
lyses of HRS data, that retirees with bridge jobs research on bridge employment? Zhan and Wang
were more likely to be in a maintaining pattern (2015) suggest three areas as foci for new direc-
of psychological well-being in retirement com- tions in this eld of research: the engagement in
pared to retirees without bridging employment. bridge employment and the transition to retire-
That is, they experienced fewer changes in psy- ment from the retirees perspective, organiza-
chological well-being during the transition to tional human resource (HRM) practices and job
retirement compared to their fully retired counter- design, and issues related to rening the measure-
parts. In a longitudinal study, Dingemans and ment of bridge employment.
Henkens (2014) found that those who wanted a Wang et al. (2011) note the lack of empirical
bridge job but were unable to secure one reported studies examining individual resources and indi-
decreased life satisfaction with their lives vidual differences such as personality and disposi-
postretirement. Similar to Baltes model of Selec- tional traits as predictors of retirement adjustment
tive Optimization with Compensation, Atchleys in general. Zhan and Wang (2015) also cite a lack
theory does allow for some changes or withdrawal of evidence around the role of retirees psycholog-
from activities in order to adapt to changed cir- ical characteristics in the bridge employment pro-
cumstances, such as declines in health, function, cess and suggest a stronger focus on personality
or motivation. Key resources that individuals rely traits (e.g., the big ve), individual motivations,
on to maintain continuity include educational and attitudes to work and retirement in general in
level, health, and nancial status (Wang understanding the nature of retirement transitions.
et al. 2008). As Zhan et al. (2009) argue, understanding the
Role theory maintains that the roles available to motivations for engaging in bridge employment
the individual change as they transition to retire- (e.g., for fullling career goals, transition to full
ment. Roles may need to be substituted or adapted retirement) may provide insight into the different
in order to prevent stress and anxiety and to suc- health trajectories that occur in retirement and
cessfully adjust to retirement (Bosse et al. 1996). beyond into older age.
One way for retirees to manage the loss of Human resource practices are also suggested as
the career work role is to engage in bridge an avenue for future research in understanding
employment to maintain role identity. In doing bridge employment decision making. What types
so they may mitigate the negative health of work environments encourage older workers to
effects of role loss and role transition (Zhan engage in bridge employment either within their
et al. 2009). Zhan et al. (2009) argue that the own career eld or in another eld? Flexible work
effects of participation in bridge employment arrangements such as working from home, reduced
can be viewed as similar to those associated workload pressures, exible work schedules, and
with job reemployment (where the unemployed phased retirement, although valued by older
reenter the work role). That is, where reentering workers, are often not made available by organiza-
the work role can restore well-being to tions (Alpass et al. 2015). Zhan and Wang (2015)
preunemployment levels, so too can the bridge argue that organizations would benet from an
employment role have a positive impact on health understanding of the work preferences of older
and well-being for those previously engaged in workers so that HRM practices can be designed
career employment. to maximize the potential of older workers for
On the other hand, substituting the work role remaining engaged in the workforce.
with other roles on retirement such as those asso- As noted earlier, there have been numerous
ciated with leisure and family pursuits may also denitions put forward to describe the
contribute to sustaining and maintaining well- experience and process of bridge employment.
being (Wang et al., 2009). In addition, categories for different types of bridge
employment have been put forward (e.g., career Shultz (2010). Instead of conceptualizing bridge
bridge employment versus bridge employment in employment as a one-off decision, a dynamic
a different eld). Alcova et al. (2014) propose that perspective views bridge employment as part of
researchers develop internationally useable de- a longitudinal transition process from the individ-
nitions that precisely specify the different types of uals retirement decision to the state of full retire- B
bridge employment. This would encourage more ment. The approach allows for the investigation of
cross-country comparisons of the nature and proximal and distal predictors of bridge employ-
extent of bridge employment. Zhan and Wang ment as well as outcomes variables in retirement
(2015) note that precise denitions are required such as adjustment, life satisfaction, and mental
so that the impact on bridge employment decision and physical health.
making of societal and economic factors (e.g., In sum, it has become increasingly obvious over
retirement age, workforce age structure, and the past three decades that retirement can no longer
social security systems) can be more fully be described as a discrete event. Instead, as Wang
investigated. In addition, multiple indicators of and colleagues argue, retirement should be viewed
retirement adjustment are needed (Wang as a dynamic process nested within the individual
et al 2011), incorporating inter- and intradis- context and societal circumstances. The process of
ciplinary approaches and the use of longitudinal retirement may occur over an extended period of
data to understand both proximal and distal inu- time in ones life and may include an extensive
ences on the retirement adjustment process should period of withdrawal and reentry to the paid work-
be prioritized (Alcova et al. 2014). force through bridge employment. Engagement in
The participation in bridge employment is not bridge employment may be driven by a number of
necessarily under the individuals control factors, including personal, work-related, organiza-
(Dingemans and Henken 2014). Dingemans and tional, and societal factors. The effects of bridge
colleagues (2015) found that the transition to employment on postretirement outcomes are com-
bridge employment is strongly inuenced by ing under increased focus and future research direc-
the opportunities and restrictions in the social tions provide the opportunity to investigate new
context in which the retirement process unfolds theoretical perspectives and further rene
(p. 10). They argue that a process of cumulative measurement.
disadvantage may hinder some older workers
who seek to extend their working lives. There is
little empirical work that has investigated the pro-
Cross-References
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Career Development and Aging
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Employment of Older Workers
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Flexible Work Arrangements
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Job Loss, Job Search, and Reemployment in
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Later Adulthood
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Motivation to Continue Work After Retirement
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Postretirement Career Planning
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Work to Retirement
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Burden of Disease and Aging 425
Definition GBD study, the Gates Foundation and other spon-

sors supported the program, and it includes statis-
Burden of disease (BoD) is a population measure tics for 291 diseases across 21 regions and
of the effects of a specic disease or health 187 countries across the full sociodemographic
problem. range. The GBD program has partnered with Lan- B
It is usually measured by Disability-Adjusted cet to provide a widely accessible publication
Life Years (DALYs) and/or by the related concept forum for its results. The 2013 update following
of Quality-Adjusted Life Years (QALYs). on the 2010 study is the rst of a series of annual
A DALY is a year of healthy life that is lost updates that will track changes and trends in GBD
because of a specic condition. When the DALYs into the future. This will provide a more frequent
associated with a condition within a population and regular ability to governments to track key
are summed, this is the burden of disease (BoD). trends and patterns in health and disease within
The burden of disease is the number of healthy their countries. This is a highly useful policy and
years lost in a population compared to full health. decision-making tool.
The QALY is the persons length of life multiplied
by a valuation of their health-related quality of
life. QALY measures are frequently used in the Patterns of Burden of Disease Among
economic evaluation of health interventions. The Older People
World Health Organization coordinates a major
ongoing global study of BoD, the Global Burden As outlined in the 2013 GBD update, the growth
of Disease Study. in global burden of disease is fueled by population
aging: . . . the analysis showed the global transi-
tion towards a rapid increase in YLDs due to
Introduction global population growth and ageing, combined
with little progress in reduction in age-specic
The purpose of this chapter is to outline BoD in YLD rates (Global Burden of Disease Study
older populations, dene, discuss and critically 2013 Collaborators, 2015). Thus, globally policy
evaluate BoD concepts and measures, and discuss makers are increasingly focused on the gains that
statistical, moral, and ethical issues in the use of can be made in terms of increased health status
BoD concepts particularly in older populations. and well-being and reduced burden of disease
Most countries use DALYs in their health eco- among older people.
nomics analyses and health and social policy- As illustrated in Fig. 1 below which shows
making. There has been strong global DALYs for people aged 60 years and over,
co-operation in global burden of disease studies noncommunicable diseases (NCDs) have been
in the form of the Global Burden of Disease pro- identied as the major global source of and under-
gram. The Institute for Health Metrics and Evalu- lying cause for burden of disease. The World
ation (IHME) at the University of Washington Economic Forums (Bloom et al. 2011) report
supervises the conduct of the Global Burden of asserted that NCDs represent 63% of all deaths
Disease (GBD) program in close collaboration being the worlds main killer. The Forum
with the World Health Organization. In its initial asserted that over the next 20 years, NCDs will
1990 emendation, the GBD program was predom- cost $USD30 trillion (or 48% of the 2010 global
inantly funded by the World Bank in partnership GDP) and that they will have devastating global
with WHO, and the outcomes were reported in its economic impacts. Burden of disease concepts
landmark 1993 World Development Report and data are therefore used to identify where
(World Bank 1993). The GBD program has resources may be most optimally allocated to
grown substantially from its initial Harvard Uni- achieve the greatest impact across the target
versity base. It now involves over 1,000 populations. The link between population aging
researchers from over 100 countries. In the 2010 and increased impact of NCDs has been widely
2010 Global Burden of Disease Studys estimated DALYs for all

people aged 60 years and older
Ischaemic heart disease
Stroke
COPD
Diabetes
Low back pain
Cancers of the respiratory system
condition
Falls
Visual Impairment
Dementia
Hypertensive heart disease
Tuberculosis
Stomach cancer
Major depressive disorder
Osteoarthritis
Hearing loss
0 10 20 30 40 50 60 70 80 90
DALYs in millions
Burden of Disease and Aging, Fig. 1
acknowledged both by researchers and policy Murrays paper provides a clear discussion of
makers. the design choices made in the construction of the
These data provide interesting insights into the DALY. He stated:
drivers of population of burden of disease. Many The intended use of an indicator of the burden of
of these conditions are inuenced by personal disease is critical to its design. At least four objec-
behaviors and lifestyle factors, in addition to the tives are important.
environmental and genetic factors. Before the dis- 1. To aid in setting health service (both curative
and preventive) priorities;
cussion of the critiques of BoD and the utility of 2. To aid in setting health research priorities;
BoD concepts in older populations, the following 3. To aid in identifying disadvantaged groups and
section describes the operationalization of BoD targeting of health interventions;
measures. 4. To provide a comparable measure of output for
intervention, programme and sector evaluation
and planning.
There are various measures of burden of dis-

Rationale for and Operationalization ease with the two most common being Disability-
of Measures Adjusted Life Years (DALYs) and Quality-
Adjusted Life Years (QALYs). These in turn rely
Burden of disease is a population measure of the upon the measurement of Years of Life Lost
effects of a specic disease or health problem. (YLL) from premature mortality in the population
Murrays (1994) landmark article in the Bulletin and the Years Lived with Disability (YLD) for
of the WHO outlines the intent and technical people living with the condition.
characteristics of BoD indicators and specically The equations and denitions for each of these
the DALY indicator. measures are as follows:
A Disability-Adjusted Life Year (DALY) is a enables the benets of different interventions to

year of healthy life that is lost because of the be compared with each other, the goal generally
condition. When the DALYs associated with a being to obtain interventions that have a low cost
condition within a population are summed, this per QALY. However, the use of these data in this
is the burden of disease. The burden of disease is fashion has generated some controversy. B
the number of healthy years lost in a popula-
tion compared to full health taking into account
both deaths and years lived in suboptimal states of Critiques of Burden of Disease Concepts
health: and Measurement
DALY YLL YLD The burden of disease concept has been subjected
to signicant, some may say trenchant, criticism
Years of Life Lost (YLL) are years lost to pre- by a variety of scholars since its inception. Parks
mature disability. Years of Life Lost are the dif- (2014) review of burden of disease provides a
ference between the actual age at death and the clear analysis of the key arguments advanced by
longest expected life expectancy for a person at its critics. She acknowledges that DALYs are in
that age. So if a person dies at 70 but the life wide use in the eld of global health but that they
expectancy is 80, then the Years of Life Lost is have been subjected to a barrage of criticism
10 years. (Anand and Hanson 1997) over an extended
Years Lived with Disability (YLD) is the period. Phillips argues that QALYs are far from
number of years lived with less than perfect health. perfect as a measure of outcome, with a number of
The prevalence of the health condition being mea- technical and methodological shortcomings, but
sured is multiplied by the (disability) weight for she also notes that Nevertheless, the use of
that specic condition. The weights are determined QALYs in resource allocation decisions does
by expert analysis of community studies of health mean that choices between patient groups com-
impacts of the condition (See Klarman et al. 1968; peting for medical care are made explicit.
Torrance 1986). The disability weight is the sever- Essentially the criticism falls into two main
ity or extent of health loss for the specic health categories: linked conceptual and statistical objec-
state or condition. There is a considerable literature tions and ethical/moral objections.
concerning the most appropriate methods for esti-
mation of health utilities and weights. Conceptual and Statistical Issues
A QALY is a year of life spent in perfect
health. In this sense a QALY is a mirror image Weighting
conceptualization of disease burden when com- The statistical objections concern the measure-
pared to a DALY. The National Institute for Health ment and weighting systems used in the measure-
and Clinical Excellence (NICE) has provided the ment process underpinning BoD. Essentially in
following denition of QALY as a measure of a assessments of the perfect health state, the arbi-
persons length of life weighted by a valuation of trary value of 1.0 is assigned to perfect health and
their health-related quality of life. the arbitrary value of 0.0 is assigned to death.
Intermediate values on this continuum are calcu-
lated using tools and methods that have been
QALY Life expectancy weighted quality subject to expert review and considerable debate.
of the remaining life years Arnesen and Nord (1999) express their conceptual
concerns neatly when they note that The disabil-
QALYs are typically combined with cost estimates ity weightings in use tell us that the value of one
of what it would cost for an intervention to generate year for 1000 people without disabilities on aver-
a year of perfect health (a QALY) and that process age is set equivalent to the value of one year for
yields a cost utility ratio estimate. This process 9524 people with quadriplegia, 4202 people with
dementia, 2660 blind people, 1686 people with (2011) systematic review of multi-morbidity
Downs syndrome without cardiac malformation, found that among 41 reviewed papers that preva-
1499 deaf people, 1236 infertile people, and 1025 lence of multi-morbidity in older persons ranged
underweight or overweight people (1999, from 55% to 98% with increasing rates for older
p. 1424). people, females, and low socioeconomic status.
Thus, while these tools may well have been The number of conditions experienced especially
designed by experts, the values assigned at the end by older people is quite high. For example,
of the day are arbitrary constructs that do not Collerton and colleagues (2016) report a multi-
relate directly to the natural world. As with all morbidity rate of 92.7% with a median number of
tools measuring constructs, the burden of disease 4 conditions among the Newcastle 85+ study
measurement tools are not psychometrically per- sample.
fect. No tool is. Hence they contain measurement Fortin et al. (2014) who are the pioneers of
error and hence intrinsically on occasion will pro- multi-morbidity research have recently published
vide erroneous results. Nevertheless the statistical studies linking multi-morbidity and (unhealthy)
assumptions for the tools are clearly stated and lifestyle factors including smoking, alcohol con-
therefore can be evaluated. Burden of disease is a sumption, fruit and vegetable consumption, phys-
key tool in health policy and program evaluation. ical activity, and body mass index. The
It has deciencies in its implementation, but there aggregation of unhealthy lifestyle factors has
is a clear focus to address them in its many users. been found to be strongly associated with multi-
morbidity. Multi-morbidity can create technical
Individual Differences Among Older People problems in the measurement of burden of disease
and Multi-morbidity because of the need to attribute the unique contri-
While the uses of concepts such as burden of butions of individual diseases or conditions to the
disease intrinsically take a population or large levels of disability experienced by the individuals
subgroup perspective, the large individual differ- concerned.
ences among older people must be recognized and Afshar and colleagues (2015) have made the
incorporated in service design and policy. Failure pertinent point that while aging is considered an
to understand that BoD measures use the concept important driver of increased burden of disease,
of the average person or the aggregated person multi-morbidity and socioeconomic factors are
who do not in fact exist is a major concern in the also important related factors.
use of such measures. Beard and Blooms 2015
Lancet commentary includes the highly pertinent Ethical and Moral Issues
comment that great interindividual functional In terms of ethical and moral arguments against
variability is a hallmark of older populations. DALYs and other BoD measures, some disability
They go on to conclude that this variability advocates have argued that the whole concept of
poses major challenges to policy formulation disease burden intrinsically devalues the lives of
and program design. There are many studies that people with disabilities by representing them as of
support the general nding that aging involves the lesser value than those experiencing good
experience of different individual trajectories that health.
one size does not t all. Hsu and Jones (2012) With regard to the use of QALYS and DALYs
provide details of the quite variable trajectories in health resource allocation, one might arrive at
that older people follow in aging. the conclusion that it is poor public policy to over-
A growing preoccupation in burden of disease invest in services for older people because they
research and service delivery is the issue of multi- will not deliver the returns in terms of DALYs and
morbidity or multiple conditions experienced by QALYs that are achievable with other groups.
especially older people. Various studies have However, the evidence for this proposition is
identied very high rates of multi-morbidity highly arguable as illustrated in the previous sec-
among older people. Marengoni and colleagues tions of this entry. Older people respond well and
effectively in terms of disease burden reduction to Burden of Disease and Aging, Table 1 WHO policy
investment in them. Ory and Smiths volume con- actions to promote healthy aging in older people
tains numerous counterexamples to this position. Actions
Murrays exhortation that BoD indicators must Ensure access to older person-centered and integrated
aid in identifying disadvantaged groups is also care
B
a reminder of how the pioneering developers of Orient systems around intrinsic capacity
Ensure a sustainable and appropriately trained health
burden of disease concepts and methodology
workforce
argued from the outset that burden measures Establish the foundations for a system of long-term care
were not intended to be used to justify disinvest- Ensure a sustainable and appropriately trained workforce
ment in health programs and services for older for long-term care
people. Ensure the quality of long-term care
Combat agism
Enable autonomy
Can Burden of Disease Be Modified Support healthy aging in all policies at all levels of
and Reduced Among Older People? government
Agree on metrics, measures, and analytical approaches
for healthy aging
There is ample evidence that the health of older Improve understanding of the health status and needs of
people can be improved through interventions. older populations
However, the quantication of the benets that is Increase understanding of healthy aging trajectories and
required to calculate reliable cost utilities is a what can be done to improve them
particular challenge. Providing a key policy
framework for healthy aging, the WHO World
Report on Ageing and Health (Beard et al. 2015) indicative of the strong and growing evidence
points to the major gains that can be obtained with base for effective interventions for older people.
coordination of focus on healthy aging in health
and social programs. The policy actions outlined
in Table 1 below are proposed within the report to Conclusion
enhance healthy aging and reduce age-related bur-
den of disease. There is a strong psychosocial and BoD is a widely used system of measurement of
cultural focus in the proposed actions. The iden- the effects of diseases in populations. BoD in
tication of the need to combat agism, to older populations is currently driven largely by
improve understanding of the health status and ischemic heart disease, stroke, and COP-
needs of older populations, and to enable auton- D. Criticisms of BoD focus on the arbitrary nature
omy for older people reects an approach that is of the statistical weightings and the intrinsic
not merely centered on disease. devaluation of people with disabilities involved
Many commentators have argued for the high in measuring their decrements. For older people
utility of investment in health promoting actions the concept is often applied in a way that does not
among older people (Prince et al. 2015). Fortu- address heterogeneity/individual differences in
nately there are now many interventions and pro- health outcomes in old age and multi-morbidity,
grams that have established evidence for but this current practice is not an intrinsic feature
effectiveness in the prevention and management of its design. Despite these shortcomings, BoD
of NCDs among older people. Most of them can help policy makers make transparent and
include behavioral changes (Browning and informed decisions about where to place
Thomas 2005) in the targeted populations. Ory resources to maximize health outcomes for older
and Smiths (2015) volume in Frontiers in Public people. The early prevention and management of
Health includes 59 contributions concerning suc- chronic diseases and conditions are an obvious
cessful health-related programs and interventions approach to promoting healthy aging. However
for older people from a range of countries and is the design and implementation of programs to
promote health and manage disease for older peo- for social and public health. Edinburgh: Churchill Liv-
ple need to incorporate the structural drivers of ingstone. ISBN 0443073570.
Collerton, J., Jagger, C., Yadegarfar, M. E., Davies, K.,
health, namely, healthy environments and person- Parker, S. G., Robinson, L., & Kirkwood, T. B. (2016).
centered, diversity sensitive, and integrated Deconstructing complex multi-morbidity in the very
health-care systems. old: Findings from the Newcastle 85+ study. Biomed
Research International, 2016, 8745670.
Fortin, M., Haggerty, J., Almirall, J., Bouhali, T.,
Cross-References Sasseville, M., & Lemieux, M. (2014). Lifestyle factors
and multi-morbidity: A cross sectional study. BMC
Public Health, 14, 686.
Healthy Aging Hsu, H. C., & Jones, B. L. (2012). Multiple trajectories of
successful aging of older and younger cohorts. Geron-
tologist, 52, 843856.
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C
Canadian Longitudinal Study on and advanced data collection methods, the study
Aging, A Platform for Psychogeriatric provides a unique opportunity to examine the
Research aging process and factors that shape healthy
aging. After describing the study design of the
Vanessa Taler1, Christine Sheppard2,3, CLSA, an overview of the measures used to assess
Parminder Raina4 and Susan Kirkland5 psychological functioning is provided. The chap-
1
University of Ottawa and Bruyre Research ter concludes with a discussion of how the CLSA
Institute, Ottawa, ON, Canada provides a unique opportunity to investigate the
2
University of Waterloo, Waterloo, ON, Canada internal and external factors that inuence psy-
3
Bruyre Research Institute, Ottawa, ON, Canada chological functioning in mid- to late-life.
4
Department of Clinical Epidemiology and
Biostatistics, McMaster University, Hamilton,
ON, Canada Introduction
5
Departments of Community Health and
Epidemiology and Medicine, Dalhousie The ability to maintain autonomy, perform every-
University, Dalhousie, NS, Canada day activities, and engage in society is highly
dependent on the level of psychological function-
ing, and this relationship is magnied with age.
Synonyms Changes in cognitive functioning are a component
of normal aging and begin in mid-life or even
CLSA; Cognition; Cohort; Depression; Mood; earlier. While some higher brain functions (e.g.,
Personality traits; Psychopathology; PTSD processing speed) are highly sensitive to
age-related change, other abilities are well pre-
served in healthy aging (e.g., comprehension of
Definition word meaning) (Park and Schwarz 2000).
Changes may also be observed in the pragmat-
The recently launched CLSA is the largest and ics of cognitive functioning, which are largely
most comprehensive study of aging ever under- captured under the rubric of social cognition (i.e.,
taken in Canada. Through its innovative design how we perceive and interpret our world) (Baltes
1993).
Identifying the links between personality vari-
Noted at end of chapter On behalf of the CLSA Psychology ables and wellness is also emerging as a predom-
Working Group (Table 2). inant research topic. Research reveals complex
DOI 10.1007/978-981-287-082-7
432 Canadian Longitudinal Study on Aging, A Platform for Psychogeriatric Research
associations between personality and well-being, Most previous large-scale adult development
both physical and mental. In part, these associa- and aging studies that address psychology have
tions appear to be a function of the link between focused on the development of specic psycho-
personality traits, mood states, and psychopathol- logical processes such as memory and intelligence
ogy and the resulting effects upon physical well- or have been conducted in the context of specic
ness. For example, negative emotional states disorders, such as dementia. The CLSA will
appear to have a signicant inuence upon bio- expand this domain of research by examining
logical functions such as immune function and several psychological constructs as precursors or
regulation (which become less efcient in later mediators of specic and global aspects of health
life), thus increasing the risk of many health prob- and health-related outcomes. This chapter
lems (Kiecolt-Glaser and Glaser 2002). describes the study design and measures included
Longitudinal research is critical in order to in the CLSA, with particular emphasis on those
achieve a clear understanding of age-related that are focused on the assessment of the transi-
changes in psychological function and the links tions and trajectories of psychological functioning
between psychological function and wellness. over the latter half of the adult life course.
The Canadian Longitudinal Study on Aging
(CLSA) will follow 50,000 adults aged 4585
for at least 20 years, collecting critical information Methods
on psychological and social function, as well as
indices of physical and mental well-being. This CLSA Study Design
will allow for examination of psychological pro- An overview of the CLSA design and methodol-
cesses as precursors and mediators in relation to ogy was published in a special supplement to the
measures of social, biological, psychological, and Canadian Journal of Aging (Raina et al. 2009a).
adaptive functioning (e.g., social participation, Additional papers describing the recruitment strat-
diseases, everyday functioning). egy (Wolfson et al. 2009), methods for ascertain-
ment of chronic disease (Raina et al. 2009b), study
feasibility (Kirkland et al. 2009), feasibility of bio-
The Canadian Longitudinal Study logical sample collection (Balion et al. 2009), and
on Aging linkage with health-care utilization databases
(Raina et al. 2009c) were also included. The
The recently launched CLSA is the largest and CLSA is a prospective cohort study of 50,000
most comprehensive study of aging ever under- residents of Canada aged 4585 years at baseline
taken in Canada. Through its innovative design and followed for at least 20 years. Of the 50,000
and advanced data collection methods, the study participants, 20,000 provided data through
provides a unique opportunity to examine the computer-assisted telephone interviews (CATI),
aging process and the factors that shape healthy and the remaining 30,000 participated in data col-
aging. The goal is to better understand the com- lection that included an in-home interviewer-
plex interplay among the many determinants of administered questionnaire and a comprehensive
health through the examination of inuences physical assessment at a dedicated data collection
from cells to society, providing the most accu- site. Major data collection is repeated every 3 years
rate picture possible of the dynamic process of and in between waves, a short maintaining contact
adult development and healthy aging. By telephone interview is conducted in order to mini-
collecting information on the changing biological, mize the loss to follow-up and also to collect addi-
medical, psychological, social, lifestyle, and eco- tional data as needed.
nomic aspects of peoples lives as they age, the In addition to the psychological assessment, a
CLSA will contribute to the identication of mod- vast array of common core information is col-
iable factors that can be used to develop inter- lected through questionnaires (Table 1). For the
ventions to improve the health of Canadians. 30,000 members of the CLSA who undergo
Canadian Longitudinal Study on Aging, A Platform for Psychogeriatric Research 433
Canadian Longitudinal Study on Aging, A Platform Canadian Longitudinal Study on Aging, A Platform
for Psychogeriatric Research, Table 1 CLSA baseline for Psychogeriatric Research, Table 1 (continued)
measures
Cohort (n = 50,000)
Cohort (n = 50,000) Comprehensive Telephone
Comprehensive Telephone face to face interview
face to face interview Measures (n = 30,000) (n = 20,000)
Measures (n = 30,000) (n = 20,000)
Psychological measures
strength, timed up C
and go, balance, gait)
Memory Basic activities of Q Q
Rey auditory verbal Q Q daily living
learning test Instrumental Q Q
Executive function activities of daily
Mental alteration test Q Q living
Prospective memory Q General health Q
test Life space index Q Q
Stroop Q Womens health Q Q
neuropsychological Chronic conditions Q Q
screening test Health-care Q Q
Controlled oral word Q utilization
association test Medication use Q Q
Animal naming Q Q Dietary supplement Q Q
Psychomotor speed use
Simple and choice T Oral health Q Q
reaction times Injury and falls Q Q
Mood and Pain and discomfort Q Q
psychopathology
Sleep Q
Depression Q Q
Biological measures
Life satisfaction Q Q
Blood Collected
Post-traumatic stress Q Q
Urine Collected
disorder
Social measures
Psychopathology Q
Social networks Q Q
Personality traits Q Q
Online social Q Q
Physical measures
networking
Lean muscle mass PE
Social support Q Q
and body
availability
composition
Social participation Q Q
Waist and hip PE
circumference Care receiving Q Q
(formal care)
Blood pressure PE
Care receiving Q Q
Bone density PE
(informal care)
Aortic calcication PE
Caregiving Q Q
Lung function PE
Retirement status Q Q
Electrocardiogram PE
Preretirement labor Q Q
(ECG)
force participation
Carotid intima- PE
Labor force Q Q
media thickness
Retirement planning Q Q
Vision PE and Q Q
Social inequality Q Q
Hearing PE and Q Q
Wealth Q Q
Weight and height PE Q
Transportation, Q Q
Functional status PE Q
mobility, migration
Functional PE
Built environment Q Q
performance (grip
Lifestyle and behavior
(continued)
(continued)
Canadian Longitudinal Study on Aging, A Platform psychometric properties (e.g., sensitivity and spec-
for Psychogeriatric Research, Table 1 (continued) icity), and feasibility in terms of the time to
Cohort (n = 50,000) administer, the cost, and the need for unique
Comprehensive Telephone resources or equipment. Table 1 presents a sum-
face to face interview mary of the measures included at baseline and at
Measures (n = 30,000) (n = 20,000)
the rst follow-up. Furthermore, based on algo-
Physical activity Q Q
rithms based on information from disease symptom
Nutritional risk Q
Nutritional intake Q
questions and medication use, the CLSA is able to
Tobacco use Q Q ascertain whether participants have a number of
Alcohol use Q Q chronic diseases including cardiovascular diseases;
Q: assessed via questionnaire (either telephone or face-to-
diabetes; hypertension; cerebrovascular disease;
face administration) arthritis of the knee, hip, and hands; osteoporosis;
T: measured using a performance test involving an inter- respiratory diseases such as COPD; hyper- and
active computer touch screen hypothyroidism; dementia including Alzheimers
PE: measured by physical examination at the data collec-
tion site
disease and Parkinsons disease; and depression.
In CLSA, several instruments measuring various
domains of psychological aspects of aging were
face-to-face assessment, the core information is used at baseline. These domains include cognition
supplemented by additional interview question- (memory, executive function, and psychomotor
naires about diet, medication use, chronic disease speed), mood, psychopathology, post-traumatic
symptoms, and sleep disorders. Measures col- stress disorder (PTSD), depression, and personality
lected at the data collection site include tests of traits (openness, conscientiousness, extraversion,
physical function (e.g., grip strength and 4-m agreeableness, and neuroticism).
walk test), anthropometrics (e.g., height and
weight), and clinical status (e.g., vision and hear- Cognition
ing) as well as cognitive function. Each partici- Cognition may be dened in terms of domains
pant also provides a blood and urine sample and (e.g., memory, executive functions, speed of
signed consent to link their data to provincial processing), each of which can be further charac-
health-care databases. In collaboration with terized into component processes. Age-related
Health Canada, air pollution exposures have changes are observed in many of these domains
been estimated for each participant in the CLSA. and processes; for example, robust age-related
For the baseline, core chemistry biomarkers are changes are observed in processing speed, whereas
available on all 30,000 participants, gene-wide other domains, such as semantic memory
genotyping on 10,000 participants, and targeted (knowledge about facts and concepts in the
epigenetics on 5,000 participants. The data collec- world), remain relatively intact with aging. There
tion has been further expanded for the rst follow- can be great intraindividual variability within a
up of the CLSA to include measures of child testing session or across testing sessions, and
maltreatment, elder abuse, hearing handicap there is reason to believe that marked variability
inventory, oral health, subjective memory, meta- may be predictive of early cognitive impairment.
memory, gender identity, health-care access, and Participants in the CLSA Comprehensive
unmet needs as it relates to health-care delivery. cohort are assessed in three domains of cognitive
function: memory, executive function, and psy-
Psychological Measures Within the CLSA chomotor speed. The cognitive battery takes
Expert working groups selected psychological, approximately 27 min to administer. CLSA
physical, biological, social, and lifestyle measures telephone-based participants are assessed in two
for inclusion in the CLSA. Measures were selected domains of cognitive function, memory and exec-
based on their relevance to adult development and utive function, by telephone only (approximately
aging, availability in English and French, 8 min to administer).
Memory (interference condition), the participant is asked

to quickly name the color of the ink in which
Rey Auditory Verbal Learning Test (RAVLT) (Trial color words are written in (e.g., say blue for the
1 and Delay Trial). The RAVLT (Rey 1964) is a word green written in blue ink). There are
15-item word learning test that assesses both 100 items in a trial for this version. Scoring may
learning and retention. The list of words is read be by time, error, both, or the number of items read
at the rate of one per second, and the participants or named within a specied time limit. C
responses are recorded. One learning trial and one Controlled Oral Word Association Test
delayed recall trial (with a delay of 30 min) are (COWAT). The COWAT (Spreen and Benton
used. The RAVLT has been shown to be 1977) is a measure of verbal uency based on an
extremely sensitive in detecting early cognitive orthographic criterion. It requires the time-limited
decline. generation of words that begin with a given letter
(e.g., participants are asked to name as many
words as possible that begin with the letter F).
Executive Function Following standard protocols, CLSA administers
three 1-min trials with the letters F, A, and S. The
Mental Alternation Test (MAT). The MAT score is the total number of admissible words
(Himmelfarb and Murrell 1983) comprises two produced.
parts, A and B. Part A requires participants to Animal Fluency Test. The animal uency test
count aloud from 1 to 20 and to say the alphabet (Himmelfarb and Murrell 1983) is a measure of
as quickly as possible; the purpose is to ensure that verbal uency based on a semantic criterion. Par-
participants can perform Part B. If a participant is ticipants are required to name as many animals as
unable to perform these tasks, then the MAT cannot possible in 60 s.
be administered. In Part B, the participant is asked
to alternate between number and letter (i.e., 1-A, 2-
B, 3-C . . .) as quickly as possible for 30 s. The Psychomotor Speed
number of correct alternations in 30 s, discounting
any errors, determines the score, which ranges Computer-administered simple and choice reac-
from 0 to 51. The MAT is highly sensitive and tion time tests (West et al. 2002) were used to
specic for detecting cognitive impairment. assess psychomotor speed.
Prospective Memory Test (PMT). The PMT Choice Reaction Time (CRT) (Computer-
(Lowenstein and Acevedo 2001) contains both Administered Test). In this test, participants
event-based and time-based prospective memory receive a warning stimulus consisting of a hori-
tasks that are cued after either 15- or 30-min delays. zontal row of four plus signs on a computer
The scoring system is based on three criteria: inten- screen. After a delay of 1,000 ms, one of the
tion to perform, accuracy of response, and need for plus signs changes into a box. The location of
reminders. There is increasing evidence that both the box is randomized across trials. Participants
time-based and event-based prospective memory are instructed to touch the interactive computer
decline with age and the PMT is sensitive to cog- touch screen at the location of the box as quickly
nitive impairment. as possible. Although the instructions emphasize
Stroop Neuropsychological Screening Test speed, participants are also instructed to minimize
(Victoria). The Stroop test (Golden 1978) is a mea- errors. The measures used are the latencies and
sure of inhibition, attention, mental speed, and percent correct for the 52 test trials (there are
mental control. The Golden version (Golden 10 practice trials).
1978) of the Stroop test has three parts. First, the Choice Reaction Time 1-Back (CRT-1)
participant reads a list of words printed in black. In (Computer-Administered Test). This task uses the
the second part, the participant is asked to name the same stimulus display and computer touch screen
ink color of printed Xs. In the third part as the CRT. However, in this version of the task,
when the plus sign changes into a box, partici- which comprises ve questions and takes about
pants are instructed to touch the screen at the 90 s to administer. The SWLS is one of the most
location where the box appeared on the previous widely used scales to measure the life satisfaction
trial as quickly as possible. A total of 10 practice component of subjective well-being.
trials and 52 test trials are administered.
Post-traumatic Stress Disorder (PTSD)
Mood and Psychopathology The lifetime prevalence of PTSD in Canada has been
Current research indicates complex associations estimated at 9.2%. The CLSA includes the four-item
between positive and negative mood states, psy- primary care PTSD (PC-PTSD) screening instru-
chopathology, and physical and mental well- ment (Pins et al. 2003), which takes about 30 s to
being (ORourke 2002; Watson and Pennebaker administer. The CLSA has included this short tool as
1989). Negative emotional states in themselves part of the CLSAVeterans Health Initiative, in which
may increase susceptibility to an array of health all CLSA participants are asked a set of veteran
conditions and are associated with poorer progno- identier questions.
ses. For example, negative emotions appear to
inuence immune function and regulation Psychopathology
(which become less efcient in later life), thus Nonspecic psychological distress is measured using
increasing the risk of a myriad of health condi- the Kessler Psychological Distress Scale (K10)
tions (Kiecolt-Glaser et al. 2002). (Kessler et al. 2002), which was developed using
Social science research has been criticized for the item response theory to maximize discriminant
equating well-being with the absence of psycho- ability at the severe range of psychological distress.
pathology (Stroller and Pugliesi 1989; Stull The K10 is becoming one of the most widely used
et al. 1994). In other words, persons deemed to screens for psychological distress in epidemiological
be free of psychiatric distress were assumed to be surveys. It takes approximately 2 min to administer
well, happy, or satised with life. Implicit in such and is included only in the Comprehensive
studies was the assumption that emotional expe- Maintaining Contact questionnaire.
rience existed along a single continuum. How-
ever, more recent research indicates that Personality Traits
psychological well-being and psychopathology Personality traits are enduring patterns of per-
(and their correlates) are separable phenomena ceiving, relating to, and thinking about oneself
(Ryff et al. 1998). Therefore, to assume the exis- and the environment that are exhibited in a wide
tence of one on the basis of the absence of the range of social and personal contexts (American
other is empirically unsupported; both need to be Psychiatric Association 1994). The Big Five per-
assessed in order to arrive at a balanced under- sonality traits are ve broad domains of personal-
standing of emotional wellness. ity (openness, conscientiousness, extraversion,
agreeableness, and neuroticism) that have been
Negative Mood State extensively studied and are related to self-rated
Depressive symptoms are measured in the CLSA health. The CLSA measures personality traits
Tracking and Comprehensive cohorts using the using the Ten-Item Personality Inventory (TIPI)
short form of the Center for Epidemiologic Stud- (Gosling et al. 2003), which takes approximately
ies Depression (CES-D10) Scale (Andresen 1 min to administer and is included only in the
et al. 1994), which takes approximately 3 min to Comprehensive Questionnaire.
administer and has been used extensively in large All the measures described above and in Table 1
studies. will be repeated in each follow-up wave of the
CLSA, providing a rich source of information on
Positive Mood State (Life Satisfaction) changing risk factors as well the changing nature of
Life satisfaction is measured using the Satisfac- disease, function, and psychosocial outcomes.
tion with Life Scale (SWLS) (Diener et al. 1985), However, the CLSA also provides the opportunity
to add new measures in each of the follow-up ample evidence that psychological characteristics
waves to investigate new and emerging areas of such as attitudes are related to recovery from
research. As noted previously, a new psychological illness (Institute of Medicine Committee on
measure of subjective cognitive decline has been Assessing Interactions Among Social BaGFiH
added to the follow-up assessment. Complaints et al. 2006). Similarly, environmental context
about memory are extremely common in middle- can inuence response to treatment and health
aged and older people. While these complaints can outcomes (Institute of Medicine Committee on C
occur in the setting of cognitive disorders such as Assessing Interactions Among Social BaGFiH
mild cognitive impairment or a dementia, they are et al. 2006). CLSA will provide a unique oppor-
also common in individuals without an overt cogni- tunity to address research questions where cogni-
tivedisorder. TheCLSA is an ideal vehicle to explore tive performance functions as a mediator between
the natural history, risk factors, and conditions asso- biological and functional status, such as: How do
ciated with subjective cognitive decline. The Multi- cognitive functions mediate relations between
factorial Memory Questionnaire (Troyer and Rich biological/health status and adaptive functioning
2002) will be used to assess self-reported cognitive and/or social participation (e.g., what are the
ability in everyday life. This reliable and valid mea- underlying mechanisms involved)?
sure examines subjective cognitive complaints to As might be expected, there are numerous fac-
capture preclinical signs of cognitive impairment tors that inuence health outcomes at different
and has been validated in both English and French. points in the life span. Cognition and disorders
Two additional questions have been included to cap- of cognition can be viewed as psychological out-
ture perceived change in memory and whether this comes that may be related to a number of different
perceived memory change worries participants. precursors and mediators. These changes in cog-
nitive functioning occur in relation to aging and,
Psychological Factors as Precursors, Mediators, as noted, may be inuenced by many other factors
and Outcomes including biological, psychological, and social
The CLSA provides a unique opportunity to inves- factors. Thus, CLSA data may be used to address
tigate the multitude of internal and external factors research questions such as: Are changes over time
that inuence the trajectory of psychological func- in cognition (memory, executive function, and
tioning from mid- to late life. These factors may psychomotor speed) associated with specic bio-
act as precursors related to increased risk of ill- logical states and/or lifestyles?
ness. It is known that psychological variables such
as depressive symptomatology can inuence the
onset and progression of illness. Research in the CLSA as a Data Platform for Research
area of stress and psychoneuroimmunology speaks
to these interrelations. CLSA provides the oppor- Data and Sample Access
tunity to examine stress-disease relationships in a A fundamental principle of the CLSA is to provide
large representative sample of Canadians. Simi- the research community with the collected data
larly, CLSA data can be used to investigate ques- while protecting the privacy and condentiality of
tions where cognitive changes function as study participants. The Data and Sample Access
precursors to disease states. For example, is Committee (DSAC) reviews all applications for the
decline in cognitive functioning in mid- and later use of CLSA data and is responsible for monitoring
life associated with subsequent adverse health- the approved applications for progress. Exclusive
related (or biological) outcomes (e.g., diagnosis access to the platform cannot be granted to any
of dementia, diagnosis of vascular disease, sleep applicant. Users are entitled to use the CLSA plat-
fragmentation, or sleep disturbance)? form (i.e., data and/or biospecimens) only for the
Psychological, social or environmental, and duration and purposes of the approved research as
biological factors may also serve as mediators presented in the application. The user is not entitled
between illness and health outcomes. There is to publish or otherwise disseminate any CLSA
Canadian Longitudinal Study on Aging, A Platform for Psychogeriatric Research, Table 2 Authorship: CLSA
Psychology Working Group
Last name First name Title Degree Afliation
Tuokko Holly Ph.D. University of Victoria
Carrier Julie Professeure Universit de Montral
titulaire
Davidson Patrick Associate Ph.D. University of Ottawa
Professor
Doiron Maxime Ph.D. research
candidate
Dupuis Kate Postdoc fellow Ph.D., C.Pysch. Baycrest and University of Toronto
Gagliese Lucia Associate Ph.D. York University
professor
Hadjistavropoulos Thomas R.Psych., Ph.D. University of Regina
Hofer Scott Director University of Victoria
Ingles Janet Associate Ph.D. School of Human Communication
professor Disorders
Jutai Jeffrey Professor M.Sc., Ph.D. Interdisciplinary School of Health
Sciences
Loken Thornton Wendy Associate R.Psych, Ph.D. Simon Fraser University
professor
Lorrain Dominique Professeure Ph.D. Universit de Sherbrooke
titulaire
MacDonald Stuart Assistant Ph.D. University of Victoria
professor
OConnell Megan Assistant R.Psych., Ph.D. University of Saskatchewan
professor
Pichora-Fuller Kathy Professor University of Toronto Mississauga
Ritchie Lesley Assistant University of Manitoba
professor
Simard Martine Professor Ph.D. Universit Laval
Smart Colette University of Victoria
Taler Vanessa Associate Ph.D. University of Ottawa
Professor
Tierney Mary Ph.D. Sunnybrook Hospital
data, any assay data, or any derived variable data at Life and Living in Advanced Age, A Cohort
the individual participant level. Study in New Zealand, Te Puawaitanga o Ng
Tapuwae Kia Ora Tonu (LiLACS NZ)
Life Span Developmental Psychopathology
PTSD and Trauma
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440 Career Development and Aging
Definitions career developmental stages are determined

according to ones age, and life periods of stability
Career development is dened as the develop- are usually followed by life periods of change
mental process of an employee along a path of (Levinson 1986). Levinson describes early (age
experience and employment in one or more orga- 2040), middle (age 4060), and late adulthood
nizations (Baruch and Rosenstein 1992) or a life- (age 60 and over). These life stages have prescrip-
long process of managing work experiences tive developmental tasks: in early adulthood one
within or between organizations (Business Dic- needs to create and test initial choices about pref-
tionary 2015). Late career development is thus the erences for adult living, develop a sense of per-
career development of older workers. Some sonal identity in the world of work and nonwork,
authors dene the late career stage as early as and strive toward achievement of personal and
from age 40, but usually it is dened as the career professional goals. In middle adulthood one
of employees aged from 50 years old up to retire- needs to review the life structure earlier adopted
ment (Hedge and Borman 2012). and make strong commitments to work, family,
and community. In late adulthood one needs to
recognize mortality and limits on achievements
Traditional Views on Late Career and answer the questions raised by these issues
Development (Levinson 1986). Crons career stage theory (Cron
1984) is the third inuential theory that describes
Career development over the life-span is usually adult development in the work context. Cron
described by career stage theories. These career describes career concerns, developmental tasks,
development theories describe career develop- personal challenges, and psychosocial needs of
ment over the life-span as a continuous sequence each career stage. The four career stages comprise
of stages through which the individual gradually (1) exploration (nding an appropriate occupa-
passes. The most inuential of these theories are tional eld), (2) establishment (successfully
the theories of Super (Super 1990), Levinson establishing a career in a certain occupation),
(1986), and Cron (1984). Supers life-span (3) maintenance (holding on to what has been
model contains ve large career stages: growth, achieved, reassessing the career and possible redi-
exploration, establishment, maintenance, and rection), and (4) disengagement (completing
decline (Super 1990). These stages pose distinct ones career) (Cron 1984). Whereas in the earlier
career developmental tasks which people need to stages of ones career, achievement, autonomy,
fulll in order to successfully master the next and competition are important, in the later career
career stage. In the growth stage, ones self- stages, reduced competitiveness, higher need for
concept needs to be developed and work-related security, generational motives (helping younger
attitudes and needs should be identied. In the colleagues), and, nally, detachment from the
exploration stage, the relevant tasks are to identify organization and the organizational life are
interests and capabilities, nd a professional self- central topics.
image, and establish an optimal t between the These three stage models prescribe that older
self and work. In the establishment phase, career workers have to detach from work and gradually
commitment needs to be increased, career establish a self-identity independent of their
advancement and growth achieved, and a stable career. The described developmental tasks reect
work and personal life created. In the maintenance traditional career paths pursued in a small number
phase, ones self-concept needs to be maintained of organizations, when after a linear and rather
and people have to hold onto accomplishments conformal working life, older workers are
achieved previously. Finally, in the decline phase, assumed to prepare for retirement.
workers need to develop a new self-image that is However, a few decades have passed since the
independent of career success (Super 1990). In introduction of the delineated career theories, and
Levinsons life stage developmental model, the the working environment underwent some
substantial changes in that time. Today, many Protean Career Orientation: The
countries and organizations are faced with Necessity of Self-Directed Career
an aging workforce and often longer-lasting Management
careers (Schweitzer et al. 2014). In most devel-
oped countries, the number of late career As reviewed above, the traditional career theories
employees is expected to grow substantially in introduced in the rst section described the late
the next decades due to declining birth rates and career as a phase of general disengagement, C
longer life expectancies (Van Der Heijden decline, and nally withdrawal from work.
et al. 2008) meaning that companies are in need These theories need to be complemented by
of healthy, productive, and motivated older newer understandings of late careers, especially
workers to remain in the workforce longer in considering the contextual changes in the work
order to satisfy the demand for well-educated environment described in the previous section.
and experienced staff. The protean career describes such a modern
type of career that corresponds to the demands
that the before-mentioned changes in todays
Changing Career Contexts work environment pose on employees (Inkson
2006). The protean career orientation highlights
Whereas the traditional career theories assumed the importance of individual and value-driven
an intra-rm focus, environmental stability, agency of the worker when developing ones
and hierarchically advancing careers which career according to subjective success criteria
progressed in a linear manner, todays work envi- (Direnzo and Greenhaus 2011). With careers
ronment is characterized by increasing competi- being less predictable and structured by the orga-
tiveness and complexity, fewer opportunities for nization, employees need to increasingly custom-
vertical mobility, higher levels of voluntary as ize and self-manage their careers in order to
well as involuntary inter-organizational mobility, balance out the risks of a growingly insecure
and heightened probabilities of job loss at every work environment. Especially for late career
career level and stage (Greenhaus and Kossek employees who might have had a rather tradi-
2014; Sullivan 1999). Due to global competition, tional career path and did not get accustomed to
organizations increasingly need to be lean and changes in the labor market, the risk of getting
exible in order to compete internationally and unintentionally laid off might be highly stressful
increasingly opt for short-term transactional and increases the importance to remain employ-
exchanges with their employees instead of able as an older worker. Because the protean
traditional long-term employment relationships career is primarily values driven and self-directed,
(Direnzo and Greenhaus 2011). This change is holding a protean career orientation is an adaptive
also reected in new psychological career con- response to performance and learning demands in
tracts (Hall and Mirvis 1995) which refer to the the current work environment (Sullivan and
mutual expectations between employees and Baruch 2009).
employers regarding their career and work. Tradi- Greenhaus et al. (2009) emphasize the impor-
tional psychological contracts previously focused tance of a protean, self-directed career orientation
on loyalty between the employee and the organi- especially in the maintenance phase: late career
zation and an expectation of job security in employees need to remain productive and satisfy
exchange for loyal service of the employee. The their needs for security and to feel useful as well as
new career contract describes the shift from potential motivations for passing on their knowl-
the formerly organizationally driven career to the edge to younger colleagues through activities
employee-driven career and focuses on rather such as mentoring. In the late career, sustainability
short-term transactions of work effort in exchange and meaningful work that is aligned with ones
for career development opportunities (Hall and values becomes of higher subjective importance.
Mirvis 1995). To this end, Newman (2011) describes a model of
sustainable careers with three central propositions to Hall and Mirvis (1995), the most important of
that can be of great value for older workers espe- these meta-skills are identity awareness and
cially: (1) being renewable (renewing assign- heightened adaptability. Identity awareness is
ments, refocusing, re-education) in order to considered to be a fundamental resource for career
prevent burnout and create resilience and engage- development (Rosso et al. 2010). Because the
ment in employees; (2) being exible (continuous work domain has a large importance in peoples
learning, adaptability) in order to prevent stagna- life, individuals identify with key characteristics
tion, facilitate innovation, and create an optimal of their work. Particularly older workers look for
alignment between employer and employee meaning in their life and in their work. This mean-
needs; and (3) being integrative (bringing dispa- ing can only be found if individuals nd their own
rate information together, knowledge manage- answers to their identity questions: Who am I?
ment) in order to highlight the bigger picture, Who do I want to become? What is important to
apply knowledge in new ways, create a meaning- me in the work role? The traditional career paths
ful contribution at work, and retain critical knowl- provided a sense of stability and predictability for
edge. Sustainable careers provide benets for both employees that facilitated addressing such iden-
organizations and employees: older employees tity issues. However, in the current work context,
can stay fully engaged and have the capacity to employees need to create stability within them-
impart knowledge and use specialized knowledge selves (i.e., develop a clear professional identity
in new ways. Late career employees are also well that gives meaning to their work experiences) in
suited to integrate knowledge across units and order to successfully manage their careers in a
functions as well as to mentor younger colleagues self-directed manner. For older workers, who are
and can thus improve intergenerational relation- more likely to be values driven (Briscoe
ships as well as facilitate the development of et al. 2006), less likely to be motivated by extrin-
younger generations. From the employers sic rewards, and more motivated to act autono-
point of view, sustainable careers enable more mously (Ryff 1995), a clear self-concept may
productive, motivated, and healthier employees already be present. However, this self-concept
as well as lower employment costs through needs to be constantly reexamined and
reduced turnover and better knowledge retention reconstructed as work demands and typical career
(Newman 2011). development tasks change in late career.
Despite the necessity and benets of enabling
older workers to remain active and valuable at
work, research demonstrated that late career Career Adaptability
employees receive less support from supervisors
to participate in career development activities and Apart from identity, career adaptability represents
have generally less access to organizational career the second meta-competency for a self-directed
support programs (Van Der Heijden 2006). career (Hall and Mirvis 1995). The reviewed
Because older workers have often spent a sig- career development stage theories imply a sequen-
nicant part of their careers developing tial and predictable order where experiences,
organization-based identities and job-specic skills, and competencies acquired in the stage
skills, it is of particular importance for this popu- before are sufcient preparation to enter the next
lation to acquire the skills needed for the protean, stage. Thus inherent to stage models of career
employee-driven career. Of highest importance is development is the notion of readiness to move
the acquisition of so-called meta-skills (Hall and to the next stage. In Supers work, for example,
Mirvis 1995). Meta-skills help to acquire new individuals who are ready to make educational
skills and encompass the knowledge of learning and vocational choices are thought to possess
how to learn, developed through many career career maturity (Savickas 1997). Career maturity
learning cycles or continuous learning instead was thought to be particularly relevant for adoles-
of a single lifelong career stage cycle. According cents, but the concept of adaptation seemed more
appropriate for adults (Super and Knasel 1981). can anticipate that changes may be required, can
This focus on adaptation highlights the continual explore solutions and options to best implement
need to respond to new circumstances and novel these changes, and can condently enact the nec-
situations, rather than to master a predictable and essary changes. This allows older workers to
linear continuum of developmental tasks address the career development tasks of being
(Savickas 1997, p. 254). Thus adaptation or adapt- exible and open to professional reorientation.
ability are concepts well suited to the new career Although physical mobility is likely to decrease C
context where the capacity to adjust rapidly and with age, psychological mobility remains
display exibility are prerequisites for career unchanged with age (Segers et al. 2008)
development. Adaptability specic to the career suggesting that opportunities for mobility still
context, known as career adaptability, is a psycho- exist for older workers. Older workers adaptabil-
social coping resource, a set of self-regulation ity may help them envision more exible work
capacities or skills, important for problem solving, options that combine paid work with nonwork
career transitions, responding to unexpected activities reecting personal interests, made pos-
events, constructing a career reality, and partici- sible by the increased blurring of the boundaries
pating in the work role (Savickas et al. 2009; between work and nonwork domains of life (Hall
Savickas and Porfeli 2012). and Mirvis 1995).
Because adaptability is a meta-competency Empirically, the specic subject of career
(Hall and Mirvis 1995), adaptability permits indi- adaptability in older workers has not yet received
viduals to develop the skills and competencies focused attention. However, a select number of
associated with a protean career orientation. qualitative studies with either mid-career
Career adaptability may thus be a specially bene- employees (Ebberwein et al. 2004) or women
cial resource for older workers by enabling aged above 50 (McMahon et al. 2012; Whiston
career orientations more suited to the new career et al. 2015) highlighted career adaptability as a
context such as a protean orientation (Chan theme associated to positive experiences at work
et al. 2015) and by helping them successfully and transitions. In a quantitative study among a
address specic career development tasks. sample of workers older than 54, Zacher and
Because the challenges of reorienting and Grifn (2015) found that adaptability positively
updating ones knowledge, skills, and abilities predicted job satisfaction over time (more
may be particularly evident for older workers, strongly for those with still a few years left before
their career adaptability may be an especially use- retirement), suggesting that enhancing career
ful resource in this regard. The psychosocial adaptability may contribute to the retention of
aspect of career adaptability is paramount and older workers.
suggests a responsiveness to the context or envi-
ronment where adaptability resources can be
activated as needed, such as in response to unem- Conclusions and Implications
ployment or during career transitions (Ebberwein
et al. 2004; McMahon et al. 2012). An aging population and workforce provide the
Career adaptability consists of four dimen- opportunity for many people to look forward to a
sions: (1) concern about the future that includes longer, healthier, and more satisfying life and late
the anticipation of demands and challenges; career. Nevertheless the aging of the workforce
(2) control entails a personal responsibility for also entails some challenges for late career
actively managing the self and the environment; employees as well as for organizations that need
(3) curiosity implies a broadening of options and to be addressed. In the current chapter, we
self and environment exploration; and nally outlined traditional career development theories
(4) the condence to implement ones plans and their developmental tasks and put them in
(Savickas and Porfeli 2012). Thus, using the relation to new career concepts and changes in
meta-competency of adaptability, older workers the work environment. Special emphasis was put
on the protean career orientation and career adapt- (Wang et al. 2012) and enable a successful and
ability that represent very important career sustainable late career phase. The meta-
resources (Hirschi 2012) also for older workers. competencies of adaptability and identity can
However, there is a need for more research to help older workers establish the skills and compe-
address how a protean career orientation and tencies associated with the protean career orienta-
career adaptability are affected by age, how tion and consequently extend a productive and
older workers understand career adaptability, satisfying career maintenance phase. When it
what career development tasks in the late career comes time to fully or partially disengage from
(such as changing jobs) mean for older workers, the work role, identity and adaptability meta-
and how a protean career orientation and career competencies will also support this transition.
adaptability can help older workers cope with
these challenges. Future research should also
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2015). Training at Work and Aging
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446 Caregiving and Carer Stress
Definition number of persons with chronic diseases requiring

ongoing support and supervision has also
Caregiving has been broadly dened as the act of increased. Families provide the largest amount of
providing unpaid or informal support and assis- informal long-term care and assistance. In the
tance to an older person with physical, mental United States and most European countries, this
impairment, or both. This assistance might family involvement in caregiving is due in part to
include personal care, emotional support, house- the major emphasis of public policy aimed at
hold activities, nancial management, shopping promoting community care and delay institution-
and transportation, and supervising/monitoring alization of dependent older persons. Thus, fami-
care. Informal caregivers are mainly family mem- lies have been considered the heart of these care
bers. Usually, spouses offer more assistance than systems.
adult children, and adult children tend to provide A growing body of evidence has suggested the
more care than other groups of informal care- negative effects of caregiving on the caregivers
givers, such as family friends or neighbors. Care- physical and psychological health, social life, lei-
giving can last for a short period of time or, more sure, and nances. Chronic conditions in the per-
commonly, extend over years. The act of caregiv- son receiving care entail high caregiving demands
ing is now seen as a normative life event, at least and long-term dependency lead to more strains for
for spouses and adult children in most Western family caregivers. Contemporary societal changes
countries. have also intensied the strains on families
Caregiving had been described mainly as a resources to provide care (Sales 2003; Zarit
burden or stressful experience. However, there is et al. 2007). First, older people are living longer
a lack of consensus and rigor in dening burden. after the onset of disabilities, which demands
This has led to development of more sophisticated more extensive care. Usually, the caregiving role
conceptual models about what happens when is assumed by an older spouse, who has frequently
stress demands exceed coping abilities, also called to cope with his/her own age-related limitations,
transactional approaches to stress. The stress pro- or by adult children (often, a daughter) who have
cess model is one of such models and considers to deal simultaneously with several roles of
caregiver stress as a process of multiple interre- worker, spouse, and parent of young children.
lated conditions, involving the proliferation of Second, smaller family sizes and greater geo-
stress from direct care-related dimensions to graphical distance may intensify the constraints
other caregivers life domains. of families to provide care. Third, changes in
health-care policy, such as delaying institutional
placement, have increased systems reliance on
Introduction family caregivers.
Family caregiving has been conceptualized as
Forty years have passed since Fandetti and a complex and multidimensional experience, pri-
Galfand (1976) published one of the rst articles marily explained in terms of stress. The impact of
about family caregiving in a prestigious scientic the caregiving process on the caregiver has been
American journal dedicated to gerontology The described in terms of the caregiver burden, a
Gerontologist. The authors studied a sample of concept that encompasses multiple and inconsis-
Italian and Polish residents to determine their tent denitions. The following is an attempt to
attitudes toward caring for aged relatives. Since clarify the meanings and use of these two
then, there has been a massive expansion of terms burden and stress which are often used
research on caregiving, which is still one of the interchangeably to describe the impacts of care-
most researched topics in gerontology. giving on the caregiver. The stress and burden
As would be expected, along with the rapidly approaches to understand the caregiving experi-
growing population of older adults worldwide, the ence have informed, over the last two decades, the
development of interventions targeted to attenuate work on dementia caregiving, they have dened
the negative outcomes of this event. burden as the caregivers feelings about their emo-
tional, physical health, social life, and nancial
status as a result of caring for their family mem-
Caregiver Burden bers. Zarit et al. (1980) viewed caregiver burden
as a subjective process and not necessarily as a
The concept of caregiver burden has become one negative consequence of caregiving. The authors C
of the core concepts of interest in the eld of developed one of the most widely used measures
gerontology. Caregiver burden is typically dened of caregiving burden: the Zarit Burden Interview.
as the physical, emotional, psychological, and This self-reported inventory covered several
nancial difculties experienced by family or dimensions of burden, including caregivers
informal caregivers as a consequence of older health and psychological well-being, social life,
persons disease and impairment. Researchers nances, and the relationship between the care-
more or less agree on the need to distinguish the giver and the cared-for person.
objective and subjective dimensions of burden. Subsequent to the work of Zarit et al. (1980),
However, much less agreement is found about several attempts to rene the conceptualization of
the conceptual denition of burden, which is caregiving burden had been made. For instance,
often studied both as an outcome and a predictor Poulshock and Deimling (1984) considered bur-
of other caregiving outcomes. The lack of regular den as the caregivers appraisal of the tiring,
conceptualization and operational denition has difcult, or upsetting nature of caregiving tasks
led to inconsistency in burden measures and (p. 233). George and Gwyther (1986) dened
results across interventional studies. A clear caregiver burden as the physical, psychological
understanding of burden has been further hin- or emotional, social, and nancial problems that
dered by the tendency for researchers to use the can be experienced by family members caring for
term interchangeably with stress, impacts, conse- impaired older adults (p. 253).
quences, or strain. Later, studies have tried to clarify the differ-
The concept of burden was rst introduced by ences between objective and subjective caregiver
Grad and Sainsbury in regard to the community burden. Objective burden refers to the events and
care for people with psychiatric disorders (Grad changes in caregivers various life domains which
and Sainsbury 1996). The authors sought to assess result from the caregiving role. These include the
how these patients affected their family life in direct tasks of care (e.g., helping patients with the
terms of income, employment, social and leisure activities of daily living, supervising care), indi-
activities, domestic routines, health of the family rect tasks of care (e.g., domestic tasks or nancial
members, and relations with neighbors. Not long management previously performed by the
after the work of Grad and Sainsbury, Hoenig and patient), providing emotional support to the
Hamilton (1966) suggested the need to distinguish cared-for person, and the effects on other life
between objective and subjective burden. The roles (e.g., family routines, leisure, social rela-
term objective burden was related to the adverse tions, nances, job career) (Sales 2003). The sub-
effects on the family, such as income loss, poorer jective burden is related to the caregivers
health, or general changes in household routines. reactions or emotional responses to care demands.
Subjective burden was dened as what families Some argue that objective and subjective burden
felt and to what extent they considered the can be analyzed separately (Montgomery
patients illness had been a burden to them et al. 1985). Others consider that most measures
(p. 287). of objective burden rely on caregivers self-report/
During the1970s and 1980s, Zarit and col- subjective perceptions of the extent of their care-
leagues (1980) made great strides in establishing giving tasks, which is far from being objective
and clarifying the concept of burden. Within their (Sales 2003). Furthermore, while some consider
the consequences of caregiving on various life model and other the stress process theories is
domains as objective (Montgomery et al. 1985), explained in the following section.
others regard it as subjective (Braithwaite 1992).
The critical need to document caregiving bur-
den has been shown by the variety of instruments Caregiver Stress in the Context
developed to measure it. Some authors argue that of Transactional Models
burden is a unique domain of the caregiving expe-
rience that is not captured by more generic mea- Perhaps the rst theoretical conceptualization of
sures of well-being (Stull et al. 1994). There are the term stress was introduced by Hans Selye
currently about 30 instruments described in scien- (1956). He dened stress as a response to an
tic literature to assess the caregiver burden (Van antecedent stimulus or event. The underlying
Durme et al. 2012). Most of these measures are assumption is that stress is linearly determined
multidimensional, assess both objective and by the nature of the event itself.
subjective burden, and are administrated to the However, the experience of caring for an older
primary caregiver. However, as burden is concep- family member has been conceptualized within
tualized differently by various authors, the tools the context of transactional models of stress.
used to measure it differ as well, leading to nd- Among those models, Lazarus and Folkmans
ings that are difcult to integrate across studies model of stress and coping (Lazarus and Folkman
and limiting the ability to inform clinical and 1984) and Pearlin and colleagues stress process
policy settings (Bastawrous 2013). model (Pearlin et al. 1990) have anchored family
Nevertheless, decades of research on chronic caregiving research on a stronger conceptual
conditions such as dementia, cancer, or stroke foundation. Lazarus and Folkman (1984) have
have suggested that caregivers burden increases dened stress as a relationship between the per-
the risk of negative physical, psychological, and son and the environment that is appraised by the
physiological outcomes. However, a number of person as taxing or exceeding his or her resources
comparative studies propose that different chronic and endangering his or her well-being (p. 17).
conditions present different caregiving demands; This denition emphasizes the relationship
hence, research needs to distinguish each dis- between the person and the context, considering
eases specicities from the common aspects of the characteristics of both. From this perspective,
caregiving. For instance, chronic diseases stress is viewed as a process rather than simply a
characterized by cognitive impairments (e.g., reaction to an environmental stimulus. The
Alzheimers disease) have been found to be authors acknowledge the role of individuals cog-
more burdensome (Papastavrou et al. 2012). In nitive appraisals which are more important than
addition, disorders with an unpredictable course the actual stressors. So, an event only becomes a
(e.g., cancer) present more physical burden and stressor if the person interprets it as such. Within
psychological distress for caregivers than those their transactional model of stress, Lazarus and
with an expected trajectory (e.g., diabetes) (Kim Folkman (1984) described three steps: primary
and Schulz 2008). appraisal, whereby a potential stress can be per-
While many earlier scientic studies on care- ceived as irrelevant, benign-positive, or stressful
giver burden were not based in theory, more (harm/loss, threat or challenge); secondary
recent work has been developed in an attempt to appraisal, as the person identify coping strate-
anchor caregiver burden in a broader theoretical gies/resources and their effectiveness to deal
framework and to outline some of its basic dimen- with the potential stressor; and reappraisal,
sions, as well as the links among those dimen- which refers to a changed appraisal considering
sions. The stress process model, developed by the new information from the environment, from
Pearlin and his colleagues (1990), is one of those the persons own reactions, or both. This three-
frameworks, where burden can be treated as a step stress and coping process involves asking: Is
primary stressor. How burden ts within this this event something that I need to respond? Does
it pose a threat, harm or challenge? If the answer captivity). The secondary stressors consist of
is no, then no action is necessary. But if the those difculties that derive from the caregiving
answer is yes, then a secondary appraisal arises. (but do not directly entail the provision of care)
By this time the question that occurs is: Which and proliferate into other dimensions of the care-
strategies or resources do I have to cope with the givers life. These include role strains that are
event? The person then selects the mechanism found in activities and roles outside the caregiving
(coping) to deal with the stressor. Next, a situation (e.g., family conict, nancial strain, C
reappraisal is made to see if the response has work conict) and intrapsychic strains which,
worked, thereby either reducing the perceived for the most part, involve dimensions of self-
threat or leading to a new approach to coping concept (e.g., doubts about ones competence or
strategies if the perceived threat is not sufciently mastery). The moderators regulate not only the
reduced (Nolan et al. 1996). focal stressor-outcome relationships but also the
The caregiving literature has moved increas- processes whereby stressors generate more
ingly toward transactional models of stress. stressors. Coping skills and social support are
Largely grounded in sociological perspectives of usually regarded as the two main moderators.
stress, the stress process model proposed by The nal major components of the stress process
Pearlin and colleagues (1990) is perhaps the are the outcomes, in terms of caregivers well-
most used approach to understand the caregiving being, physical and mental health, and their ability
experience. Both models proposed by Lazarus to sustain themselves in their social roles.
and Folkman (1984) and Pearlin et al. (1990) con- In the light of the stress process model, burden is
ceptualize stress in terms of transactions between treated as a primary stressor affected by the care-
the person and the environment. However, Laza- givers background and the caregiving context.
rus and Folkmans work emphasizes cognitive Burden, in turn, affects directly outcomes such
appraisals and the microlevels of the stress pro- physical and mental health, as well as indirectly
cess, whereas Pearlin and colleagues stress pro- through secondary role strains and intrapsychic
cess model is more concerned with the contextual strains. Coping and social support moderate these
and macro-levels (Kinney 1996). This stress pro- interactions and explain differences in outcomes
cess model presents caregiver stress as a among caregivers experiencing similar situations.
multidimensional and interrelated process involv- While Pearlin et al. (1990) conceptualize bur-
ing four components (Pearlin et al. 1990): back- den as a primary stressor; Yates et al. (1999) sug-
ground characteristics and context, stressors, gest that burden should be treated as a secondary
moderators, and outcomes. According to the appraisal variable based on the argument that it is
authors, the caregiving experience is shaped by equal to subjective burden perception. Yates
key characteristics of the caregiver (e.g., gender, et al. (1999) considered the primary stressors
age, education, occupational and economic con- from the Pearlin model (e.g., number of hours of
ditions), the caregiving history (e.g., relationship informal care) as a primary appraisal variable that
between caregiver and care receiver dyad), the leads indirectly to secondary appraisal of care-
family network, and program/resources avail- giver overload (burden) and depression.
ability in the community. Pearlin et al. (1990) Although the stress process model was devel-
have dened stressors as the conditions, experi- oped from research on dementia caregiving, it is
ences, and activities that are problematic for peo- considered one of the most comprehensive care-
ple (p. 586). These are conceptualized as primary giving theoretical frameworks and has been
and secondary in nature. The primary stressors widely applied to conceptualize and interpret
are those that arise directly from providing care to observational and interventional research in a
a dependent relative, involving both the objective broad range of other caregiving settings such as
conditions of caregiving (e.g., supporting ADL) stroke (Cameron et al. 2014), cancer (Gaugler
and subjective reactions incited by these objective et al. 2005), and chronic liver disease (Nguyen
conditions (e.g., a sense of role overload or et al. 2015).
Caregiving and Ethnicity responsibility, resulting in an underutilization of

formal support (Lai 2010). Filial piety was also
A growing body of research has explored how found to signicantly predict the appraisal of the
culture and ethnicity inuence the caregiving caregiving experience as rewarding among
experience. Despite apparent inconstancy in Chinese-Canadian caregivers, although no signif-
results, this research generally suggests that the icant direct effect on caregiving burden was found
caregiving role is experienced differently by dif- (Lai 2010).
ferent ethnic groups. Ethnic variations in the care- Research has also explored the experience of
giving experience may be attributable to caregiving for Latino or Hispanic-American care-
differences in the levels of stressors, coping strat- givers. This research suggest that, compared to
egies, social support, as well as different percep- Caucasian-American caregivers, Latino dementia
tions of family obligations. For instance, a number caregivers reported lower levels of perceived bur-
of systematic reviews have found that, compared den (Montoro-Rodriguez and Gallagher-
to other ethnic groups, African-American care- Thompson 2009) and lower appraisals of stress
givers appear to have lower levels of burden and (Coon et al. 2004). Latino caregivers also reported
depression (Pinquart and Srensen 2005; higher levels of self-efcacy in managing disrup-
Dilworth-Anderson et al. 2002) and higher levels tive behaviors of the patients and controlling
of uplifts and subjective well-being (Pinquart and upsetting thoughts (Montoro-Rodriguez and
Srensen 2005). Several studies reported that Gallagher-Thompson 2009), as well as appraised
African-American caregivers receive more infor- caregiving to be a signicantly more positive
mal support than White caregivers. Others suggest experience than Caucasian caregivers (Coon
that African-American caregivers might be better et al. 2004). These ndings might be inuenced
able to cope with caregiving because they have by a cultural perspective that sees the act of caring
learned to cope with adversity in their lives and for an older relative as congruent to the Latino
because of their strong religious orientation and cultural value of familism wherein reciprocity and
the use of more positive reappraisal (Pinquart and solidarity among family members help support
Srensen 2005). caregivers and their roles. In addition, Latino
Also, Asian-American caregivers were found caregivers appraisal of stress may be more related
to be more depressed than White-American care- to the degree of disruption caregiving eventually
givers (Pinquart and Srensen 2005). Pinquart brings to their families rather than to themselves
and Srensen (2005) reported that Asian- as individuals. Also, Latino caregivers were more
American caregivers used signicantly less for- likely to rely on religious and spiritual activities,
mal support than Whites. Sampling bias or lan- which may serve as effective coping strategies for
guage barriers might account to partially justify them to help buffer against the daily stress of
these results. However, the cultural value of lial caregiving throughout their promotion of social
piety can also add some explanation to these nd- integration, social support, and relationship with
ings. Filial piety is a fundamental Confucian value God (Coon et al. 2004).
common among many Asian cultures and histor- The caregiving experience has also been
ically instructs people to be respectful to their researched in cross-country studies. For instance,
parents, emphasizes intergenerational relation- high ratings of burden and lower health-related
ships, and places family needs over individual quality of life have been recently found among
interests. Adult children are expected to sacrice caregivers of people with dementia in eastern and
their nancial, physical, and social needs for the southern European countries, compared to north
benets of their aging parents (Miyawaki 2015). or central European countries (Bleijlevens
In this sense, the cultural expectation of caring for et al. 2015). Differences in health and social care
aging parents might pressure some Asian care- systems may account for variation in these out-
givers to perceive the use of formal services as comes. In general, the provision of formal support
losing face or an evasion of ones own is lower and informal care is higher in southern
and eastern European countries. In Spain, family companionship, and supervision. This is, per-
caregiving plays a more central role compared to haps, the most widely used type of respite
other countries. On the other hand, countries like services.
the Netherlands or Sweden offer as extensive (b) Day care centers, which are structured, com-
health and social care system, and long-term prehensive community-based centers that
care is primarily considered a responsibility of provide a variety of social and health-care
country councils and municipalities (Bleijlevens services in a supervised setting during part C
et al. 2015). of the day, freeing the caregiver for other
Together, all these studies underscore the rele- activities or rest.
vance of understanding how social and cultural (c) Overnight respite, which involves the admis-
factors inuence both caregivers outcomes and sion of the dependent person for a night,
mediator variables. weekend, or longer in a residential care facil-
ity or nursing home, depending on the needs
of the caregiver.
Interventions for Caregivers (d) Institutional respite and vacation/emergency
respite, which includes round-the-clock sub-
The last two decades has seen a substantial stitute care, usually used for longer, continu-
increase in the development of caregiver interven- ous periods of time, often when caregivers
tions designed to reduce both the adverse effects need to be away for short periods of time
of care and early nursing-home placement of the (e.g., when they need a holiday, become tem-
dependent older person. Increasingly, these inter- porarily ill, or in emergency situations such as
ventions have applied the transactional models of a death in the family).
stress, particularly Pearlins stress process model,
to identify modiable variables of the stress pro- In general, there is some evidence that care-
cess that can lead to improved outcomes. The givers do not use respite services or use them too
approaches to caregiver interventions can be little or too late in the caregiving trajectory
divided into two main groups (Srensen (Figueiredo 2009). Yet, while Srensen et al.
et al. 2002): (i) those aimed at reducing the objec- (2002) observed respite care effectiveness in
tive burden or amount of care provided by care- terms of dementia caregiver burden, depression,
givers (e.g., respite care) and (ii) those aimed to or subjective well-being, more recent reviews
improve caregivers well-being and coping skills, (Schoenmakers et al. 2010) found that respite
generally called psychosocial interventions (e.g., was associated with an increase in burden, proba-
support groups, psycho-education, psychother- bly due to family caregivers concerns about
apy). More recently, an integrated approach has respite care quality and difculties to accept
emerged, combining a range of strategies, and is handing over their dependent older relative.
classied as multicomponent. Also, Mason et al. (2007) observed that the effects
Respite care was designed to relieve caregivers of all types of respite care upon caregivers were
periodically or temporarily from the provision generally small, with better-controlled studies
of care to their dependent relative. This rest nding modest benets only for certain sub-
allows the caregiver to take some time for his/her groups. Further, empirical evidence suggests that
own and carry out other activities. The main respite does not delay institutional placement.
types of respite services include (Figueiredo Psycho-education includes structured inter-
2009): ventions designed to provide information on the
disease process, symptoms management and com-
(a) In-home respite, which provides relief in the munity support resources, and training to provide
home by workers with suitable training. care and respond to disease-related problems. It
Examples of the type of care provided are also includes a supportive component aiming to
help with personal care and housework, normalize experiences, give mutual support, and
provide problem-solving and emotional- narrowly targeted interventions (Srensen

management strategies for coping with the disease et al. 2002; Parker et al. 2008).
demands. Systematic reviews and meta-analysis Caregivers can rely on several of interventions
studies have shown that psycho-educational inter- and services developed to help them to cope
ventions have consistent short-term effects on a with the caregiving role. However, intervention
wide range of dementia caregivers outcome indi- studies designed to prevent stress and alleviate
cators (Srensen et al. 2002; Pinquart and burden present inconsistent results and have
Srensen 2006; Parker et al. 2008). Similar nd- shown only modest effects. No single intervention
ings were found for stroke family caregivers; is completely successful in responding to all the
however, evidence is limited (Cheng et al. 2014). needs and difculties of caregivers. Some inter-
Support group interventions might include ventions (psycho-education, psychotherapy,
both professionally led and peer-led unstructured multicomponent) seem to have broad, nonspecic
support which focuses on building up a rapport effects over several outcomes, while others have
among participants and developing opportunities more specic effects on target outcomes (respite).
to share experiences of caregiving. In these Conceptual and methodological issues have
groups, peers provide emotional support as well been identied as main reasons to explain incon-
as insights into successful strategies for dealing sistency in results. Some argue that the outcome
with several aspects of the caregiving role. In measures used may be sensitive to change to
contrast to psycho-educational programs, support greater or lesser degrees (e.g., caregiver burden
group interventions are seldom standardized and appears to be less changeable than subjective
education is not their primary focus. In their meta- well-being). In addition, studies frequently
analysis, Chien et al. (2011) found that support include outcome measures that do not have obvi-
groups had a signicant positive effect on demen- ous relationship or that do not match the inter-
tia caregivers psychological well-being, depres- vention goals. Moreover, caregivers are a
sion, burden, and social outcomes. heterogeneous population with diverse risk pro-
Psychotherapy involves establishing a thera- les, cultural backgrounds, resources, and experi-
peutic relationship between the caregiver and a ences of stress and burden. Thus, the one size ts
trained professional. Most psychotherapeutic all approach is not appropriate for caregiving
interventions with caregivers adopt a cognitive- intervention (Zarit and Femia 2008). In some
behavioral approach in which therapists aim to cases, studies use multidimensional measure-
(Srensen et al. 2002) improve self-monitoring, ments of burden but fail to address the distinction
challenge negative thoughts and appraisals, help between objective and subjective burden, which
caregivers to develop problem-solving skills, and might mitigate the ndings of interventional
reengage in positive experiences. As with psycho- research (Bastawrous 2013). Finally and perhaps
educational interventions, Srensen et al. (2002) the most basic constraint in caregiving interven-
found that psychotherapy have the most tion research is viewing caregiving as if it were a
consistent short-term effects over different types psychiatric disorder like major depression (Zarit
of outcomes. Specically, cognitive-behavioral and Femia 2008). This means that, basically, par-
therapy was found to have a large effect on ticipants are enrolled in the intervention studies
decreasing depression and a small to moderate because they are caregivers, independently of
effect on lowering burden (Pinquart and Srensen feeling or not feeling burdened, depressed, or
2006). having other negative outcomes. There are two
Multicomponent interventions include the major consequences of this approach. First,
combination of several strategies (e.g., education, when the goal of treatment is to reduce burden
respite, psychotherapy) and target multiple out- depression, but some of the participants are not
comes. Multicomponent interventions seem to burdened or depressed, that means that a part of
be more effective in improving caregivers well- the sample will not show improvements after the
being and reducing burden compared to more treatment, leading to a loss of statistical power to
detect change. Second, it is possible that treating developed, there is a need for conceptual
participants for a problem they do not present may frameworks that explain and predict positive
actually worsen their situation (Zarit and Femia outcomes.
2008). Viewing caregiving as stressful and burden-
Many other factors related to intervention char- some event has encourage researchers and practi-
acteristics, the caregiving situation, or research tioners to develop interventions based on a decit
design can mediate the effectiveness of interven- approach in which caregivers are assumed not to C
tions, such as the dosage and length of treatment, have the necessary resources, skills, and compe-
individual interventions as opposite to group tences to cope successfully with their stressful
interventions, the characteristics of the cared-for situations (Figueiredo 2009). This negative view,
person (e.g., interventions for caregivers of people alongside research design and methodological
with dementia are less successful than those issues, might in part explain the incongruent
designed for caregivers of older people with ndings of intervention studies. A more
other chronic conditions), the relationship with salutogenic approach could provide a focus on
the care receiver (adult-children interventions as the strengths rather than on the burdens, in order
opposed to spouse interventions), and the extent to enhance caregivers resilience and personal
to which participants adhere to the treatment empowerment.
(regularity of attendance or dropout rate). Moreover, the stress/burden paradigm can be
reductionist. It has emphasized individuals in their
caregiving role and had not really examined the
Future Directions cared-for person and the family as a system, as
data has been obtained mainly from the primary
With the current demographic trends on the caregiver. A family systems approach would be
growth of older people population, the role of focused on the analysis of family dynamics and
informal caregivers is expected to continue to adaptations, relationships, and patterns of interac-
assume a great importance. Research has conceptions, providing a more comprehensive picture of
tualized informal caregiving as a stressful event, the caregiving experience. Interventions should
likely to involve signicant burden. Based on this be targeted at the family as a system, involving
approach, several burden indicators have been all family members, as they all take part in the
developed, and ndings have showed that many adjustment to care demands.
caregivers experience high levels of burden, Finally, the dominant focus has been on the use
depression, anxiety, social isolation, and nancial of cross-sectional designs, ignoring the changes in
strain. Conceptualizing the caregiving experience the cared-for person needs and chronic disease
in the light of stress and burden paradigms has trajectory over time. The challenges of families
unquestionably become a major contributor to when dealing with the diagnosis or acute phase are
understanding this complex phenomena, but has different from those of the chronic or terminal
also hindered the opportunity to nd out more phase of the disease. These cross-sectional data
about the neutral and the positive aspects of care hinders to understand how the demands, needs,
and to promote them. There is, however, growing and coping mechanisms of all family members
evidence that positive outcomes or rewards, such change over time.
as a sense of reciprocity or personal growth, can
be derived from the caregiving experience,
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Challenging Behavior 455
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elders in residence: Issues in the measurement of bur- ual, other residents, or caregivers. Challenging
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of Life Research, 12, 3341. aggressive behavior, agitation, sexually inappro-
Schoenmakers, B., Buntinx, F., & DeLepeleire, J. (2010). priate behavior, or wandering. Interventions
Supporting the dementia family caregiver: The effect of discussed in this entry include medications,
home care intervention on general well-being. Aging &
Mental Health, 14, 4456. behavioral interventions, systematic individual- C
Selye, H. (1956). Stress of life. New York: McGraw-Hill ized interventions, cognitive/emotion-oriented
Book. interventions, sensory stimulation interventions,
Srensen, S., Piquart, M., & Duberstein, P. (2002). How and psychosocial interventions. For each inter-
effective are interventions with caregivers: An updated
meta-analysis. The Gerontologist, 42, 356372. vention, a brief description is provided and the
Stull, D., Kosloski, K., & Kercher, K. (1994). Caregiver effectiveness of the intervention discussed.
burden and generic well-being: Opposite sides of the
same coin? The Gerontologist, 34, 8894.
Van Durme, T., Macq, J., Jeanmart, C., & Gobert,
M. (2012). Tools for measuring the impact of informal Introduction
caregiving of the elderly: A literature review. Interna-
tional Journal of Nursing Studies, 49, 490504. In 2013 the number of individuals with dementia
Yates, M., Tennstedt, S., & Chang, B. (1999). Contributors worldwide was estimated to be 44.4 million, and
to and mediators of psychological well-being for infor-
mal caregivers. Journal of Gerontology: Psychological this number is expected to increase substantially
Sciences, 54B, 1222. over the next 15 years (Alzheimers Disease Inter-
Zarit, S., & Femia, E. (2008). A future for family care and national 2015). Dementia is often accompanied
dementia intervention research? Challenges and strate- by a variety of challenging behaviors. For exam-
gies. Aging & Mental Health, 12, 513.
Zarit, S., Reever, K., & Bach-Peterson, J. (1980). Relatives ple, approximately 50% of individuals with
of the impaired elderly: Correlates of feelings of bur- dementia exhibit agitated behaviors every month
den. The Gerontologist, 20, 649655. (Livingston et al. 2014). These behaviors often
Zarit, S., Bottigi, K., & Gaugler, J. (2007). Stress and have consequences for the quality of life of
caregivers. In G. Fink (Ed.), Encyclopedia of stress
(2nd ed., pp. 416418). San Diego: Academic. both the individual with dementia and the care-
givers. A variety of pharmacological and non-
pharmacological interventions have been used to
treat these challenging behaviors, with mixed
Challenging Behavior results. The evidence for interventions that
focused on the most commonly targeted challeng-
Casey Cavanagh and Barry Edelstein ing behaviors in residential care facilities, with an
Department of Psychology, West Virginia emphasis on the ones for which there is at least
University, Morgantown, WV, USA promising evidence to support efcacy, was
reviewed. Additionally, a few interventions for
which there is limited support, based primarily
Synonyms on reviews that require randomized control trials
(RCT), are included. Finally, some interventions
Maladaptive behaviors; Neuropsychiatric symp- with virtually no empirical support are included
toms of dementia; Problem behaviors because they appear to be used in spite of the
paucity of support. This is a selected rather than
an exhaustive review of all interventions for all
Definition challenging behaviors associated with dementia.
Most studies addressed multiple challenging
Challenging behaviors among individuals with behaviors. Literature reviews (e.g., systematic
dementia are dened as maladaptive behaviors reviews, meta-analyses, Cochrane reviews)
that contribute to a diminished quality of life for described outcome measures, but many of these
456 Challenging Behavior
were scores on behavior rating scales that (e.g., nausea, drowsiness, sedation), with these
included multiple behaviors or categories (e.g., effects varying across specic drugs. Sedative-
aggressive behavior, wandering, agitation). hypnotic medications (e.g., the benzodiazepines)
Therefore, it was difcult to organize this presen- have been used to treat acute cases of agitation,
tation around specic challenging behaviors. In but they increase the risk of impaired cognitive
light of that and in the interest of brevity, much of functioning and falls. Mood stabilizers (e.g., car-
this discussion is devoted to studies of specic bamazepine, valproate, gabapentin) have been
interventions that are often used to address a vari- used to manage challenging behaviors, but only
ety of challenging behaviors. carbamazepine has research support. However,
carbamazepine has signicant adverse effects
Pharmacological Interventions (e.g., sedation, hyponatremia). The deliberations
While the principal focus is non-pharmacological and recommendations of a panel of experts
interventions, it is also important to briey men- regarding the use of psychotropic medications to
tion these interventions and address some of the manage neuropsychiatric symptoms of dementia
issues associated with this approach to behavior (NPS) were summarized by several researchers
management. The US Food and Drug Adminis- (Kales et al. 2014). They concluded that Given
tration (FDA) has not approved pharmacological the limitations in the evidence-base, the panel
interventions for challenging behaviors associated consensus was that psychotropic drugs should be
with dementia. Pharmacological interventions are used only after signicant efforts have been made
therefore used off-label. The safety and efcacy of to mitigate NPS using behavioral and environ-
pharmacological interventions for dementia- mental modications and medical interventions
related problems have been questioned for several if needed, with three exceptions (p. 767) (Kales
years. The 1987 Omnibus Budget Reconciliation et al. 2014). These included situations in which
Act brought about a substantial reduction in the there was signicant and imminent risk to the
use of psychotropic medications to control individual or others.
dementia-related challenging behaviors in the US-
A. Strong appeals for reconsideration of pharma- Behavioral Interventions
cological interventions have come from the UK as Behavioral interventions for the management of
well, for example, the NICE Guidelines (National challenging behaviors are variously termed
Institute of Clinical Excellence 2007). Clinicians behavior modication, behavior therapy, behav-
must weigh the benets against the potential ioral problem-solving, and functional analysis-
adverse effects of the medications. based interventions. These can involve direct
First-generation antipsychotic medications interventions by staff and alteration of the envi-
(e.g., haloperidol, loxapine) have been used to ronment to reduce the frequency or duration of
manage challenging behaviors for many years, challenging behaviors or to increase more adap-
but they have associated severe adverse effects tive behaviors. Interventions emphasize the func-
(e.g., cardiovascular problems, extrapyramidal tion of the challenging behavior and typically
symptoms, tardive dyskinesia, increased risk of involve the identication of the variables control-
death). Atypical antipsychotic medications (e.g., ling the target behavior. This includes identica-
risperidone, olanzapine) also have signicant tion of the antecedent stimuli (A) that set the
adverse effects that vary across medications occasion for (trigger) the challenging behavior
(e.g., extrapyramidal symptoms, sedation, meta- (B), which is strengthened or maintained by spe-
bolic syndrome, orthostatic hypotension). Several cic consequences (C). The analysis and interven-
antidepressant medications (e.g., sertraline, tion is usually individualized, as the controlling
citalopram) have been used to manage challeng- variables can differ between individuals. In recent
ing behaviors, but there is limited support for their years some researchers have conceptualized chal-
use (Seitz et al. 2011). In addition, adverse effects lenging behaviors as arising from unmet needs,
are associated with the use of antidepressants with the intervention aimed at meeting those
needs. As with earlier behavioral conceptualiza- the ndings. Overall, there is promising support
tions, the focus remains on the function of the for the effectiveness of many behavioral
challenging behaviors, but the interventions approaches to reducing the frequency of challeng-
are individualized and conducted across large ing behaviors associated with dementias (Moniz-
sample sizes. Cook et al. 2012).
One of the difculties of reviewing this litera-
ture was that some researchers employed multiple Systematic Individualized Intervention C
interventions that focused both on the individual This approach appears to have been developed
and the environmental determinants of the chal- from a behavioral perspective and is based on
lenging behaviors. A variety of different care- the notion that one can reduce agitated behaviors
givers (e.g., nurses, nurses aides) have been associated with dementia by addressing unmet
employed as well. Finally, the outcome measures needs of the individual that are thought to be the
have varied considerably across studies. Some basis for the behaviors (e.g., pain, feelings of
studies focused on the frequency or duration of loneliness or isolation, boredom, sensory depriva-
specic behaviors (e.g., wandering, hitting, bit- tion). As previously noted, this approach is similar
ing), some on classes of behaviors (e.g., aggres- to other behavioral approaches that focus on the
sion, agitation), and others on scores obtained on function of the challenging behavior and identify
rating scales that incorporated several different the antecedents and consequences of challenging
behaviors and yielded a total score that included behaviors. However, the studies of this
all behaviors. approach have combined characteristics of group
Several reviews have found mixed results for (nomothetic) and individualized (idiographic)
the effectiveness of behavioral interventions. approaches with large numbers of participants.
Results of studies in which an intervention was This large-scale approach has been used exclu-
applied to groups of participants have yielded sively with agitation. In two placebo-controlled
mixed results even with studies employing similar studies, agitation was directly observed. Agitated
interventions and outcome measures. In addition, behaviors included physically agitated (e.g.,
it is difcult to offer an overall judgment regard- repetitive movements) and verbally agitated
ing the effectiveness of these approaches in light (e.g., screaming) behaviors. Interventions were
of the variety and combinations used in the liter- individualized and included, for example, individ-
ature. The interventions employing what is vari- ualized music, family videotapes and pictures,
ously termed a behavior analytic (Spira and stress balls, electronic massagers, and pain treat-
Edelstein 2006) or functional analytic approach ment. The results revealed signicant reductions
(Moniz-Cook et al. 2012) appear to have some of in agitation when compared to the control groups.
the clearest supporting evidence. Studies Although these studies were not included in recent
employing single-case designs with individuals reviews, this approach has sufcient evidence,
have demonstrated support for the use of stimulus including one randomized, placebo-controlled
control interventions for wandering behavior. study, to support its effectiveness. Please note
These interventions involved manipulating envi- there is some overlap between some of the stimuli
ronmental stimuli (e.g., disguising doors, used in these studies and those used in simulated
installing visual barriers, covering doorknobs, presence therapy, described in a subsequent
placing grids on oors) that contributed to wan- section.
dering behavior. Several single-case studies have
been published demonstrating the effectiveness of Cognitive/Emotion-Oriented Interventions
individual interventions (e.g., reinforcement of Cognitive/emotion-oriented interventions, such
appropriate behaviors, differential reinforcement as reminiscence therapy, simulated presence ther-
of other behaviors) for a wide range of challeng- apy, and validation therapy, have been examined
ing behaviors. However, all of these studies need as treatment for a range of challenging behaviors,
to be replicated to establish the generalizability of including agitation/aggression and comorbid
disorders, such as depression and anxiety (ONeil Validation Therapy

et al. 2011). Although the effectiveness of these Naomi Feil developed validation therapy for older
cognitive/emotion-oriented interventions in adults with cognitive impairment, particularly
reducing challenging behaviors is mixed, each those with dementia. Feil classies cognitively
intervention will be briey reviewed (ONeil impaired individuals according to four stages:
et al. 2011). mal orientation, time confusion, repetitive
motion, and vegetation. The emphasis of the inter-
Reminiscence Therapy vention is on acknowledging and dignifying the
Reminiscence therapy for older adults grew out of feelings and experiences of a person. A variety of
the work of Robert Butler on life review. Life techniques comprise the approach (e.g.,
review is conceived as a naturally occurring pro- paraphrasing, touching, linking behavior with
cess of recalling past experiences, including unmet needs). Feil identied several principles
unresolved conicts. Reminiscence therapy that she believes underlie her approach (e.g., all
involves a progressive awareness of ones past people are unique and should be treated as such,
experiences, which affords older adults the oppor- there is reason behind the behavior of disoriented
tunity to examine these experiences, resolve con- behavior of older adults, and older adults should
icts, and place their lives in perspective. Various be accepted nonjudgmentally).
forms of this approach with dementia patients Outcomes measured employed in studies of
appear in the literature. Common features include, validation therapy have included cognition,
for example, discussions of past experiences behavior, emotional state, and activities of daily
accompanied by familiar objects (e.g., old photo- living. As previously noted (Neal et al. 2005), and
graphs) that are used to stimulate discussions. unchanged today, there are few experimental stud-
There is considerable support in the literature for ies of validation therapy, and their results are
the reduction of depression (Woods et al. 2009) mixed, with insufcient evidence to support this
but little evidence to support the reduction of approach.
challenging behaviors associated with dementia.
Sensory Stimulation Interventions
Simulated Presence Therapy Sensory stimulation interventions and comple-
Similar to reminiscence therapy, simulated pres- mentary and alternative medicine (CAM) include
ence therapy involves the recalling of a patients interventions such as massage therapy, acupunc-
positive life experiences and memories (Zetteler ture, aromatherapy, light therapy, music therapy,
2008). However, in simulated presence therapy, Snoezelen or multisensory stimulation therapy,
the recalling of positive life experiences is accom- and transcutaneous electrical nerve stimulation
plished through the use of audiotaped or (ONeil et al. 2011). Sensory stimulation interven-
videotaped recordings of conversations with a tions and CAM therapies have both been investi-
patients family members (Zetteler 2008). The gated as interventions to reduce problem or
purpose of these recordings is to bring challenging behaviors, including agitation/
comfort to the patient by serving as a reminder aggression, wandering, and inappropriate sexual
of the patients family (Zetteler 2008). There is behavior.
mixed evidence regarding the effectiveness
of simulated presence therapy. Additionally, Massage Therapy
there is evidence that simulated presence therapy In general, massage or touch therapies involve
can produce increases in agitation or disruptive applying pressure to the body. This application
behaviors (Zetteler 2008). Overall, these results of pressure may include a variety of styles of
suggest that simulated presence therapy may be touch, such as slow strokes, expressive touch,
effective in reducing challenging behaviors. How- rubbing, kneading, and efeurage (Hansen
ever, current ndings need to be replicated and et al. 2008; Moyle et al. 2012). Massage may
extended. also be applied to different body areas, including
the back, shoulders, neck, hands, lower legs, or intervention or integrated in other activities
feet (Moyle et al. 2012). Typically, massages are (ONeil et al. 2011). Music therapy may be indi-
conducted by nursing staff or massage therapists vidualized by employing the patients favorite
(Hansen et al. 2008; Moyle et al. 2012). The music. In contrast, standardized music therapy
limited number of studies precludes the ability to protocols typically employ relaxing, quiet, classi-
evaluate the effectiveness of massage therapy cal, and big-band music (Livingston et al. 2005;
(Hansen et al. 2008; Moyle et al. 2012). However, McDermott et al. 2013). C
the preliminary evidence suggests that massage Music therapy is effective in producing short-
therapy may reduce agitated behavior among term (during and immediately following the inter-
older adults with dementia, at least in a short term. vention) decreases in disruptive behavior (i.e.,
agitation and aggression) (ONeil et al. 2011; Liv-
Multisensory Stimulation Therapy ingston et al. 2005; McDermott et al. 2013).
The goal of multisensory stimulation (MSS) or However, there is no evidence that the decreases
Snoezelen therapy is to promote balance of the in agitation and aggression are maintained
sensory system through stimulation of the ve (McDermott et al. 2013). Evidence regarding the
senses by using a range of stimuli (e.g., music, effectiveness of music therapy in reducing
aromatherapy) (ONeil et al. 2011). In some cases, other challenging behaviors is mixed
guidelines identify specic stimuli that should be (ONeil et al. 2011). Despite the promising nd-
included in treatment. Alternatively, patient pref- ings of several reviews, poor methodological
erences may be used to identify specic stimuli quality and reporting of studies prevented the
(Chung et al. 2009). The current evidence for the ability to draw conclusions about the effectiveness
effectiveness of MSS is mixed. There is prelimi- of music therapy (Vink et al. 2011).
nary evidence that disruptive behavior decreases
during MSS treatment. However, these effects are Light Therapy
not maintained when treatment is discontinued Light therapy increases exposure to bright and
(Livingston et al. 2005). Other research concluded naturalistic light and is therefore hypothesized to
that there is no evidence for the effectiveness of help regulate circadian rhythms and reduce
MSS on agitation/aggression among individuals fragmented or disrupted sleep, which in turn is
with dementia (Chung et al. 2009). Further, the hypothesized to reduce challenging behaviors
evidence for the effectiveness of MSS on wander- (i.e., agitation, cognitive dysfunction, functional
ing is inconclusive (ONeil et al. 2011). In sum, impairment, and depression) (Forbes et al. 2014).
the limited evidence available suggests that MSS Light therapy involves use of varying levels of
may be effective in reducing some challenging brightness (e.g., between 2500 and 10,000 lx).
behaviors (i.e., disruptive behavior). Recent research suggests that light therapy should
involve exposure to light in the short wavelength
Music Therapy range (i.e., 450 to 500 nm, the blue to green
Music therapy typically involves listening to range) as this is the light range at which
music or playing musical instruments, but may melanopsin cells are stimulated to shift circadian
also involve having patients compose music or rhythms (Forbes et al. 2014). Exposure to light
dance (ONeil et al. 2011; Livingston can be produced by using a light box, wearing a
et al. 2005). In active music therapy, patients and light visor, light xtures, or dawn-dusk simulation
providers participate in the intervention (e.g., (Forbes et al. 2014). One advantage of light
composing, singing, dancing, and playing instru- therapy is that few adverse effects have been
ments). Receptive music therapy involves having reported (Forbes et al. 2014). Overall, there is a
patients listen to music and therefore involves less lack of sufcient evidence to support light
interaction (McDermott et al. 2013). Similar to therapy as an effective treatment for reducing
other sensory stimulation interventions, music challenging behaviors (ONeil et al. 2011; Forbes
therapy may be implemented as a stand-alone et al. 2014).
Transcutaneous Electrical Nerve Stimulation functioning(Woods et al. 2012, p. 2). Outcome

Transcutaneous electrical nerve stimulation assessments of challenging behaviors were based
(TENS) has also been explored as a potential on care provider ratings of participant behavior.
treatment for challenging behaviors, such as More specically, ratings of general behavior and
aggressiveness, among individuals with demen- behavior scales were used as outcome measures.
tia. TENS involves the application of biphasic No differences in challenging behaviors were
pulsed waveform, pulsed electrical currents, to found between intervention and control groups.
the skin and can produce muscle contraction Consequently, reality orientation therapy cannot
depending on the intensity of the current (ONeil be recommended as an intervention for challeng-
et al. 2011; Cameron et al. 2009). When TENS is ing behaviors.
used to treat individuals with dementia, electrodes
are applied to the head or earlobes, which Psychosocial Interventions
produce cranial electrical stimulation (Cameron Psychosocial interventions, such as animal-
et al. 2009). TENS is associated with minor side assisted therapy and exercise, promote social
effects, such as dull pain in the head, and therefore interaction and communication and have been
may be advantageous as compared to other inter- examined as interventions to reduce challenging
ventions (Cameron et al. 2009). Literature exam- behaviors.
ining the effects of TENS on challenging
behaviors is limited. One Cochrane review noted Animal-Assisted Interventions
a lack of sufcient data limited the ability to draw Animal-assisted interventions are a broad cate-
conclusions about the effects of light therapy on gory, which includes three main types of interven-
challenging behaviors, specically aggressive- tions, animal-assisted activities, animal-assisted
ness (Cameron et al. 2009). therapy, and service animal programs (Bernabei
et al. 2013). Animal-assisted interventions can
Reality Orientation Therapy (Cognitive involve the use of living animals such as, dogs,
Stimulation) cats, or even sh. Alternatively, these interven-
Reality orientation therapy was originally devel- tions may employ nonliving animals, such as
oped for the rehabilitation of war veterans and robot animals or toy animals (e.g., plush dog or
later used to address the disorientation of older cat). Animal-assisted activity involves the use a
adults in hospitals. This approach is typically companion animal. Animal-assisted therapy
directed at individuals with dementia and involves employs therapy animals, is typically provided
the presentation of information regarding time, by health or human service professionals, and
place, and person with the goal of reorienting the addresses specic treatment goals (Kamioka
individual. Clocks and calendars are often et al. 2014). Service animal programs employ
employed to assist with this endeavor. One review service animals (Kamioka et al. 2014). Research
examined all randomized controlled trials (RCTs) suggests that exposure to animals has benecial
of cognitive stimulation for dementia that effects on health, may reduce depressive symp-
focused on cognitive change outcomes (Woods toms, and may improve socialization and interac-
et al. 2012). These included studies in which the tion (Bernabei et al. 2013). Moreover, animal-
following terms were used to describe the inter- assisted interventions reduced challenging behav-
vention: cognitive stimulation, reality orientation, iors, such as aggressiveness and irritability,
memory therapy, memory groups, memory sup- although it is unclear whether these effects were
port, memory stimulation, global stimulation, and maintained (Bernabei et al. 2013).
cognitive psychostimulation. Cognitive stimula-
tion, the overarching term, was dened as Physical Exercise Interventions
engagement in a range of activities and discus- In general, there are several types of physical
sions (usually in a group) aimed at general exercise/activity programs, including mobility
enhancement of cognitive and social training (e.g., walking), isotonic exercises,
strength training, or mixed modalities (e.g., chair information that is often more externally valid
exercises, aerobic dance class) (Heyn et al. 2004). than that obtained from studies with very strict
These exercise programs may be delivered as an inclusion criteria. The conclusions of this entry
independent activity or may be incorporated into are driven largely on the basis of major reviews of
recreational activities/programs. The primary goal the relevant literature. Further, research that does
of these types of programs is to increase older not meet the standards for RCTs (e.g., reviews of
adults ability to perform tasks of everyday living behavior analytic interventions) was also C
(Forbes et al. 2013). An additional goal of some reviewed when possible. The conclusions tend to
exercise interventions is to increase socialization. be mixed, which is consistent with the ndings of
Similar to other psychosocial interventions most of the reviews cited in this entry. The most
reviewed, the effects of exercise on challenging promising approaches to managing challenging
behavior are mixed (Forbes et al. 2013; behavior appear to be the ones that are individu-
Eggermont and Scherder 2006). Currently, there alized in general and those that attempt to address
is insufcient evidence to determine if exercise the antecedents and function of the challenging
reduces aggressive/agitated or wandering behav- behaviors in particular. Future research should
ior among individuals with dementia (Forbes offer a balance of methodologies; address the
et al. 2013). lack of a consistent operationalization of challeng-
ing behavior and use of inconsistent outcome
measures; and explore whether the reductions in
Summary and Conclusions challenging behaviors are maintained once treat-
ment is terminated. In addition, reviewers should
The primary focus of this entry is psychosocial consider the implications of eliminating empiri-
interventions for challenging behaviors associated cally sound and externally valid studies which
with dementia in residential care. Additionally, may not meet all of the criteria previously required
pharmacological interventions are briey for inclusion.
addressed. Reliance on pharmacological interven-
tions continues in spite of limited support and
potential adverse effects. Psychosocial interven-
tions offer safer alternatives, but conclusions Cross-References
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China Health and Retirement Longitudinal Study (CHARLS) 463
above) will drop from about 4.9:1 in 2010 to

China Health and Retirement 1.4:1 in 2050 (United Nations 2013).
Longitudinal Study (CHARLS) With the rapid aging of Chinese population, the
problem of providing for the aged population is
Xinxin Chen1, James Smith2, John Strauss3, becoming increasingly important. One feature of
Yafeng Wang1 and Yaohui Zhao4 rapid economic growth is that lifetime incomes for
1
Institute of Social Science Survey, Peking younger people tend to be considerably higher C
University, Beijing, China than they were for their elderly parents, making
2
Rand Corporation, Santa Monica, CA, USA the elderly one of the largest disadvantaged
3
School of Economics, University of Southern groups in China. At the same time, Chinas birth
California, Los Angeles, CA, USA control policy means that Chinas elderly today
4
National School of Development, Peking have fewer children to support them than in the
University, Beijing, China past. How to deal with problems of support for the
well-being of the elderly is one of the greatest
challenges to the fast-booming Chinese society
Synonyms in the decades to come.
In face of challenges posed by population
CHARLS aging, the health status of the elderly population
is of great importance. A healthy older population
can not only reduce the nancial and personal care
Definition needs but can also contribute to the family and
society in the form of working or helping to take
This entry provides an overview of the China care of the young children.
health and retirement longitudinal study, focusing Of all dimensions of health, psychological
on its value in geropsychology research in China. health is at least as important as physical health
The entry starts with an introduction on CHARLS to the functionality of older persons. Depression is
Sampling and Implementation including the back- already listed as a major cause of death and dis-
ground, the sampling procedure and design, track- ability in China (Yang et al. 2013; Phillips
ing protocol, data release, and demographics of et al. 2002). In the United States, dementia or
the respondents. It then describes the contents of cognitive impairment has been shown to cause
the questionnaire, followed by psychologic mea- major caring burdens to the family (Hurd
surements. This entry is concluded with future et al. 2013).
plans. At present, scientic studies of Chinas aging
psychological health problems are still at an early
stage, the greatest obstacle being a lack of suf-
Introduction cient micro-longitudinal data. The existing data
tend to be small scale in parts of China, not
China has the largest aging population in the collecting the breadth of data necessary for good
world and also one of the highest aging rates in social scientic analysis of psychological health
the world today. It is projected that the proportion of the older population. China Health and Retire-
of those aged 60 or over will increase from 13% of ment Longitudinal Study (CHARLS) is the rst
the population in 2010 (National Bureau of statis- nationally representative survey of the older pop-
tics of China 2011) to 33% in 2050 (United ulation that enables the study of psychological
Nations 2013), whereas the elderly support ratio health of the older population in China patterned
(the number of prime-age adults aged 2059 after the Health and Retirement Study (HRS) in
divided by the number of adults aged 60 or the United States, English Longitudinal Study of
464 China Health and Retirement Longitudinal Study (CHARLS)
China Health and Retirement Longitudinal Study (CHARLS), Table 1 Response rates: 2011 Baseline, Wave
2, 2013
Wave 1 2011 Wave 2 2013
Householdsa Total 2011 household Refresher Households who did not
respondentsb Households respond in 2011
Response 80.5 N/A 91.0 81.6 51.6
rate (%)
No. of 10,257 10,832 9,022 615 1,129
households
No. of 17,708 18,648 15,684 1,107 1,857
respondents
a
Household response rate: the ratio of number of responded households to the number of age-eligible households
b
2013 Individual R-rate: respondents who completed at least one module/(total individuals in 2011 minus 2011
respondents who died by 2013)
Ageing (ELSA), and the Study of Health, Ageing, (Zhao et al. 2013). Hence, CHARLS is nationally
and Retirement in Europe (SHARE). represented for both rural and urban areas within
This entry will give a comprehensive introduc- China. Counties and districts in 28 provinces are
tion of the CHARLS data set, its sampling included in the CHARLS sample (Zhao et al.
method, longitudinal tracking protocol, the con- 2013).
tent of the questionnaire especially existing psy- In light of the outdated household listings
chological measures, and plans for future data at the village/community level due to population
collection. migration, CHARLS designed a mapping/listing
software (Charls-GIS) that makes use of
Google Earth map images to list all dwelling
CHARLS Sampling and Implementation units in all residential buildings to create sampling
frames.
Baseline Sampling The response rate for the baseline survey was
CHARLS is a biennial survey that aims to be 80.5%, 94% in rural areas and 69% in urban areas,
representative of the residents of China aged lower in urban areas as is common in most sur-
45 and older, with no upper age limit. The veys undertaken in developing countries (Table 1)
CHARLS national baseline survey was conducted (Zhao et al. 2013). A description of the sample for
in 20112012 and wave 2 in 2013. CHARLS is a waves 1 and 2 is provided in Table 1. After apply-
nationally representative survey that includes one ing sampling weights created using the sampling
person per household aged 45 years of age or older procedure, the CHARLS sample demographics
and their spouse, totaling 17,708 individuals in mimics very closely that of population census in
wave 1, living in 10,257 households in 450 vil- 2010 (Zhao et al. 2013).
lages/urban communities (Zhao et al. 2013, 2014). In each sampled household, a short screening
At the rst stage, all county-level units were sorted form was used to identify whether the household
(stratied) by region, within region by urban dis- had a member meeting the age eligibility require-
trict or rural county, and by GDP per capita (Tibet ments. If a household had persons older than
was the only province not included). Region was a 39 and meeting the residence criterion, one of
categorical variable based on the NBS division of them will be randomly selected. If the chosen
province area. After this sorting (stratication), person is 45 or older, then he/she became a main
150 counties or urban districts were chosen with respondent and his or her spouse was interviewed.
probability proportional to population size (Zhao If the chosen person was between ages 39 and
et al. 2013). For each county-level unit, three PSUs 44, he/she was reserved for refresher samples for
(villages and urban neighborhoods) are randomly future waves. In wave 2, respondents who were
chosen with probability proportional to population aged 4344 in wave 1 (plus their spouses) were
China Health and Retirement Longitudinal Study (CHARLS), Table 2 Number and age/sex structure of individuals:
2011 Baseline and Wave 2, 2013
Baseline, 2011 Wave 2, 2013
Total Male Female Total Male Female
50 4,277 1,806 2,471 4,178 1,754 2,424
5155 2,848 1,412 1,436 2,712 1,302 1,410
5660 3,523 1,697 1,826 3,523 1,702 1,821 C
6165 2,695 1,372 1,323 3,124 1,574 1,550
6670 1,802 913 889 2,037 1,032 1,005
7175 1,214 652 562 1,442 732 710
7680 790 386 404 787 410 377
80+ 548 231 317 830 374 456
OBS 17,708 8,476 9,232 18,648 8,882 9,766
Note: There are 11 individuals in 2011 and 15 individuals in 2013 lacking age information
added from the refresher sample. The same for baseline and wave 2 (464 deaths), including ver-
wave 3 (4) will be done in 2015 (2017), out of bal autopsies using the 2012 version from the
those aged 4142 (3940) in wave 1. Starting in World Health Organization. In addition, the
wave 5 (2019), a new mapping/sampling exercise households which were not found in the baseline
will be conducted to replenish the sample with were revisited. One thousand one hundred
appropriate aged cohorts. twenty-nine of these (51.6% of those
households who had age-eligible members living
Tracking Protocol in nonempty dwellings) were contacted. The
Respondents and spouses will be tracked if they households that split because of divorce or
exit the original household. While the original moving were also followed. The total household
CHARLS sample is of the noninstitutionalized size in wave 2 is 10,832 households with a
elderly population, if a respondent becomes total of 18,648 individuals (main respondents
institutionalized, such as entering a nursing plus spouses). The age distribution of
home or hospital for a long stay, CHARLS fol- respondents in baseline and wave 2 is shown in
lows them. This potentially matters for obtaining Table 2.
prevalence rates for dementia since it might be
that some of the population with dementia is Data Release
institutionalized. However, in China, the institu- The national baseline data and documentation
tionalized population is very small, so in practice were released publicly, on the CHARLS website
for CHARLS, this is unlikely to be an important (www.charls.ccer.edu.cn/en), in early February
issue. 2013, less than 1 year after the eldwork was
Main respondents and spouses in the baseline completed. The second wave of the national
survey are followed throughout the life of CHARLS sample was elded in the summer and
CHARLS or until they die. If a main respondent through the fall of 2013. It was released publicly
or spouse remarries, the new spouse is inter- at the end of this January.
viewed so long as they are still married to the
baseline respondent at the time of the specic Demographics of the CHARLS Sample
wave. In wave 2, only 25 couples split up because Table 2 describes the age/sex composition of the
of divorce. CHARLS sample. There are 17,708 individuals in
For respondents in the baseline, after deaths, the national baseline sample, of which 52.1% are
91% of them were recontacted (Table 1). Four female. While most of the samples are the younger
hundred twenty-seven exit interviews were old, 40% are aged 60 years and older. Of the
conducted on respondents who died between the sample, 91.3% were directly interviewed and
8.7% were interviewed by proxy respondent health behaviors. This includes detailed informa-
(Table 2). tion on smoking, drinking, and physical activities.
Health Status: Biomarkers

Content of the Household Survey Following ELSA and HRS, detailed biomarkers,
blood and non-blood, were collected. Non-blood
Household Survey Instruments biomarkers such as anthropometrics and blood
The core survey consists of the following sec- pressure were collected in waves 1 and 2 and
tions: (1) demographics; (2) family structure/ will again be in wave 3. Then the blood bio-
transfer; (3) health including biomarkers; markers was collected in wave 1 and will be
(4) health insurance and healthcare utilization; collected in every other wave, to harmonize with
(5) work, retirement, and pension; (6) relative HRS and other aging surveys. In CHARLS the
income; (7) family income, wealth, and expendi- data are collected on height, lower leg and upper
tures; (8) personal income, assets; and (9) housing arm lengths (useful to get measures related to
characteristics. All interviews are conducted using height not contaminated by shrinkage), waist cir-
the computer-assisted personal interview (CAPI) cumference, blood pressure (measured 3 times),
technology. The health modules will be described grip strength (measured by a dynamometer two
in detail. times for each hand), lung capacity measured by a
peak ow meter, and doing a timed sit to stand
Health Status: Self-Reports and Assessments (5 times starting from a full sit position on a
The self-reports start with the respondent rating common, plastic stool). The balance tests are
health on a scale of excellent, very good, good, also conducted, just the same as those used
fair, and poor or instead very good, good, fair, in HRS, and a timed walk at normal speed for
poor, and very poor. As in HRS, respondents 2.5 m again follows HRS.
self-assessment is asked twice, using each scale,
once at the start of the module and once at the end Healthcare Utilization and Insurance
of the sub-module asked randomly determined Indicators of curative and preventive healthcare
within CAPI. This is followed by questions asking utilization and health insurance coverage are col-
about diagnoses by doctors of a set of chronic lected in this module. A separate section on health
diseases, including stroke and separately psychol- insurance is asked to collect details of current and
ogy diseases, and the timing of diagnoses of spe- past coverage and whether coverage was lost.
cic conditions. Where relevant, current Healthcare utilization of outpatient care for the
medications and treatments for each specic con- last 1 month is asked, with details about last
dition are also collected. Questions about eye- visit. Inpatient utilization over the past 1 year is
sight, hearing, and dental health are asked next asked, with details about last visit. The questions
and then questions on hedonic well-being. The include from whom and at what location medical
CHARLS team follows this subsection with a care was received, how much was total cost, what
section to obtain information on activities of was out of pocket cost, whether insurance was
daily living (ADLs), instrumental activities of used, if others help pay for the care, whom, and
daily living (IADLs), and physical functioning. how far respondents traveled.
For those who have been identied as having
difculties in ADL or IADL, the care givers are Life Histories
collected. Up to three names are chosen from all A special wave to collect life histories was elded
of list of family members. Time of care and nan- in 2014. Life histories can greatly add to aging
cial arrangement are asked. Sections on depres- surveys because they help to ll in very important
sive symptoms and cognition follow. details regarding earlier periods in the respon-
In addition to self-reported health outcome dents life, which are germane to understanding
variables, information is collected on several outcomes when older. Ways to minimize recall
China Health and Retirement Longitudinal Study (CHARLS), Table 3 CES-D questions
English Mandarin
DC009 I was bothered by things that dont usually bother me
DC010. I had trouble keeping my mind on what I was doing
DC011. I felt depressed
DC012. I felt everything I did was an effort
DC013. I felt hopeful about the future C
DC014. I felt fearful
DC015. My sleep was restless
DC016. I was happy
DC017. I felt lonely
DC018. I could not get going
error have been greatly improved primarily insurance and health facilities; and pensions and
through the use of calendars that are anchored to prices. In addition, the Policy Questionnaire col-
key lifetime or calendar events (both national lects details of social welfare programs such as
events, like the Cultural Revolution and local, pensions and health insurance, In addition, at the
like a major ood) that are salient to respondents county level.
memory. Such calendars have been developed.
The CHARLS life histories are developed
using as a base the ELSA and SHARE life histo- Psychological Health Measures
ries, the most complete life histories of the
HRS-type aging surveys. The CHARLS life his- Depression
tory includes retrospectives on domains that cover CHARLS uses the ten-question version of the
family background when the respondent was a Center for Epidemiologic Study depression
child, child health and health care, work and (CES-D) battery (The CES-D ten questions are
retirement, marriage, childbirths, migration, reported in Appendix Table 3, and CHARLS
some retrospective information on income, wealth uses the Chinese translation provided at the Cen-
and poverty status when young, and schooling is ter for Epidemiologic Studies website). The
collected. Some special history issues germane to answers for CES-D are on an f-scale metric,
China are also included, such as experiences dur- from rarely, to some days (12 days), to occasion-
ing the Cultural Revolution and the Great Famine ally (34 days) to most of the time (57 days).
and during local events such as a major local Lei et al. (2014a) provides a descriptive analy-
ood. These life histories will be especially useful sis of the depressive symptoms as revealed in
for linkage with the CHARLS ADAMS 2 data. CHARLS. They scored these answers using the
metric suggested by Radloff (1977). Numbers
Community Survey Instrument from 0 for rarely to 3 for most of the time are
One special feature of CHARLS that is new to the used for negative questions such as do you feel
HRS-type surveys is to collect detailed panel data sad. For positive questions such as do you feel
from community-level informants (e.g., formal happy, the scoring is reversed from 0 for most of
and informal community leaders). Basic commu- the time to 3 for rarely. A validation exercise of
nity information is collected on, for example, land answers to these questions indicates a reasonable
and its allocation, population, and the most popu- level of internal consistency. Lei et al. (2014b)
lous surnames and their numbers. More standard report that in 2011/12 a high fraction of Chinese
information is also collected, such as details about people 45 and older, both men and women, are
local infrastructure and public facilities such as suffering from high levels of depressive symp-
roads, electrication, water and sanitation infra- toms, with some 30% of men and 43% of
structure, and the availability of schools; health women having CES-D scores 10 and over (out
China Health and Retirement Longitudinal Study (CHARLS), Table 4 Word recall list, English and Mandarin
List A List B List C List D
A01. RICE B01. STOOL C01. MOUNTAIN D01. WATER
A02. RIVER B02. FOOT C02. STONE D02. HOSPITAL
A03 DOCTOR B03. SKY C03. BLOOD D03. TREE
A04. CLOTHES B04.MONEY C04. MOTHER D04. FATHER
A05. EGG B05. PILLOW C05. SHOES D05. FIRE
A06.CAT B06. DOG C06. EYE D06. TOOTH
A07. BOWL B07. HOUSE C07. GIRL D07. MOON
A08. CHILD B08. WOOD C08. HOUSE D08. VILLAGE
A09. HAND B09. SCHOOL C09. ROAD D09. BOY
A10. BOOK B10. TEA C10. SUN D10. TABLE
of 30 as a maximum). Rural residents have sub- patterned on the HRS number series test (Fisher
stantially higher levels of depressive symptoms et al. 2013; Prindle and McArdle 2013).
than urban residents. In CHARLS wave 4, it is scheduled to diag-
nose dementia and impaired of cognition among
Cognition the CHARLS respondents aged 65 and older. This
In the rst two waves, CHARLS used a reduced will be done in two steps. First, a formal validation
form of the Telephone Interview for Cognitive sample will be collected from which both inter-
Status, TICS (Brandt et al. 1988). This includes viewer assessment and doctor diagnosis will be
recognition of date: month, day, year, season conducted. From these data, a statistical model
(lunar calendar is allowed in addition to Gregorian will be built to use interview tests to predict
calendar), day of the week, how the respondent dementia and CIND. This information will be
rates their own memory on an excellent, very used to inform the nal choice of tests and the
good, good, fair, poor scale, and serial subtraction estimation of weights and cutoff points specic to
of 7s from 100 (up to ve times). The respondent China with which to classify CHARLS respon-
is asked to redraw a picture of overlapping penta- dents as having dementia and CIND. Among the
gons. In addition, immediate and delayed word tests currently planned are the mini-mental state
recall is used, using ten nouns randomly chosen exam (MMSE); immediate and delayed word
from a list of four groups of words, with approx- recall; a measure of verbal uency, animal nam-
imately 5 min between the immediate and delayed ing; the symbol digit modalities test; and back-
answers. The words will not be read out a second wards digit span.
time before the delayed recall (the word lists are
reported in Appendix Table 4).
Acknowledgments This work was supported by the
CHARLS shows a steep decline of cognitive Behavioral and Social Research division of the National
functions with age (Lei et al. 2014b). There exist Institute on Aging (grant numbers 1-R21-AG031372-01,
large sex-related differences in cognition to the 1-R01-AG037031-01, and 3-R01AG037031-03S1); the
Natural Science Foundation of China (grant numbers
disadvantage of women, with the large sex-related 70910107022, 71130002 and 71273237); the World Bank
gap in education being the primary reason for this. (contract numbers 7145915 and 7159234); China Medical
These sex-related disparities are eliminated in Board, and Peking University.
younger cohorts.
Cross-References
Future Plans
English Longitudinal Study of Aging (ELSA)
Starting in wave 3 (2015), CHARLS will be intro- Health and Retirement Study, A Longitudinal
ducing a number series test of uid intelligence, Data Resource for Psychologists
Chinese Longitudinal Healthy Longevity Study 469
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2012 Revision (Online database). Available from
United Nations Retrieved 2015-4-26, from United
Nation. http://esa.un.org/unpd/wpp/unpp/panel_indica Tireless efforts are made to explore the secret of
tors.htm human longevity throughout history. However, it
Yang, G., Wang, Y., Zeng, Y., et al. (2013). Rapid health is not until very recent that science-based studies
transition in China, 19902010: Findings from the
on the mechanism of longevity appeared with
Global Burden of Disease Study 2010. Lancet, 381,
19872015. sufcient sample sizes and multidisciplinary per-
Zhao, Y.-H., Strauss, J., Yang, G., Giles, J., Hu, P., Hu, Y., spectives have been launched (Poon and Cheung
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Study- 20112012 National Baseline Users Guide,
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http://charls.ccer.edu.cn/en/page/documentation/2011_
national_baseline
Zhao, Y.-H., Hu, Y., Smith, J. P., Strauss, J., & Yang,
Disclaimer: Views expressed in the study are only those of
G. (2014). Cohort prole: The China Health and Retire-
the authors and do not reect those of the United Nations,
ment Longitudinal Study. International Journal of Epi-
National University of Singapore, Duke University, or
demiology, 43(1), 6168.
Peking University
470 Chinese Longitudinal Healthy Longevity Study
beyond, namely centenarians (Poon and Cheung 1995. Several European countries have also
2012; Zeng 2012). launched centenarian studies since the early
The urgent call to study centenarians is largely 1990s such as the Italian Multi-center Study on
due to the increasing importance of this special Centenarians (IMUSCE) (around 2,000 centenar-
subpopulation. Because of the steady decline of ians) and the Longitudinal Danish Centenarian
mortality at very old ages (Vaupel et al. 1998; Study (about 300 centenarians) (Koenig 2001;
Wilmoth et al. 2000), the number of centenarians Poon and Cheung 2012). These centenarians and
is booming in the world (Robine et al. 2010; all other relevant studies have resulted in a boom
Wilcox et al. 2008, 2010) and is projected to in centenarian studies and improved understand-
exceed three million by 2050 and possibly 20 mil- ing about their secret of longevity.
lion by 2100 in a conservative estimation of the However, nearly all centenarian studies are
United Nations Population Division (2015). More from developed countries. There was almost no
importantly, with the world population aging, cen- scientic research project with a sufcient sample
tenarians come to be considered as a model of size of centenarians in developing countries
successful aging or healthy aging (Andersen- before the late 1990s (Zeng et al. 2001). Because
Ranberg et al. 2001; Poon et al. 2010). But why the contributions of sociodemographics, psycho-
could some people live up to age 100 and beyond, logical factors, and behavioral factors to longevity
while others die at much younger ages? Why vary in different cultures and societies with differ-
could some people live so long but still remain ent development stages (Poon et al. 2010;
healthy? Although there has been a consensus Kolovou et al. 2014; Willcox et al. 2006), it
among researchers that socioeconomic, behav- would be interesting to study centenarians from
ioral, environmental, and biological factors jointly developing countries where the socioeconomic
determine ones longevity and health, to what resources, healthcare service, and technology are
extent and how exactly these factors contribute limited. Furthermore, while there were about
to centenarians exceptional long and healthy life 50 centenarians per million in Western Europe
is mostly unknown. (Jeune and Vaupel 1995; United Nations Popula-
There have been a number of centenarian stud- tion Division 2015), there were less than three
ies around the world to attempt to address such centenarians per million in China in the 1990s
research questions. For example, the longest (United Nations Population Division 2015). The
ongoing centenarian study in the contemporary genomes of long-lived individuals from China
world is the Okinawa Centenarian Study (OCS), may be more enriched for disease-preventive
which was launched in 1975. The OCS has here- genes than their counterparts in the West, because
tofore collected over 900 centenarians and several they survived the brutal mortality regimes of the
thousands of their siblings of septuagenarians, past when famine, civil wars, and starvation
octogenarians, and nonagenarians in Okinawa, affected their birth cohorts of many millions. In
Japan. The Georgia Centenarian Study (GCS) is addition, the genetic composition of the Han Chi-
the longest centenarian study in the USA, which nese ethnic group is relatively homogeneous.
started in 1988. In the Phase I (19881992), the Unlike Western countries that received many
GCS collected 76 centenarians with 92 octogenar- immigrants from other parts of the world and
ians and 89 sexagenarian as comparisons; thus provide relatively heterogeneous genetic
250 centenarians were further included with compositions even within the same ethnic group,
80 octogenarians as comparison in the Phase III China received very few international immi-
(20012009). The largest centenarian study in the grants. Consequently, the Han Chinese are rela-
USA is the New England Centenarian Study tively genetically homogenous, compared to the
(NECS), which was launched in 1995. The Western counterparts. For example, it was esti-
NECS has collected data from about 1,600 cente- mated that the average of genetic differences
narians in the USA with 500 children (in their between Han Chinese population samples
70s and 80s) and 300 younger controls since (FST = 0.002) was much lower than that among
European populations (FST = 0.009) (Xu and Jin nancial supports from the National Institute on
2008). This is a comparative advantage to increase Aging, the National Natural Science and Social
statistical power for studying effects of genetic Sciences Foundations of China, UNFPA, and
and GxE interactions on healthy aging. other resources.
Another major limitation of existing literature The CLHLS aims to collect extensive data on a
on centenarian studies has been the lack of sur- large sample of the oldest-old aged 80 years and
veys with large sample sizes. To address above older with a comparison group of younger elders C
research questions, including investigating aged 6579. The project also collected informa-
genetic variations in longevity and examining tion on the offspring of the elderly in 2002 and
gene-environment interaction effects on longevity 2005 to better investigate the role of
and health, large samples are required. Small sam- intergenerational transfers and its association
ple sizes of surveys often produce results with with human longevity. Starting in 2009, adult
insufcient statistical power or poor robustness; children of centenarians and controls of nonrela-
and in some cases, small-sized surveys on cente- tives of centenarians in seven longevity areas
narians often lack representativeness when the (later becoming eight longevity areas in 2012
size of underlying centenarian population is rela- and 2014) were included in the CLHLS (see sec-
tively large, such as in China. Yet, with few exception Centenarian Sub-Sample in the CLHLS
tions, the sample sizes of most centenarian studies below). More specically, the objectives of the
around the world are less than 1,000 centenarians CLHLS research project are threefold: (1) to
(Koenig 2001; Poon and Cheung 2012). To pro- shed light on the determinants of healthy longev-
mote centenarians studies, there is thus a need for ity and to discover social, behavioral, environ-
studies with large representative samples in devel- mental, and biological factors that may have an
oping societies, such as in China which homes inuence on the healthy longevity of human
about 1.3 billion population or about 19% of the beings, as well as to answer questions such as
world total population. why some people survive to very old age without
much suffering while others suffer considerably;
(2) to ll in the data gap and gain a better under-
Research Objectives of the CLHLS standing of demographic and socioeconomic con-
ditions, as well as of the health status and
Launch of the CLHLS care-giving needs of the oldest-old population;
While it is very useful and important to uncover and (3) to provide a scientic base for sound
the secrets of human longevity to study centenar- policy making and implementation, so as to
ians, it is also equally important or even more improve the system of care-giving services and,
prominent to study the oldest-old population ultimately, the quality of life of the elderly.
aged 80 or older. This is because the remarkable
increase in the number of oldest-old population in Sampling Strategy of the CLHLS
the recent years and near future presents a serious The CLHLS is conducted in a randomly selected
public health challenge to promote the quality of half of the counties and cities in 22 of Chinas
life. Because their large consumptions of social 31 provinces. The 22 provinces are Liaoning,
and medical care services and benets of research Jilin, Heilongjiang, Hebei, Beijing, Tianjing,
on them are far out of proportion to their size, the Shanxi, Shaanxi, Shanghai, Jiangsu, Zhejiang,
oldest-old population in aging and longevity stud- Anhui, Fujian, Jiangxi, Shandong, Henan,
ies has received increasing attention over the past Hubei, Hunan, Guangdong, Guangxi, Sichuan,
decades. In this context, Drs. Yi Zeng and James and Chongqing (see Fig. 1). The exclusion of
W. Vaupel launched a nationwide project in China nine provinces in the North-West parts of China,
on determinants of healthy longevity in 1998, where ethnic minorities represent a high propor-
titled as the Chinese Longitudinal Healthy Lon- tion of total population, was based on concerns
gevity Survey (CLHLS). This project received about the inaccuracy of age-reporting among
Chinese Longitudinal Healthy Longevity Study, map do not imply the expression of any opinion whatso-
Fig. 1 Spatial distribution of the sampled counties/cities ever on the part of the Secretariat of the United Nations
in the CLHLS, the 2008 wave. Note: This map was made concerning the legal status of any country, territory, or area
by the authors based on a county boundary map from the or of its authorities or concerning the delimitation of its
National Bureau of the Statistics of China. The designa- frontiers or boundaries
tions employed and the presentation of material on this
local elders. Previous studies have evidenced to participate in the study. For each centenarian
major inaccuracy (mainly exaggeration) in age interviewee in each wave, the CLHLS
reporting at old ages in these nine provinces interviewed one nearby octogenarian (aged
(Coale and Li 1991; Huang 1993). In contrast, in 8089 years) and one nearby nonagenarian (aged
the 22 provinces as chosen, local people, mostly 9099 years) with predened age and sex.
Han, tend to use the Chinese lunar calendar and/or Nearby is loosely dened it could be in the
Western solar calendar to specify their birthdays, same village or in the same street, if available, or
which largely reduces the inaccuracy of age in the same town or in the same sampled county or
reporting. The accuracy and reliability of age city district. The predened age and sex are ran-
reporting for Han Chinese is related to the fact of domly determined, based on the randomly
their cultural tradition that the exact date of birth is assigned code numbers of the centenarians, to
signicant for them in making decisions on have comparable numbers of males and females
important life events such as matchmaking for at each age group. In the rst two waves (1998 and
marriage, date of marriage, and the date to start 2000), the CLHLS did not collect data from elders
building a house, among other events (Coale and aged 6579 years. Since the 2002 wave, the
Li 1991; Zeng 2012). The total population of the CLHLS extended its sample to include elders
survey areas constituted about 85% of the total aged 6579 under same sampling strategy with
population in China in 2000 and 82% in 2010. So approximately three nearby elders aged 6579 of
far, seven waves in 1998, 2000, 2002, 2005, 2008/ predened age and sex in conjunction with every
09, 2011/12, and 2014 have been conducted. two centenarians. Respondents who were younger
In the sampling areas, the CLHLS aims to than age 100 at an interview but subsequently died
interview all centenarians who voluntarily agreed before a subsequent wave or resettled or refused to
be interviewed at a subsequent wave were Data Quality of the Centenarians

replaced by new interviewees of the same sex Accurate age reporting is crucial in centenarian
and age (or within the same 5-year age group). studies. The CLHLS has employed different
However, such a strategy was not applied to the methods to verify centenarians ages, including
sixth and seventh waves where only follow-ups birth and marriage certicates if available; house-
were performed due to shortage of budget, except hold registration information; ages of their sib-
the eight longevity areas where new participants lings, children, and relatives; genealogical C
were recruited to replace the deceased or the record; any relevant document from local commu-
refusals. nities if available; and reported ages in Chinese
To avoid the problem of small subsample sizes zodiac. (The Chinese zodiac is a repeating cycle of
at the more advanced ages, the CLHLS 12 years, with each year being represented by an
oversampled respondents at more advanced animal according to the Chinese lunar calendar.
ages, especially among male elders, in addition These zodiac animals are used to record ones date
to recruiting all centenarians with a consent agree- of birth). Based on the solid comparisons of var-
ment. Consequently, appropriate weights were ious demographic indices, it was concluded that
generated based on the age-sex-rural/urban- although the age reporting quality of centenarians
specic population distribution in the census. of Han Chinese was not as good as in Sweden,
The method for computing the age-sex-rural/ Japan, England, and Wales, it is almost as good as
urban-specic weights and the associated discus- in Australia and Canada, slightly better than in the
sions are presented in Zeng et al. (2008) and USA (white, black, and other races combined),
available at the CLHLS web page. and much better than in Chile (see Zeng
The questionnaire design was based on et al. 2008).
international standards and was adapted to the The systematic assessment of data quality of
Chinese cultural/social context and carefully the CLHLS indicates that there was no substantial
tested by pilot studies. The CLHLS collects underreporting of deaths, and most variables or
various information covering demographics, items in the questionnaire were in high quality.
socioeconomic conditions, psychological traits, However, the causes of death of centenarians
health practice, and various health condition. reported by next-of-kin might not be reliable,
All data were collected via in-home visits. The because nearly 60% of reported deaths had no
basic physical capacity tests were performed information on causes of death (Zeng
by a local doctor, a nurse, or a medical et al. 2008). This might be due to that signicant
student. portion of the centenarians did not go to the hos-
pital to diagnose/treat the disease prior to death or
they in fact died without specic disease.
Centenarian Subsample in the CLHLS
In-Depth Study of Longevity Areas Including
Subsample of the Centenarian Interviewees Adult Children of Centenarians
In the research design of the CLHLS, the group of The CLHLS launched a subproject for an in-depth
centenarians is one of the major components. As study in seven longevity areas where the density
shown in Table 1, the CLHLS from 1998 to 2014 of centenarians is exceptionally high in 2009 as
interviewed 10,804 centenarians in total with part of the 5th wave of the CLHLS, and in eight
2,130 male centenarians and 8,674 female longevity areas (the previous seven plus a new
centenarians. The total number of interviews one) in 2012 and 2014 as part of the 6th and 7th
of these centenarians is 16,582, of which 3,876 waves of the CLHLS, to investigate why some
centenarians have two interviews and 1,360 cen- areas have a much higher proportion of healthy
tenarians have three interviews; only 372, 117, and long-lived individuals than other areas. The
39, and 14 have 4, 5, 6, and 7 interviews, seven areas in 2009 were Chenmai County
respectively. (Hainan Province), Yongfu County (Guangxi
Chinese Longitudinal Healthy Longevity Study, Table 1 Sample distributions of centenarians in the 1998, 2000,
2002, 2005, 20082009, 2011/12, and 2014 waves of the CLHLS
Waves
1998 2000 2002 2005 20082009 20112012 2014 Total
Men
New recruits 481 256 420 360 519 62 32 2,130
One follow-up 262 124 131 99 146 33 795
Two follow-ups 132 47 38 44 64 325
Three follow-ups 43 15 21 24 103
Four follow-ups 17 6 10 33
Five follow-ups 8 4 12
Six follow-ups 3 3
Total 481 518 676 581 688 287 170 3,401
Women
New recruits 1,937 1,022 1,615 1,462 2,100 355 183 8,674
One follow-up 891 506 483 420 613 168 3,081
Two follow-ups 392 156 115 122 250 1,035
Six follow-ups 11 11
Total 1,937 1,913 2,513 2,216 2,725 1,170 707 13,181
Both sexes
New recruits 2,418 1,278 2,035 1,822 2,619 417 215 10,804
One follow-up 1,153 630 614 519 759 201 3,876
Two follow-ups 524 203 153 166 314 1,360
Six follow-ups 14 14
Total 2,418 2,431 3,189 2,797 3,413 1,457 877 16,582
Note: The number of centenarians at a follow-up wave includes those whose ages were in 90s or 80s in a previous wave of
the CLHLS who are not presented in the table. For the number of sample distribution for other ages, please refer to Zeng
(2012:138)
Province), Mayang County (Hunan Province), longevity areas was recruited since the 6th wave.
Zhongxiang City (Hubei province), Xiayi County The purpose of such design is to collect data on
(Henan Province), Sanshui City (Guangdong factors associated with longevity by comparing
Province), and Laizhou City (Shandong Prov- longevity transmission between families with
ince). Rudong County (Jiangsu Province) was and without centenarians. In addition to the
added since 2012. The criteria of section for lon- regular home-interviews, the in-depth study on
gevity areas come from the Committee of the these longevity areas includes more sophisticated
Chinas Longevity Areas associated with the Chi- health exams and blood and urine sample collec-
nese Society of Gerontology, including high den- tions for biomarker analysis.
sity of centenarians and nonagenarians, high life In 2002, with support from the Taiwan Acad-
expectancy, and a series of within-area consis- emy Sinica and Mainland China Social Sciences
tency checks including good health status and Academy, the CLHLS collected a sample of 4,478
good environment quality, etc. One biological adult children aged 3565 of the elderly inter-
child of each centenarian interviewee in the viewees in eight provinces out of the 22 CLHLS
Chinese Longitudinal Healthy Longevity Study, Table 2 Distributions of deceased centenarians between adjacent
waves from 1998 to 2014, CLHLS
Wave interval
2008/
20052008/ 20092011/ 2011/
19982000 20002002 20022005 2009 2012 20122014 Total
Men 348 292 450 429 437 203 2,159
C
Women 1,213 930 1,635 1,502 1,722 692 7,694
Both sexes 1,561 1,222 2,085 1,931 2,159 895 9,853
Note: The number of centenarians at death during two adjacent waves includes those whose ages were in 90s in a previous
wave
sampled provinces: Guangdong, Jiangsu, Fujian, he/she was sick. Data on how many days before
Zhejiang, Shandong, Shanghai, Beijing, and death the elder did not go outside and how many
Guangxi (mostly eastern coastal provinces). Of days before death the elder spent more time in bed
4,478 dyadic pairs of data, there are 440 pairs than out of bed were collected as well. Informa-
for centenarians and their adult children in these tion on socioeconomic and demographic charac-
eight provinces. Unlike the dyadic pairs of dataset teristics, such as marital status, family structure,
in the longevity areas which deals with familial caregivers, nancial situation, and living arrange-
transmission of longevity, this dyadic dataset ment before death, as well as the caregiving costs
focused on the family dynamics of adult within 1 month before the death were also
children and their intergenerational transferring. collected.
One follow-up survey for these 4,478 adult Table 2 presents the number of the decreased
children was conducted in the 2005 wave. centenarians between two adjacent waves from
Such a study design is rare and valuable, as these 1998 to 2014 in the CLHLS, which was 9,853
dyadic datasets are particularly useful for studying centenarians with 2,159 males and 7,694 females,
familial factors that are associated with healthy for whom the data in the 2 years prior to death
aging. have been collected.
Deceased Centenarian Interviewees Between DNA Samples and Home-Based Health

Surveys Examinations
One unique feature of the CLHLS is the relatively The CLHLS collected DNA samples from 4,849
comprehensive information collection on the centenarians in addition to 5,190 nonagenarians,
extent of disability and suffering before dying of 5,274 octogenarians, 4,770 aged 6579, and
each centenarian (also of each respondent of other 4,609 aged 4064. Health exams for a total of
age groups) who died between two adjacent 2,035, 2,862, and 2,651 participants in the lon-
waves. The information was retrospectively col- gevity areas were performed in 2008/09, 2011/12,
lected from the next-of-kin or the primary care- and 2014, respectively, by local certied doctors
giver of those deceased centenarians as well as and nurses who are afliated with the China Cen-
other died respondent. The information includes ter for Disease Control and Prevention (CDC) as
dates and causes of death, and health and contracted for this project. The medical personnel
healthcare conditions from the last interview to used standard instruments to check heart, lungs,
the time of death, such as chronic diseases, activ- breast, waist, lymph, limbs, and thyroid of the
ities of daily living (ADLs), number of hospitali- participants. They also wrote down impressions
zations, whether the centenarian had been and symptoms of disorder if any, and furthermore
bedridden, and whether the subject had been enquired about the participants family disease
able to obtain adequate medical treatment when history and current medications.
In sum, the large population-based sample size, wave, this has been well justied by the fact that
the focus on healthy longevity (rather than on a about 75% of the oldest-old respondents who
specic disease or disorder), the simultaneous were unable to answer these questions were due
consideration of various risk factors, and the use to health problems (this proportion was about
of analytical strategies based on demographic 95% among centenarians who were unable to
concepts make the CLHLS as an innovative pro- answer).
ject of demographic data collection and research In order to better quantify the contribution of
(Zeng 2012). these psychological traits to exceptional longev-
ity, these seven variables were dichotomized
(coding 1 for answering always and 0 otherwise
Psychological Traits of Chinese for positive affect called as always positive
Centenarians affect, whereas coding 1 for answering never
and 0 otherwise for negative affect called as
Variables of Psychological Traits never negative affect) and then generated an
In addition to the internationally standardized index of always positive and never negative affect
mini-mental status examination (MMSE) of cog- (abbreviated as APNNA) by summing these seven
nitive function tests, the CLHLS contains seven dummies, which ranges from 0 to 7. Because
variables relevant to psychological traits: (1) Do the wording of psychological traits questions in
you look on the bright side of things? (being the 1998 wave is slightly different from that of
optimistic) (2) Do you keep things neat and the other waves and because the 2014 wave is
clean? (3) Can you make your own decisions not publicly available yet, in this section the
concerning your personal affairs? (self- focus of analyses of psychological trait of
determination) (4) Do you feel as happy as when Chinese centenarians was on the waves from
you were young? (5) Do you feel fearful or anx- 2000 to 2011/12.
ious? (6) Do you feel lonely and isolated? (7) Do
you feel useless? Each question above has six Positive and Negative Affect in Centenarians
response options: always, often, sometimes, sel- Figure 2 shows that there was a clear decreasing
dom, never, and unable to answer; proxy trend with age in the score of the APNNA index.
responses were not allowed. The rst four ques- The overall mean scores of the index in centenar-
tions reect positive affect of psychological traits, ians were signicantly lower than those in other
while the latter three questions refer to the nega- age groups (Fig. 2). However, when demo-
tive affect. graphics (age, urbanrural residence), socioeco-
These questions are mainly derived from the nomic status (education, primary lifetime
Positive Affect and Negative Affect schedule occupation, economic independence), family and
(PANAS) scale and could also be considered a social support (marital status, coresidence with
short version of a recently developed Scale of children), health practice (smoking, alcoholic
Positive and Negative Experience (SPANE). intake, exercising), and health condition (ADLs,
Both PANAS and SPANE scales mainly focus instrumental ADLs, cognitive function) were con-
on the general adult population (see Diener and trolled, the pattern was reversed (results not
Biswas-Diener 2009). Different from the SPANE shown). That is, centenarians had the highest
and PANAS scales, psychological traits ques- mean scores of the APNNA, followed by nonage-
tions in the CLHLS contain an option unable narians and octogenarians, whereas the elders
to answer for each question, which aims to aged 6579 had the lowest mean score. The dif-
accounting for the possibility that some oldest- ference between centenarians and older adults
olds may not be able to answer the question due aged 6579 was signicant (p < 0.01) for males
to, for example, various health problems or dif- but not for females.
culties in making up their minds. Based on the Table 3 reveals that with few exceptions (e.g.,
CLHLS data from the 1998 wave to the 2011/12 self-determination (column 3) and loneliness
2.5
2.22
Women Men
2.0 1.84 1.80
1.48 1.44
C
mean scores
1.5
1.24
1.18
0.95
1.0
0.5
0.0
65-79 80-89 90-99 100+ 65-79 80-89 90-99 100+
Ages Ages
Chinese Longitudinal Healthy Longevity Study, the APNNA index ranges from 0 to 7, which includes four
Fig. 2 Mean scores of the APNNA index and their 95% always positive affect variables and three never negative
condence intervals for centenarians by sex in comparison affect variables
with other ages, CLHLS 20022011/12. Note: The score of
Chinese Longitudinal Healthy Longevity Study, Table 3 Percentage distribution of always positive affect and never
negative affect among centenarians by sex in comparison with other age groups, CLHLS 20002011/12
Always positive affect (%) Never negative affect (%)
1 2 3 4 5 6 7
Men
Ages 100+ 11.3 8.1 20.6 18.6 30.1 25.2 14.1
Ages 9099 10.7 9.0 27.3 20.2 32.9 30.2 14.6
Ages 8089 11.8 10.6 37.4 22.8 38.8 38.2 16.9
Ages 6579 15.4 12.1 49.6 29.3 43.9 46.7 23.9
Women
Ages 100+ 8.2 9.8 13.6 15.7 21.6 19.7 8.1
Ages 9099 8.5 11.6 19.8 17.8 28.2 25.4 11.1
Ages 8089 8.9 14.0 28.8 21.4 31.3 31.0 13.2
Ages 6579 11.1 15.1 38.7 26.5 35.1 39.3 19.7
Both sexes
Ages 100+ 9.0 9.4 15.2 16.4 23.6 21.0 9.5
Ages 9099 9.2 10.8 22.2 18.5 29.7 26.9 12.2
Ages 8089 10.1 12.6 32.4 22.0 34.4 34.0 14.7
Ages 6579 13.2 13.6 44.1 27.9 39.5 43.0 21.8
Note: (1) 1, being optimistic; 2, keeping things clean and neat; 3, self-determination; 4, as happy as when you were young;
5, feeling fearful or anxious; 6, feeling lonely; and 7, feeling useless. Please refer to denitions for positive affect and
negative affect in section Variables of Psychological Traits. (2) Percentages for positive affect refer to always, while
percentages for negative affect refer to never.
2.0
1.84
1.8 1.77
1.67 1.66
1.6
1.39 1.42 1.37 1.42
1.4
mean scores
1.2
1.0 p<0.05
0.8 birth cohorts 1905-1909
birth cohorts 1901-1904
0.6
0.4 n=101 n=83 n=637 n=60 n=547 n=31
n=172 n=158
0.2
0.0
Women, Women, Men, Men, Women, Women, Men, Men,
No Yes No Yes No Yes No Yes
Chinese Longitudinal Healthy Longevity Study, 2000 to 2011/12. Note: (1) The score of the APNNA index
Fig. 3 Mean scores of the APNNA index by birth cohort, ranges from 0 to 7, which includes four always positive
sex, and whether the respondents interviewed in 2000 who affect variables and three never negative affect variables.
survived to age 100 (as indicated by yes for survival to age (2) n, sample size. (3) Only the results from birth cohorts
100 and no for those who deceased before age 100) from 19011904 were signicant
Chinese Longitudinal Healthy Longevity Study, Table 4 Relative mortality hazards of the APNNA index of
centenarians in comparison with other age groups, CLHLS 20002011/12
Model I Model II Model III Model IV
Ages 100+ 0.95*** 0.95*** 0.96*** 0.98**
Ages 9099 0.92*** 0.92*** 0.93*** 0.97***
Ages 8089 0.89*** 0.89*** 0.90*** 0.95***
Ages 6579 0.84*** 0.84*** 0.85*** 0.90***
Note: (1) Please refer to section Variables of Psychological Traits for denition of the APNNA index. (2) The results are
almost identical for men and women across age groups and models and thus only results for both sexes are presented.
(3) Model I controlled for demographic factors (singe-year of age, sex, urban/rural residence, ethnicity, marital status, and
coresidence with children). Model II further controlled for socioeconomic factors (education, primary lifetime occupation,
and economic independence). Model III additionally controlled for health practice (smoking, alcoholic taking, and doing
regular exercise). Model IV added baseline health condition (function in activities of daily living (ADL), cognitive
function, and chronic disease conditions) in Model III. All variables in the models were considered as time-varying
covariates whenever possible. (4) The sample sizes are 8,036 for centenarians, 10,872 for nonagenarians, 11,593 for
octogenarians, and 10,490 for septuagenarians and sexagenarians. Those who were lost to follow-up were excluded from
the analyses (with 5,281 females and 3,746 males). (5) *p < 0.05, **p < 0.01, ***p < 0.001
(column 6)), the difference in percentage was not Psychological Traits and Healthy Longevity
large for both male and female centenarians in Table 4 shows that each additional increase in the
comparison with their younger counterparts. Fur- APNNA index (or each additional positive pos-
thermore, Fig. 3 reveals that centenarians were session out of the seven psychological traits)
likely more psychologically robust in terms of among centenarians reduced mortality risk by
APNNA than their same cohort peers who died 45% (Model I to Model III). Even after control-
between ages 90 and 99. These results suggest that ling for baseline health (function in activities of
presence of positive affect and absence of nega- daily living, cognitive function, and chronic con-
tive affect among centenarians may have contrib- ditions), such a protective effect of psychological
uted to their exceptional longevity. traits was still signicant, although the effective
Chinese Longitudinal Healthy Longevity Study, Table 5 Odds ratios of onsets of ADL disability and cognitive
impairment for the APNNA index for centenarians by sex in comparison with other age groups, CLHLS 20002011/12
ADL disabled at follow-up Cognitive impaired at follow-up
Model I Model II Model III Model I Model II Model III
Men
Ages 100+ 0.95 0.94 0.93 0.81** 0.82* 0.85+
Ages 9099 0.93** 0.92*** 0.92*** 0.86*** 0.86*** 0.89*** C
Ages 8089 0.91*** 0.90*** 0.90*** 0.87*** 0.89*** 0.89***
Ages 6579 0.84*** 0.83*** 0.83*** 0.87** 0.89* 0.89*
Women
Ages 100+ 0.94* 0.94* 0.94* 0.89** 0.89** 0.89**
Ages 9099 0.93*** 0.93*** 0.93*** 0.91*** 0.91*** 0.91**
Ages 8089 0.96* 0.96* 0.96* 0.89*** 0.89*** 0.90***
Ages 6579 0.89*** 0.89*** 0.89*** 0.87** 0.88** 0.89**
Both sexes
Ages 100+ 0.94** 0.94** 0.94* 0.87*** 0.88*** 0.88**
Ages 9099 0.93*** 0.92*** 0.92*** 0.89*** 0.89*** 0.90***
Ages 8089 0.94*** 0.93*** 0.93*** 0.88*** 0.89*** 0.90***
Ages 6579 0.87*** 0.86*** 0.87*** 0.87*** 0.89*** 0.89***
(1) Please refer to section Variables of Psychological Traits for the denition of the APNNA index. (2) Model
I controlled for demographic factors (singe-year of age, sex, urban/rural residence, ethnicity, marital status, and
coresidence with children). Model II further controlled for socioeconomic factors (education, primary lifetime occupation,
and economic independence). Model III additionally controlled for health practice (smoking, alcoholic taking, and doing
regular exercise). All variables in the models were considered as time-varying whenever possible. (3) For onset of
disability in activities of daily living (ADL) models, only those who were ADL not disabled were at a given wave were
included. The sizes of the female sample are 1,327 for centenarians, 2,714 for nonagenarians, 4,387 for octogenarians, and
4,872 for septuagenarians and sexagenarians model, whereas the sizes of the male sample are 352 for centenarians, 2,065
for nonagenarians, 4,351 for octogenarians, and 5,144 for septuagenarians and sexagenarians. For onset of cognitive
impairment models, only those who were cognitively unimpaired were included in a given wave. The size of the female
sample are 951 for centenarians, 1,986 for nonagenarians, 3,464 for octogenarians, and 3,411 for septuagenarians and
sexagenarians model, whereas the sizes of the male sample are 301 for centenarians, 1,587 for nonagenarians, 3,431 for
octogenarians, and 3,552 for septuagenarians and sexagenarians. The cognitive impairment is measured by mini-mental
status examination with the cut-off point at a score of 18. In all models of the both panels, those who were lost to follow-up
were excluded from the analyses. (4) *p < 0.05, **p < 0.01, ***p < 0.001
size was reduced to 2% (Model IV). The protec- However, such a reduction was not signicant
tive effect of psychological traits on mortality was in male centenarians, possibly due to the
larger in other ages: the younger the age group, the smaller sample size. The reduction in other,
greater the protective effect of psychological younger age groups of males was signicant
traits. The results further reveal (not shown) that and mostly larger than in the corresponding
the protective effect of psychological traits on age groups of females. The right panel of
mortality were the same for both males and Table 5 shows that the reduction in onset of
females and for both centenarians and other age cognitive impairment due to one additional
groups. point of the APNNA index was about 11% in
The left panel in Table 5 further reveals that female centenarians and did not change in pres-
each additional increase in the APNNA index ence of covariates. Females in other age groups
among female centenarians reduced the odds of had a similar pattern. In contrast, for male
onset of ADL disability by 6%. Such a reduc- centenarians, such a reduction was slightly
tion was similar to those in female nonagenar- larger than in female centenarians and other
ians and octogenarians and persists even after age groups of males, although the signicance
controlling for a rich set of covariates. was weakened when covariates were added.
Concluding Remarks instable results from small sample sizes (Willcox

et al. 2006). Moreover, more studies are encour-
Using data from more than 10,000 centenarians of aged to examine the association between psycho-
mainland China, the largest centenarian sample in social traits and longevity, relative to biologically
the contemporary world, this entry presents a sum- based studies (Poon and Perls 2007). This entry
marized introduction of the CLHLS and a brief uses the large-sized sample of the CLHLS to inves-
description on psychological traits of centenarians tigate how psychological traits are associated with
in comparison with other older adults. We nd that longevity and subsequent health condition, which
centenarians were more psychologically robust than echoes the new initiatives above and adds new
noncentenarian peers of the same birth cohorts evidence highlighting the importance of psycho-
when they were all in ages of 90s and further report logical factors to exceptional longevity.
a signicant association between possession of pos- However, due to space limit, details about the
itive psychological traits and mortality and health role of other psychosocial factors to longevity
worsening in centenarians. These ndings suggest were not discussed, although many of them were
that centenarians are better able to handle stress, already included in the models as covariates. The
depression, or other unfavorable condition than interactions between psychological traits, envi-
their cohort peers, which is in line with many ronmental factors, and genetics in determining
other centenarian studies and that maintaining a longevity were also not investigated. As Poon
good psychological well-being is an important and Cheung (2012) pointed out, to eventually
pathway to reach age 100 (e.g., Gondo et al. 2006; unearth the secrets of longevity, there is still
Jopp and Rott 2006; Perls 2006; Poon et al. 2010). much unexplored on what, how, and why some
The ndings of the present study are also sim- individuals survive to age 100 with good health.
ilar to one recent study by Zeng and Shen (2010) By the end of 2015, only a very small portion of
that applied a concept of psychological resilience studies focuses on centenarians out of 450 peer-
to Chinese centenarians based on questions (1), reviewed publications in English, Chinese, and
(3), (5), (6), and (7) in section Variables of Psy- 76 Ph.D. and M.A. theses/dissertations that used
chological Traits and two other variables in the the CLHLS data since 1998.
CLHLS (to whom the respondent usually talks One limitation of the present study in analyz-
most frequently in daily life? and who does the ing centenarians psychological traits and its asso-
respondent ask rst for help when having prob- ciation between subsequent survival is the way of
lems/difculties?). That study reports that cente- coding of those who were not able to answer the
narians are more psychologically resilient than psychological trait questions. In the case of
elders of young ages and that psychological resil- always positive affect, they were classied into
ience positively contributes to exceptional lon- the group of those who did not always experience
gevity. Indeed, when further accounting for the positive affect. In the case of never negative
response option unable to answer for these affect, they were classied into the group of
questions, one recent study found that there are those who never experienced negative affect.
still about 69% of centenarians whose psycho- Such a coding system may somewhat underesti-
logical well-being is as good as those elders aged mate the psychological traits in centenarians. As a
6579 years (Gu and Feng 2016). consequence, the association between good psy-
Recently, there is a call among scholars in stud- chological traits and subsequent survival among
ies of exceptional longevity, emphasizing the the centenarians may be somewhat biased. Nev-
importance of both quantitative and qualitative ertheless, as the majority of these respondents
methodologies, replication of mechanisms, inter- were in a very poor health condition, such biases
disciplinary and systems perspectives, and gener- would be only mild. Some researchers adopted an
alizability of results (Poon and Cheung 2012). alternative approach by excluding those who were
Among these new directions of the future studies unable to answer the questions in the analyses
in centenarians, scholars particularly concern about (e.g., Zeng and Shen 2010). However, since
those who were not able to answer the questions Jeune, B., & Vaupel, J. W. (1995). Exceptional longevity:
were not missing at complete random, the exclu- From prehistory to the present. Odense: Odense Uni-
versity Press.
sion approach may overestimate centenarians Jopp, D., & Rott, C. (2006). Adaptation in very old age:
good psychological traits to some extent. More Exploring the role of resources, beliefs, and attitudes
research on this issue is clearly warranted. for centenarians happiness. Psychology and Aging,
In sum, more studies on centenarians are 21(2), 266280.
warranted in this eld, and the CLHLS has been
Koenig, R. (2001). An island of genetic parks. Science,
291(5511), 20752076.
C
becoming an important resource for scholars in Kolovou, G. D., Kolovou, V., & Mavrogeni, S. (2014). We
this eld with a large and representative sample are ageing. BioMed Research International, Article ID
size of respondents at extremely old ages in a 808307. doi:10.1155/2014/808307.
Perls, T. T. (2006). The different paths to 100. American
longitudinal context plus the voluminous psycho- Journal of Clinical Nutrition, 83(Suppl), 484S487S.
social and biological data. Poon, L. W., & Cheung, S. L. K. (2012). Centenarian
research in the past two decades. Asian Journal of
Acknowledgments Yi Zengs work is supported by NIA Gerontology and Geriatrics, 7(1), 813.
grant (R01 AG023627), National Natural Science Founda- Poon, L. W., & Perls, T. T. (2007). The trails and tribula-
tion of China (71110107025, 71233001, 71490732), and tions o studying the oldest old. In L. W. Poon &
National Key Basic Research Program of China T. T. Perls (Eds.), Annual review of gerontology and
(2013CB530700). We thank Dr. Huashuai Chen for his geriatrics: Biopsychosocial approaches to longevity
assistance in calculating the sample distribution of the (pp. 17). New York: Springer.
2014 wave. Poon, L. W., Martin, P., Bishop, A., et al. (2010). Under-
standing centenarians psychosocial dynamics and
their contributions to health and quality of life. Current
Gerontology and Geriatrics Research, 2010, Article ID
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482 Clinical Issues in Working with Older Adults
map for disease-gene discovery. The American Journal emphasized in the last years in emblematic articles
of Human Genetics, 83, 322336. (Knight 2004) and in psychological association
Zeng, Y. (2012). Toward deeper research and better policy
for healthy aging-using the unique data of Chinese professional practice guidelines. A representative
longitudinal healthy longevity survey. China Economic example is the Guidelines for Psychological
Journal, 5(2/3), 131149. Practice With Older Adults originally developed
Zeng, Y., & Shen, K. (2010). Resilience signicantly con- by the Division 12, Section II (Society of Clinical
tributes to exceptional longevity. Current Gerontology
and Geriatrics Research, 2010, Article ID 525693. Geropsychology) and Division 20 (Adult Devel-
Zeng, Y., Vaupel, J. W., Xiao, Z., et al. (2001). The healthy opment and Aging) Interdivisional Task Force
longevity survey and the active life expectancy of the on Practice in Clinical Geropsychology and
oldest old in China. Population: An English Selection, approved as an American Psychological Associa-
13(1), 95116.
Zeng, Y., Poston, D. L., Jr., Vlosky, D. A., & Gu, D. (2008). tion (APA) policy in August 2003. Their main aim
Healthy longevity in China: Demographic, socioeco- is to assist psychologists and gerontology practi-
nomic, and psychological dimensions. Dordrecht: tioners in evaluating their own readiness for work-
Springer. ing with older adults, and in seeking and using
appropriate education, training, and supervision
to increase their knowledge, skills, and experience
thought to be relevant for this domain of practice.
The specic goals of these professional practice
Clinical Issues in Working with Older
guidelines are to provide practitioners with (a) a
Adults
frame of reference for engaging in clinical work
with older adults and (b) basic information and
Margarida Pedroso de Lima
further references in the areas of attitudes, general
Faculty of Psychology and Educational Sciences,
aspects of aging, clinical issues, assessment, inter-
University of Coimbra, Coimbra, Portugal
vention, consultation, professional issues, and
continuing education and training relative to
work with this age-group.
Synonyms
The APA Guidelines for Psychological Prac-
tice With Older Adults are organized into six
Rapport; Therapeutic relation
sections; the third concerns Clinical Issues and
comprises three specic guidelines: The rst is
Guideline 7, which states that Psychologists
Definition
strive to be familiar with current knowledge
about cognitive changes in older adults.
Clinical issues are the aspects that should be
According to this guideline, from a clinical per-
taken into consideration when performing clinical
spective, one of the greatest challenges facing
interventions with older adults. The term clini-
practitioners who work with older people is
cal is here used primarily for those professionals
acknowledging when to attribute subtle observed
who work in behavioral health (i.e., nonsurgical,
cognitive changes to an underlying neurodegen-
nonmedication), both at an assessments and inter-
erative condition versus normal developmental
vention level, with older individuals.
changes. Multiple moderating and mediating fac-
tors, like lifestyle, contribute to age-associated
cognitive changes, maintenance, or decline within
Background
and across individuals.
Guideline 8 states that Psychologists strive to
Dont tell us, show us (Morenos Psychodrama understand the functional capacity of older adults
Dictum)
in the social and physical environment. Here it is
The importance of giving attention to clinical strained that the majority of older adults maintain
issues in working with older adults has been well high levels of functioning, suggesting that factors
Clinical Issues in Working with Older Adults 483
related to health, lifestyle, and the match between metatheoretical framework to guide an integrated
functional abilities and environmental demands psychotherapeutic approach with the elderly. In
more powerfully determine performance than this theory the author advocates that an interven-
does age (Baltes and Smith 2008). The degree to tion with older people should take into consider-
which the older individual retains everyday com- ation the positive (i.e., cognitive and emotional
petence (i.e., the ability to function indepen- complexity) and negative (i.e., physical decline)
dently vs. rely on others for basic self-care) factors of the maturation process of the client, as C
determines the need for support in the living envi- well as specic sociocultural environments (i.e.,
ronment. In adding aids in the older adults living values and beliefs), the surrounding context (i.e.,
environment, it is important to balance with the living in an institution vs. community), the cohort
persons need for autonomy and active and safe effect (i.e., inuences like education that affect the
quality of life. Changes that have impact in func- members of a particular generation), and the chal-
tional capacity may immediately lead to modi- lenges of old age (i.e., chronic disease). Together,
cations in social roles and may place emotional these contextual and individual factors contribute
strain in the individual and informal carers. Older and inuence the problem presented by the older
people must deal not only with the personal impli- client and his/her expectations and degree of
cations of these losses but also with the challenges involvement in psychotherapy, as well as to the
of nding meaning in a more limited lifestyle. For options of intervention appropriate to a particular
some older adults, spirituality and other belief case. It is therefore crucial to recognize the intri-
systems may be particularly important in dealing cate interaction between the older adult and
with these losses (Ribeiro and Arajo 2013). his/her environment.
Guideline 9 states that Psychologists strive to
be knowledgeable about psychopathology within
the aging population and savvy of the prevalence Therapeutic Relationship with Older
and nature of that psychopathology when provid- Clients
ing services to older adults. This last guideline
stresses that although the majority of older adults To rightly respond to functional, personal, social,
have good mental health, it should be taken in cognitive, and psychopathological challenges of
consideration that approximately 2022% of older clients it is indispensable to establish a
older adults may meet criteria for some form of meaningful therapeutic relationship. For the ther-
mental disorder, including dementia. For those apeutic process with older adults to successfully
living in a long-term care setting during their unwind theoretical and technical expertise are also
later years, estimates are much higher, with almost necessary. However, independently on the orien-
80% suffering from some form of mental disorder. tation of the intervention, the therapist must have
Older adults may therefore present a broad array the ability to establish a deep connection with the
of psychological issues for clinical attention. client the therapeutic relationship (Fagan and
These issues include the majority of the problems Shepherd 1970; Duffy 1999; Haley 1999; Zarit
that affect younger adults and those experienced and Knight 1996). Regardless of the elderly inter-
due to late life events and tasks. These represent vention context, the communication skills of the
challenges that are specic to late life and include therapist are one essential ingredient to the suc-
developmental and maturational issues and social cess of the intervention (Woolhead et al. 2006).
demands. As examples of developmental issues Listening and responding accordingly is always
we can mention the decrease of sensory acuity and important, requiring more attention when the
increased likelihood of losing signicant people older person has hearing difculties. Speaking in
and, as a social demand, retirement. a simple, direct, clear, and objective way, taking
Knight and Poon (2008) proposed CALTAP into account the nonverbal communication and
(Adult Lifespan Contextual Theory for Adapting without using technical language, is essential. It
Psychotherapy) with the aim of providing a is also important to be present in the relationship,
not paddling against the current, with the ther- for the ourishing of the older client. In this sense,
apist open to the ow of experience, recognizing the quality of the relationship has a major weight
their limits as professionals and with attention to (though, certainly, other variables such as the
their own prejudices. therapeutic setting, client motivation, theoretical
Accordingly, geropsychologists must work to soundness, and the training and experience of the
actively reduce ageism. Ageism as a pervasive therapist are also important). By quality of the
discrimination against older adults is widespread. relationship it is meant the ability to establish
The nondominant group (older adults in this case) good contact, i.e., the ability to listen to the other
is viewed as homogeneous and portrayed as hav- (literal and latent meanings), to produce a real
ing a variety of negative characteristics. People in action that can enhance change in the other, and
old age are viewed stereotypically as alike; alone to detect central aspects that can be worked
and lonely; sick, frail, and dependent; depressed; through with the client with the aim of fostering
rigid; and unable to cope (Frazer et al. 2011). This well-being. The therapists attitude is based on
pervasive view portrays all older adults in a neg- empathy, willingness to help, and mostly on
ative light, ignoring the incredible heterogeneity accepting the patients experience without
of aging and old age and the strengths and judgment.
positive attributes of older adults. Those Fagan and Shepherd (1970) in a classic text on
geropsychologists working in clinical settings Gestalt Therapy refer to ve aspects that the ther-
must be particularly cognizant of their own ageist apist should take into account for the clinical
thoughts and beliefs, and acknowledge its impact relationship to be effective: (1) accurate assess-
and try to prevent and minimize them within the ment and diagnosis; (2) having control of the
therapeutic relationship. Rogers (1951) formu- therapeutic session (i.e., it is the therapist who
lated this issue in a fundamental way: Can the wields the session for the clients benet);
therapist meet with this other individual as a per- (3) solid theoretical and practical knowledge;
son in the process of being, or will he stay tied (4) humanity and compassion toward the client;
to his own past or the clients past? If the therapist and (5) commitment and openness to continue
relates to the older client as old, rigid, limited, learning. To make a therapeutic intervention
immature, ignorant, unstable, or sick, each of involves the therapist as a whole person and con-
these concepts will limit the relationship. Conrm stitutes therefore a challenge. Nevertheless, it is a
means accepting the potential totality of the other. condition for fostering the well-being of the client
If the therapist accepts the other as something and will enable the older client to build self-
xed, as diagnosed and classied, as shaped support skills and a more realistic and adaptive
by the past, he will be doing his part to conrm view of life.
this restrictive hypothesis. On the other hand, if he
accepts the client as in process of becoming, he
will be doing what he can to conrm or make real Working with Older Adults
the potential of the individual.
Instead of giving unconditional positive The therapist working with older adults should be
regard, most of us give value conditions, able to work outside the box, i.e., be more
depending on the satisfaction of our needs and exible concerning place, duration, and frequency
expectations. When we care and we have no qual- of sessions and to have the ability to take on
ications or conditions, there is the uncondi- multiple roles (Haley 1999) in order to respond
tional positive regard. Rogers (1951) argued to customers that often have multiple physical and
that this quality of absoluteness, along with con- psychosocial problems and diverse and complex
gruence and empathy, would be essential to foster needs. Before starting a clinical intervention, the
a more condent human being capable of geropsychologist should pay attention to the
enjoying life more fully. It is then the therapists entire therapeutic setting i.e., all the details
responsibility to create these favorable conditions concerning the environment, the physical layout
Clinical Issues in Working with Older Adults 485
of the room, and the prevention of possible inter- techniques (Corey et al. 1983). Those therapists
ruptions (Frazer et al. 2011). If these aspects are working with older people also benet in being
attained and an environment where there is trust, more exible in their roles (i.e., feeding the
openness, and acceptance is provided, patients patient, helping to call for other people, fostering
will express themselves without fear of censorship other relationships) and more active and partici-
and engage actively in the therapeutic process. patory (i.e., speak about themselves, give exam-
This is why it is important to identify resistances, ples) (Knight 2004). C
make them explicit, and not pretend they do not The conceptual framework and the therapists
exist. The resistance decreases when people take personality often dictate the choice of which tech-
responsibility for how the interaction functions nique to use, but this is also inuenced by the link
(Egan 1986). established with the client. There is always a huge
Depending on the case and on the theoretical variability of possibilities (i.e., the use of animals
framework of the therapist during the therapeutic for people with dementia (Crowley-Robinson
process several techniques (e.g., challenging, clar- et al. 1996)), depending on age, purpose, and
ication, breathing and body awareness tech- level of functioning of the patient but also on the
niques) may be used to explore the material expertise and creativity of the therapist. However,
provided in favor of the natural course of the the therapist should recurrently question the
session and, therefore, consolidate and increase appropriateness of a certain technique. When it
awareness and individual power and responsibil- is possible and meaningful, it is important to ask
ity, even when the older client is very frail and this the client their willingness to participate and to
seems nearly impossible. Techniques are means acknowledge any possible resistance. The clini-
not ends and should not divert the therapist from cal/therapeutic setting is a eld for authentic
the creative and unique relationship with the older human interaction and learning. In this sense, the
client and from the attention required to the techniques should not be seen as tricks but tools to
emerging themes and needs in a session. In this be used in support of patient needs.
sense, there are no recipes that the therapist The therapists countertransference analysis
should follow but tools and exible guidelines (how I feel with what the client said/did? What
that can be used. Moreover, the use of techniques does it mean to me?) is crucial in a relationship
can often mask the quality of a relationship. that is often regulated by unusual changes on the
Change, support, and problem solving are not therapeutic context. For instance, in many inter-
made only on the basis of technical aids but come vention cases the older client is bedridden
mainly from the relationship between the therapist (Altschuler and Katz 1999; Smith 2006). How-
and the patient. It is the quality of the relationship ever, the transference and countertransference,
that will dictate (adduced to the sensitivity of the which depend on the previous relationships of
therapist) the time to use certain techniques (e.g., the client and of the therapist, may lead to thera-
role play). Accordingly, the personal qualities and peutic impasse and resistance to treatment (Knight
advocated values of the therapist are the most 2004). Taboos (e.g., certain themes should not be
important and powerful tools regarding the ease spoken with older or younger people) and the
of the therapeutic process. In this sense, the ther- complexity of the institutional contexts (e.g., the
apist should trust in his/her intuition and be clinician can have different roles in the same
authentic, since the techniques are received in institution; different professionals dealing with
the light of the attitudes of the facilitators that the client make clinical decisions more complex)
employ them (Egan 1986; Corey et al. 1983; can make the management of this dynamic an
Corey 1990). In short, the techniques are valuable enormous challenge. In this sense, the therapist
and important but should be used with caution has the responsibility to examine personal preju-
(Yalom 2005; Corey et al. 1983). If the therapist dices in relation to age, disease and gender, and
has a solid background and supervised experi- any beliefs or conicts with their own parents and
ence, it is less likely to abusively use the grandparents that he may bring as relational
patterns to the therapeutic relation. If this does not life can be the authentic creative encounter that the
happen, the therapist may be limiting the possi- therapeutic relationship enables and therefore
bilities of helping clients to develop. In general, should be promoted.
the therapist is blocked where he/she often has
difculties as a person (Perls 1976).
When clients are considered experts in their Cross-References
own lives, they feel mobilized and encouraged to
use their resources toward their goals (Smith Acceptance and Commitment Therapy
2006) and to be active and interventional agents Age Discrimination
in their own change process (Smith 2006). This Interprofessional Care
perspective about patients as being a repository of Training Psychologists in Aging
resources, rather than being seen as a conuence
of problems, favors the therapeutic alliance. To References
promote the quality of life of the elderly in face
of the complex amount of problems, difculties, Altschuler, J., & Katz, A. D. (1999). Methodology for
diversity of personality proles, and the discovering and teaching countertransference toward
multiple needs and desires people often have to elderly clients. Journal of Gerontological Social
Work, 32(2), 8193.
deal with in the last phase of their life cycle the Baltes, P. B., & Smith, J. (2008). The fascination of
availability of a wide range of therapeutic possi- wisdom. Its nature, ontogeny and function. Perspec-
bilities is crucial. Numerous psychological thera- tives on Psychological Science, 3(1), 5664.
pies have been demonstrating their effectiveness Corey, G. (1999). Theory and practice of counseling and
psychotherapy (5th ed.). Pacic Grove: Brooks/Cole.
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concerning education, training, and supervision Zaha.
are therefore core aspects in providing all the Crowley-Robinson, P., Fenwick, D., & Blackshaw, J.
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homes with visiting and resident dogs. Applied Animal
to understand each person within a biopsychosocial Behaviour Science, 47, 137148.
framework. It is also important to acknowledge that Duffy, M. (Ed.). (1999). Handbook of counseling and
all geriatric care occurs within a team context (see psychotherapy with older adults. New York: Wiley.
the Interprofessional Care entry for this pur- Egan, G. (1986). The skilled helper: A systematic approach
to effective helping (3rd ed.). Monterey: Brooks/Cole.
pose) and that integrated care is the preferable Fagan, J., & Shepherd, I. L. (Eds.). (1970). Gestalt therapy
model. Clinical geropsychologists should addition- now: Theory, techniques and applications. Palo Alto:
ally know how to use multiple methods of assess- Harper & Row.
ment, including brief assessment tools. Frazer, D. W., Hinrichsen, G. A., & Jongsma, A. E. (Eds.).
(2011). The older adult psychotherapy treatment plan-
The focus on the relationship, the meeting ner. New York: Wiley.
that the encounter between two persons (therapist Haley, J. (1999). Problem-solving therapy (2nd ed.). San
and client/group) allows, updates some of the Francisco: Jossey-Bass.
principles that have been repeatedly conrmed Knight, B. G. (2004). Psychotherapy with older adults
(3rd ed.). New York: Sage.
by research and due to the vicissitudes of the Knight, B., & Poon, C. (2008). Contextual adult life span
context or of daily life therapists tend to forget. theory for adapting psychotherapy with older adults.
Such principles allow human ourishing and can Journal of Rational-Emotional and Cognitive-
be summarized in the importance of humanization Behavioral Therapy, 26, 232249.
Perls, F. S. (1976). The gestalt approach and eye witness to
of health services and interventions, the impera- therapy. New York: Bantam Books.
tive need of adequate training and supervision in Ribeiro, ., & Arajo, L. (2013). Centenrios e os desaos
interventions with older patients, the importance da longevidade. REDITEIA, revista de poltica
of empowering and giving personal responsibility social envelhecimento ativo, 45, 117128.
Rogers, C. (1951). Client-centered therapy: Its current
to the individual, and the crucial role of both practice, implications and theory. London: Constable.
creativity and dignity interventions. The answer Smith, E. (2006). The strength-based counseling model.
to the wish to grow in all stages and contexts of The Counseling Psychologist, 34, 1379.
Cognition 487
Woolhead, G., Tadd, W., Boix-Ferrer, J., Krajcik, S., in centenarians without dementia. In the future, an
Schmid-Pfahler, B., Spjuth, B., Stratton, D., & important goal is to further clarify the nature of
Dieppe, P. (2006). Tu or Vous? A European qual-
itative study of dignity and communication with older cognitive changes among centenarians. Finally,
people in health and social care settings. Patient we summarize risks and protective factors that
Education and Counseling, 61, 363371. might inuence cognitive decline or dementia in
Yalom, I. (2005). The theory and practice of group centenarians. Findings from genetic, biomedical,
counseling and psychotherapy (5th ed.). New York:
Basic Books. and psychosocial perspectives can help clarify the C
Zarit, S. H., & Knight, B. G. (Eds.). (1996). A guide to mechanism of cognitive aging throughout the
psychotherapy and aging: Effective clinical interven- life span.
tions in a life-stage context. Washington, DC: Ameri- Taking into account the changing demographic
can Psychological.
structure in aging societies, the proportion of indi-
viduals aged 75 years and over is expected to
increase substantially. As a consequence, the
number of individuals presenting cognitive
Cognition decline with and without dementia is also
expected to increase. The World Health Organi-
Yoshiko Lily Ishioka1,2 and Yasuyuki Gondo3 zation and Alzheimers Disease International
1
Tokyo Metropolitan Institute of Gerontology, (2012) reported an overview of the epidemiology
Tokyo, Japan of dementia and policy and plans in the world.
2
Graduate School of Science and Technology, It is estimated that the number of people aged
Keio University, Yokohama, Japan 60 years and over with dementia worldwide
3
Department of Clinical Thanatology and doubles every 20 years, from 35.6 million in
Geriatric Behavioral Science, Osaka University 2010 to 65.7 million in 2030 and 115.4 million
Graduate School of Human Sciences, Suita, Japan in 2050 (World Health Organization and
Alzheimers Disease 2012). Thus, coping with
dementia is a common challenge in aging socie-
Synonyms ties. Dementia has received attention as one of the
key health threats and social issues in the twenty-
Alzheimers disease; Cognitive aging; Cognitive rst century.
impairment; Dementia One of the major predictors of dementia is age.
The age-specic prevalence of dementia nearly
doubles every 5 years from 60 to 95 years old
Definition (Hofman et al. 1991). The Leiden 85+ study
(Heeren et al. 1991) found that the prevalence of
This entry reviews the literature on the prevalence dementia was 15.2% in the 8589-year-old age
of dementia among centenarians, the cognitive group, 32.5% in the 9094-year-old age group,
function in centenarians without dementia, as and 41.2% in the 95-year-old age group.
well as risks and protective factors of cognitive Although the total number in the 95-year-old
function in very late life. Dementia prevalence age group in the study was only 14, these ndings
among centenarians might be substantially higher suggested that the probability of a dementia diag-
than that among younger older individuals; nosis seriously increases in very old age.
however, the exact prevalence rate among cente- In this entry, we focus on two topics relating
narians is unclear. First, we examine the method- to cognitive function among centenarians. Cente-
ological problems to be considered in future narian studies could provide information on the
studies. Large representative data sets and similar characteristics and degree of aging-related cogni-
protocols across studies are needed to clarify the tive changes until the nal stage of human life. At
inconsistent results. Second, we discuss the char- rst, we will give an overview of dementia prev-
acteristics of domain-specic cognitive functions alence in centenarians; however, the exact
488 Cognition
prevalence rate among centenarians is unclear. We among centenarians was very high, but there were
will also state the methodological problems to be dissociations in the prevalence across studies.
considered in future studies. Second, we will pre- The varying prevalence of dementia across
sent the characteristics of domain-specic cogni- studies might indicate ethnic or cultural inuences
tive functions in centenarians, although there are on the progression of dementia with aging. How-
few existing studies on this. Finally, we will sum- ever, before we go on to discuss this issue, two
marize signicant risk and protective factors that essential problems need to be pointed out. One is
might inuence cognitive decline or dementia in related to methodology, and the other is gender
centenarians from genetic, biomedical, and psy- differences. The methodological problems
chosocial perspectives. include sampling, denition of dementia, and
assessment procedures in centenarian studies.
Gender differences refer to the issue that the
Prevalence of Dementia dementia prevalence in centenarian samples
varies depending on the ratio of female and male
Dementia prevalence among centenarians has centenarians.
been reported over the past 20 years in various A small sample size can lead to an
countries. Three review papers on centenarians overestimation or underestimation of results and
dementia prevalence have been published yield inconsistent dementia prevalence among
(Calvert et al. 2006; Gondo and Poon 2007; centenarians. Previous centenarian studies include
Slavin et al. 2013). All three papers pointed out sample size ranging from 17 to 304 (Table 1).
that dementia prevalence varies across studies, Furthermore, there are often wide individual var-
due to methodological problems. Based on the iations and possibilities of large amounts of miss-
estimation of the age-specic prevalence of ing data in cognitive tests on centenarians. A total
dementia (Hofman et al. 1991), prevalence number exceeding hundreds of participants might
among centenarians is assumed to range between therefore be required for reliable statistical ana-
60% and 70%. Following reports of prevalence in lyses and valid estimations (Calvert et al. 2006).
previous reviews, we can roughly divide these In addition, researchers have to make an effort to
ndings into the following three categories: con- obtain representative data and to carefully inter-
siderably lower than the estimated prevalence pret results having a potential selection bias.
(e.g., less than 50%), almost within the estimated The denition of dementia is one of the funda-
range (e.g., around 60%), and much higher than mental problems in the comparison of results from
the estimated prevalence (e.g., more than 70%). different studies. Most studies have used stan-
Table 1 gives a detailed overview of 11 centenar- dardized diagnosis criteria for dementia. How-
ian studies reporting on dementia prevalence. ever, these criteria emphasize different
These studies showed that the dementia preva- dimensions considered for evaluation, to enable
lence ranged from 33% to 100%, and the average identication of dementia. The third edition
prevalence was 62% (males; 48.5%, females; revised and fourth edition of the Diagnostic and
66.1%). The study that presented the highest prev- Statistical Manual of Mental Disorders (DSM-III-R,
alence, the Dutch Centenarian Study (Blansjaar DSM-IV) have often been used for the diagnosis of
et al. 2000), included only 17 centenarians. On the dementia. Pioggiosi et al. (2004) explored the vari-
other hand, the study with the lowest prevalence, ation in dementia prevalence among 34 nonagenar-
the Finnish Centenarian Study (Sobel et al. 1995), ians and centenarians using four common diagnostic
excluded mild dementia. Except for one study, the criteria. They found different prevalence rates apply-
Yamanashi prefecture study (Asada et al. 1996) ing these criteria to the same participants. The prev-
showed only slightly more than 70%, and the alence of dementia was 47.1% with the use of the
other prevalence ranged from 50.7% to 67.6%. DSM-III-R; 41.2% with the DSM-IV; 29.4% with
These results suggested that dementia prevalence the World Health Organizations International Clas-
sication of Disease, 10th revision (ICD-10); and
Cognition, Table 1 Prevalence of dementia in centenarian studies
Authors
(publication Those who Those who
Cognition
year) agreed were tested Participated Age range

Project name countries Subjects (women: N, %) (women: N, %) ratio (%) mean SD Assessments Cognitive status Males Females
Dutch Blansjaar 17 in three 17 (15, 88.2%) 15 (13, 86.7%) 88.2 100104 CDR, Informant Dementia: 100% Dementia: Dementia: 100%
Centenarian et al. (2000) Dutch towns agreed, M = 101.2 Questionnaire on Cognitive (15/15) 100% (2/2) (13/13)
study The 2 females did Decline in the Elderly, CDR = 1: 20.0% CDR = 1: CDR = 1: 15.4%
Netherlands not test Amsterdam Dementia (3/15) 50% (1/2) (2/13)
Screening Test, Clock CDR = 2: 53.3% CDR = 2: CDR = 2: 53.8%
Drawing, Explaining says (8/15) 50% (1/2) (7/13)
CDR = 3: 26.7% CDR = 3: 30.8%
(4/15) (4/13)
New England Silver 43 in 36 (31, 86.1%) 34 (29, 85.3%) 79.1 100107 MMSE, CDR, DSM-IV, CDR = 0: 20.6% No gender No gender data
Centenarian et al. (2001) Massachusetts agreed, Mattis Dementia Rating (7/34) data
Study The United state 2 females died Scale, Boston Naming Test, CDR = 0.5:
States before test Trail-Making Test A & B, 11.8% (4/34)
Clock Drawing, Drilled Word Dementia: 67.6%
Span Test, Cowboy Story, CDR = 1: 8.8%
Presidents since Franklin (3/34)
Delano Roosevelt, Spiers CDR = 2: 29.4%
Calculations, Geriatric (10/34)
Depression Scale, Telephone CDR = 3: 20.6%
Interview for Cognitive (7/34)
Status, Test for Severe CDR = 4: 2.9%
Impairment, Tactile Naming, (1/34)
Cognition and Health History, CDR = 5: 5.9%
Psychiatry History (2/34)
Yamanashi Asada 50 in 50 (39, 83.0%) 47 (39, 83.0%) 94.0 100109 HDSR, DSM-III-R, Normal: 6.4% No gender No gender data
prefecture et al. (1996) Yamanashi agreed, 3 died M = 102 NINCDS-ADRDA, ICD-10, (3/47) data
study Japan prefecture before visit physical examination, Barthel Cognitive
index, medical and impairment
psychiatric history, a family without
history, current health status, dementia: 23.4%
Hachinski Ischemic Scale (11/47)
score Dementia: 70.2%
(33/47)
Mild: 31.9%
(15/47)
Moderate: 23.4%
(11/47)
Severe: 14.9%
(7/47)
(continued)
489
C
490
Cognition, Table 1 (continued)

Authors
Korean Choi 103 in Seoul, 89 (78, 87.6%) 89 (78, 87.6%) 86.4 100115 CDR, physical and mental CDR 0: 6.7% CDR 0: CDR 0: 5.1% (4/78)
Centenarian et al. (2003) Kyungsang, examination, laboratory tests (6/89) 18.2% (2/11) CDR 0.5: 30.8%
Study Korea Chunra, and CDR 0.5: 31.5% CDR 0.5: (24/78)
Cheju; the (28/89) 36.4% (4/11) Dementia: 64.1%
mean age was Dementia: 61.8% Dementia: (50/78)
102.4 2.6 (55/89) 45.5% (5/11) CDR 1: 25.6%
years CDR 1: 27.0% CDR 1: (20/78)
(24/89) 36.4% (4/11) CDR 2: 15.4%
CDR 2: 14.6% CDR 2: 9.1% (12/78)
(13/89) (1/11) CDR 3: 23.1%
CDR 3: 20.2% CDR 3: 0% (18/78)
(18/89) (0/11)
Heidelberg Kliegel and 156 from 91 agreed, 90 (81, 90.0%) 57.7 100 A shortened MMSE No cognitive No gender No gender data
Centenarian Skwinski 60 km around 1 did not test M = 100.2 (21 points max.), GDS impairment 22% data
Study (2004), Heidelberg 0.41 Very minor: 7%
Kliegel Minor: 12%
et al. (2004b) Moderate: 10%
Germany Substantial: 21%
Severe: 16%
Very severe: 12%
Northern Ravaglia 154 in 100, 1 woman 92 (56, 60.9%) 59.7 100107 MMSE, CDR, DSM-IV, No dementia No dementia: No dementia 14.3%
Italian et al. (1999) Bologna and died, 7 persons M = 101.8 ICD-10, NINCDS-ADRDA 20.7% (19/92) 30.6% (8/56)
Centenarian Italy Ravenna were out of the 1.6 Cognitive (11/36) Cognitive
Study study setting impairment Cognitive impairment without
without impairment dementia: 12.5%
dementia: 15.2% without (7/56)
(14/92) dementia: Psychiatric diseases
Psychiatric 19.4% (7/36) other than
diseases other Psychiatric dementia: 3.6%
than dementia: diseases (2/56)
2.2% (2/92) other than Dementia: 69.6%
Dementia: 62.0% dementia: (39/56)
(57/92) 0% (0/36) CDR = 0.5: 7.1%
CDR = 0.5: 6.5% Dementia: (4/56)
(6/92) 50.0% CDR = 1: 1.8%
CDR = 1: 2.2% (18/36) (1/56)
(2/92) CDR = 0.5: CDR = 2: 7.1%
CDR = 2: 7.6% 5.6% (2/36) (4/56)
Cognition
(7/92) CDR = 1: CDR = 3: 16.1%
CDR = 3: 17.4% 2.8% (1/36) (9/56)
(16/92) CDR = 2: CDR = 4: 16.1%
Cognition
CDR = 4: 14.1% 8.3% (3/36) (9/56)

(13/92) CDR = 3: CDR = 5: 21.4%
CDR = 5: 14.1% 19.4% (7/36) (12/56)
(13/92) CDR = 4:
11.1% (4/36)
CDR = 5:
2.8% (1/36)
Finnish Sobel 271 in Finland 185 were 179 66.1 100+ Pfeiffers Short Portable Normal: 44.1% Normal: Normal: 41.7%
Centenarian et al. (1995) interviewed (151, 84.4%) Mental Status Questionnaire, (79/179) 57.1% (63/151)
Study Finland took blood DSM-III-R Cognitive (16/28) Cognitive decline/
sample decline/mild Cognitive mild dementia:
dementia 22.9% decline/mild 22.5% (34/151)
(41/179) dementia: Dementia: 35.8%
Dementia: 33.0% 25.0% (7/28) (54/151)
(59/179) Dementia:
17.9% (5/28)
Longitudinal Andersen- 276 in 207 207 75.0 100 ICD-10, CDR, MMSE, CDR = 0: 25.1% No gender No gender data
Study of Ranberg Denmark (162, 78.3%) (162, 78.3%) medical records, physical (52/207) data
Danish et al. (2001) examination, ADLs, IADLs, Probably no:
Centenarians Denmark proxy interview 11.1% (23/207)
CDR = 0.5: 7.7%
(16/207)
Dementia: 50.7%
(105/207)
CDR = 1: 16.9%
(35/207)
CDR = 2: 20.3%
(42/207)
CDR = 3: 13.5%
(28/207)
Not
classied:5.3%
(11/207)
(continued)
491
C
492
Cognition, Table 1 (continued)

Authors
Tokyo Homma 509 in Tokyo 509 218 42.8 100+ HDS, CDR, family history, CDR = 0: 15.1% CDR = 0: CDR = 0: 8.4%
Centenarian et al. (1992) (379, 74.5%) (155, 71.1%) M = 100.6 medical record, physical (33/218) 31.7% (13/155)
Survey Japan 1.3 examination, ADLs CDR = 0.5: (20/63) CDR = 0.5: 17.4%
16.5% (36/218) CDR = 0.5: (27/155)
Dementia: 62.8% 14.3% (9/63) Dementia: 71.0%
(137/218) Dementia: (110/255)
CDR = 1: 21.6% 42.9% CDR = 1: 20.6%
(47/218) (27/63) (32/155)
CDR = 2: 21.1% CDR = 1: CDR = 2: 23.2%
(46/218) 23.8% (36/155)
CDR = 3: 20.2% (15/63) CDR = 3: 27.1%
(44/218) CDR = 2: (42/155)
Unknown:5.5% 15.9% Unknown: 3.2%
(12/218) (10/63) (5/155)
CDR = 3:
3.2% (2/63)
Unknown:
11.1% (7/63)
Georgia Poon about 1200 in 244 240 20.0 98108 GDS, MMSE, CDR, GDS = 12 GDS = 12: GDS = 12: 22.7%
Centenarian et al. (2012) Northern (207, 84.8%), (203, 84.6%) M = 100.6 Wechsler Adult Intelligence (no dementia): 20.9% (9/43) (45/198)
Study The United Georgia four females 2.04 Scale, Direct Assessment of 22.4% (54/241) GDS = 3: GDS = 3: 22.7%
States had missing Functional Status scale, GDS = 3 (MCI): 37.2% (45/198)
data Controlled Oral Word 25.3% (61/241) (16/43) GDS = 47:54.5%
Association Test, Behavioral GDS = 47 GDS = 47: (108/198)
Dyscontrol Scale, ADLs, (dementia): 41.9%
IADLs 52.3% (126/241) (18/43)
Cognition
Tokyo Gondo 1194 in the 514 304 25.5 100107 MMSE, CDR, GDS, scales CDR = 0:24.3% CDR = 0: CDR = 0: 19.2%
Centenarian et al. (2006) 23 wards of (239, 78.6%) M = 101.1 for mental state and daily (74/304) 43.1% (46/239)
Study Japan metropolitan 1.7 living activities for the elderly CDR = 0.5: (28/65) CDR = 0.5: 13.4%
Cognition
Tokyo 13.8% (42/304) CDR = 0.5: (32/239)

Dementia: 61.8% 15.4% Dementia: 67.4%
(188/304) (10/65) (161/239)
CDR = 1:18.8% Dementia: CDR = 1: 19.2%
(57/304) 41.5% (46/239)
CDR = 2: 9.5% (27/65) CDR = 2: 10.0%
(29/304) CDR = 1: (24/239)
CDR = 3: 16.4% 16.9% CDR = 3: 18.8%
(50/304) (11/65) (45/239)
CDR = 4: 8.9% CDR = 2: CDR = 4: 10.5%
(27/304) 7.7% (5/65) (25/239)
CDR = 5: 8.2% CDR = 3: CDR = 5: 8.8
(25/309) 7.7% (5/65) (21/239)
CDR = 4:
3.1% (2/65)
CDR = 5:
6.2% (4/65)
Note: ADLs activities of daily living; CDR clinical dementia rating; DSM-III-R the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders; DSM-IV
fourth edition of the Diagnostic and Statistical Manual of Mental Disorders; GDS the Global Deterioration Scale; HDS Hasegawa Dementia Scale; HDSR Hasegawa Dementia
Scale Revised; IADLs instrumental activities of daily living; ICD-10 the World Health Organizations International Classication of Disease, 10th revision; MMSE the Mini-Mental
State Examination; NINCDS-ADRDA the National Institute of Neurological and Communicative Disorders and Stroke and the Alzheimers Disease and Related Disorders
Association
493
C
494 Cognition
38.2% with the Cambridge Examination for Mental hearing disabilities as questionable cases. These
Disorders of the Elderly (CAMDEX). The ICD-10 sensory impairments are very common in very old
criteria for dementia yielded the lowest rate of age and are likely to hinder the understanding or
dementia among the four criteria. This dissociation following of instructions of the cognitive tests,
appears to be due to requirements for evaluation. which may result in overestimating the cognitive
The ICD-10 criteria always required impairments in issues in centenarians. Thus, dementia prevalence
three executive functions. On the other hand, the is inuenced by how researchers dene and use
DSM-III-R criteria, leading to the highest rate, these questionable cases in their studies (e.g.,
required at least one or more impairments in abstract considering them as part of the dementia group
thinking or judgment or impairment of higher corti- will lead to an increase of the prevalence, while
cal functions or personality changes. The DSM-III- treating them as a part of the group without
R is less restrictive than the DSM-IV in assessing dementia will decrease the prevalence).
cognitive function except for memory. Conse- Gender differences can also result in varying
quently, the DSM-IV criteria, including impairments prevalence. The Northern Italian Centenarian
in executive function or condition of having central Study (Ravaglia et al. 1999) reported different
nerve damage, such as aphasia, lead to the second prevalence rates, depending on gender and sever-
highest rate. The CAMDEX, with the second lowest ity of dementia. Their reports on dementia preva-
rate, has different characteristics in requirements of lence were based on the DSM-IV criterion and
progressive deterioration for the diagnosis and of included questionable cases. At 69.6% (N =
impairments in behavioral and emotional functions. 39/56), dementia prevalence among women was
This is why the proportion of dementia by the higher than that among men, at 50.0% (N =
ICD-10 seems to be lowest among these criteria. 18/36). However, there was no signicant differ-
As mentioned in a later section, centenarians tend ence in prevalence rate and severity of dementia
to show large dissociations in the decline of different between female and male centenarians, likely due
cognitive domains. This characteristic might to the small case number in each subgroup. Using
increase the chances of variations occurring as a a larger sample of 304 individuals, the Tokyo
result of the use of different denitions. Centenarian Study (Gondo et al. 2006) reported
Differences in exclusion criteria of cases with different prevalence rates for dementia according
questionable dementia were also observed. Some to gender. In this sample, the ratio of women to
studies, for example, excluded in their reports men was roughly 1:3.6, which was almost similar
cases where the criteria to identify dementia to the total centenarian population in this research
were not sufcient and the diagnosis was uncer- area. They showed that the dementia prevalence
tain. In the Longitudinal Study of Danish Cente- was 61.8% (188/304) of the total, 67.4%
narians (Andersen-Ranberg et al. 2001), a (161/239) among women, and 41.5% (27/65)
comprehensive survey was conducted on all indi- among men, based on a CDR score with the
viduals living in Denmark who were aged exactly range of 15 to determine dementia. The ndings
100 during the survey period. One-hundred sixty- showed clear differences in prevalence between
two out of 222 women and 45 out of 54 men female and male centenarians. The higher the
participated in this study. According to the criteria percentage of female centenarian sample, the
of ICD-10 and the Clinical Dementia Rating scale higher the dementia prevalence in the overall
(CDR), the identied prevalence rate of dementia, sample. Thus, gender-specic data should be
including mild, moderate, and severe dementia, reported to interpret results while taking into
was 51% in 100-year-old individuals. They account the gender ratio.
excluded cases with the probably no dementia Currently, the direct comparison of dementia
cases and the questionable cases. If they had prevalence across centenarian studies is problem-
treated these cases as the category with dementia, atic due to the issue mentioned above. For precise
the prevalence would have increased. Some stud- comparisons, researchers should collect data from
ies have also considered individuals with visual or larger representative samples, with uniform
Cognition 495
procedures and denitions of dementia. Adopting et al. (2009) compared the scores of centenarians
this kind of careful assessment procedures would and younger controls on ve cognitive domains,
reduce errors in identication of dementia among as measured by the MMSE. They reported that
centenarians. Otherwise, discussion of cohort, concentration, language and praxis (i.e., reading
regional, and cultural differences in dementia and obeying, listening and obeying, writing a
prevalence among centenarians is likely to lead sentence, copying pentagons, and naming), and
to questionable conclusions. repetition among centenarians were not lower, C
compared to those of individuals in the younger
age groups. Both studies showed small age differ-
Cognitive Function in Non-demented ences in the domain relating to language, but large
Centenarians age differences in episodic memory. These nd-
ings might indicate that a fundamental character-
As described above, there is a very high preva- istic of intellectual aging, namely, a smaller
lence of dementia among centenarians. Most cen- decline in the pragmatic domains and a larger
tenarian studies have assessed cognitive function, decline in the mechanic domains are well-known
using dementia screening tests such as the Mini- phenomena, was still preserved among
Mental State Examination (MMSE), CDR, or the centenarians.
Global Deterioration Scale (GDS). The mean of The Georgia Centenarian Study examined the
MMSE scores among 244 individuals aged role of intelligence, memory performance, and
98108 years old was 16.2 8.80 (SD) (Dai problem-solving ability in cohorts aged from
et al. 2013), indicating that mean cognitive func- 60 to 80 and to 100 years old (Poon et al. 1992).
tion in non-demented centenarians was much The study showed that centenarians had
lower than that among younger older individuals. maintained their everyday problem-solving abili-
Considering 68 centenarians who had a CDR ties, measured by the nine real-life problems
score of 0, the mean of MMSE was 22.3 3.32 encountered at home on an everyday basis. Fur-
(Inagaki et al. 2009). These ndings showed thermore, the study also showed that problem-
global cognitive function in centenarians to be solving abilities had an effect on mental health
equal to or only slightly lower than the established as well as personality and coping. Moreover, cen-
clinical cutoffs in younger older individuals. At tenarians with high cognitive function obtained
the same time, large individual differences were high levels of activity of daily living. These nd-
reported among non-demented centenarians. ings suggested that the maintenance of the
To date, no study has reported trajectory of mechanic domains of cognitive function might
domain-specic cognitive aging from younger be possible in centenarians and that it might
older individuals to centenarians. Descriptions enable them to manage and cope with old-age
of domain-specic conditions in centenarians adversity.
can contribute toward an understanding of
normal, aging-related cognitive change and sta-
bility in very old people. Few studies mentioned Risk for Cognitive Decline and Dementia
this issue. The Georgia Centenarian Study pro- in Centenarians
vided norm data of domain-specic abilities in
verbal abstract reasoning, uency, and memory Recently, the risk factors for dementia and cogni-
(Mitchell et al. 2013). They reported that cente- tive decline among individuals in very old age
narians obtained cognitive performance averages have received increasing attention. The disclosure
that were lower than those of octogenarians. of risk factors might contribute toward the devel-
Moreover, age differences in verbal abstract rea- opment of strategies for a healthy long life. To
soning, uency, and recognition were smaller than date, few centenarian studies have addressed this
those in immediate and delayed recall. Using data issue. Interestingly, limited ndings suggest that
from the Tokyo Centenarian Study, Inagaki centenarians and younger older people may not
496 Cognition
have the same risk factors. Complex and mutual in centenarians (r = 0.37, p = 0.001), also
relationships among risk factors for cognitive showing a pulse pressure (PP) range that was
decline and dementia are still not clear, even for narrower in individuals with dementia, as com-
the younger older adults. Findings from centenar- pared to those without it. Moreover, Szewieczek
ian studies might help clarify these conundrums. et al. (2015) reported that centenarians with
We will describe this issue by focusing on brain SBP>=140 mmHg and with diastolic BP
aging in centenarians from genetic, biomedical, (DBP)>=90 mmHg had higher likelihood for a
and behavioral viewpoints. subsequent 180-day survival. The association
between SBP and MMSE scores was expressed in
an inverted-U-shaped curve, whereas that between
Genetic Factor DBP and MMSE scores was best in a liner curve.
These results indicate an association between high
The apolipoprotein E (APOE) gene, recognized BP and good cognitive function, depicting a con-
for its important roles of transporting and tradictory relationship to that found among individ-
delivering lipids, is one of the most commonly uals in younger older age. Centenarians with
investigated gene polymorphisms. Among three moderately high BP might show better cognitive
common alleles, including e2, e3, and e4, the e4 performance.
allele might facilitate ineffective repair and pro-
tection from neuronal damage. The presence of
the e4 allele has been identied as a major risk Nutrition Factors
factor for the development of AD in younger older
adults (Ashford and Mortimer 2002). However, As factors related to metabolic activities of the
whether the APOE e4 has an effect on cognitive brain, we must focus attention on nutrition in old
function among individuals in very old age is still age. The Georgia Centenarian Study examined the
controversial. While there was a signicant nega- role of diet for cognitive function in centenarians
tive association between the e4 allele and cogni- (Johnson et al. 2013). Signicant relationships
tive function among 103 Korean centenarians were observed between cognitive performance
(Choi et al. 2003), this association was not and dietary carotenoids, including serum lutein,
observed in 179 Finnish (Sobel et al. 1995) and zeaxanthin, and b-carotene in the serum and brain.
33 Japanese centenarians (Asada et al. 1996). However, these relationships differed from those
Compared to younger older people, centenarians observed in other studies for the younger older
tend not to have the e4 allele. Thus, the survival population.
effect for individuals with the APOE e4 might Arai et al. (2015) showed that well-nourished
hamper the evaluation of the effect of the APOE centenarians who showed high serum albumin
on cognitive function in centenarians. levels had signicantly higher MMSE scores. In
addition, the study found that high serum albumin
levels and inammation suppression were associ-
Cardiovascular Factors ated with low CRP and IL-6 levels among cente-
narians. Although the nutritional status in the
Hypertension, a cardiovascular disease, is a sig- blood serum shows a relationship with cognition,
nicant risk factor for cognitive impairment. no study has shown a direct relationship between
However, some centenarian studies have shown food intake and cognitive function among cente-
higher blood pressure (BP) to be associated with narians. They speculated that inammatory reac-
better cognitive performance and survival. tions occurring along with aging might lead to
Richmond et al. (2011) showed that systolic BP a low nutritional status and low cognitive
(SBP) positively correlated with the MMSE score function in very old age. In the future, there is a
Cognition 497
need for a comprehensive study focusing on the performance when reaching centenarian status,
associations between food intake, nutrition level are necessary to enable a better understanding of
in the blood serum, and cognitive function among healthy cognitive aging in very old age.
centenarians.
Summary and Future Directions

Psychosocial Factors C
This entry has summarized ndings on the preva-
In addition to the factors mentioned above, recent lence of dementia among centenarians, the cogni-
gerontology studies have started considering psy- tive function levels in non-dementia centenarians,
chosocial factors as pathways to maintenance of as well as risk and protective factors of cognitive
cognitive function in old age. Specically, studies function in very late life. Findings suggest that
examined the effect of life antecedents, such as dementia prevalence among centenarians was sub-
education, work, and leisure activities, on late-life stantially higher than that among younger older
cognition and the risk of dementia. Studies individuals and that women tended to have higher
addressing the complexity of work engaged prevalence rates than men did. However, large
throughout their main lifetime reported that highly differences in dementia prevalence rates across
demanding work was associated with a low risk of different studies have also been observed. A large
cognitive impairment in younger older age. representative database and similar protocols are
A review paper showed the positive effects of needed to clarify the inconsistent results previously
high control and work complexity on cognition obtained. Furthermore, researchers should examine
in late life (Then et al. 2014). Moreover, many the inuence of genetic, biomedical, and environ-
ndings support the notion that physical activi- mental factors on cognitive function and dementia
ties, social engagements, and intellectual stimula- among centenarians. As protective factors, nutri-
tion in leisure activities could promote cognitive tion in the serum and an active lifestyle across the
function in old age (Hertzog et al. 2008). There is lifespan might maintain cognitive function until
a need to examine whether complexity of work in very old age; however, few studies relating to this
midlife and engagement in leisure in old age could have been conducted. In addition to the
affect cognitive function among centenarians. abovementioned issues, the following topics will
A prospective study is recommended for such also be important in clarifying the nature of cogni-
research topics; however, it is not feasible in cen- tive aging among centenarians.
tenarian studies. In one centenarian study, cente-
narians and their proxies were interviewed, with
their lifelong engagements in cognitive activities GeneEnvironment Interaction
retrospectively evaluated (Kliegel et al. 2004a).
The study demonstrated that higher education and More recently, the role of geneenvironment
the number of intellectual activities engaged in interactions in older adults cognitive function
predicted higher cognitive function in centenarians. has gained interest. Wang et al. (2012) reported
Moreover, the number of intellectual activities that that higher education might modify the effect of
adults engaged in mediated the association the APOE e4 on the risk of dementia among
between childhood education and cognitive func- participants aged 65 years. In the study, among
tion in centenarians. A prior active lifestyle might the e4 allele carriers, if they had more than 7 years
be an important predictor of cognitive ability, even of education levels, the risk of dementia was
in centenarians. Further retrospective studies reduced by half, compared to those with less
assessing the activities performed during their 80s than 8 years of education levels. Environmental
and 90s, in order to link these to the cognitive factors must be controlled for, to enable
498 Cognition
clarication of the effect of genetic factors on enhancement, decrement, and variability in scores
cognitive function even in very old age. across the 8-month testing period (Margrett
et al. 2012). Examining intraindividual changes
or patterns of cognitive changes would be
Neuropathology in the Brain recommended because it might prove more sensi-
and Cognition tive to cognitive impairments than would a
one-shot assessment of cognitive performance.
Autopsy studies in very old age suggest that there
is some level of dissociation between the neuro-
Acknowledgments This study was funded through a
pathological change of the brain and cognitive grant from the Grant-in-Aid for Scientic Research
performance. The prevalence of neuropathology (B) (No. 26310104), allocated by the Japan Society for
associated with AD ranged from about 20% to the Promotion of Science, and one from the Human Sci-
ence Project at Osaka University.
about 40% when individuals met at least several
criteria for AD-related neuropathology (Price
et al. 2009). The result suggests that some people
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Deckert, S., Nieuwenhuijsen, K., Seidler, A., &
Riedel-Heller, S. G. (2014). Systematic review of the life expectancy at birth has increased from about
effect of the psychosocial working environment on 45 years in the 1800s to above 75 years in the
cognition and dementia. Occupational and Environ- twentieth century. This remarkable 30-year gain
mental Medicine, 71, 358365. in physical health is, however, not necessarily
Wang, H.-X., Gustafson, D. R., Kivipelto, M., Pedersen,
N. L., Skoog, I., Windblad, B., & Fratiglioni, L. (2012). accompanied by cognitive tness and mental
Education halves the risk of dementia due to apolipo- well-being into old age. Faced with the rapid
protein e4 allele: A collaborative study from the Swed- growth of aging populations worldwide and an
ish brain power initiative. Neurobiology of Aging, 33, ever-expanding prevalence of dementia and
1007.e11007.e7.
World Health Organization, Alzheimers Disease Interna- other aging-related neuropathologies, understand-
tional. (2012). Dementia: A public health priority. ing basic mechanisms of the still preserved cog-
Geneva: World Health Organization. nitive and brain plasticity in old age in order to
uphold and delay functional declines of the aging
mind has become a key challenge for cognitive
neuroscience, psychology, and gerontology in the
21st century.
Cognitive and Brain Plasticity As foreshadowed in the quote from Baltes et al.
in Old Age (2006) above, cognitive interventions and brain
plasticity are closely interwoven. This brief
Franka Thurm1 and Shu-Chen Li1,2
1 review will rst introduce theoretical concepts of
Department of Psychology Chair of Lifespan
plasticity that are pertinent for geropsychology,
Developmental Neuroscience, TU Dresden, followed by a selected overview about cognitive
Dresden, Germany
2 plasticity in key domains of cognition, focusing
Center for Lifespan Psychology, Max Planck specically on episodic memory, working mem-
Institute for Human Development, Berlin, ory, and executive control. Using memory plastic-
Germany ity as an example, dopaminergic neuromodulation,
the frontalparietal circuitry, and neurogenesis
What seemingly was often overlooked is that the brain
involving the brain-derived neurotrophic factor
itself is a dependent variable, something that is co-shaped
by experience and culture, something that does not (BDNF) will be highlighted as intermediate mech-
operate within an environmental vacuum, but that at any anisms that link brain and cognitive plasticity. In
moment is subject to environmental constraints and the last section, plasticity in populations with
affordances.
aging-related neuropathologies as well as potential
Paul B. Baltes, Patricia A. Reuter-Lorenz, &
noninvasive brain stimulations as additional inter-
Frank Rsler, 2006 vention approaches beyond cognitive and physical
(Italics added; Lifespan Development and the Brain, p. 4) tness interventions will be reviewed.
Cognitive and Brain Plasticity in Old Age 501
Theoretical Propositions correlations among sub-facets of intellectual func-

of Developmental Plasticity tioning (e.g., perceptual speed, reasoning, mem-
ory, and verbal knowledge) or basic cognitive
The concept of plasticity has a long history in processes (e.g., working memory and episodic
psychology and neuroscience. In his classical vol- memory) are higher in old age than in early adult-
ume, The Principles of Psychology, William hood, indicating dedifferentiation in the orga-
James (1980) considered neural mechanisms of nization of cognitive processes in old age C
the mind to be endowed with substantial poten- (Li et al. 2004). At the brain level, extant evidence
tials to be inuenced by experiences and learning. also indicates that, relative to young adulthood,
Around the same time, Santiago Ramn y Cajal brain processes of various cognitive functions in
(1894) in neuroscience also contemplated about old age tend to activate more diffused networks or
the possibilities of mental exercises as means recruit additional brain regions (see Park and
for facilitating the connections between neural Reuter-Lorenz 2009 for a review).
networks.
Among modern concepts of plasticity, in our
view, the following propositions are particularly Cognitive Plasticity
relevant from the perspectives of lifespan devel-
opment and geropsychology. First is the concept Notwithstanding evidence for developmental
of developmental reserve capacity in old age reserve capacity in old age, cognitive intervention
(Baltes 1987): notwithstanding declines in their research over the past decades also revealed that
neurocognitive resources, older adults still pos- the potential for training gains is more limited in
sess considerable latent reserve capacity, such old age relative to other periods of the lifespan.
that if suitable environmental supports or inter- The degree of plasticity limitation, however,
ventions could be provided, their performance varies between cognitive domains. In terms of
could be maintained or even improved. This con- the extent of training gains in episodic memory,
cept underlies much of the training and interven- evidence from research that applied mnemonic
tion research conducted cover the past decades, strategies for training the encoding and retrieval
which aims at maintaining or enhancing cognition of associative memory revealed substantially
in old age by cognitive and/or physical tness reduced plasticity in old age relative to younger
training and lifestyle enrichments (see Hertzog adults and children (Brehmer et al. 2007; Shing
et al. 2009 for a review). A second notion is that et al. 2008). Specically, the so-called baseline
prolonged mismatches between task demands and plasticity i.e., the potential to benet from
supplies of neurocognitive resources can trigger being instructed with memory strategies
alternations in cognitive and brain processes (e.g., method of loci or paired associates) was
(Lvdn et al. 2010). Recognizing that the comparable between different age groups,
demandsupply balance is an important factor in whereas the plasticity in implementing those
driving plasticity implicates that programs or respective memory strategies through practice to
methods for enriching older adults cognitive strengthen associative memory was much more
and physical experiences need to closely adjust limited in older adults compared to younger adults
the balance between task demands and individual and children (see Fig. 1; Brehmer et al. 2007). In
abilities during the course of training for optimal contrast, the plasticity of working memory and
intervention results. A third proposition is that executive control functions seem to be less age
exible adaptions to declines in neurocognitive dependent. A recent meta-analysis (Karbach and
resources and increases in task demands can lead Verhaeghen 2014) revealed comparable effect
to reorganizations of cognitive processes sizes (around 0.6) of training gains in these two
(Li et al. 2004), and brain mechanisms (Park and domains of functions in younger and older adults.
Reuter-Lorenz 2009) that go beyond effects on the Beyond training or practice gains, whether the
levels of performances or functions. Indeed, the training benets would transfer to other untrained
Cognitive and Brain

Plasticity in Old Age,
Fig. 1 Lifespan age
differences in episodic
memory plasticity (Data
adapted from Brehmer
et al. (2007) with
permission; copyright
American Psychological
Association 2007)
tasks is an additional indicator that is of practical cognitive intervention effects, the effects of phys-
relevance when considering interventions for ical tness training on older adults cognitive per-
maintaining or improving older adults daily cog- formance also differed between domains of
nitive competence. Results from a meta-analysis functions, with executive control processes (e.g.,
showed that in older adults transfer of training working memory, inhibition, and multitasking)
benets at the level of specic tasks is usually in showing the largest training benet (Colcombe
the range of moderate effect sizes (0.20.4) for and Kramer 2003; see Fig. 2).
working memory or episodic memory functions
(Karbach and Verhaeghen 2014). Relatedly, a
unique extensive cognitive intervention study Linking Levels of Memory Plasticity:
(Schmiedek et al. 2010, the COGITO study) com- From Brain to Cognitive Plasticity
pared transfer effects of an intensive training on
multiple domains of cognitive functions (i.e., over This section focuses specically on plasticity of
6 months of 1-h daily practice of perceptual speed, working memory and episodic memory to high-
working memory, and episodic memory tests). Of light the multiple levels of mechanisms involved,
note, in both younger and older adults, transfer from neurobiological to behavioral plasticity.
effects were not only observed with respect to A number of relevant neurochemical mechanisms
individual tests but also for cognitive abilities have been identied. Specically, neurotransmit-
represented as latent factors. This indicates that ters such as acetylcholine, norepinephrine, and
training benets can be observed at the level of dopamine are implicated in the modulation of
cognitive abilities, instead of just at the level of long-term potentiation (LTP), which is an impor-
specic tests. However, the transfer effects at the tant molecular mechanism of memory (Squire and
level of latent cognitive abilities were more lim- Kandel 1999). Given that dopamine and other
ited in older than in younger adults. neurotransmitters are involved in affecting synap-
Other than cognitive interventions, aerobic tic plasticity, lifespan age differences in the ef-
physical tness trainings have been shown to cacy of neuromodulation thus would have direct
yield transferrable benets to cognition, beyond implications on experience-dependent tuning of
physical functions. Specically, a recent review of synaptic connections. Over the past two decades,
physical intervention research over the last studies investigating the impact of aging on the
decades (Prakash et al. 2015) points to positive brains neurochemical processes have yielded the
cross-domain transfer effects of enhancing aero- consensus of substantial age-related declines in
bic physical tness on executive control and the efcacy of various neurotransmitter systems.
memory functions in older adults. Similar to Of particular interest here are aging-related
Cognitive and Brain

Fig. 2 Effect sizes of
aerobic tness training on
cognitive performance in
older adults for different
types of cognitive tasks.
Plotted are mean
differences in pre- and post-
C
training cognitive
performances of the training
and control groups (Data
adapted from Colcombe
and Kramer (2003) with
permission; copyright
American Psychological
Society 2003)
declines in different components of the dopami- memory training and changes in dopamine signal-
nergic system. Estimates based on currently avail- ing in various brain regions that are crucial for
able cross-sectional evidence indicate about 10% working memory functions. In younger adults,
decline in dopamine receptor functions per decade working memory training over 5 weeks was asso-
starting from the age of early 20s (see Bckman ciated with changes of dopamine D1 receptor
et al. 2006; Li and Rieckmann 2014 for reviews). binding potential in the prefrontal and parietal
Frontalstriatal dopamine signaling is closely cortex (McNab et al. 2009) as well as D2 receptor
involved in regulating working memory and exec- binding in the striatum (Bckman et al. 2011).
utive control functions. In healthy young adults, Furthermore, individuals who showed larger per-
better working memory performance has been formance improvements as a function of working
associated with higher capacity of striatal and memory training also exhibited a greater training-
extrastriatal dopamine synthesis (see Li and related change in receptor binding potential
Rieckmann 2014 for review). Regarding aging, a (McNab et al. 2009).
recent study (Rieckmann et al. 2011) showed that The direct effect of aging-related decline in
functional connectivity between the prefrontal dopaminergic modulation on memory plasticity
and parietal cortices, key regions of the network has thus far not yet been empirically established,
that underlies working memory, was reduced in but a theoretical link has already been suggested
older compared to younger adults. Importantly, in for more than a decade. Modeling aging-related
older adults, interindividual differences in the decline in dopaminergic neuromodulation by sto-
frontalparietal connectivity correlated positively chastically attenuating the gain control of the
with striatal caudate D1 receptor density: those sigmoidal activation function that models presyn-
older adults whose D1 receptor availability was aptic to postsynaptic inputresponse transfer,
higher relative to same-aged peers showed higher computational stimulations results accounted for
frontalstriatal functional connectivity during the reduced associative memory plasticity and
working memory. These results suggested that working memory capacity in old age
age-related losses in striatal DA receptors could (Li et al. 2001; see also Li and Rieckmann 2014
contribute to age-related decline in functional for a recent review). Although without direct mea-
brain dynamics of working memory. sures of dopamine synthesis or binding, a recent
Of particular interest, two recent positron emis- functional brain imaging study showed that
sion tomography (PET) receptor imaging studies reduced striatal activity may contribute to reduced
established the rst empirical links between transfer effects of working memory training in
Cognitive and Brain

Fig. 3 (a) The left dorsal
frontal cortex and the left
occipitoparietal cortex
showed increased activity
after the method of loci
memory training relative to
a pretest baseline. (b) Group
differences in the
comparison of method of
loci use with pretest. The
younger and the improved
older adults, but not the
unimproved old, activated
the left occipitoparietal
cortex. (c) Age differences
in the comparison of
method of loci use with
pretest. The young but not
the old adults activated the
left dorsal frontal cortex
(Data adapted with
permission from Nyberg
et al. (2003); copyright the
National Academy of
Sciences, USA, 2003)
older adults (Dahlin et al. 2008). Given that dopa- effects of dopaminergic modulation on episodic
mine pathways extensively innervate the striatum, spatial memory in a crossover pharmaco (ON/
this nding hints at the possibility that aging- OFF)-behavioral design. Using Parkinson's dis-
related decline in transfer effects of working ease as a model disorder which is characterized
memory training may be related to impaired by severe and progressive degeneration of
striatal dopaminergic modulation. nigrostriatal dopamine, the authors showed that
Regarding brain correlates of episodic memory dopaminergic medication facilitated striatum-
plasticity in old age, the plasticity of the dependent spatial learning based on cue-location
frontalparietal network as a function of memory associations. A positive medication effect on hip-
training has also been investigated (Nyberg pocampus-dependent spatial memory relying
et al. 2003). After being instructed to use the more on relations between object locations and a
method of loci as a mnemonic strategy, increased local spatial boundary depended on prior experi-
brain activities in frontal as well as occipito- ence with the navigation task (Thurm et al. 2016).
parietal regions were observed in younger adults. Given these results, aging-related decline in the
In contrast, accompanying their reduced episodic dopamine system might differentially affect spa-
memory plasticity as indicated by the reduced tial memory plasticity and transfer effects of nav-
training gain, older adults did not show training- igation trainings might depend upon the task-
related increase in frontal activity, and only those relevant underlying brain structures.
older adults who beneted from the memory train- Turning to effects of aerobic physical tness
ing showed increased occipitoparietal activity training on episodic memory (see Prakash
(see Fig. 3). A recent study further investigated et al. 2015 for a recent review), a study of
a LEFT HIPPOCAMPUS RIGHT HIPPOCAMPUS

5.2 5.2
Hippocampus
5.1 5.1
Volume (mm3)
Volume (mm3)
5 5
4.9 4.9
4.8 4.8
4.7 4.7 C
4.6 4.6
Baseline 6-months 1-year Baseline 6-months 1-year
b 100 c 25
% change in Memory performance

80 20
15
% change in BDNF
60
10
40 5
20 0
0 5
20 10
15
40
20
60 25
Shrinking Growing r =.37; p<.01 Shrinking Growing r =.33; p<.02
80 30
10 5 0 5 10 15 20 10 5 0 5 10 15 20
% change in Right Hippocampus Volume % change in Right Hippocampus Volume
Cognitive and Brain Plasticity in Old Age, Fig. 4 (a) volume is correlated with memory performance improve-
Effects of aerobic tness training on hippocampal volume ment in older adults (Data adapted from Erickson
in older adults. (b) Positive effects of exercise on increased et al. (2011) with permission; copyright the National Acad-
serum BDNF level are correlated with increased hippo- emy of Sciences, USA, 2011)
campal volume in older adults. (c) Increased hippocampal
particular interest (Erickson et al. 2011) showed hippocampal volume suggest that cell prolifera-
that aerobic exercise (3 days/week over 1 year) tion or increased dendritic branching might con-
increased the volume of the hippocampus in older tribute to the training-related increases in
adults by 2%, thus effectively reversed the hippocampal volume and memory function in
age-related loss in hippocampal volume by 1 to older adults (see Erickson et al. 2011 for review).
2 years (see Fig. 4). Moreover, the increase in
hippocampal volume was associated with
improved spatial memory performance and with Cognitive Plasticity in Aging-Related
greater serum levels of brain-derived neurotrophic Neuropathology
factor (BDNF). The hippocampus is central for
episodic and spatial memory and is rich in BDNF, A range of neuropathological conditions are age
which is a putative mediator of neurogenesis and associated. Therefore, this section focuses on cog-
dendritic expansion. Early animal studies showed nitive plasticity in populations manifesting aging-
that voluntary wheel running enhances BDNF related neuropathology. Mild cognitive impair-
gene expression, neurogenesis, and cell prolifera- ment (MCI) refers to a transitional zone between
tion in the hippocampus of mice and rats (Adlard normal and pathological cognitive aging. Older
et al. 2005; Neeper et al. 1995), decreases beta- adults with MCI or caregivers of individuals
amyloid plaque load in the brains of transgenic with MCI usually report subjective memory de-
Alzheimer mice, and increases the animals spatial cits. Furthermore, cognitive declines in these
memory performance (van Praag et al. 1999). populations have been objectively conrmed by
Thus, the ndings of aerobic tness training neuropsychological tests in at least one cognitive
increasing the level of circulating BDNF and domain (Winblad et al. 2004). In general, daily
functioning of older adults with MCI remains AD, and PD are few and inconclusive at the cur-
intact, and they do not yet fulll clinical criteria rent stage.
of dementia. However, older adults with MCI
have an increased risk of developing Alzheimers
disease (AD). About 1015% of those seniors Outlook
with classied MCI convert to AD within
12 months compared to only 12% of the general, In light of aging- and pathology-related decreases
age-matched population (e.g., Petersen et al. in training gains and transfer effects, it is impor-
1999). AD is the most common form of dementia tant to investigate other options for improving
in late life with complex multifactorial pathogen- cognitive and brain plasticity in old age. Repeti-
esis. AD leads to progressing memory deteriora- tive transcranial magnetic stimulation (rTMS) and
tion and further exacerbates decits in other anodal transcranial direct current stimulation
cognitive domains, including executive functions (atDCS) are noninvasive brain stimulation
and visuo-motoric, visuospatial, and language methods that could have transient facilitative
abilities that impair independent living and qual- effects on cognitive function (see Freitas
ity of life. Idiopathic Parkinsons disease (PD) is et al. 2013 for a recent review). Very recently, a
another aging-related neurodegenerative disease, few explorative studies have begun to use nonin-
which in its initial stages is rather recognized by vasive brain stimulations in older adults. Some
motor than cognitive decits. PD is associated preliminary successes in terms of ameliorating
with a drastic degeneration of dopaminergic neu- cognitive aging decits could be demonstrated.
rons, especially in the substantia nigra pars For instance, atDCS applied over the left inferior
compacta (SNc) and its terminals in the dorsal frontal gyrus improved performance in a semantic
striatum (caudate and putamen). With disease pro- word generation task that implicates frontal cog-
gression, the loss of dopamine further affects the nitive control and working memory in old adults.
ventral tegmental area (VTA) and its terminals in Moreover, atDCS also reduced the nonspecic
the ventral striatum (nucleus accumbens) as well recruitment of the right prefrontal regions in
as the mesolimbocortical dopamine system (Agid older adults, thus modied functional brain activ-
et al. 1993). ity of older adults to more resemble those
Many cognitive intervention studies targeting observed in younger brains (Meinzer et al.
the training of either compensatory cognitive 2013). Regarding effects on episodic memory
strategies or specic cognitive abilities in older consolidation, atDCS over the right
adults with MCI and AD reported performance temporoparietal cortex further improved object-
improvements in the trained tasks but failed to location learning and delayed free recall after
provide relevant long-term transfer effects on one week in old adults (Flel et al. 2012).
other cognitive functions or abilities needed in Research over the past decade indicates that the
daily life (e.g., Belleville et al. 2006; Davis facilitating effects of rTMS or atDCS on cognition
et al. 2001). More recent neuroplasticity-based might not be restricted to healthy young and older
cognitive trainings have yielded promising results adults. Application of rTMS improved facename
in some studies with healthy older adults, but association memory in older adults with subjec-
yielded contradicting results in older adults with tive memory complaints and amnestic MCI (e.g.,
increased risk of dementia and MCI (e.g., Barnes Turriziani et al. 2012). In AD patients with early
et al. 2009). Cognitive training and intervention to more advanced cognitive decits, rTMS and
studies with PD patients provide a similar picture atDCS have been shown to improve memory
with small to moderate improvements mainly in functions (e.g., Cotelli et al. 2014). In PD patients,
trained fronto-striatal tasks (e.g., Nombela atDCS stimulation has also been shown to
et al. 2011), without transfer to other untrained improve working memory (Boggio et al. 2006).
functions. Taken together, randomized controlled These initial progresses notwithstanding, further
cognitive training or intervention studies in MCI, research is needed to gain better understandings
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Cognitive Behavioural Therapy 509
Definition as in mid-life adults (Hofmann et al. 2012) and

there is some debate about the effectiveness of
Cognitive behavioral therapy (CBT) refers to a CBT for anxiety disorders when compared to
psychotherapeutic framework in which cognitions other treatment modalities.
and behaviors are theorized to be the underlying
core factors in the development and maintenance
of psychological distress. According to the CBT Outline of CBT C
model, maladaptive cognitions, or schemas, about
the world and oneself result in emotional distress CBT interventions often occur in three main
and problematic behaviors in the individual. The phases: psychoeducation, skills acquisition, and
goal of cognitive behavioral therapy is to alter an relapse prevention (Sorocco and Lauderdale
individuals maladaptive cognitions and problem- 2011). Psychoeducation involves teaching the
atic behaviors, which result in the alleviation of patient about the CBT model for their particular
psychological distress. disorder or symptoms and may take place over
one or several sessions. Psychoeducation for older
adults may take longer than for younger adults
Introduction due to an increased unfamiliarity with psychoso-
cial interventions (Sorocco and Lauderdale 2011).
Cognitive behavioral therapy (CBT) is a psycho- Next, therapy moves on to teaching new skills.
therapeutic intervention focused on the alteration Skill acquisition involves teaching and demon-
of maladaptive cognitions and behaviors in the strating tools related to both maladaptive cogni-
alleviation of psychological distress. CBT blends tions and behaviors (Sorocco and Lauderdale
elements from both behavioral and cognitive ther- 2011). For example, maladaptive cognitions are
apies into a cohesive intervention in which both altered through the use of cognitive techniques
behaviors and thoughts are theorized to effect, and like cognitive restructuring (e.g., replacing mal-
to be effected by, an individuals emotional state. adaptive automatic thoughts with more realistic
CBT is considered an evidence-based treatment thoughts) and the downward arrow technique
for a multitude of mental disorders, including (e.g., asking the individual to describe the mean-
anxiety, depression, bipolar disorder, eating disor- ing of their thoughts until the individual uncovers
ders, anger control, insomnia, and substance a core belief about themselves). In the CBT
abuse, and there is growing evidence for the use model, an individuals thoughts or interpretation
of CBT with personality disorders and schizo- of a situation is theorized as the mediating factor
phrenia (Sorocco and Lauderdale 2011; Hofmann between the situation itself and the individuals
et al. 2012). In the treatment of depression, CBT subsequent emotional response. The alteration of
has been found to be at least as efcacious as ones automatic thoughts to the situation allows
medication alone. A combination approach of the person to alter their emotional response as
medication and CBT has growing support to be well, thus decreasing distress. The relationship
considered as the most effective approach for between thoughts, behaviors, and situations is
short-term changes in mood, although CBT con- typically monitored through the use of ABC
tinues to demonstrate the most enduring results worksheets, where A represents the activating
for mid-life samples (Sorocco and Lauderdale event, B is the belief or automatic thought
2011). There is growing evidence for the effec- held by the patient, and C represents the con-
tiveness of CBT in geriatric samples. Recent stud- sequence or emotional reaction to the situation as
ies have demonstrated the efcacy of CBT in the result of the automatic thought (Sorocco and
treating older adults suffering from depression, Lauderdale 2011). The worksheets used to moni-
anxiety, insomnia, and pain (Sorocco and tor thoughts may vary based on the patients
Lauderdale 2011), although the effects found for symptoms and cognitive ability. Different types
insomnia may not be as long lasting in older adults of thoughts are captured within the worksheet.
Automatic thoughts are themselves the result of conceptualization process starts at intake but is
an individuals underlying schemas, or their way modied repeatedly throughout as new informa-
of viewing the world. These kinds of thoughts are tion develops. The conceptualization allows for
reected in the belief portion of the worksheet. clinicians to hypothesize about the cognitive,
Deeper thoughts or themes, known as schemas, behavioral, and situational factors that may be
develop over the course of an individuals life as contributing to an individuals current psycholog-
the result of an interaction between genetic pre- ical distress (Sorocco and Lauderdale 2011). Cli-
dispositions and learned responses over time. The nicians are able to consider the effect of possible
therapist and patient can look for common themes age-related factors, such as cognitive decline and
in the worksheets to identify schemas. social situation, when creating a treatment plan for
Maladaptive behavior patterns also develop geriatric patients.
over time and can exacerbate psychological dis-
tress by decreasing the opportunities for individ-
uals to receive positive reinforcement from their Anxiety and Obsessive-Compulsive
environment (Sorocco and Lauderdale 2011). Spectrum Disorders
Behavioral problems related to psychological dis-
tress are altered through the use of behavioral Up to 27% of older adults may suffer from anxiety-
activation, in the case of depression, and exposure related symptoms and up to 10% of community-
exercises, in the case of obsessive-compulsive dwelling older adults may meet criteria for an
spectrum, trauma, and anxiety disorders. Modi- anxiety disorder (Petkus et al. 2014). The preva-
cation of maladaptive behaviors typically starts lence of anxiety disorders in late life may be even
with activity monitoring worksheets, where the higher in medical settings (Goncalves and Byrne
patient monitors his or her activities and mood 2012). Generalized anxiety disorder (GAD) and
over the course of a week. This allows the patient specic phobia are the two most common anxiety
and the clinician to assess for patterns related to disorders found in late life (Petkus et al. 2014).
the patients behaviors and subsequent mood. Older adults suffering from anxiety disorders
Next, the clinician and the patient work together are likely to prefer psychotherapy to either medi-
to incorporate pleasurable activities throughout cation or a combined psychotherapy-medication
the patients week. Problem solving and social approach (Goncalves and Byrne 2012). Further,
skills training are also often incorporated into older adults report being more satised with a
behaviorally based interventions in order to CBT-based protocol than a discussion group inter-
decrease the obstacles faced by patients during vention (Ayers et al. 2014a).
this process (Sorocco and Lauderdale 2011). There is currently a debate in the literature
With respect to exposure exercises, patients must about the most effective treatment for anxiety
face the stimulus that they are repeatedly disorders in older adults, which may be due to a
avoiding. This can be done through imagery or dearth of large treatment trials studying late-life
actually engaging with the fear-provoking stimu- anxiety (Goncalves and Byrne 2012; Gould
lus. Finally, clinicians and patients work together et al. 2012). While some studies suggest that
to create maintenance plans for the patients to CBT does not surpass other active treatments of
decrease the likelihood of their symptoms geriatric anxiety, including relaxation training
returning. Relapse prevention in the treatment of (Hofmann et al. 2012; Petkus et al. 2014), there
older adults is typically done over multiple ses- is also evidence that CBT is equal to or surpasses
sions and possible includes planning for follow- other treatment modalities, including relaxation
up sessions either in person or over the phone therapy, supportive therapy, or psychodynamic
(Sorocco and Lauderdale 2011). therapy (Hofmann et al. 2012). Further, some
A case conceptualization process is typically literature suggests that although CBT may be an
utilized as a necessary component of a CBT model effective treatment for late-life GAD, the effect
(Sorocco and Lauderdale 2011). The case may be less signicant than what has been
Cognitive Behavioural Therapy 511
observed in younger samples (Petkus et al. 2014; increased problem solving skills and teaching
Ayers et al. 2014a; Gould et al. 2012). There are strategies may help to increase long-term out-
multiple reasons why CBT may be less effective comes for anxiety disorders (Ayers et al. 2014a).
in older adults than it is in younger adults. Most Similar results have been found for hoarding dis-
notably, older adults with GAD are likely to have order when using a CBT-adapted protocol that
maladaptive schemas and behaviors that have focused on compensatory cognitive training
been reinforced over several decades, resulting in and exposure and response prevention (Ayers C
a psychopathology that is more highly ingrained et al. 2014b). Compensatory cognitive training
than in younger adults (Petkus et al. 2014). Further, focuses on skills related to prospective memory
age-related difculties with cognitive restructuring and planning, attention and vigilance, learning
may result from increased levels of cognitive dys- and memory, and cognitive exibility, and
function and reality-based worries (e.g., worries problem solving. This enables patients with exec-
about health and nances) (Petkus et al. 2014). utive functioning problems to work around their
Because CBT requires relatively intact executive decits when engaging in treatment (Ayers
functioning in order to be fully engaged in tradi- et al. 2014b).
tional CBT exercises, cognitive dysfunction may
serve as a moderator for CBT treatment response in
older adults (Ayers et al. 2014a). There may also be Mood Disorders
additional confounding factors which could have
affected the generalizability of the results of many The prevalence of mood disorders in late life
of the major investigation of CBT for late- rivals that of anxiety disorders: as many as 25%
life anxiety, including self-referral, concurrent of community-dwelling older adults have
unregulated pharmacotherapy, and a lack of control reported experiencing symptoms related to
of nonspecic therapeutic effects (e.g., social sup- depression (Shah et al. 2012). Older adults with
port) (Gould et al. 2012). a late onset of depression symptoms are more
Obsessive-compulsive disorder (OCD) is less likely to have a poor prognosis and greater dis-
frequent in older adults than anxiety-related disability associated with their symptoms that are
orders, only effecting 1.5% of older adults (Ayers individuals with early-onset depression (Sorocco
and Najmi 2014). The rst line of treatment for and Lauderdale 2011). The CBT model of depres-
OCD is Exposure and Response Prevention sion postulates that depressed mood is a combi-
(ERP), a form of CBT; however, there has been nation of maladaptive cognitions, social isolation,
little systematic investigation of the efcacy of and decreased performance of pleasurable activi-
ERP in older adults with OCD beyond assorted ties (Shah et al. 2012). In the treatment of mood
case studies (Ayers and Najmi 2014). Hoarding disorders, CBT has been found to be equally effec-
disorder, an obsessive-compulsive spectrum dis- tive as other treatment modalities, such as interper-
order with strong ties to anxiety disorders, may be sonal therapy and behavioral therapy (Sorocco and
as prevalent as 15% in geriatric samples (Ayers Lauderdale 2011; Shah et al. 2012), and may even
and Najmi 2014). Hoarding disorder has also surpass other treatment models in the maintenance
received poor results when treated with CBT in of long-term results (Hofmann et al. 2012).
geriatric samples, with few individuals responding Research suggests that a combined CBT and med-
to treatment and no evidence of long-term effects ication approach in late-life samples does not
of treatment (Ayers et al. 2014b). Treatment of late- increase the effectiveness of either approach alone
life hoarding is further complicated by low insight, (Hofmann et al. 2012). CBT-based protocols for
executive functioning problems, and decreased older adults with depression are often modied to
levels of social engagement (Ayers et al. 2014b). take into consideration age-related changes in cog-
Modied CBT protocols may show more nition and memory, as well as physical limitations
promise than traditional CBT-based interventions (Sorocco and Lauderdale 2011; Shah et al. 2012).
for late-life anxiety. Interventions involving Typical modications include using telephone or
home-based therapy, incorporating breaks within to the CBT framework (Sorocco and Lauderdale
sessions, the simplication of thought records, 2011). This includes explaining the purpose and
increased use of handouts, and booster sessions benets of homework, the organization of treat-
(Sorocco and Lauderdale 2011). The majority of ment sessions, and an overview of the CBT model
sessions in a typical CBT intervention for geriatric (Sorocco and Lauderdale 2011). Finally, clini-
depression are focused on both the identication of cians working with older adults should be espe-
maladaptive cognitions and the generation of more cially mindful of suicide risk and assess for
helpful alternative thoughts as well as behavioral suicidal ideation throughout the therapeutic pro-
activation and the introduction of pleasurable or cess, as older adults are more likely to have
positively reinforcing activities (Sorocco and increased risk factors, such as social isolation
Lauderdale 2011). Problem solving skills may be (Sorocco and Lauderdale 2011).
introduced in later sessions and can help to increase As individuals age, their opportunities for pos-
the mastery felt by geriatric individuals (Sorocco itive reinforcement, such as interacting with
and Lauderdale 2011). friends or exercising, may decrease due to
Bipolar disorder, a mood disorder character- changes in available resources and their own
ized by alternating manic and depressive states, physical health (Sorocco and Lauderdale 2011).
is estimated to be prevalent in 0.10.5% of Cognitive impairment may also decrease the abil-
community-dwelling older adults (Sorocco and ity of older adults to fully engage in some of the
Lauderdale 2011). CBT is considered the treat- core facets of CBT, such as cognitive restructuring
ment of choice for bipolar disorder, especially in or behavioral activation. When constructing lists
light of the high rates observed for patient of pleasurable activities for geriatric patients to
noncompliance (4050%) for pharmacological incorporate into their daily lives, clinicians should
treatments (Sorocco and Lauderdale 2011). consider how activities that individuals used to
Unfortunately, there is little research on the ef- enjoy could be altered to be appropriate for their
cacy of CBT for bipolar disorder in geriatric current levels of functioning (Sorocco and
patients (Sorocco and Lauderdale 2011). Lauderdale 2011). For example, if an older adult
enjoyed kayaking but is no longer able to perform
due to a medical illness, they might consider
Adaptations for Geriatric Samples walking in the park to be a suitable alternative to
incorporate into their daily routine. Clinicians
Older adults may be more likely to seek therapy may want to consult with patients primary care
due to external pressures from their medical doc- providers before suggesting any new physical
tors or children and may be less likely to attend activities be added to patients daily routines.
treatment for self-motivating reasons (Sorocco Older adults who have difculty with cognitive
and Lauderdale 2011). Consequently, it is espe- restructuring due to possible cognitive impair-
cially important for geriatric mental health pro- ment may benet from the use of coping cards,
fessionals to assess motivation for treatment and which rely on recognition rather than recall mem-
to engage in motivational interviewing when nec- ory (Sorocco and Lauderdale 2011). Patients write
essary (Shah et al. 2012). This may be especially down common maladaptive cognitions and alter-
important for older adults exhibiting low levels of native thoughts on coping cards and then refer to
insight into their symptoms, as is often witnessed them as needed, rather than having to generate
in geriatric hoarding disorder (Ayers et al. 2014b). alternative thoughts spontaneously. Other alter-
Older adults may also have increased obstacles to ations that may increase the efcacy of CBT for
treatment, including transportation or nancial geriatric patients include a lengthened course of
issues (Sorocco and Lauderdale 2011; Ayers therapy, increased structure, and an increased use
et al. 2014b). Because geriatric patients may be of examples (Sorocco and Lauderdale 2011). Cli-
unfamiliar with psychological services, extra time nicians should also consider the incorporation of
may need to be spent to socialize late-life patients booster sessions every 36 months to decrease the
Cognitive Compensation 513
occurrence of re-emerging symptoms (Sorocco and Ayers, C. R., Strickland, K., & Wetherell, J. L. (2014a).
Lauderdale 2011) or reminder calls in between Cognitive behavioral therapy for late life generalized
anxiety disorder. In P. Arean (Ed.), Treatment of late-
sessions to help increase homework compliance life depression, anxiety, trauma, and substance abuse.
(Ayers et al. 2014a). Because older adults may Washington, DC: American Psychological Association.
report feelings of guilt at homework Ayers, C. R., Najmi, S., Howard, I., & Maddox, M.
noncompliance (Ayers et al. 2014b), booster calls (2014b). Hoarding in older adults. In G. Steketee &
may also increase the therapeutic alliance between
R. Frost (Eds.), The Oxford handbook of hoarding and
acquiring. New York: Oxford University Press.
C
the patient and the clinician. Emphasizing the Goncalves, D. C., & Byrne, G. J. (2012). Interventions for
behavioral aspects of CBT over the cognitive skills generalized anxiety disorder in older adults: Systematic
may also lead to increased outcomes for older review and meta-analysis. Journal of Anxiety Disor-
ders, 26, 111.
adults (Ayers et al. 2014a). For instance, more Gould, R. L., Coulson, M. C., & Howard, R. J. (2012).
time is spent doing behavioral activation and Efcacy of cognitive behavioral therapy for anxiety
in vivo exposures as opposed to cognitive therapy disorders in older people: A meta-analysis and meta-
techniques. In summary, accommodations can be regression of randomized controlled trials. Journal of
the American Geriatrics Society, 60, 218229.
made to address cognitive and physical issues. Hofmann, S. G., Asnaani, A., Vonk, I. J. J., Sawyer, A. T.,
& Fang, A. (2012). The efcacy of cognitive behavioral
therapy: A review of meta-analyses. Cognitive Therapy
Future Directions and Research, 36, 427440.
Petkus, A., Merz, C., & Wetherell, J. L. (2014). Anxiety
disorders in older adulthood. In P. Emmelkamp &
Although depression and anxiety disorders are often T. Ehring (Eds.), The Wiley handbook of anxiety disor-
comorbid in older adults, little research has been ders (1st ed., pp. 599611). West Sussex: Wiley.
done on the effectiveness of CBT for comorbid Shah, A., Scogin, F., & Floyd, M. (2012). Evidence-based
psychological treatments for geriatric depression. In
late-life anxiety and depression (Ayers et al. 2014a). F. Scogin & A. Shah (Eds.), Making evidence-based
Some evidence suggests that CBT for anxiety may psychological treatments work with older adults.
also decrease depression symptoms (Gould Washington, DC: American Psychological Press.
et al. 2012). Depression may also be more effectively Sorocco, K. H., & Lauderdale, S. (2011). Cognitive behav-
ioral therapy with older adults: Innovations across
treated by CBT than are anxiety disorders, further care settings. New York: Springer.
suggesting the need for increased research into alter-
native therapies (Gould et al. 2012).
Cross-References Cognitive Compensation

Anxiety Disorders in Later Life Allison A. M. Bielak
Behavioral Analysis Department of Human Development and Family
Clinical Issues in Working with Older Adults Studies, Colorado State University, Fort Collins,
Depression in Later Life CO, USA
Interpersonal Psychotherapy
Problem-Solving Therapy
Suicide in Late Life Synonyms
References Cognitive plasticity
Ayers, C., & Najmi, S. (2014). Treatment of obsessive-

compulsive spectrum disorders in late life. In Definition
E. A. Storch & D. McKay (Eds.), Obsessive-
compulsive disorder and its spectrum: A life-span
approach (pp. 97116). Washington, DC: American The ability to maintain everyday functioning
Psychological Association. despite quantiable age-related decline in
514 Cognitive Compensation
cognitive ability (i.e., memory, attention, execu- processing speed, spatial skills, working memory,
tive functioning, speed of processing informa- and reasoning. A person is completing a task
tion). Compensation can be achieved in a based on uid intelligence when the task requires
number of ways, including reliance on pragmatics adaptation to new situations for which prior edu-
or experience, strategy use, task modication, cation or learning provide little advantage (Berg
cognitive plasticity or growth, and cognitive and Sternberg 2003, p. 105). On the other hand,
reserve (i.e., education, activity engagement). crystallized intelligence involves experience,
expertise, or pragmatics (i.e., practical knowl-
edge). This includes abilities such as general and
Overview procedural knowledge, skills, strategies, verbal
knowledge, occupational expertise, and the ability
It is well established that as adults age, they expe- to solve real-life problems such as counting
rience decline in various cognitive capacities, change.
including certain types of memory, executive To further illustrate this distinction, imagine a
functioning, attention, and processing speed bicycle. The mechanical or basic entities of the
(Schaie 1996; Hultsch et al. 1998). Given the bicycle would be the wheels, chain, pedals, han-
size of these decits, one might expect that older dlebars, and frame. If there is deterioration in the
adults must substantially revise how they com- mechanics of the bicycle, such as if the air in a tire
plete day-to-day tasks, or require considerable is low, the bike can still function, but it becomes
assistance carrying out chores such as managing harder to pedal. Similarly, a decline in the basic
nances, meal preparation, and taking care of mechanics of cognition, such as processing speed,
grandchildren. However, the changes in cognitive would make completing a task that relies on uid
ability do not tend to translate over to noticeable intelligence more challenging. In contrast, if a
declines in the ability to complete everyday tasks. person is cycling down a hill, their practical
Rather, older adults continue to go about their knowledge or experience would let them know
daily lives with the same levels of vigor and that they do not have to continue pedaling down
prociency as when they were younger. They the hill but can use their momentum and coast to
may even make achievements that they were not reach the bottom of the hill. The mechanics of
capable of when they were younger. For example, their bicycle, deated tire or not, would not be at
the majority of CEOs for Fortune 500 companies play in this scenario, and the person can rely on
are between their late 40s and early 60s (Salthouse their experience in riding the bicycle to efciently
2012). There are no parallel declines in everyday manage the hill.
functioning because older adults can compensate The distinction between uid and crystallized
for cognitive decline in a number of ways, includ- intelligence is relevant to cognitive compensation
ing reliance on pragmatics or experience, strategy because the two types change differently across
use, task modication, cognitive plasticity or the lifespan. Fluid intelligence begins to decline
growth, and cognitive reserve (i.e., education, soon after age 30, while crystallized intelligence
activity engagement). increases until the mid-40s and remains stable
until the 70s (Li et al. 2004). Therefore, even
Reliance on Pragmatics though an individual experiences decline in uid
There are two general categories of cognition: intelligence with age, they can compensate for this
uid intelligence and crystallized intelligence decit by relying more on their crystalized intel-
(Horn and Cattell 1966). Fluid intelligence uses ligence (i.e., acquired knowledge, pragmatics,
cognitive abilities that rely on biology and are expertise, and experience) to complete tasks.
termed the mechanics of cognition. Fluid intel-
ligence involves all of the basic processes needed Everyday Life is Different from Cognitive Tests
to complete higher-order cognitive tasks or solve Another key factor related to cognitive compen-
novel problems. It includes domains such as sation is that the tests used in the laboratory to
assess cognitive change are very different from In addition, Park and Gutchess (2000)
the tasks essential to everyday life. Hess (2005) described that everyday tasks become automa-
described laboratory-administered memory tasks tized and require little cognitive effort to fulll.
as relatively stripped down in terms of familiarity While the effortful component of memory
or meaningfulness (p. 383), as a person rarely has declines with age, the processes that rely on auto-
to memorize a list of unrelated words or discover matic cognitive processing that occur without
the pattern among sets of letters in the real world. conscious awareness or effort do not (Jacoby C
Because of this, tests have been developed that et al. 1996). Therefore, age-related declines in
attempt to assess a persons prociency in com- processing abilities will only be apparent in situ-
pleting tasks required in their daily life. These ations that need mental effort. It is important to
measures provide participants with real-life stim- note that the automation of tasks is very specic to
uli like nutrition labels, medication labels, or an individual, and the same situation that requires
appliance instructions and ask them to complete little cognitive demand for one older adult may
tasks designed to assess everyday problem solv- involve effortful processing for another (e.g.,
ing or cognition (i.e., balancing a checkbook, driving into a large city can be effortful for a
reading a bus schedule). Tests of everyday ability tourist versus being rather automatic for a local)
show moderate correlation with standard cogni- (Park and Gutchess 2000). Overall, although it
tive test scores (Allaire and Marsiske 1999), indi- may appear that older adults are engaging in sub-
cating that while there is overlap between stantial compensation for cognitive decline, an
successful completion of both types of tasks, the alternative explanation is that the tasks they com-
ability to solve everyday problems is distinct from plete everyday are fundamentally different than
typical cognitive tasks. However, tests of every- the tasks used in the lab that repeatedly demon-
day ability still do not provide a precise measure strate age-associated cognitive decline.
of how well an adult can actually function in the
real world. Strategy Use and Task Modification
Salthouse (2012) discussed facets of our If necessary, cognitive compensation can also be
everyday lives that may help to explain why achieved through explicit strategy use or modi-
there are not greater consequences in real life as cation of the task to accommodate cognitive
a result of age-related cognitive decline. First, decline. Possible internal strategies include rote
successful fulllment of daily activities only rehearsal (e.g., repeating a name or word multiple
require ones typical level of functioning, times), mental imagery (e.g., recalling ingredients
whereas academic cognitive tests assess maxi- by picturing the nished dish one plans to make),
mum effort and ability. It may be that cognitive method of loci (i.e., mentally placing items to be
decline with older age is only noticeable when recalled in familiar locations, then walking
attempting to achieve the upper echelons of through the location to assist in recalling the
human cognitive ability (i.e., on cognitive items), or mental retracing of past steps or events.
tests), and the level of cognitive exertion However, older adults tend to be less likely to
required in our daily lives is not sensitive to spontaneously use such strategies and continue
detect age-related cognitive decits. Second, to perform worse than younger adults even when
day-to-day tasks are likely only slightly different instructed on how to use them (Cavanaugh and
over time, limiting the amount of novel tasks and Blanchard-Fields 2011). Rather, it is common to
situations encountered in daily life and allowing rely on external aids such as lists, address books,
the majority of ones daily function to be solved calendars, notes, or smartphones to aid memory in
by relying on past solutions. Consequently, everyday contexts. A well-known strategy is to
everyday tasks that rely purely on uid intelli- use medication organizers or pillboxes to assist
gence, which declines with age, would be an with medication adherence, although the efcacy
exception rather than the rule and experienced of this aid is inconsistent (Bosworth and Ayotte
only rarely in daily life. 2009). Collaborative cognition, where two or
Cognitive
Compensation, 700
Fig. 1 Interkey interval for
choice reaction time and
typing tasks across 600
adulthood (Salthouse,
TA. Effects of age and skill
Interkey Interval (msec)

in typing. Journal of 500 Choice Reaction Time
Experimental Psychology:
General, 113(3), 345371,
1984. American 400
Reprinted with permission)
300
200
100
Typing
20 30 40 50 60 70
Chronological Age
more people work together to complete a cogni- there was no correlation between age and typing
tive task, can also be an aid in everyday life. This speed. Rather, Salthouse determined that older
method can be particularly effective when the typists had increased their anticipation span, or
other person is ones family or friend as they can were looking farther ahead in the text to be tran-
have a shared past and familiarity with one scribed, and this allowed them to compensate for
another that allows them to tailor their reminder their slower processing speed.
cues to their partner (Rauers et al. 2011). Similarly, having greater domain-specic
Extensive practice with the task at hand can knowledge (i.e., crystallized intelligence) for a
also benet older adults. For example, older adults task or being an expert appears to positively
who are given very large numbers of practice trials impact performance. Studies have evaluated
(i.e., at least 500) on attention-based tasks can expertise in a wide range of abilities, including
perform just as well as younger adults ying, music, chess, bridge, graphic design, and
(Cavanaugh and Blanchard-Fields 2011). Older the game of Go. In general, being an expert in a
adults may also simply need more time to com- task appears to attenuate but not eliminate age
plete a task, or perform their best when no time effects on performance and only for tasks specic
limits are imposed. to the area of expertise (Hess 2005).
Individuals may also begin to approach the
same cognitive task differently with age, allowing Cognitive Plasticity and Training
them to compensate for any possible declines in Improving our cognitive performance despite
basic processing resources. Salthouse (1984) age-related cognitive changes is another way cog-
completed a seminal study demonstrating this nitive compensation is possible. Cognitive plas-
phenomenon. Experienced typists between ticity refers to the idea that cognition can be
17 and 72 years of age completed a range of trained or improved. In other words, our cognitive
typing-related tasks. As can be seen in Fig. 1, ability is not set in stone and can be changed or
choice reaction time, a test of basic processing show growth over the lifespan.
speed, was slower with age. However, even Numerous studies have attempted to improve
though typing presumably involves similar skill, older adults cognitive performance via intense
training or practice of various cognitive skills. nd generalized improvement to untrained tasks

One seminal investigation was the Advanced (Schmiedek et al. 2010; Smith et al. 2009). Few
Cognitive Training for Independent and Vital studies evaluate intervention effects on everyday
Elderly (ACTIVE) trial, a multisite intervention function, and the follow-up time of training studies
that involved 2832 adults aged 6594 years (Ball is relatively short (i.e., mostly immediate posttest
et al. 2002). Participants were randomized to or months later), putting the durability of effects
receive training in either processing speed, rea- into question. C
soning, or memory ability over ten 6075 min Another way to enhance cognitive perfor-
sessions over 56 weeks or were assigned to a mance is with interventions that involve increased
control group. All training conditions involved activity rather than specic practice in cognitive
strategy instruction and extensive practice, with tasks. For these interventions, stimulation is
tasks becoming more challenging over time. The achieved via an intellectually and socially com-
training conditions involved the following: plex environment or particular activity (Park
processing speed training focused on visual et al. 2007). Older adults who have been assigned
search skills, particularly when attention was to learn theater performance (Noice et al. 2004),
divided; reasoning training focused on identifying competed in team problem-solving tournaments
the pattern in various real-life (e.g., travel sched- (Stine-Morrow et al. 2014), or participated in an
ules) and laboratory sequences (e.g., the next let- intense elementary school volunteering program
ter to appear in a series); and memory training have shown signicant gains on various cognitive
involved recall for word lists, text, and stories, in tests (Carlson et al. 2008). Although the novelty
terms of both real-life (e.g., shopping lists) and of the activity may be relevant to instituting cog-
laboratory-like (e.g., recall a paragraph) tests. nitive growth, it may be critically important as to
Immediately after the training period, participants whether the activity requires the acquisition of
who received the training sessions performed bet- new skills or involves productive engagement
ter on cognitive tests than the control group, but (Park et al. 2007). This is in contrast to activities
only in the same domain as the training they that rely only on existing knowledge or receptive
received (e.g., the memory training group engagement. Park and colleagues (2014) demon-
performed better on memory tasks only). This strated the importance of this distinction by nd-
demonstrated that cognitive ability can be ing that older adults who learned to design and
improved in older age, but the training gains sew quilts, practice digital photography, or a com-
were task specic and did not generalize to other bination of the two over a 3-month period
types of cognition. Impressively, the training improved on episodic memory tasks compared
gains were maintained even 10 years later for the to those who were assigned to the two receptive
speed of processing and reasoning groups (Rebok engagement conditions. One condition provided
et al. 2014). Moreover, after 10 years participants only novelty but not skill acquisition (e.g., eld
in each training group reported less difculty in trips), and the other involved traditional mental
completing tasks of everyday living. Therefore activities (e.g., completing puzzles).
cognitive training not only resulted in immediate The longevity of the cognitive changes
cognitive compensation but also extended to help- resulting from engagement-based interventions
ing participants be more effective in their daily is unclear, but these interventions have the poten-
lives. tial of being more easily integrated into everyday
Despite the remarkable cognitive gains shown life compared to those assigning cognitive train-
from the ACTIVE trial, the success of interventions ing. However, given the documented cognitive
that involve extensive practice of tasks or training growth from both methods, each method holds
of particular strategies is not entirely clear. In some potential benet. It remains to be seen if the two
studies, improvements are limited to the cognitive intervention techniques are only additive or if
domains that were targeted (Ackerman et al. 2010; cognitive improvement can be maximized by
Owen et al. 2010), whereas other interventions do introducing both techniques.
Finally, it is important to note that there also et al. 2009). Active older adults also have a
appear to be limits to the cognitive plasticity reduced risk of developing dementia (Wang
available to older adults. Although older adults et al. 2006; Wilson et al. 2002). It is unclear
do show cognitive gains from training and activity whether lifestyle engagement slows the rate of
engagement, the magnitude of possible improve- age-associated cognitive change per se or simply
ment is smaller than that for younger individuals increases cognitive ability level to a higher
(Nyberg 2005) even if this varies by cognitive starting point and that advantage is maintained
domain (Schmiedek et al. 2010). Therefore, with age (Salthouse 2006; Bielak et al. 2014).
although one method of cognitive compensation The precise mechanisms for the association with
may be to increase cognitive capacity via inten- cognitive performance are unclear and vary by
sive training or engagement, it is unlikely that this activity domain (Bielak 2010).
method can completely rescind age-related cogni- It is hypothesized that physical exercise may
tive declines. increase blood ow to the brain, positively impact
hormone levels, or increase synaptic connections.
Cognitive Reserve Moreover, those who frequently exercise are more
Another way cognitive compensation can occur is likely to have other healthy lifestyle behaviors
via cognitive reserve. The concept of cognitive (e.g., adequate sleep and nutrition) and health
reserve was created because there is not a direct status (e.g., healthy weight) that can have reper-
relationship between the severity of neurological cussions for their cognitive health. Social engage-
insult or disease and a persons level of cognitive ment can enhance emotional well-being through
functioning. Rather, individuals may continue to decreasing stress and providing opportunities for
perform at a level higher than expected or show no instrumental and emotional support which can
obvious signs of neurological disease despite decrease the physical toll on the body and brain.
diagnosed pathology such as Alzheimers disease. Finally, stimulating cognitive activity may be neu-
In other words, older adults appear to be compen- rologically benecial by increasing cerebral blood
sating for neurological decline. Stern (2002) ow, increasing the number of synapses, or
described cognitive reserve as the ability of the allowing optimal neurochemical compositions.
brain to maximize performance by either using Exposure to cognitive activity may also produce
neural networks more efciently or recruiting a feedback loop that encourages further engage-
alternate neural pathways or cognitive strategies. ment in similarly challenging environments and
Cognitive reserve is also known as active reserve, activities. The environmental complexity hypoth-
in that the brain actively compensates for pathol- esis also proposes that exposure to complex envi-
ogy, compared to passive brain reserve which is ronments offer opportunities for intellectual
determined by brain volume or the number of exibility and practice that in turn enhance cogni-
synapses. Cognitive reserve is believed to be tive performance (Schooler and Mulatu 2001).
acquired by engagement in lifestyle activities Greater years of formal schooling are also
and educational and occupational attainment. associated with less cognitive decline compared
Individuals with more of these resources or to those who receive fewer years of education, but
reserve are consequently better able to tolerate the relation appears to vary by cognitive domain
higher levels of brain pathology before showing (Kramer et al. 2004). Low levels of education are
signs of clinical impairment (Stern 2002). Each of a well-established risk factor for Alzheimers dis-
these potential sources of reserve and their link to ease, but higher levels do not appear to attenuate
cognition is briey described. the rate of cognitive change (Zahodne et al. 2011;
It is well established that older adults who Wilson et al. 2009). Greater exposure to formal
engage in more physical, social, and cognitive education settings would provide high levels of
activities such as jogging, talking with friends, cognitive stimulation, and highly educated indi-
or playing board games perform better on cogni- viduals are likely more condent completing tasks
tive tests than less active individuals (Hertzog that challenge their cognitive skills and may seek
out similar environments. Educational attainment methods involve explicit compensatory tech-
is also highly correlated with socioeconomic sta- niques or training, while others are achieved indi-
tus, and individuals with greater education are rectly through participation in other activities or
more likely to partake and experience other activ- passive reliance on other skills. Despite these
ities known to be benecial for cognitive health various sources, older adults do not appear to be
including good nutrition, holidays to relieve able to achieve the same level of performance on
stress, and knowledge of healthy lifestyle behav- cognitive tests as younger adults. However, the C
iors. Consequently, it is unclear to what extent relevance of this limitation is negligible given that
education per se is inuencing cognitive reserve age-associated cognitive decline does not have a
versus other related factors. signicant negative impact on everyday life for
The complexity of the tasks one completes in older adults.
their occupation has been linked to cognitive per-
formance. Those who worked in occupations that
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Cognitive Control and Self-Regulation 521
Wilson, R. S., et al. (2002). Participation in cognitively allow pursuing internal goals and exibly
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Zahodne, L. B., et al. (2011). Education does not slow trol can be attributed to a distributed brain
cognitive decline with aging: 12-year evidence from
the Victoria Longitudinal Study. Journal of the Inter- network with the prefrontal cortex (PFC) taking C
national Neuropsychological Society, 17(6), a critical role. Due to its extensive connectivity,
10391046. the PFC seems to be strongly activated whenever
multimodal information from sensory and motor
systems and subcortical structures needs to be
integrated and maintained in a highly accessible
Cognitive Control state (Miller and Wallis 2009). Specically, this
and Self-Regulation PFC activation ensures the maintenance of goal-
related information against distraction and serves
Hannah Schmitt1 and Jutta Kray1,2 the top-down guidance of neuronal activation in
1
Saarland University, Saarbrcken, Germany other brain areas required for the execution of
2
Department of Psychology, Saarland University, controlled behavior. Advancing age is character-
Saarbrcken, Saarland, Germany ized by a marked neuronal deterioration particu-
larly affecting the integrity of the PFC (Raz 2005).
This neuronal alteration in the healthy aging brain
Synonyms has been linked to a pronounced decline of per-
formance in tasks assessing cognitive control
Executive control; Self-control processes.
Cognitive control and self-regulation are key

determinants of goal-related behavior and known Age Differences in Components
to be highly susceptible to increasing age. of Cognitive Control
This entry provides an overview about new
insights into the geropsychology of cognitive con- Researchers suggested three key components of
trol and self-regulation. In two sections, each con- cognitive control that are assumed to be interre-
cept is briey dened in combination with lated but separable abilities: (1) the updating and
existing knowledge about their neuronal under- monitoring of working memory (WM) represen-
pinnings. Then, empirical evidence on age differ- tations, (2) the inhibition of predominant response
ences in cognitive control and self-regulatory tendencies, and (3) the exible switching between
abilities as well as on how these can be improved cognitive tasks (Buitenweg et al. 2012). At the
by cognitive interventions will be summarized. theoretical level, aging researchers investigating
cognitive control aimed at determining whether
age differences in these abilities reect process-
Definition of Cognitive Control specic limitations or whether they can be
explained by age differences in one single general
The term cognitive control refers to a set of factor reecting age-related changes in speed of
higher-order processes that regulate basic sensory, cognitive processing (Kray and Eppinger 2010).
motor, and cognitive operations for planning, At the applied level, aging researchers become
guiding, and coordinating goal-directed behavior more and more interested in assessing the extent
in everyday life (Miller and Wallis 2009). As these to which these abilities can be improved by cog-
higher-order cognitive processes are assumed to nitive interventions (Kray and Ferdinand 2014).
522 Cognitive Control and Self-Regulation
In the following, evidence on both levels will be might require executive control processes, partic-
reviewed for each of the three key components of ularly in older adults (Reuter-Lorenz and Jonides
cognitive control. 2007). Evidence for this view comes from studies
Working Memory. There is now ample empir- using functional magnetic brain imaging (fMRI)
ical evidence that WM is a crucial determinant of data. Older adults recruit regions of the PFC asso-
age differences in cognitive control. In its tradi- ciated with cognitive control even in simple stor-
tional conceptualization, WM includes domain- age tasks, while these brain regions are not
specic buffers for short-term storage of signicantly activated in younger adults. These
visuospatial and verbal information along with ndings suggest that the recruitment of the PFC
central executive processes that monitor and serves as a compensatory mechanism to maintain
manipulate the storage contents in the service of good performance in older adults, as assumed by
controlled, goal-directed operations (Hale the Compensation-Related Utilization of Neural
et al. 2007). The large number of existing WM Circuits Hypothesis (CRUNCH) (Reuter-Lorenz
tasks distinguishes tasks that measure storage and Jonides 2007). However, as task complexity
capacity, generally termed simple-span tasks increases, and thereby the demands on executive
(Reuter-Lorenz and Jonides 2007), from tasks control, older adults perform poor on WM tasks
that assess both storage capacity and central because their control processes are already taken
executive processing, generally termed complex- up by lower storage demands (Reuter-Lorenz and
span tasks. For instance, digit-span tasks can be Jonides 2007).
classied as simple-span tasks. They are It is now well known that age differences in
assumed to assess the individuals ability to WM tasks are particularly pronounced with
actively store a number of visually or auditorily increased cognitive control demands. A critical
presented items and to recall them in the correct question from an applied perspective is whether
order. In contrast, complex-span tasks assess not WM can be improved by cognitive interventions
only storage processing but also the manipulation even in elderly individuals. In the last decade, a
of the stored information or the processing of a variety of training studies aimed at improving
secondary task (Reuter-Lorenz and Jonides 2007). WM performance by means of computerized
For instance, reading-span tasks require the training programs (Klingberg 2010). These pro-
processing of a sequence of sentences and decid- grams often used adaptive training schedules to
ing for each sentence whether it is meaningful or optimally adjust training demands to individuals
not. At the same time, individuals have to encode performance levels. Results of these studies indi-
the nal word of each sentence and to remember cate that a variable amount of training on visuo-
these until the end of the task (Reuter-Lorenz and spatial and verbal WM tasks results in
Jonides 2007). considerable training gains not only in the trained
Researchers investigating age differences in task but also in closely related but untrained WM
simple-span tasks found a differential decline in tasks (Buitenweg et al. 2012; Klingberg 2010). Less
the performance on visuospatial and verbal WM consistent evidence is reported on the extent to
tasks in older relative to younger adults, indicating which these training gains can be maintained over
larger decits in visuospatial relative to verbal a longer period of time and can be generalized to
WM tasks (Hale et al. 2007). Other studies show other cognitive tasks (Buitenweg et al. 2012;
that age differences are even more pronounced in Klingberg 2010). These inconsistencies might be
complex-span tasks, tapping both storage and due to differences in the duration of the training
executive processes, than age differences in stor- interventions as well as in the type of training. For
age measures per se. While some researchers tried instance, it has been shown that practice of explicit
to separately investigate storage and executive memory strategies leads to WM improvements in
processes of WM in order to identify process- older adults, but these strategies are not easily trans-
specic limitations in old age, others argued that ferred to other memory tasks. In contrast, adaptive,
this separation is articial, as even storage tasks process-oriented WM training sometimes also leads
to performance gains in other cognitive tasks suggested that older adults show better inhibitory
(Buitenweg et al. 2012). control in the morning than in the evening, based
Inhibition. Pronounced age differences have also on circadian arousal patterns for inhibitory pro-
been demonstrated in cognitive control tasks requir- cesses that predominantly peak in the morning in
ing the ability to inhibit irrelevant responses and the elderly (Hasher et al. 2007). In addition, there
predominant actions (Buitenweg et al. 2012). One are some rst results indicating that physical t-
frequently used task to measure the efciency of ness is linked to better inhibitory control that is C
inhibition processes is the Stroop task (Kray and explained by increased prefrontal oxygenation. In
Eppinger 2010). This task consists of color words this regard, it has been shown that 8 weeks of
either printed in a compatible color (i.e., red moderate aerobic training can improve perfor-
printed in red ink) or in an incompatible color mance on an inhibition task in older adults
(i.e., red printed in blue ink) (Kray and Eppinger (Berryman et al. 2014).
2010). Subjects are usually instructed to perform Task Switching. Age differences in cognitive
the less-practiced color naming and to inhibit the control are also obtainable in tasks assessing the
more-automatized reading of the word meaning. exible switching between task rule representa-
Results typically show longer reaction times and tions. In these types of tasks, subjects are required
larger error rates in cases in which the word reading to alternate between two or more simple categori-
interferes with the color naming, that is, on incom- zation tasks such as deciding whether a stimulus
patible stimuli relative to compatible ones. This belongs to the category of fruits or vegetables
so-called Stroop interference effect is usually larger (picture task) or whether it is gray or colored
in elderly adults than in younger adults. Results (color task). Results of a meta-analysis on age
from a meta-analysis suggest that the larger Stroop differences in task switching show larger general
interference effect in older adults can be fully (or global) switching costs in older than younger
explained by age differences in general speed of adults when two tasks are performed in an alter-
processing as a general underlying factor (Kray and nating order on a task-switching block relative to
Eppinger 2010) and not by specic limitation in performance on a single task block (also termed
inhibitory processing. However, when the demands mixing costs) (Kray and Ferdinand 2014). These
on controlled processing are increased, for instance, age-related decits seem to map on age differ-
by manipulating the frequency of trials on which ences in WM as a key determinant of cognitive
subjects have to inhibit automatic responses, older control, as age differences in the implementation
adults tend to show larger decits in inhibitory of a task switch within a task-switching block,
control than younger adults. The greater need to termed specic (or local) switching costs, are
exibly recruit cognitive control on less frequent less pronounced than age differences in general
conict trials, inducing higher demands on cogni- switching costs (Kray and Ferdinand 2014).
tive control, lead to pronounced impairments in Importantly, age effects in these costs remain reli-
inhibition tasks in the elderly, similar to the reported able after controlling for age differences in
ndings on age differences in WM tasks (Kray and processing speed, suggesting process-specic
Eppinger 2010). limitations in the ability to maintain and select
Despite the existing age-related decline in task sets.
measures of inhibition, studies that aim to enhance Further evidence for this view comes from
inhibitory control in old age are lacking aging studies measuring the neuronal activity dur-
(Buitenweg et al. 2012), although there is some ing task preparation and response selection by
evidence for practice-related improvement in the means of fMRI and event-related potential
Stroop tasks in older adults. Whether these train- (ERP) data. For instance, if the upcoming task in
ing gains also transfer to other inhibitory control a task-switching paradigm is announced by a pre-
tasks or even to improvements in other measures ceding task cue, changes in neuronal activity sug-
of cognitive control remains to be examined gest that older relative to younger adults tend to
(Buitenweg et al. 2012). It has also been update the appropriate task representations in
WM after task-cue presentation all the time, even control task (e.g., inhibition, WM (Kray and
if not required, i.e., when the response rules are Ferdinand 2014)), suggesting the training of cog-
exactly repeated compared to the previous task. nitive control processes, and in particular, the
Moreover, older adults seem to recruit a larger training of maintaining and selecting (biasing) of
proportion of the PFC than younger adults even tasks as required in dual-task-like situations is a
in single task blocks in which no task switching is promising approach to induce broader transfer to
required. Similar to age differences in WM, this other cognitive domains (Buitenweg et al. 2012;
nding may reect that older adults tend to com- Kray and Ferdinand 2014).
pensate for difculties in maintaining task rule
representations by activating a larger network of
prefrontal brain areas (Kray and Ferdinand 2014). A Theoretical Framework for Explaining
Together, the results of task-switching studies Age Differences in Cognitive Control
favor process-specic limitations, as behavioral
and psychophysiological measures suggest age In sum, age-related differences in cognitive con-
differences in the representation and selection of trol have been shown in WM, inhibition, and
task goals in WM that cannot be attributed to switching tasks. Recently, the dual mechanisms
processing speed as a single underlying factor. In of control (DMC; Braver et al. 2007) theory pro-
contrast, the switching process itself seems to be poses that age differences in all of these tasks can
relatively preserved in old age (Kray and be explained by age differences in one common
Ferdinand 2014). mechanism, namely, the ability to process context
Despite these age-related limitations, recent information. Context information is described as
intervention studies revealed substantial plasticity the internal representation of task-relevant infor-
in task-switching abilities among older adults mation such as rules, goals, or instructions within
(Buitenweg et al. 2012; Kray and Ferdinand WM that is maintained and updated to serve con-
2014). Strategy-based interventions, for instance, trolled, goal-related behavior. Within this frame-
employed labeling strategies such as verbalizing work, context processing relies on the interaction
the next task to promote the planning and prepa- between the dorsolateral PFC (DL-PFC) and the
ration of the upcoming task switch and thus to midbrain dopamine (DA) system. More precisely,
facilitate goal-directed behavior. Results on these sustained neuronal activity of the DL-PFC pro-
kinds of interventions show a substantial benet vides the online maintenance of context informa-
of verbal self-instructions on switching costs par- tion in order to bias the activity in posterior and
ticularly in older adults, indicating language pro- subcortical brain regions responsible for goal-
cesses to offer a promising approach to support related behavior in accordance with the current
action control in old age (Kray and Ferdinand context representation. At the same time, phasic
2014). Process-based interventions aim to DA projections toward the DL-PFC in response to
enhance cognitive control by the practice of the new, salient, or reward-predicting context cues are
underlying cognitive control processes involved proposed to act as a gating mechanism, i.e., ensur-
in task switching. Recent studies reported a con- ing the appropriate updating of context informa-
siderable reduction in switching costs for younger tion in the DL-PFC (Braver et al. 2007). Hence,
as well as older adults, indicating substantial sustained activity within the DL-PFC ensures the
potentials to improve switching ability stability of goal-directed behavior against distrac-
(Buitenweg et al. 2012). Both age groups also tion, whereas the DA-guided gating mechanism
showed larger performance gains in an untrained simultaneously allows for the exible adaptation
but structurally similar switching task, and these to changing task demands. Given the well-known
gains were even more pronounced in the older age-related neurobiological changes observed in
than in the younger age group. Importantly, train- the PFC and the midbrain DA system, decits are
ing gains also generalized to untrained cognitive expected in both the active maintenance and the
gating of new context information that in turn temporal differences in context updating seem to
impairs performance on a variety of cognitive account for age differences in inhibition, WM,
control tasks. For instance, the active maintenance and task shifting that are often regarded as sepa-
of task-relevant context information serves to pro- rable components of cognitive control (Braver
tect information against interference, and distur- et al. 2007).
bances therein particularly affect WM capacity. In Age-related differences in context updating
a similar vein, decits in actively maintaining con- have been shown to be susceptible to different C
text representations may also impair the ability to training regimes. In two training studies, the AX
inhibit predominant response tendencies, as the continuous performance task (AX-CPT, Braver
maintenance of a contemporary task rule is thought 2012) was applied in order to measure an individ-
to enable the activation of a weaker, task-relevant uals ability to process context cue information
against a stronger but task-irrelevant response. required for correct responding to a subsequent
Finally, phasic DA responses to the DL-PFC indi- probe stimulus. It has been demonstrated that both
cating the need for updating context representations extended practice and directed strategy training
are particularly important in task switching. Therein, toward the use of cue-based, proactive control in
context information represents the currently relevant the AX-CPT reduced context processing decits
task rule, and decits in the gating mechanism might in older adults, indicating process- and strategy-
impair the updating and exible attention shifting based interventions to benet context updating in
between cognitive tasks. These examples outline old age. Moreover, the behavioral improvements
that instead of separating age differences in cogni- in the AX-CPT in older adults were accompanied
tive control into a decline of subprocesses such as by increased PFC activation to the presentation of
WM, inhibition, and attention shifting, the DMC contextual information (Braver 2012). These
theory considers age differences in the neurobiolog- results correspond to a recent training study show-
ical basis of context processing to be fundamental to ing training-related alterations in PFC activity to
account for age decits in subcomponents of cogni- underlie the transfer of training gains to untrained
tive control (Braver et al. 2007). cognitive control tasks (Bamidis et al. 2014). In
Recent behavioral and neuroscientic studies this study, older adults performed an adaptive
on testing the assumptions of the DMC theory multitasking video game training offering a large
show that changes in the interplay between the stimulus variability and continuous feedback. The
PFC and the DA system inherent to healthy aging multitasking approach in particular encompassed
predominantly affect the time course of updating the need for resolving task interference in the
context information. Younger adults exhibit an dual-task situation. Training gains were larger
early, proactive manner of context updating by after multitask training than after training both
the time context information is presented and tasks in isolation, transferred to other untrained
hence update context information to prepare for cognitive control tasks such as WM and attention,
an upcoming task in advance. In contrast, older and remained stable at a follow-up measurement
adults show a late, reactive manner of context 6 months after the training. Moreover, robust cor-
updating, only when needed such as when interrelations between multitasking ability and
ference is detected in a reactive fashion (Braver changes in activation patterns of the PFC
2012). While the temporal shift of context predicted the transfer gains to the untrained cog-
updating in a pro- versus reactive manner with nitive control tasks. Hence, process-based training
increasing age has been supported on the basis interventions, such as multitasking training, that
of fMRI and ERP data (Braver 2012; Schmitt aim at improving cognitive control can result in
et al. 2014), age differences in maintaining con- alterations of the neuronal recruitment of the PFC
text information have revealed mixed results and in elderly individuals that may also generalize to
seem to occur only under specic task conditions. other cognitive tasks relying on cognitive control
However, the DMC theory is promising as networks (Bamidis et al. 2014).
Definition of Self-Regulation abilities depend on a network of specialized pre-

frontal brain regions, including the lateral PFC
The concept of self-regulation refers to the indi- (L-PFC), the ventromedial PFC (VM-PFC), and
vidual control of own actions, thoughts, and emo- the anterior cingulate cortex (ACC) (Wagner and
tions toward the achievement of desired outcomes Heatherton 2011). The L-PFC is highly related to
and intentions (Bauer and Baumeister 2011). It is other prefrontal regions, especially to motor cor-
very loosely dened and considered as a con- tices, the VM-PFC, and the ACC, and is assumed
glomeration of abilities, consisting among others to contribute to the mere self-control processes
the capability to override automatic habits, basic involved in self-regulation, such as inhibiting
affects, and impulses, to control and monitor per- inappropriate behaviors, maintaining multiple
formance, to achieve distal aims, and to resist goals in WM and exibly selecting between
short-term temptations to the benet of long- them, dealing with distraction, and carefully plan-
time goals. Accordingly, failures of self- ning the sequence of goal-directed actions
regulatory ability affect both exible behavior (Wagner and Heatherton 2011). In contrast, the
and social adaptation that can be observed in a VM-PFC is highly connected to subcortical struc-
broad range of psychological phenomena such as tures involved in affective processing (e.g., the
gambling, addiction, eating disorders, under- amygdala, the hypothalamus, the insula, and the
achievement, prejudice, aggression, and so on ventral striatum). Therefore, the VM-PFC is seen
(Bauer and Baumeister 2011). to be particularly important for regulating affec-
In general, self-regulatory processing is con- tive and appetitive processes and adapting to
sidered as a system of feedback loops in which social norms (Wagner and Heatherton 2011).
individuals concurrently monitor the discrepancy This assumption has been supported by case
between the actual behavioral outcomes and feed- reports showing patients with damage to the
back and the individuals goal and intentions VM-PFC to exhibit drastic personality changes
(Bauer and Baumeister 2011). Whenever there is such as aggressive, socially inhibited behavior
a discrepancy, individuals automatically or con- and a particular inability to respect social norms
sciously engage in self-regulatory abilities to min- (Wagner and Heatherton 2011). Despite their
imize the discrepancy until the goal is achieved. functional differences, both the L-PFC and the
Hence, similar to the concept of cognitive control, VM-PFC are interconnected with the ACC that
self-regulation is highly important to adaptive, shares many connections with subcortical (e.g.,
goal-directed behavior (Bauer and Baumeister the ventral striatum) and motor regions. Patient
2011). For instance, it has been shown that indi- studies show that due to its close connection to
viduals with better cognitive control ability, such motor cortices and subcortical structures involved
as higher WM capacity, also tend to show better in reward processing, damage to the ACC may
self-regulatory skills, such as less mind- result in general apathy, loss of motivation or
wandering or more resistance toward the tempta- interest, and an inability to generate behavior
tion of eating candy (Hofmann et al. 2011). (Wagner and Heatherton 2011). Moreover, given
its anatomically strategic position, neuroscientic
research regards the ACC as a neuronal correlate
Neuronal Underpinnings of a conict detection mechanism, signaling the
need for increased control toward the L-PFC
Recent research has also identied subprocesses whenever performance errors are detected. This
of cognitive control to play an important role in role closely reects the conceptualization of self-
the mechanisms of self-regulation (Wagner and regulation as a system of feedback loops (Wagner
Heatherton 2011), in particular the self-control and Heatherton 2011).
aspects of self-regulation. This view is supported The strong anatomical and functional overlap
by evidence that akin to the mechanisms of cog- between control processes (e.g., inhibition of
nitive control, a broader range of self-regulatory temptations and automatic behaviors) attributable
to both the concepts of cognitive control and self- rhythms, with smaller decits obtained in the
regulation has led to systematic investigations of morning than afternoon based on biological
their interaction. In the Strength Model of Control changes in the underlying neuronal resource.
and Depletion (Bauer and Baumeister 2011), it Therefore, older adults showed more risky gam-
has been argued that these control processes bling and socially inappropriate behavior when
depend on a limited, domain-general physiologi- they were tested in the afternoon relative to
cal resource that once depleted results in when the experiment took place in the morning C
impaired performance on task relying on this (Von Hippel and Henry 2011). On the other hand,
resource. Dieters, for example, whose resource evidence exists that older adults are able to man-
for self-regulatory control on eating behavior age self-regulatory decits and inhibit expressing
was stressed by inhibiting temptation from nearby stereotypes or inappropriate behaviors when they
food, showed impaired performance not only in a are aware of it. For instance, if older adults are
subsequent task on self-regulation (i.e., eating ice forewarned about an upcoming, irrelevant stereo-
cream) but also on a cognitive control task (i.e., typic situation or if they know beforehand that
WM) relative to non-dieters and dieters whose they have to suppress a socially inappropriate
self-regulation was not additionally depleted by action later on (Von Hippel and Henry 2011),
tempting foods (Bauer and Baumeister 2011). they do not differ in the appropriateness of their
Likewise, participants who were required to take behavior relative to younger adults. This suggests
part in a difcult cognitive control task (i.e., atten- that older adults may prepare for potential inhib-
tional control) showed impaired self-regulatory itory control decits, and hence, can exert con-
control (i.e., emotion regulation) compared to scious control over their self-regulatory abilities.
control participants who did not complete the Furthermore, there are also ndings suggesting
cognitive control task (Wagner and Heatherton increased self-regulatory skills in older adults
2011). than in younger adults (Von Hippel and Henry
2011). For instance, in the domain of emotion
regulation, it has been shown that older adults
Age Differences in Self-Regulation focus more on positive than negative or neutral
information in order to voluntarily enhance their
Age-related decits in self-regulation have been emotional well-being. This phenomenon, known
strongly associated with impairments in cognitive as the age-related positivity effect (Mather 2006),
control and in particular with impairments in has been explained in the framework of the socio-
inhibitory control (Von Hippel and Henry 2011). emotional selectivity theory (Mather 2006). This
On the one hand, due to a failure to inhibit and theory posits that personal goals have to be
control automatically activated thoughts and regarded within future time constraints. In the
temptations, older adults seem to express more case that individuals value future time horizons
social stereotypes (i.e., race-related prejudices), as enduring, they will focus on goals related to the
exhibit more socially inappropriate behavior future, such as gaining knowledge. In contrast, if
(i.e., talking about private issues in public and individuals recognize future time as restricted, just
generating gratuitous comments), and engage as it occurs in older age, they will focus on imme-
more in risky gambling (i.e., larger perseverance diate, meaningful goals, such as emotional regu-
in the absence of reward) than younger adults lation and gratication (Mather 2006).
(Von Hippel and Henry 2011). Interestingly, Accordingly, relative to younger adults, older
individual differences in inhibitory decits adults expressed higher emotional stability and
(as measured with standard cognitive control skills of emotion regulation, showed more effec-
tasks) seem to directly mediate the extent of self- tive social problem-solving, focused more
regulatory failure in older adults (Von Hippel and strongly on positive relationships with others,
Henry 2011). Moreover, these inhibitory decits and reported less self-conscious negative emo-
have been shown to be sensitive to circadian tions (Mather 2006). Similar to the controlled
compensation of inhibitory decits, the age- cognitive control), future research studies in older
related positivity effect seems to be more pro- adults might investigate whether and to what
nounced when older adults are forewarned and extent these interventions are able to transfer to
for older adults with better cognitive control abil- self-regulatory skills. Finally, these studies might
ity. In contrast, when cognitive load is increased also turn to training-related changes in the under-
or cognitive control abilities are impaired as in lying brain network of self-regulation and cogni-
pathological aging, older adults are less able to tive control.
invest in controlled processing of emotional
information and the positivity effect vanishes
(Mather 2006). Summary
Apart from the stable or even improved ability
of emotion regulation in the elderly, there are only There is now accumulated evidence for age-
a few studies that have investigated whether self- related limitations in cognitive and self-regulatory
regulatory skills can be improved by cognitive control that are associated with alterations in
interventions. These studies show that already a different underlying neuronal networks. Age
limited amount of practice in self-regulatory con- differences in cognitive control occur in tasks
trol, for instance, by controlling eaten food or requiring high demands on WM, inhibitory
engaging in regular physical exercises, is able to control, and task switching that can be explained
translate into improvements in key aspects of self- by a recent neurobiological theory on context
control in laboratory tasks and also transfers to processing. Age differences in self-regulation
self-regulatory skills in everyday life (e.g., primarily concern self-control, while emotion reg-
decreased consumption of cigarettes, alcohol, ulation is relatively preserved. Intervention
and unhealthy food) (Bauer and Baumeister studies have revealed considerable plasticity in
2011). So far these studies have mainly been cognitive control in elderly individuals, while
conducted in younger or middle-aged individuals the potential benet of training in self-regulation
and largely neglected the effect of self-regulatory is not known yet. Given that cognitive control and
practice in older adults (Hofman et al. 2012). self-regulation partly rely on similar neuronal net-
However, given existing evidence for self- works, it will be an important challenge for future
regulatory failures in old age (e.g., problematic research to determine whether training in either of
gambling), it might be especially important to these abilities will lead to improvements in the
create successful self-control trainings and to corresponding other one.
investigate any potential transfer to measures of
self-regulation in this age group. In this respect, it
is also interesting to note that improvements in
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530 Cognitive Dissonance and Aging
Cognitive Dissonance changes in mental and physical health status may

also affect the way that dissonance is experienced
Cognitive dissonance is a ubiquitous aspect of in peoples lives.
human social life. Introduced into the scientic The plan of this entry is to describe the basic
literature by Leon Festinger (1957), the concept tenets of cognitive dissonance theory and the focal
was dened as a state of arousal caused by incon- areas that have received the preponderance of
sistency among a persons cognitions. In research attention. Alternative formulations of
Festingers view, people abhor inconsistency. dissonance will be examined as will the accompa-
When faced with discrepancy among cognitions, nying evidence for those alternatives. Changes in
people experience a motivation akin to hunger or mental processes and brain activities that charac-
thirst. It is an uncomfortable drive-like state that terize passage into older age will be presented
we are motivated to reduce. We resolve our incon- along with a discussion of the ways that such
sistencies in myriad possible ways that are changes affect the arousal and reduction of cogni-
designed to alleviate the tension state and restore tive dissonance.
equanimity.
Festinger (1957) offered a set of hypothetical Cognitive Dissonance as Function of Choice
examples that helped to describe some of the Our lives are replete with choices. We choose a
circumstances that might lead to the arousal of breakfast cereal to begin the morning, we choose
dissonance. Among those circumstances are the clothes we put on, and, possibly, we choose
choosing to smoke when you know that smoking the means of transportation we use to shop or go to
is damaging to your health, making a statement work. If we have been fortunate in our lives, we
contrary to your true opinions, choosing one com- have chosen the job we currently have or the
modity or action from a set of attractive alterna- school that we attended. What is little noted in
tives, holding an opinion that is inconsistent with all of these choices is the fact that choices create
more general values or opinions, or observing the conditions for the arousal of cognitive disso-
events that are inconsistent with past experience. nance. Imagine a couple that has recently retired
Despite our preference for consistency, there and decided to change their living accommoda-
are numerous times in our daily lives in which we tions from a private home to a retirement commu-
are confronted with a set of inconsistent cogni- nity. They have narrowed their choice to two
tions. Because the perception of inconsistency facilities that they view as highly attractive. One
leads to an uncomfortable state of arousal, we community offers excellent recreational activities
have developed ways to reduce the inconsistency. but comes at a steep cost. Another may have a
We may respond to inconsistency by changing a dearth of recreational facilities but has excellent
cognition to make it t with other cognitions we food and costs appreciably less. The choice is an
hold. We can also change the importance of a important one for it has implications for future
cognition or act to avoid noticing the inconsis- lifestyle and happiness.
tency altogether. Cognitive dissonance theory predicts that these
Aging may affect the dissonance process. At retirees will experience cognitive dissonance as
the very least, the cognitions that people nd to be soon as they decide which facility to join. Prior to
important change with age. Young children may the choice, the many facets of the decision were
be invested in the toy they are allowed to choose; examined carefully and objectively. In the
young adults may be profoundly affected by the pre-decision period, people try to make the very
cost of attending university; older adults may be best decision possible and consider their options
most interested in the types of leisure activities without bias. However, once the decision is made,
they can choose or the age of retirement from their then every attractive feature of the unchosen alter-
careers. More profoundly, changes in memory and native stands in contradiction to the choice that
emotional processes may also affect the quality was made. So, too, does every unattractive feature
and magnitude of dissonance arousal, and of the chosen alternative. For example, if the
retirees decide to join the facility that had the best then given an opportunity to select one of two
recreational activities, they will be comforted by highly attractive items. The choice was a difcult
the fact that recreation as well as all other pos- one because the items had been ranked similarly
itive features of this choice t with their deci- in attractiveness. Brehm found that, following the
sion. They can envision hours on the treadmill, or choice, the participants came to feel that the item
the golf course. On the other hand, the cost of the they had chosen was even more attractive than it
facility will make it less feasible for them to travel had been prior to the choice and the item they had C
for holidays or family visits. Moreover, by choos- rejected was rated as less attractive. The spreading
ing the facility with the better recreational activi- of alternatives following a choice has been repli-
ties, the couple will not be able to savor the cated with children and adult participants and is
excellent meals at the second facility. robust across cultures (Cooper 2007).
Cognitive dissonance theory predicts that,
once having made a choice, all of the conse- Cognitive Dissonance and Induced
quences of that choice that are inconsistent Compliance
with the selected alternative become grist for Induced compliance is the name given to the
the dissonance process. The perception of social situation in which someone is induced to
inconsistency for example, foregoing the excel- argue for a position that is contrary to the persons
lent food at the rejected community and paying own beliefs. In the rst experiment of its type,
the steep price at the chosen community creates Festinger and Carlsmith (1959) asked participants
the aversive feeling state of cognitive dissonance. to engage in a performance task in the laboratory
In order to reduce the aversive state of dissonance, that was designed to engender a negative attitude.
the couple is motivated to reevaluate the compo- It was tedious, boring, and apparently without
nents of their decision in order to support the purpose. Participants were then induced to lie to
conclusion they came to. They can decide that a person who was waiting to take part in the
they did not really want to be saddled with the experiment. They were asked to convince the
burden of having to go to the rejected alleged next person that the performance task
communitys elaborate dinners and that traveling was fun, engaging, and enjoyable. Because the
is not a highly prized activity after all. They might statement was clearly contradictory to the partic-
also engage in selective memory by recalling all ipants attitudes, it aroused cognitive dissonance.
of the consequences consistent with their choice In order to reduce the arousal of the unpleasant
while forgetting those that are inconsistent. In the tension state, participants changed their attitudes
end, dissonance theory predicts that the couple to make them more consistent with their
will become more satised with their choice than behavior that is, they came to agree that the
they were when they made their selection. In brief, task was interesting.
the inconsistency created by making a difcult Dissonance has a magnitude (Festinger 1957).
choice between alternatives arouses the uncom- People who hold cognitions that are incompatible
fortable tension state of dissonance. In order to can experience dissonance to different degrees.
reduce dissonance, the chosen alternative is seen Some of the variance is due to individual differ-
as more attractive and the rejected alternative ences in tolerance for inconsistency (Cialdini
becomes less attractive. This is known as the et al. 1995). Most of the research on the magni-
spreading of alternatives, one of the signature tude of dissonance, however, has focused on
predictions of cognitive dissonance theory. situational differences in the inducement for
Numerous laboratory studies have supported counterattitudinal behavior. For example, asking
this prediction (Cooper 2007). In the rst empiri- people to make a counterattitudinal statement for a
cal investigation of the consequences of free small, or no, incentive creates more dissonance
choice, Brehm (1956) asked adult consumers to than making the same request for a substantial
rank a number appliances in terms of how attrac- incentive. Festinger and Carlsmith predicted and
tive they would be to own. The consumers were found that making attitude-discrepant speeches in
return for a small incentive ($1) created more justication (Aronson and Mills 1959), effort is
attitude change than making attitude-discrepant considered to be any activity that is difcult and
speeches for a large incentive ($20). unpleasant or would otherwise not be engaged
The situation that Festinger and Carlsmith in. Imagine that a person hopes to join a book
employed in their research was well controlled discussion club at a neighborhood senior citizen
but somewhat articial. Enjoyment of a specic center. Imagine, too, that the group has require-
laboratory task is not a concern in most peoples ments that could be considered onerous. In order
lives. Nonetheless, there are instances in peoples to join, members have to pay a deposit as a pre-
lives in which they may nd themselves advocat- caution against damages, must read and write
ing positions that they do not fully endorse and reports on several books so that their reading and
these may lead to the arousal of cognitive disso- intellectual abilities can be assessed, and agree to
nance. Imagine that a special interest group hires a lead more than their share of group discussions.
retiree to advocate for privatization of a pension or Assuming that the deposit, the extra reading, and
retirement system. Although the retiree does not reports are unpleasant or effortful, then engaging
endorse privatization, he consents to advocate on in them arouses cognitive dissonance. If they were
behalf of this plan. Consistent with dissonance engaged in for the purpose of joining the club,
theory predictions, the retiree is likely to change then the club ought to be a very good one in order
his attitude in favor of privatization. The less he is to justify the amount of effort expended. Suppose
paid for his advocacy, the greater the dissonance that objectively it is only mediocre. In that case,
and the greater the attitude change in favor of the the effort expended to join the group is inconsis-
privatization plan. tent with the groups quality. This increases the
Empirical research has supported the predic- amount of dissonance. The unpleasant arousal
tion that people change their attitudes toward state can be reduced by distorting the perception
important issues that affect their lives. People of the quality of the group. Rather than viewing
have been induced to change their attitudes the book club as mediocre, people can alter their
about banning controversial speakers, students attitude to believe that the group is wonderful,
have changed their attitudes toward raising thereby justifying the effort and expense they
tuition, and taxpayers have changed their attitudes paid to join.
about raising taxes after being induced to make
statements contrary to their attitudes. And, as in Alternative Models of Dissonance
the laboratory, the less the incentive, the greater The New Look Model. Cooper and Fazio (1984)
the dissonance and the more the attitude change proposed an alternate model for the basis of cog-
(Cooper 2007). nitive dissonance. They outlined a theory in which
An additional feature of the induced compli- dissonance is caused by assuming responsibility
ance situation critical for the maximization of for a behavior that results in a potentially
dissonance is that the attitude-discrepant behavior unwanted consequence. In the New Look model,
must lead to an unwanted consequence. If a retiree dissonance is not aroused by inconsistent cogni-
makes a statement advocating privatization of tions per se but is rather a coping strategy to deal
pension plans, the statement will lead to disso- with ones responsibility for bringing about aver-
nance if there is a consequence to his behavior. sive events.
The likelihood that someone will be convinced by The New Look model raises an important issue
the counterattitudinal statement facilitates maxi- that affects many people as they age. Any number
mal cognitive dissonance and will lead to attitude of unwanted consequences may occur as a func-
change. tion of growing older. People may need to retire
because of failing health or because of arbitrary
Effort Justification age restrictions. Home environments may need to
People often engage in effortful activities in order be modied or people may need to move to spe-
to achieve a goal. In the literature on effort cial care facilities. These consequences of aging
are often unwanted and aversive, which seem consequences of behavior. When people behave,
suited to evoking the arousal of dissonance. Dis- they assess the valence of the consequences by
sonance often works to the advantage of people comparing them to a particular standard of judg-
who must make difcult decisions about retirement. Stone and Coopers self-standards model
ment or health because it typically serves to make proposes that the choice of standards of judgment
them feel more positively about the decisions they moderates the role of the self in the dissonance
have made. The critical factor that determines process. When people are motivated by situational C
whether the unwanted consequences of aging or dispositional factors to assess their behavior
lead to dissonance is whether people feel person- against normative standards of judgment, such as
ally responsible for the occurrence of the aversive How would most people assess this behavior?,
events. In principle, if dissonance is aroused, it then self-esteem does not factor into the disso-
will lead to cognitive activity designed to reduce nance process. However, when people evaluate
the dissonance. If moving to a senior facility leads their behavior by using a personal standard of
to something objectively unwanted, people will judgment, then self-esteem is very much a part
experience dissonance and take action to reduce of the dissonance process. As a general rule, the
it. It would be reasonable to predict that people higher the self-esteem, the greater is the
will be motivated to like their new living facilities dissonance.
as a way to reduce dissonance but only to the What can we expect about the role of self-
extent that they feel personal responsibility for esteem in the aging process? To the extent that
their choices. If they feel retirement has been dissonance is based on personal standards of judg-
forced on them or they had no role in a decision ment, an aging population will experience more or
to move to a new facility, then dissonance will not less dissonance depending on changes in their
occur and there will be no motivation to raise their self-esteem over the life span. Research
evaluations. concerning the self-esteem of the elderly leans
The Action-Based Model. Harmon-Jones toward the conclusion that older adults have a
(1999) proposed a functional approach to the lower sense of self-esteem than younger adults
motivation for cognitive dissonance. The action- (Robins et al. 2002), which would suggest that
based model suggests that people are motivated to dissonance may be less acute with an aging pop-
reduce inconsistency because the negative arousal ulation. On the other hand, self-esteem of older
interferes with peoples distal motivation to pre- adults tends to be related not only to chronological
pare for unequivocal action. Because inconsistent age but also with their ability to assimilate into
cognitions imply inconsistent actions, the discrep- their social environment and to manage difcult
ancy needs to be resolved. life events (Alaphilippe 2008). Self-esteem of the
Self-Esteem Approaches. Aronsons self- elderly also shows fewer uctuations than the
esteem model (Aronson 1968) and Steeles self- self-esteem of younger adults. Empirical research
afrmation theory (Steele 1988) suggest that the has not yet addressed the role of aging as a mod-
central motivation for dissonance arousal and erator of the role of self-esteem in the dissonance
reduction is to maintain a high sense of self- process but it is likely that self-esteem is a com-
esteem. Acting inconsistently threatens peoples plex factor of chronological age and social
self-worth. Therefore, restoring consistency is at circumstances.
the service of reestablishing a self-worth and Neuropsychology of Dissonance. Dissonance
global self-esteem. is accompanied by the psychological experience
Self-Standards Model and the Role of Self- of discomfort (Elliot and Devine 1994) and by
Esteem in Aging. Stone and Cooper (2001) pro- autonomic physiological arousal as assessed by
posed a resolution of the role of self-esteem in elevated skin conductance responses (SCR)
dissonance. They showed that the effect of the self (Croyle and Cooper 1983; Losch and Cacioppo
in the arousal of dissonance is moderated by the 1990). In the brain, research has associated cog-
standards that are used to evaluate the nitive dissonance with increased neural activity in
the right inferior frontal gyrus, the medial appear to be necessary for dissonance reduction.
frontoparietal regions, and the ventral striatum Lieberman and colleagues (2001) tested amne-
and decreased activity in the anterior insula siacs whose explicit memory was impaired and
(Jarcho et al. 2011). Such processes are found to compared them to normal adults in a free-choice
engage quickly at the moment of decision without dissonance situation. In the experiment, amne-
extensive deliberation. Van Veen et al. (2009) siacs and normals were asked to make a selection
found that attitude change associated with cogni- between attractive alternatives. Lieberman et al.
tive dissonance engages the dorsal anterior cingu- found that amnesiacs engaged in choice-
late cortex and the anterior insula. More broadly, supportive reevaluation of the alternatives despite
greater left frontal activity appears to be activated their having no explicit recollection of the initial
in the dissonance process, linking it to other neg- choice. Consistent with dissonance theory, and
ative, approach-oriented motivations such as similar to the responses of normal participants,
anger (Harmon-Jones 2004). amnesiacs spread the attractiveness of the choice
alternatives to support the initial decision they
had made.
Dissonance in the Aging Process Older adults are more averse to negative affect
than are younger adults. For example, they are
Numerous changes occur during aging that affect more likely to rate highly arousing negative stim-
dissonance. The magnitude of dissonance is uli as more negative than do younger adults and
inuenced by factors that undergo change during are vigilant to minimize the occurrence of nega-
the life span. For example, when making a choice tive experiences. Older adults concentrate on
between alternatives, a persons age may determine avoiding regret and boosting contentment
the importance of the choice and therefore the (Carstensen and Hartel 2006). When asked to
magnitude of dissonance. More fundamentally, report their emotional experiences, older adults
increased age brings with it changes in psycholog- report as many positive emotional experiences as
ical functioning and neurological integrity. These younger adults but report fewer negative experi-
changes are likely to affect cognitive dissonance in ences (Carstensen et al. 2000). In general, older
fundamental ways. adults spend more time and resources regulating
Older adults experience deteriorations in neu- emotional experiences, both in laboratory
ral areas important for executive functioning. The research tasks and in daily life tasks, and do so
prefrontal cortex is one of the areas most affected with a bias that leads to emotional satisfaction
by aging. With increasing age, the prefrontal cor- (Scheibe and Carstensen 2010).
tex responds more slowly than, for example, the As people age, they become more procient at
limbic system, when processing emotional stimuli knowing the emotional effects of future events and
(Gross 2013). The vmPFC shows marked struc- have the enhanced ability of tailoring their
tural decline after the age of 60 (Asp et al. 2012). emotion-regulatory strategies to meet contextual
Neuronal density in the frontal gyrus is measur- demands (Scheibe and Carstensen 2010). Thus,
ably different when people enter their 70s. Yet, the future emotional implications of decisions
despite the atrophy in structure, activation in areas may be weighted heavily by older adults,
associated with dissonance and decision making suggesting that because the elderly are concerned
remain strong in older age. Activations in the with their view of self, decisions and actions that go
dorsolateral prefrontal cortex and the ventral against their attitudes and views may intensify their
medial frontal cortex remain strong, as do the experience of dissonance. This effect in the elderly
parietal areas. can be further understood through the life-span
There are decreases in explicit memory with theory of control (Heckhausen & Schulz 1995),
age, but the decreases are not associated with which suggests that peoples capability to regulate
diminished ability to process or respond to disso- their environments and attain their growth-related
nant information. Explicit memory does not goals declines in older adulthood. Therefore, older
adults increasingly use secondary control tools, choice-supportive memory effect regardless of
such as emotion regulation, which is aimed at condition, indicating that they used selective and
changing the self to be able to adjust to a given distorted memory as ways to adjust negative feel-
situation, instead of relying on primary control ings that were aroused by dissonance.
strategies that change the situation itself. In Mather and Johnsons research, participants
The increase need for emotion regulation com- were also administered a neuropsychological test
bined with diminished structural integrity of fron- battery to measure frontal brain region pathology. C
tal brain activity suggest that older adults devote The results showed poorer overall memory among
more of their cognitive resources to regulating people identied with neuropathological disor-
emotion, with particular emphasis on avoidance ders but found even greater ratios of choice-
of negative states. Because cognitive dissonance supportive memory in this subpopulation. This is
is experienced as a specically negative emotional consistent with the notion that the weakening of
state, older adults are motivated to engage in cognitive executive function causes people to put
dissonance reduction, consistent with their orien- more of their available resources toward the goal
tation to avoid negative emotional states. Mather of regulating emotion by becoming more emo-
and Johnson (2000) examined peoples recollec- tionally satised with the choices they made
tions of the positive and negative features of (Mather and Johnson 2000).
choice alternatives in a free-choice (Brehm Further research (Mather and Johnson 2000)
1956) situation. Older adults (6483) and younger conrmed that the distortions of memory are consis-
adults (1826) were given the option to choose an tent with dissonance theory predictions. Participants
alternative in a set of two-choice options. Choices either chose one of the alternatives or were assigned
included selections of which of two houses they one of them. Results conrmed that choice-
would prefer or about which of two candidates supportive memory distortions occurred only in the
they would select for a job. Several positive and free-choice conditions known to produce cognitive
negative attributes of each alternative were dissonance (Brehm 1956) but not in conditions in
described. Following their choice, participants which the alternatives were merely assigned.
were asked to recall as many of the attributes as
they could remember. The older participants
showed more choice-supportive memory than Conclusion
the younger adults. Older adults remembered
more positive attributes and fewer negative attri- Cognitive dissonance is a state of aversive arousal
butes of the alternatives they selected. They also that occurs when people perceive inconsistency
recalled more negative and fewer positive aspects among their cognitions. Although dissonance was
of the alternatives they rejected. Older participants not theorized to be age related, empirical work on
also misattributed attributes of the alternatives in a dissonance had been primarily focused on conve-
choice-supportive manner. When given the oppor- nience samples of young adults. Recent research
tunity to attribute positive and negative features to suggests that, to the extent that gerontological fac-
the alternatives that had not been mentioned in the tors inuence the course of cognitive dissonance,
original list, they made errors of memory in the older adults may be particularly sensitive to disso-
same choice-supportive fashion. nance effects. With increasing age, changes in psy-
In order to assess the crucial role played by chological functioning imply different needs, goals,
emotion regulation, participants were either asked and abilities. Although regions of the brain associ-
to remember the facts or remember how they felt ated with memory and executive function show
when making their decisions. Younger adults did structural and functional decline with age, regions
not show choice-supportive memory when asked associated with cognitive dissonance show no con-
for a factual review. They manifested the choice- sistent pattern of decline. Instead, research in emo-
supportive memory effect only when asked tion regulation suggests that the need to achieve
how they felt. Older adults showed the positive emotional states increases with age along
with the concomitant sensitivity to potential nega- Elliot, A., & Devine, P. G. (1994). On the motivational
tive threats. Cognitive dissonance is a potential nature of cognitive dissonance: Dissonance as psycho-
logical discomfort. Journal of Personality & Social
threat. Reducing it in a choice-supportive manner Psychology, 67, 382394.
appears to be an increasing priority of the aging Festinger, L. (1957). A theory of cognitive dissonance.
process. Stanford: Stanford University Press.
Festinger, L., & Carlsmith, J. M. (1959). Cognitive conse-
quences of forced compliance. Journal of Abnormal &
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Cognitive Neuroscience of Aging 537
cognitive tasks, is accomplished via methods such

Cognitive Neuroscience of Aging as functional magnetic resonance imaging
(fMRI). These are just some of the many methods
Laura E. Paige and Angela H. Gutchess used in cognitive neuroscience research, but these
Brandeis University, Waltham, MA, USA are the methods that will be predominantly
discussed in this entry. Studies employing these
methods begin to uncover how age-related C
Synonyms changes to the brain impact behavior, including
not only how neural regions support cognitive
Aging; Cognition; Neural differences; Structural function with age but also the overall efciency
changes in engaging processes. Importantly, the applica-
tion of cognitive neuroscience methods has shown
that aging is not simply deterioration of the brain,
Definition but it also reveals evidence for reorganization and
compensation underlying cognitive processes.
While physical changes are obvious with age, For example, some research illustrates how an
cognitive neuroscience sheds light on the struc- older brain is able to adapt to physiological
tural and functional changes that occur in the brain changes to perform a task comparably well as a
throughout the lifespan. Using behavioral and younger brain, albeit not as efciently. Much of
neural measures, cognitive neuroscience suggests the literature argues that older adults recruit addi-
that with increasing age, there are not only cogni- tional activation in brain areas that were not acti-
tive decits, but also the potential for reorganiza- vated in younger adults performing the same task.
tion and stability of these underlying cognitive While the function of these activation changes is
processes. still greatly debated in the eld, it indicates, at the
very least, exibility in the brain recruitment of
older adults. Cognitive neuroscience has helped
Introduction progress the eld by seeking to understand the
behavioral impairments on a neural level and
Much of the previous behavioral research has how brain plasticity attempts to compensate for
focused on losses with age the senses become these changes.
less sharp, performance worsens on tasks, and it is
easier to become distracted and forgetful. While
aging brings readily apparent changes to areas Structural Changes in Aging
such as physical appearance, health, and stamina,
it also brings signicant changes to the brain. With aging, the brain typically undergoes wide-
Cognitive neuroscience has greatly impacted the spread cortical thinning. The gaps (sulci) between
way in which aging is understood by probing the cortex widen, while the volume of the folds of
these internal changes. New methods have the cortex (gyri) decreases, as evidenced with
shown that aging leads to alterations in multiple methods such as MRI. However, certain regions
aspects of the brain, including structure, integrity, are more prone to atrophy than others, and indi-
and active engagement of neural regions. The viduals vary widely in their extent of change. For
physical anatomy of the brain changes in terms example, the hippocampus, orbitofrontal cortex,
of both gray matter (as assessed with methods and entorhinal cortex have all been shown to
such as magnetic resonance imaging, MRI) and decrease in volume over time, whereas regions
white matter (as assessed with method such as like the primary visual cortex, putamen, and
diffusion tensor imaging, DTI). Determining pons remain relatively intact (see Fig. 1a; Raz
functional activation in the brain, such as how et al. 2010). Longitudinal studies of cortical thick-
different regions are engaged during demanding ness have also shown that regions such as the
538 Cognitive Neuroscience of Aging
Hippocampus Entorhinal Cortex

a 3.0
8.0 2.7
Adjusted Volume (cm3)

7.2 2.4
6.4 2.1
5.6 1.8
1.5
4.8
1.2
0.0 0.0
0 45 50 55 60 65 70 75 80 85 90 0 45 50 55 60 65 70 75 80 85 90
Age (years) Age (years)
b Longitudinal subsample +0.75 12

Orbito-frontal Cortex
n = 207
11
annual % change

+0.1
10
9
0.1
7
0.75
6
0
0 50 55 60 65 70 75 80 85
Age (years)
Cognitive Neuroscience of Aging, Fig. 1 Atrophy in aged 6093. This is represented by a color-coded brain
the aging brain is exhibited by overall cortical thinning of map where percent decrease in cortical thickness is
the cortex. (a) Volume was measured twice, 15 months represented by yellow and red, appearing as lighter and
apart, in individuals aged 49 and older. This is depicted by darker gray in the grayscale version. The longitudinal
two measurements, connected by a line for each individual. sample showed a mean annual change of 0.59% across
Most individuals show decreases in volume, even in this the cortical surface. This reduction was especially seen in
short time frame, with the vast majority of lines connecting regions such as the lateral frontal, temporoparietal, and
the two points showing a downward trend. The overall lateral occipital cortices (Source: (a) adapted from Raz
trend line reects that the volume of the region tends to et al. (2010) with permission; (b) adapted from Fjell
decline after age 49. (b) Annual percentage change in et al. (2014) with permission)
cortical thickness was measured in a longitudinal sample
lateral frontal, temporoparietal, and lateral occip- performance and shows substantial atrophy both
ital cortices all exhibit an increased mean annual in Alzheimers disease and in normal aging (Fjell
percent change with age (see Fig. 1b; (Fjell et al. 2014). A role for entorhinal cortex in mem-
et al. 2014)). ory is consistent with its location in the medial
Although there is much interest in linking temporal lobes near the hippocampus, an impor-
structural measures of the brain with performance tant structure for memory.
on cognitive tasks, there is not always a straight- Classically, atrophy in the brain has been stud-
forward link between these measures. However, ied by examining gray matter, which is the tissue
relationships have emerged for some regions, that contains the cell bodies and dendrites of neu-
such as the entorhinal cortex. The cortical thick- rons. However, cognitive neuroscience has
ness of this region is associated with memory revealed that it is also important to study the
a Young Adults Old Adults b

10
old
R = 0.614
P = 0.034
Frontal Activity
5
young
R = 0.06
0
C
P = ns
10
10 0 10 20 30 40 50
Word-Pair Cued-Recall
Occipital Activity
Cognitive Neuroscience of Aging, Fig. 2 Changing between occipital and frontal activations in younger
brain activation patterns with aging. (a) Support for the (depicted as circles) and older (depicted as squares) adults.
HAROLD model reveals that prefrontal cortex activation Consistent with the PASA model, older adults (relative to
during a cued-recall task (e.g., studied parents-piano, younger adults) showed less occipital activity concomi-
presented with parents-??? at test) was right lateralized in tantly with increased frontal activity. This suggests
younger adults but bilateral in older adults. Activation age-related decits in sensory processing that require
appears as a yellow/orange blob, gray in the grayscale recruitment of regions involved in organization and recon-
version. Concurrent with HAROLD and reductions in struction of information (Source: (a) adapted from Cabeza
hemisphere asymmetry, older adults recruited two hemi- (2002) with permission; (b) adapted from Davis
spheres to complete a task that only required recruitment of et al. (Davis et al. 2008) with permission)
one hemisphere for younger adults. (b) Correlations
connections between regions of the brain formed patterns. For many tasks, older adults can activate
by white matter, the tissue that contains the axons more brain regions than younger adults (Park and
of neurons and that is necessary for communica- Reuter-Lorenz 2009). This includes patterns of
tion and coordination between regions (Gunning- bilaterally recruiting the same region in both the
Dixon et al. 2009). One metric used in DTI is left and right hemispheres and shifting from acti-
fractional anisotropy (FA), which characterizes vating regions largely in the back of the brain to
the presence of white matter ber tracts by study- those in the front (Cabeza 2002; Davis
ing how much water diffuses in one direction. et al. 2008). Several models have sought to under-
Intact bers restrict the ow of water, increasing stand the causes and functions of these age-related
the measure of FA. Research using this method changes in activation.
has shown that aging causes deterioration of tissue The Hemispheric Asymmetry Reduction in
microstructure, decreasing FA (Gunning-Dixon Older Adults (HAROLD) model looks at how
et al. 2009). As a result, there is no longer an younger adults activate a region in one hemi-
exclusive focus on just gray matter. White matter sphere when performing a task, whereas older
changes with aging can be profound and may adults have a tendency to activate the same region
explain much of age-related cognitive decline in both hemispheres (see Fig. 2a; Cabeza 2002).
(Gunning-Dixon et al. 2009). This pattern of bilateral activity, or reducing the
asymmetry of hemispheric activations, can some-
times be linked to better cognitive performance,
Age-Related Differences in Neural suggesting that additional bilateral recruitment
Activity may support older adults performance to be on
par with that of younger adults.
While structural measures of gray and white mat- While HAROLD considers patterns of activa-
ter largely reveal a pattern of decline, research tion across hemispheres, the posterior-anterior
with functional measures can reveal different shift in aging (PASA) model studies a different
pattern with aging changes in activation from of aging and cognition (STAC) shows older adults
the back of the brain to front. Specically, compensate with task difculty by recruiting
decreases in occipital lobe activation occur con- additional regions, creating new connections,
comitantly with increases in frontal lobe activity and enhancing neural systems to improve cogni-
(see Fig. 2b; Davis et al. 2008). The occipital lobe tive performance (Park and Reuter-Lorenz 2009).
is involved in sensory-related processes that Cognitive neuroscience methods have helped
become decient with age (e.g., difculty orga- develop important theories like STAC to advance
nizing sensory input of a previously seen image). our understanding of aging. Unlike other theories,
PASA suggests that older adults try to offset sen- STAC actually accounts for both cognitive
sory decits and underrecruitment in these areas decline as well as the ability to utilize additional
by overrecruiting in frontal regions. This change resources to improve performance with age.
may reect greater reliance on high-order cogni- STAC incorporates the possibility that while cog-
tive processes responsible for directing sensory nitive declines may be inevitable with age, inter-
input or reconstructing poor signals coming from ventions such as cognitive training or physical
sensory cortices, also known as top-down exercise could help subside some of the
processing (Davis et al. 2008). age-related challenges to cognition.
Like HAROLD, another pattern of activity
known as dedifferentiation illustrates a decrease
in the specialization of regions with age Theories of Cognitive Aging
(Park et al. 2004). In contrast to HAROLD or
PASA, which emphasize the location of the brain Thus far, this chapter has reviewed ways in which
areas recruited differently with age, dedifferentia- cognitive neuroscience has led to new ways of
tion usually emphasizes the specialization of the thinking about aging. However, data using these
process. For example, parts of the brain that methods have also substantiated or enriched clas-
respond specically to seeing faces in younger sical theories of cognitive aging originally based
adults may respond less distinctly to faces but on behavioral data.
also respond to other images, such as places or Speed of processing. Slowing in older adults
words, for older adults (Park et al. 2004). This loss is true both physically and mentally, as our ability
of specialization in activity can occur even in to process information slows with age. Known as
brain regions that do not show atrophy with speed of processing, this ability is assessed by
aging, such as the ventral visual cortex (Park how many judgments can be made in a short
et al. 2004). period of time (Salthouse 1991). Performance
Within the literature, there is much debate over declines with age because older adults are slow
whether these increased patterns of activation are to complete initial cognitive tasks and processes
actually compensatory, helping to improve older within a trial, and this prevents them from com-
adults performance. If this is the case, older pleting later stages of tasks (Salthouse 1991).
adults could be bringing online additional cog- Underlying neural regions involved in executive
nitive resources in response to task demands. One function, such as the prefrontal cortex, have been
theory has focused on how changing task shown to decrease with age leading to increased
demands (e.g., increasing or decreasing difculty response time and inaccuracy in tasks specically
of task) can alter activation in older adults. The measuring speed and efciency (Rypma
compensation-related utilization of neural cir- et al. 1999). As previously mentioned, cognitive
cuits (CRUNCH) hypothesis suggests that making neuroscience helped establish the importance of
a task more difcult should proportionally studying white matter pathways. It has now been
increase neural activity for older adults at levels shown that damage to connections between the
of difculty that would not be considered strenu- prefrontal cortex and other regions formed by
ous for younger adults (Cappell et al. 2010). white matter tracts can largely account for such
Building off of that theory, the scaffolding theory cognitive slowing (Gunning-Dixon et al. 2009).
Memory. There are two major subtypes of is associated with age-related decreases in prefron-
memory, both of which are affected by aging. tal cortex activity, parahippocampal gyrus, and
Working memory manipulates and stores infor- occipitoparietal cortex (Dennis et al. 2014). Unlike
mation online, such that it can be stored, the comparable memory performance for true rec-
retrieved, or transformed at the same time (Craik ollection, older adults have higher rates of false
and Byrd 1982). Looking up a phone number, recollection. The resulting activation then suggests
keeping it active in mind, and dialing it a few a reduced ability to reconstruct perceptual details C
minutes later would be an example of this. The leading to increased false memories (Dennis
ability to manipulate information decreases with et al. 2014).
age. Research suggests older adults require addi- Inhibition. Older adults difculty with speed
tional cognitive resources to maintain information of processing and memory could be largely
in mind as task demands increase (e.g., remem- connected to breakdowns in inhibition with age.
bering a string that is three numbers vs. nine num- Inhibition, or the ability to focus on important
bers long). In line with the PASA model, older target information and inhibit attention to irrele-
adults try to counteract decits in underrecruited vant information, becomes increasingly difcult
sensory regions by recruiting higher-order cogni- with age (Hasher et al. 1991). Successful versus
tive processes mediated by frontal regions unsuccessful ignore trials have revealed differ-
(Cabeza and Dennis 2012). This leads to a pattern ences in brain activation. When told to ignore
of prefrontal overactivation in older adults as certain words, younger adults activated rostral
additional resources are needed. Interestingly, a prefrontal cortex and inferior parietal cortex
similar pattern of activation happens for younger more than older adults, and activity in these
adults too, but not until they reach seemingly regions was negatively correlated with priming
higher memory loads (Cappell et al. 2010). This for distracting words (Campbell et al. 2012).
suggests that older adults are using compensatory Younger adults remembered fewer of the ignore
processes but require them at lower levels of task words than older adults. Besides activating the
difculty than younger adults. rostral prefrontal cortex less during to-be-ignored
Aging also affects long-term memory or last- trials, older adults also had reduced functional
ing storage of information. As previously men- connectivity within the frontoparietal network.
tioned, structural decits to regions involved in These results suggested that increased distractibil-
memory processes have been shown to occur ity could be due to decreased engagement of this
with age and accelerate in Alzheimers disease cognitive control network and impairment in how
(Fjell et al. 2014). One consideration within this this network works together with other networks
type of memory is true versus false recollection involved in ignoring information (Campbell
of items. True recollection, or correctly remem- et al. 2012).
bering an event in enough detail to feel as if it
were being reexperienced (rather than feeling
only generally familiar), is associated with Socioemotional Information and Aging
age-related decreases in occipital activation and
increases in prefrontal cortex activation (Dennis This chapter has shown that aging brings changes
et al. 2014). Despite recruitment of different neu- to structural integrity of the brain and the cogni-
ral regions, older and younger adults have similar tive processes necessary to carry out various tasks.
behavioral rates of true recollection. This pattern Aging can also impact the ways in which one
of activation therefore suggests an age-related interacts with the environment. The application
inability to retrieve perceptual details and a of cognitive neuroscience methods to social psy-
greater reliance on familiarity and gist (e.g., gen- chology has allowed researchers to understand the
eral meaning that lacks distinct features) for neural changes involved in social domains and
older adults to complete the task (Dennis emotional responses. Importantly, the inclusion
et al. 2014). On the other hand, false recollection of aging into social and affective neuroscience
research highlights how age-related differences in relying on executive function, to achieve the same
social cognition, similar to cognitive function, are behavioral results.
not just about loss. Changes in emotion. In contrast to the other
Changes in social cognition. Social neurosci- abilities reviewed thus far, emotion regulation, or
ence research has revealed a variety of activation the ability to control reactivity to valenced stimuli,
patterns. Some patterns are consistent with the seems to improve with age. Unlike other areas of
cognitive literature, showing that age-related the brain that undergo large amounts of atrophy,
declines in cognitive processes may also contribute the amygdala is relatively preserved with age
to social domains. Other patterns, however, suggest (Nashiro et al. 2012). Further, aging seems to
that social domains may be more preserved with affect the is processed way in which valenced
age. One ability that seems to be largely preserved information. Older adults show a positivity effect,
with aging is self-referencing. In these tasks, par- whereby they spend more time viewing positive
ticipants must reference words or items to oneself items and less time viewing negative items. As a
or to another person, and this process can enhance result, older adults remember relatively less neg-
the memorability of information. When comparing ative information and more positive information
activation between younger and older adults, it was (Mather and Carstensen 2005). Behavioral theo-
found that both groups engage the medial prefron- ries suggest that the positivity effect seen with
tal cortex similarly (Gutchess et al. 2007). This aging is due to a greater focus on regulating emo-
nding was interpreted as evidence for preserved tions and required cognitive processes (Mather
social functioning, and corresponding neural activ- and Carstensen 2005). This cognitive control the-
ity, with age. ory predicts that prefrontal emotion regulation
Other research, however, suggests that patterns processes diminish amygdala responses to nega-
of activation in social cognition are consistent tive but not positive stimuli (Nashiro et al. 2012).
with the functional deteriorations seen in the cog- Using cognitive neuroscience methods, one
nitive literature. Processes like inhibition and can examine the ways in which different regions
speed of processing which decline in age may in a network operate together to contribute to this
contribute to changes in social cognition by way shift in emotional processing with age. Research
of their contribution to executive function. For suggests that emotional processing differences are
example, executive functions are necessary for the result of age-related changes in encoding pro-
regulation of bias, specically toward stigmatized cesses when viewing positive stimuli only. In
individuals (e.g., individuals with facial deformi- these instances, the connectivity between the ven-
ties, homeless people). It has been shown that tromedial prefrontal cortex, amygdala, and hippo-
high-functioning older adults, who had relatively campus was stronger during encoding of positive
preserved levels of executive function, activated trials only (Addis et al. 2010). There were no
areas of lateral prefrontal cortex more than youn- changes in connectivity between regions during
ger adults and low-functioning older adults encoding of negative trials (Addis et al. 2010).
(Krendl et al. 2009). On the other hand, younger This suggests that aging may not weaken emo-
adults had greater activity in medial prefrontal tional network connections (as in the negative
cortex than older adults in response to stigmatized stimuli) but rather strengthen them (in relation to
individuals that were considered less negative the positive stimuli), allowing for increased atten-
(Krendl et al. 2009). Because high-functioning tion and memory for positive information.
older adults and younger adults showed similar
attitudes toward stigmatized targets, the differ-
ences in the groups neural activity suggest Conclusion
high-functioning older adults and younger adults
rely on different underlying processes The growth of cognitive neuroscience has
(Krendl et al. 2009). High-functioning older changed the way aging is studied and understood.
adults may have exerted greater cognitive effort, Brain volume and cortical thickness decrease, and
important connections between regions lose EmotionCognition Interactions

integrity as white matter tracts deteriorate. In Executive Functioning
aging there are also general brain activation pat- History of Cognitive Aging Research
terns that change, such as reduced hemispheric Positive Emotion Processing, Theoretical
asymmetry and overrecruitment of frontal Perspectives
regions. Importantly, cognitive neuroscience has Psychological Theories of Successful Aging
shown that aging is not just a downward spiral of Social Cognition and Aging C
loss but can include compensation by bringing
additional regions online and reorganizing neu-
ral circuits. Despite the increased appreciation for References
malleability in neural circuits with age, changes in
the brain do affect cognition, causing older adults Addis, D. R., Leclerc, C. M., Muscatell, K. A., &
Kensinger, E. A. (2010). There are age-related changes
to process information slower, demonstrate short-
in neural connectivity during the encoding of positive,
and long-term memory problems, and experience but not negative, information. Cortex, 46, 425433.
difculty attending to important information Cabeza, R. (2002). Hemispheric asymmetry reduction in
while ignoring irrelevant information. In regard older adults: The HAROLD model. Psychology and
Aging, 17, 85.
to social cognition, research is split on whether
Cabeza, R., & Dennis, N. A. (2012). Frontal lobes and
social domains may be preserved in aging. Some aging. In Principles of frontal lobe function (2nd ed.,
aspects appear to be affected by underlying cog- pp. 628652). New York: Oxford University Press.
nitive processes that are known to deteriorate, Campbell, K. L., Grady, C. L., Ng, C., & Hasher, L. (2012).
Age differences in the frontoparietal cognitive control
whereas other abilities seem to be unaffected.
network: Implications for distractibility. Neuropsy-
Age-related differences are also seen in emotional chologia, 50, 22122223.
processing, with older adults exhibiting a positive Cappell, K. A., Gmeindl, L., & Reuter-Lorenz, P. A.
bias when viewing and remembering information. (2010). Age differences in prefontal recruitment during
verbal working memory maintenance depend on mem-
Research has shown this change could be the
ory load. Cortex, 46, 462473. doi:10.1016/j.
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with aging or altered connections between neural Craik, F. I., & Byrd, M. (1982). Aging and cognitive
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Davis, S. W., Dennis, N. A., Daselaar, S. M., Fleck, M. S.,
information over negative. Ultimately, develop-
& Cabeza, R. (2008). Que PASA? The posterior-
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Age-related differences in the neural correlates mediat-
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changes that occur through aging and how these
Gunning-Dixon, F. M., Brickman, A. M., Cheng, J. C., &
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(1991). Age and inhibition. Journal of Experimental
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544 Cognitive Rehabilitation
investigation of age differences in inhibiting prejudice. Definition

Psychology and Aging, 24, 530541. doi:10.1037/
a0016065.
Mather, M., & Carstensen, L. L. (2005). Aging and moti- Cognitive rehabilitation refers to therapy designed
vated cognition: The positivity effect in attention and to restore, substitute, or compensate for cognitive
memory. Trends in Cognitive Sciences, 9, 496502. abilities lost due to injury or illness. Cognitive
doi:10.1016/j.tics.2005.08.005. rehabilitation typically refers to training targeting
Nashiro, K., Sakaki, M., & Mather, M. (2012). Age differ-
ences in brain activity during emotion processing: improvement of skill by regaining (reestablishing
Reections of age-related decline or increased emotion or strengthening) abilities that were intact prior to
regulation? Gerontology, 58, 156163. doi:10.1159/ the loss. The other focus of cognitive rehabilita-
000328465. tion is developing compensatory strategies for lost
brain: Aging and neurocognitive scaffolding. Annual abilities when they cannot be regained. In con-
Review of Psychology, 60, 173. trast, the term cognitive intervention refers to
Park, D. C., et al. (2004). Aging reduces neural specializa- targeted training of a particular cognitive skill or
tion in ventral visual cortex. Proceedings of the domain for the purpose of enhancement regard-
National Academy of Sciences of the United States of
America, 101, 1309113095. doi:10.1073/pnas. less of the baseline state of cognitive abilities. As
0405148101. such, many cognitive interventions target healthy
Raz, N., Ghisletta, P., Rodrigue, K. M., Kennedy, K. M., & functioning individuals. Distinct from rehabilita-
Lindenberger, U. (2010). Trajectories of brain aging in tion and intervention, cognitive stimulation ther-
middle-aged and older adults: Regional and individual
differences. NeuroImage, 51, 501511. apy refers to a brief psychological intervention
Rypma, B., Prabhakaran, V., Desmond, J. E., Glover, used to provide general stimulation of cognitive
G. H., & Gabrieli, J. D. E. (1999). Load-dependent abilities in individuals with mild to moderate
roles of frontal brain regions in the maintenance of dementia.
working memory. NeuroImage, 9, 216226.
doi:10.1006/nimg.1998.0404. The techniques used in cognitive rehabilitation
Salthouse, T. A. (1991). Mediation of adult age-differences can be applied to any individual who experiences
in cognition by reductions in working memory cognitive loss due to an injury or illness. Most
and speed of processing. Psychological Science, 2, commonly, cognitive rehabilitation is used with
179183. doi:10.1111/j.1467-9280.1991.tb00127.x.
stroke victims and traumatic brain injury patients.
Additionally, while less common, cognitive reha-
bilitation techniques and programs have been
designed for elders with cognitive decline due to
normal aging, mild cognitive impairment (MCI),
Cognitive Rehabilitation or neurodegenerative disease (Attix and Welsh-
Bohmer 2006; Camp 2010).
Nicholas T. Bott1,2 and Abigail Kramer1,3
1
Sierra Pacic Mental Illness Research,
Education, and Clinical Centers (MIRECC), VA
History of Cognitive Rehabilitation
Palo Alto Health Care System, Palo Alto,
in Old Age
CA, USA
2
Pacic Graduate School of PsychologyStanford
As the name suggests, cognitive rehabilitation
PsyD Consortium, Stanford, CA, USA
3 represents a diverse set of therapeutic interven-
Pacic Graduate School of Psychology, Palo
tions aimed at restoring, substituting, or compen-
Alto University, Palo Alto, CA, USA
sating for cognitive abilities impacted by injury or
illness through the use of specic strategies or
adaptations. These interventions are nonpharma-
Synonyms cological and nonsurgical and are aimed at
remediating the cognitive capacities (Prigatano
Adaptation; Cognitive strategies; Cognitive 2005). Historically, cognitive rehabilitation has
training; Compensation focused on specic kinds of acquired brain injury
Cognitive Rehabilitation 545
such as traumatic brain injury (TBI) and stroke more generalized theory of neural compensation
(Parente and Stapleton 1996). While injury sever- within which the concept of cognitive reserve
ity necessarily limits the extent to which cognitive remains an important factor associated with better
rehabilitation can be effectively utilized, age is neural compensation. Such additional brain
also a signicant factor contributing to the ef- recruitment has been observed in both structural
ciency (e.g., time, cost) of cognitive rehabilitation and functional imaging studies. For example, Ilg
for acquired brain injury (Flanagan et al. 2005) as and colleagues (2010) investigated practice- C
well as later-life cognitive impairment and induced neural activation associated with mirror
dementia. reading and found that short-term gray matter
To combat the effects of cognitive decline in signal increase was associated with task-specic
older adults, cognitive rehabilitation was born processing. Similarly, Steffener and colleagues
out of plasticity research in the 1970s, which (2009) investigated age-related changes in work-
conceptualized the cognitive aging process as both ing memory using an fMRI paradigm. They found
multidimensional and multidirectional (Verhaeghen that while decreased regional volume in the
2000). At that time, the performance-potential primary neural network was associated with
divide associated with cognitive aging spurred increased secondary network utilization indepen-
the search for modiability, which would later dent of age, only older adults demonstrated
be described as plasticity. Baltes and Willis increased activation in the secondary neural net-
(1982) dened plasticity as the range of intellec- work as working memory load increased.
tual aging under conditions not normally existent in Whether this recruitment represents neural com-
either the living ecology of older persons or in the pensation in the facilitation of task completion
standard assessment situation provided by classical remains debated (Park and Reuter-Lorenz 2009).
test of psychometric intelligence. While early
experiments focused on the enhancement of perfor-
mance on tests of intelligence, plasticity research Preventative Cognitive Training
with elders quickly branched out into the domain of
episodic memory function and has since expanded Increasingly, however, targeting healthy older
to include nonspecic cognitive stimulation adults before symptoms of impairment develop
targeting a variety of cognitive domains has been a focus of research. Shatenstein and
(Smith et al. 2009). As the construct of brain plas- Berberger-Gateau (2015) have recently posited
ticity has matured, it has come to stand alongside, if four categories of modiable cognitive risk or
not over shadow, cognitive rehabilitation training protective factors for older adults: (1) collective
programs focused on strategy use. This is in part societal factors, (2) individual psychosocial fac-
due to the lack of generalized gains from direct tors, (3) lifestyle factors, and (4) cardiometabolic
strategy instruction outside of the specic cognitive factors. Within these four categories, seven indi-
tasks related to the training. Additionally, it can be vidual modiable factors account for 28% of the
difcult for older adults to continue learning new risk of developing Alzheimers disease: diabetes,
approaches to cognitive processing, as use of spe- obesity or hypertension in middle age, low phys-
cic strategies require. ical activity, depression, smoking, and low educa-
One of the dominant theories underlying cur- tional level. Within this model, Shatenstein and
rent understanding of neuroplasticity in cognitive Berberger-Gateau identify primary prevention as
aging is known as the scaffolding theory of aging reduction of the occurrence of specic risk fac-
and cognition (STAC; Goh and Park 2009). STAC tors, with secondary prevention aimed at early
posits that the aging brain responds to neural prevention of disease by identication of clinical
insults (e.g., volume reduction, white matter deg- or biological markers that could lead to early
radation) through the recruitment of additional detection and treatment of at-risk individuals.
brain regions to achieve adequate function. Historically, cognitive interventions have been
Barulli and Stern (2013) identify STAC as a used to remediate intellectual decline in normal
older adults. In a longitudinal study conducted by were performing comparable or better than their
Schaie and Willis (1986), their ndings suggest baseline level compared to 49% of controls. Mem-
that decline is associated with the disuse of cog- ory performance was comparable between the
nitive abilities overtime. With the implementation intervention and control groups after 10 years.
of cognitive training, two thirds of the participants With respect to IADLs, individuals across all
were able to improve their intellectual function- three intervention groups endorsed less subjective
ing. Specically, 40% of the participants that had difculty with IADLs than control participants;
shown signicant decline over a 14-year period however, performance on objective measures of
were able to return to their pre-decline perfor- functional abilities was comparable across inter-
mance (Schaie and Willis 1986). Furthermore, vention and control groups.
the outcomes of this cognitive training were In summary, ACTIVE was the rst multisite
shown to be long-lasting, with the benets clinical trial to test the effects of cognitive training
persisting 7 years after training in comparison to interventions on cognitive abilities and daily
controls (Schaie et al. 1994). function in healthy functioning older adults.
The potential benets of targeting healthy The relative success of the ACTIVE trial provides
older adults have been rigorously demonstrated support for preventative cognitive interventions in
in the recent Advanced Cognitive Training for this population and has signicant economic
Independent and Vital Elderly (ACTIVE) study. implications given the aging of the US population.
The ACTIVE study was a randomized, controlled Interventions that reliably extend healthy cogni-
single-blind trial (n = 2832) with three interven- tive aging trajectories could signicantly reduce
tion groups and a no-contact control group to the economic burden associated with cognitive
determine the effects of cognitive training on cog- impairment and dementia.
nitive abilities and everyday function over a
10-year period. Each of the three intervention
groups targeted a specic cognitive domain: Cognitive Rehabilitation for Mild
memory, reasoning, and speed-of-processing. Cognitive Impairment
The intervention consisted of an initial
ten-session training (6070 min per session) for MCI is often described an intermediate stage
one of the three cognitive domains, with some between cognitive decline due to normal aging
participants receiving a four-session booster train- and dementia (Huckans et al. 2013). Criteria for
ing at 11 and at 35 months after training. Outcome MCI diagnosis are (a) evidence of modest cogni-
measures included both objective measures of tive decline from a previous level of performance
memory, reasoning, and processing speed and in one or more cognitive domains including mem-
functional measures of IADLs. ory, language, attention, visuospatial functioning,
At the conclusion of the study, all groups and executive functioning, or as documented
showed declines from their baseline tests across by standardized neuropsychological testing,
cognitive domains. Interestingly, individuals who (b) cognitive decits do not interfere with
received training in reasoning and processing capacity for independence in everyday activity,
speed evidenced fewer declines than those in the (c) cognitive decits do not occur exclusively in
memory and control groups. Results of the cogni- the context of a delirium, and (d) it is not better
tive tests after 10 years reported by Rebok and explained by another mental disorder and does not
colleagues (2014) demonstrated that nearly three meet criteria for dementia (American Psychiatric
quarters of those individuals that received reason- Association 2013). Although many people with
ing training were still performing reasoning tasks MCI live independently, declines in subjective
above their pretrial baseline level. In contrast, and objective memory and cognition impact qual-
only 62% percent of control participants showed ity and degree of independence in daily life. Def-
above pretrial performance. Similarly, 71% of icits may impact scheduling, transportation, or
those receiving the processing speed intervention nancial management. Functional impact may be
greater for those struggling with multiple domain A different approach is to train cognition
MCI rather than in a single domain (Huckans through the development of new processing
et al. 2013). Within the older adult population, approaches. Here, cognitive training draws on
the prevalence rate of MCI is estimated to range internal strategies to work around the decit
from 3% to 42% (Ward et al. 2012). However, it is when the impairment cannot be improved through
estimated that 1440% of people with MCI return repetition. Examples of such cognitive training
to normal cognitive functioning (Ganguli strategies include visual imagery, chunking infor- C
et al. 2004) and others maintain MCI functioning mation, storytelling, and creating acronyms to
without progressing to dementia (Manly et al. remediate memory difculties. Other strategies
2008). The use of cognitive rehabilitation in this such as structured problem solving and planning
population may have particularly benecial out- methods can be used to address specic executive
comes (Huckans et al. 2013), as gains will not be decits (Huckans et al. 2013). Teaching mindful-
obscured by progressive decline. ness to double check and develop habits and rou-
A large proportion of patients (3585%) with tines may also be helpful for some individuals
MCI have additional psychiatric comorbidities, (OSullivan et al. 2015). Compensatory tech-
such depression, anxiety, irritability, apathy, niques can also involve external aids such as day
disinhibition, and sleep disorder (Monastero planners, calendars, and personal notebooks
et al. 2009). Therefore, effective management of (Kurz et al. 2009). Navigation devices can be
MCI will not only focus on cognitive decline but helpful for those with visuospatial compromises.
also incorporate strategies to address neuropsy- Additionally, environmental strategies may be
chiatric symptoms and lifestyle. used, such as setting up a quiet workspace in
Although many cognitive rehabilitation pro- order to avoid distracting visual and auditory
grams exist to treat MCI, there are several strate- stimuli (Huckans et al. 2013). Quinn and col-
gies and interventions that are consistent across leagues (2015) recently reviewed three self-
programs. The rst and most directive approach to management interventions for individuals with
address cognitive impairment is restorative cog- MCI that focused on information, communica-
nitive training. The aim of this technique is to tion, social support, and skills training. They con-
enhance or restore cognitive abilities through cluded that continued study of this intervention is
neuroplasticity mechanisms. This is most com- necessary to test the efcacy of self-management
monly done through the utilization of structured techniques in an MCI population.
and repeated practice of specic cognitive tasks Treatment benet will likely be maximized if
and mental exercises (Huckans et al. 2013). These additional treatment modiers, such as mood and
tasks are tailored to the individuals ability level lifestyle factors, are also addressed (Attix and and
and in the domain that is impaired, such as mem- Welsch-Bohmer 2006). Education about MCI as a
ory or attention. The exercises have the potential risk state, rather than prognostic indicator, can be
to improve or maintain functioning in these cog- quite helpful. Information about lifestyle practices
nitive domains with the goal to improve perfor- that involve protective factors (e.g., diet, exercise,
mance that will generalize beyond the immediate and cognitively stimulating activities) and risk
training task. However, the impact and the dura- factors (e.g., smoking, heavy substance use) is
tion of task repetition remain unclear (OSullivan also relevant. This can be done through direct
et al. 2015). Belleville and colleagues (2006) behavioral engagement or through the use of
demonstrated that instruction in episodic memory motivational interviewing with patients
strategies is effective in improving memory per- (Huckans et al. 2013; Kurz et al. 2009). Lastly,
formance in individuals with MCI. More recently, psychotherapeutic interventions are utilized to
Gagnon and Belleville (2012) reported that indi- treat the neuropsychiatric symptoms that fre-
viduals with a single-domain executive function quently accompany MCI. For example, relaxation
decit benet from an attentional control cogni- exercises and deep breathing can be taught to
tive intervention. reduce anxiety, and cognitive-behavioral
interventions can be utilized to address negative effectiveness. Attix and Welsh-Bohmer (2006)
thoughts and feelings related to MCI (Kurz detail the importance of the initial clinical evalu-
et al. 2009; OSullivan et al. 2015; Huckans ation in maximizing the effectiveness of cognitive
et al. 2013). While not every patient will need interventions through careful incorporation of
cognitive retraining, compensatory strategies, relevant patient data. These variables include
modication of lifestyle interventions, and psy- goals, motivation, neuropsychological evaluation,
chotherapy, these interventions are each part of a insight, affective status, unique patient and envi-
comprehensive treatment model to improve over- ronmental factors, and current compensatory
all quality of life in patients with MCI. methods and activities.
Cognitive rehabilitation techniques for people
with more signicant decits in dementia include
Cognitive Rehabilitation in Dementia reminiscence therapy, reality orientation, and val-
idation therapy, among others. Reminiscence ther-
Due to the progressive nature of neurodegenera- apy encourages individuals to recall past events
tive diseases, many do not believe that cognitive and life experiences through stimuli that evoke
rehabilitation is a suitable treatment for people memories, such as photos, objects, music, and
with progressive dementias such as Alzheimers videos. These sessions typically take place in a
disease, progressive vascular disease, and Lewy group setting in order to stimulate conversation
body disease. However, when the goal is to about common subjects (Mountain 2005). Reality
improve quality of life rather than return to orientation is a technique that presents orientation
premorbid cognitive ability, cognitive interven- information such as time, place, and person-
tion can be a proactive approach to improve over- related. The goal of providing information about
all functioning (Marshall 2005). Dementia is a the surroundings is to improve the quality of life
relatively common condition in older adults aged in confused individuals by increasing their sense
65 and older, affecting approximately 5% of the of control. Bianchetti and Trabucchi (2001) found
population (Jolley 2005). Alzheimers dementia that this therapy was able to delay entry into
(AD) has an insidious onset and progressive cog- extended-care facilities and slow cognitive
nitive decline, predominately in the domain of decline when administered over an extended
episodic memory, and is most evident in the abil- period of time to people in early- to middle-stage
ity to register and retain new information. How- dementia. In contrast, validation therapy provides
ever, people with AD tend to maintain the ability a way to communicate with older individuals with
to recall stories from early in their lives, as well as dementia in a way that is opposite to reality ori-
habits and skills performed over decades (Jolley entation. Instead of helping the individual under-
2005) until late stages of the disease. Cognitive stand the truth of their surroundings, this
intervention is primarily used in individuals with communication style validates rather than corrects
dementia to help them utilize their remaining the individuals erroneous sense of reality (Neal
memory functioning most effectively, learn how and Briggs 2003). The purpose of these three
to compensate for difculties, and create environ- therapeutic orientations aims to compensate for
mental adjustments to reduce the need for mem- decline rather than attempt to reverse it. This
ory (Mountain 2005). In other words, cognitive approach can ultimately lead to greater acceptance
intervention aims to assist patients and families and increased quality of life for people with
discover new ways to handle problems that arise dementia (Mountain 2005). Importantly, however,
due to cognitive decline and help the individual this therapeutic approach has received criticism
maintain the ability to engage in pleasurable activ- with respect to its underlying evidence base.
ities and interact with loved ones for as long as Moreover, in their 2003 review of the effects of
possible (Clare 2005). The treatment should be validation therapy, Neal and Barton concluded
client-centered, recognize the changing role iden- that there is insufcient evidence from rigorous
tities of the patient, and facilitate coping and studies (e.g., randomized control trials) to
substantiate claims of efcacy for people with including the US ENLIGHTEN trial, the Preven-
dementia or cognitive impairment. tion of Dementia by Intensive Vascular Care
Alternatives to compensatory orientations (preDIVA) study, and the Healthy Aging through
include self-management interventions, which Internet Counseling in Elderly (HATICE) pro-
equip people to manage the symptoms and life- gram, which focuses on the management of mod-
style changes present over the course of chronic iable risk factors in older people using an
health conditions. Self-management interventions Internet-based platform (Shatenstein et al. 2015). C
for individuals with dementia focus on
psychoeducation, social support, and specic
skills training. Quinn and colleagues (2016) Conclusions
recently reported modest effects of a randomized
controlled trial of a self-management intervention While cognitive rehabilitation interventions will
for individuals with early-stage dementia and their continue to be developed and used in older adult
caregivers. populations with acquired brain injury (e.g., TBI,
Adaptations to existing methods of develop- MCI), MCI, and dementia, preventative interven-
mental learning have also been successfully tions to extend healthy aging cognitive trajecto-
employed in individuals with dementia. For ries are well positioned to be more widely
example, Camp and colleagues developed Mon- disseminated. Efforts to build cognitive reserve
tessori Programming for Dementia (MPD), which and thereby extend the course of healthy cognitive
provides a framework for the translation of Mon- aging trajectories have signicant economic
tessori principles into meaningful activities for implications. For example, total annual per-
individuals with dementia (Camp 2010). MPD person payments for Medicare beneciaries with
has been used effectively within long-term care dementia are more than three times greater
settings as well as in intergenerational care pro- than payments for those without dementia
grams where programming is administered to (Unpublished tabulations based on data from
older adults and preschool-aged children in a the Medicare Current Beneciary Survey for
shared location (Camp and Lee 2011; Camp 2008. Prepared under contract by Julie Bynum,
et al. 2002). November 2011). Total payments in health care,
long-term care, and hospice for individuals with
neurodegenerative disease are currently estimated
Future Directions at $214 billion, and over the next 25 years, the
cumulative cost of care for individuals suffering
While interventions on individual modiable risk from neurodegenerative diseases such as
factors associated with cognitive decline will con- Alzheimers disease has been estimated at over
tinue to be investigated, multidomain approaches $1 trillion (Alzheimers 2014). These cost under-
for the prevention of cognitive decline are score the economic benets associated with the
strategic. This is, in part, due to the multifactorial prolongation of healthy cognitive aging trajecto-
nature of late-life dementia (Richard et al. 2012). ries even over relatively short amounts of time.
Additionally, the majority of preventative studies
to date have focused on the prevention of demen-
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study). International Psychogeriatrics, 28(5),
and Kozma Ahacic2,3
787800. 1
Rebok, G.W., Ball, K., Guey, L.T., Jones, R.N., Kim, H.Y., Department of Psychology, California State
King, J.W., Marsiske, M.,. . . Willis, S.L. (2014). University, Los Angeles, CA, USA
Ten-year effects of the advanced cognitive training for 2
Centre for Epidemiology and Community
independent and vital elderly cognitive training trial on
Medicine, Health Care Services, Stockholm
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Birth cohort; Cohort effect; Generation (e.g.,
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chology, 22, 223232. Baby boomers); Generational shift
Schaie, K. W., Willis, S. L., & OHanlon, A. M. (1994).
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Definition
Shatenstein, B., Barberger-Gateau, P., & Mecocci, P.
(2015). Prevention of age-related cognitive decline: The term cohort refers to a group of people born at
Which strategies, when, and for whom? Journal of about the same time.
Alzheimers Disease, 48(1), 3553.
In geropsychology, the term cohort refers to a
Smith, G. E., Housen, P., Yaffe, K., Ruff, R., Kennison,
R. F., Mahncke, H. W., & Zelinski, E. M. (2009). group of people born at about the same time.
A cognitive training program based on principles of While it has long been considered a nuisance
brain plasticity: Results from the improvement in mem- variable for age-based developmental studies,
ory with plasticity-based adaptive cognitive training
cohort is an important variable for many
(IMPACT) study. Journal of the American Geriatrics
Society, 57(4), 594603. researchers in the social and health sciences
Steffener, J., Brickman, A. M., Rakitin, B. C., Gazes, Y., & because it provides evidence of secular changes.
Stern, Y. (2009). The impace of age-related changes on Studies of cohort effects on intelligence, reason-
working memory functional activity. Brain Imaging &
ing, memory, and other cognitive abilities have
Behavior, 3(2), 142153.
Unpublished tabulations based on data from the Medicare garnered recent attention in both the academic and
Current Beneciary Survey for 2008. (2011, Novem- lay communities (Schaie et al. 2005; Williams
ber). Prepared under contract by Julie Bynum, M. D., 2013). A cogent example is the Flynn effect
M.P.H., Dartmouth Institute for Health Policy and Clin-
(Flynn 1987), which is the observation that gen-
ical Care, Dartmouth Medical School.
Verhaeghen, P. (2000). The interplay of growth and eration by generation, people are becoming
decline: Theoretical and empirical aspects of plasticity smarter with respect to intelligence test scores.
552 Cohort Effects
Cohort Effects, 15
Fig. 1 Cumulative cohort Verbal Meaning Spatial Orientation
differences for the primary Number
Inductive Reasoning
mental abilities in the
Word Fluency
Cumulative Mean T-Score Differences

Seattle Longitudinal Study.
Excerpted from Schaie 10
(2005) (Reprinted with
permission from Oxford
University Press.)
5
1889 1896 1903 1910 1917 1924 1931 1938 1945 1952 1959 1966 1973
Cohort
This entry will focus on cohort effects on cog- effects of cohort for a variety of measures and
nitive performance primarily in adulthood and for a variety of research questions (Schaie and
older age. After reviewing some of the methodo- Hofer 2001). Cohort-sequential studies (AKA
logical issues that affect the measurement of panel studies), which include two or more longi-
cohort and age effects, several important ndings tudinal panels of participants derived from dif-
on cohort differences in cognitive performance ferent birth cohorts, are able to assess cohort
including the Flynn effect will be reviewed. effects in two important ways. First, they can be
Finally, the issue of whether cohort differences used to measure changes in cognitive perfor-
continue into later life will be discussed. mance over birth cohort. As shown in Fig. 1,
Schaie and collaborators (Schaie et al. 2005)
have often used this approach to examine cohort
Methodological Issues changes in performance for psychometric mea-
sures of cognition. The gure shows that psycho-
Cohort is often contextualized in the metric of metric performance can be mapped over birth
years, decades, or generations. Decisions about cohorts yielding evidence of cohort trends. For
dening an appropriate time metric to assess example, one can see from Fig. 1 that there have
cohort effects are important because the gap been marked increases in inductive reasoning
between cohorts needs to be large enough to performance in more recent birth cohorts. Sec-
detect statistical differences, yet not too large as ond, cohort-sequential studies can be used to
to miss meaningful changes or turning points. assess cohort differences in time-based or
Decisions about the range of birth years to be age-based analyses of measures of cognitive per-
included in a sample are best made before initiat- formance. As shown in Fig. 2, Zelinski and
ing a study but are often constrained to the param- Kennison (2007) demonstrated this approach
eters of previously collected data in studies that when they assessed cohort differences in mean
were not specically designed with the measure- level functioning and in age-related changes of
ment of cohort in mind (Schaie et al. 2005). performance in a list recall task. The cohort dif-
Cohort-sequential longitudinal studies and ference observed from ages 56 to 74 weakens
time-lag studies have been used to assess the from ages 74 to 86.
Cohort Effects 553
Cohort Effects, List recall

Fig. 2 Estimated 80
longitudinal changes for list 75 Earlier-born cohort
recall for earlier-born (solid 70
line) and later-born (dashed Later-born cohort
line) cohorts. The chart was 65
Rasch score
created from the parameters 60
reported in Table 5 of
Zelinski and Kennison
55 C
50
(2007)
45
40
35
30
56 59 62 65 68 71 74 77 80 83 86
Age
A classic example of a cohort-sequential historical events or the accumulation of life expe-

study is the Seattle Longitudinal Study (SLS), riences nested within a broader historical period
which includes multiple longitudinal sequences (Twenge 2010; Salthouse 2015).
(panels) initiated approximately 7 years apart cur- The important design features of a valid cohort
rently providing the potential for 7, 14, 21, 28, study have been debated. Jensen in a personal
35, 42, and 49 year cohort comparisons (Schaie communication sent to and reported by Flynn
et al. 2005). Some of the other studies that have (1987) identied four elements needed to conduct
used this approach are the Victoria Longitudinal a reasonably valid cohort study. He stated:
Study (Dixon and de Frias 2004) and the Long (a) The possibility of sample bias should be elimi-
Beach Longitudinal Study (Zelinski and nated by comprehensive samples, such as mass
Kennison 2007). testing of draft registrants; (b) tests should remain
An alternative method used to assess cohort unaltered from one generation to another and esti-
mates of trends should be based on raw score dif-
effects in longitudinal studies is the practice of ferences; (c) particular emphasis should be placed
replacing lost subjects with new ones who are on culturally reduced tests like the Ravens Progres-
matched on baseline age but born to a later sive Matrices Test, as distinct from tests with items
cohort. An example of this approach can be that might easily be learned from one generation to
another; and (d) particular emphasis should be
found in the Health and Retirement Study placed on using mature subjects, subjects who
(2015), which replaces participants lost to attri- have reached the peak of their raw score
tion. In addition, as the HRS has progressed, it performance.
has included panels that represent different
cohort groups. While these criteria are generally desirable,
The other approach that is often used to study aspects of each have been challenged. On the
cohort effects is the time-lag design (Twenge rst criterion (a), the best methods for selecting
2010). In time-lag studies, groups of participants subjects such as random sampling from a well-
are tested at about the same age but at different dened population are difcult and costly to
points in time. The participants used in the differ- achieve. Many of the most consequential longitu-
ent data collections are not the same, so the dinal studies that have reported on cohort effects
approach is not longitudinal. Like cross-sectional have used convenience samples including the Vic-
studies, time-lag studies are less expensive and toria Longitudinal Study, Seattle Longitudinal
easier to conduct than longitudinal studies. How- Study, and Long Beach Longitudinal Study
ever, time effects are confounded with cohort (1, 5, and 7, respectively). Even the use of repre-
effects making it difcult to uniquely attribute sentative sampling is awed because samples are
causality; possible causes are either specic likely to become less representative as subject
554 Cohort Effects
attrition occurs over time and testings (Schaie (Horn and Donaldson 1976). In such studies, the
et al. 2005). Criterion (b), while it was originally performance of different age groups is compared
one of the central tenants of longitudinal methods, to determine whether age differences exist among
has become somewhat less important with the those groups. However, compared to a younger
development of item response theory methods age group, an older age groups participants are
(Embretson 1996), which allow tests and mea- not only older but they are also born into an earlier
sures to be equated. Criterion (d) states that sub- birth cohort, and thus any conclusions about
jects should have reached maturity before observed age differences are potentially con-
inclusion into the study, however, this does not founded by cohort differences. Depending on the
allow for the assessment of cohort differences in nature of the cohort effect, age group differences
the age at which maturity is reached (Schaie in performance can either be inated, which is the
et al. 2005). norm, or reduced (Schaie et al. 2005; Zelinski and
In recent years, many of the existing and retired Kennison 2007). Yet, even when the direction of a
longitudinal studies have archived their data for cohort effect is not clear or is inconsequential,
use by other investigators. According to the Mael- additional cohort-related noise is likely to be
strom Research webpage (Fortier and Ferretti introduced into cross-sectional data, which may
2015) there are currently 115 active or completed affect estimates of variability.
cohort-based studies worldwide and most of those While many cross-sectional studies are
studies include one or more measures of cognitive performed in the highly controlled environment
performance. Many of the databases can be found of a research laboratory, the potential for birth
on the Maelstrom website (www.maelstrom- cohort contamination is not directly knowable
research.org) or on other websites such as the from the data collected. The implicit assumption
National Archive of Computerized Data on of many researchers has been that cohort effects
Aging (NACDA) in the USA. are small and that they have only trivial effects on
conclusions about age differences (Salthouse
2015). However, such assumptions are not always
Cohort as a Nuisance Variable well founded and are contradicted by ndings
from the cohort-based results of cohort-sequential
In the developmental sciences, research studies longitudinal studies, which have shown that many
are not able to achieve pure measures of age, of the most studied measures of cognitive perfor-
cohort, or time-of-measurement (AKA period mance are indeed affected by birth cohort differ-
effects), which are likely to be the primary mea- ences (Schaie et al. 2005; Zelinski and Kennison
sures of interest. That is, the experimental designs 2007). Matched sampling, in which the younger
that are currently available are problematic such and older aged participants are matched on
that two of three time-varying measures, age, variables such as education or health can be used
cohort, and time, are always confounded with to reduce potential cohort effects, but such
one another, and the so-called ACT problem is matching strategies are not likely to be entirely
intractable (Horn and Donaldson 1976). How- effective because such variables do not fully
ever, as statistical modeling methods continue to account for observed cohort effects (Williams
advance, there is the likelihood that the magnitude 2013; Flynn 1987). While it is the case that cohort
of the three effects can be estimated and that these contamination is usually acknowledged as a lim-
estimates can be conrmed within and across itation of cross-sectional study designs, cohort
studies. If reliable estimates can be determined effects are scarcely considered in discussion
then they can be statistically controlled for. sections.
In cross-sectional studies, which are the most As shown in Figure 1, positive cohort trends,
popular type of study used to examine cognitive whereby later-born cohorts outperform earlier-
performance (Salthouse 2015), age is the variable born cohorts, have been observed for measures
of interest but cohort confounds its measurement of inductive reasoning, episodic memory, spatial
Cohort Effects 555
reasoning, and vocabulary (Schaie et al. 2005). 1948) were among the rst researchers to docu-
Such ndings suggest the likely existence of ment the phenomenon in the early to
cohort contamination in cross-sectional studies mid-twentieth century in American samples.
of age-related cognitive performance, and they Tuddenham (1948), for example, observed gains
indicate that conclusions about age differences over an 11 year gap from 1932 to 1943 in an
are likely to be overstated. Findings of cohort American sample, and he attributed the gains to
differences have been mixed for some measures advances in health, nutrition, education, and test- C
such as verbal uency and numerical ability, and taking abilities. It was not until the 1980s,
so the potential for cohort contamination is less however, that the phenomenon gained its current
clear but not necessarily inconsequential (Schaie traction and a name, when it was reported by
et al. 2005). Richard Lynn in 1982 and James R. Flynn in
Salthouse (2015) in an intriguing study inves- 1984 (Lynn 2013). It was Flynns detailed inves-
tigated the validity of longitudinal and cross- tigation and description that led to the phenome-
sectional results in light of the Flynn effect. The non being labeled the Flynn effect (Lynn 2013).
Flynn effect, the observation that more recently Although this is the term popularly used, some
born cohorts score higher on IQ measures com- refer to it as the Flynn-Lynn effect to recognize
pared to earlier-born cohorts, has largely been Lynns 1982 contribution, whose publication pre-
conrmed with time-lag studies, in which both ceded Flynns and who like Flynn has published
time-of-measurement and cohort effects are mea- extensively on the topic (Lynn 2013).
sured together and therefore confounded. If the In the United States, intelligence scores have
Flynn effect is at least partially a product of his- risen by about three IQ points per decade from
torical changes, then longitudinal results may be 1932 to 2002 on various versions of the Stanford-
contaminated by the Flynn effect. Salthouse stud- Binet and Wechsler IQ tests (Flynn and Weiss
ied Flynn effect biases in both cross-sectional and 2007). Similar strong gains have been recorded
longitudinal comparisons and concluded that in countries all across the globe, including devel-
. . .there were similar time-of-measurement oped (Flynn 1987; Flynn and Weiss 2007) and
increases in cognitive scores at different ages, developing nations (Williams 2013). These gains
which were accompanied by nearly constant have been observed in both verbally based IQ
cross-sectional age differences, but positively measures as well as for Ravens Matrices and
inated estimates of longitudinal age differences. other matrix reasoning tests, which are believed
Thus, he showed that longitudinal studies are not to be less affected by cultural and educational
immune to secular changes in performance and in inuences (Flynn 1987).
some cases may be more biased in the measure- A recent meta-analysis evaluated average IQ
ment of age effects than cross-sectional studies. gains from 1909 to 2013 for a combined sample
Others have shown that cohort effects can alter created from 271 individual samples representing
both cross-sectional and longitudinal results 31 countries of over four million participants.
(Zelinski et al. 2009). They reported IQ gains of 4.1 points per decade
for measures of uid abilities (Pietschnig and
Voracek 2015). Somewhat more modest gains
Research Findings on Birth Cohort were observed for spatial abilities (IQ gain = 3.0
and Cognitive Function points/decade), full scale IQ (IQ gain = 2.8
points/decade), and crystallized abilities
Gains in intelligence. The so-called Flynn effect is (IQ gain = 2.2 points/decade). While IQ gains
the observation that there has been a strong, pos- have been observed across most of the twentieth
itive trend of increasing intelligence scores from century, there is a growing body of evidence that
one generation to the next for nearly a century these gains have slowed or even reversed around
(Flynn 1987). Rundquist in 1936 (Rundquist the turn of the twenty-rst century for some coun-
1936) and Tuddenham in 1948 (Tuddenham tries. Teasdale and Owen (2008), for example,
556 Cohort Effects
found losses of 1.5 IQ points over a 5 year period For example, declines in uid intelligence abilities
from 1998 to 2003 in a Danish sample. (e.g., inductive reasoning, memory, and word u-
The magnitude of gains has been observed to ency) have been observed to begin soon after
be larger in people with lower IQ scores, but this human maturity is reached, around age 30, with
nding is not universal (Williams 2013). increasingly large age-related declines thereafter as
Observed gains have also been larger for urbanites conrmed in both cross-sectional and longitudinal
than for rural samples (Williams 2013). analyses (Schaie and Hofer 2001). Given these
The largest gains have usually been found for persistent declines and the expanding size of the
uid ability measures such as inductive reasoning, older adult population relative to other age groups,
word recall, and spatial reasoning (Schaie questions about whether cohort-based positive
et al. 2005; Zelinski and Kennison 2007). Some- gains in intellectual abilities will offset or partially
what smaller gains have been observed for crystal- mitigate anticipated declines in present and future
lized abilities such as vocabulary (Schaie generations are well worth considering (Zelinski
et al. 2005; Zelinski and Kennison 2007), and in and Kennison 2007).
some cases no gains have been observed (Lynn Most studies that have examined cohort effects
2013). The observed increases in uid abilities in psychometric measures have done so by exam-
have sometimes been taken as evidence that the ining mean level differences in cognitive perfor-
gains represent real gains in intelligence as opposed mance, whereby participants from different cohorts
to gains in knowledge. Yet, the inconsistent corre- are matched on age and their average performance
lation in the rise of IQ scores around the globe and is compared to determine whether cohort differ-
the small uctuations in reports of gifted individ- ences exist (Schaie et al. 2005). Such comparisons
uals have led Flynn (1987) to conclude that IQ tests have usually indicated that a later-born cohort out-
have a weak but not inconsequential relationship to performs an earlier-born cohort (Schaie et al. 2005;
the construct of intelligence. Williams 2013). Fewer studies have examined
So what explains the rather extraordinary gains cohort differences in the rate of age-related changes
in IQ performance observed over the past cen- (Schaie et al. 2005; Zelinski and Kennison 2007;
tury? Several non-mutually exclusive explana- Gerstorf et al. 2011). Such studies typically employ
tions have been proposed and at least partially growth modeling, whereby a model is t to the
supported, including increases in educational data. At least two results are typically reported:
quality and attainment (Alwin and McCammon (1) cohort differences in mean level performance
2001), exposure to technology and media (intercept) and (2) cohort differences in the rate of
(Williams 2013), the benets of better health and change (slope).
healthcare (Williams 2013; Gerstorf et al. 2011), Zelinski and Kennison (2007) examined
and reductions in poverty and malnutrition cohort differences in the Long Beach Longitudi-
(Flynn, 2008), among others (Lynn 2013). How- nal Study from ages 56 to 86 for two cohorts born
ever, none of these explanations individually or in 16 years apart on ve measures of cognition
combination fully explain the observed gains. In including inductive reasoning, list recall, text
addition, Lynn (2013) has demonstrated that recall, spatial reasoning, and vocabulary. Piece-
cohort-based IQ gains have been found in infants, wise growth models consisting of two linear
which brings into question explanations that are slopes one for young-old age (ages 5674) and
likely to occur in later development, including the other for old-old age (ages 7486) were t to
education-based explanations. Thus, the question each measure of cognition. The results indicated
of cause remains open and the search for a com- that mean level cohort differences favoring the
prehensive explanation continues to remain later-born cohort were found for all measures
elusive. except vocabulary. No differences in the rates of
Cohort effects in older adult samples. It is decline were found for inductive reasoning or
well established that there are large age-related spatial reasoning. However, for the two memory
declines in many aspects of cognitive performance. measures, list and text recall, the rate of decline for
Cohort Effects 557
60 Inductive Reasoning Inductive Reasoning

60
Reasoning (T-Score)
55
55
Reasoning (T-Score)
50
50
C
45
45
40
40
50 60 70 80
Chronological Age
35
Later-born cohort (1914-1948)
15 10 5 0
(n = 738 with 2,470 observations)
Earlier-born cohort (1883-1913) Time-to-Death
(n = 1,242 with 2,878 observations)
Later-born cohort (1914-1948)
(n = 288 with 938 observations)
Cohort Effects, Fig. 3 Cohort differences in inductive Earlier-born cohort (1883-1913)
reasoning from age 50 to age 80. Later-born cohorts (solid (603 with 1,573 observations)
lines) outperformed earlier-born cohorts (dashed lines) at
age 70 and also showed shallower rates of cognitive
decline. Excerpted from Gerstorf et al. (2011) (Reprinted Cohort Effects, Fig. 4 Cohort differences in terminal
with permission from the American Psychological decline for inductive reasoning. Mortality-related models
Association) suggest no evidence for positive secular trends in inductive
reasoning. Later-born cohorts (solid lines) showed steeper
mortality-related declines than earlier-born cohorts
the old-old age slope (age 7486) interacted with (dashed lines). Excerpted from Gerstorf et al. (2011)
cohort such that the advantage of the later-born (Reprinted with permission from the American Psycholog-
cohort disintegrated with advancing age. This ical Association)
result can be seen in Fig. 2 for list recall.
Similar ndings have been reported by Gerstorf in the oldest segment of the sample or (2) that the
et al. (2011), who examined age-related perfor- protective effects of cohort recede at the upper
mance on ve cognitive measures from the Seattle reaches of the lifespan. While greater selectivity is
Longitudinal Study including inductive reasoning, a possibility in the results reported by Kennison and
spatial reasoning, word uency, numerical ability, Zelinski (2007), the Gerstorf et al. (2011) time-to-
and vocabulary. Separate growth models were t death results reduces selectivity as a possible expla-
for age-related changes and for time-to-death nation for their results because all of their partici-
changes. The ve age-related change models each pants were followed to their deaths. They concluded
showed that a later-born cohort outperformed an that [the] results are in line with the idea that
earlier-born cohort and that the gap increased from mortality-related mechanisms and the progressive
50 to 80 years of age. Figure 3 demonstrates this processes leading toward death (e.g., deteriorating
nding for inductive reasoning. Yet, the time-to- health) are so pervasive that they override historical,
death models showed that the cohort advantage cohort-related effects that were apparent earlier in
enjoyed by the earlier-born cohort receded as life. Thus, these results suggest that cohort effects,
death approached. Figure 4 shows the collapse of while quite robust, may not persist across the entire
the advantage in performance of the later-born lifespan, especially at the upper reaches of the
cohort compared to the earlier-born cohort as lifespan.
death nears. Still there is considerable evidence that birth
Possible explanations for the reduction of cohort cohort differences favoring the later-born cohort
effects in very old age include: (1) greater selectivity exist in older samples, and this suggests that the
558 Cohort Effects
effects of early developmental experiences are illustrating changes in memory compensation. Aging,
likely to be long lasting, even into old age. There Neuropsychology, And Cognition [serial online], 11
(23), 346376.
is also growing and compelling evidence that Embretson, S. (1996). Item response theory models and
cognitive, social, and physical engagement spurious interaction effects in factorial ANOVA
among adults enhances level of cognitive func- designs. Applied Psychological Measurement [serial
tioning (Hertzog et al. 2008). These ndings com- online], 20(3), 201212.
Flynn, J. (1987). Massive IQ, gains in 14 nations: What IQ
bined with ndings that later-born cohorts are tests really measure. Psychological Bulletin [serial
more likely to engage in such positive health online], 101(2), 171191.
behaviors (Baltes et al. 2006) suggests that the Flynn, J., & Weiss, L. (2007). American IQ gains from
level of age-related declines that are seen in 1932 to 2002: The WISC subtests and educational
progress. International Journal of Testing [serial
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future generations (Skirbekk et al. 2013). Fortier, I., & Ferretti, V. (2015). Retrieved from https://
www.maelstrom-research.org
Gerstorf, D., Ram, N., Hoppmann, C., Willis, S., & Schaie, K.
(2011). Cohort differences in cognitive aging and terminal
Conclusion decline in the Seattle Longitudinal Study. Developmental
Psychology [serial online], 47(4), 10261041.
The cohort-based ndings reviewed in this entry Health and Retirement Study, public use dataset. (2015).
have far reaching societal and institutional impli- Produced and distributed by the University of Michi-
gan with funding from the National Institute on Aging
cations as they have been linked to secular (grant number NIA U01AG009740). Ann Arbor.
changes in education, technology, health, health Hertzog, C., Kramer, A., Wilson, R., & Lindenberger, U.
care, etc. Yet, a comprehensive explanation of the (2008). Enrichment effects on adult cognitive develop-
observed positive cohort trends remains a work in ment: Can the functional capacity of older adults be
preserved and enhanced? Psychological Science in the
progress. While methodological constraints per- Public Interest [serial online], 9(1), 165.
sist, much progress has been made towards under- Horn, J., & Donaldson, G. (1976). On the myth of intellec-
standing age, cohort, and time effects and their tual decline in adulthood. American Psychologist
interactions by employing a variety of different [serial online], 31(10), 701719.
Lynn, R. (2013). Who discovered the Flynn effect? A review
study designs, sampling frames, and statistical of early studies of the secular increase of intelligence.
techniques. The cognitive performance advan- Intelligence [serial online], 41(6), 765769.
tages enjoyed by later-born cohorts are likely to Pietschnig, J., & Voracek, M. (2015). One century of global
persist into old age, however, as death approaches, IQ gains: A formal meta-analysis of the Flynn effect
(19092013). Perspectives on Psychological Science
these advantages may recede. Finally, the ndings [serial online], 10(3), 282306.
reviewed here give hope that the typical cognitive Rundquist, E. (1936). Intelligence test scores and school
declines seen in older adults today are likely to be marks of high school seniors in 1929 and 1933. School
smaller and less intrusive in future generations of & Society [serial online], 43, 301304.
Salthouse, T. (2015). Implications of the Flynn effect for
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Teasdale, T., & Owen, D. (2008). Secular declines in Historical Context and Background
cognitive test scores: A reversal of the Flynn Effect. to the Common Cause Hypothesis
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Tuddenham, R. (1948). Soldier intelligence in World Wars
I and II. American Psychologist [serial online], 3(2), Since Galtons early work in the late 1800s
5456. (Galton 1883), psychologists have long attempted
Twenge, J. M. (2010). Time-lag study. In N. J. Salkind to draw conceptual and empirical links between
(Ed.), Encyclopedia of research design (pp. 293357).
Thousand Oaks: Sage. sensory discrimination and intelligence, particu- C
Williams, R. (2013). Overview of the Flynn effect. Intelli- larly those adopting an individual differences
gence [serial online], 41(6), 753764. perspective (Deary 1994). For example, sensori-
Zelinski, E., & Kennison, R. (2007). Not your parents test motor abilities have been identied as important
scores: Cohort reduces psychometric aging
effects. Psychology and Aging [serial online], 22(3), structural components in hierarchical models of
546557. human intelligence (Carrol 1993). In more recent
Zelinski, E., Kennison, R., Watts, A., & Lewis, K. (2009). times cognitive scientists, guided by an informa-
Convergence between cross-sectional and longitudinal tion processing framework, have recognized that
studies: Cohort matters. In Aging and cognition:
Research methodologies and empirical advances cognition and sensation do not operate in isola-
(pp. 101118). Washington, DC: American Psycholog- tion, but constitute an integrated system in which
ical Association. top-down and bottom-up processes are intrinsi-
cally intertwined. Of interest to geropsychology
is the way in which the coupling between these
two domains changes with age. While there is no
Common Cause Theory in Aging evidence to suggest that sensory functioning is
strongly linked to cognitive performance in early
Kim M. Kiely and Kaarin J. Anstey life or mid-life, a small number of studies
Centre for Research on Ageing Health and conducted sporadically during the latter half of
Wellbeing, Research School of Population the 1900s consistently demonstrated an associa-
Health, The Australian National University, tion between cognition and sensory functioning
Canberra, ACT, Australia (particularly hearing ability) in older age-groups
(Schaie et al. 1964; Anstey et al. 1993; Rabbitt
1990a; Granick et al. 1976). These cross-domain
Synonyms interassociations were important from the view-
point of life-span developmental psychology as
Common cause hypothesis; Common cause they appeared to emerge during later life and
factor; Dedifferentiation; Shared age-related therefore provided an example of discontinuity
variance; Shared inuence models in life-span development (Lindenberger and
Baltes 1994). They also indicated that dedifferen-
tiation may extend beyond the cognitive domain
Definition (Anstey et al. 2003a) and were relevant to theo-
retical debates concerning the extent to which
The common cause theory of cognitive aging age-related changes in a variety of domains
hypothesizes that age-related declines in cogni- could be accounted for by a broad and general
tive, sensory, and sensorimotor functioning can mechanism, rather than a number of unrelated
primarily be attributed to a domain-general neu- domain-specic factors (Salthouse and Czaja
robiological mechanism. It predicts an increasing 2000).
association between cognition and sensory acuity Despite the signicance of these ndings for
with advancing age and was originally proposed theories of cognitive aging, it was not until the
as a broad third variable explanation to account mid-1990s that there was a concerted research
for shared variance between age, cognitive, and program seeking to understand why cognitive
noncognitive variables. and noncognitive variables are increasingly
560 Common Cause Theory in Aging
Common Cause Theory

in Aging,
Fig. 1 Schematic of
mediation model analogous
to those tested by
Lindenberger and Baltes
(1994) and Anstey (Anstey
and Smith 1999; Anstey
et al. 2001). *Sensory
functioning is generally
found to be a stronger
predictor of age-related
individual differences in
cognition than processing
speed
related at older ages. At the start of the decade, intellectual (or cognitive) abilities. In the rst
Rabbitt (1990b) strongly argued that cognitive study (Lindenberger and Baltes 1994), visual acu-
scientists with an interest in late-life phenomena ity and auditory pure-tone thresholds explained
should indeed be interested in lower-level sensory 49% of the total variance and 93% of the
systems. Critically, this period coincided with a age-related variance in a second-order general
greater appreciation of the underlying role that intelligence factor comprising perceptual speed,
degeneration of the central nervous system plays reasoning, memory, verbal uency, and knowl-
in driving age-related declines in sensory acuity edge. In addition, vision and hearing fully medi-
(Baltes and Lindenberger 1997). That is, ated the effects of age on intelligence that is,
age-related sensory decline could be attributed after adjusting for sensory functioning, there
to neuronal deterioration beyond the level of were no direct effects of age on intelligence (see
the end organ. It was therefore timely for Fig. 1). Importantly, excluding participants with
geropsychologists to consider joint contribution suspected dementia or severe sensory impairment
of brain aging to cognitive and sensory decline did not alter the pattern of results. The explanatory
(and more broadly to motor functions), and this power of sensory functioning was then compared
culminated with a proposal by Lindenberger to that of processing speed, which had been iden-
and Baltes for a common cause hypothesis tied as a potential broad mechanism underpin-
(Lindenberger and Baltes 1994). ning cognitive aging. These analyses indicated
that vision and hearing were at least as powerful
as processing speed in predicting age-related indi-
Shared Age-Related Variance vidual differences in an intelligence factor dened
by reasoning, memory, verbal uency, and knowl-
Motivated by previous empirical ndings and edge (i.e., excluding speed). Moreover, while sen-
their potential implications for cognitive aging sory functioning subsumed all the age-related
theory, Lindenberger and Baltes (Lindenberger variance in processing speed, processing speed
and Baltes 1994; Baltes and Lindenberger 1997) was unable to account for 15% of the age-related
conducted two studies using baseline data from variance in vision and 9% of the variance in hear-
the Berlin Aging Study to investigate the roles of ing. This nding was later supported by compa-
vision and hearing in explaining age differences in rable analyses of other datasets (Anstey
Common Cause Theory

in Aging, Fig. 2 Venn
diagrams depicting cohort
differences in shared
variance patterns among
age, sensory functioning
(visual acuity and pure-tone
audiometry), uid cognitive C
mechanics (speed,
reasoning, and memory),
and crystallized cognitive
pragmatics (knowledge and
uency). Overlapping areas
reecting proportions of
shared variance are
approximated from results
reported in Baltes and
Lindenberger (1997) and
Anstey (Anstey and Smith
1999); however, the
schematic is illustrative
only and not based on
actual data
et al. 2001). Lindenberger and Baltes (1994) variance among the younger participants, thus
argued that of the two, sensory functioning was replicating their previous ndings across a
the more powerful predictor of general intellectual broader age range. A more nuanced pattern of
abilities. Their conclusion was signicant because results emerged when the cognitive abilities
speed of information processing was considered were classied according to a dual-process
an important cognitive primitive and central to model of intellectual functioning. (Dual process
resource-based accounts of cognitive aging. models of intellectual development across the
Such theories included the generalized slowing life-span make a distinction between cognitive
and processing speed hypotheses, which had mechanics (also referred to as uid intelligence)
been proposed in various forms by Birren, and cognitive pragmatics (referred to as crystal-
Cerella, and Salthouse (for review see Hartley lized intelligence). Cognitive mechanics are
2006). content poor, have a strong neurophysiological
The link between intellectual abilities and sen- basis, and typically undergo age-related declines
sory acuity was later reexamined in a larger com- throughout adulthood. Cognitive pragmatics
posite sample that augmented the baseline sample reect knowledge acquired through experience,
of participants from the Berlin Aging Study with are culturally shaped, and increase with age.)
newly recruited younger participants (Baltes and There were no cohort differences in the proportion
Lindenberger 1997). Rather than modeling the of age-related variance shared by vision or
indirect effects of age on a second-order general hearing and variables reecting uid cognitive
intelligence factor, each cognitive ability was mechanics (speed, reasoning, and memory).
examined individually. Vision and hearing were In contrast, while sensory functioning predicted
more strongly associated with individual differ- age-related variance among variables reecting
ences in the ve cognitive abilities within the crystallized cognitive pragmatics (uency
older cohort (ages 70103), relative to the youn- and knowledge) within the older cohort, this
ger cohort (ages 2569). But there remained a was not the case within the younger cohort
signicant proportion of shared age-related (see Fig. 2).
The Common Cause Hypothesis (1993) concluded that sensorimotor functioning

and Alternative Explanations was an important indicator of intellectual decline,
and this may be interpreted as evidence for a
Overall, the key ndings from these studies were decline in Gf related to biological changes in the
that (a) there was considerable shared brain, central nervous system, and motor systems
variance between age, general intelligence (Anstey et al. 1993, p. 568). Such broad explana-
(primarily in uid abilities), and sensory acuity tory mechanisms implied by common cause fac-
and (b) sensory functioning fully mediated tors are attractive to cognitive aging theorists
age-cognition associations. Lindenberger and because they are parsimonious and reduce the
Baltes offered etiological and functional explana- search for potential mechanisms to a single or
tions to account for age-related covariation small number of underlying causes.
between cognitive and sensory functioning. Whereas the common cause theory hypothe-
These included the neurological common cause sizes an underlying etiology, other explanations
hypothesis, sensory deprivation hypothesis, and propose more functional and directional causal
cognitive load on sensory performance hypothe- pathways between cognitive and sensory aging.
sis. A brief description of each of these hypothe- The sensory deprivation hypothesis identies
ses is provided below, but interested readers may reduced sensory functioning as a long-term ante-
like to refer to Schneider and Pichora-Fuller cedent of cognitive decline, linking the two via
(2000) who provide a thorough overview of social engagement. Specically, declining sen-
these hypotheses and additional explanations. sory acuity creates communication and mobility
The common cause hypothesis maintains that a difculties, increasing the likelihood of social
domain-general mechanism is responsible for a withdrawal and disengagement from intellectu-
substantial amount of the age-related decline in ally stimulating activities, which over an extended
cognitive, sensory, and sensorimotor functions. It period (spanning years to decades) will eventually
was argued that the emergent association between result in the lowering of levels of general cogni-
sensory and cognitive function in late life tive ability. Thus, according to this view,
reected an expression of the physiological age-related sensory impairment initiates an
architecture, or the mechanics, of the [aging] upward cascade of effects that ultimately impact
brain (Lindenberger and Baltes 1994, p. 339). on central cognitive functioning. Such explana-
Clearly the original intention of the hypothesis tions had previously been described by Sekular
identied the underlying etiology as being neuro- and Blake who referred to the process as
logical in nature. Though often construed as a protracted sensory underload (1987; cited in
single determinant, it was recognized that as a Lindenberger and Baltes 1994) and Rabbitt
third variable explanation, the common cause fac- (1990b) who noted that sensory loss in late life
tor could reect an ensemble of senescent pro- can inhibit social interaction, employment,
cesses affecting brain structure, physiology, and enjoyment of life, learning new skills, and cogni-
function. In addition, other third variables such as tive engagement (p. 231) and have secondary
bodily functions were not discounted (Baltes knock-on effects on everyday memory and
and Lindenberger 1997). The common cause comprehension. These accounts therefore invoke
hypothesis was consistent with contemporaneous the notions of brain reserve or cognitive reserve,
views offered by researchers interested in which posit that novel and mentally stimulating
operationalizing functional biomarkers as an activities are important for maintaining cognitive
index of primary aging. For example, after ability levels (or at least attenuating rates of cog-
reporting that a bioage factor (a latent variable nitive decline) by promoting neuroplasticity
reecting biological age; Anstey 2008) compris- which creates a buffer against the impacts of
ing measures of sensory acuity and physical func- accumulating neuropathology.
tioning mediated the relationship between age and Alternative upward cascade models have also
uid intelligence (Gf), Anstey and colleagues been proposed. The perceptual degradation
and cognitive permeation hypotheses place limits opportunities to moderate the adverse
age-related sensory decline as a driver of poor impacts of brain aging.
cognitive performance, but over a more immedi- As the original analyses of the Berlin Aging
ate time frame (Schneider and Pichora-Fuller Study employed observational and cross-sectional
2000; Valentijn et al. 2005). According to the research designs, it was not possible to rule out
perceptual degradation explanation, encoding any of the proposed explanations. Baltes and
errors of degraded sensory inputs impinge on Lindenberger (1997) also acknowledged that C
higher-level cognitive processing. Similarly, the each of the hypothesized causal pathways was
cognitive permeation hypothesis maintains that potentially related. Nevertheless, they argued
greater attentional, executive, and working mem- that a common cause explanation was most con-
ory resources must be allocated to processing of sistent with their results for the following reasons.
low-delity sensory inputs, thus compromising Firstly, sensory functioning had weaker associa-
cognitive functioning by diverting cognitive tions with experientially based cognitive abilities,
resources away from higher-order processes whose development was considered to be more
(Lindenberger and Ghisletta 2009). A key predic- reliant on an enriched social environment. Sec-
tion of such explanations is that correcting for ondly, it was expected the impacts of protracted
sensory loss should moderate the association sensory underload would be more pronounced
between sensory and cognitive function. among individuals with greater levels of sensory
A popular approach to testing this hypothesis impairment, yet there was no evidence of a curvi-
has been to examine the effect of cataract surgery linear relationship between sensory and cognitive
on cognitive function. While some studies have functioning. Finally, sensory measures were
been argued to demonstrate that cataract surgery is thought to mediate age-cognition relations
associated with lower levels of cognitive impair- because they were assumed to provide a more
ment after surgery, these investigations have been reliable and direct measurement of brain aging
limited by small sample size, lack of appropriate (Lindenberger and Baltes 1994). Similar argu-
control groups, failure to assess baseline cognitive ments were made by those who adopted a bio-
function, or inadequate control for confounding marker mediation model of cognitive aging,
factors (Hall et al. 2005). Studies employing more whereby sensorimotor variables were conceptual-
rigorous research designs have failed to show that ized as functional biomarkers that indexed pri-
removal of cataracts improves cognitive function mary (normative) aging processes with greater
(Hall et al. 2005; Anstey et al. 2006). reliability than chronological age (Anstey
The cognitive load on sensory performance et al. 1993; Anstey and Smith 1999).
suggests that deterioration of cognitive abilities
such as attention and processing speed adversely
affect the control and execution of simple sensory Evidence for Common and Domain-
tasks. For example, decits in sustained attention Specific Factors
may diminish an individuals capacity to detect
auditory or visual stimuli. It is important to Even though these studies arose from opportune
note that these explanations are not mutually circumstance and were framed as being explor-
exclusive, but are related and likely to operate atory (Lindenberger and Baltes 1994; Baltes and
interdependently in a cycle of cumulative and Lindenberger 1997), their clear rationale and robust
reciprocal effects. For example, if cognitive ndings meant they quickly became a catalyst for
resources become more limited and sensory acu- rigorous conceptual, methodological, and empiri-
ity declines due to brain aging, this may cal examination of the interassociations between
increase the cognitive load for basic processing age, cognition, sensory perception, and other indi-
of sensory information. This increases the likeli- cators of physical ability. Because of the emphasis
hood of social withdrawal and reduced participa- placed on a common cause interpretation, this
tion in mentally stimulating activities, which theory became the main focus of subsequent
investigations. In particular, debate centered on variance across cognitive and noncognitive vari-
quantifying the degree of interdependency across ables and regress age onto the common factor as
a variety of functional domains and whether it was well as each of the individual domains or indica-
reasonable to infer that a common cause was pri- tors. This approach, when applied to multifacto-
marily responsible for age-related declines. rial data, is depicted in Fig. 3 and typically
The common cause theory was originally involves the comparison of (at least) three nested
concerned with cognitive and sensory domains, conceptual models, namely, (i) an independent
with a focus on visual acuity and pure-tone audi- factor model (no common cause factor) which
ometry; subsequent investigations broadened the only includes direct effects of age on each domain,
explanatory scope of the theory to include other (ii) a hierarchical common factor model with indi-
functional domains that also exhibit declines in rect age effects mediated by a common cause, and
performance with age. Studies have examined (iii) a hierarchical common factor model with both
age-related associations with cognition for a range direct and indirect age effects (see Allen
of sensory variables such as contrast sensitivity, et al. (2001) for a detailed description of each of
central auditory processing, proprioception, vibra- these conceptual models and some additional var-
tion sense, and balance. The general nding has iations). An alternative depiction of these shared
also been extended to motor and physiological variance models is presented in Fig. 4.
functions including grip strength, lower limb When studies were designed to test common
strength, walking ability and gait, lung function, cause factor models following procedures outlined
and blood pressure (Schneider and Pichora-Fuller in Fig. 3, it quickly became apparent that there
2000; Anstey and Smith 1999; Li and were both direct and indirect effects of age on
Lindenberger 2002; Clouston et al. 2013; Krall cognitive and sensorimotor variables (Salthouse
et al. 2014), though blood pressure has not always and Czaja 2000; Anstey et al. 2001; Christensen
been shown to load onto a common factor et al. 2001; Salthouse et al. 1998; Salthouse and
(Christensen et al. 2001). All such cross-sectional Ferrer-Caja 2003). Thus, these analyses demon-
studies have typically reported moderate to large strated that there were shared and unique portions
interassociations with age. However, it has been of age-related variance among cognitive and
suggested that the magnitude of the age-related noncognitive variables. Sensorimotor variables
associations between different pairs of cognitive have also been reported to correlate with cognitive
and sensorimotor variables may vary. For example, variables independent of age (particularly vari-
data from the Australian Longitudinal Study of ables reecting crystallized cognitive pragmatics)
Aging indicates that vision and hearing are more (Anstey and Smith 1999). Consequently by 2003,
strongly linked to episodic memory than other there was a broad consensus that age-related
general cognitive abilities (Anstey et al. 2001). declines in cognitive and sensorimotor function-
It was not unusual for cross-sectional evidence ing could be attributed to both a broad common
of shared age-related variance to be interpreted as cause factor and separate domain-specic mecha-
suggestive of a broad explanatory mechanism nisms, tempering the earlier emphasis placed on
(Salthouse and Czaja 2000). Early studies common cause interpretations. In an important
employing structural equation modeling or hier- appraisal of the common factor methods used to
archical regression analyses generally identied support broad mechanisms, Allen and colleagues
sensory functioning as the mediator of (Allen et al. 2001) argued that many analyses
age-cognition associations as depicted in Fig. 1. failed to adequately assess the comparative t of
In these cases, a common cause interpretation all competing models. They demonstrated that
relied on the assumption that sensorimotor func- hierarchical common factor models did not
tioning was a more direct indicator of the integrity always t the data better than independent factor
of the central nervous system. A more formal models, particularly when independent factors
approach to assessing common cause factors is were allowed to have correlated disturbance
to dene latent variable that reects shared terms.
Age
Common Cause Theory in Aging
Sensory Cognitive
factor factor
vision hearing balance memory reasoning speed*
Age Age
Common Common
factor factor
Sensory Cognitive Sensory Cognitive

factor factor factor factor
vision hearing balance memory reasoning speed* vision hearing balance memory reasoning speed*
Common Cause Theory in Aging, Fig. 3 Top: Independent factor model with direct age effects. Bottom Left: Second-order (hierarchical) common factor model with indirect
age effects, Bottom Right: Second-order (hierarchical) common factor with direct and indirect age effects (Figures adapted from Salthouse and Czaja (2000) and (Allen et al. 2001))
565
C
Common Cause Theory

in Aging, Fig. 4 Venn
diagrams depicting three
possible models of shared
variance between age,
cognitive, and sensorimotor
functioning. Left: No
common factor (domain-
specic factors only); Top
right: Common factor;
Bottom right: Common and
domain-specic factors.
Sensorimotor variables
have also been described as
functional biomarkers
(Anstey et al. 1993;
Lindenberger and Ghisletta
2009)
Longitudinal Evidence for the Common et al. 2003b). Bivariate dual change score models
Cause have been used to test bidirectional time-ordered
associations between cognition and sensory func-
Recognizing that longitudinal designs were nection (Ghisletta and Lindenberger 2005). In these
essary to properly examine within-person cou- analyses, levels of visual acuity were predictive of
pling of cognitive and noncognitive variables subsequent declines in processing speed, and con-
(Hofer and Sliwinski 2001), a number of research versely, levels of processing speed were predic-
groups employed multivariate latent growth curve tive of subsequent declines in visual acuity.
(and related) techniques to test covariation in Consistent with other studies, large domain-
levels and rates of change between cognitive and independent effects were reported. Ghisletta and
sensory measures (Anstey et al. 2003a, b; Lindenberger (2005) framed their discussion of
Lindenberger and Ghisletta 2009). Importantly, this dynamic link between cognitive and sensory
these studies demonstrated only modest associa- functioning in relation to common cause, bio-
tions between rates of sensory and cognitive marker mediation, and cascade hypotheses. Each
decline (e.g., 9% shared variance between change of these longitudinal studies provides a complex
in memory and vision; Lindenberger and picture of the interdependent nature of cognitive
Ghisletta 2009), as well as providing support for and sensory aging, but overall supports the notion
domain-specic factors. Again, it was argued that that there are both common and independent fac-
the evidence for a common cause factor was stron- tors driving declines in cognition and sensation. In
gest for memory and vision and for memory and addition, the modest interassociations suggested
speed, which were the only inter-domain pairings that initial enthusiasm for the overarching impor-
to have correlated rates of change in the Austra- tance of a common cause factor was overstated.
lian Longitudinal Study of Ageing (Anstey The divergence in ndings from earlier studies
demonstrates the importance of longitudinal data (Christensen and Mackinnon 2004). Thus, at the
for modeling time-dependent processes that are time the common cause was attracting peak
inherent to theories of psychological development research attention, it was not possible to specify
and aging. Longitudinal designs enable direct the broad mechanism (Salthouse and Czaja 2000).
examination of age changes and covariation in In the words of Ghisletta and Lindenberger
rates of change which is necessary to test pre- (2005), the common cause theory is empirically
dictions made by the common cause hypothesis. and theoretically under-identied (p. 580). C
Indeed, it has been well documented that age Indeed, when conjecturing about the common
changes are confounded with age differences and cause, proponents have cast a wide net when
population trends in cross-sectional data, and this naming candidate mechanisms. These have
can produce positively biased correlations ranged from general notions of brain aging
between variables that actually share no associa- and integrity of the central nervous system to
tion, or even a negative association, in their devel- more specic etiology such as structural changes
opmental trajectories over time (Hofer and or atrophy, white-matter loss or hyperintensities,
Sliwinski 2001; Lindenberger et al. 2011; gray-matter loss, impaired frontal circuitry,
Lindenberger and Potter 1998). dopaminergic neuromodulation, inammation,
oxidative stress, telomere length, and genetic
expression (Salthouse and Czaja 2000;
Limitations of the Common Cause Ghisletta and Lindenberger 2005; Christensen
Theory and Mackinnon 2004). Unfortunately, many stud-
ies examining the common cause theory have
The common cause theory has both conceptual lacked direct measurement of any of these mech-
and methodological limitations that constrain its anisms. It is for these reasons that the latent vari-
overall attractiveness as a comprehensive expla- able reecting a common factor should be
nation for cognitive aging. Although common distinguished from a putative common cause
factor models often provide good t of cross- mechanism (Christensen and Mackinnon 2004).
sectional associations between cognitive and
noncognitive variables and are often interpreted
as reecting broad explanatory mechanisms Conclusion
(Salthouse and Czaja 2000), simulation studies
have shown that common factor models cannot Understanding relations between functional
always be rejected even when they are false (Allen domains is an important step to developing a
et al. 2001). Many of the analytic strategies complete description of human life-span develop-
employed provide supporting evidence of a comment. Cognition, sensation, and motor function-
mon factor rather than conduct critical hypothesis ing are broad ability domains that are central to the
testing of the common cause theory. study of human aging. Their age-related associa-
One of the main challenges for the theory is tions demonstrate the importance of considering
that it implicates a wide range of psychological cross-domain interdependencies in human devel-
and physical functions with no obvious candidate opment. The common cause hypothesis shone a
(s) for the ensemble of common causes. A broad spotlight on this important eld and stimulated
range of measures including peripheral hearing, research into shared mechanisms underlying sen-
visual acuity, reaction time, grip strength, lung sory and cognitive aging. It remains plausible that
capacity, processing speed, and episodic memory a common etiology underlies some of the
have all been shown to converge onto a common age-related declines in both cognitive abilities
age-related factor to varying degrees, yet there is and sensorimotor function (Li and Lindenberger
no well-dened system that is known to directly 2002; Christensen and Mackinnon 2004), but it is
underlie performance across all of these domains clear that a comprehensive account of cognitive
aging must also include domain-specic factors. Anstey, K. J., Hofer, S. M., & Luszcz, M. A. (2003a).
According to relatively recent evaluations, it is Cross-sectional and longitudinal patterns of dedifferen-
tiation in late-life cognitive and sensory function: The
reasonable to expect that substantial portions of effects of age, ability, attrition, and occasion of mea-
decline across a range of domains can be attrib- surement. Journal of Experimental Psychology: Gen-
uted to a small number of causal pathways eral, 132, 470487.
(Lindenberger and Ghisletta 2009). Common Anstey, K. J., Hofer, S. M., & Luszcz, M. (2003b). A latent
growth curve analysis of late-life sensory and cognitive
causes are likely to draw from some of the central function over 8 years: Evidence for specic and com-
processes underpinning brain aging, such as sys- mon factors underlying change. Psychology and Aging,
temic inammation affecting vascular health, oxi- 18, 714726.
dative stress, and genetics. It is important that Anstey, K. J., et al. (2006). The effect of cataract surgery on
neuropsychological test performance: A randomized
future research directly assesses the role(s) of can- controlled trial. Journal of International Neuropsycho-
didate common causes. logical Society, 12, 632639.
Baltes, P. B., & Lindenberger, U. (1997). Emergence of a
powerful connection between sensory and cognitive
functions across the adult life span: A new window to
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From the perspective of the life span theory of
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Gerontology, 19, 453457. and Nussbaum 2001; Fowler et al. 2015), com-
Schneider, B. A., & Pichora-Fuller, M. K. (2000). Impli- munication may become the sole avenue to
cations of perceptual deterioration for cognitive aging
research. In F. I. Craik & T. A. Salthouse (Eds.),
exercising personal control for those older adults
The handbook of aging and cognition (2nd ed.). in declining health. Although normal aging is
Mahwah: Lawrence Erlbaum Associates. associated with changes in hearing and cognition
Valentijn, S. A. M., et al. (2005). Change in sensory func- (e.g., name recall) that can affect language and
tioning predicts change in cognitive functioning:
Results from a 6-year follow-up in the Maastricht
communication, the extent to which individual
aging study. Journal of American Geriatrics Society, older adults experience these changes varies
53, 374380. widely and most develop coping strategies that
570 Communication with Older Adults
enable them to maintain their communication communication style, or elderspeak, constitutes

skills (Kemper et al. 2015). Yet negative age ste- patronizing talk because it implicitly (or in some
reotypes about the communication competence of cases, explicitly) questions the competence of the
older adults create challenges for them and their older person. In doing so, it challenges the older
communication partners across contexts. This individuals autonomy to control his or her behav-
relationship between negative age stereotypes ior and decisions (Savundranayagam et al. 2007).
and communication carries implications for not Although control is an element in all patroniz-
only the psychological and social, but also the ing talk, the degree of control can vary from
physical, well-being of older individuals. moderate to high and the accompanying emo-
tional tone may be warm or cold (Hummert
et al. 2004). Three examples of moderate control
The Communication Predicament illustrate variations in emotional tone from warm
of Aging to cold: (1) Heres the form, dear. Let me explain
it to you; (2) Mom, dont overdo it youre not
Age stereotypes can be positive (e.g., the wise and as young as you used to be; and (3) Tom, as your
loving perfect grandparent) as well as negative physician, I think that I know whats best for you.
(e.g., the bitter and demanding shrew/curmud- Two high control forms of patronizing talk are
geon), but negative stereotypes are more accessi- also distinguished by emotional tone. The rst
ble and numerous than positive ones (Hummert form, directive talk (I said to take your pill
2011). Even in East Asian cultures that tradition- NOW), lacks any hint of warmth that might
ally have placed a strong value on lial piety, soften the control message and indicate concern
negative age stereotypes predominate and play a for the recipient. The second high control form is
role in intergenerational communication (Giles called secondary baby talk (Now, sweetie pie, its
and Gasiorek 2011). Negative age stereotypes time to take our pill.) due to its similarity to the
include beliefs about the physical, cognitive, and intonation patterns, warm emotional tone, and
psychological characteristics of older adults that simple language used with infants (Caporael
have implications for their communication com- 1981). Older adults express their dissatisfaction
petence. Examples are hard-of-hearing, sick, inar- with patronizing talk, and both middle-aged and
ticulate, slow-thinking, forgetful, sad, lonely, younger adults evaluate it as disrespectful and
inexible, and demanding (Hummert 2011). controlling (Giles and Gasiorek 2011; Hummert
Drawing on communication accommodation the- et al. 2004).
ory, the communication predicament of aging In addition to capturing the antecedents that lead
model (CPA; Ryan et al. 1986) illustrates how to patronizing talk, the CPA model outlines the
these stereotypical beliefs contribute to a negative consequences that create a feedback cycle with
feedback cycle in communication with older negative outcomes for older adults and their com-
adults. munication partners (Giles and Gasiorek 2011).
According to the CPA model, when a younger These include unsatisfactory intergenerational rela-
person meets an older person, recognition of the tionships, avoidance of intergenerational contact,
physical signs of age (grey hair, wrinkles, etc.) may and reinforcement of negative age stereotypes in
activate these stereotypical beliefs and result in a the younger and older individuals in the conversa-
communication style that accommodates to the tion. Ultimately, to the degree that the older person
presumed needs of the older person. That is, the internalizes and conforms to the negative stereo-
younger person may speak slowly and loudly, use types as a result of such interactions, declines in
short sentences and simple language, employ exag- physical functioning may follow (Hummert
gerated intonation for emphasis, and/or call the et al. 2004; Hummert 2012). Experimental studies
older person by rst name or a diminutive (e.g., and analysis of longitudinal data sets by Levy and
honey, dearie), all in an effort to communicate colleagues (Levy 2009) have identied an associa-
effectively. This stereotype-based, age-adapted tion between negative self-stereotyping and an
increased risk of illness or death for older adults. settings can emerge in several additional ways
The relationship between patronizing talk and neg- that disadvantage the older patient: not allowing
ative stereotyping has been documented in numer- time for the patient to describe concerns, failing to
ous studies, but a recent study links patronizing talk explore comments that hint at health problems,
to both cognitive performance and physiological using an authoritative style that precludes the
stress, a risk factor for health problems. Hehman opportunity for questions, avoiding eye contact
and Bugental (Hehman and Bugental 2015) ran- with the patient, attributing complaints to the C
domly assigned older and younger participants to patients age, or directing communication to the
receive instructions for a cognitive task in either a patients companion rather than to the patient
patronizing or nonpatronizing style. Analysis of (Fisher and Canzona 2014). Institutional and
performance and stress responses revealed that medical settings make age stereotypes salient not
older participants exposed to patronizing talk had only for physicians and staff but also for residents
poorer performance and higher stress responses in and patients (Miche et al. 2014). Thus, these set-
comparison to older participants in the tings increase resident and patient vulnerability to
nonpatronizing condition and young participants the declines in psychological and physical well-
in both conditions. being that can follow from exposure to patroniz-
ing talk (Giles and Gasiorek 2011; Hummert
et al. 2004; Williams et al. 2009).
Context and the Risk of Patronizing Talk Age is salient within the family context
because families are intergenerational by deni-
Communication with older adults occurs in a wide tion. In comparison to institutional and medical
variety of contexts such as family, social, institu- settings, the family context is one that is associ-
tional, organizational, and medical. Although ated with positive age stereotypes about the
patronizing talk and its consequences as illus- warmth and wisdom of elders (Miche
trated in the CPA model can occur in any context, et al. 2014). At the same time, older family mem-
it is more likely to occur in contexts which make bers report that they experience patronizing talk
negative age stereotypes salient than in other con- from their adult children (Hummert et al. 2004;
texts (Giles and Gasiorek 2011; Hummert Hummert 2012; Hummert in press). These prob-
et al. 2004). Three contexts assume prominence lematic interactions primarily take the form of
due to their importance to the psychological and unsolicited advice and/or directives around topics
physical well-being of older persons: institutional, of health, nances, living arrangements, and
medical, and family. safety (e.g., driving) (Hummert et al. 2004;
Institutional and medical settings in particular Hummert in press), all of which are related to
evoke negative age stereotypes of illness, frailty, negative age stereotypes of decline and incompe-
and decline (Kornadt and Rothermund 2015). In tence. Within families, these conversations reect
fact, the initial identication of secondary baby a tension between paternalism (i.e., the desire to
talk occurred in observations of nursing home protect family members from harm) on the part of
staff interactions with residents (Caporael 1981). the adult child, on the one hand, and autonomy
Frail older adults in such living facilities may have (i.e., the desire to control ones own actions) on
repeated interactions that involve the more the part of the older parent, on the other (Cicirelli
extreme forms of patronizing talk and thus are 1992). Parallels can be seen in the problematic
especially susceptible to the consequences illus- interactions between parents and adolescents,
trated in the CPA model (Giles and Gasiorek although in those interactions the expectation is
2011; Hummert et al. 2004; Williams that the adolescents will later achieve indepen-
et al. 2009). Community-dwelling older adults dence (Hummert 2012). With older parents, the
may encounter patronizing talk from physicians expectation is that the need for paternalism will
and other medical staff in both hospital and increase and the parents ability to be independent
out-patient settings. Patronizing talk in these will decline.
Older adults recognize that patronizing talk necessary to accommodate needs of the individ-
from their adult children is based on care and ual, empowering that person as a coequal partner
concern for their well-being, and so may nd it with the provider or family member. The move-
difcult to discount as unwarranted even as they ment toward person-centered communication in
nd it dissatisfying. Experiencing patronizing talk caregiving is consistent with the individualized
from valued family members therefore increases communication envisioned in the communication
the parents subjective experience of aging and enhancement model (Savundranayagam et al.
susceptibility to negative self-stereotyping (Giles 2007; Williams et al. 2009; Storlie 2015).
and Gasiorek 2011; Hummert et al. 2004; Diehl Empowering older adults through individualized
et al. 2014) and the related negative psychological communication increases the satisfaction of all
and physical consequences of the CPA model. parties and optimizes the opportunity for the older
Communication between grandparents and person to achieve improved well-being. It also sets
grandchildren is also susceptible to the inuence in motion a positive feedback cycle by enabling the
of negative age stereotypes and their conse- older person to maximize his or her communication
quences (Soliz et al. 2006), illustrating that these skills and competence. The benets of the commu-
patterns of talk may be transmitted and reinforced nication enhancement model require conscious
across the generations. commitment, monitoring, and effort on the part of
providers and family members. Intervention stud-
ies and assessment of training programs demon-
Improving Intergenerational strate that use of patronizing talk by caregivers can
Interactions be decreased and person-centered communication
increased to yield benets for older individuals in
Older and younger adults have the opportunity to residential facilities (Savundranayagam et al. 2007;
reduce the impact of negative age stereotypes on Williams et al. 2009).
intergenerational communication. These opportu- The age stereotypes in interaction (ASI) model
nities are addressed in the communication considers how older adults themselves can use
enhancement, the age stereotypes in interaction, communication to avoid negative stereotypes at
and communicative ecology of successful aging the beginning of an interaction or to redirect an
models, all of which build on the communication interaction in a more positive direction after it has
predicament of aging model (Fowler et al. 2015; begun (Giles and Gasiorek 2011; Hummert
Giles and Gasiorek 2011; Hummert et al. 2004). et al. 2004). According to the ASI model, positive
The communication enhancement model or negative age stereotypes may be salient at the
offers suggestions on ways that caregivers and beginning of an interaction with an older adult
family members can use communication to based not only on the context (e.g., family or
empower frail older persons, creating an alterna- medical) as discussed previously but also on the
tive positive feedback cycle to the CPA model way in which the older adult communicates.
(Savundranayagam et al. 2007; Hummert Young, middle-aged, and older individuals asso-
et al. 2004). In the CPA model, negative stereo- ciate several communication behaviors of older
types inuence communication with older adults adults with negative age stereotypes (Giles and
when the recognition of age cues leads to implicit Gasiorek 2011; Hummert et al. 2004; Hummert
activation of beliefs about the communication 2012): painful self-disclosures (i.e., revealing a
needs of the older adult involved and the uncon- distressing personal experience such as the death
scious or automatic accommodation to those of a spouse or child to a stranger or acquaintance),
needs that can result in patronizing talk. The com- off-target verbosity (i.e., rambling and/or
munication enhancement model calls for redirecting the conversation to a tangential or
disrupting this process at the outset by conscious unrelated topic), self-stereotyping (e.g.,
focus on the individuality of the older person. referencing ones age or labeling a memory lapse
Communication can then be modied as as a senior moment), and older-to-younger
patronizing talk (e.g., disapproving/disrespectful The three models may be compared on (a) their
talk, over-parenting by offering unsolicited and assignment of agency to older adults or others, and
unwelcome advice, etc.). The ASI model predicts (b) their applicability across contexts (family,
that the association of these communication social, institutional, organizational, and medical).
behaviors with negative age stereotypes increases The communication enhancement model empha-
the likelihood that their use will initiate the nega- sizes the responsibility of caregivers and providers
tive feedback cycle of the CPA model. Con- to engage in adapting their communication to the C
versely, older adults ability to tell interesting individual needs of older persons in order to sup-
stories, especially those that put history in context port their full engagement in the communication
or provide an uplifting narrative to listeners, are process. Although being sensitive to ones commu-
associated with positive age stereotypes and a nication partner is good advice in general, the
reduced likelihood that the negative cycle of the communication enhancement model is particularly
CPA will follow (Hummert et al. 2004). applicable in institutional, medical, or family set-
The ASI model also considers how older adults tings in which the frailty or acute health condition
can use their communication skills to interrupt and of older individuals make it difcult for them to
redirect the negative feedback cycle of the CPA assert their agency without supportive communi-
through their responses to patronizing talk (Giles cation partners.
and Gasiorek 2011). The challenge for older adults In contrast, the ASI and ecology models assign
is to respond to patronizing talk in ways that assert agency to the older adult, but the former focuses
their autonomy and establish their competence, but on agency within individual interactions whereas
to do so in a manner that builds a mutually respect- the latter considers agency in communication
ful relationship with the other individual. Experi- holistically. In the case of the ASI model, the
ments have tested the effectiveness of passive, older adults have the ability to use their commu-
direct assertive, appreciative, and humorous nication skills to avoid beginning the negative
response styles in achieving this goal. Results feedback cycle captured in the CPA model or to
show that direct assertive responses, in comparison interrupt and redirect that cycle after it has begun.
to passive responses, are better at establishing the Within the ecology model, older adults have the
competence of the older person but are perceived as agency to create the communication environment
more controlling and less respectful. Humorous that supports their desired experience of aging.
and appreciative responses emerged as the most Both of these models apply across all contexts,
effective in establishing the competence of the but within medical and institutional contexts their
older speaker in a warm and respectful way (Giles applicability may be limited by the extent to
and Gasiorek 2011; Savundranayagam et al. 2007; which older adults health status affects their com-
Hummert et al. 2004). munication agency.
Increasing older adults awareness of how their
own communication relates to age stereotypes
can help them to avoid the consequences of the Concluding Thoughts
CPA model and achieve the benets envisioned in
the ASI and communication enhancement Age-related conditions such as stroke, dementia in
models. This awareness is at the center of the its various forms, and Parkinsons disease create
communicative ecology model of successful specic communication challenges for older
aging (Fowler et al. 2015). The ecology model adults, their family members, and caregivers.
focuses on the power of older adults to use com- End-of-life communication also has its own
munication to reduce their uncertainty about unique characteristics and challenges. Neither of
aging, increase their self-efcacy, take advantage these topics is addressed specically in this entry.
of new communication technologies, and reach However, the communication principles outlined
their own denition of successful aging (Fowler here the dangers inherent in drawing on negative
et al. 2015). age stereotypes as guides, the benets of adopting
an individualized approach, and the importance Hehman, J. A., & Bugental, D. B. (2015). Responses to
of older adults using their communication skills patronizing communication and factors that attenuate
those responses. Psychology and Aging, 30, 552560.
to achieve their version of successful aging Hummert, M. L. (2011). Age stereotypes and aging. In
provide a useful framework for communication K. W. Schaie & S. L. Willis (Eds.), Handbook of the
with and by older adults in these special psychology of aging (7th ed., pp. 249262). San Diego:
circumstances. Academic.
Hummert, M. L. (2012). Challenges and opportunities for
communication between age groups. In H. Giles (Ed.),
Handbook of intergroup communication
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Comorbidity 575
Williams, K. N., Herman, R., Gajewski, B., & Wilson, K. to physical conditions, approximately three-
(2009). Elderspeak communication: Impact on demen- fourths of older Americans have hypertension,
tia care. American Journal of Alzheimers Disease and
Other Dementias, 24, 1120. half have arthritis, one-third have heart disease,
one-quarter have some type of cancer, and
one-fth have diabetes (Administration on
Aging: A prole of older Americans 2013).
Older age is associated with the presence of C
Comorbidity more chronic conditions (Bayliss 2014), which
makes comorbidity an essential topic for
Christine E. Gould1,2, Sherry A. Beaudreau1,3,4 geropsychologists. Moreover, patients with
and Ruth OHara1,3,4 chronic medical conditions have high rates of
1
Department of Psychiatry and Behavioral depression and other mental illnesses (Bower
Sciences, Stanford University School of et al. 2014). The prevalence of psychiatric disor-
Medicine, Stanford, CA, USA ders may be as high as 45% among medical inpa-
2
Geriatric Research, Education, and Clinical tients and outpatients (Kaszniak 1996). Other
Center (GRECC), VA Palo Alto Health Care psychiatric conditions like anxiety or substance
System, Palo Alto, CA, USA abuse are more likely to occur when the index
3
Sierra Pacic Mental Illness Research Education condition of depression is also present. In light
and Clinical Center, VA Palo Alto Health Care of the ubiquity of chronic medical conditions in
System, Palo Alto, CA, USA late life and high rates of co-occurrence of medical
4
School of Psychology, The University of and psychiatric disorders, one must assess and
Queensland, Brisbane, QLD, Australia manage comorbid conditions when working with
older adults. Failure to consider medical
comorbidities may dilute treatment effects and
Synonyms confound diagnostic accuracy. Consideration of
comorbidities may also rene our psychiatric phe-
Co-occurring disorders; Dual diagnosis; notypes, help us identify the genetic bases of
Multimorbidity mental health disorder, and reveal their patho-
physiological mechanisms. Before considering
the identication and management of comorbid
Definition disorders, one should rst carefully characterize
comorbidity.
Comorbidity generally denotes the occurrence of
two or more psychiatric or mental health disorders
in one person. Two conditions that co-occur are Defining Comorbidity
considered to be comorbid regardless of whether
the etiology of the disorders overlaps or is distinct, The term comorbidity, rst used by Feinstein in
regardless of the chronological development of 1970, refers to the coexistence of two or more
the disorders (Goodell et al. 2011). disorders within one person. One important aspect
of Feinsteins denition was that one of the disor-
ders was the index disease being studied (Fortin
Background et al. 2014). The term comorbidity originated in
the medical literature but was soon adopted for
Most older Americans have at least one chronic use in psychiatry. The study of comorbidity
condition (Administration on Aging: A prole of became quite important with the 1980 publication
older Americans 2013) and one in four has two or of the third edition of the Diagnostic and Statisti-
more chronic conditions (U.S. Department of cal Manual of Mental Disorders (DSM)
Health and Human Services 2010). With respect (American Psychiatric Association 1980) because
576 Comorbidity
of the use of polythetic criteria to characterize of one disorder (e.g., Downs syndrome) may
psychiatric disorders. Polythetic criteria allowed signal that clinicians should screen for another
for differing clusters of symptoms to be charac- disorder (e.g., dementia). The third type, familial
terized as the same disorder. Additionally, symp- comorbidity, describes comorbidity that occurs
toms such as sleep disturbance may be included in when the prevalence of one disorder differs
multiple psychiatric disorders. among relatives of patients with a second disorder
By the 1980s and 1990s, researchers when compared with relatives of patients without
began using the term multimorbidity (Fortin the second disorder. For instance, the occurrence
et al. 2014) to describe the burden of multiple of obsessive-compulsive disorder is higher in rel-
medical conditions. Currently, multimorbidity is atives of individuals with Tourette syndrome
most often used when three or more conditions are compared with families without Tourette syn-
present. Comorbidity usually has one condition of drome. Lastly, disorders that do not t into these
interest (i.e., index condition), whereas in other three categories, that may simply co-occur at
multimorbidity there is no specic condition of random, and that have no relevance to clinical
interest. Multimorbidity encompasses the com- decision-making would be called random comor-
plexities resulting from the presence of multiple bidity using Kraemers model (Kraemer 1995).
conditions, as is often seen in primary care set- For example, the presence of social anxiety disor-
tings (Fortin et al. 2014). When working with der and a completely unrelated condition like
patients with multimorbidity, clinicians must sort shingles could be considered randomly comorbid.
out different recommendations resulting from the Unrelated disorders such as these are considered
separate clinical management guidelines for each an example of random comorbidity.
chronic condition. Reconciling different clinical Prognosis and treatment recommendations can
management guidelines often leads to confusion vary based on co-occurrence of conditions in clin-
on the part of the patients and polypharmacy and ical comorbidity (Kraemer 1995). This entry,
even results in contradictory recommendations. therefore, focuses on issues relevant to clinical
Multimorbidity is an important term to be aware comorbidity because it is most relevant to
of for clinical geropsychologists, but here, comor- geropsychologists in both clinical practice and
bidity is the term that is focused on as specialized clinical research settings.
elds such as geropsychologists often focus on
one presenting problem or one index condition.
Kraemer (1995; Kraemer et al. 2006) dened Diagnostic, Prognostic, and Treatment
several distinct types of comorbidity that are espe- Implications of Ignoring Comorbidities
cially relevant for those studying aging: clinical
comorbidity, epidemiological comorbidity, famil- Among older adults, age-related physiological
ial comorbidity, and random comorbidity. The and other body system changes can complicate
rst type, clinical comorbidity, refers to a situation diagnosis and treatment. One disorder may cause
in which the prognosis differs for people who another (e.g., hypothyroidism can lead to depres-
have the index disorder and a second disorder sion), whereas other conditions may exacerbate
when compared with those who have the index one another (e.g., anxiety and chronic obstructive
disorder and not the second disorder. The second pulmonary disease). Hence, prognosis and treat-
type, epidemiological comorbidity, occurs when ment recommendations may vary based on the
two disorders co-occur more often than one would comorbid disorders present.
expect by chance alone. Epidemiological comor- Sleep disturbance is one of the most frequent
bidity may occur when the two disorders share complaints among those with depression or anxi-
genetic risk factors or if the two disorders are ety in late life and as such can be thought of as a
different clinical manifestations of the same dis- core-presenting symptom of these two mental
order. Epidemiological comorbidity is of interest health disorders. Nevertheless, sleep disturbance
to clinicians and researchers because the presence can also occur due to the presence of a
Comorbidity 577
diagnosable sleep disorder, such as sleep apnea, of comorbidity. Often in the DSM, which relies on
an extraordinarily common sleep disorder in older polythetic criteria, there is substantial symptom
adults. Failing to adequately assess for and diag- overlap, which can lead to increased rates of
nose sleep apnea can mean patients obtain a diag- comorbidity; however, the use of a hierarchy in
nosis of a psychiatric disorder when in fact they making diagnoses reduces rates of comorbidity.
should be given the diagnosis of a sleep disorder. A commonly reported issue relating to differ-
In the example of sleep apnea misdiagnosed as ing comorbidity rates and assessment is the halo C
depression, treatment with antidepressants may effect, whereby an assessment geared toward
have modest results at best, whereas augmenting detecting a particular disorder might also increase
antidepressant treatments with continuous posi- the assessors awareness of a particular disorder.
tive airway pressure (CPAP) could alleviate the A halo effect also could be a function of the
sleep-disordered breathing while also improving assessors assumptions about disorders being
depressive and anxiety symptoms. related (Frances et al. 1990). Another reported
With respect to prognosis, a person with an issue regarding assessment and comorbidity
anxiety disorder and breathing disorder may be includes selection of comprehensive versus
slower to respond to behavioral treatments narrower assessments. A comprehensive assess-
because of modications needed in teaching dia- ment, such as the Structured Clinical Interview for
phragmatic breathing or breathing retraining com- DSM (SCID), is more likely to detect the presence
pared with a person with an anxiety disorder and of comorbid conditions than would be the case if
no breathing difculties. Indeed, it is well select measures of specic disorders were used. In
documented that the presence of such comorbid the case of structured interviews (e.g., SCID), the
disorders such as pain and depression slows the assessor is comparing an individuals symptoms
response to pharmacological and psychological to the set list of diagnostic criteria. Assessors
treatments for late-life depression. Such examples likely detect more conditions when using struc-
are very common in geropsychology. Given the tured interviews compared with using a limited set
considerable implications of many comorbid con- of selected measures (e.g., depression and anxiety
ditions for diagnosis, prognosis, and treatment, it screens) because structured interviews force
is imperative that geropsychologists adequately assessors to consider many different types of psy-
assess for and address comorbid medical and psychiatric conditions as the assessor reviews a set list
chiatric disorders in older adults. of diagnostic criteria for each disorder. Different
settings also affect the likelihood that specic
pairs of comorbid conditions will co-occur, such
Assessing Comorbidities as in an anxiety disorder clinic, where depression
may be more likely to co-occur with social anxiety
A critical issue is how best to evaluate and assess a disorder; however in primary care clinics, depres-
comprehensive range of comorbid disorders. sion may be more likely to co-occur with chronic
The main challenge to studying comorbidity is medical conditions. The main challenge to char-
the inherent heterogeneity of ones sample. Con- acterizing comorbidity in psychiatry is the use
sideration of this heterogeneity is essential to of diagnoses based on groups of symptoms
identifying the effectiveness of evidence-based rather than etiologically dened disorders
treatments, yet characterization of comorbid sam- (Fyer et al. 1990). Prospective longitudinal stud-
ples is challenging. Frances et al. (1990) highlight ies will elucidate the etiology and course of psy-
several issues that inuence how comorbidity is chopathology, which is needed to better
measured and classied. To start, with more dis- understand the common pathways and courses of
orders included in a classication system, there is comorbid diseases.
more likelihood of comorbidity. Additionally, In the medical literature, the burden of multiple
splitting disorders and using categorical classi- conditions (i.e., multimorbidity) is measured
cations increase the rates of disorders and the rate using disease counts and established comorbidity
578 Comorbidity
indices such as the Charlson Comorbidity Index reporting subthreshold depression (Zarit and Zarit
(Charlson et al. 1987). These indices and counts 2007) and 2029% reporting subthreshold anxiety
do not characterize the specic relationship (Gellis et al. 2014). Researchers have argued for a
between an index condition and the associated dimensional approach to understanding psychiatric
conditions, as is the focus of comorbidity disorders, rather than a purely categorical one, in
research. These indices are helpful in predicting order to capture these subthreshold psychiatric con-
negative outcomes such as mortality, but they ditions (Maser and Cloninger 1990). The rationale
have less relevance when trying to characterize for implementing a dimensional approach is all the
specic comorbidities. more salient in older adults given the ubiquity of
Personalized approaches to assessment can subthreshold symptoms. Because subthreshold
also be used. This would entail a multimodal psychiatric disorders are associated with substan-
assessment including reviews of medical evalua- tial medical and cognitive comorbidity, especially
tions, cognitive testing, functioning assessments, in older adults, documenting and treating them is
behavioral observations, and clinical interviews critical.
with the patient and an informant if possible. Anxiety and depressive disorders frequently
The thorough review of somatic symptoms can co-occur and as such have garnered much of the
help differentiate medical disorders from psychi- attention regarding psychiatric comorbidity (Zarit
atric disorders. In the review of somatic symp- and Zarit 2007). This has led some theorists to
toms, identifying the onset of symptoms and propose that anxiety and depression represent dif-
other factors in the time line is essential. Investi- ferent phenotypic (i.e., expressed) manifestations
gations of whether disparate treatment outcomes of the same underlying disorder. Others have
occur with different groups of comorbid patients argued that the lifelong durability and trait-like
will also help elucidate the relationships among nature of anxiety disorders increase the risk of
comorbid conditions. developing depressive disorders, which tend to
be cyclic over the life span. Older adults with
any number of anxiety disorders, such as panic
Common Psychiatric Comorbidities disorder and social anxiety disorder, often suffer
from coexisting dysthymic disorder or major
Many aspects of psychiatric comorbidity remain depressive disorder. In fact, there has been some
true from younger to older adulthood, although suggestion that this overlap of depression and
some differences exist. Psychiatric disorders sel- anxiety in older adults is greater than what is
dom occur in isolation from other psychiatric seen in younger adults, particularly when sub-
symptoms or disorders regardless of a persons threshold symptoms are included. Cognitive dis-
age. The psychiatric disorders ranked from orders, namely, minor and major neurocognitive
most (anxiety disorders) to least common disorders, are much more likely to co-occur in
(schizophrenia) follow the same pattern in youn- older adults with psychiatric disorders than in
ger, middle-aged, and older persons (Kessler older adults without any threshold or subthreshold
et al. 2001; Zarit and Zarit 2007). The tendency psychiatric issues.
for some psychiatric disorders to occur together In addition, comorbid psychiatric issues
more often than others is also somewhat age require additional consideration in clinical situa-
invariant. The prevalence of psychiatric disorders tions with older patients, particularly because
and subthreshold symptoms, however, differs with individuals with coexisting psychiatric problems
age. In particular, the prevalence of any psychiatric often have more severe symptoms. The decision
disorder decreases with age, but subthreshold anx- to treat one disorder, such as the anxiety
iety and depressive symptoms are documented as disorder as primary versus treating the depressive
common with as many as 25% of older adults disorder as primary, has implications for
Comorbidity 579
treatment selection. Behavioral interventions disorders are notably higher (73%) in older indi-
targeting anxiety typically focus on reducing anx- viduals with adult-onset depression than late-life-
iety through relaxation skills training or desensi- onset depression (45%) (Mordekar and Spence
tization through real or imagined exposure to 2008). With regard to anxiety disorders, comorbid
feared situations or objects. Treatments for DSM-5 Cluster C personality disorders (avoidant,
depression typically work to increase the persons obsessive-compulsive, or dependent) are fre-
social interactions, activity level, and experience quently observed in individuals of all ages who C
of the environment as positive through a con- experience an anxiety disorder. Treatment of an
certed effort to partake in enjoyable activities. older patient becomes even more challenging, as
These behavioral skills have been successfully personality disorders are often associated with
used in older patients suffering from psychiatric poorer prognosis. They complicate treatment
disorders (Zarit and Zarit 2007). The presence of delivery and can require a more sophisticated
anxiety and depressive disorders could require a intervention approach and skill level of therapist
combined treatment approach or staged approach for older adults seeking help.
where the more urgent of the two disorders is rst
treated before treating the second disorder. With
regard to pharmacological interventions, both Common Medical Comorbidities
anxiety and depression can be treated with some
of the same medications (i.e., selective serotonin Older adults with psychiatric disorders often also
reuptake inhibitors or SSRIs), rendering this have comorbid medical conditions. Psychiatric-
comorbidity issue potentially less relevant for medical comorbidity is likely a function of many
medication management. Nevertheless, other sit- factors including but not limited to age, poorer
uations, such as comorbid schizophrenia with self-care, greater disability, and cognitive impair-
generalized anxiety disorder, could require a ment. When working with older adults who have
more complicated medication regimen due to both psychiatric and medical disorders, one must
potential interactions and negative side effects of determine the extent to which the medical disor-
medications that treat the two separate disorders. der contributes to the psychiatric disorder of inter-
Less often discussed, but a critical issue for est. Additionally, the manner in which the medical
understanding psychiatric comorbidity in older and psychiatric disorders are related temporally is
adults, is the co-occurrence of personality disor- important. For instance, chronic conditions may
ders (Mordekar and Spence 2008). These disor- lead to depression, whereas depression itself may
ders are characterized by long-standing patterns of be a risk factor for chronic conditions and func-
inexible and maladaptive behaviors that often go tional decline (Bower et al. 2014). Moreover,
against society and cultural norms. This often depression may make it more difcult for a patient
leads to disruptions in interpersonal relationships. to be motivated to manage their chronic condi-
Again, as with other psychiatric disorders, the tions, leading to poorer outcomes, as may be
prevalence of personality disorders declines with observed in individuals with comorbid depression
age (Segal et al. 2006). The comorbidity of per- and diabetes (Bower et al. 2014).
sonality disorders with other psychiatric disor- There are multiple pathways through which
ders, however, is quite high in older persons. psychiatric and medical disorders interact. To
Mood and anxiety disorders are the most com- illustrate this point, take the example of late-life
monly reported diagnoses comorbid with person- anxiety disorders. Chronic medical conditions,
ality disorders. For example, it has been reported such as chronic obstructive pulmonary disease,
that 24% of older individuals with major depres- may lead to physiological changes that predispose
sive disorder also meet criteria for a personality older adults to anxiety (Zarit and Zarit 2007).
disorder. Further, rates of comorbid personality Alternatively, an acute illness or hospitalization
580 Comorbidity
may lead to an exacerbation of worry and other worsening of chronic medical conditions (Bower
anxiety symptoms (Zarit and Zarit 2007). It is also et al. 2014).
possible that medications such as steroids or anti-
cholinergics prescribed to older adults could exac-
erbate or even cause anxiety (Zarit and Zarit Treating Patients with Comorbidities
2007). The presence of an anxiety disorder prior
to the development of a chronic condition may Personalized or patient-centered medicine ideally
make the management of the medical condition can be used to tailor treatments to patients with
more difcult, such as the presence of agorapho- comorbidities. Individualized treatments can take
bia would likely interfere with patients into account the patients medical and psychiatric
attendance at medical appointments. These are comorbidities. Individualized treatments allow
only a few examples of the multiple pathways providers to consider the index condition being
connecting psychiatric and medical disorders. treated as well as other factors, such as cognition,
In addition to the pathways connecting psychi- which can inuence outcomes. Careful assessment
atric and medical disorders, oftentimes the preva- provides a strong foundation for tailored, personal-
lence of psychiatric disorders may be greater and ized treatments. Additionally, interdisciplinary
severity worse among older medical patients. For teams are an essential part of delivering patient-
instance, depression is more prevalent among centered treatments to those with comorbidities.
older adults with medical illness (Zarit and Zarit The team members can address medical and psy-
2007). Functional limitations associated with chiatric conditions through the collaboration and
medical illnesses, sensory impairments, ambula- communication across disciplines.
tion difculties, and pain may limit an older There is also a need to include patients with
patients ability to engage in pleasant activities. comorbidities in randomized control trials
Behavioral theorists posit that these functional (RCTs). Patients with comorbidities are included
limitations reduce participation in enjoyable in large and inclusive RCTs called pragmatic or
activities and thus cause depression. effectiveness RCTs rather than the smaller ef-
Psychological stress, experienced by those cacy studies. Effectiveness trials focus on exam-
with psychiatric disorders, may also adversely ining the effects of treatment under the usual
affect physical health by exacerbating chronic conditions (i.e., in community practice) rather
conditions like hypertension (Haley 1996) and than under the ideal conditions (i.e., controlled
preventing immune responses that are important research setting) as is the case for efcacy studies.
in recovery (e.g., cancer). Individuals with severe Moderator analysis (Kraemer et al. 2006) can be
mental illness (SMI), such as schizophrenia, die used to examine the effect of comorbidities on
1015 years earlier than their counterparts without treatment outcomes. The resulting ndings will
SMI. These individuals with SMI also have ele- likely yield information about what treatments
vated risk of having comorbid medical conditions work best for which groups of patients. These
likely due to multiple factors. The presence of ndings can be used to rene existing treatments,
SMI requires substantial management and can develop new treatments, and inform patient-
result in the psychiatric disorder taking prece- centered medicine.
dence over and obfuscating other problems,
which is referred to as diagnostic overshadowing
(Bower et al. 2014). Some antipsychotic medica- Conclusions
tions contribute to weight gain, increased risk of
diabetes, and metabolic syndrome, whereas other Psychiatric and medical comorbidities are common
lifestyle choices (e.g., sedentary, poor diet) and across the life span. Among older patients, high
comorbid conditions (e.g., substance use disor- rates of comorbid psychiatric disorders co-occur
ders) may contribute to the development or frequently with chronic medical conditions.
Comorbidity 581
Medical conditions and associated functional mood and anxiety disorders (pp. 4160). Washington,
impairments may precede and lead to psychiatric DC: American Psychiatric Press.
Fyer, A. J., Liebowitz, M. R., & Klein, D. F. (1990).
conditions. Chronic psychiatric conditions can also Treatment trials, comorbidity, and syndromal complex-
affect an individuals physiology and immune ity. In J. D. Maser & R. C. Cloninger (Eds.), Comor-
responses, lifestyle, and the clinicians assessment bidity of mood and anxiety disorders (pp. 669680).
(i.e., diagnostic overshadowing). The complex Washington, DC: American Psychiatric Press.
relationship between comorbid psychiatric disor-
Gellis, Z. D., Kim, E. G., & McCracken, S. G. (2014).
Anxiety disorders in older adults literature review. In
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org/File.aspx?id=23504
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content/dam/farm/reports/issue_briefs/2011/rwjf69438/
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582 Complementary and Alternative Medicine
(World Health Organization 2011). This comes

Complementary and Alternative at the cost of increased economic and social pres-
Medicine sures on a range of systems and infrastructure
globally. How health services are consumed and
Emma E. Poulsen provided is changing across both traditional and
School of Psychology, The University of nontraditional services.
Queensland, Brisbane, QLD, Australia The ageing population will place particular
strain on the health system with disease
patterns moving from acute short-term, infectious
Synonyms or parasitic diseases to chronic long-term,
noncommunicable diseases (Hale et al. 2007).
Holistic medicine; Natural medicine; Non- As longevity increases, frailty and chronic illness
conventional medicine; Unorthodox medicine rise as physical and cognitive capacities decline at
the later stages of life (World Health Organization
2011). In particular, the demand for chronic care,
Definition rehabilitation services, and palliative care all
increase with the ageing of populations (Hale
Complementary and alternative medicine (CAM) et al. 2007).
is an umbrella term used to describe a group of Criticisms have been made of the existing
diverse medical and healthcare systems, practices, medical system and the difculty it will face
and products that are not generally considered part catering to the increased demand on services due
of conventional medicine, that have not been part to changing disease patterns (Holman 2004). The
of the public healthcare system or administered by current health system is typically focused towards
conventional medical practitioners (Adams treating acute illnesses that are episodic where the
et al. 2009). There has been a noted increase in health practitioner typically has the majority of
CAM use across all populations during the past control in determining treatment and management
20 years (Andrews 2002), including older adults approaches, and the patient is largely a passive
(aged over 65). Depending on how CAM is mea- recipient. It has been argued the traditional med-
sured, studies suggest 4065% of older adults use ical model of health care (that focuses on biolog-
either some form of CAM therapy and/or over- ical aspects of disease and illness) is less
the-counter CAM products (Cohen et al. 2002). conducive to treating chronic illnesses where
Older adults have been identied as being signif- treatment is ongoing and long-term management
icant consumers of CAM, and the factors that of symptoms is often the goal, rather than seeking
inuence this use are varied and have unique a cure. Due to the ongoing and often personalized
implications compared to other cohorts. experience of chronic illness, it is argued that the
roles in treatment need to shift from the health
practitioner having full control to provide the
Population Ageing, Chronic Illness, patient with more authority over their treatment
and Health System Responsiveness plan, allowing them more responsibility and
autonomy in management of their conditions
Complementary and alternative medicine (CAM) (Holman 2004). The current model of healthcare
is broadly consumed by older adults and its use is delivery offers limited exibility.
on the rise. CAM, and indeed health care in gen-
eral, is being inuenced by the demographic shift
of the ageing population (Adams et al. 2009). It is Chronic Illness and CAM Use
predicted that there will be 1.5 billion individuals
over the age of 65 by 2050, driven by decreasing The ageing population is at increased risk of
fertility rates and improved life expectancy chronic health complaints illness (Cherniack
Complementary and Alternative Medicine 583
et al. 2001). Older consumers are cognizant of the with population ageing (World Health Organiza-
need to treat these health complaints, and it has tion 2011).
been found that as health conditions deteriorate, Traditional medicine and CAM use are very
CAM use increases (Cherniack et al. 2001). much rooted in cultural contexts, and the legiti-
Indeed, CAM use is ve times higher in the chron- macy of both health treatment options is
ically ill population compared to a healthy popu- inuenced by sociocultural perspectives (Root
lation. In general, research completed with Wolpe 2002). The sociocultural context not only C
chronic illness populations have noted that CAM inuences peoples perceptions of both traditional
use rates are elevated and typically centered medicine and CAM but also the illnesses that
around management of health conditions trigger their use. In the literature surrounding
(Cherniack et al. 2001). health service provision, there is an expanding
Within the chronically ill population, the use of body of research attempting to describe a shift
CAM has been linked to a belief that CAM is a towards consumerism and the identity of health
safer option than conventional medicine with users (Milewa 2009). The typical health consumer
fewer side effects to conventional medicine now interacts with health services as an active
(Vincent and Furnham 1996). Furthermore, participant, picking and choosing the products
CAM users have reported strong beliefs in the best tailored and personally suited to their needs
efcacy of the CAM product/service being con- rather than being a passive consumer. The ability
sumed (Vincent and Furnham 1996). Practitioners to make personal decisions, select from a range of
who provide CAM services often have longer options, and make choices based on a sense of
consultations and reportedly provide more per- personal responsibility and shared decision mak-
sonalized services than offered by conventional ing are valued by many patients. Patients who
medical systems (Gammack and Morley 2004). adopt this viewpoint are more likely to look for
This in itself has a therapeutic benet that can be broader healthcare options beyond what is offered
particularly useful in the treatment of non-life- by traditional health service providers, including
threatening chronic illnesses. services offered by CAM.
With higher uptake of CAM use, there is
increasing pressure for conventional medical
The Active Consumer practitioners to have knowledge about individual
patients CAM usage. Historically, many doctors
Researchers have noted that the exibility in ser- have not discussed CAM usage with their
vices offered through CAM allows the individual patients. Research has demonstrated that up to
to play an active role in the management of their 77% of CAM users did not disclose their CAM
long-term chronic disease (Bishop et al. 2007). use to their treating practitioner (Xue et al. 2007).
CAM offers a different approach to the traditional CAM users who discussed their CAM use with
biomedical model, and studies have shown it can their medical practitioner were more likely to
provide a prevention-focused, exible healthcare describe themes of acceptance and control
model for chronic and degenerative diseases whereas CAM users who did not have these con-
(Bishop et al. 2007). While the need for conven- versations were more likely to describe their
tional medicine is still undisputed, the argument treating physicians as narrow minded (Vincent
that CAM offers a more versatile form of care and Furnham 1996). To add to this, general prac-
when dealing with non-life-threatening and titioners frequently underestimate the extent to
chronic ailments has merit and may assist in which their patients use CAM (Nahin and Straus
addressing the need created by the ageing popu- 2001). This is concerning as studies have addi-
lation. This shift appears to be occurring as traditionally shown that patients often have a poor
tional health systems are not currently structured understanding of the effects of CAM. Harmful
to cater for the increase in long-term chronic dis- interactions have been found between some
eases that is occurring across the globe associated CAM products and conventional medicine
approaches, e.g., herbal therapies and pharmaceu- being primary consumers (Weiss and Bass
tical therapies (Votova and Wister 2007). 2002). An increased focus on positive frame-
works of growing older that include the denial of
The Third Age physical signs of ageing and the promotion of
Increasing longevity of life has contributed healthy active living has been witnessed. In par-
towards a period of time referred to as the Third ticular, the chronological process of ageing has
Age, between postretirement but prior to been reframed as a transition, emphasizing a dis-
age-imposed limitations such as illness (Weiss tinction between chronological age and cognitive
and Bass 2002). This growing generation in gen- age of individuals.
eral has improved physical and mental health,
greater wealth, and higher levels of education,
with predicted longer life-spans than their prede- Personal Motivators of CAM Use
cessors. The Third Age provides a platform for
older adults to explore personal growth, self- Some researchers have categorized the motivators
fulllment, freedom, and personal engagement, for individuals choosing to use or not use CAM as
with a noted increase in the desire to maintain being in terms of push/pull inuences. Pushes
health status and postpone the inevitable decline indicate factors that push an individual away
in health (Weiss and Bass 2002). Indeed, there is from conventional medicine. Typically, these
often an acute awareness of ones mortality experiences are underpinned by dissatisfaction
coupled with uncertainty about future health with conventional medicine, e.g., poor communi-
needs (Weiss and Bass 2002). The combination cation, adverse side effects, poor treatment
of increased resources and the time to use them options (Sirois and Gick 2002). Pulls in contrast
has placed older adults in an optimal position to indicate factors that draw the individual towards
experiment with previously unexplored services CAM, e.g., holistic approach, long appointment
and products, e.g., CAM. There is often a sense of times, and perceived safety of the approach
responsibility for personal self-maintenance that (Furnham 2005). Typically, there appears to be a
promotes concepts such as awareness of medical mix of motivators that change over time and an
conditions, proactive intervention, wellness tech- interplay factors that inuence whether an indi-
niques, self-care of diet and exercise, and new vidual is a CAM user or nonuser. It is often the
learning. With this combination of factors, an case that older adults use CAM in conjunction
increase in CAM use among this population is with conventional medicine, as a concurrent ser-
understandable (Andrews 2002). vice to the management of their health care.
Indeed, in some studies CAM users were found
Antiageing Movements to consult with a specialist doctor more frequently
Antiageing movements through media and mar- than non-CAM users (Adams et al. 2003). The
keting have additionally inuenced the use of researchers hypothesized that this suggested a
CAM through increased consumerism of pragmatic approach to selecting treatments that
antiageing products (Milewa 2009). There exists best t their health concerns.
a marked increase of interest in products and Research on push versus pull factors has been
services that are marketed as being able to slow varied and there is little consensus in the literature
down or even reverse the natural ageing process. on which variables are consistently associated
Improvements in access and marketing that tar- with CAM use in the past or future. For example,
gets consumers through media such as the press, one found that personal control over health and
television, and Internet have contributed to this dissatisfaction with conventional medicine were
increased interest. While CAM services have inversely related to CAM use (Testerman
increased broadly, there has been a particular et al. 2004). In previous research however, criti-
boom in CAM technologies aimed towards cisms of the existing medical system have been
antiageing with middle-aged and older adults proposed to inuence CAM use (Willison and
Complementary and Alternative Medicine 585
Andrews 2001). A more recent study that found treatments, natural treatments, and life philoso-
dissatisfaction with conventional medicine was phies and how they related to CAM use (Bishop
positively correlated with past but not future use et al. 2007). The researchers reported that a desire
(McFadden et al. 2010). An important variable for participation in treatment decisions, active
that is not always addressed in research is dissat- coping styles, and holistic approaches to health
isfaction with conventional medicine treatment were all signicantly related to CAM use, how-
versus dissatisfaction with the treating physician. ever control was not. Many of these studies use a C
For some individuals, there were high rates of cross-sectional design so directionality cannot be
satisfaction with their physician; however, they easily established to determine if beliefs about
felt that the use of CAM would assist in relieving CAM use, active coping styles, and holistic
symptoms in a way that conventional medicine approaches to health were formed before or as a
was not able to provide (Testerman et al. 2004). result of CAM use. Other research has found
A number of attitudinal dimensions have been positive relationships between personal control
identied as being related to CAM use. Those and CAM use for healthy individuals
who are more likely to seek CAM have been (McFadden et al. 2010). Testerman et al. (2004)
identied as having a heightened awareness and did not nd such a link but his population was
commitment to environmental issues (Astin 1998; recruited from a medical clinic. These studies
Kranz and Rosenmund 1998). Other attitudes that demonstrate that the specic relationships
have been linked to CAM use include a belief in between predictor variables are often
personal responsibility towards health and holistic complicated.
healthcare approaches (Astin 1998). Holistic
beliefs include views of the mindbody relation-
ship as being in balance and maintained by self- Structural and Sociodemographic
healing. Some studies have noted that as holistic Influences on CAM Use
beliefs and health complaints increased, so too did
CAM use, indicating that both personal beliefs There are also a number of structural and personal
about health care and a desire to relieve illness sociodemographic inuences that inuence fre-
symptoms inuence CAM use (Vincent and quency and type of CAM use (Kelner and
Furnham 1996). It has been proposed that conven- Wellman 1997). The physical availability and
tional medicine, through focusing on the physical access to CAM products, personal income, insur-
elements of a disease, fails to account for the ance plans, private health care, and distance trav-
person as a whole (Kranz and Rosenmund elled to access services have all been linked to
1998). For individuals holding this perspective, CAM use (Kelner and Wellman 1997). Studies
CAM provides an appealing alternative. have consistently shown that CAM use is higher
It has been suggested that CAM users perceive in rural and remote regions compared to urban
that they have increased control over the active settings (Robinson and Chesters 2008), and
management and choices concerning their health lower in Metropolitan areas compared to
(Astin 1998). Previous researchers have hypothe- nonurban locations (Adams et al. 2003). This is
sized that a desire for control (Astin 1998) and a an issue of particular concern to older adults as
sense of personal responsibility towards health there are often mobility and driving restrictions
and holistic healthcare approaches (Furnham and that further complicate their access compared to
Kirkcaldy 1996) are important factors that inu- younger cohorts (McLaughlin and Adams 2012).
ence an individuals choice to use CAM. The Difculty accessing conventional health services
desire to seek holistic, natural, and preventative in rural regions compared to urban areas may be
approaches is often motivators for commencing inuential in the decision to use CAM (Robinson
CAM use (Kranz and Rosenmund 1998). and Chesters 2008). Indeed, the relationship
A systematic review explored 94 studies that between geography and location to CAM use is
included themes of control, illness, holism not as strongly established in the literature as other
elements including health status, gender, income, Adams, J., Sibbritt, D., & Lui, C.-W. (2011).
and level of education. Connected elements to The urbanrural divide in complementary and alterna-
tive medicine use: A longitudinal study of 10,638
geography may include population of available women. BMC Complementary and Alternative Medi-
clinicians, proximity of specialist services and cine, 11, 2.
range of services, socioeconomic status of the Andrews, G. (2002). Private complementary medicine and
region and policies, and politics of the region older people: Service use and user empowerment. Age-
ing and Society, 22, 343368.
(Adams et al. 2011). A number of studies specif- Astin, J. A. (1998). Why patients use alternative medicine:
ically exploring older adult CAM use in rural Results of a national study. The Journal of the Ameri-
settings found that CAM is used far more broadly can Medical Association, 279, 15481553.
than the treatment of existing health complaints, Bishop, F. L., Yardley, L., & Lewith, G. (2007).
A systematic review of beliefs involved in the use of
but also for maintaining current health status and complementary and alternative medicine. Journal of
well-being (Adams et al. 2003; Robinson and Health Psychology, 12, 851867.
Chesters 2008). Cherniack, E., Senzel, R., & Pan, C. (2001). Correlates of
use of alternative medicine by the elderly in an urban
population. The Journal of Alternative and Comple-
mentary Medicine, 7, 277280.
Conclusion Cohen, R. J., Ek, K., & Pan, C. X. (2002). Complementary
and alternative medicine (CAM) use by older adults.
The ageing population, the antiageing movement, The Journals of Gerontology. Series A, Biological Sci-
and shifts in consumerism and disease patterns ences and Medical Sciences, 57, 223227.
Furnham, A. (2005). Complementary and alternative med-
have all contributed to changing the way in which icine: Shopping for health in post-modern times. In
older adults consume traditional health care and P. White (Ed.), Biopsychosocial medicine: An inte-
CAM. CAM use amongst older adults is an grated approach to understanding illness
increasing phenomenon that is uniquely impacted (pp. 151171). New York: Oxford University Press.
Furnham, A., & Kirkcaldy, B. (1996). The health beliefs
on by a number of broader cultural shifts. The and behaviours of orthodox and complementary medi-
combination of the ageing population and the rise cine clients. British Journal of Clinical Psychology, 35,
of chronic illness requires all health providers, 4961.
independent of their qualications or personal Gammack, J. K., & Morley, J. E. (2004). Anti-Aging
medicine The good, the bad, and the ugly. Clinics in
beliefs, to recognize and be informed about the Geriatric Medicine, 20, 157177.
processes and factors inuencing CAM uptake in Hale, W., Joubert, J., & Kalula, S. (2007). Aging
the older population. There is a need for future populations and chronic illness. New York: McGraw-
research to investigate directional relationships to Hill.
Holman, H. (2004). Chronic disease The need for a new
explain the mechanisms which inuence decisions clinical education. The Journal of the American Medi-
to adopt and maintain CAM therapies. This infor- cal Association, 292, 10571059.
mation will potentially provide guidance for Kelner, M., & Wellman, B. (1997). Health care and con-
healthcare service providers who seek to under- sumer choice: Medical and alternative therapies. Social
Science & Medicine, 45, 203212.
stand how CAM usage interacts with conventional Kranz, R., & Rosenmund, A. (1998). Motivation for use of
medicine, and will help ensure that the most effec- alternative medicine. Schweizerische Medizinische
tive health-related outcomes for those in later life. Wochenschrift, 128, 616622.
McFadden, K. L., Hernandez, T. D., & Ito, T. A. (2010).
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Conceptual Model of Habit Reforming to Improve Balance and Prevent Falls 587
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Root Wolpe, P. (Ed.). (2002). Medical culture and CAM adapted and changes maintained are core concepts
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Sirois, F. M., & Gick, M. L. (2002). An investigation of the
health beliefs and motivations of complementary medi- ities and routines with the goal of reducing the risk C
cine clients. Social Science & Medicine, 55, 10251037. of falling.
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Vincent, C., & Furnham, A. (1996). Why do patients
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British Journal of Clinical Psychology, 35, 3748. ronmental or situational cues developed through
Votova, K., & Wister, A. (2007). Self-care dimensions of
complementary and alternative medicine use among repetition in consistent contexts.
older adults. Gerontology, 53, 2127. Falls: an event which results in a person com-
Weiss, R., & Bass, S. (2002). Challenges of the third age: ing to rest inadvertently on the ground or oor or
Meaning and purpose in later life. Oxford: Oxford other lower level (WHO).
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World Health Organization. (2011). Global Health and
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Xue, C. C. L., Zhang, A. L., Lin, V., Da Costa, C., & Story, movements, or activity that is closely aligned
D. F. (2007). Complementary and alternative medicine
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Journal of Alternative and Complementary Medicine, Lifestyle-integrated exercise: This is a specic
13, 643650. type of functional exercise whereby activities or
actions that are designed to improve physical
ability, such as to challenge balance or improve
muscle strength, are embedded within everyday
Conceptual Model of Habit tasks and routines (Clemson, 2012).
Reforming to Improve Balance
and Prevent Falls
Introduction
Lindy Clemson and Jo Munro
Ageing, Work and Health Research Unit, Faculty This entry outlines a conceptual framework that
of Health Sciences, The University of Sydney, underpins the adoption of an innovative approach
Lidcombe, NSW, Australia to balance and lower limb strength training to
reduce the risk of falls. The Lifestyle-integrated
Functional Exercise (LiFE) program, proven
Synonyms effective in reducing falls and improving function
in a randomized trial, (Clemson et al. 2012)
Automatic behaviors; Challenge your balance; embeds balance and lower limb strength activities
Cues to action; Do more and be safe; Integrate within daily life tasks and routines. Activities are
balance and strength training within daily tasks; tailored to the persons capacity and their lifestyle.
Load your muscles; Visualize and plan The framework is an applied one and is based on a
588 Conceptual Model of Habit Reforming to Improve Balance and Prevent Falls
habit reforming theory, principles of self-efcacy, With poor health, slow gait, and unsteady bal-
and an understanding of occupation-person- ance predictive of difculty in long-term engage-
environment demand theories. ment in exercise, it is not surprising that the effect
of any exercise dissipates after the program ceases
(Gine-Garriga et al. 2013). To maintain outcomes,
Functional Exercise Programs That the program needs to have an effect more than just
Improve Balance, Reduce Falls, preventing falls, for example, improving func-
and Improve Function tional capacity. Typical positive comments from
LiFE participants such as I can keep catching the
There is strong evidence for the core role of bal- buses so I can still get to visit my daughter or I
ance in providing protection from falls for older can stand up now to put on my trousers or I can
people with studies demonstrating that balance keep going to the club because I can easily get out
training is more effective than strength training of the chair reect that personal outcomes must
alone in preventing falls (Sherrington et al. 2008). be relevant to the person and their lifestyle.
Further, the evidence for functional exercise train- Understanding what enables older people to con-
ing having direct benet in improving balance, tinue to exercise will also provide guidance as to
physical function, and the capacity of older adults what features are essential when undertaking
to perform activities of daily living is growing training and also what tools are needed to facili-
(Liu et al. 2014). Functional training has been tate adoption and personal sustainability.
dened as any type of training that is performed
with purpose to enhance a certain movement or LiFE Trial Outcomes
activity (Liu et al. 2014). Functional exercise LiFE was tested in a three-arm randomized trial
appears to be most effective when the training (Clemson et al. 2012) where LiFE and a structured
content is specic to the outcome (Liu exercise program were compared to a control group
et al. 2014; Chou et al. 2012) and activities that who received a sham gentle exercise. The trial
involve dual or multitasking have a greater capac- recruited 317 people 70 years or older who had
ity to reect function. either had two falls in the previous year or one
Exercise programs that involve multiple com- injurious fall. After a 12-month follow-up, there
ponents are suggested as the most appropriate for was a 31% signicant reduction in rate of falls (IRR
physically frail older adults because they align = 0.69) for the LiFE participants compared to the
more closely with the demands of functional situ- control group who received a gentle exercise pro-
ations (Cadore et al. 2013). Examples of specic gram. The structured program (balance and
functional training programs include a music- strength exercises performed three times a week)
based multitask training program which improved showed reduced falls, but this was not a signicant
gait and balance and reduced falls through activity difference compared to the control group. In the
to music and involved dual tasking (Trombetti LiFE program, there were signicant and moderate
et al. 2011). Other approaches to improving phys- effect sizes for both static balance and dynamic
ical tness and capacity to perform daily life balance and for balance condence. For LiFE,
activities have tested programs that specically while there were steady improvements for hip and
incorporate activities of daily living. One such knee strength, ankle strength was the only strength
program used a multistation circuit approach measure to show a signicant effect. LiFE demon-
which mimicked daily functional tasks (Dobek strated moderate to large effect sizes in measures of
et al. 2007). The Lifestyle-integrated Functional function and daily activity and in a measure of
Exercise program (LiFE) (Clemson et al. 2012) is participation. Adherence was sustained with 64%
different to these in that it embeds balance and still engaged in LiFE activities at 12 months.
strength training into daily life activities through- The LiFE program has been successfully
out the day and is performed within the partici- implemented in a restorative home care service
pants home and their community environments. showing positive outcomes in a pragmatic
Concepts underpinning LiFE

Embedding balance and strength into daily routines
Beliefs
LiFE principles for C
balance and Habitual Change
strength Active memory till
Understanding embedded in routines Experience
links to function, functional
Planning &Visualising
falls and gait outcomes
how, when and
where Embedded balance Plans achieved
Situational and and strength
Balance,
environmental cues training into daily
function
serve as prompts to activities and
Skill action routines Confidence and
Finding LiFE participation
Practice and repetition
opportunities in the same context Protection from
Challenges self falls
Self-monitoring:
Mastery Reinforcement and
Upgrading LiFE repetition
activities &
Autonomy
Conceptual Model of Habit Reforming to Improve integrated Functional Exercise (LiFE) Program to prevent
Balance and Prevent Falls, Fig. 1 Conceptual frame- falls. Trainers manual. Clemson, Munro and Fiatarone
work underpinning embedding balance and strength train- Singh, 2014 Sydney University Press)
ing into daily life activities and routines (Lifestyle-
randomized trial (Burton et al. 2013). It has also linked to specic daily tasks using situational
been incorporated in a group-based program for and environmental cues that serve as prompts to
women at retirement (Fleig et al. 2015). action. Planning includes both setting what activ-
ities and where and how they will be performed
and visualizing doing this in selected situations.
The Lifestyle-integrated Functional They are performed intentionally and consciously
Exercise (LiFE) Conceptual Model until they become habitual and embedded in daily
occupation. Feedback, monitoring, and positive
Embedding Balance and Strength Training reinforcement are strategies used to improve
into Daily Routines skill and enhance self-efcacy in the performance
Figure 1 summarizes the main concepts underpin- of the activities. The experience of positive func-
ning how to embed balance and lower limb tional outcomes will sustain engagement in the
strength activities into daily life activities and program. These outcomes may include protection
routines (Clemson et al. 2014). The LiFE program from falls, increased function, self-condence in
includes features that enhance beliefs, attitudes, balance demanding activities, and greater partici-
and understanding of the program as well as train- pation in activities and life roles.
ing in skills specic to the program. A central and
core process of change are strategies to encourage Beliefs
habitual change, based on habit re-framing theory When training people to implement such programs,
(Lally and Gardner 2013). LiFE activities are we believe it is important for participants to
understand the principles of balance and strength benecial outcomes can impact motivation. We
training underlying the program. Motivation can be suggest that there would be numerous opportuni-
enhanced if people are able to link doing the parties during assessment and training to provide
ticular activities to specic outcomes. Features of examples which link the exercises to improved
the model are designed to inform and enhance function in doing daily living tasks, to improved
beliefs, attitudes, and understanding of the under- gait, and how the LiFE activities can provide
lying principles of the program. To engage in an protection from falling. These examples need to
embedded exercise program, it is necessary to have be relevant to the person. This is intended as
a belief that it is possible to improve balance and conversation during training at appropriate
strength and that this will have a direct impact and moments when the opportunity arises and not
benet; this may be to reduce fall risk, to improve intended as a didactic lecture. For example, mov-
gait or to improve functional capacity in ing sideways or sideways stepping is one of the
performing activities of daily living. balance activities. This could be illustrated by
referring to how strong hip abduction is important
LiFE Principles for Balance and Strength if a sideways stepping response is required to
Many people are unaware that they have poor protect from overbalancing. Further, people with
balance. Only 6% of the general older population a previous hip fracture are more likely to have
engages in any balance challenging activities. poor hip abduction strength suggesting the impor-
Being able to safely and functionally maintain pos- tance of strong hip muscles.
ture requires motor planning and sensory input
from the vestibular system, vision, and propriocep- Improving Balance and Strength Can Improve
tion. Being able to maintain balance is a complex Walking Stability and Strength
process. Further, the notion that balance is some- Other examples could relate to the ability to walk
thing that a person can improve is a very poorly safely. Understanding how the gait changes and
understood phenomenon. Most people do not how this impacts fall risk may provide a motiva-
understand that they can improve their balance. tion for older people to engage in balance and
Nor are they aware how they could do this, that strength training which can also improve their
is, by challenging themselves in specic ways that mobility. The changes in gait in the older person
are tailored to their personal capacity. The program may be inuenced by a variety of factors includ-
outlines several principals for challenging balance ing musculoskeletal changes such as decreased
(Clemson et al. 2014). The LiFE principles for strength, reducced range of motion at a variety
improving muscle strength are applied to the of joints, neurological factors, or low condence.
groups of muscles known to provide protection Gait analysis is complex. However, a simpli-
from falls hip, knee and ankle muscles. The ed analysis of the gait of older people generally
program does not use weights or resistance bands states that older people have a shorter stride
as these would not be part of the participants daily length, a wider base of support, and a slower
routine. Instead it relies on the person using their pace. Anecdotally, many older people shufe.
own body weight (e.g., standing up from a chair This means that their feet are in contact with the
slowly to increase quadriceps strength). ground for longer periods of time through the
The overarching LiFE principles are (i) to phases of the gait cycle. This may make them
improve balance, we must challenge balance and feel more stable but may not necessarily protect
continuously increase the challenge to our bal- them from falls. The inability to lift the foot to
ance, and (ii) to improve strength, we must con- effectively clear an obstacle may make the person
tinue to load the muscles. more likely to trip and therefore fall.
Improving balance and strength in the legs
Understanding Links to Gait, Function, and Falls should translate to an improved ability to walk.
Providing brief but targeted explanations about For example, strengthening the dorsiexors may
how the type of exercises directly link to lead to an improved ability to lift the forefoot for
heel strike and less chance of catching the toe transfer to other functional tasks. It may be that the
and tripping. If this is added to better balance tailored and embedded activities of LiFE enhance
while standing on one leg, therefore a more stable the integration of skills such as task coordination,
supporting leg in the stance phase in the persons postural control, and spatial processing.
gait cycle will be improved. This in turn should
lead to safer walking and possibly more con- Functional Activities Also Involve Planning,
dence walking. The program encourages partici- Concentration, and Attention C
pants to think about the way they walk, with the Activities that involve planning, concentration,
heel down and the toe up. That is, they need to attention, and strategizing could have a direct
concentrate on making contact with their heel and impact on function (Liu-Ambrose et al. 2008).
then consciously pushing off with their toe. With Think of what is involved in challenging balance
improvements in both strength and balance, the when talking on the phone, carrying things while
person is encouraged to walk with an improved turning around or going up stairs, or tandem walk-
gait and encouraged to scan ahead as they walk ing down the hall carrying a cup of tea.
(Clemson and Swann 2008). Liu-Ambrose et al. (2012) propose that it is not
just physiological improvements that can be
Balance Challenges While Dual Tasking Can gained from exercise but that executive function
Have a Functional Benefit and functional plasticity can improve from
LiFE activities often involve tasks that require targeted exercise. They draw on understandings
multiple skills to be used at the same time. This of brain function, evidence from their own and
is often referred to as dual tasking as the tasks others work in resistance training, and on studies
involve varying combinations of physical move- exploring the relationship between fallers perfor-
ment and upper and lower limb coordination, as mance on tasks that demand attention and tasks
well as attention to the task at hand. Examples of involving executive function (Anstey et al. 2008).
dual tasking include a one-legged stand while They assert that, along with physiological change,
cleaning your teeth or squatting (bending at the such mechanisms may play an important role in
knees) rather than bending at the waist when how exercise improves function and reduces
selecting items from a lower shelf in the fall risk.
supermarket.
By embedding LiFE activities in daily life rou- Skills
tines, the person is automatically placed in situa-
tions of competing demands. This connects Finding LiFE Opportunities
balance and strength training to daily living tasks There are many opportunities throughout the day
which naturally adds challenging demands. This to embed balance and strength activities. The
can include, for example, selectively paying atten- starting point is to chart a typical day routine
tion to the environment around them as well as over a week. LiFE activities are then matched to
dual tasking as they are doing the LiFE activity. specic daily routines or tasks for that individual.
Having a poor capacity to perform dual tasking Rather than looking for ways to do less, partici-
in tasks that involve gait variation and demand pants are encouraged to look for ways to do more
attention has been shown to predict an increasing and to add balance and strength activities into
risk of falls (Kuptniratsaikul et al. 2011). This risk more daily tasks.
is increased for repeat fallers (Beauchet
et al. 2008). Training in dual-task activities that Challenges Self and Mastery
challenge balance in clinic situations has been The concepts of challenging oneself, mastery, and
shown to improve gait stride and variability and upgrading are interconnected. They are all impor-
dynamic and static balance (Silsupadol tant skills that underpin most exercise programs.
et al. 2009). LiFE has shown that this can be To improve and continue to improve balance, a
done in everyday situations and that these skills person will need to practice challenging balance
activities. To improve strength, a person has to require joint decision-making, a sense of owner-
continue to load their muscles and continue ship of the goal, and encouragement to contribute
increasing the load on their muscles. To continu- how, when, and where more LiFE activities can
ously upgrade their activities, the participant be undertaken.
needs to be able to set a goal related to a LiFE
activity, determine when they have mastered that Habitual Change
activity or achieved the goal, and then set a new, Facilitating habit change requires strategies that
more challenging goal. Self-efcacy refers to the transition the novel activity into a routine part of
perception of ones ability to reach a specic goal the daily task (Lally and Gardner 2013). That is,
(Bandura 1997). The ability to set realistic, short- LiFE activities need to become habitual. When the
term, achievable goals as well as mastering an activities become habitual, they are more likely to
activity can increase the participants beliefs be sustained.
about self-efcacy when they prove that they can
master the activity. Active Memory Till Embedded in Routines
Mastery refers to the ability to perform an Habits are automatic actions. So to change a habit
activity at a certain level. Inherent in this concept requires thinking and planning within active mem-
is the idea that new challenges can always be ory until it becomes stronger than the current action
created once a particular challenge has been met. and becomes automatic or embedded. This sug-
Mastering a skill involves breaking it down into gests also that the number of activities chosen to
simple and manageable steps and having incre- change at one time should be manageable.
mental goals working toward achieving these While learning the program during the training
steps. In the LiFE program, participants have to phase, participants must consciously think about
master an activity at a lower level before they the activities and embed them into daily tasks.
can safely progress to a more challenging activity. That is bringing them into consciousness or
For example, when a participant can stand on one active memory. We learn new habits by incremen-
leg with two-hand support, then the goal becomes tally processing over time using our active
moving to a one-hand support and then one-hand (or procedural) memory. Over time they become
intermittent support. Participants master the activ- habitual and automatically embedded in daily occu-
ity and then set a new goal which upgrades their pation. Habits are routine, goal-directed behaviors
level of activity. that are set in motion by situational or environmen-
tal cues (Ronis et al. 1989). These can be automatic
Upgrading LiFE Activities and Autonomy and may go unnoticed or may be intentional where
Upgrading is based on the principles, that is, pro- the situation needs to prompt us to action.
gressively increasing challenges to balance or Changing habits requires time. This is why
increasing load on lower limb muscles within training in the LiFE program was taught over ve
one activity or combining activities that target sessions, two phone calls, and two booster sessions
two or more principles (e.g., sway to limits of but which extended over a 12-week period. LiFE
stability sideways when standing on one leg and requires working with active memory until the
climbing up stairs two steps at one time without activity becomes a stable and enduring habit and
using the handrail for support are both very is embedded in routine. This is facilitated by prac-
advanced LiFE activities). tice and repetition in the same context.
Finally, and most importantly, the aim is to
give the participants the skills to become autono- Planning and Visualization: How, When,
mous in implementing the program themselves, to and Where
understand how to upgrade, and to select appro- Holland et al. (2006) stated that planning and
priate activities that will continue to challenge visualizing changes were important because they
their balance and load their muscles in safe and helped formulate the intent to action and acted to
correct ways. Thus, planning and setting goals strengthen the association between the situation or
environment and the action. Participants in the old habits with new ones is dependent on both
LiFE program are expected to plan when and conscious planning and the inuence of situa-
where they will perform the activities and to tional cues (Lally and Gardner 2013; Holland
which of their daily tasks they will link the activ- et al. 2006; Lally et al. 2011). Changing behavior
ity. They are also asked to visualize themselves requires prompts to elicit the desired behavior. In
performing the activity while doing their daily LiFE there are several methods of providing the
tasks. The particular task then becomes the cue cues to prompt the desired behavior. There are C
for remembering to do the LiFE activity. For general prompts that apply to all participants.
example, a participant could practice tandem These include bending your knees if you need to
standing while washing up; then doing the wash- reach for anything below waist height or go on
ing up becomes the cue to do the tandem stand. your toes if reaching above waist height.
But in addition to practice, they are also encour- To facilitate the embedding process, the partic-
aged to imagine or visualize themselves in the ipants plan which daily tasks the LiFE activities
future doing this. will be linked to or embedded within. These tasks
When they have mastered the skill of then become the situational cues to prompt the
performing the desired activity embedded in a spe- performance of the LiFE activity. Situational
cic daily task and are doing this routinely, they cues can be a place and time, for example, the
should then try to visualize themselves performing kitchen sink in the morning; a feature of the envi-
it in other daily tasks. Participants can then gener- ronment, for example, the doorway between the
alize the activity performance to other contexts. hall and the bathroom; or a pattern of interaction
The idea is to be able to transfer the activities to with the environment, for example, standing in the
as many tasks and places as possible through their supermarket line. These cues act as a prompt to
daily routine. They can plan to embed the activity elicit the behavioral response the performance of
in the new task in addition to the former task. the LiFE activity.
For example, they might start with bending The program encourages participants to make
their knees (squatting) to get the detergent from changes to their environment to facilitate the per-
below the sink. Once this is mastered, they then formance of the LiFE activities such as moving
plan and visualize themselves bending their knees commonly used items to a different place to pro-
in other situations such as the bathroom to get the mote repeated performance. Some examples
toothpaste out of the cupboard or in the kitchen include moving the detergent to a lower shelf to
when getting the plates out for dinner. prompt knee bends and moving the tea cups to a
Visualization is a strategy to assist intent to higher shelf to prompt toe raises. The aim is to
action and included as a step in planning where have participants performing the strength and bal-
the activities can and will be embedded. It also ance activities without having to consciously
assists participants to generalize the activities to a think about including them in their daily tasks.
variety of tasks and places. Recording how, when, This way, they become habitual.
and where on the LiFE Activity planner is Fleig et al.s (2015) implementation of LiFE
important to clarify steps and to commit to action, with younger women in a group setting particu-
but it is the visualizing and planning that are the larly noted the importance of habit theory and how
key features of this process. Such intentions to using activity and object-based cues were partic-
implement the action and planning will greatly ularly effective in generating action and
increase the chance of carrying out the action. automaticity.
Situational and Environmental Cues Serve Practice and Repetition in the Same Context
as Prompts to Action Practice and repetition is crucial to habit forma-
A planned commitment to a behavioral response tion. Lally and Gardner (2013) outline the stages
occurs within a particular situation and in of habit formed in a similar context each day. So
response to a particular cue. The ability to replace rather that planning too many different contexts,
you might start with squatting (instead of bending ways. If they engage in the planned activities
your back) every time you close a drawer in the and can upgrade over time, they will achieve
bedroom and kitchen. Once habits are formed, this improved balance and function and increased con-
can be generalized to broader contexts such as the dence in mobilizing and in desired activities and
supermarket, the garage, or other places that the will have more protection against future falls.
participant goes. In fact, protection from falls alone, although a
Planning and practice are both critical in major outcome, is not going to be an ongoing
implementing new habits. Participants have to incentive. Other outcomes are needed, such as
plan to do the activity, visualize themselves better balance and function, in order to enhance
doing the activity, and then practice doing the motivation sufciently to adopt and sustain the
activity consciously and repeatedly until it program.
becomes habit. When a new action is performed,
a mental association between situation and action
is created, and repetition reinforces and estab- Applied Theory in Practice
lishes this association in memory.
The innovative LiFE program is different to a
Self-Monitoring, Reinforcement, and Repetition usual exercise program and may require a shift
Participants engage in planning the changes. in thinking or focus for therapists and trainers and
The therapists demonstrate the activities and the participants. Occupational therapists look for
provide opportunity for participants to practice, ways of making tasks easier for their clients or of
self-monitor through planning and recording sheets having them do less. The LiFE program encour-
between sessions, and provide feedback and posi- ages participants to look for ways of doing more
tive reinforcement. To enable habit change, this and seeking out more demanding environments.
approach to exercise needs to be taught over a Physical therapists are more familiar with pre-
period of at least 8 weeks and preferably scriptive programs where dosage is increased by
12 weeks. Therapist support is needed to assist in repetition, weights, or external resistance and
setting session goals initially and then to move to performed in sets at regular times each week.
increasing autonomy so participants are planning, The model is intended to be applied in practice,
setting how, when, and where themselves, and and providing this framework enables the assess-
monitoring their progress. To change habits, there ments, planning, and recording tools as well as the
must be continual repetition and practice. training process be conducted such that they inte-
The power of goal setting, feedback sheets for grate the key elements and features of the model.
monitoring exercise that are acknowledged by the This kind of program requires the participant to
trainer, and other forms of encouragement and spend time implementing the program throughout
self-incentives relative to personal goals cannot their day, and it therefore needs to be tailored,
be overestimated. In resistance training, self- relevant, practical, and functional.
regulation is known to directly contribute to The LiFE approach has been shown to work in
enhanced condence in maintaining performance different settings and provides another choice for
at challenging levels, to using correct form and to a successful fall prevention program with poten-
continual upgrading as one level is mastered tial to maintain function. Further work could elu-
(Winett et al. 2009). This requires cognitive cidate which groups of people an embedded
(knowing what to do), motivational (wanting to approach of balance and strength training would
perform and the condence that you can), and benet the most. In addition, qualitative inquiries
behavioral (being able to do it) factors. would be welcome that can further elucidate the
features and mechanisms of the concepts under-
Experience Functional Outcomes pinning the program which are essential to suc-
Participants gain intrinsic reinforcement for the cessful uptake and long-term sustainability of
performance of the activities in a variety of such programs.
Cross-References Dobek, J. C., White, K. N., & Gunter, K. B. (2007). The

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596 Conflict Management and Aging in the Workplace
Training-related changes in dual-task walking perfor- parties, including individuals, units, departments,
mance of elderly persons with balance impairment: A - and organizations. It involves cognitive and
double-blind, randomized controlled trial. Gait &
Posture, 29(4), 634639. behavioral reactions toward incompatible goals,
Trombetti, A., Hars, M., Herrmann, F. R., Kressig, R. W., competing interest in scarce resources, and inter-
Ferrari, S., & Rizzoli, R. (2011). Effect of music-based ference in goal attainment (Hocker and Wilmot
multitask training on gait, balance, and fall risk in 1991). Depending on ones attitudes, values, and
elderly people: A randomized controlled trial. Archives
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Winett, R., Williams, D., & Davy, B. (2009). Initiating and a threat to ones interests or an opportunity to
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Sports Medicine, 43(2), 114119.
mines whether escalatory or de-escalatory action
should be taken.
Abundance of conict research has provided
Conflict Management and Aging in evidence for the detrimental effects of conict
the Workplace when it is managed poorly. In particular, prior
research has found that workplace conict contrib-
Dannii Y. Yeung1 and Henry C. Y. Ho2 utes to reduced job satisfaction and organizational
1
Department of Applied Social Sciences, commitment, poorer health and well-being, and
City University of Hong Kong, Hong Kong, disruptive behaviors that are costly to employers,
China such as absenteeism and turnover (De Dreu 2011).
2
School of Public Health, University of Hong However, although it is undeniable that conict can
Kong, Hong Kong, China result in a number of negative outcomes, research
from the past two decades shed light on the positive
and constructive benets of conict when it is
Synonyms managed appropriately in the workplace. For
example, workplace conict has been found to
Conict strategies; Conict styles enhance communication, resolve continuing prob-
lems, facilitate team performance, stimulate learn-
ing, and promote creative thinking under the
Definition
condition that the conict is problem-focused,
cooperatively oriented, and involves integrative
Workplace conict emerges when there is a dis-
efforts to achieve optimal solutions (De Dreu
agreement between two or more parties in the orga-
2011). Therefore, effective conict management is
nization or when a person perceives incompatible
crucial to team effectiveness and work productivity.
needs, goals, desires, or ideas with another person
The number of mature workers aged 45 and
(Deutsch 1994). There are two major forms of
above in the labor force has been growing drasti-
conict in the workplace: Interpersonal conict
cally over the past decade, for example, from
takes place when a worker perceives that his/her
34.9% to 42.9% in the United States (US Bureau
valued outcomes are deprived due to interference
of Labor Statistics 2011). The composition of
from the opposing worker, while intergroup conict
labor force becomes more diverse, comprising
arises when a group of workers perceive a depriva-
mature workers from the baby boom cohorts
tion of valued outcomes due to interference from
(19461964) and later cohorts from generations
the opposing group (De Dreu 2011).
X (19651976) and Y (19771992). The presence
of workers from multiple age groups within an
Introduction organization intensies the occurrence of conict
because of differences in work values, work
Conict is inevitable in the workplace as long as ethics, goal orientations, and conict styles
there is social interaction between two or more between younger and older workers.
Conflict Management and Aging in the Workplace 597
In the face of changing demographic trends, collaborating with the opposing party in order to
how conict can be managed effectively is a reach a mutually agreed solution so that the inter-
major concern for many organizations. It is there- ests of both parties are satised. Avoiding strategy
fore a pressing task to identify and unravel the is used when concern for self and others are both
underlying mechanisms of conict in the mature low. This involves neglecting the conict entirely
workforce. By drawing from various areas of to allow the conict to dissipate on its own.
research, valuable insights can be obtained to Compromising strategy is used when concern for C
reveal the inuences of motivational orientation, self and others are both moderate. This involves a
goal orientation, and social identity on conict give and take negotiation so that an intermediate
strategy preferences among younger and older position can be reached.
workers. Effective measures can then be proposed Similar to motivational orientation, another
in light of the conditions that are required for line of research examined goal orientation as the
conict to result in positive outcomes. In the rst underlying determinant of conict behaviors.
section of this entry, the dual concern model According to the theory of cooperation and com-
(Rahim 2011) and the theory of cooperation and petition (Deutsch 1994), goal interdependence,
competition (Deutsch 1994) will be discussed to which is the perception of how goals are related,
identify the major determinants of conict strat- inuences social interaction. Specically, goal
egy in the workplace. The second section will interdependence can be grouped into three cate-
discuss the socioemotional selectivity theory gories: cooperative goals, competitive goals, and
(Carstensen 2006) and the social identity theory independent goals. These three types of goal ori-
(Tajfel and Turner 1986) and review the empirical entation are proposed to have a signicant impact
ndings on age differences in conict manage- on the way conict is handled. For cooperative
ment. Implications and future directions on man- goals, individuals perceive their goals to be posi-
aging the workplace conict will be discussed in tively related to each other so that successful
the concluding section. achievement of ones goal would lead to the suc-
cessfulness of another in reaching his/her goal.
Individuals who are motivated by cooperative
Conflict Management in the Workplace goals would avoid the escalation of conict since
working cooperatively as a group would be more
Working adults responses to conict can yield effective in achieving the most desirable outcome
diverse consequences. According to the dual con- for both parties. In comparison, for competitive
cern model, the ways to deal with interpersonal goals, individuals perceive their goals to be nega-
conict can be categorized into ve styles, includ- tively related to each other; so increasing the
ing obliging, dominating, integrating, avoiding, chances of success for one person would diminish
and compromising (Rahim 2011). The selection the chances of success for another person. Under
of conict styles is determined by ones motiva- this win or lose perspective, conict will most
tional orientation, i.e., the degree of attempts to likely be escalated since individuals are motivated
satisfy concern for self and concern for other to do better than others and behave competitively
parties. In particular, obliging strategy is used in order to ensure that they succeed while
when concern for self is low and concern for others fail. For independent goals, individuals
others is high. This involves meeting the needs perceive their goals to be unrelated to the goals
of the opposing party and giving into his/her of others; so their personal goal attainment is
demands. Dominating strategy is used when con- prioritized, while other peoples goals are irrele-
cern for self is high and concern for others is low. vant to their concerns and efforts. Motivated by an
This involves forcing the opposing party to accept independent orientation of goals, actions are taken
and give into ones personal views and demands. in order to ensure ones personal interests are met,
Integrating strategy is used when concern for self regardless whether the other party is satised
and others are both high. This involves or not.
Age Differences in Conflict Management motivates them to concern for others more than
themselves and to cooperate instead of to com-
Although the dual concern model and the pete, such that they are more likely to use passive
theory of cooperation and competition are prom- strategies such as obliging or avoiding. Assertive
inent in the literature on conict management, strategies such as dominating style are less likely
they generally assume that goals and motivation to be utilized by older workers as these strategies
remain more or less constant over the life span. will prevent them from maximizing positive emo-
Applying these two frameworks to the age- tional experiences. In contrast, younger workers
diversied workforce would lead to the prediction tend to use more assertive strategies to manage
that a workers behavioral responses are deter- conict situations as they focus on knowledge-
mined by his/her motivational or goal orientation, related goals and are concerned for themselves
regardless of his/her age. For example, an older more than others. These speculations are
worker who has high concern for self and low supported by research ndings. For example, in
concern for others would be as likely as a younger a national survey of 1785 working adults in the
worker to prefer the use of dominating strategy. United States, Schieman and Reid (2008) revealed
However, the literature on life span development that among male workers with higher authority,
stresses that older adults shift their goal orienta- younger workers engaged in more aggressive and
tion from knowledge-related goals to emotional competitive conict behaviors than did older
goals when they perceive future time as increas- workers. Similarly, Davis et al. (2009) examined
ingly limited (Carstensen 2006). Therefore, it is behavioral responses toward workplace conict in
doubted whether these two models can fully a sample of 2513 American working adults. This
explain the patterns of conict strategy use in an study demonstrated that both younger and older
age-diversied workforce. workers used activeconstructive strategies such
Socioemotional selectivity theory (SST; as perspective taking or creation of solutions to
Carstensen 2006) can be applied to understand deal with conict incidents at work, though older
conict behaviors of older workers since it pro- workers displayed a greater tendency to utilize
vides a theoretical explanation for age-related passive-avoidant strategies such as yielding or
changes in developmental goals and social behav- adapting.
ior. According to this theory, the way emotion is Past research on conict management showed
regulated is guided by future time perspective, that the selection of conict strategies varies by
which becomes increasingly limited as the person role of the conict partner. For instance, in the
ages. Younger individuals who are likely to per- study measuring conict styles of 1219 managers
ceive an expansive future time prioritize in the United States, Rahim (1986) demonstrated
knowledge-related goals, including knowledge that employees were more likely to use obliging to
acquisition, career advancement, and expansion handle conict with superiors and utilize
of social network. As individuals grow older, compromising with peers. When resolving con-
they are more likely to perceive limited time and ict with subordinates, they tended to use inte-
therefore shift their priority to emotional goals grating as primary styles and avoiding as backup
such that emotionally meaningful experiences styles. Both Lees (1990) and Nguyen and Yangs
are emphasized and valued. Therefore, the (2012) experimental studies further support the
emphasis of emotional goals motivates older indi- inuence of the role of the conict partner in the
viduals to make use of adaptive emotion regula- selection of conict strategies. Specically, there
tory strategies that can maximize positive was a greater tendency to use direct and assertive
emotional experiences, while younger individuals strategies to resolve conict with subordinates,
are less likely to focus on emotion regulation. compromising strategies to deal with peer con-
When applying SST to predict conict styles of ict, and indirect and harmony-preserving strate-
younger and older workers, it is expected that gies to handle conict with supervisors. However,
older workers emphasis of emotional goals these studies did not take age into consideration in
the examination of conict behaviors. To address competition and social conict, causing a higher
the limitation of the prior research, Yeung likeliness for opposing intergroup relations to be
et al. (2015) measured behavioral responses to formed (Dencker et al. 2007).
workplace conict in a sample of 280 Hong While the social identity theory makes general
Kong Chinese managerial and executive assumptions about the behavioral responses of
employees aged between 22 and 66 years. The conict, ve types of conict strategy can be
participants were asked to recall a personal work- predicted by integrating with the dual concern C
place conict experience that happened in the past model (Haslam 2004). According to the integrated
3 months. They also reported their goal orienta- model of conict, the two axes of the dual concern
tions and conict responses during the conict model, concern for self and concern for others,
situation. Results of this study revealed that rela- can be reconceptualized as the salience of sub-
tive to younger employees, older employees uti- group identity and the salience of superordinate
lized more avoiding to handle conicts with identity, respectively. Salience of subgroup iden-
supervisors and less dominating with subordi- tity refers to ones social identication with a
nates. These age differences could be explained subgroup (younger or older workers), while
by the higher level of cooperative goals held by salience of superordinate identity refers to ones
the older workers relative to their younger coun- social identication with a superordinate group
terparts, supporting the proposition of SST on the (employees of an organization). This reconcep-
age-related variation in goal orientation. tualization is possible because concern for self is
In addition to the inuences of motivational consistent with the behavioral intentions of sub-
orientation and goal orientation reviewed above, group identity, while concern for others is consis-
ones social identity can also affect the selection tent with the behavioral intentions of
of conict strategies, especially during intergroup superordinate identity. As presented in Fig. 1,
conict. The social identity theory, which was conict between younger and older workers is
developed to provide theoretical contributions escalated when dominating strategy is utilized by
toward social phenomena such as intergroup rela- those who have a salient age group identity. In
tions, stereotyping, and group processes (Tajfel and order for the conict to be reconciled, social iden-
Turner 1986), is suitable to explain the intergroup tity must be salient on both subgroup and super-
dynamics of an age-diversied workforce. Social ordinate dimensions so that an integrative solution
identity is dened as an individuals self-concept can be reached.
based on his/her perceived membership of relevant To test the effect of social identity on conict
social groups that are of value and emotional sig- behaviors, Ho (2014) examined the relationships
nicance to him/her. In a conict involving a youn- among social identity, goal orientation, and con-
ger worker and an older worker, the individuals ict strategies in a cross-sectional survey among
may identify themselves as members of the youn- 380 clerical workers in Hong Kong. Two hypo-
ger or older age group, which subsequently inu- thetical scenarios involving conict with a youn-
ences their thoughts, feelings, and behaviors ger worker and an older worker were used to
toward the intergroup conict (De Dreu 2011). stimulate workplace conict. In response to each
Members of an in-group are motivated to enhance conict scenario, participants were asked to
positive distinctiveness compared with the respond to a questionnaire on how they perceived
out-group members. This in-groupout-group their goals as related to the opposing worker and
bias is commonly manifested in intergroup conict the type of conict strategies that they prefer to
where members of opposing parties utilize strate- utilize under the circumstances. Results of the
gies that favor the in-group and denunciate the moderated mediation models revealed that orga-
out-group. Intergroup conict is expected to be nizational and age group identities had a com-
most severe in organizations with age diversity bined inuence on conict strategies through
and distinct group boundaries between younger goal orientation, but the pattern differed by the
and older workers, as this can foster intergroup age of the opposing party. In the conict with a
Conflict Management
High
and Aging in the
Salience of superordinate identity

Workplace, Fig. 1 The Obliging Integrating
integrated model of conict
(Adapted from Haslam
2004)
Compromising
Avoiding Dominating
Low
Low High
Salience of subgroup identity
younger worker, individuals were more likely to ideology, it is a virtue to respect senior adults and
use integrating when both of their organizational sacrice ones own interests to establish and
and age group identities were high. Individuals maintain relationships with older people. There-
who were identied as members of the organiza- fore, during conict with older workers, ones
tion but had moderate age group identication cooperative intention is a major determining fac-
were more likely to use compromising toward tor of how the conict should be managed. Nev-
the younger worker. Furthermore, organizational ertheless, consistent with the ndings of the
identication was related to the use of obliging literature on intergroup conict, in-group mem-
toward the younger worker when age group dif- bership can diminish conict of interest and facil-
ferentiations were minimal. It was also found that itate cooperation between opposing parties.
these relationships could be explained by the low
level of independent goals held by the Implications for Managing an Age-Diversified
respondents. Workforce
In the conict with an older worker, individuals In general, the literature on conict management
were more likely to use integrating strategy when in the workplace holds the assumption that the
their organizational and age group identities were same set of predictive factors of conict behaviors
high. Individuals who were identied as members is applicable to all working adults, regardless of
of the organization but had minimal age group their age. However, as reviewed above, goal ori-
identication were more likely to use obliging entations change as a person grows older,
strategy toward the older worker. Furthermore, suggesting that the way older workers deal with
organizational identication was related to the use conict incidents may not be the same as those
of compromising strategy toward the older worker utilized by younger workers. Even though
when the level of age group differentiations was researchers can infer from past aging research on
moderate. These relationships could be explained interpersonal tensions to predict conict
by the high level of cooperative goals held by the responses of older workers, these studies focus
respondents. largely on conicts with family members and
Hos (2014) study suggests that social identity close friends. Therefore, it remained unclear
contributes more to independent goal orientation whether younger and older workers react to work-
with younger workers and cooperative goal orien- place conict differently, as it usually involves
tation with older workers. This difference in goal coworkers and clients who are not perceived as
orientation when the age of the opposing party emotionally close as family members and close
differs may be explained by values deeply rooted friends. The ndings of our research tentatively
in the Chinese culture. According to Confucius suggest that similar to other nonwork conicts,
older workers utilize more passive strategies (e.g., reduced job satisfaction (De Dreu and Dijkstra
avoiding) and fewer destructive strategies (e.g., 2004). It is questioned whether older workers
dominating) to manage workplace tensions than greater preference for avoiding strategies is asso-
do younger workers (Yeung et al. 2015). Putting ciated with poorer work outcomes and psycholog-
research ndings from the literatures on life span ical well-being. However, according to SST, older
development and conict management together, it adults use of passive strategies is indeed consis-
seems older individuals manage daily interpersonal tent with their developmental goal orientation that C
conicts in a similar way, regardless of the context. emphasizes on emotional goals and interpersonal
This proposition awaits future investigation to closeness (Carstensen 2006). Therefore, greater
explicitly compare within-individual use of conict use of passive strategies should contribute posi-
strategies and goal orientations across different life tively to their well-being or have a less harmful
domains to conrm whether the age-related pattern effect. Cross-sectional studies of Yeung and Fung
of conict management is context-specic or not. (2012) and Yeung et al. (2015) have demonstrated
In addition, by integrating the dual concern model that the use of emotional suppression and
and social identity theory, Ho (2014) further dem- avoiding strategies is benecial to the older
onstrated that social identity can inuence goal workers by improving their sales productivity
orientation, which would in turn inuence ones and lowering the level of negative emotions and
preference for conict strategy. Specically, interpersonal tensions. These ndings imply that
workers with higher organizational and age group the use of passive strategies is not always harmful
identities tend to hold more cooperative goals and to working adults but depends largely on the age
therefore use more integrating strategies to handle of the users. The long-term benecial effects of
conicts with an older conict partner. Future passive strategies on older workers though await
research should include the assessment of social future investigation.
identity to accurately predict conict strategies of
working adults.
The majority of conict management research
Conclusion
was conducted on Western populations. Past
cross-cultural studies on conict management
Age differences in conict management are
suggest that Chinese employees, in general, are
observed, which can be explained by age-related
more likely to utilize non-confrontational strate-
changes in goal orientation and social identity.
gies (such as avoiding or compromising) than
their Western counterparts (Bazerman et al.
2000). Yeung et al.s (2015) study demonstrated Acknowledgments Both Ho (2014) and Yeung et al.
a robust age effect, even in a sample of working (2015) measured conict strategies by the Rahim Organi-
zational Conict Inventory II (Form C), which was used
adults with cultural norms of non-confrontational
with permission from the # Center for Advanced Studies
conict approaches. Older Chinese workers in Management. Further use or reproduction of the instru-
displayed higher level of avoiding strategies ment without written permission is prohibited.
when handling conicts with supervisors than
did younger Chinese workers. Future studies
should replicate this age effect in a cross-cultural Cross-References
comparison study by recruiting both Western and
Asian working adults of a wide age range. Socioemotional Selectivity Theory
In addition to the examination of age variation
in conict management, future studies should also
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U.S. Bureau of Labor Statistics. (2011, January). Employ- the CALTAP model draws on lifespan develop-
ment and earnings online. Retrieved from http://www. mental principles and social contexts (both current
census.gov/compendia/statab/2012/tables/12s0586.xls
and historical and at a cultural and cohort level).
Yeung, D. Y., & Fung, H. H. (2012). Impacts of suppres-
sion on emotional responses and performance out- The model has also been designed to be
comes: An experience sampling study in younger and transtheoretical in nature rather than being
Contextual Adult Life Span Theory for Adapting Psychotherapy (CALTAP) and Clinical Geropsychology 603
wedded to any one particular type of therapy (e.g., The CALTAP model also encourages consid-
cognitive behavioral therapy, interpersonal psy- eration of both strengths and challenges within
chotherapy, etc.). The CALTAP model therefore individual (e.g., maturation, presenting problem),
offers the opportunity for the clinician to explore environmental (e.g., context), and social contexts
the case history of the client at a broad level and (e.g., culture, cohort). The focus of this model is
then determine the best therapeutic approach to on exploration and adaptation, encouraging the
meet the goals of therapy. psychologist to adapt to the needs of the client C
Drawing on Knights (1996) contextual, cohort- (based on the information they gather) rather than
based, maturity-specic challenge (CCMSC) having the client adapt to the psychotherapy or the
model of psychotherapy, the CALTAP model elab- underlying beliefs of the therapist. At its broadest
orates on the CCMSC model by outlining a more level, the model considers both intra- and
integrated approach to psychotherapy with older interindividual factors as they relate to the client.
adults and adding consideration of the importance The model also encourages consideration of inter-
and relevance of culture (Knight and Lee 2008). personal, intergenerational, and intercultural ele-
CALTAP identies the following factors for con- ments. Therefore, the CALTAP model is a tool
sideration in psychotherapy with older adults: that encourages a structured approach to gathering
context, culture, and cohort. The CALTAP model information about the client, which is multi-
(like the CCMSC model) is designed to be factorial in nature and considers the client from a
transtheoretical; that is, the model is not linked to number of different perspectives (e.g., interper-
any one particular approach to therapy and as such sonal, intergenerational, and intercultural). Such
may be used across approaches to psychotherapy. a comprehensive method of collecting data guides
Regardless of therapeutic focus, the model has the therapy goals and offers both the therapist and the
goal of increasing the therapists understanding of client a means of understanding who the client is
the client, outside the context of any one particular and what they bring to therapy.
type of therapy, by encouraging the importance of
understanding and incorporating the depth and
breadth of contextual inuences (Knight and The Elements of the CALTAP Model
Poon 2008). Having such an understanding not
only guides case conceptualization but provides a The Element of Context
frame for selecting and adapting therapeutic The inner circle of the model (see Fig. 1) focuses
modalities, the use of clients idiosyncratic on the individual and immediate context. The
strengths and challenges, and choice of therapeutic central diagram (i.e., positive maturation,
method which avoids reliance on stereotypical negative maturation, specic challenges,
beliefs which can be subtle in nature and insidious presenting problem, therapeutic relationship)
in effect. For example, while older adults are more encapsulates intraindividual factors, while the
likely to experience chronic illness, some cope domain of context within which this central
better with chronic illness than others. The diagram sits considers both interindividual and
CALTAP model therefore encourages the interpersonal factors. This portion of the model
clinician to explore the clients experience of therefore highlights the importance of consider-
chronic illness both with respect to their current ation of the elements that might be broadly framed
circumstances and to current and historical as the everyday context in which the client lives,
contextual factors that may be contributing to including personal, environmental, and social fac-
their ability to cope. A stereotypical mind-set with- tors. With regard to personal factors, consider-
out guidance from a model such as CALTAP, on ation is given to what the clients themselves
the other hand, might assume that all older adults bring to therapy and the therapeutic relationship,
have difculty coping with chronic illness, as well as the interactions between those elements,
resulting in treatment missing the most appropriate which are captured via the central diagram within
therapeutic goal(s). the center circle. In considering environmental
Contextual Adult Life

Span Theory for CULTURE
Adapting Psychotherapy COHORT
(CALTAP) and Clinical
Geropsychology, CONTEXT
Fig. 1 Contextual Adult
Lifespan Theory for
Adapting Psychotherapy Positive Negative
(CALTAP) model Maturation Maturation
Specific Presenting
Chanllenges Problem
Therapeutic
Relationship
and social factors, the focus is on the context in unstructured learning, that result in what can be
which the individual currently lives and socially summarized as maturation in cognition. Emo-
engages, including such things as housing and tional complexity refers to the notion that as peo-
living arrangements, the medical environments ple age, they become better able to regulate their
in which they engage, recreational settings, inter- emotions (Mather and Carstensen 2005) and also
personal environments, and family and social set- experience more complex, as well as less intense,
tings, for example. emotions than those perceived to be experienced
The maturation elements capture lifespan by younger adults (Ong and Bergeman 2004).
developmental processes, those positive and neg- Negative maturation, on the other hand, encom-
ative changes that are posited to occur naturally as passes the broad areas of both physical decline
people age. Positive maturation reects gains with and cognitive decline. Physical decline encom-
increasing age, and negative maturation includes passes the idea that as people age, their body and
decrements in functioning with age, along with bodily functions tend to become less efcient and
those things that people are more at risk of with less effective, and the risk of illness increases.
increasing age (e.g., reduced processing speed, Variability in decline is inuenced by lifestyle
increased risk of illness, etc.). The broad and choices of the individual as well as the normative
generic nature of the model also allows for con- changes associated with aging. Cognitive decline
sideration of variations in developmental pro- refers to the normative changes in cognition as the
cesses, acknowledging the fact that while the individual ages. Such changes include decrements
lifespan developmental literature offers insight in processing speed, attention, and memory (e.g.,
into normative developmental processes, individ- Kemper et al. 2003; Light 2000; Salthouse and
ual differences in development can and do occur. Ferrer-Caja 2003). As with physical decline, and
Positive maturation refers to the elements of all elements of maturation, the level of decline
cognitive and emotional complexity (Knight and and/or development (i.e., negative maturation
Poon 2008). Cognitive complexity encompasses and positive maturation) will, in part at least,
the accumulation of knowledge and skills across a depend on the life that the individual has led and
lifetime, as a result of both structured and the genetic hand they have been dealt.
The CALTAP model structures a holistic form relationships, including with a therapist,
approach, neglecting neither the positive nor the and will shape the therapists ability to form a
negative aspects of developmental processes at good rapport with the older client. The direction
an individual level in order to build understand- of the arrows and links they create among the
ing of the client within a therapeutic context. elements within the center circle make intuitive
Specic challenges refer to life circum- and clinical sense, although such relationships
stances that challenge the individual and therefore have not been established via research specically C
can impact on the sense of self and the sense of focused on the CALTAP model. One might need
well-being. Examples of such challenges can to consider at the very least, for example, whether
include chronic illness, disability, and changes in bidirectional arrows should exist between spe-
interpersonal functioning (e.g., dealing with grief, cic challenges and therapeutic relationship
caregiving, role changes, etc.). To illustrate, with and between specic challenges and
regard to chronic illness and disability, not all presenting problem. The bidirectional arrow
older adults will develop such conditions, and between positive maturation and negative mat-
how much of a challenge such factors are to the uration highlights the interrelationship between
individual will depend on a number of elements, these elements as coexisting within lifespan
not the least of which being the severity of the development.
illness or disability, the coping ability of the indi- As a group (i.e., the central portion of the
vidual, and the support available. Grief is another diagram), the aforementioned elements are
example of a specic challenge, which may not located within the center circle labeled context.
only cause the person to think about his or her The construct of context itself looks to capture
own existence but can also impact on psychoso- details of the settings within which older adults
cial functioning. Length and intensity of relation- currently engage, including the environments in
ship, manner of death, coping skills, and support which they live, work, and play. It therefore looks
all play a role in how well the individual might to emphasize consideration of what elements of
cope with the challenge of grief. Specic chal- the individuals living arrangements, work or
lenges also include role changes such as caregiv- volunteer commitments, and socializing (at
ing. Older adult caregivers can be frail and ill professional and personal levels) might be rele-
themselves; they may lack support or experience vant to the presenting problem and therapeutic
emotional distress as a result of the changes in intervention choices.
their partner and themselves. With regard to the Context is an apt name for this central por-
challenges that role changes may create, tradition of the model given that exploration of such
tional partner roles can be challenged when the elements provides the psychotherapist with an
person who always saw themselves as the care- appreciation of the immediate context within
giver becomes the care receiver. Like the elements which the client both exists and presents. One of
of maturation, there is no clear formula or tem- the key strengths of this portion of the model then
plate here, which is considered a strength of the is to discourage stereotypical beliefs about the
CALTAP model as it encourages consideration of older adult and call attention to both environmen-
the individual, in his or her own context and tal and intraindividual inuences as a rm basis
specic circumstances. upon which to begin effectively meeting the ther-
As illustrated in the central portion of the dia- apeutic needs of the individual client. However,
gram via the arrow congurations, the CALTAP the positioning of the central portion of the dia-
model also highlights that the elements of posi- gram (which focuses on intraindividual factors)
tive maturation, negative maturation, and specically within context (which focuses on
specic challenges each play a role in shaping interindividual factors) can be confusing since
the therapeutic relationship as well as the intuitively it makes sense to look at each of
presenting problem. An individuals context those factors separately outside the realms of
will necessarily impact on his or her ability to such a model. It may therefore be benecial for
the clinician to think of the central diagram and overarching qualities assumed to be characteristic
context as two separate elements, rather than as of a particular population rather than seeing
one embedded within the other. clearly the qualities of the individual. Clinicians
are encouraged to avoid pigeonholing their clients
The Elements of Cohort and Culture within one popularized cohort by using infor-
Moving out from the center circle, cohort and mation about one fact in the context. Consider-
culture form the outer ring of the model and ation should also be given, therefore, to the
represent consideration of interindividual factors. potential areas of inuence within the cohort por-
This is a change from the rst iteration of the tion of the model, which may include such things
CALTAP model (Knight and Lee 2008), where as intellectual abilities, education level, personal-
the two elements were initially presented as sepa- ity development, historical experiences, norms,
rate rings. The signicance of the two elements and values. As such, the cohort inuences are
now being encapsulated within the one ring rep- based primarily on life experiences and the impact
resents a recognition by the authors that, realisti- those experiences have on the development of the
cally, cohort and culture are inseparable, with each individual.
having an effect on the other, and so now present More specically, cohort encourages the psy-
them together (Knight and Poon 2008). While the chologist to explore and gain an understanding of
illustration of the model does not highlight this the older adults sense of self, which has been
point, consideration of both historical and current developing over a lifetime. As previously men-
contextual factors for cohort and culture is tioned, consideration should be given to both the
encouraged. historical context and the current context in order
to understand where the older adult has come
Cohort from and where she or he is now. Cohort inu-
At a population level, cohort refers to portions ences are historical in nature, which act to build
(sometimes arbitrarily determined) of the popula- the individual into who they are today and how
tion thought to share common characteristics as a they interpret their world. A key implication of the
result of what might be termed shared world expe- cohort portion of the model is that many of the
riences. Knight and Lee dene cohort, specically distinctions that can be made between young peo-
in relation to the CALTAP model, as a group of ple and older people at any point in time may be
people, often determined based on when a person due to cohort inuences and the sociohistorical
was born, who are therefore assumed to have been context in which the individual became an adult
. . .socialized into certain abilities, beliefs, atti- rather than developmental changes due to aging or
tudes, and personality dimensions, which remains of being at different points in the lifespan. Recent
relatively stable with age and distinguishes the discussions regarding the CALTAP model have
group from other cohorts (Knight and Lee made it clear that the model is also seen as useful
2008, p. 61). For example, an individual born in terms of helping clients understand their own
between the years of 1946 and 1965 is dened aging processes and the meaning of variations
as belonging to the baby boomer cohort, a group between themselves and younger family members
of people born in the Western world after World as caused at least partially by differences in cohort
War II, when conception rates were high with the rather than age (Knight and Pachana 2015).
arrival of peace. Slight variations in denition can
occur depending on, for example, in which coun- Culture
try the individual was born. Further, Knight and The nal element of the CALTAP model is cul-
Lees denition implies that to think of someone ture, which Knight and Poon (2008) describe as
as belonging to a larger cohort such as baby twofold, with variations in both cultural
boomers may risk stereotyping the individual by values and beliefs, as well as ethnic and racial
characterizing the client in terms of the considerations, being important considerations.
These factors contribute to not only who the cli- The importance of this is that formulation models
ents are but also how others treat them, how the (i.e., models for conceptualizing a clients case in
clients interpret psychological distress, and their order to guide treatment focus) for specic types
willingness to seek assistance. of therapy often neglect such factors, providing
Knight and Lee (2008) offer a denition of instead only a snapshot of the client as applicable
culture that encompasses the idea of the individual to the needs of the therapeutic approach
taking on group characteristics via the process of being used. Contextual factors, however, are C
socialization, expressed as customs, language, an important addition in understanding how
beliefs, and behaviors. The element of culture to best apply therapy to the case of the
highlights the importance of interpreting each cli- individual client. The CALTAP model therefore
ent in the context of her or his own cultural exis- encourages consideration of both the forest and
tence, thus refraining from relying on ill-informed the trees.
or stereotypical beliefs when it comes to exploring The breadth of scope of the model, however, is
the element of culture with the client. Assump- also one of its limitations. There is comfort in
tions about culture from such concrete factors as having small, targeted goals as can be established
skin color and general appearance miss important from formulation models associated with specic
factual information with regard to how the client types of therapy. The CALTAP model, on the
actually interprets themselves under the banner of other hand, looks to incorporate much more
culture. data, which can lead to lack of clarity with regard
Also encouraged is the exploration of the cul- to establishing the goals of therapy. However, by
tural beliefs toward older adults within the clients exploring the elements of the CALTAP model
own environment. The model therefore also with the client, the clinician has the opportunity
encourages consideration of culture from two per- to assist the client in broadening their understand-
spectives, that of the client and that of those ing of their own context, which may in fact help
around them. The importance of this consider- provide for the development of more nuanced
ation is that it helps to determine the clients goals.
place within her or his environment, potentially The CALTAP model recently was explored as
highlighting such things as the availability of sup- a useful tool for consideration within the cognitive
port and the degree of respect (or place they hold) assessment context as well (Knight and Pachana
within the particular environment. As with all the 2015). Knight and Pachana (2015) expand on the
elements of the CALTAP model, such in-depth models utility by highlighting its relevance
considerations highlight the need to have an within the cognitive assessment domain. The
understanding of the individual beyond stereotyp- authors encourage clinicians to become similarly
ical beliefs, one that species the individual aware of the depth and breadth of the clients
within the heterogeneous older adult population individual context given that such knowledge
as a guide toward appropriate and effective treat- contributes detail and richness to the data avail-
ment decisions. able in the assessment arena, as well as inuenc-
ing assessment decisions, thereby improving
validity overall and allowing for more targeted
Summary assessment choices and more individualized rec-
ommendation strategies.
As a transtheoretical model, CALTAP offers the The CALTAP model encourages psychologists
psychotherapist the ability to develop an to consider the range of contexts within which the
understanding of the individual that can assist in older adult client presents at the level of the indi-
guiding therapeutic approach by focusing the vidual, offering a transtheoretical tool to assist in
clinicians attention on both intra- and individualizing therapy and to help both the client
interindividual factors of relevance. and the psychotherapist understand the intra- and
608 Creative Aging, Drawing on the Arts to Enhance Healthy Aging
interindividual factors of relevance to the

presenting problem. Authors of the model primar- Creative Aging, Drawing on the Arts
ily leave the decision of how to use the model in to Enhance Healthy Aging
practice up to the individual clinician although the
model is intended to guide more than the intake Andrzej Klimczuk
interview. CALTAP was designed as a tool to Warsaw School of Economics, Warsaw, Poland
guide case conceptualization and as a broader
framework that can guide assessment, selection,
and adaptation of therapeutic approaches and Definitions
identify relevant factors for assessing outcomes.
The term creative aging, in the broadest sense,
describes an aging policy idea that focuses on
highlighting the creativity of older adults in
Cross-References order to prepare individuals and communities to
manage old age. Programs focus on the evolution
Interpersonal Psychotherapy of creativity over the lifespan and aim to provide
meaningful participatory engagement, especially
References through the arts.
Kemper, S., Herman, R. E., & Lian, C. H.-T. (2003). The

costs of doing two things at once for young and older A General History of the Creative Aging
adults: Talking while walking, nger tapping and
ignoring speech or noise. Psychology and Aging, 18,
Movement and Best Practices
181192.
Knight, B. G. (1996). Psychotherapy with older adults The history of professionally led creative aging
(2nd ed.). London: Sage. programs may be traced back to the origins of the
Knight, B. G., & Lee, L. O. (2008). Contextual adult
lifespan theory for adapting psychotherapy. In
constructs of successful aging and healthy aging.
K. Laidlaw & B. Knight (Eds.), Handbook of emotional These gerontological concepts were developed in
disorders in later life: Assessment and treatment the 1960s in opposition to the prevailing construct
(pp. 5988). Oxford, UK: Oxford University Press. at that time, namely disengagement theory. At the
Knight, B. G., & Pachana, N. A. (2015). Psychological
assessment and therapy with older adults. Oxford, UK:
same time, aging interest groups emerged which
Oxford University Press. promoted cultural and lifestyle issues for older
Knight, B. G., & Poon, C. Y. M. (2008). The socio-cultural adults.
context in understanding older adults: Contextual adult Some of the well-known creative aging pro-
lifespan theory for adapting psychotherapy. In B. Woods
& L. Clare (Eds.), Handbook of the clinical psychology
grams started in the 1970s in the United States
of aging (pp. 439456). West Sussex: Wiley. (USA) with combining art and activities for older
Light, L. L. (2000). Memory changes in adulthood. In adults. These programs were led by professional
S. H. Qualls & N. Abeles (Eds.), Psychology and the artists, such as Susan Perlstein (the founder of
ageing revolution: How we adapt to longer life
(pp. 7397). Washington, DC: American Psychological
Elders Share the Arts) and Liz Lerman (the foun-
Association. der of the Dance Exchange). Also, organizations
Mather, M., & Carstensen, L. L. (2005). Ageing and moti- such as the Society for the Arts in Healthcare,
vated cognition: The positivity effect in attention and founded in 1990, and Generations United,
memory. Trends in Cognitive Science, 9, 496502.
Ong, A. D., & Bergeman, C. S. (2004). The complexity of
established in 1986, began various activities and
emotions in later life. Journals of Gerontology. programs related to the creativity of older adults in
Series B, Psychological Sciences and Social Sciences, the context of health care, intergenerational pro-
59, 117122. grams, and public policies.
Salthouse, T. A., & Ferrer-Caja, E. (2003). What needs to
be explained to account for age-related effects on mul-
Cutler (2009) describes the creative aging
tiple cognitive variables? Psychology and Aging, 18, movement also emerging in Europe in the 1970s.
91110. However, at that time similar early initiatives
Creative Aging, Drawing on the Arts to Enhance Healthy Aging 609
related to the arts and aging were usually workshops for seniors and tend to be delivered
described as part of the community arts move- by professionals in diverse settings (e.g., long-
ment. Examples in the United Kingdom term care facilities, public libraries, senior centers,
(UK) include the Plymouth Arts Centre and com- and non-governmental organizations that focus on
munity arts funding initiatives of the Calouste education, culture, heritage, and socialization).
Gulbenkian UK Trust. More specialized programs Creative aging programs may also be consid-
emerged in the 1980s, such as the Age Exchange ered as examples of new healthcare services that C
(a center of reminiscence and intergenerational deliver enjoyable and fun activities in safe envi-
arts). Moreover, in Europe various initiatives ronments. As Hanna and Perlstein (2008) argue,
were (and still are) established through the Uni- creative aging may also provide a new perspective
versities of the Third Age movement, such as that encourages and promotes the potential
courses, workshops, and debates focused on the (capital) of older adults rather than emphasizing
arts and humanities. their problems. To achieve this, creative aging
In recent years, the creative aging movement programs should be aimed at increasing morale
became widespread around the world. There is a and passing on a legacy to younger and future
growing diversity of activities, but the arts remain generations of older adults as a means of sustain-
at the core of initiatives. In the USA in 2001, Gene ing the culture (a cultural and symbolic capital),
Cohen and Susan Perlstein established one of the improving physical health (human capital), and
best-known such organizations, the National Cen- building relationships (social capital). In other
ter for Creative Aging (NCCA) by building a words, such programs provide the basis to foster
partnership with the National Council on Aging the empowerment of older adults by the promo-
and the National Endowment for the Arts (NEA), tion of emancipation or social justice, democratic
in afliation with George Washington University. citizenship, and human capital (Payne 2012).
The organization advocates on issues concerning
the arts and aging, promotes combining of the arts
and aging policy, organizes events and confer- Creative Caregiving
ences, provides training and e-learning courses
and toolkits, and maintains databases of resources Creative caregiving techniques and exercises
and best practices. mainly draw on creative and art therapies to
enhance the quality of life in both older people
and caregivers, the latter including both informal
Creative Aging Programs (e.g., family) and professional caregivers
(NCCA Creative Caregiving Guide 2016). In
Creative aging programs aim to foster older per- addition to the arts, creative approaches can
sons social engagement, skills, and opportunities draw on culture, science, business, and technol-
for creative expression (Creative Aging Toolkit ogy. Artistic creativity, for example, involves
for Public Libraries (2016)). Three forms of cre- exploring new ways of interpreting the world
ative aging practice include: (1) health and well- that can produce texts, sounds, and images in
ness programs (e.g., use of art therapies in response to stimulating thought-provoking ques-
institutionalized settings for older adults with tions. Creativity can also result from innovation
dementia); (2) community engagement programs and design. The innovation may involve the trans-
that focus on civic involvement of older people lation of ideas into new products, services, man-
through the arts (e.g., volunteering, mentoring, agement models, or social processes. The design
and intergenerational programs); and (3) lifelong includes processes integrating creativity and inno-
learning (LLL) programs that aim to improve the vation, leading to useful solutions in a caregiving
quality of life of older adults by building skills context. Creative caregiving is congruent with
during various courses. Thus, creative aging pro- older-person-centered and integrated care pro-
grams are not simply synonymous with art moted by the World Health Organization (2015).
610 Creative Aging, Drawing on the Arts to Enhance Healthy Aging
Creative Aging Policy productivity tests that usually lead to the conclu-
sion that with age, people tend to lose their crea-
Creative aging policy can be used both as theories tive abilities. This model has been criticized for
(descriptive models) and as ideologies or strate- excessive attention to results from standardized
gies (normative models) that provide frameworks tests of creativity, which may not tap creativity
for constructing positive responses to population as it is expressed throughout the lifespan. In con-
aging. This form of policy is typically considered trast, the lifespan developmental model (also
in the context of other aging policies ideas such as known as the continuity model) relies more on
successful aging, productive aging, healthy aging, the qualitative measurement of creativity, with a
active aging, positive aging, aging in place, and greater focus on mechanisms leading to growth,
intergenerational policy. change, and the evolution of creativity over the
Creative aging policy aims to engage older lifespan (Reed 2005).
adults in creative activity and involves a shift Research conducted by Gene D. Cohen is con-
away from highlighting problems of aging to pro- sidered groundbreaking in the eld of arts and
moting the potential of older adults (Klimczuk aging. Cohen has focused on the development of
2015). It focuses on providing opportunities, tech- the brain in old age and its relation to creativity.
nological innovations (gerontechnologies), and His studies explore the hypothesis that
social innovations for all older adults, not only maintaining a high level of creativity in old age
those who have had careers within cultural and requires not only appropriate external stimulation
creative industries. It supports a creative approach but also the inner need to solve increasingly com-
to leisure time in old age, regardless of whether plex problems with the use of creativity, and that
the focus is on professional or amateur activities. this leads to positive health outcomes.
There is a complementarity of creative aging According to Cohen (2009), creativity in old
policy to the ofcial United Nations active aging age may be presented as the creativity equation
policy and thus to the related concept of healthy (C = me2). Here creativity (C) may be seen as the
aging, both referred to in the 2002 Madrid Inter- result of ones mass (m) of knowledge, which is
national Plan of Action on Ageing (MIPAA). multiplied by the effects of ones two dimensions
A glocalization of policy ideas, that is, translat- of experience (e2). These dimensions include an
ing and implementing general policy ideas from individual inner world experience (emotions and
international organizations policies to the local personality), and the outer world (experience and
level (cities and communities) and regional level, wisdom). From this perspective, aging has a pos-
is also implied. itive inuence on creativity due to the accumula-
tion of knowledge and experience. Thus, the
aging brain is still developing with new experi-
Selected Theories and Research ences and learning (Cohen 2001, 2005). These
on Creativity and Aging activities lead to the creation of new brain cells
between our early 50s and late 70s. Thus, with
There are two contrasting frameworks the peak proper stimulation and good health, further intel-
and decline model and the lifespan develop- lectual development is possible. Moreover, with
mental model that provide frameworks to age, brain functioning becomes more balanced in
understand creative aging as a means of the areas responsible for emotions, and the brains
constructing positive responses to population two hemispheres are more evenly used. These
aging. changes allow older people to be more creative.
The peak and decline model is based on the Cohen and his team (2006) carried out a study
Western cultural denitions of creativity that of the impact of community-based cultural pro-
highlight production, quantity, and novelty grams on the physical health, mental health, and
(Levy and Langer 1999). These features can be social activities of older people (aged 65 and
evaluated through use of psychometric and older). The research sample consisted of 166
Creative Aging, Drawing on the Arts to Enhance Healthy Aging 611
older people from the region of Washington, DC. care settings may lead to increased quality of life for
Participants were divided into two groups an staff, improved retention of personnel, facilitation
intervention (chorale program) and comparison of points of communication for visitors, increased
(usual activity) group. These groups were assisted social cohesion, the development of volunteering,
by researchers at the beginning of the project, after and the establishment of new programs of activi-
12 months, and after 24 months. The programs ties. Finally, benets may also accrue to the general
included artistic activities such as painting, public. Positive outcomes include here the C
ceramics, dance, music, poetry, theater, and promotion of intergenerational solidarity, the devel-
talks on material culture and spoken histories. opment of positive older role models, the establish-
The research demonstrated that the cultural pro- ment of cooperation between different sectors of
gram participants reported a better overall degree society, and the provision of new strategies to reach
of physical health, fewer doctor visits, less medi- diverse groups of older adults.
cation usage, fewer falls, and fewer other health
problems than the comparison group. Advantages
in sociological terms were primarily better Conclusion and Future Directions
morale, increased activity, and less loneliness
than the control group. In other words, the inter- In recent years, the dissemination of creative
vention helped in reducing the risk factors that aging practices has appeared across the globe
may increase the necessity for long-term care (Bloom 2014). However, at this point, barriers
services. This is potentially due to an increase in and challenges remain for the development of
a sense of control and meaningful social creative aging programs. These observations
engagement. may be at the same time considered as potential
directions for further research.
One set of challenges concerns insufcient
Potential Personal and Societal Benefits dissemination among the public and healthcare
of Creative Aging professionals about outcomes from arts and
aging programs. In addition, there has been only
The literature about the arts and creative aging pro- limited development of standardized techniques
grams provides various examples of effects that for evaluating the use of the arts in healthcare
may be achieved by the arts and creative expression programs and identifying best practices (e.g.,
intervention programs. For example, Moloney Thomas and Lyles 2007). Use of the knowledge
(2006) and Ehlert et al. (2010) proposed several and skills of professional artists in engaging with
groups of beneciaries from such programs. First, older adults within the community and healthcare
older adults themselves may achieve personal ful- settings remains limited. Aside from creative
llment, a sense of meaning, new competencies to agings greatest advocate, Gene Cohen, there is
cope with daily challenges, new social relation- limited promotion of knowledge about the bene-
ships, and opportunities for maintaining and ts of creative aging. There is a need for greater
improving health. Second, organizations that are research efforts and a common language
developing and implementing programs, particu- concerning creative aging. Finally, funding for
larly within the arts sector, may nd benets includ- interdisciplinary strategies in healthcare regarding
ing engagement of older artists, access to new the arts remains scarce.
audiences, the development of learning communi-
ties, and changes in program funding opportunities.
Third, the health sector may benet through Cross-References
increased health benets for older adults, such as
fewer visits to doctors and lower levels of depres- Age-Friendly Communities
sion (Castora-Binkley et al. 2010). Moreover, the Gerontechnology
engagement of older adults in creative activities in Healthy Aging
612 Cross-Cultural Aging
Leisure Activities in Later Life Payne, M. (2012). Citizenship social work with older peo-
Music Therapy, Applications in Geropsychology ple. Chicago: Lyceum Books.
Reed, I. C. (2005). Creativity: Self-perceptions over Time.
Person-Centered Care and Dementia Care The International Journal of Aging and Human Devel-
Mapping opment, 60(1), 118.
Workplace Creativity, Innovation, and Age Thomas, J. E., & Lyles, K. (2007). Creativity and aging:
Best practices. Washington, DC: National Endowment
for the Arts.
References World Health Organization. (2015). World report on age-
ing and health. Geneva: World Health Organization.
Bloom, M. (2014). Creativity in older adults. In
T. P. Gullotta & M. Bloom (Eds.), Encyclopedia of
primary prevention and health promotion (2nd ed.,
pp. 19331941). New York: Springer.
Castora-Binkley, M., Noelker, L., Prohaska, T., &
Cross-Cultural Aging
Satariano, W. (2010). Impact of arts participation on
health outcomes for older adults. Journal of Aging, Yang Fang*, Xianmin Gong*, Minjie Lu* and
Humanities, and the Arts, 4(4), 352367. Helene H. Fung
Cohen, G. D. (2001). Creativity with aging: Four phases of
potential in the second half of life. Geriatrics, 56(4),
Department of Psychology, The Chinese
5157. University of Hong Kong, Hong Kong, China
Cohen, G. D. (2005). The mature mind: The positive power
of the aging brain. New York: Basic Books.
Cohen, G. D. (2009). Creativity, later life. In D. S. Carr
(Ed.), Encyclopedia of the life course and human
Synonyms
development. Vol. 3 later life (pp. 8589).
Detroit: Gale Cengage Learning/Macmillan Reference Aging in different cultures; Cross-cultural differ-
USA. ences in aging
Cohen, G. D., Perlstein, S., Chapline, J., Kelly, J., Firth,
K. M., & Simmens, S. (2006). The impact of
professionally conducted cultural programs on
the physical health, mental health, and social Definition
functioning of older adults. Gerontologist, 46(6),
726734.
Creative Aging Toolkit for Public Libraries. (2016).
In the current entry, cross-cultural aging is dened
Retrieved from http://creativeagingtoolkit.org as cultural differences in aging of human psychol-
Cutler, D. (2009). Ageing artfully: Older people and pro- ogy, including cognitive aging, socio-cognitive
fessional participatory arts in the UK. London: Baring aging, and socio-emotional aging. The scope of
Foundation.
Ehlert, A., Fricke, A., & Marley, M. (2010). The increase
cultural difference in the extant literature focuses
guide: A manual about intercultural creativity of older mainly on comparison between East Asian and
age. Badajoz/Glasgow/Remscheid/Wolfenbttel: Western (North American and Western European)
Increase Learning Partnership. cultures.
Hanna, G. P., & Perlstein, S. (2008). Creativity matters:
Arts and aging in America. Washington, DC: Ameri-
cans for the Arts. Introduction
Klimczuk, A. (2015). Economic foundations for creative
ageing policy, volume I: Context and considerations.
New York/Basingstoke: Palgrave Macmillan. Population aging is a worldwide phenomenon.
Levy, B., & Langer, E. (1999). Aging. In M. A. Runco & This entry provides an overview of extant
S. R. Pritzker (Eds.), Encyclopedia of creativity. vol- research on how age differences in cognition,
ume 1 (pp. 4552). San Diego: Academic.
affect, and behavior vary across cultures. While
Moloney, O. (2006). Age & opportunity guidelines for
working with older people in the arts: A resource for this inquiry is driven by the need for science to
Bealtaine organisers and others involved in the arts understand the relative contributions of culture in
and older people. Dublin: Bealtaine Festival/Age & explaining the impact of aging on human
Opportunity.
NCCA Creative Caregiving Guide. (2016). Retrieved from
http://creativecaregiving.creativeaging.org *
Author contributed equally with all other contributors.
Cross-Cultural Aging 613
psychology, it also underscores the importance of attend to certain types of information at the
recognizing the role of culture, in a world growing expense of other information (e.g., context-object
in its awareness of cultural diversity. The contents bias). This, in turn, has a major inuence on
of this entry are thematically organized into cog- follow-up cognitive processes of the selected
nitive aging, socio-cognitive aging, and socio- information (including those that were once
emotional aging with a focus on differences thought of as basic processes) (Park et al. 1999).
between Eastern (typically East Asian) and West- Therefore, cultural differences in cognitive aging C
ern (typically North American) cultures. may not neatly follow the dichotomous character-
ization of cognitive processes.
To better comprehend the interplay of age and
Age Differences in Cognition Across culture in cognition, Park, Nisbett, and Hedden
Cultures developed a new theoretical framework, based
on a distinction between culture-invariant and
Cognition has long been theorized to comprise culture-saturated cognitive tasks and measures
two components: one is the biologically based (Park et al. 1999). These authors asserted that
hardware of basic cognitive functions, supporting the effects of culture and age on cognition were
speed of processing and working memory, for task dependent. On culture-invariant cognitive
example, and the other is the culturally based tasks, individuals from different cultures would
software of cognitive functions, supporting lan- perform similarly, and age-related declines on
guage and decision-making. These components of the tasks would happen at an equivalent rate
cognitive functions have also been characterized across cultures. On culture-saturated cognitive
as uid and crystallized intelligence, cognitive tasks, however, individuals performance would
mechanics, and cognitive pragmatics, as well as vary as a function of culture. Specically, cul-
primary and secondary processes. tural differences would increase with age if the
This division provides a possible framework to differences are based on automatically activated
understand cultural differences in age-related cog- processes and would decrease (termed as cultural
nition. Specically, biologically based hardware convergence) with age if they are based on effort-
of basic cognitive functions declines with age and ful, strategic cognitive processes. Accordingly,
does so equivalently across cultures, whereas cul- age-related cultural convergence could result
turally based software of cognitive functions from the leveling effects of biologically based
could be cultivated by culture and be more resis- functional declines on basic cognitive processes,
tant to the effects of aging (Park et al. 1999). inuencing ones cognitive resources. On a
According to this view, few cultural differences resource-demanding task, older adults would
would be detected in the hardware of cognition in have insufcient resources to support exible
either younger or older adults. In contrast, one use of strategies, resulting in cross-culturally
might expect more profound cultural differences equivalent task performance.
in the life-span developmental trajectory of the According to Park et al.s framework, culture is
software of cognition. more likely to interplay with age on culture-
Recent evidence, however, suggests that cul- saturated than on culture-invariant cognitive
ture also moderates the aging of the hardware of tasks and measures. To understand this inuence,
cognitive processes (Park et al. 1999). For it is necessary to identify culture-saturated cogni-
instance, Hedden and colleagues found superior tive measures and then discuss the interaction
performance in Chinese versus American younger effects of culture and age on these measures.
adults on auditory digit span task (a working
memory measure), but no difference in Chinese Holistic-Analytic Thinking
and American older adults (Hedden et al. 2002). Previous literature has well documented a pref-
Park et al. posited that culture might bias people at erence for holistic thinking in collectivistic
the very beginning phase of cognitive encoding to Eastern cultures and a preference for analytic
thinking in individualistic Western cultures. similarity of features and attributes among

Individuals with holistic thinking tend to attend objects, whereas thematic information refers to
to contextual information, emphasize relation- causal, spatial, and temporal relationships among
ships and group functions, make relatively little objects (Ji et al. 2004). For example, in the
use of natural categories, and rely on intuitive, chicken-cow-grass test (Chiu 1972), Westerners
dialectical reasoning. Individuals with analytic tend to pair the chicken and cow together due to
thinking, however, attend to objects, emphasize their shared taxonomic similarity (i.e., both are
individual functions, readily make use of cate- animals), while Easterners tend to categorize the
gorical information, and rely on rational, logical cow and grass together due to their functional
reasoning (Masuda et al. 2008). relationship (i.e., cows eat grass).
These cultural differences in processing of cat-
Context-Object Bias egorical information become amplied with age.
The cultural divergence on holistic-analytic think- For example, cultural differences in memorizing
ing results in different attentional biases in East- categorical information are larger among older
erners and Westerners. Easterners normally pay than younger adults, and the age-related decline
greater attention to contextual information (e.g., a in memorizing categorical information is more
pictures background) and tend to bind context and pronounced in Eastern versus Western cultures
object together, whereas Westerners normally pay (Gutchess et al. 2006; Yang et al. 2013). These
greater attention to objects, even when they are interaction effects could be interpreted within
embedded in the background (Masuda et al. 2008). Park et al.s framework. Specically, limitations
Cultural differences in context-object bias have in cognitive resources make it increasingly dif-
been found to diminish with age. For example, cult for older Easterners to employ an unfamiliar
some studies nd that younger East Asians are strategy (i.e., categorization), and therefore East-
more sensitive to the context of facial expressions erners may suffer more severe age-related loss in
than younger North Americans. However, this cul- using categories. In contrast, cultural preferences
tural discrepancy disappeared in older adults and prolonged experience make it less resource
(Ko et al. 2011; Masuda et al. 2008). The results demanding for older Westerners to categorize, and
of these studies are consistent with Park et al.s therefore their age-related decline in category
framework in which they assert that cultural differ- processing may be reduced (Gutchess et al. 2006).
ences in cognition could decrease with age on tasks In short, divergent thinking styles make people
that require effortful and controlled processing. In from Eastern and Western cultures process infor-
these studies, it was highly resource consuming to mation differently. The cultural differences in
integrate contextual and facial information, making cognition are especially evident in measures of
both Asian and American older adults unable to context-object bias and categorical processing of
complete the tasks well and leading to age-related information all of which appear to be readily
cultural convergence (Park et al. 1999). accounted by Park et al.s theoretical framework
of the interaction between age and culture on
Categorical Processing of Information cognition.
The divergence on holistic-analytical thinking
also leads to differences in categorization strate-
gies used by Easterners and Westerners. First, Age Differences in Social Cognition
Easterners typically make less use of natural cat- Across Cultures
egories compared to Westerners when categories
are not highly salient. Second, Easterners use Attributions of Social Behavior
more thematic categorization, whereas Westerners A well-established nding in social psychology is
use more taxonomic categorization when catego- errors of attribution error. People tend to explain
ries are salient enough to be accessed (Park causal relationships in terms of dispositional (e.g.,
et al. 1999). Taxonomic information refers to personality traits), rather than situational forces
(e.g., social pressure). This bias manifests as the insignicant, than younger Chinese (Blanchard-
correspondence bias, which refers to ones lack of Fields et al. 2007). The researchers suggest that
awareness of situational constraints, leading to age-related changes in susceptibility to the corre-
insufcient correction for these constraints when spondence bias are not driven by decline in cog-
making dispositional inferences. nitive processing capacity but rather by lifelong
Besides social psychologists, life-span psy- accumulation of cultural experience, which helps
chologists have also focused on social attributions older adults to internalize cultural-specic C
in the context of aging. With an American sample, models of attribution.
Blanchard-Fields and Horhota (Blanchard-Fields
and Horhota 2005) found that older and middle- Implicit Theories and Their Consequences:
aged adults displayed the correspondence bias to a Dialecticism and Holism
greater extent than did younger adults (Blanchard- Another psychological domain investigating the
Fields and Horhota 2005). The difference between effects of culture on age concerns the lay theory of
older and younger adults was eliminated only naive dialecticism (often simply referred to as
when a plausible motive (but not other situational dialecticism). Naive dialecticism is a constella-
constraints) for the actors behavior was made tion of lay beliefs about the nature of world
salient. The researchers attributed this nding to whose roots can be traced to folk Taoism, with
cognitive decline and insufcient motivation of inuences from Buddhist thoughts (Spencer-
older adults to consider the situation faced by the Rodgers et al. 2009). The beliefs related to naive
actor if they were not prompted to consider the dialecticism revolve around three themes: that
actors plausible motives. everything is related to one another (holism), that
The cross-cultural difference in susceptibility change is cyclical, and that we should be tolerant
to the correspondence bias is well established. of contradiction. These themes are endorsed by
People from relatively individualistic cultures, members of a number of East Asian cultures,
such as the United States, Canada, and Western including Japan, China, and Korea. Dialecticism
Europe, are more susceptible to this bias than inuences cognition, affect, and behavior in a
people from relatively collectivistic cultures, number of ways. For example, members of dia-
such as East Asian countries including Japan, lectical cultures are more likely to prefer dialecti-
Korea, and China. This tendency is chiey cal proverbs to nondialectical proverbs, reason
explained in terms of East Asians subscription more dialectically about social contradictions,
to the holism the notion that nothing is isolated and perceive emotions of opposite valence as
and everything is connected and their tendency to compatible with each other (Spencer-Rodgers
take constraints faced by individuals imposed by et al. 2009).
the social collectives and situational contexts they As the culture-specic inuence of dialectical
are embedded in into account (Nisbett et al. 2001). beliefs on emotional experience and well-being
Blanchard-Fields, Chen, Horhota, and Wang across the life-span will be covered in another
inquired into cultural differences in correspon- entry, this section will focus on how dialecticism
dence bias at different ages by comparing adults inuences self-concept and cognitive-behavioral
from two age groups, younger and older, in two tendencies in older adults. Zhang and his col-
cultures, American and Chinese (Ko et al. 2011). leagues examined age-related changes in
In addition to nding a cultural difference (the dialecticism (and its close conceptual counter-
Americans showed stronger correspondence bias part, holism) cross-culturally (Zhang
than the Chinese regardless of age group), they et al. 2014). Comparing younger and older adults
found that this cultural difference was affected by in Hong Kong and America, they found distinct
age older Americans demonstrated a stronger age-related changes in self-reported dialecticism
correspondence bias than younger Americans and a behavioral measure of holism, the framed-
(replicating prior ndings), whereas older Chi- line test (FLT). Specically, while older people
nese showed a weaker bias, albeit statistically reported being less dialectical than younger
people in both cultures, only Chinese older face (concern of others opinion of oneself), and
adults, not their American counterparts, exibility (seeing others views or methods).
exhibited stronger holistic tendencies on the Notably, these CPAI personality factors, which
behavioral measure of holism, the FLT. These include interpersonal relatedness, replicate fairly
ndings suggest a potential for the inuence of well in European American populations, hence
culturally endorsed implicit theories to grow supporting the CPAI applicability in cross-
with age, but such growth is likely to be domain cultural personality research (Lin and Church
specic. 2004).
Interestingly, when measured across the life-
span, changes in interpersonal relatedness
Age-Related Changes in Personality showed cross-cultural variation. Fung and Ng
Across Cultures found that interpersonal relatedness is higher
among older Chinese than younger Chinese, but
Personality is characterized by habitual patterns in this age difference is not found among European
behavior, thought, and emotion. This section Canadians (Fung and Ng 2006). This suggests
reviews some models of personality and examines that Chinese exhibit culturally valued norms and
their manifestation in younger and older age traits more strongly as they age. The same trend
groups in different cultures. is also observed in the domain of dispositional
optimism: Americans (who live in a culture that
Big Five and Indigenous Models of Personality value optimism) become more optimistic with
Often regarded as the most inuential model of age, whereas Hong Kong Chinese (who live a
personality, the ve-factor model (FFM) has been in a culture that value optimism considerably
supported in cross-sectional and longitudinal less) become less optimistic with age (You
studies in multiple cultures (McCrae et al. 1999). et al. 2009).
The model comprises ve dimensions of
personality extraversion, openness to experi- Collectivistic and Individualistic Tendencies
ence, neuroticism, agreeableness, and conscien- Research on personality development across the
tiousness. Evidence further suggests that, across life-span using nonfactor-based approaches has
cultures, older people are more conscientious, corroborated the aforementioned nding that
more agreeable, less neurotic, less open to expe- age-related differences in personality across the
riences, and less extraverted than younger people life-span can vary among cultures. In Labouvie-
(McCrae et al. 1999). Vief, Diehl, Tarnowski, and Shens exploratory
However, some personality psychologists have study, they examined how 20 folk concept scales
argued that the FFM is culturally biased and is of personality taken from the California Psycho-
insufcient when it comes to explaining person- logical Inventory changed over the life-span in
ality variability in cultures outside of North Amer- Americans and Mainland Chinese (Labouvie-Vief
ica and Western Europe. This sentiment has et al. 2000). They discovered that older Chinese,
spurred an emic (indigenous) approach to the compared to younger Chinese, expressed increases
study of personality. In China, this has resulted in self-control and good impression, together with
in the development of the Chinese Personality a reduction in self-acceptance and exibility. These
Assessment Inventory (CPAI) (Cheung results suggest that collectivistic tendencies,
et al. 2001), which argues that a sixth personality which are related to norm orientation, are stronger
construct, interpersonal relatedness, should be among older Chinese, whereas individualistic ten-
added to increase its relevance to the Chinese dencies, characterizing extraversion and individ-
context. Interpersonal relatedness comprises har- ual initiative, are weaker among older Chinese,
mony (avoidance of interpersonal conict), Ren compared to younger Chinese. In general, the
Qing (abiding by the rules of social exchange), age-related patterns found in the Chinese sample
are either absent or less pronounced in the Ameri- is inuenced by domain-specic importance of
can sample. different types of wisdom in each culture.
Taken together, ndings from these cross-
cultural studies suggest that aging can strengthen
the endorsement and expression of traits and char- Age Differences in Emotion and
acteristics valued in ones culture (e.g., social Well-Being Across Cultures
reciprocity and collectivistic tendencies in the C
Chinese culture and optimism and individualistic Emotion Perception
tendencies in the American culture). As people grow older, they tend to show prefer-
ence for processing positive information rather
than negative or neutral information. This effect
Age-Related Gains in Wisdom Across was coined as positivity effect (Charles
Cultures et al. 2003). For example, Charles and colleagues
found that, while young participants demonstrated
Most cultures tend to agree that we gain wisdom as a negativity dominance during memory tasks
we age, though recent evidence shows that (remember negative images better), such an effect
age-related gains in different aspects of wisdom was less pronounced among older adults,
vary as a function of culture. With three age groups suggesting a reduction in negativity with increas-
(younger adults, middle-aged adults, and older ing age. However, recent cross-culture studies
adults), Grossmann and his colleagues examined suggest that this aging-related positivity effect
wise reasoning (e.g., acknowledging multiple per- might not be universal. In Western cultures, pos-
spectives, recognizing likelihood of change, per- itive information is perceived as more emotionally
ceiving exibility in conict development) about useful because it helps individuals maintain opti-
interpersonal and intergroup conicts in Japanese mism and self-esteem, which in turn fullls cul-
and Americans aged 2575 years (Grossmann turally endorsed values of autonomy and
et al. 2012). They found that younger and middle- uniqueness. In East Asian cultures, social har-
aged Japanese, compared to their American coun- mony and interpersonal relationships are more
terparts, showed greater use of wise reasoning important than individual uniqueness or auton-
strategies only for reasoning about interpersonal omy. Thus, to maintain social harmony and
conicts, but not for intergroup conicts, and this avoid social mistakes, individuals may pay atten-
cultural difference did not extend into old age. In tion to different social cues from the environment,
terms of intergroup conicts, while Japanese and including both positive and negative information,
Americans started out at a similar level of and then provide appropriate responses accord-
intergroup wisdom at a younger age, only Ameri- ingly. Hence, in these cultures, negative informa-
cans exhibited age-related growth in this type of tion may not be perceived as less important as
wisdom. The ndings were interpreted as evidence positive information. This may, in turn, lead to a
for interpersonal wisdom to emerge at a younger cultural difference in the aging-related positivity
age among Japanese than Americans, due to the effect, such that the bias for processing positivity
relevance of wise reasoning to keeping harmonious is not generalized to interdependent cultures.
relationships with others. Conversely, age-related Evidence showing this cultural difference
growth in wise reasoning about intergroup conicts comes largely from comparisons of Western and
is only observed in America. This may be because the Hong Kong Chinese cultures studies
of the United States relatively higher ethnic diver- conducted in Korea demonstrated the same
sity that calls for wisdom in the intergroup domain. age-related positivity bias as in Western cultures
This nding suggests that although wisdom is a (Ko et al. 2011). For example, Fung and her
psychological quality that shows age-related colleagues found that, although older participants
growth across cultures, the trajectory of the growth remembered positive information better than
neutral information (positivity enhance effect), across cultures (Grossmann et al. 2014). In West-
they also remembered negative images as well as ern cultures, well-being might be enhanced by
the neutral images (no negativity reduction effect) experiencing more positivity and less negativity,
(Fung 2013). In another study, older adults recog- and research shows that this is what Westerners
nized an announcement that conveyed negative tend to pursue, being more strongly motivated to
emotions better than an announcement that con- maximize their positive emotional feelings and
veyed neutral emotions. Using eye tracking meth- minimize negative one. However, in East Asian
odology, Fung and colleagues demonstrated that cultures that encourage tolerance for contradic-
Chinese older participants looked away from pos- tions and changes, well-being is dened by a
itive stimuli (Fung 2013). dialectical way of mixing positive and negative
Later, Fung and colleagues tested whether the experience. Based on this dialectical belief,
cultural value of interdependence held by individ- maintaining positive feelings and avoiding neg-
uals moderated the age-related bias for positive ative feelings may become less important for
information (Fung 2013). In both studies with East Asians; they might instead prefer to strive
memory tasks and attention tasks, results for a balance between the positive and negative
suggested that the age difference in negativity (Grossmann et al. 2014). Indeed, in Grossmans
reduction effect was only observed among partic- study, older Japanese participants reported a
ipants with lower levels of interdependence, sim- higher level of positive emotions than did their
ilar to the result that has been demonstrated by younger counterparts. Yet they reported the same
Western samples. Yet, among Chinese partici- level of negativity as did their younger counter-
pants with higher level of interdependence, no parts, including the intensity of negative emo-
age difference was found. tions, the focus on past negative experience,
To summarize, accumulated evidence has and the proportion of perceived negative
demonstrated the cultural variation in age-related interpersonal relationships. In another study
positivity effect. Individuals from Chinese cul- conducted in Hong Kong, a similar pattern was
ture, who value interdependence more than West- found, such that age was associated with more
ern individuals, may not regard negative positive emotions, but there was no correlation
information as more important than positive infor- between age and negative emotions (Yeung
mation and thus exhibit the age-related positivity et al. 2011).
effect to a lesser extent. In summary, in both Western and Eastern cul-
tures, aging correlates with an increase in positive
Emotional Experience and Well-Being emotions, while a decrease in negative emotions is
In the Western literature, previous ndings have more frequently observed in Western cultures.
demonstrated that older people exhibit a higher
level of emotional well-being (more positive Emotional Regulation
emotions and fewer negative emotions) com- As outlined above, older people tend to report
pared to their younger counterparts (Shiota and higher emotional well-being. Urry and Gross pro-
Levenson 2009). The same pattern was found in posed that the underlying mechanism might be
the Chinese culture. Pethtel and Chen compared that older adults become better at regulating their
the emotional experience among a group of emotions (Urry and Gross 2010). More speci-
Mainland Chinese participants and found that cally, to regulate emotions, older adults may tend
older adults reported lower levels of negative to employ antecedent-focused strategies (e.g., cog-
emotions than did younger adults (Pethtel and nitive reappraisal, attentional deployment) more
Chen 2010). However, some recent studies than response-focused strategies (e.g., expression
observed a different pattern in other Asian cul- suppression) (Carstensen et al. 1999). The former
tures. Grossman and colleagues argued that is also associated with healthier outcomes. For
although emotional well-being might be a uni- example, as abovementioned, compared to youn-
versal goal, the way to achieve it might vary ger adults, older adults pay more attention to
positive information and stimuli, suggesting they Conclusion

tend to use the strategy of attentional deployment.
Given that the antecedent-focused strategies This entry provides an overview of how
downregulate the negative emotions before they age-related changes in cognition, affect, and
are full-blown, preventing individuals from nega- behavior vary as a function of culture. It should
tive and stressful experience, they tend to be asso- be acknowledged that most cross-cultural com-
ciated with healthier outcomes. parisons reported in this entry are mostly East C
Cross-culturally, age differences in emotion versus West comparisons in other words,
regulation only partially hold true in East Asian imprecise depictions of the rich cultural diversity
cultures. During the SARS outbreak in Hong in our world. This bias in current research on
Kong, Yeung and Fung found that compared to culture should be an inspiration for researchers
young participants, older participants reported to broaden the scope of inquiry of age differences
more emotional-focus coping and lower levels of into cultures that are, at present, underrepresented.
anger both at the peak of the SARS epidemic and Similarly, most of the reported studies are cross-
at its end, suggesting that older people were more sectional (reecting existing aging research in
successful in managing their negative emotions general), and their conclusions may be con-
under stressful situations (Yeung and Fung founded by cohort effects. Despite these limita-
2007). In another study conducted in Hong tions, our review suggests that aging does take
Kong, Yeung and colleagues found that different forms, or at least manifest in different
an age-related increase in using cognitive ways, in some domains across cultures. Examin-
reappraisal partially accounted for the age differing the intersection of aging and culture may
ences in positive feelings (Yeung et al. 2011). reveal important mechanisms about adult
These data support the hypothesis that older peo- development.
ple are better at antecedent-focused emotion
regulation.
However, in the same study, no age difference
Cross-References
in suppression was found. Yeung and colleagues
speculated that because Asian cultures empha-
Age-Related Positivity Effect and its Implica-
sized interpersonal harmony, suppressing ones
tions for Social and Health Gerontology
emotions to avoid social conict was always
encouraged across different life periods (Yeung
Emotional Development in Old Age
et al. 2011). Hence, older adults exhibited the
Positive Emotion Processing, Theoretical
same level of suppression as younger adults. In
Perspectives
another study, older adults beneted from
Psychology of Wisdom
suppressing emotion. This emotional suppression
was positively correlated with a lower intensity of
negative emotion and better work performance
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Crystallized Intelligence 621
least 2,000 years. In 1963, Raymond B. Cattell out particular tasks are usually useless for any
was the rst to propose a psychometric model for others.
these distinct abilities (1963). Horn and Cattell Horn and Cattells distinction also implies a
(1966) further developed his theory and Horn contrast between the difculty of inventing, learn-
(Horn 1968, 1982; Horn and Noll 1997) applied ing, and using a difcult procedure for the rst
it to changes in cognitive abilities in old age. time and its easy and automatic deployment once
Horn showed that our abilities to solve problems it has become familiar. This applies to cultural as C
rapidly and accurately (and so achieve high well as individual accomplishments. Clay tablets,
scores on intelligence tests), to respond fast to papyrus, libraries, and the World Wide Web can
simple signals, and to quickly learn unfamiliar all be envisaged as means of crystallizing and
material such as lists of random words peak in indenitely preserving semantic and procedural
our early twenties but decline as we grow older. information that most individual humans could
These changes are slight from our 30s through not discover or invent on their own: For example,
our 50s but accelerate throughout our 60s, 70s, it took Leibniz and Newton years of hard thought
and 80s. Horn and Cattell termed these uid to invent the Calculus that schoolboys can now
abilities or uid intelligence (gf) because easily learn from textbooks in a few weeks.
they are not specic to particular problems but The Cattell/Horn distinction raises interesting
support performance in all mental tasks. In con- practical questions as to how we should view our
trast to waning uid abilities, Horn showed infor- likely trajectories of competence in our everyday
mation that we have learned throughout our lives lives throughout our lifespans. Though our uid
is relatively age robust. Following Cattell, Horn intelligence declines as we get older, can we still
called such bodies of acquired information crys- continue to practice demanding professions
tallized intelligence (gc). Their choice of the supported by information and skills that we have
word intelligence emphasizes that Cattell and learned throughout our lives and still retain in our
Horn did not regard gc only as a mental archive old age? An associated question is whether some
of semantic information, such as vocabulary, or kinds of crystallized abilities may be more age
collections of names of birds or trees, or athletic robust than others so that professional compe-
records but also as tool kits that we have invented tence based on these durable abilities can be
or learned to carry out procedures. Some maintained longer than on more age-fragile skills?
examples of these procedures might be A key issue is that retaining effective proce-
constructing grammatical sentences, doing alge- dures is one thing, but carrying them out is quite
bra, working out lines of play in chess or go, or another. Another helpful metaphor from informa-
managing a bank, a business, or a kitchen. This tion technology is the difference between devel-
distinction is clear in Horns discussions but oping and storing a program that is ideal to
while his experiments do show that vocabulary perform a particular task and having a system
and other kinds of semantic knowledge can sur- that is adequate to run it. As the benchmark
vive well into old age with little loss, he did not bandwidth and memory capacity of an informa-
systematically explore how far this is also true of tion processing system reduce, so will the maxi-
complex procedural skills that we have learned mum complexity of the programs that it can run.
over our lifetimes. Horns early experiments and For humans working memory (see also entry
discussions also do not make the important point Crystallized Intelligence in this volume) is a con-
that, in contrast to uid intelligence or uid venient term coined by Alan Baddeley and Gra-
abilities, the crystallized skills are intensely ham Hitch (1974) as a blanket label for our
domain specic. That is, mastery of a particu- abilities to rapidly shift attention from less to
lar skill may be of little help in learning or using more important information, to process new infor-
others, even if these may seem quite similar. An mation and to relate it to other information that has
analogy from information technology is that been recently registered or held in memory for
computer programs written to efciently carry many years, and to reorder all of this old and
new information so as to decide and implement Does this mean that some skills are more age
what we should do next. All of the abilities resistant than others?
implicit in the general concept of working mem- Lehman pointed out that his data were not ideal
ory are, in Cattell and Horns terms, uid and to address these questions. Many of the careers
age fragile. However, without a well-functioning documented took place in the eighteenth and nine-
uid working memory system, we cannot man- teenth centuries when life expectancy was much
age to do complicated things for which we, long shorter and career trajectories were very different.
ago, learned reliable procedures: e.g., to produce a Recent studies conrm early age-related losses in
long, grammatical sentence, to understand and scientic productivity but suggest that these now
solve a complex business problem, to cook a happen much later than in the historical periods
complicated dish, or to plan and carry out apt for which Lehrman collated data. Studies of Brit-
sequences of moves in chess. So, as the efciency ish psychologists in the 1970s and 1980s (Over
of working memory sharply declines with age 1982); of large groups of less eminent physicists,
(Salthouse et al. 1989), we may still be able to geologists, physiologists, and biochemists in
perfectly describe effective procedures for com- 1989 (Levin and Stephan 1989); and of the careers
pleting complex tasks but become unable to meet of economists and other scientists (Cohen 1991;
the demands these make on our diminishing Bayer and Dutton 1977), all found that, as they
working memory capacity when we attempt to grow older, all academics publish less and in less
put them into practice. prestigious journals. Recent studies of average or
A neat illustration of this is Susan Kempers slightly above-average scientists nd that their
(1990) analyses of diaries written by citizens of plateaux of greatest productivity last more than a
Kansas during the late nineteenth and early twen- decade longer than Lehmans analyses suggested.
tieth centuries. These often covered 40 or 50 years Studies of artistic productivity also revise his con-
of their authors lives. As diarists aged the ranges clusions. A 1999 analysis of the number of paint-
of words that they used only slightly reduced ings produced by 739 graphic artists, works by
(as Horn and Cattells empirical results predicted). 719 musicians, and books by 229 authors found
Nevertheless, although their youthful diary entries that, like most contemporary scientists, their
were often long sentences and complex grammat- periods of maximum output were in their 30s
ical constructions, as they grew old, their and 40s. Unfortunately literary skills are not
sentences became shorter and their grammatical immune to changes that come with old age and
constructions increasingly simple. Retaining large with approaching death. Suedeld and Piedrahita
numbers of words and retaining the ability to (1984) analyzed the late work of distinguished
assemble them into complex sentences are differ- novelists and found that the quality of writing in
ent things. their correspondence declined during the 10 years
This raises the interesting practical question before they died.
whether some crystallized abilities, that is, Other recent studies nd that while the learned
kinds of learned knowledge and skills, can survive skills of bankers and business executives allow
later in life than others. In 1935 Lehman (1935) them to competently do their jobs in late middle
pioneered studies of the ages at which distin- age and even give them some advantage over
guished mathematicians, scientists, poets, novel- younger colleagues with less experience, their
ists, musicians, and artists had made their most ability to correctly analyze and cope with novel
remarkable contributions (Lehman 1942; Lehman problems tends to have decline by their late 40s
and Ingerham 1939). Ages of greatest productiv- and 50s (Colonia-Willner 1998, 1999).
ity and achievements were the early 20s and 30s The current consensus is that while compe-
for mathematicians, physicists, and chemists; the tence, even at learned and highly practiced skills,
40s and 50s for historians, philosophers, and nov- does decline with age, these changes are much
elists but might be as late as the 60s, 70s, or even smaller and slower than the earliest surveys
80s for some visual artists and musicians. suggested. The contrast between early owering
Crystallized Intelligence 623
and early decline in the hard sciences and late formidable body of learned crystallized knowl-
owering and late decline in the humanities and edge of tactics and strategy.
visual arts now seems less clear-cut. One problem Statisticians such as Arpad Elo developed very
is nding comparable standards across different sensitive and reliable systems for rating the relative
disciplines. Assessments of quality in the arts are strengths of different chess players. Because these
much more contentious and differ sharply have been used and validated for at least 50 years,
between various kinds of achievement. Standards even small changes in the playing strengths of C
of comparison are more elusive than the earliest individual grand masters can now be tracked from
studies assumed. For example, a tally of the year their 20s through to their 70s. Elos initial studies
2000 market value of paintings by 51 modern US (Charness et al. 2005) found that nearly all the
artists found that for painters born before 1920, careers he compared showed improvements until
the average peak age for the valuation of their 30s or 40s, a plateau of the best achievement until
paintings was 50.6, but for those born after the late 50s or, in some few cases, early 60s but
1920, it was only 28.8. Changes from a cautious then a signicant decline. During the historical
to a speculative market account for similar dis- spans of this and later analyses, chess at the highest
crepancies (Colonia-Wilner 1999). From current level evolved so rapidly that players could not keep
sale prices, we might conclude that artists who or improve their ranks unless they continually
are now elderly are painting much better (or at revised a vast body of theory on openings and
least much more protably!) than their young end games. It is cheering to nd that gifted individ-
contemporaries or, indeed, than themselves when uals can, though perhaps with gradually increasing
young. effort, remain at the very peak of an extraordinarily
Ideal data to examine differences between demanding profession until their seventh decades.
uid and crystallized abilities would be the Evidently, acquired knowledge and endless prac-
achievements of large numbers of extremely tice can support even a skill that is, essentially,
gifted people on the same, difcult, mental skill computational and demanding of uid intelligence
on which they can be compared against each other until late in life. We must also remember that long
in terms of a common objective standard. The after they had retired from competitive chess, these
careers of chess masters are as close to this as we remarkable people could still play at a level that
get. Chess requires high levels of both uid abil- most humans cannot hope to reach at any age. We
ities, such as working memory and intelligence. It should also remember the wise comment of Gary
also requires crystallized knowledge because it Kasparov, perhaps the greatest player yet: Excel-
has been so exhaustively researched and ling at chess has long been considered a symbol of
documented that, even for young prodigies, suc- more general intelligence. That is an incorrect
cess at the highest levels needs long and intensive assumption in my view, as pleasant as it might
study. Chess play requires an ability to simulta- be. Crystallized intelligence is intensely task
neously hold many variables in mind and to rec- specic.
ognize, as rapidly as possible, how patterns of
relationships between these variables will alter if
particular moves are made. Clearly there is a nat- References
ural talent for chess because some prodigies play
at a remarkably high standard at ages as early as Baddeley, A. D., & Hitch, G. (1974). Working memory.
Psychology of Learning and Motivation, 8, 4789.
612 years. However, a study by Charness and Bayer, A. E., & Dutton, J. E. (1977). Career age and
colleagues found that even maintaining success at research-professional activities of academic scientists.
much lower levels than grandmaster chess The Journal of Higher Education, 48, 259283.
requires 5,000 or more hours of deliberate practice Cattell, R. B. (1963). Theory of uid and crystallized
intelligence: A critical experiment. Journal of Educa-
over 10 years (Colonia-Wilner 1999). In terms of
tional Psychology, 54(1), 1.
John Horns dichotomy, chess mastery requires Charness, N., Tufash, M., Krampe, R., Reingold, E., &
both considerable uid intelligence and a Vasyukova, E. (2005). The role of deliberate practice in
chess expertise. Applied Cognitive Psychology, 19(2), Kemper, S. (1990). Adults diaries: Changes made to writ-
151165. ten narratives across the lifespan. Discourse Processes,
Cohen, L. E. (1991). Size, age and productivity of scientic 13, 207223.
and technical research groups. Scientometrics, 20, Lehman, H. C. (1935). The chronological years of greatest
395416. productivity; chemists, inventors, poets et altera. Psy-
Colonia-Willner, R. (1998). Practical intelligence at work. chological Bulletin, 32, 676693.
Relationship between aging and cognitive efciency Lehman, H. C. (1942). The creative years; oil paintings,
among managers in a bank environment. Psychology etchings, and architectural works. Psychological
and Aging, 13, 4547. Review, 49, 1942.
Colonia-Wilner, R. (1999). Investing in practical intelli- Lehman, H. C., & Ingerham, D. W. (1939). Mans creative
gence: Aging and cognitive efciency among execu- years in music. Science Monthly, New York, 48,
tives. International Journal of Behavioural 431443.
Development, 23, 591604. Levin, S. G., & Stephan, P. E. (1989). Age and research
Horn, J. L. (1968). Organization of abilities and the devel- productivity of academic scientists. Research in Higher
opment of intelligence. Psychological Review, 75(3), Education, 30, 531549.
242. Over, R. (1982). Does research productivity decline with
Horn, J. (1982). The theory of uid and crystallised intel- age? Higher Education, 11, 511520.
ligence in relation to concepts of cognitive psychology Salthouse, T. A., Mitchell, D. R., Skovronek, E., &
and aging in adulthood. In F. I. M. Craik & S. Trehub Babcock, R. L. (1989). Effects of adult age and work-
(Eds.), Aging and cognitive processes (pp. 237278). ing memory on reasoning and spatial abilities. Journal
New York: Plenum Press. of Experimental Psychology: Learning, Memory, and
Horn, J. L., & Cattell, R. B. (1966). Renement and test of Cognition, 15(3), 507.
the theory of uid and crystallized general intelli- Suedfeld, P., & Piedrahita, L. E. (1984). Intimations of
gences. Journal of Educational Psychology, 57(5), 253. mortality. Integrative simplication as a precursor of
Horn, J. L., & Noll, J. (1997). Human cognitive capabili- death. Journal of Personality and Social Psychology,
ties: Gf-Gc theory. doi.apa.org. 47, 848852.
D
Decision Making computation of expected value, that is, the

weighting of the value of possible outcomes by
Rui Mata their probability of occurrence (Bernoulli 1954).
University of Basel, Basel, Switzerland Variations of this principle introduce the idea of
subjective value/utility and probability functions
that may vary as a function of individual charac-
Synonyms teristics or situations, but such approaches typi-
cally do not make reference to the specic
Choice; Inference cognitive architecture underlying these calcula-
tions. One example of such a theory is cumulative
prospect theory (Tversky and Kahneman 1992).
Definition A second approach, strongly anchored in
cognitive science and psychology, tries more
Decision making is the process by which a course explicitly to link descriptions of decision pro-
of action is chosen from among two or more cesses to cognitive functions of attention, learn-
alternatives. This denition is broad enough to ing, and memory. The models associated with
span different decision types and domains, from such an approach may also describe the computa-
fast, habitual decisions to complex, life-changing tion of value and probability but often will make
ones. The extent to which such disparate decisions stronger assumptions about information search
share or not the same underlying cognitive pro- and updating of information. For example,
cesses and are differentially affected by sequential-sampling and reinforcement-learning
age-related change is an ongoing topic of models make assumptions about information
research. sampling and updating to describe decision mak-
ing. Other related approaches attempt to describe
decision making at the algorithmic level by mak-
Historical Background ing assumptions about the series of computational
steps required for search, stopping, and deciding
There are a number of different traditions in psy- (Gigerenzer and Brighton 2009). Third, and
chology, economics, and related disciplines to nally, a more recent approach investigates the
describe and formalize decision-making pro- neural basis of decision making, often making
cesses. The perhaps most prominent approach links to some of the formal and computational
comes from expected value theory and related theories described above (Glimcher and Fehr
views, which describe decision making as the 2014).
DOI 10.1007/978-981-287-082-7
626 Decision Making
Decision Making, 200 2

Fig. 1 Depiction of an
estimate of the number of
publications on aging and
Percentage of Publications
decision making as well as 150
Number of Publications
the corresponding
percentage relative to all
publications on decision
making in the past 40 years.
100 1
The search was conducted
using the terms aging and
decision making in all
elds in PubMed
50
0 0
4
197
197
198
198
199
199
199
200
200
201
201
Year
The question of how decision making changes demands and affordances interact with particular
across the life span and, in particular, with aging, cognitive strategies. To better understand this
has received some attention. Yet, the eld of aging interaction, one needs to describe the structure of
and decision making represents less than 2% of all decision environments and the cognitive or affec-
work in decision making, albeit there has been an tive components that such environments exploit
increase in the relative proportion of decision (Mata et al. 2012a). In what follows, the specic
research focusing on aging (see Fig. 1). key research areas that have received most atten-
tion in the past are described with the goal of
exemplifying the importance of age-related
Key Research Areas changes in cognitive and motivational compo-
nents and the moderating role of ecological
There are a number of reviews on aging and (i.e., task) characteristics on decision making.
decision making that emphasize how different
aspects of age-related change can inuence deci- Perceptual Decision Making
sion making, including affective and motivational Perceptual decision making refers to low-level
(Samanez-Larkin and Knutson 2015), as well decisions about immediately presented stimuli,
as cognitive and ecological, factors (Mata et al. with most research on aging having been carried
2012a). A complete understanding of the impact out on visual discrimination, such as discrimina-
of aging on decision making will likely require tion between different letters (E vs. F) or varying
the integration of different perspectives (Hess levels of brightness in stimuli presented very
et al. 2015). Crucially, the ecological perspective briey on a computer display (e.g., for less than
suggests that there is no domain-general answer to 1 s). The state-of-the-art approach is to use
the question of how changes in motivational or sequential-sampling models (e.g., diffusion
cognitive capabilities impact decision making. models) to describe both reaction times and accu-
For example, the impact of age-related cognitive racy of responses simultaneously and account for
decline should depend strongly on the demands of possible speedaccuracy trade-offs. The latter
specic task environments, such as memory models are able to distinguish between different
demands. In other words, the quality of decisions components, such as motor components, response
made by people of all ages is the result of how task criteria components, and evidence accumulation
Decision Making 627
components, because each makes different pre- has a long tradition in decision research with
dictions about the shape of the reaction time dis- various strategies having been proposed, each
tribution of correct and error responses. Key with its particular cognitive demands and domain
results in this area are that older adults do seem of execution (Shah and Oppenheimer 2008). For
motivated to perform well and show motivational example, some strategies, like take-the-best
adaptations by adopting more conservative deci- (TTB), ignore signicant amounts of information
sion criteria than the younger adults. Older adults because they infer which of the two alternatives
are also overall slower in noncognitive (e.g., has the higher value on a criterion by (a) searching
motor) components. However, the quality of evi- through cues in order of validity (i.e., how much D
dence accumulation driving the decision process the cue is correlated with the criterion),
is signicantly lower for older relative to younger (b) stopping search as soon as a cue discriminates
adults in some but not all tasks (Ratcliff between decision alternatives, and (c) choosing
et al. 2007), suggesting that task characteristics, the alternative this cue favors. In turn, other strat-
such as the nature of the stimuli, can be crucial in egies, like weighted-additive strategy (WADD),
engendering age differences in perceptual deci- consider all information by (a) multiplying each
sion making. The extent to which the results cue value by the respective cue weight (i.e., a
from perceptual decision making can be directly measure of how important this cue is to the pre-
translated or are correlated to performance in diction), (b) summing up the results for each alter-
higher-level decisions is yet to be investigated. native, and (c) choosing the alternative with the
highest sum. TTB does well in environments with
Multiple-Cue Decision Making many redundant cues or in which search is costly,
The bulk of decision-making research has focused the opposite being true for WADD. In the infer-
on problems in which decision makers have to ence domain, there is some inherent difculty in
integrate different pieces of information (i.e., distinguishing age-related changes in preferences
cues, attributes) and deliberately decide between from the impact of age-related cognitive decline
two or more options. The nature of information on the selection and application of specic deci-
presentation may vary dramatically from those sion strategies that impact the search and integra-
cases in which it is conveniently summarized in tion of information. Overall, work on inferential
a table or, alternatively, needs to be retrieved from decision making suggests that older adults tend to
memory. A major distinction in this eld concerns search for less information prior to making a deci-
the existence of an objective criterion that deter- sion (Mata and Nunes 2010) and use simpler
mines the correctness of the decision, such that strategies that ignore some information (Mata
decisions amount to inferences, and those cases et al. 2007) or strategies that do not rely heavily
for which no objective criterion exists decisions on memory (Mata et al. 2012b) to integrate infor-
thus represent expressions of individual prefer- mation, possibly due to age-related cognitive
ences. Some work on aging and multiple-cue decline. There are, however, other aspects related
decision making has articially created objective to age-related changes in motivation and prefer-
criteria and examined the strategies selected by ences that can affect decision making. The work
younger and older adults in inferential decision on the impact of aging on preferential decisions is
making (Mata et al. 2007). Strategies can be summarized below for a number areas in which
dened as sequences of operations or processes age differences have been investigated, such as in
that are goal directed, that is, are aimed at the domains of risky, intertemporal, and social
accomplishing a particular task and, therefore, decision making.
mediate task performance. The strategy concept
has been used to describe cognitive processes and Risky Decision Making
mechanisms of human cognition in many Conceptions of risk and risk taking abound, with
domains, including memory, arithmetic, and deci- economists viewing risk as the variance or
sion making. In particular, the strategy approach probability of possible outcomes, whereas
628 Decision Making
psychologists and lay people often emphasize the (i.e., constant discounting per time period).
link between risk and the possibility of losses. Instead, humans typically show a present bias by
There are a number of measures and tasks that showing valuations that fall rapidly for small
attempt to capture individual and age differences delay periods, but slowly for longer delay
in the tendencies to decide for or against risky periods. The empirical literature concerning age
courses of action. Some behavioral tasks provide differences in intertemporal decisions is mixed
explicit information about outcome magnitudes, (Rieger and Mata 2015; Samanez-Larkin et al.
whether outcomes are positive (gains) or negative 2011). However, the majority of existing studies
(losses), as well as their respective probabilities seem to suggest a pattern, whereby older adults
(decisions from description), but others require are more patient, by showing choices indicative of
individuals to learn about probability and out- either less steep discounting rates or increased
come information over time (decisions from expe- neural responses to later rewards (Samanez-
rience). A review of the literature suggests that the Larkin and Knutson 2015).
pattern of age differences in risky decision making
is heterogeneous and may depend heavily on task Social Decision Making
characteristics (Mata et al. 2011). In particular, in Aging is traditionally perceived as being associ-
decisions from experience, age-related differences ated with increased wisdom, including an
in risk taking seem to be a function of decreased increased ability to navigate the social world.
learning performance: Older adults may be more But do older adults deal more or less strategically
(or less) risk seeking compared to younger adults and prosocially relative to younger adults in social
depending on whether learning leads (or not) to contexts? Standard economic theory assumes that
risk-avoidant behavior. In decisions from descrip- people are, perhaps exclusively, motivated by
tion, younger and older adults may show more material self-interest and thus do not care about
similar risk-taking behavior at least when the cog- the well-being of others. A number of studies have
nitive demands of the task are low. The exact rejected this assumption and suggested that indi-
decision strategies used by younger and older viduals of all ages have prosocial motivations
adults in these tasks have not been fully investi- (Engel 2011). The typical measures used to assess
gated, thus making it difcult to disentangle the prosocial motivations consist of having individ-
role of age-related changes in risk preferences due uals (i.e., players) make decisions in the context of
to motivational factors and more cognitive fac- groups in which other individuals may or not be
tors, such as the changes in strategy use due to anonymous. For example, individuals may be
age-related cognitive decline (Depping and asked to allocate monetary amounts to themselves
Freund 2011). One interesting avenue for future and others, with the amount assigned to the social
research is to investigate which behavioral tasks partner being used as an indicator of prosocial
can best capture the underlying risk preferences of motivation. The economic games include the dic-
older adults as captured in commonly used self- tator, ultimatum, and trust games, among many
report measures. others (Rieger and Mata 2015; Engel 2011). The
literature on age differences in social preferences
Intertemporal Decisions in such games is relatively scarce and most work
Many important life decisions require trading off has only considered age as a nuisance variable.
immediate rewards against future ones, such as Some work does suggest an increase in prosocial
the choice between spending and saving. This motivations with increased age (Engel 2011), but
type of decisions is typically studied empirically there is evidence that such patterns may not hold
using monetary decisions between smaller-sooner across tasks or populations (Rieger and Mata
and larger-later amounts of money, for example, 2015). More empirical studies investigating a
$10 today or $20 in 1 week. Overall, humans more culturally and age-diverse set of participants
seem to deviate from the assumption of economic are still needed to characterize age differences in
theory, which assumes exponential discounting such strategic social interactions.
Decision Making 629
Another area of research that has received satisfactory choices in many real-world consumer
some attention concerns decision making and environments (Mata and Nunes 2010).
problem solving in a social context. Such abilities In sum, aging seems to be associated with
are typically assessed by tallying the number and changes in decision making, from simple percep-
quality of solutions participants generate to deal tual decisions to complex social ones. The moti-
with everyday problems, for example, the course vational and cognitive mechanisms leading to
of action to take under nancial distress or how to such changes still need to be uncovered, as do
handle a social conict between members of a the task characteristics that foster or hinder suc-
couple. A meta-analysis of such problems con- cessful choices by aging decision makers. D
cluded that there is a decline in effectiveness of
everyday decision making (Thornton and Dumke
2005), with a medium effect size difference Cross-References
between younger and older adults (Hedges
g 0.4). However, moderator analyses revealed Aging and Strategy Use
that age differences were reduced when problems Decision-Making Capacity in Older Adults,
were of a social nature (Hedges g 0.2). Over- Overview of
all, the literature suggests that there may be Everyday Cognition
changes in social decision making, but it remains Risk Taking in Older Adulthood
an open issue whether these are due to motiva- Working Memory in Older Age
tional or cognitive factors.
References
Future Directions Agarwal, S., Driscoll, J. C., Gabaix, X., & Laibson,
D. (2009). The age of reason: Financial decisions over
An important avenue for future work concerns the life cycle and implications for regulation. Brookings
Papers on Economic Activity, 40, 51101.
evaluating the consequences of basic age-related Bernoulli, D. (1954). Exposition of a new theory on the
changes in motivational and cognitive changes on measurement of risk. Econometrica, 22, 2336.
real-world decisions. There is some evidence for Depping, M. K., & Freund, A. M. (2011). Normal aging
an inverted-U-shaped function of age and nan- and decision making: The role of motivation. Human
Development, 54, 349367.
cial decision making in the real world (Agarwal Engel, C. (2011). Dictator games: A meta study. Experi-
et al. 2009). Yet, the exact mechanism for this mental Economics, 14, 583610.
pattern remains unknown, and it could be a func- Gigerenzer, G., & Brighton, H. (2009). Homo Heuristicus:
tion of age-related changes in nancial knowl- Why biased minds make better inferences. Topics in
Cognitive Science, 1, 107143.
edge, numeracy, uid cognitive abilities, Glimcher, P. W., & Fehr, E. (Eds.). (2014).
motivation, or all of the above. Prospective and Neuroeconomics. San Diego: Elsevier.
longitudinal studies of decision making that Hess, T. M., Strough, J., & Lckenhoff, C. (2015). Aging
include real-world outcomes are yet to be and decision making. San Diego: Academic.
Mata, R., & Nunes, L. (2010). When less is enough: Cog-
conducted but are sorely needed to distinguish nitive aging, information search, and decision quality in
such different possibilities. consumer choice. Psychology and Aging, 25, 289298.
The area of consumer decision making provides Mata, R., Schooler, L. J., & Rieskamp, J. (2007). The aging
an interesting future test-bed for different theories decision maker: Cognitive aging and the adaptive selection
of decision strategies. Psychology and Aging, 22, 796810.
because it likely conates different inuences, Mata, R., Josef, A. K., Samanez-Larkin, G. R., & Hertwig,
including cognitive and motivational factors R. (2011). Age differences in risky choice: A meta-
(Yoon et al. 2009). One important principle to analysis. The Annals of the New York Academy of
keep in mind in such work is that age-related Sciences, 1235, 1829.
Mata, R., Pachur, T., von Helversen, B., Hertwig, R.,
cognitive decline may not always be associated Rieskamp, J., & Schooler, L. (2012a). Ecological rational-
with poor choice outcomes. For example, simple ity: A framework for understanding and aiding the aging
strategies that ignore information can lead to decision maker. Frontiers in Neuroscience, 6, 19.
630 Decision-Making Capacity in Older Adults, Overview of
Mata, R., von Helversen, B., Karlsson, L., & Cpper, Definition
L. (2012b). Adult age differences in categorization
and multiple-cue judgment. Developmental Psychol-
ogy, 48, 11881201. The necessary cognitive and functional abilities
Ratcliff, R., Thapar, A., & McKoon, G. (2007). Application required to perform a specic task or make a
of the diffusion model to two-choice tasks for adults specic decision.
7590 years old. Psychology and Aging, 22, 5666.
Rieger, M., & Mata, R. (2015). On the generality of age
differences in social and nonsocial decision making.
The Journals of Gerontology Series B: Psychological Introduction
Sciences and Social Sciences, 70, 202214.
Samanez-Larkin, G. R., & Knutson, B. (2015). Decision The term capacity refers to a persons ability to
making in the ageing brain: Changes in affective and
motivational circuits. Nature Reviews. Neuroscience, perform a specic task or make a specic deci-
16, 278289. sion. Determinations of capacity have historically
Samanez-Larkin, G. R., Mata, R., Radu, P. T., Ballard, been made by clinicians in clinical settings. This is
I. C., Carstensen, L. L., & McClure, S. M. (2011). in contrast to the legal term competency, which is
Age differences in striatal delay sensitivity during
intertemporal choice in healthy adults. Frontiers in a determination made by the court. At times these
Neuroscience, 5, 126. terms have been used interchangeably; however,
Shah, A. K., & Oppenheimer, D. M. (2008). Heuristics for the purposes of this section, we henceforth use
made easy: An effort-reduction framework. Psycholog- the terms clinical capacity and legal capacity.
ical Bulletin, 134, 207222.
Thornton, W. J. L., & Dumke, H. A. (2005). Age differ- Psychologists are increasingly called upon to
ences in everyday problem-solving and decision- make determinations of capacity. The reasons for
making effectiveness: A meta-analytic review. this are multifactorial. It is widely cited that the
Psychology and Aging, 20, 8599. number of older adults worldwide has grown
Tversky, A., & Kahneman, D. (1992). Advances in pros-
pect theory: Cumulative representation of uncertainty. exponentially. And while not all older adults
Journal of Risk and Uncertainty, 5, 297323. develop dementia, they may experience physical
Yoon, C., Cole, C. A., & Lee, M. P. (2009). Consumer and mental changes as they age that place them at
decision making and aging: Current knowledge and future risk for impaired capacity. There has also been
directions. Journal of Consumer Psychology, 19, 216.
shift of wealth from the World War II generation
to the baby boomers and now to the Generation X,
in increasingly diverse families that are separated
Decision-Making Capacity in Older geographically. Consequently, probate courts are
Adults, Overview of seeing an increase in contested wills and guard-
ianship proceedings (Moye and Marson 2007).
J. Kaci Fairchild1, Melissa A. Yanovitch2 and The probate law has also shifted from a global
Caitlin S. Moore3 and absolute view of capacity towards a more
1
Sierra Pacic Mental Illness Research Education task- or decision-specic standard of capacity,
and Clinical Center, VA Palo Alto Health Care recognizing a person can have capacity in one
System, Stanford University School of Medicine, area but not another. Thus to meet the current
Palo Alto, CA, USA legal standard of capacity, the capacity evaluation
2
PGSP-Stanford PsyD Consortium, Palo Alto, has also evolved to include neurocognitive, psy-
CA, USA chological, and functional assessments. Psychol-
3
Ryan Dolby Brain Health Center, California ogists are often trained in these assessments thus
Pacic Medical Center Neurosciences Institute, are well suited to conduct capacity evaluations
San Francisco, CA, USA (Lichtenberg et al. 2015).
Yet while psychologists may have the appro-
priate training to address the functional, cognitive,
Synonyms and mental health components of the evaluation,
they are often less familiar with the term capacity
Assessment; Competency; Decision-making or the interventions available to persons with
Decision-Making Capacity in Older Adults, Overview of 631
diminished capacity. To further complicate the This has shifted over time and current legal prac-
issue, professionals who often work with the pro- tice uses the term capacity to refer to a persons
bate laws surrounding capacity (i.e., lawyers and ability to complete a specic task or decision
judges) may be less familiar with the unique needs (Bailar-Heath and Moye 2014), thus recognizing
of and challenges in working with older adults. So that a person can have capacity in one area (e.g.,
in 2003, the American Bar Association (ABA) medical decision-making) but not another (e.g.,
and the American Psychological Association driving). Another relatively recent change has
(APA) formed a workgroup to develop educa- replaced the term incompetency with the
tional materials and handbooks for lawyers, term incapacity as the determination of these D
judges, and psychologists. The intent of this have evolved to integrate clinical ndings into
workgroup was to provide a framework for pro- legal ndings in a multidisciplinary manner
fessionals to draw upon in capacity determina- (American Bar Association and American Psy-
tions as opposed to more rigid standards of chological Association Assessment of Capacity
practice. The workgroup produced the rst hand- in Older Adults Project Working Group 2008).
book, Assessment of Older Adults with Dimin- This shift is in keeping with the view of capacity
ished Capacity: A Handbook for Lawyers, in as being decision relevant, which holds that judg-
2005. The second handbook, Judicial Determina- ments of capacity are for specic abilities at spe-
tion of Capacity of Older Adults in Guardianship cic time in a specic context and relevant to a
Proceedings: A Handbook for Judges, was specic decision (Buchanan and Brock 1989).
published in 2006. The nal handbook, Assess- The past few decades have yielded signicant
ment of Older Adults with Diminished Capacity: reform in legal practice pertaining to adult guard-
A Handbook for Psychologists, was published in ianship in the United States. The ABA denes
2008. These handbooks are available online at guardianship as legal decision-making power
www.apa.org/pi/aging and www.abanet.org/ given to an outside entity or person in response
aging (American Bar Association and American to a determination of incapacity. The term itself is
Psychological Association Assessment of Capac- often used interchangeably with conservator-
ity in Older Adults Project Working Group 2008). ship depending on the state or country in which
The following sections will detail the evolution the determination is being made and may be used
of the legal capacity and guardianship laws; the in reference to guardianship of property speci-
core ethical principles inherent in decision- cally (American Bar Association and American
making capacity; the requisite functional abilities Psychological Association Assessment of Capac-
for determinations of capacity; the role of culture ity in Older Adults Project Working Group 2008;
in capacity evaluations; a framework for capacity Bailar-Heath and Moye 2014). Criteria for guard-
evaluations; and future directions for the eld. ianship fall under state and not federal regulation,
and thus there is variability across states in how
Evolution of Legal Capacity and Guardianship guardianship determinations are made. These
Over the past 65 years, the legal aspects of capac- decisions are dened by either statutory or case
ity evaluations have undergone signicant change law and are transaction specic. Examples of
in the United States and internationally. In transaction-specic capacity include testamentary
essence, there has been a shift towards increased capacity, donative capacity, contractual capacity,
autonomy and limited guardianship, resulting in capacity to execute a durable power of attorney,
various legal reforms. Historically, the concept of and capacity to consent to medical care. Despite
capacity was global and absolute in that a person the inconsistency in legal denition, basic guide-
deemed incapacitated would have his or her legal lines for determining diminished capacity include
rights revoked in a broad range of legal domains disabling condition, functional behavior, cogni-
(American Bar Association and American Psy- tive functioning, and consideration of the least
chological Association Assessment of Capacity restrictive alternative. These guidelines are com-
in Older Adults Project Working Group 2008). monly expanded upon by state law (American Bar
Association and American Psychological Associ- benchmark of an individuals ability to care for
ation Assessment of Capacity in Older Adults person or property (Bailar-Heath and Moye
Project Working Group 2008). 2014). In Germany, the guardianship model has
As part of the recent capacity reforms, 32 states shifted focus towards a care and assistance
have passed comprehensive reform bills, and model that allows the individual to be appointed
261 separate capacity laws have been passed. with a caretaker who carries out specic tasks as
Currently, more than 30 states now require clinical dened by the court, protecting the incapacitated
evaluation for capacity to determine whether an individual from losing his or her legal rights.
adult may qualify for guardianship (Bailar-Heath Sweden offers two possibilities for legal support
and Moye 2014). Further, the majority of US for incapacitated persons. In both, the individual
states have done away with the global and abso- is appointed an administrator, mentor, or
lute determination of incapacity in favor of the trustee that is responsible for assisting him or
relatively recent model of limited guardianship. In her. Additionally, the person may forfeit legal
the limited guardianship model, a guardian is capacity in specied domains only or may not
appointed on for the areas in which the person lose any of his or her legal rights. Israel is gradu-
has been deemed to lack capacity (American Bar ally transitioning from guardianship laws that
Association and American Psychological Associ- eradicate the legal rights of the individual in all
ation Assessment of Capacity in Older Adults domains, to the appointment of a guardian and
Project Working Group 2008). In determining retention of legal competence (Bailar-Heath and
whether a person is in need of guardianship, all Moye 2014).
states begin with the assumption of capacity and In Hong Kong, the courts that determine
put the burden of proof on the party attempting to guardianship appointment are multidisciplinary
establish guardianship. In other words, every per- panels made up of lawyers, someone who has
son is assumed to have capacity until established personal experience with incapacitated individ-
otherwise. uals, and either physicians, psychologists, or
In contrast to the variability of laws pertaining social workers. The structure of the panels in
to capacity determinations based on state jurisdic- Hong Kong illustrates the shift towards a
tion in the United States, international law offers a psycholegal construct of capacity that has been
more unifying standard. Since the 1960s, guard- the recent trend in numerous countries. Similarly,
ianship law has been of particular concern in Australian guardianship tribunals include mem-
many countries. In 2006, the Convention on the bers of the community as well as legal profes-
Rights of Persons with Disabilities (CRDP) sionals, and various provinces in Canada require
marked a major international milestone in the collaboration of legal and clinical professionals
legal rights of persons deemed to have diminished (Bailar-Heath and Moye 2014).
capacity. The CRDP brought signicant changes The legal aspects of capacity evaluations are
to the laws of member nations to protect the legal complicated by variance in laws according to
rights, status and autonomy of incapacitated country and state jurisdiction. However, recent
adults, and to provide support to this legally vul- reforms both in the United States and internation-
nerable population (Bailar-Heath and Moye ally point to a shift in consciousness towards
2014). Among other things, these changes mark providing those who are legally determined to be
an increase in the emphasis on autonomy and incapable of safely making decisions about their
independence, cultural sensitivity, and the consid- person or property the least restrictive guardian-
eration of least restrictive alternatives (Doron ship and preserving many of their legal rights. By
2002). including clinical assessments in legal proceed-
Within the broader legal standards outlined in ings that determine capacity, the system is begin-
the CRDP, the laws regarding capacity determina- ning to allow for a more holistic view of the
tions vary by country. Canada, the United King- individuals abilities as opposed to the historically
dom, and Portugal dene incapacity using the broad revocation of legal rights.
Principlism in Health Care obligates providers to act on the basis of unbiased

The concept of capacity spans the elds of health decision-making in the face of competing claims.
care and law. Yet health-care ethics is a third area Thus the principle of justice extends beyond equi-
which is central to the concept of capacity. table access to treatment, as it obligates providers
Principlism is system of ethics deployed in health to be aware of their own biases to ensure the fair
care that based on four moral principles of: distribution of health-care resources.
(1) respect for autonomy, (2) benecence, These four principles are not hierarchical; thus
(3) nonmalecence, and (4) justice. clinicians have an obligation to uphold each of
The principle of respect for autonomy, also them. While this is the ideal, ethical clinical prac- D
referred to as self-determination, is the persons tice dictates that the clinician must examine the
ability to make his or her own decisions. This balance of these principles by examining their
principle is rooted in the longstanding belief respective weights on a case-by-case basis. Thus
of the importance of personal freedom and indi- to weigh the respective weights is to carefully
vidualism. Health-care providers are tasked evaluate the risks involved in the situation.
with ensuring that autonomous decisions are There are no hard and fast rules that dictate that
intentionally made, with substantial understand- one principle take precedence over another. To
ing, and free from coercion (Beauchamp 2007; further complicate the matter, different profes-
Beauchamp and Childress 2011). sionals may place a greater emphasis on different
Benecence may be viewed as a group of principles. When faced with the same clinical
principles that both prevents harm and also pro- case, providers may recommend different treat-
vides benets that outweigh costs and risks. This ments based on their evaluation of the potential
principle reects the moral obligation to act for the risks and benets involved. For example, a pro-
benet of others and is often considered a foun- vider may recommend an older adult with a his-
dational value in health-care ethics. It could be tory of falls and mild cognitive impairment be
argued that the obligation to promote patient wel- discharged to home with the assistance of home
fare is of the utmost importance in medicine. health aides in order to promote the respect for the
Benecence obligates health-care providers to patients autonomy. However, another provider,
assist older adults in furthering their interests, when presented with the same clinical scenario,
often by removing or minimizing risk and harm may recommend the patient be discharged to an
to the patient (Beauchamp 2007). assisted living facility in order to promote the
The principle of nonmalecence prevents pro- principle of benecence (i.e., prevent the patient
viders from causing harm to others, or put simply from sustaining future harm). As is highlighted in
is the do no harm principle. While benecence this example, determinations of capacity are often
includes the prevention of harm or reduction of a balancing act between these foundational prin-
risk for the ultimate benet of the patient, ciples of health-care ethics.
nonmalecence is the intention to avoid unneces-
sary harm or injury to the patient. As noted by Essential Functional Abilities
Beauchamp (Beauchamp 2007), nonmalecence Assessment of functional abilities is a core com-
is one of the most frequently cited codes in health- ponent of capacity evaluations. In the eld of
care ethics. Some have advocated to place the geropsychology, the concept of functional abili-
greatest emphasis upon this obligation, even if ties often refers to a persons ability to perform
that is to the detriment of other obligations, includ- activities of daily living (i.e., bathing, grooming,
ing the respect for autonomy. Nonmalecence obli- eating) and instrumental activities of daily living
gates providers to inict the least amount of harm (i.e., shopping, bill payment, household chores).
to achieve a benecial outcome. Yet in capacity evaluations, the legal concept of
Finally, the principle of justice requires the functional abilities also refers to the intact deci-
fair distribution of benets, costs, and risks sional abilities that are generally agreed to convey
(Beauchamp 2007). Put another way, this principle capacity (Lichtenberg et al. 2015). These abilities,
which are drawn from case law, include under- a choice should not be minimized as there are
standing, appreciation, reasoning, and expressing situations in which a person may be able to under-
a choice (Grisso 2003; Smyer 2007). stand, appreciate, and rationally reason about a
In the context of capacity assessments, under- decision; however, due to a physical condition,
standing refers to the ability to comprehend such as stroke, is unable to express a choice. In
the nature of a proposed decision, including an situations such as this, it is impossible to know
awareness of its risks and benets. The ability to what that persons preference or desire would be.
adequately understand a proposed decision is In addition to these four functional abilities,
impacted by several factors including the persons the role of values in the determination of capacity
intelligence, educational level, and the method by cannot be overstated. The ABA and APA Assess-
which the information is presented to them. The ment of Capacity in Older Adults Project Working
risks and benets of a decision must be presented Group (American Bar Association and American
to a person in a manner that promotes their Psychological Association Assessment of Capac-
understanding. ity in Older Adults Project Working Group 2008)
While there are different interpretations of dened values as an underlying set of beliefs,
appreciation, it is generally thought to refer to concerns, and approaches that guide personal
the ability to understand the relevance or applica- decisions. This denition is useful as it not only
bility of a decision to the older adult. At the most denes values but also highlights the relationship
basic level, older adults must recognize that a between values and decision-making. As high-
decision must be made, that they are the lighted in Moye (Moye 2007), the extent to
decision-maker, and it is their life that will be which a persons expressed choice is consistent
affected by the decision. Thus it is not surprising with their values is an indicator of capacity; thus,
that appreciation is greatly impacted by the degree it is an essential component to the assessment of
of patient insight, as well as the type of decision to these functional abilities. An understanding of a
be made and the complexity of that decision. persons values will also greatly assist in the
Reasoning entails the process of rationally development of appropriate treatment recommen-
comparing different treatment options or pro- dations. Providers should also be aware of their
posed solutions in a consistent manner. Older own values so that any inherent biases regarding
adults must demonstrate that they can weigh the the decision at hand can be appropriately
risks and benets of the proposed choices as well addressed.
as the possible consequences. The ability to rea-
son directly impacts understanding and apprecia- The Role of Culture in Capacity
tion. If a person cannot rationally reason or In addition to being one of the fastest growing
logically manipulate the presented information, segments of society, older adults are one of the
it is not possible to fully understand or appreciate most culturally diverse groups. That diversity is
the issues in the decision (Grisso and Appelbaum projected to continue to expand in coming years
1998). as evidenced by recent US census data. In 2014,
Older adults must also be able to express a 14% of the adults in the United States were age
choice; those who are unable to outwardly com- 65 or older. A closer analysis of this census data
municate a choice or who waver in their choice are reveals that within this older segment of the US
seen as lacking capacity (Lichtenberg et al. 2015; populace, approximately 1 in 7 (14%) sampled
American Bar Association and American Psycho- identied as a racial minority. That percentage of
logical Association Assessment of Capacity in racial minorities is projected to steadily grow to
Older Adults Project Working Group 2008; 18% by 2030 and 23% by 2050 (U. S. Census
Grisso 2003). That choice should be consistent Bureau 2014). As noted by Karel (2007), within
with the persons value or beliefs; however, it is these racial groups are further subgroups (denoted
accepted that a persons value and beliefs may by their countries of origin) with their own values
change over time. The importance of expressing and beliefs. These values and beliefs are often the
foundation for their views on aging, health care, situation, ways of enhancing capacity, and a clin-
family and familial roles, nances, and end-of- ical judgment of capacity.
life. Among older White Americans, there are While a capacity assessment is a clinicians
further ethnic, regional, and religious subgroups. opinion about a persons ability to perform a spe-
And not surprisingly, these subgroups have strong cic task or make a specic decision, that task or
values and beliefs that inuence their views on decision has a specic legal standard. A clinical
many of the abovementioned issues. judgment regarding a persons capacity can then
There are also cross-cultural differences within have a direct impact on that persons legal rights
the aforementioned principles of health-care henceforth. Therefore, a familiarity with the legal D
ethics. In Western cultures, the principle of respect standard is a requisite initial step in the approach
for autonomy or self-determination is strongly to a capacity assessment. The expectation here is
valued. This is evident in the widespread use of not that a provider becomes an expert in the legal
advance care directives and durable powers of standards surrounding the capacity in question,
attorney, which are designed to foster patient but more that the provider becomes familiar with
autonomy in situations where patients are unable the legal standard. This can be accomplished
to make their own decisions. This emphasis on through a review of a states statutory or case
patient autonomy is unique to Western cultures, as law or through a consultation with an attorney.
other cultures encourage collective decision- Information gleaned from this review or consul-
making that involves the patients community tation should be then used to guide the selection of
and family. In cultures that value benecence, the assessment battery, so as to ensure all aspects
providers are obligated to encourage hope above of the legal standard are met (American Bar Asso-
all else. This is contrasted with those cultures that ciation and American Psychological Association
value nonmalecence, in which providers protect Assessment of Capacity in Older Adults Project
patients from harm by not directly addressing Working Group 2008). It should be noted that
seemingly negative outcomes such as death or from the legal perspective, all persons are pre-
end-of-life (Searight and Gafford 2007). sumed to have capacity until proven otherwise.
The ABA-APA framework builds off of the
Conceptual Framework of Capacity previous work by Grisso (1986) to expand the
The ABA-APA Working Group on the Assess- concept of function to also include the identi-
ment of Capacity in Older Adults detailed a cation and evaluation of the functional elements
nine-part framework for conceptualizing capacity essential to the questioned capacity. Capacity
assessments (American Bar Association and assessments should include a tailored evaluation
American Psychological Association Assessment of the specic task or specic decision which can
of Capacity in Older Adults Project Working be accomplished through specic questions in a
Group 2008). The model builds off of the frame- clinical interview as well as through direct assess-
works for guardianship as well as the framework ment or observation of the persons functioning
for capacity assessment previously developed by (American Bar Association and American Psy-
Grisso (American Bar Association and American chological Association Assessment of Capacity
Psychological Association Assessment of Capac- in Older Adults Project Working Group 2008).
ity in Older Adults Project Working Group 2008; This portion of the capacity assessment will vary
Grisso 2003; Moye 2007). Components of the based upon to the type of decision-making capac-
nine-part framework proposed by the ABA-APA ity being assessed. For instance, if the assessment
work group includes the identication of: the rel- is one of nancial decision-making, the provider
evant legal standards, functional abilities of should include a structured assessment of nan-
capacity, relevant medical or psychiatric diagno- cial decision-making. If the assessment were one
ses contributing to incapacity, cognitive function, of testamentary capacity, the provider should
psychological and emotional factors, values and include specic questions in the clinical interview
preferences, risks to the individual and of the designed to demonstrate a persons ability to
describe a will, to describe the nature and extent of through their effect on cognitive functioning.
ones assets, to name potential heirs, and to Impaired cognitive functioning can result in
describe plans for distribution of ones wealth. impaired insight or impairment in the cognitive
This focus on functional abilities specic to the abilities necessary to perform a specic task or
task or decision to be made is a dening feature of make a specic decision. This portion of the
the capacity assessment. capacity assessment should include assessments
The purpose of establishing or documenting a designed to comment directly on the cognitive
diagnosis in the capacity assessment is to identify functions necessary to perform a specic task or
a possible causal factor for potential incapacity specic decision, in addition to measures of over-
(Grisso 2003). Older adults are vulnerable to all cognitive function. For instance, assessments
many physical and psychiatric illnesses that may of nancial capacity may include measures of
impact capacity including dementia, delirium, written arithmetic whereas an assessment of driv-
neurodegenerative disease (e.g., Parkinsons, ing capacity may include measures of visual atten-
Alzheimers), stroke, and many more. Yet these tion and processing speed (American Bar
conditions can have markedly different long-term Association and American Psychological Associ-
outcomes, thus it is important to recognize the ation Assessment of Capacity in Older Adults
role of the prognosis of the condition in judgments Project Working Group 2008). As with the deter-
of decision-making capacity. For instance, mination of medical and psychiatric diagnoses,
Alzheimers disease is a progressive neurodegen- the purpose of the cognitive assessment is to
erative disorder for which there is no cure. This is characterize the level and nature of cognitive impair-
contrasted with delirium, which is a life- ment and determine if (and how) the decision-
threatening medical condition in which a persons making process is impacted by cognitive status.
cognition can rapidly uctuate, though with med- Similar to the cognitive assessments, the pur-
ical intervention can fully resolve. In both of these pose of the screening for symptoms of mental
conditions, patients will have impaired decision- health disorders is to detect possible underlying
making ability. Yet in the case of delirium, factors that may impact a persons decision-
patients are often able to fully recover decision- making ability. Mental health disorders, like
making abilities while those patients with psychotic spectrum disorders and severe mood
Alzheimers disease are not likely to regain their disorders, can impair a persons insight and ability
decision-making ability (American Bar Associa- to rationally weigh the risks and benets of the
tion and American Psychological Association proposed choices as well as the possible conse-
Assessment of Capacity in Older Adults Project quences. Many mental health disorders are ame-
Working Group 2008). While a diagnosis can nable to intervention which presents with greater
serve as a causal factor for the impaired likelihood that the patient will regain decision-
decision-making, it can also serve as a prognostic making ability (American Bar Association and
indicator as to if capacity is likely to be regained. American Psychological Association Assessment
Yet a medical or psychiatric diagnosis by itself is of Capacity in Older Adults Project Working
insufcient to establish a patients decision- Group 2008). It should be noted that many
making capacity as patients with impaired cogni- patients with clinically signicant mental health
tive function due to a medical or psychiatric symptoms are not captured by strict criteria-based
disorder may still retain the ability to make some diagnostic categories (Lyness et al. 2015), thus
decisions. Thus the focus should not be on the again the focus of these measures is not just diag-
presence of the diagnosis but on the inuence of nosis but to comment on the impact of the mental
the diagnosis on the persons decision-making. health symptoms on cognitive and functional abil-
Most states include a comment on a persons ities relevant to the questioned capacity.
cognitive function as a necessary element in the As aforementioned, values are the beliefs,
determination of capacity. The causative role that concerns, and experiences that directly inform
many diagnoses have on decision-making is often ones decisions. The ABA-APA handbook
distinguishes values from preferences, as former American Psychological Association Assessment

refers to preferred option of various choices that of Capacity in Older Adults Project Working
is informed by values. Assessment of values and Group 2008).
preferences is an essential component to a capac- All capacity evaluations should include con-
ity assessment as one of the requisite functional siderations of what can be done to maximize a
abilities is the expression of a choice that is con- patients functioning. As noted by Moye (2007),
sistent with a persons values. It should be noted many of these recommendations are practical in
that values and preferences can change over time nature and include things such as hearing or visual
thus a change in persons values may not represent aids or medication management systems. Other D
impaired decision-making capacity (American interventions may include work with occupational
Bar Association and American Psychological or physical therapy as well as additional training
Association Assessment of Capacity in Older or counseling. Efforts to maximize patient func-
Adults Project Working Group 2008). In addition tioning represent opportunities for potential clini-
to conveying capacity, knowledge of a patients cally impactful interventions (American Bar
values and preferences can assist in the develop- Association and American Psychological Associ-
ment of effective treatment recommendations that ation Assessment of Capacity in Older Adults
are more likely to be accepted by the patient. Project Working Group 2008).
Some have argued that at its most basic, a In the nal component of the ABA-APA
capacity evaluation is a type of risk assessment framework, the provider takes into consideration
(American Bar Association and American Psy- all of the data gathered through the capacity eval-
chological Association Assessment of Capacity uation and provides a clinical opinion regarding
in Older Adults Project Working Group 2008; the patients questioned capacity. This clinical
Moye 2007; Ruchinskas 2005). The provider opinion is oft expected to be presented in the
must consider all available data, including medi- form of a dichotomous conclusion (e.g., yes or
cal and psychiatric diagnoses, cognitive and func- no). There will be situations in which the deter-
tional impairment, and patient values and mination of capacity will be clear based upon the
preferences, in the context of the risk of the situ- available information such as when a patient is
ation. In addition to evaluating the patient in terms grossly impaired across multiple cognitive and
of the risk of the situation, the provider should functional domains or is unable to express a
also take account of social and environmental choice due to signicant neurological impairment.
supports, as these may serve to mitigate or exac- Other decisions are more complex due to varying
erbate the initial risk (American Bar Association levels of impairment across multiple domains. In
and American Psychological Association Assess- situations such as these, providers are encouraged
ment of Capacity in Older Adults Project Working to review the available data in the context of the
Group 2008; Moye 2007). For instance, the dis- patients values and preferences as well as any
charge of an older adult with limited mobility to environmental supports or risks (American Bar
independent living would carry more risk if that Association and American Psychological Associ-
older adult lived in a two-level home and had no ation Assessment of Capacity in Older Adults
immediate family in the area to provide assis- Project Working Group 2008).
tance. Those risks would be mitigated, however,
if the older adult had the nancial means to install
a stairway lift and employ regular home health Conclusion
aides to assist him. Thus these risks were miti-
gated with effective interventions to enhance the The rapid global growth of older adults has com-
older adults capacity. All recommended interven- pelled geropsychologists to gain the requisite
tions should match the level of risk in the situation knowledge and skills to address issues surround-
so to ensure the deployment of the least restrictive ing capacity. This topic is particularly relevant
means necessary (American Bar Association and to geropsychologists as these professionals
understand the physical and mental changes that health care ethics (2nd ed., pp. 310). Chichester:
occur in late life and can often increase the risk of Wiley.
Beauchamp, T., & Childress, J. (2011). Principles of bio-
impaired capacity. Geropsychologists are also medical ethics (5th ed.). Oxford: Oxford University
trained in the psychological, neurocognitive, and Press.
functional assessments that are included in the Buchanan, A. E., & Brock, D. W. (1989). Deciding for
capacity assessment. Yet while geropsychologists others: The ethics of surrogate decision-making. Cam-
bridge: Cambridge University Press.
have the clinical expertise, they are often less Doron, I. (2002). Elder guardianship kaleidoscope-A com-
familiar with the legal standards required to deter- parative perspective. International Journal of Law,
mine capacity. The legal and health-care elds Policy and the Family, 16, 368398.
continue to evolve in their denitions of capacity Grisso, T. (1986). Evaluating competencies. New York:
Plenum.
as the focus has shifted towards one that recog- Grisso, T. (2003). Evaluating competencies: Forensic
nizes capacity to be decision and domain specic assessments and instruments (2nd ed.). New York:
as opposed to a global judgment of ability. Kluwer.
Geropsychologists may nd capacity evaluations Grisso, T., & Appelbaum, P. A. (1998). The assessment of
decision-making capacity: A guide for physicians and
to be a type of risk assessment that requires the other health professionals. Oxford: Oxford University
balancing of the four moral health-care principles, Press.
which requires an understanding and appreciation Karel, M. (2007). Culture and medical decision-making. In
of the role of culture on these principles. While S. H. Qualls & M. Smyer (Eds.), Changes in decision-
making capacity in older adults. Assessment and inter-
there are no current gold standards for the vention (pp. 145176). Hoboken: Wiley.
assessment of capacity, there are conceptual Lichtenberg, P. A., Qualls, S. H., & Smyer, M. A. (2015).
frameworks as well as other assessment-specic Competency and decision-making capacity: Negotiat-
tools available to assist those in evaluations such ing health and nancial decision-making. In
P. A. Lichtenberg & B. T. Mast (Eds.), APA handbook
as these. Psychologists who work with older of clinical geropsychology: Vol. 2. Assessment, treat-
adults are encouraged to explore these frame- ment, and issues in later life (pp. 553578). Washing-
works and suggested assessments as they move ton, DC: American Psychological Association.
towards achieving competency in assessment of Lyness, J. M., King, D. A., Cox, D., Yoediono, Z., &
Caine, M. D. (2015). The importance of subsyndromal
decision-making capacity. depression in older primary care patients: Prevalence
and associated functional disability. Journal of Ameri-
can Geriatrics Society, 47(6), 647652.
Cross-References Moye, J. (2007). Clinical frameworks for capacity assess-
ment. In S. H. Qualls & M. Smyer (Eds.), Changes in
Clinical Issues in Working with Older Adults decision-making capacity in older adults. Assessment
and intervention (pp. 177190). Hoboken: Wiley.
Cognition
Moye, J., & Marson, D. C. (2007). Assessment of decision-
making capacity in older adults: An emerging area of
practice and research. The Journal of Gerontology:
References Psychological Sciences, 62(1), P3P11.
Ruchinskas, R. (2005). Risk assessment as an integral
American Bar Association and American Psychological aspect of capacity evaluations. Rehabilitation Psychol-
Association Assessment of Capacity in Older Adults ogy, 50, 197200.
Project Working Group. (2008). Assessments of older Searight, H. R., & Gafford, J. (2007). Cultural diversity at
adults with diminished capacity: A handbook for psy- the end of life: Issues and guidelines for family physi-
chologists. Washington, DC: American Bar Associa- cians. American Family Physician, 71(3), 515522.
tion and American Psychological Association. Smyer, M. (2007). Aging and decision-making capacity:
Bailar-Heath, M., & Moye, J. (2014). International per- An overview. In S. H. Qualls & M. Smyer (Eds.),
spectives on capacity assessment. In N. A. Pachana & Changes in decision-making capacity in older adults.
K. Laidlaw (Eds.), The Oxford handbook of clinical Assessment and intervention (pp. 324). Hoboken:
geropsychology (pp. 248266). London: Oxford Uni- Wiley.
versity Press. U. S. Census Bureau. (2014). Prole of selected social
Beauchamp, T. L. (2007). The four principles approach to characteristics. Retrieved February 22, 2016 from,
health care ethics. In R. E. Ashcroft, A. Dawson, http://factnder.census.gov/faces/tableservices/jsf/pages/
H. Draper, & J. R. McMillan (Eds.), Principles of productview.xhtml?pid=ACS_14_5YR_DP02&src=pt
Delirium 639
delirium with subtypes. These include delirium

Delirium due to an underlying medical condition (delirium
due to a medical condition), medications
Nadine A. Schwab1, Catherine C. Price1,2 and (substance-induced delirium, substance intoxica-
Terri G. Monk3 tion delirium), or withdrawal from medications
1
Department of Clinical and Health Psychology, (substance withdrawal delirium). Delirium can
University of Florida, Gainesville, FL, USA also be multifactorial (delirium due to multiple
2
Department of Anesthesiology, University of etiologies) (see Table 1 for criteria and descriptor
Florida, Gainesville, FL, USA information; ICD-10 criteria are presented in D
3
Department of Anesthesiology and Perioperative Table 2). Delirium can be present at hospital
Medicine, University of Missouri-Columbia, admission and presurgically, although it is more
Columbia, MO, USA often seen in postsurgically managed general
medical units and most frequently in intensive
care units (ICUs).
Synonyms
Confusion; Derangement; Irrationality; General Characteristics of Delirium

Hallucination
Delirium characteristics can vary by individual.
Delirium is characterized by an acute change in an Most common is uctuating arousal with waxing
individuals mental state, marked by uctuating and waning awareness of orientation. It is often
patterns of confusion and inattention. It is unfor- accompanied by altered sleep-wake cycle and
tunately encountered by nurses, family, and phy- reversed night cycles. Hallucinations and delu-
sicians, both in hospital and home-based care sions are common. Variability can be seen in
settings. Delirium can affect individuals of any activity levels; however, patients can present
age, though it is more frequently experienced by with hyperactive, hypoactive, or mixed hyper-
older individuals. It raises the risk of mortality, hypo active cognitive and motor states.
causes distress to both patients and caregivers, and Hyperactive patients show increased psychomo-
increases health care expenditures. It is an acute tor activity, such as rapid speech, irritability, and
condition that may present independently or in restlessness. These patients can be disruptive,
combination with other dementia syndromes; time-consuming, and harmful to staff. They are
therefore, accurate diagnosis and timely treatment therefore more readily identied and treated.
are imperative. In this entry, the authors discuss Hypoactive patients, by contrast, typically show
delirium in the general hospitalized patient, then a calm appearance combined with inattention,
subsequently focused on postoperative delirium decreased mobility, and have difculty answering
for major orthopedic and cardiac surgeries that simple questions about orientation. Due to their
have the highest rates of delirium-affected calm appearance, these individuals are unfortu-
individuals. nately less readily identied with delirium and
may be inappropriately treated (Peritogiannis
et al. 2015).
Delirium Defined
Delirium is an acute and temporary change in Significance of Delirium

orientation and cognition. The Diagnostic and
Statistical Manual of Mental Disorders (DSM-V; Although a temporary condition, delirium is a
American Psychiatric Association and American medical and societal stressor from an economic
Psychiatric Association, DSM-5 Task Force 2013, and healthcare standpoint. Delirium occurs in at
www.dsm5.org) provides a description of least 1024% of the general patient population,
640 Delirium
Delirium, Table 1 The following criteria are derived Delirium, Table 2 The following criteria are derived
from the Diagnostic and Statistical Manual of Mental from the 2016 ICD-10 Procedure Coding System (ICD-
Disorders, 5th ed. All criteria (A-E) are required for 10-PCS)
diagnosis
ICD-10 diagnostic criteria
DSM-V diagnostic criteria for delirium (A) Clouding of consciousness, i.e., reduced clarity of
(A) A disturbance in attention (i.e., reduced ability to awareness of the environment, with reduced ability to
direct, focus, sustain, and shift attention) and awareness focus, sustain, or shift attention
(reduced orientation to the environment) (B) Disturbance of cognition, manifest by both:
(B) An additional disturbance in cognition (e.g., (1) impairment of immediate recall and recent memory,
memory decit, disorientation, language, visuospatial with relatively intact remote memory; and
ability, or perception) (2) disorientation in time, place, or person
(C) The disturbances in Criteria A and C are not better (C) At least one of the following psychomotor
explained by another preexsisting, established, or disturbances:
evolving neurocognitive disorder and do not occur in the (1) Rapid, unpredictable shifts from hypoactivity to
context of a severely reduced level of arousal, such as a hyperactivity
coma (2) Increased reaction time
(D) There is evidence from the history, physical (3) Increased or decreased ow of speech
examination, or laboratory ndings that the disturbance is
(4) Enhanced startle reaction
a direct physiological consequence of another medical
condition, substance intoxication, or withdrawal (i.e., due (D) Disturbance of sleep or the sleep-wake cycle,
to a drug of abuse or to a medication), or exposure to a manifest by at least one of the following:
toxin, or is due to multiple etiologies (1) Insomnia, which in severe cases may involve total
Specify whether: sleep loss, with or without daytime drowsiness, or
reversal of the sleep-wake cycle
Substance intoxication delirium
(2) Nocturnal worsening of symptoms
Substance withdrawal delirium
(3) Disturbing dreams and nightmares which may
Medication-induced delirium
continue as hallucinations or illusions after awakening
Delirium due to another medical decision
(E) Rapid onset and uctuations of the symptoms over
Delirium due to multiple etiologies the course of the day
Specify if: (F) Objective evidence from history, physical and
Acute: Lasting a few hours or days neurological examination, or laboratory tests of an
Persistent: Lasting weeks or months underlying cerebral or systemic disease (other than
Specify if: psychoactive substance related) that can be presumed to
Hyperactive: The individual has a hyperactive level be responsible for the clinical manifestations in AD
of psychomotor activity that may be accompanied by Comments: Emotional disturbances such as depression,
mood lability, agitation, and/or refusal to cooperate with anxiety or fear, irritability, euphoria, apathy or wondering
medical care perplexity, disturbances of perception (illusions or
Hypoactive: The individual has a hypoactive level hallucinations, often visual), and transient delusions are
of psychomotor activity that may be accompanied by typical but are not specic indications for the diagnosis
sluggishness and lethargy that approaches stupor Use the fourth character to indicate whether the delirium
Mixed level of activity: The individual has a normal is superimposed on dementia or not: F05.0 Delirium, not
level of psychomotor activity even though attention and superimposed on dementia; F05.1 Delirium,
awareness are disturbed. Also includes individuals whose superimposed on dementia; F05.8 Other delirium; F05.9
activity level rapidly uctuates Delirium, unspecied
with reports up to 50% of hospitalized older adults Assessing Delirium

(over 65) (Inouye et al. 2014). Indirect costs of
delirium stem from lost work and personal pro- To assist with diagnosis, a number of investigators
ductivity by patients and caregivers and have been have collaborated to develop and validate rapid
estimated to total more than $164 billion in the bedside approaches to diagnose patients at the
USA alone (Inouye et al. 2014). Acute postopera- bedside and ICU. The Confusion Assessment
tive delirium has been shown to be an independent Method (CAM; Inouye et al. 1990) is the most
predictor of functional decline and morbidity after well-known measure for assessing delirium. The
cardiac and orthopedic surgeries. CAM assesses four features: acute onset and
Delirium 641
uctuating course (feature 1), inattention (feature 2), consciousness, cognitive function, and psycho-
disorganized thinking (feature 3), and altered level motor activity. The NuDESC is a measure used
of consciousness (feature 4). Delirium diagnosis exclusively in surgical and recovery ward patients
requires the presence of features 1 and 2 and either and can be administered by trained nursing staff. It
3 and 4 (note that memory impairment is not consists of a 5-item scale assessing disorientation,
included, for this is sometimes absent in mild delir- inappropriate behavior and communication, hal-
ium, whereas it is present in other conditions, such lucinations, and psychomotor retardation over a
as dementia (Inouye et al. 1990)). 24-h period. See Table 3.
The Society of Critical Care Medicine has D
strongly recommended routine evaluation of
delirium in ICU patients. For critically ill patients Prevalence of Delirium Type
where delirium prevalence ranges from 11% to and Considerations for Risk Factors
87% (Aldemir et al. 2001; Ely et al. 2001a), the in General Medical and Surgical
CAM-ICU (Ely et al. 2001b) was designed. It Populations
assesses the same four features of the original
CAM, but relies more on nonverbal responses. The prevalence of delirium is reported highest
For this exam, patients are observed to assess before hospital discharge, this being often associ-
the presence of acute mental status change, inat- ated with respiratory infections, cellulites, and
tention, disorganized thinking, and altered levels urinary tract/kidney infections. Central nervous
of consciousness. We encourage you to review system disorders have the second most frequently
some excellent video introductions to the reported delirium codes with this particularly seen
CAM-ICU available via the Internet. among those having craniotomy, CNS neoplasms,
The CAM has been translated into 20 other degenerative nervous system disorders, strokes/
languages including Chinese, Dutch, German, transient and other seizures/headaches, and other
and Spanish, with the CAM-ICU having high nervous system disorders (Lin et al. 2010).
validity relative to other delirium scales available Delirium due to a medical condition is the most
in those languages. Overall, the CAM and common type of delirium, with drug-induced
CAM-ICUs simple algorithms allow them to be delirium being the second most frequently
useful for rapid identication of delirium by both reported (Lin et al. 2010). Patients with drug-
physicians and staff nurses. After training, both induced delirium, however, are typically younger
scales should take approximately 2 min to than the other delirium groups and had the lowest
administer. proportion of comorbidities. Drug-induced delir-
Aside from the CAM instruments, other fre- ium was also most common in patients who have
quently encountered screening tools include the lower extremity orthopedic surgery (relative to
Delirium Rating Scale-Revised-98 (DRS-R-98; comparison groups of patients with pneumonia,
Trzepacz et al. 2001), the Memorial Delirium urinary tract infection, congestive heart failure)
Assessment Scale (MDAS; Breitbart et al. 1997), (Lin et al. 2010). Dementia-related delirium, by
and the Nursing Delirium Screening Checklist contrast, is associated with high rates of admission
(NuDESC; Gaudreau et al. 2005 ). The DRS is a from long-term facilities and older adults. This
10-item scale, rated by a clinician with psychiatry subtype typically has a higher mortality rate and
training and is based on a patients behavior over a greater frequency of atrial brillation, pneumonia,
24-h period. The DRS was later revised and and urinary tract infections. General delirium risk
renamed the DRS-R-98. The DRS-R-98 includes factors include male sex type, increasing age, and
a 16-item clinician-rated scale, including 13 items cerebrovascular risk factors.
assessing delirium severity and three diagnostic Structural brain disease traits are additional
items. The MDAS is a 10-item clinician-rated considerations for delirium risk. Although studies
scale, based on DSM-IV criteria, which assesses are of variable quality with regard to imaging
disturbances in arousal and level of methods, studies show that delirium patients
642 Delirium
Delirium, Table 3 Common delirium screening tools

Sensitivity/
Toola Pro Con specicityb
CAM Based on DSM criteria; best in ED, Potential for false negatives in 46100%/63100%
postoperative and mixed inpatient postop population
settings; high interrater reliability
CAM-ICU Brief assessment (<2 min); can be used Be used in nonverbal pts in postop 46100%/63100%
in nonverbal pts population
MDAS Best in postop settings; designed to track Tested in modest number pts, 64.1%/100%
changes in delirium limited generalizability; may only
be assessed by physician
DRS More useful than DRS-R-98 in more May only be assessed by 91100%/8492%
impaired patients psychiatric physician; not useful
with repeated admin
DRS-R-98 Can assess severity of delirium; May only be assessed by a trained 91100%/8492%
distinguishes delirium from dementia nurse and <75%/<75%
(in older adults)
NuDESC Best sensitivity and specicity of tools May only be used by a trained 85.7%/86.8%
for postsurgical populations; brief nurse
assessment
a
CAM: Inouye et al. (1990); CAM-ICU: Ely et al. (2001b); DRS: Trzepacz et al. (1988); DRS-R-98: Trzepacz et al. (2001);
MDAS: Breitbart et al. (1997); NuDESC: Gaudreau et al. (2005)
b
Information adapted from De and Wand (2015). See article for further review
have preexisting brain differences. Patients with functional connectivity between the intralaminar
delirium are reported to have preexisting larger thalamic and caudate nuclei were reduced during
ventricle sizes, basal ganglia or caudate lesions/ a delirious episode, but this connectivity recov-
lacunes, white matter abnormalities in the ered to normal function after resolution of delir-
periventriclar and deep regions of the brain, ium (Choi et al. 2012).
greater cortical and subcortical atrophy, and These studies lend further support to the
decreased regional and overall perfusion. An hypothesis that there are predisposing demo-
important caveat, however, is that almost all of graphic, comorbidity, and brain vulnerability fac-
these studies are confounded by age; tors contributing to the development of delirium.
delirium patients are signicantly older in age Attention will now shift to specically discuss
than those without delirium. White matter unique risk and treatment applications associated
abnormalities and atrophy increase with age for with two major surgery types: orthopedic and
many individuals, particularly those with cardiac surgery.
hypertension and hypercholesterolemia. See De
Groot and Slooter (2014) for a more thorough
review. Reducing Postoperative Delirium:
Functional MRI techniques may improve Anesthetic Considerations
understanding of neural mechanisms for delirium. and Perioperative Variables
Choi and colleagues (2012) assessed the func-
tional brain patterns of delirious subjects. They Postoperative delirium typically presents around
found that activity in the dorsolateral prefrontal 24 h after surgery and resolves in most patients by
cortex and posterior cingulate cortex were 48 h; however, in rare cases it can last for up to
strongly correlated in patients during an episode months or even a year or more. Different risk
of delirium, as compared with control subjects factors for orthopedic and cardiac surgery have
who demonstrated an inverse correlation between been discussed in the literature and are therefore
these regions. The authors also revealed that reviewed separately below.
Delirium 643
Specific to Orthopedic Surgery pain relief; (5) avoidance of delay in transfer

Although delirium can be noted in elective ortho- logistics; (6) daily delirium screening; (7) avoid-
pedic surgery, it is more prominent and ance of polypharmacia (sedatives/hypnotics with
concerning among urgent orthopedic surgeries anticholinergic properties given in restriction); and
such as hip fracture. Patients who develop delir- (8) anesthesia recommendations (premedication
ium after hip fracture surgery have higher rates of with paracetamol, propofol and/or alfentanil iv on
mortality, are more likely to be diagnosed with arrival to operating suite, spinal anesthesia with
dementia or mild cognitive impairment, and/or bupivacain, sedation with propofol) with systolic
require institutionalization. There is an increased blood pressure maintained at >2/3 of baseline or D
need to identify ways to reduce delirium in these >90 mmHG, red blood cell transfusion only when
patients. Recent randomized controlled studies there is increased blood loss (>.3 l) or hemoglobin
suggest that analgesia and pain management and (<100 g/l), and postoperative analgesia with para-
depth of general anesthesia are important modi- cetamol as the rst choice or in combination with
able factors for delirium prevalence after hip an opioid. Findings showed less delirium in the
fracture surgery. A Cochrane review (Parker intervention group relative to the control group,
et al. 2004) compared outcome differences in hip suggesting value of multifactorial perioperative
fracture patients versus regional anesthesia. From intervention approaches rather than the use of one
ve randomized controlled trials meeting inclu- or two therapies alone.
sion criteria, there were more patients with post- Presurgical education may be an additional
operative confusion in the general anesthesia approach. One study (Krenk et al. 2012) showed
groups relative to the regional anesthesia groups. that delirium did not occur for elective orthope-
The authors concluded that with hip fracture sur- dic surgery patients who were provided with
gery, regional anesthesia relative to general anes- more information about the anesthesia and sur-
thesia results in a twofold reduction of acute gical procedures, as well as prehabilitated by
delirium. Zywiel and colleagues (2014) found physiotherapists for appropriate exercise
mixed results (Zywiel et al. 2014), however. regimes commonly used after surgical interven-
They identied that patients who receive general tion. The authors cite the need to engage patients
versus regional anesthesia during a hip replace- in their own rehabilitation as well as consistent
ment surgery experience delirium at a greater monitoring of cognitive changes. The study was
frequency, though after a few days postsurgery, limited, however, in that subjects were all cogni-
the differences are no longer signicant. tively well (Mini Mental State Exam >23) and
Identifying and treating delirium risk factors in may have experienced a protective factor in this
patients prior to surgery may also be a venue for regard.
reducing postoperative delirium. Investigators
have recently lead a quasi-experimental interven- Specific to Cardiac Surgery
tion study (Bjorkelund et al. 2010) where preop- Delirium after cardiac surgery has been reported
erative patients with hip fractures admitted to the for many years, but has recently been shown to be
hospital were either treated with a multifactorial a strong independent predictor of mortality for up
intervention program (n = 131) or served as a to 10 years postoperatively, even in younger indi-
control group (n = 132). The multifactorial inter- viduals and in those without prior stroke. Coro-
vention program included: (1) the use of supple- nary artery bypass graft or valve surgery is also
mental oxygen; (2) intravenous iv uid associated with risk of functional decline at
supplementation and extra nutrition; (3) increased 1 month after discharge, with this outcome inde-
monitoring of vital physiological parameters pendent of comorbidity, baseline function, and
(oxygen saturation, systolic blood pressure cognition.
maintained >90100 mmHg, red blood cell trans- Operative risk factors include impaired left
fusion should be considered if hemoglobin ventricular ejection fraction, time on cardiopul-
<100 g/l, avoid hypo/hyperthermia); (4) adequate monary bypass, high perioperative transfusion
644 Delirium
requirement, and postoperative hypertension. (nicotinic and muscarinic). They impair memory
Microemboli, common to all cardiac surgical pro- performance by antagonizing the neurotransmitter
cedures, has not, to date, been specically associ- acetylcholine and muscarinic receptors in the
ated with delirium although it continues to be brain. High serum anticholinergic levels of anti-
considered a potential contributor when it occurs cholinergic drugs are associated with delirium and
in combination with other risk factors such as cognitive impairment. Unfortunately, these medi-
hypoperfusion. cations are commonly taken by older adults over
There may be specic modiable risk factors the counter for sleep aids (any pm medication).
for delirium after cardiopulmonary bypass (CPB). Common anticholinergic medications include tri-
In a group of individuals receiving standardized cyclic antidepressants used to treat mood but also
surgery, anesthesia, and postoperative pain man- pain and sleep (i.e., amitriptyline), antihistamines,
agement protocols, and daily delirium evalua- and antibiotics (e.g., cephalosporin, third genera-
tions, Burkhart and colleagues (2010) identied tion). Anesthesiologists should identify patients
that delirium risk factors were: (1) the dose of on anticholinergic medications prior to surgery.
fentanyl per kilogram of body weight adminis- One potential mechanism for anesthetic action is
tered during the operation, (2) the duration of via the suppression of cholinergic cells (i.e.,
mechanical ventilation, and (3) maximum value isourane and sevourane suppress acetylcholine
of C-reactive protein measured postoperatively release). Thus, there is potential for increased
(Burkhart et al. 2010). The authors pose that fen- depletion of cholinergic activity. Randomized
tanyl, with questionable anticholinergic effects, prospective studies are needed to identify the
may be a modiable risk factor; alternatives such extent to which presurgery anticholinergic medi-
as remifentanil or other opioids may be worth cations interact with anesthesia to increase vulner-
considering for intervention trials. Duration of ability to delirium and even postoperative
mechanical ventilation requires sedation and cognitive dysfunction. There have been attempts
therefore may be a consequence of the specic to prevent postoperative delirium with cholines-
drugs used to maintain sedation. Sedation depth terase inhibitors (e.g., rivastigmine) in random-
may also be worth considering. Postoperative ized treatment trials. Unfortunately, to date, these
rates of C-reactive protein suggest a systemic have been largely unsuccessful for both elective
inammatory response to surgery. This may indi- total joint replacement and cardiopulmonary
cate a relationship to endotoxin, a common con- bypass. Large intervention trials appear needed.
sequence of coronary artery bypass grafting
(CABG) and trauma-induced intraabdominal
infections. Buckhart and colleagues (2010) Considerations for Postsurgery
C-reactive protein ndings coupled with others Dementia Development or Progression
ndings that cortisol levels also correlate with
postoperative delirium suggest that these areas Threshold and Brain/Cognitive Reserve
need further investigation. Clearly, there is a spe- The concept of a threshold and brain/cognitive
cic need for intervention trials with potentially reserve is often mentioned when attempting to
modiable risk factors in cardiac patients. explain why certain individuals may: (1) develop
delirium or (2) proceed to dementia.
Martin Roth and colleagues (Roth 1971) rst
Considerations for Anticholinergic introduced the concept of a threshold in their
Medications and Anesthesia postmortem Newcastle upon Tyne studies. These
researchers observed patterns in senile plaque
Anticholinergic drugs and/or interaction of these counts and measures of disease/dementia severity.
drugs with anesthetic agents is a probable factor For example, in Parkinsons disease, clinical Par-
for postoperative delirium. Anticholinergic drugs kinsonism does not appear until 85% of the cells
compete for acetylcholine receptor subtypes of the nigrostriatal system are depleted and
Delirium 645
dopamine has declined in a similar proportion. insult to the brain. The development of interven-
A similar pattern has been reported in Alzheimers tions to prevent and treat delirium and postopera-
disease with regard to neurobrillary plaques and tive cognitive dysfunction is essential with our
tangles. ever-increasing older adult population.
Paul Satz contributed signicantly to the con-
cept of a threshold by formally providing some
general properties for a threshold theory and Cross-References
reserve (Satz 1993). Satz outlines two postulates:
A) how greater brain reserve (as measured by Cognitive and Brain Plasticity in Old Age D
premorbid intellectual abilities, academic abilities, Dementia and Neurocognitive Disorders
or current intelligence) serves as a protective factor End of Life Care
to a lesion or pathology and B) how lesser brain Frailty in Later Life
reserve serves as a vulnerability factor to lesion Palliative Care
or pathology. He also provides subpostulates Physiological Effects on Cognition
discussing the effects of aggregate lesions, disease
progression, and challenge. Satz (1993) postulates
References
apply to the topics of delirium.
Unfortunately, it is difcult to dene and mea- Aldemir, M., et al. (2001). Predisposing factors for delir-
sure reserve and use the concept to predict risk for ium in the surgical intensive care unit. Critical Care,
delirium. Some researchers propose that educa- 5(5), 265270.
tion is a surrogate marker for cognitive reserve. American Psychiatric Association and American Psychiat-
ric Association, DSM-5 Task Force. (2013). Diagnostic
The concept of education is multifold, however. and statistical manual of mental disorders: DSM-5
Education may signify more neuronal connec- (5th ed.). Washington, DC: American Psychiatric Asso-
tions, but also it may simply mark better test ciation. Xliv, 947 p.
taking abilities, better social networks, and Bjorkelund, K. B., et al. (2010). Reducing delirium in
elderly patients with hip fracture: A multi-factorial
healthcare. For these reasons, reserve has been intervention study. Acta Anaesthesiologica
extensively studied beyond that of education Scandinavica, 54(6), 678688.
alone. According to Yacob Stern, Ph.D. at Colum- Breitbart, W., et al. (1997). The memorial delirium assess-
bia University, a leader on the topic of cognitive ment scale. Journal of Pain and Symptom Manage-
ment, 13(3), 128137.
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Reserve can be characterized: (1) as simply brain risk factors for postoperative delirium after cardiac sur-
reserve (essentially brain structure) or (2) as gery with cardiopulmonary bypass. Journal of Cardio-
cognitive reserve represented by neural reserve thoracic and Vascular Anesthesia, 24(4), 555559.
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tionally dening both brain and cognitive reserve American Journal of Psychiatry, 169(5), 498507.
remains challenging and are topics worthy of De Groot, J. C., & Slooter, A. J. (2014). PET and SPECT in
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De, J., & Wand, A. P. (2015). Delirium Screening: A Sys-
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Conclusion Statement lated patients: Validity and reliability of the confusion
assessment method for the intensive care unit
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646 Dementia and Neurocognitive Disorders
Inouye, S. K., et al. (1990). Clarifying confusion: The Definition

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induced, dementia-associated and non-dementia,
non-drug delirium hospitalizations in the United States, Psychiatric Association 2013).
19982005: An analysis of the national inpatient sam-
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Parker, M. J., Handoll, H. H., & Grifths, R. (2004). Anaes- Introduction
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Behavioural Neurology. doi:10.1155/2015/416792. neurocognitive disorder in the fth edition of
Roth, A. M. (1971). Classication and etiology in mental
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Satz, P. (1993). Brain reserve capacity on symptom onset erative disorders (i.e., presence of known struc-
after brain injury: A formulation and review of evidence tural or metabolic brain disease). Furthermore,
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Trzepacz, P. T., Baker, R. W., & Greenhouse, J. (1988). A authors proposed this amendment to differentiate
symptom rating scale for delirium. Psychiatry research, neurodegenerative diagnoses from other illness
23(1), 8997. with cognitive sequelae (such as psychiatric Axis
Trzepacz, P. T., et al. (2001). Validation of the delirium rating 1 disorders), because a temporal relationship
scale-revised-98: Comparison with the delirium rating
scale and the cognitive test for delirium. Journal of Neu- between psychiatric illness and cognitive decits
ropsychiatry and Clinical Neurosciences, 13(2), 229242. is an exclusion criterion for the diagnosis of
Zywiel, M. G., et al. (2014). The inuence of anesthesia dementia (Ganguli et al. 2011).
and pain management on cognitive dysfunction after Recent advances especially in the eld of
joint arthroplasty: A systematic review. Clinical Ortho-
paedics and Related Research, 472(5), 14531466. genetics and neuroimaging modalities have gen-
erated a variety of potential biomarkers that
may predict the presence of a neurodegenerative
disease years before diagnosis or full manifesta-
Dementia and Neurocognitive tion of the clinical symptoms. Consequently,
Disorders reformulation of diagnostic criteria for neurode-
generative disorders is underway. For example, in
Kamini Krishnan1 and Glenn E. Smith1,2 recognition of underlying disease biomarkers, the
1
Mayo Clinic, Rochester, MN, USA National Institute on Aging (NIA) and the
2
University of Florida College of Public Health Alzheimers Association have proposed new
and Health Professions, Gainesville, FL, USA syndromic stages of Alzheimers disease
(AD) including preclinical and prodromal stage
of AD, which will be discussed in detail in this
Synonyms chapter (Jack et al. 2011).
This entry will include a review the general
Dementia and major neurocognitive disorder; criteria for neurocognitive disorders (major and
Mild cognitive impairment and minor minor). The next section will discuss updates to
neurocognitive disorder research criteria based on biomarkers to delineate
Dementia and Neurocognitive Disorders 647
between syndromic presentations (i.e., preclinical 2. The subtle but measurable cognitive decit
state, mild cognitive impairment [MCI], and does not impede the individuals independence
dementia). Finally, a brief overview of etiology in instrumental activities of daily living (i.e.,
specic criteria for neurocognitive disorders is complex activities such as driving, medication
included. For detailed etiology (e.g., Alzheimers and nancial management, employment), but
disease) review, we encourage readers to refer to may require greater effort or compensatory
that entry in this encyclopedia (also cross- strategies to maintain an independent level of
referenced with this entry). functioning.
3. The cognitive decits do not occur exclusively D
in the context of a delirium.
Diagnostic Clinical Criteria 4. The cognitive decits are not wholly or primar-
ily attributable to another Axis I disorder (e.g.,
In the latest revision of the DSM (American Major depressive disorder, schizophrenia).
Psychiatric Association 2013), major
neurocognitive disorder (MND) replaced demen- Clearly, mND criteria comport with early sug-
tia while mild neurocognitive disorder (mND) gestions for recognizing MCI (Smith et al. 1996;
was elevated from research criteria only to full Petersen et al. 1999) but eliminates previously
clinical use. Etiologies related to the syndrome are delineated subtypes: amnestic MCI-single domain
included as speciers for both MND and mND (primary decit in memory), amnestic MCI-
(e.g., due to Alzheimers disease, Parkinson's dis- multiple domains, nonamnestic MCI-single
ease, frontotemporal lobar degeneration, vascular domain, and nonamnestic MCI-multiple domains
disease, Lewy body disease, or traumatic brain based on the nature of the cognitive impairment
injury). Delirium remains as a separate category (Petersen et al. 1999).
under neurocognitive disorders (American Psychi-
atric Association 2013). Major Neurocogntive Disorder (MND)
The DSM-5 criteria (American Psychiatric Asso-
Minor Neurocognitive Disorder (mND) ciation 2013) are:
The DSM-5 criteria (American Psychiatric Asso-
ciation 2013) are: 1. Evidence of signicant cognitive decline from
a previous level of performance in one or more
1. Evidence of modest cognitive decline from a cognitive domains (complex attention, execu-
previous level of performance in one or more tive ability, learning and memory, language,
cognitive domains (complex attention, execu- visual constructional-perceptual ability, or
tive ability, learning and memory, language, social cognition) based on both the criteria
visual constructional-perceptual ability, or listed below.
social cognition) based on both the criteria (a) Report or concern for signicant cognitive
listed below. decline by patient, a knowledgeable infor-
(a) Report or concern for possible cognitive mant, or by the clinician
decline by patient, a knowledgeable infor- (b) Quantiable documentation of cognitive
mant, or by the clinician decits, preferably with standard neuropsy-
(b) Quantiable documentation of cognitive chological testing, typically > 2.0 standard
decits, preferably with standard neuropsy- deviations (SD) below the mean (or below
chological testing, typically 1.02.0 stan- the 2.5th percentile) based on a reference
dard deviations (SD) below the mean population (i.e., comparable with respect to
(or 2.5th-16 percentile) based on a reference age, gender, education, premorbid function-
population (i.e., comparable with respect to ing, and cultural background)
age, gender, education, premorbid function- 2. The documented cognitive impairments signif-
ing, and cultural background) icantly interfere with the individuals ability to
Max CSF A42

Amyloid PET
SDF tau
MRI + FDG PET
Biomarker abnormality
Cognitive impairment
Dementia
k
ris
gh
Hi
k
ris
MCI
w
Detection
Lo
threshold
Normal
Min
Time
Dementia and Neurocognitive Disorders, Fig. 1 Model red arrows), which accelerates detection of tauopathy and
integrating Alzheimers disease biomarkers and CSF tau (light blue arrow). Later still, FDG PET and MRI
immunohistology. Ab amyloid b. FDG-PET uorodeox- (dark blue arrow) rise above the detection threshold.
yglucose Positron Emission Tomography, CSF Cerebro- Finally, cognitive impairment becomes evident (green
spinal Fluid, MCI mild cognitive impairment. The gray arrow) depending on the individuals risk prole (light
area denotes abnormal pathophysiological changes below green-lled area) (Reprinted from The Lancet Neurology,
the biomarker detection threshold (black line). In this 12, Jack, Clifford R., et al. Tracking pathophysiological
model, tau pathology precedes other markers at a subprocesses in Alzheimers disease: an updated hypothetical
threshold level. Ab deposition occurs independently and model of dynamic biomarkers, 210(2013), with permission
rises above the biomarker detection threshold (purple and from Elsevier)
independently manage instrumental activities The following section outlines the criteria for these
of daily living (ADLs) (i.e., complex activities syndromes. Figure 1 is a model demonstrating the
such as driving, medication, and nancial temporal pattern of involvement of biomarkers
management). across clinical diagnoses (Jack et al. 2013).
3. The cognitive decits do not occur exclusively
in the context of a delirium. Preclinical Stage
4. The cognitive decits are not wholly or primar- It is now possible to identify the presence of bio-
ily attributable to another Axis I disorder (e.g., markers of neurodegenerative disease years
Major depressive disorder, schizophrenia). before clinical detection of symptoms or syn-
dromes. Biomarkers for AD include genetic,
molecular, neuroimaging modalities, and
Research Criteria neurocognitive assessment (Knopman 2013;
Fields et al. 2011; Smith and Bondi 2013). For
The National Institute on Aging (NIA) and the AD, genetic markers include causative genetic
Alzheimers Association have spearheaded mutations (Sherrington et al. 1995), as well as
research criteria updates based on burgeoning susceptibility genes such as apolipoprotein
information regarding utility of biomarkers in E (APOE) gene (Knopman 2013). Neuroimaging
preclinical detection, tracking disease burden, biomarkers include positron emission topography
and evaluating efcacy of treatment interventions (PET) for amyloid detection and phosphorylated
in AD (Albert et al. 2011). While these updates tau accumulation in the brain (Knopman
have been made to AD research criteria, the pat- et al. 2013), MRI for hippocampal volume loss,
tern of differentiation between the syndromic and accumulation of a-beta42 in the cerebrospinal
presentations (preclinical, MCI, and dementia) uid are typically used in AD (Jack et al. 2011).
will be common to most etiologies of dementia. However, presence of neuroimaging biomarkers
is not denitive for future cognitive impairment as The guidelines elucidate on criteria for promi-
shown in a population based sample where over nent cognitive and behavioral symptoms observed
50% of older adults demonstrated neurodegener- in dementia (minimum of two of the following
ative ndings on neuroimaging but demonstrated (McKhann et al. 2011)):
cognitive normality (Knopman et al. 2013).
(a) Memory: Impairment in encoding and recall
Mild Cognitive Impairment of recent information. Individuals may ask
The NIA-Alzheimers Association work group on repetitive questions, frequently misplace
MCI (Albert et al. 2011) proposed core criteria belongings, forget appointments, or get lost D
for MCI followed by characterization of bio- on a familiar route.
marker data to identity level of certainty for pres- (b) Executive function: Impaired reasoning and
ence of AD etiology. The core MCI features are difculty completing complex tasks. Individ-
comparable to mND diagnostic criteria and uals may demonstrate poor decision-making,
include: poor understanding of safety risks, and may
be unable to manage nances or plan complex
1. Concern or report of change in level of cogni- activities.
tive function by patient, a knowledgeable (c) Visuospatial functioning: Individuals may
informant, or a skilled clinician. have object agnosia, impaired face recogni-
2. Presence of decline from estimated premorbid tion, simultanagnosia and alexia, difculty
level of functioning in one or more cognitive operating simple implements, or demonstrate
domains including memory, executive function, difculty nding objects despite good acuity.
attention, language, and visuospatial skills. If (d) Language (speaking, reading, and writing):
serial cognitive evaluations are present, there Individuals may have word retrieval difculty
must be a progressive decline in scores. while speaking, speech may be hesitant, and
3. Preservation of independence in functional writing may involve spelling or grammatical
abilities. Patients with MCI may struggle with errors.
complex activities such as managing nances (e) Changes in personality, behavior, or
and preparing a meal but are generally able to comportment symptoms include: Individual
function independently with minimal aids or demonstrates uncharacteristic mood uctua-
assistance. tions such as agitation, impaired motivation,
4. Absence of dementia: Observed changes initiative, apathy, loss of drive, social with-
should not signicantly impede social or occu- drawal, and decreased interest in previous
pational activities. activities, loss of empathy, compulsive or
obsessive behaviors, and socially unaccept-
Dementia able behaviors.
Similar to MCI core symptoms, the
NIA-Alzheimers Association work group pro- Role of Neuropsychological Assessment
vided diagnostic guidelines for core dementia The strongest predictive power for progression to
criteria (McKhann et al. 2011): dementia is demonstrated by cognitive bio-
markers (Fields et al. 2011). Neuropsychological
1. Interfere with the ability to function at work or assessments can provide measurable data regard-
at usual activities ing cognitive performance comparing the individ-
2. Represent a decline from previous levels of ual to a normative sample (ideally based on age,
functioning and performing education, gender, and ethnicity) and accounting
3. Are not explained by delirium or major psy- for confounding factors such as preexisting areas
chiatric disorder of cognitive weakness, preexisting mood disorder,
4. Quantiable impairment in two or more cog- and motivational factors. Neuropsychological
nitive domains evaluation can assist with diagnostic clarication
and to establish a baseline evaluation of cognitive (Ganguli et al. 2011; American Psychiatric Asso-
function, should clinical features in the future ciation 2013). A majority of patients with MCI
warrant a reevaluation. These tests may be of due to AD demonstrate prominent impairment in
greatest value in mild cognitive impairment or episodic memory (i.e., amnestic MCI), but other
early dementia states as cognitive performance patterns of cognitive impairment can also progress
in most domains deteriorates due to eventual dis- to AD over time (e.g., multidomain MCI, execu-
ease encroachment on neighboring neural structive dysfunction/nonamnestic MCI, or visual spa-
tures and can be difcult to differentiate etiology tial impairments in the posterior cortical atrophy
at later stages of the disease. variant of AD). Presence of a positive topographic
Neurocognitive assessments may broadly use (e.g., MRI evidence of medial temporal atrophy,
the heuristic cortical or subcortical to classify or FDG PET evidence of age-adjusted
dementia syndromes based on typical pattern of temporoparietal hypometabolism) or molecular
cognitive impairment (Whitehouse 1986; Salmon neuropathology of AD (e.g., lower CSF A-42
and Filoteo 2007). A typical cortical dementia and raised CSF tau measures) when available
such as AD can be characterized by decits can further characterize the pattern of MCI
in memory, language, and visuospatial and exec- (Albert et al. 2011). To further classify patients
utive functioning. Subcortical dementias based on level of certainty of etiology, the follow-
(vascular dementia or Parkinsons disease) typi- ing research criteria for AD are proposed (Albert
cally present with motor dysfunction in addition et al. 2011):
to reduced processing speed and prominent early
decits in executive function, visuoperceptual and 1. MCI of a neurodegenerative etiology: Low
constructional abilities. However, from a neuro- condence of AD etiology
pathological perspective, these proles are often (a) Core features of MCI are present.
mixed as patients with cortical dementia will (b) Negative or ambiguous biomarker evi-
often demonstrate abnormal neuropathology in dence (topographic or molecular
subcortical regions, which speaks to the poten- biomarkers).
tial presence of neuropathological biomarkers 2. MCI of the Alzheimer type: Intermediate con-
before clinical symptom presentation as seen dence of AD etiology
in Fig. 1. Neurocognitive performance in (a) Core features of MCI are present.
frontotemporal dementia and dementia due to (b) Presence of one or more topographic bio-
Lewy body disease (LBD) may demonstrate a markers (MRI evidence of medial tempo-
mixed cortical/subcortical pattern. ral atrophy or FDG PET pattern of
hypometabolism in the temporoparietal
region).
Etiologies (c) Absence of molecular biomarker
information.
Alzheimers Disease 3. Prodromal Alzheimers dementia: High con-
Majority of individuals diagnosed with dementia dence of AD etiology
will demonstrate etiology consistent with (a) Core features of MCI are present.
AD. Neuropathology reveals neuronal loss asso- (b) Presence of molecular neuropathology of
ciated with presence of neuritic plaques AD (e.g., lower CSF A-42 and raised CSF
(deposition of amyloid) and neurobrillary tan- tau measures).
gles (accumulation of tau abnormalities) (c) Further increased certainty with presence
(McKhann et al. 2011). of a topographic biomarker. However,
absence or equivocal ndings are still con-
MCI or mND due to AD (Research Criteria) sistent with the highest level of certainty
The individual meets criteria for MCI or minor that the individual will progress to AD
neurocognitive disorder as outlined previously dementia over time.
Dementia due to AD (or MND Due to AD) (b) Biomarkers obtained and negative: Meets
The most common syndromic prole of AD clinical and cognitive criteria for AD
dementia is an amnestic presentation. The decits dementia but biomarkers (CSF, structural
should include impairment in learning and recall or functional brain imaging) do not support
of recently learned information in addition to sig- the diagnosis
nicant impairments in other cognitive domains (c) Mixed presentation: Meets clinical and
as outlined in the dementia criteria described cognitive criteria for AD dementia but
above. McKhann and colleagues (2011) also pro- there is evidence of concomitant cerebro-
posed levels of certainty in AD diagnosis charac- vascular disease; this would mean that D
terized by neuropathological biomarkers, there is more than one lacunar infarct; or a
primarily used in research settings (McKhann single large infarct; or extensive and severe
et al. 2011). white matter hyperintensity changes; or evi-
dence for some features of dementia with
1. Probable AD dementia: Lewy bodies (DLB) that do not achieve a
Meets clinical and cognitive criteria for level of a diagnosis of probable DLB.
dementia given above with primary amnestic 3. Not AD Dementia
presentation. There is no evidence of alterna- (a) Does not meet clinical criteria for AD
tive diagnoses, specically, no signicant cere- dementia.
brovascular disease. In these individuals, (b) Has sufcient evidence for an alternative
presence of any one of the three features diagnosis such as HIV, Huntingtons dis-
increases certainty of AD: ease, or others that rarely, if ever, overlap
(a) Documented decline: Subsequent evalua- with AD.
tions demonstrate progressive cognitive 4. Pathologically proven AD dementia. Meets
decline based on a knowledgeable infor- clinical and cognitive criteria for probable
mant or cognitive testing (brief mental sta- AD dementia during life AND is proven AD
tus screens or neuropsychological testing). by pathological examination.
(b) Biomarker positive: Has one or more of the
following supporting biomarkers. Vascular Dementia
(i) Low cerebrospinal uid Ab42, ele- In 2011, the American Heart Association and
vated cerebrospinal uid tau or American Stroke Association workgroup jointly
phospho tau published consensus denitions and recommen-
(ii) Positive amyloid PET imaging dations for the vascular contributions to mild
(iii) Decreased FDG uptake on PET in cognitive impairment and dementia (Gorelick
temporoparietal cortex et al. 2011). Vascular pathology includes ischemic
(iv) Disproportionate atrophy on struc- and/or hemorrhagic cardiovascular disease
tural MR in medial temporal lobe (CVD), other cerebrovascular insults (subclinical
(especially hippocampus), basal and brain infarction [SBI]), multiple small vessel dis-
lateral temporal lobe, and medial ease, or cerebral autosomal dominant arteriopathy
parietal isocortex with subcortical infarcts and leukoence-
(c) Mutation carrier: Meets clinical and cog- phalopathy (CADASIL).
nitive criteria for AD dementia and has a
proven AD autosomal dominant genetic Vascular MCI
mutation (PSEN1, PSEN2, and APP). 1. Probable VaMCI:
2. Possible AD dementia. (a) Meets core MCI criteria (Albert et al.
(a) Atypical course: Evidence for progressive 2011).
decline is lacking or uncertain but meets (b) Presence of clear temporal relationship
other clinical and cognitive criteria for AD between a vascular event (e.g., clinical
dementia stroke) and onset of cognitive decits.
(c) Onset of cognitive decits or relationship normal should be classied as having unsta-
in the severity and pattern of cognitive ble VaMCI.
impairment and the presence of diffuse,
subcortical cerebrovascular disease pathol- Vascular Dementia (VaD)
ogy (e.g., as in CADASIL). Individuals meet criteria for core features of
(d) No history of gradually progressive cogni- dementia (decline in cognitive function and decit
tive decits before or after the stroke that in two cognitive domains) (McKhann et al. 2011)
suggests the presence of a nonvascular with sufcient severity to affect a persons ADLs.
neurodegenerative disorder. In addition, the impairments in ADLs are indepen-
2. Possible VaMCI: dent of the motor/sensory sequelae of a vascular
(a) Meets core MCI criteria (Albert et al. 2011). event (Gorelick et al. 2011). Criteria for probable
(b) Presence of cognitive impairment and and possible VaD are similar to those stated for
imaging evidence of cerebrovascular VaMCI, but these individuals demonstrate signi-
disease. cant impairment in activities of daily living to meet
(c) No clear relationship (temporal, cognitive criteria for dementia (vs. MCI criteria).
pattern or severity) between the demon-
strated vascular disease (e.g., silent Lewy Body Disease (LBD)
infarcts, subcortical small-vessel disease) Lewy bodies are intraneuronal inclusions primarily
and onset of cognitive decits. made of alpha-synuclein (McKeith et al. 2005).
(d) There is insufcient information for the High concentration of inclusions in substantia
diagnosis of VaMCI (e.g., clinical symp- nigra are associated with Parkinsonism (e.g., idio-
toms suggest the presence of vascular dis- pathic Parkinsons disease), where subsequent
ease, but no CT/MRI studies are available). onset of dementia is termed Parkinsons disease
(e) Severity of aphasia precludes proper cog- dementia (PDD). On the other hand, presence of
nitive assessment. However, patients can inclusions in the cortex can lead to Lewy body
be classied as probable VaMCI with disease (LBD), which can refer to any syndromic
documented normal cognitive function presentation of Lewy body (preclinical, MCI, and
(prior cognitive evaluations) before the dementia). Dementia with Lewy Body (DLB)
vascular event that resulted in aphasia. refers solely to the dementia syndrome due to LBD.
(f) There is evidence of other neurodegenera-
tive diseases or conditions in addition to Mild Cognitive Impairment of LBD
cerebrovascular disease that may affect Presence of REM Sleep Behavior disorder (RBD),
cognition, such as: which was included in the last revision of DLB
criteria (McKeith et al. 2005), has demonstrated
(i) A history of other neurodegenerative dis- 52.4% increased 12-year risk of developing DLB
orders (e.g., Parkinson disease, progres- (Postuma et al. 2009) and is thought to be associ-
sive supranuclear palsy, dementia with ated with presence of synucleinopathy (McKeith
Lewy bodies). et al. 2005). Therefore, presence of RBD and
(ii) The presence of Alzheimers disease cognitive decline can be a type of MCI due to
pathology is conrmed by biomarkers LBD and may include other cardinal symptoms
(e.g., PET, CSF, amyloid ligands) or such as Parkinsonism or visual hallucinations.
genetic studies (e.g., PS1 mutation). The cognitive prole of MCI with LBD shows
(iii) A history of active cancer or psychiatric prominent visuoperceptual and/or attention de-
or metabolic disorders that may affect cits, nonamnestic prole.
cognitive function.
3. Unstable VaMCI: Dementia with Lewy Body Disease (DLB)
Subjects with the diagnosis of probable or International diagnostic criteria (McKeith
possible VaMCI whose symptoms revert to et al. 2005) include:
1. Central feature (for diagnosis of possible or (b) In the presence of any other physical ill-
probable DLB): Presence of dementia (i.e., ness or brain disorder sufcient to account
progressive cognitive decline which signi- in part or in total for the clinical picture
cantly interferes with daily functioning) (c) If the parkinsonism only appears for the
(a) Prominent or persistent memory impairment rst time at a stage of severe dementia
may not necessarily occur in the early stages 6. Temporal sequence of symptoms:
but is usually evident with progression. DLB should be diagnosed when dementia
(b) Decits on tests of attention, executive occurs before or concurrently with parkinson-
function, and visuospatial ability may be ism (if it is present). The term Parkinson dis- D
especially prominent. ease dementia (PDD) should be used to
2. Core features (Probable DLB: 2 features, Pos- describe dementia that occurs in the context
sible DLB: 1 core feature) of well-established Parkinson disease. In a
(a) Fluctuating cognition with pronounced clinical practice setting, the term that is most
variation in attention and alertness appropriate to the clinical situation should be
(b) Recurrent visual hallucinations that are used and generic terms such as LB disease are
typically well formed and detailed often helpful.
(c) Spontaneous features of Parkinsonism
3. Suggestive features (Probable DLB: at least Frontotemporal Lobar Degeneration
1 suggestive feature and at least 1 core feature Frontotemporal lobar degeneration (FTLD) is a
while possible DLB includes: at least 1 sugges- heterogeneous collection of diagnoses (Picks
tive feature in the absence of core features) disease or Primary Progressive Aphasia) and
(a) REM sleep behavior disorder syndromes (FTD with motor neuron disease,
(b) Severe neuroleptic sensitivity corticobasal degeneration), and etiologies (e.g.,
(c) Low dopamine transporter uptake in the tauopathies versus TDP-43 proteinopathies)
basal ganglia demonstrated by SPECT or (Smith and Bondi 2013; Josephs 2008).
PET imaging Frontotemporal dementia (FTD) refers to the
4. Supportive features (commonly present but not dementia phase of FTLD. Currently, the three
proven to have diagnostic specicity) main recognized phenotypes of FTD are: behav-
(a) Repeated falls and syncope ioral variant-FTD (bvFTD), semantic dementia
(b) Transient, unexplained loss of consciousness (SD), and primary progressive aphasia (PPA).
(c) Severe autonomic dysfunction, e.g., ortho- Furthermore, PPA can be subclassied into three
static hypotension, urinary incontinence variants: logopenic (lvPPA), semantic (svPPA),
(d) Hallucinations in other modalities and agrammatic (agPPA) or nonuent progressive
(e) Systematized delusions aphasia (PNFA) (Gorno-Tempini et al. 2011).
(f) Depression Pathology for semantic and agrammatic variants
(g) Relative preservation of medial temporal of PPA are largely consistent with tauopathies and
lobe structures on CT/MRI scan TDP-43 suggestive of FTLD spectrum disorders,
(h) Generalized low uptake on SPECT/PET while the lvPPA variant is strongly associated with
perfusion scan with reduced occipital AD pathology (Josephs 2008). The diagnosis of
activity FTD is challenging due to the complexity and
(i) Abnormal (low uptake) MIBD myocardial heterogeneity in FTLD. Individuals may be
scintigraphy misdiagnosed as psychiatric disorder or AD
(j) Prominent slow wave activity on EEG with early in the disease course.
temporal lobe transient sharp waves Preclinical stage of FTD involves being a car-
5. A diagnosis of DLB is less likely: rier of genetic mutations associated with FTD
(a) With evidence of cerebrovascular disease such as MAPT, GRN, and C9ORF72 genes
(focal neurologic signs or on brain (Rohrer et al. 2013). The behavioral variant FTD
imaging) presents with impairments in social cognition
including behavioral disinhibition, apathy, loss of Vascular and Mixed Dementia

empathy, perseverative or compulsive behavior, Young-Onset Dementia, Diagnosis, Course,
and hyperorality or dietary changes early in the and Interventions
disease process (Piguet et al. 2011). Other variants
of FTD demonstrate predominant language or
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Depression and Cognition 655
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Sherrington, R., et al. (1995). Cloning of a gene bearing with advancing age (e.g., Byers et al. 2010).
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Although the prevalence of depression is lower
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impairment and dementia: Denitions, diagnosis, daily life of patients may be greater with advanc-
and treatment. Oxford/New York: Oxford University ing age due to other factors that make older adults
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Smith, G., et al. (1996). Denition, course and outcome of
a more vulnerable population (e.g., decrease in
mild cognitive impairment. Aging, Neuropsychology, physical health, cognitive changes due to normal
and Cognition, 3, 141147. aging, comorbidity with other health/mental
Whitehouse, P. J. (1986). The concept of subcortical and health disorders). In particular, cognitive declines
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due to age-related changes in the brain may com-
pound the effects of depression on the daily func-
tioning of older adults.
A review of the rate of comorbid depression and
cognitive impairment in older adults estimated it to
double every 5 years after the age of 70, with over
Depression and Cognition 25% of community dwelling 85-year olds living
with comorbid MDD and cognitive impairment
Rowena Gomez and Garima Jhingon (Ellen and David 2010). Lee et al. (2007) noted
Pacic Graduate School of Psychology, Palo Alto that a high number of depressed older adults pre-
University, Palo Alto, CA, USA sent with mild cognitive impairment, dened in
the literature as the stage between normal aging and
dementia. Moreover, these cognitive impairments
that accompany an acute depressive episode con-
Synonyms tinue long after the remission of depressive symp-
toms (Ellen and David 2010; Lee et al. 2007).
Mood disorder; Neuropsychology Furthermore, in a recent review and meta-analysis
by Diniz et al. (2013), they determined that late-life
Depression A psychiatric disorder that includes (geriatric) depression is in fact associated with a
symptoms of sad mood, higher risk of dementia, including vascular and
hopelessness, poor sleep and Alzheimers disease.
appetite, guilt or worthlessness, This encyclopedia entry will rst review the
low energy, and severe suicidal neurobiological effects of depression in older
thoughts adults. Then it will describe the effects of
656 Depression and Cognition
depression on global cognitive functioning as well through changes in the brain in older adults.
as specic cognitive domains including attention These factors include increased levels of cortisol
and working memory, processing speed, spatial and hippocampal atrophy, increased deposition of
skills, language, memory, and executive function- b-amyloid plaques, inammatory changes, and
ing. Afterward, the special considerations of age decits of nerve growth factors. In relation to
moderating the impact of depression on cognition, greater cortisol, higher levels of depression would
dementia/pseudodementia, and the effects of anti- cause the HPA axis to increase glucocorticoid pro-
depressants on cognition will be covered. duction that would damage the hippocampus and
result in a downregulation of glucocorticoid recep-
tors ultimately resulting in a vicious cycle leading to
Neurobiology of Depression in Older impairments in cognition. As for beta-amyloid rela-
Adults tionships, Byers and Yaffe hypothesized that depres-
sion may increase b-amyloid production due to a
The impact of depression on cognition in older adults stress response to depression resulting increase of
and in other age groups has been hypothesized to be cortisol. Although the research ndings are mixed,
mediated by the neurobiological effects of depression they reported some evidence that depression with a
in the brain. In fact, there are several different hypoth- high ratio of plasma b-amyloid peptide 40 (Ab40) to
eses about how this mediation occurs. For instance, Ab42 has been associated with memory, visuospatial
there is evidence that older adults with depression abilities, and executive function decits. As for the
have a higher prevalence risk for cardiovascular dis- inammation hypothesis, Byers and Yaffe stated that
ease and dementia. There is a vascular depression depression is associated with increased levels of cyto-
hypothesis (e.g., Sneed and Culang-Reinlieb 2011) kines that can lead to a decrease in inammatory and
that theorizes that heart disease may cause, be a result immunosuppressant regulation, resulting in inam-
of, or prolong depression in older adults. Further- mation of the central nervous system that would
more, this link has also been connected to brain- ultimately result in cognitive impairment and an
related changes. For instance, MRI studies have increase risk of dementia. The increase in cytokines
found signicant relations between ischemic lesions may also interfere with serotonin metabolism that can
in the brain and depression severity or diagnosis lead to decrease in synaptic plasticity and hippocam-
(Sneed and Culang-Reinlieb 2011). Specically, for pal neurogenesis. Lastly, they mentioned problems
late-life depression, the vascular depression hypoth- with nerve growth factors, specically, such as brain-
esis is specic regarding the location of deep white derived neurotrophic factor (BDNF). They stated that
matter hyperintensities (DWMH) within impairments in BDNF functioning have been found
frontostriatal circuits that are involved in executive in animal and human models of depression that have
functioning (Sneed and Culang-Reinlieb 2011). In been linked to declines in cognitive functioning.
the update by Sneed and Culang-Reinlieb (2011), In all, there seems to be multiple pathways of
the authors reported other MRI studies that have how neurobiological changes due to depression
found DWMH, reduced volume in frontal and sub- can then impact cognitive functioning and
cortical areas, neuronal abnormalities within the increase the risk of cognitive disorders, including
prefrontal cortex, and reduced neuronal density in dementia. More research is needed in this area to
the dorsolateral and ventromedial areas of the cau- determine which pathways are most related to
date nucleus. Sneed and Culang-Reinlieb con- cognitive decline in geriatric depression.
cluded that neuronal abnormalities in some LLD
are present in the frontal and striatal brain regions,
which is consistent with the vascular depression Depression on Cognition in Older Adults
hypothesis.
In a review by Byers and Yaffe (2011), they Mental Status
reported several other neurobiological factors Mental status is also commonly referred to as
related to how depression can impair cognition global cognitive functioning as is typically
measured using the mini mental status exam. samples (Tzang et al. 2015). In another study
Older adults with depression have been found to that used the N-back task as a measure of working
have lower MMSE scores than healthy older memory, the depression group performed worse
adults (Pantzar et al. 2014). But this may also be than healthy older adults (Nebes et al. 2000). This
related to the depressed group being older decit was also seen in older adults whose depres-
(healthy control age mean = 72.6 years, mild sion remitted compared to older adults without
depression mean = 78.6 years, and moderate- any history of depression (Nebes et al. 2000).
severe depression mean = 75.9 years) and having
less years of education (healthy control education Processing Speed D
mean = 12.1years, mild depression mean = 10.7 Processing speed is broadly dened as the rate at
years, and moderate-severe depression mean = which an individual can process incoming infor-
10.5 years). However, in a study by mation in order to carry out a task (e.g., Nebes
Rapp et al (2005), they also found signicantly et al. 2000). While normal aging has been known
lower MMSE scores in the older adults with recur- to slow down the speed of information processing
rent or late-onset depression versus those with no for a majority of older adults (Salthouse 1996),
history of or current depression. These diagnostic this cognitive domain is signicantly more
groups did not signicantly differ in age, years of impaired in older adults with depression
education, nor gender. (Dybedal et al. 2013; Ellen and David 2010;
In a 13-year longitudinal study, depression at Pantzar et al. 2014) compared to healthy older
baseline predicted decline in general cognitive adults. Using the trail-making task, Rapp et al.
functioning using the MMSE even after control- (2005) found no signicant processing speed dif-
ling for covariates that include age, sex, and years ferences in the easier task of Trail A but did nd
of education (van den Kommer et al. 2013). Using differences in diagnostic groups on a harder task
the Cognitive Abilities Screening Instrument of Trail B, where older adults with no history or no
(CASI) as a measure of global cognition, greater current depression were faster than older adults
depression severity is related to poorer cognitive with recurrent depression and slowest with older
performance even after controlling for age and adults with late-onset geriatric major depression
education in elderly Chinese males (Tzang (when the age of onset for a rst episode of
et al. 2015). depression occurs is 65 years old or older).
Thus, research indicates substantial evidence Another study also concluded slowed speed of
that global cognitive functioning is impaired in information processing persist even after the clin-
older adults with depression. ical symptoms of depression remit in older adults
(Thomas and OBrien 2008). Butters et al. (2004)
Attention and Working Memory and Dybedal et al. (2013) also determined that
Simple attention can be dened as the limited late-life depression is associated with a slower
capacity to passive hold information in the mind speed of information processing. In fact, Sheline
such as repeating a list of numbers in the same et al. (2006) concluded that processing speed has
order spoken as in Digit Span Forward from the emerged as the most salient cognitive impairment
Wechsler Adult Intelligence Scale. For this task, in older adults diagnosed with depression.
no effects of depression on attention were found in Longitudinal studies have also found associa-
American (Pantzar et al. 2014) and Chinese older tions between depression and slower processing
adult samples with depression (Tzang et al. 2015). speed in older adults. For instance, a 9-year
Working memory is related to general attention longitudinal study examined the impact of depres-
but includes active (versus passive) manipulation sion on cognitive functioning in older women
specically reversing the order of digits, such as in (Rosenberg et al. 2010) found that baseline
Digit Span Backward. In Digit Span Backward, depression ratings were strongly associated with
no effects of depression were found in American impairments on measures of psychomotor speed.
(Pantzar et al. 2014) and Chinese older adult Another longitudinal study examining a large
cohort of older adults found that the level of simple drawings and block design, Butters
depression at baseline predicted the rate of decline et al. (2004) found signicant differences between
in speed of information processing, such that older adults with late-life depression and healthy
more severe depression led to slower speed con- older controls. Nebes and colleagues (2000)
sistently during the 13-year follow-up period (van found depression group differences (recurrent/
den Kommer et al. 2013). These results remained current depression, remission from depression,
even after controlling for age, sex, and education. and no history of depression) on a block design
Notably, the slower processing speed at baseline task. Notably, when controlling for working mem-
also predicted worsening of depression severity ory or processing speed, the effects of depression
over time. on the visual-construction task were no longer
Salthouse has theorized that the effects of signicant. In a timed, visual pattern-matching
declines in cognitive functioning such as memory task, there was no difference in correct responses
and executive functioning are mediated by slowed between older adults with depression and those
processing speed in older adults (Salthouse 1996). without depression, but those with depression had
This also appears to be true in older adults with overall slower reaction time compared to the con-
depression. For instance, Nebes and colleagues trols (Hofman et al. 2000). Incidentally, when
(2000) conducted hierarchical regression analyses controlled for MMSE scores, the older adults
that depression explained a signicant amount of with depression had similar reaction times on
neuropsychological variance on global cognition, this task as those with dementia. In a mental
visuospatial construction, and verbal and visual rotation task, no differences were found between
memory. However, when processing resources older adults with depression and were not on
(working memory as measured by then-back antidepressants compared to healthy older adults
task and processing speed as measured by digit (Pantzar et al. 2014).
symbol substitution test) were removed rst, In sum, these studies indicate limited evidence
depression no longer accounted for a signicant of the association of depression with impairments
amount of neuropsychological performance. But- in visuospatial and visuo-construction skills.
ters et al. (2004) also determined that late-life
depression is associated with a slower speed of Language
information processing, which then impacts all As in visuospatial ability, relatively less research
other cognitive domains including memory, lan- has been conducted in examining the relation of
guage, visuospatial skills, and executive function- depression and language, compared to other cog-
ing. In addition, Sheline et al (2006) found that nitive domains in older adults. Dybedal and col-
processing speed mediated the impact of other leagues (2013) found that after controlling for age,
factors including age, education, race, depression there were no differences between the older adults
severity, and vascular risk factors on working with versus those without depression on animal or
memory, episodic memory, language processing, letter uency. Similarly, Butters et al. (2004)
and executive functioning (Sheline et al. 2006). found impaired language performance of older
However, in a relatively more recent 4-year lon- adults with late-life depression compared to
gitudinal study, Khler et al. (2010) found that healthy older adults for a task of verbally naming
although processing speed partially mediated pictures but no differences on letter or animal
some of the decits in their depressed older adult uency. Furthermore (Rapp et al. 2005), no diag-
participants, it did not adequately account for the nostic group differences were found between
differences between them and the normal control older adults with recurrent depression, late-onset
group participants. depression, remitted depression, and no history of
depression. In conclusion, the limited research in
Visuospatial Ability this cognitive domain indicates that there is gen-
In general, there are only a few studies that exam- erally little to no relationship between depression
ined spatial ability in geriatric depression. Using and language ability.
Learning and Memory were strongly associated with greater verbal mem-
Memory has been one of the most studied cogni- ory declines in a list learning task, over time.
tive domains for depression in older adults as well However, not all studies have reported signif-
as other age groups. Many studies have focused icant results. For example, Butters et al. (2004)
on verbal memory and most commonly used word found no group differences with older adults with
lists or stories to measure learning, short- and late-life depression compared to healthy older
long-term recall, and recognition. In older adults, adults on verbal memory performance for story
many studies have found poorer memory perfor- and list learning tasks. Consistent with this,
mance in depressed groups versus healthy con- Dybedal et al. (2013) conducted a more recent D
trols (Butters et al. 2004; Pantzar et al. 2014). For study that also found no verbal memory differ-
instance, Rapp et al. (2005) used a 10-item list ences on a list learning task between those with
learning task and found that older adults with no late-life depression and healthy older adults after
history of depression and no current depression controlling for age.
performed signicantly better on learning, In comparison to verbal memory, there are rela-
delayed recall, and recognition compared to tively fewer studies that examined the relation
older adults with recurrent depression and those between depression and spatial memory in older
with late-onset depression. adults, compared to verbal memory. Burt
Studies have also found that poorer verbal et al. (2000) found that within a group of patients
memory performance is related to increased diagnosed with major depressive disorder, patients
severity levels of depression. A relatively recent older than 60 years showed signicantly greater
study (Mesholam-Gately et al. 2012) examined impairments on a delayed memory task
learning and memory performance in older adults of visuospatial construction and organization (Rey
with two severity types of depression using the complex gure test) compared to younger patients.
California Verbal Learning Test. The study com- Additionally, depression severity was signicantly
pared older adults with minor depression (dened associated with poor delayed recognition. In con-
as subsyndromal depression that meets duration trast, Dybedal et al. (2013) found no visual memory
criteria but not symptom count criteria for Major differences between those with late-life depression
Depressive Episode) (Mesholam-Gately et al. and healthy older adults after controlling for age.
2012, p. 197), to those meeting criteria for major In sum, while there are substantial evidences
depressive disorder, and healthy control partici- that depression and depression severity impair
pants. The ndings indicated individuals with verbal memory in older adults, the ndings are
major depressive disorder performed signicantly not always consistent. Conicting ndings can be
worse than older individuals with minor depres- due to differences in sample size, medication,
sive symptomatology, who in turn performed types of memory task, and use of covariates in
comparably to normal control participants. Simi- the data analyses. In visual memory, the research
larly, a population-based study found that only is relatively sparse and indicates further need of
older adults with moderate to severe levels of more research in this area.
depressive symptomatology had verbal memory
impairments compared to healthy controls Executive Functioning
(Pantzar et al. 2014). However, no differences Executive functioning is a broad term used to refer
were found between the older adults with mild to higher-order cognitive skills involved in carry-
depression from the healthy controls. ing out goal-directed behavior. The skills
Longitudinal studies have also indicated a pre- involved in executive, goal-directed behavior
dictive relationship between depression and ver- include, but are not limited to, identifying future
bal memory. For instance, in a 9-year longitudinal goals, developing a plan, reasoning, solving com-
study examining the impact of depression on cog- plex problems, choosing among various alterna-
nitive functioning in older women, Rosenberg tives, and inhibiting irrelevant responses. Many
et al. (2010) found that baseline depression ratings studies have found executive function to be one of
the most profoundly impacted cognitive domains the age-related changes in the brain that may
in depressed older adults (Lockwood et al. 2002; contribute to cognitive decits or to the etiology
Pantzar et al. 2014; Rapp et al. 2005). of the depression itself. Moreover, many of the
There are many studies that have found signif- affective, behavioral, and cognitive issues among
icant relationships between depression and poorer the elderly are often the result of an interaction
executive functioning in older adults. In particular, between multiple psychiatric, neurological, and
the performance of older adults with depression on medical conditions (Ellen and David 2010).
executive measures revealed impairments in A critical clinical question is whether cognitive
response to initiation and inhibition (e.g., Dybedal decits associated with depression resolve
et al. 2013), active switching (e.g., Butters following remission of the depressive episode.
et al. 2004; Dybedal et al. 2013; Pantzar A growing body of evidence suggests the pres-
et al. 2014), and problem solving using error feed- ence of a syndrome of cognitive impairment that
back (Lockwood et al. 2002). Longitudinal studies is reversible after the successful treatment of
have also shown declines in executive functioning depression in older adults. This syndrome, popu-
in geriatric depression such as in a 9-year longitu- larly termed pseudodementia or reversible
dinal study that examined the impact of depression dementia, can masquerade as dementia and, as
on cognitive functioning in older women. Rosen- such, is an important consideration in the differ-
berg et al. (2010) found that, in terms of subtypes of ential diagnosis of dementia in the aging popula-
depression, both early and late onset of depression tion (Ellen and David 2010). It is estimated that
in the elderly, has also been linked to executive 1857% older adults with depression present with
functioning decits (e.g., Butters et al. 2004). How- a reversible syndrome of dementia that resolves
ever, the decline in executive functioning has been upon alleviation of depressive symptoms
found to be greater for older adults with late-onset (Alexopoulos and Meyers 1993). However, it is
than the early-onset cohort (Herrmann et al. 2007). extremely challenging to reliably differentiate
Notably, antidepressant treatment and remission between geriatric depression and reversible or
studies have also found that executive dysfunction irreversible dementia.
can still occur in older adults. Dybedal et al (2013) This issue becomes more complicated because
found that older adults with late-onset depression cognitive impairments that can result from
were still signicantly impaired executive function dementia can manifest with depressive symptoms
compared to healthy older adults even after control- as well (Kang et al. 2014). Some researchers have
ling for processing speed. Similarly, Elderkin- suggested that depressive pseudodementia may be
Thompson et al. (2007) found that older adults con- a transient state that eventually progresses to
tinued to show residual decits in executive function- dementia. For example, a recent review suggested
ing even after successful treatment of depression. that late-life depression is a strong predictor for
Interestingly, even when the depression is in full the progression of reversible dementia to an irre-
remission, Thomas and OBrien (2008) found versible one (Kang et al. 2014). This is also con-
declines in executive functioning in older adults. sistent with the meta-analysis of 23 studies
In all, there is substantial evidence that depres- conducted by Diniz and colleagues (2013),
sion impairs executive functioning in older adults which found that geriatric depression was signif-
and may continue to persist despite the use of icantly associated with higher risk of all-cause
antidepressants. dementia, including vascular and Alzheimers
disease.
Thus, the question of pseudodementia and
Special Considerations: depression remains unclear. While some
Pseudodementia Versus Depression researchers have concluded that depression can
mimic dementia, others state that it can also be a
Understanding the cognitive sequelae of geriatric risk factor for dementia in late life and that depres-
depression is especially challenging because of sion is likely an early manifestation of dementia
rather than a risk factor for the neurodegenerative been shown to be relatively safer for older adults
disease Panza et al. (2010). (e.g., Culang et al. 2009). Some researchers pos-
tulate that the use of antidepressants in elderly
Age Moderating the Impact of Depression patients can improve memory and other cognitive
on Cognition domains through their effects on improving the
In the adult depression literature, researchers have depressive symptoms and by the pharmacody-
reported greater relationships between depression namic effects that are mediated by neurophysio-
and cognitive impairment in the older adult logical changes in the brain (Bali et al. 2016). For
groups compared to the younger adult age groups. instance, Doraiswamy and colleagues (2003) D
Sparse research indicates some evidence that this pooled data from two double-blind 12-week stud-
pattern also exists in the old age group. For ies that included 444 older adults with depression
instance, Pantzar et al. (2014) found that the effect comparing sertraline, uoxetine, and nortripty-
size of depression on cognitive performance in line. They found that there was an improvement
depressed sample was greater for old-old age for short-term memory and psychomotor speed
group (85 years and older) than young-old age for those patients whose depression improved
group (6084 years old). (responders) and had lower anticholinergic side
Although there are several hypotheses of how effects. In order of the highest correlations
depression causes neurobiological changes that between depression improvement and cognitive
can result on cognitive decline, there is sparse improve, it was sertraline, then nortriptyline, and
data of how chronicity of the depression affects then uoxetine.
the brain and cognitive performance in older In contrast, other studies have shown that cog-
adults. Perhaps part of that problem is because nitive decit either persists or still ensues after
chronicity is so intimately related to age and age successful treatment for depression. For instance,
is a signicant factor of the relation between Nebes et al. (2003) conducted a randomized
depression and cognition, especially in old age. double-blind design examining the effects of an
SSRI (paroxetine) or a tricyclic antidepressant
Effects of Antidepressants on Cognition (nortriptyline) on cognition in older patients with
in Geriatric Depression depression. They found that after 12 weeks of
In general, typical pharmacological intervention treatment, their cognitive functioning did not
for depression includes the use of tricyclic improve more than the control group, suggesting
antidepressants (TCAs) and monoamine oxidase that the impairment in cognition due to depression
inhibitors (MAOIs). Additionally, newer classes still persists despite response to antidepressants.
of antidepressant drugs including selective sero- Culang et al. (2009) conducted an 8-week,
tonin reuptake inhibitors (SSRIs), serotonin- double-blind, placebo-controlled study that exam-
norepinephrine reuptake inhibitors (SNRIs), and ined the effects of SSRI, specically, citalopram,
medications acting on noradrenergic and dopa- on neuropsychological functioning on older
minergic neurotransmission [e.g., bupropion adults with late-life depression. They found that
(Wellbutrin)] are increasingly being used for treat- those who did not respond to the citalopram
ment. However, when treating late-life depres- (depression symptoms did not improve), declines
sion, it is important to pay special attention to were found on verbal learning and memory and in
aging considerations for this patient population. psychomotor speed. For those who did respond to
There is evidence to suggest that age-associated the medication, they improved in visuospatial
changes can alter the pharmacodynamics and functioning compared to nonresponders but not
pharmacokinetics of drugs and dictate the type better than those in the placebo group.
of medication and dosage that will be safe and In a recent longitudinal study by Saczynski and
effective for the elderly. colleagues (2015), over 3000 adults from the
Researchers generally agree that the newer National Health and Retirement Study (mean age
antidepressants including SSRIs and SNRIs have 72) were followed for 6 years on their use of
antidepressants, depression symptoms, and cog- Executive Functioning

nition, as measured by a battery of cognitive test Executive Functions
that included memory, working memory, and Memory, Episodic
naming. The researchers found that those taking Mental Health and Aging
the antidepressants declined on cognitive tasks at Working Memory in Older Age
the same rate as those who were not on antide-
pressants after controlling for baseline cognition,
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Definition
Rapp, M. A., Dahlman, K., Sano, M., Grossman, H. T.,
Haroutunian, V., & Gorman, J. M. (2005). Neuropsy- The term depression can have different meanings.
chological differences between late-onset and recurrent It can be regarded as a symptom (low mood), a
664 Depression in Later Life
syndrome (a set of symptoms with various def- Depression in Later Life, Table 1 Diagnostic criteria of
initions), or as a medically dened diagnosis depression according to DSM-5 and ICD-10 (abbreviated)
according to a classication system. Depressive DSM-5 ICD-10
symptoms can be viewed dimensionally, from Core Depressed mood Depressed mood
more or less normal reactions to pathologically symptoms Loss of interest or Loss of interest or
severe depressive symptoms. The symptoms pleasure pleasure
Decreased energy
occur on a continuum of severity from mild reac-
or increased
tions to complete disablement. The classication fatigability
systems have traditionally viewed depressive Other Weight loss or Decreased or
symptoms and depression categorically (Baldwin symptoms weight gain, increased appetite
2014). increased or with corresponding
decreased appetite weight gain
There is no dened biomarker for depression;
Insomnia or Sleep disturbance
the diagnosis is based on a clinical interview, hypersomnia of any type
observation, and supplemental information from Psychomotor Psychomotor
relatives and caregivers. A diagnosis of depres- agitation or agitation or
sion is made according to two main classication retardation retardation
systems: the American Psychiatric Associations Fatigue or loss of Loss of condence
energy and self-esteem
Diagnostic and Statistical Manual, Fifth Edition
Feelings of Unreasonable
(DSM-5), or the International Classication of worthlessness or feelings of self-
Diseases, Tenth Revision (ICD-10). To fulll the excessive or reproach or
criteria for a diagnosis of a depressive episode in inappropriate guilt excessive and
ICD-10, four depressive symptoms must be pre- inappropriate guilt
sent. To fulll the criteria for a major depressive Diminished ability Diminished ability
to think or to think or
disorder (MDD) in DSM-5, at least ve depres- concentrate or concentrate
sive symptoms must be present. In both systems, indecisiveness
the symptoms have to be present for at least Recurrent thoughts Recurrent thoughts
2 weeks, causing clinically important impairment of death, suicidal of death or suicide
ideation, attempt, or suicidal
in daily life function, and one (DSM-5) or two
or plan behavior
(ICD-10) of the symptoms should be among the
DSM-5 Diagnostic and Statistic Manual, Fifth Edition
core symptoms, which are depressed mood, loss ICD-10 International Classication of Diseases, Tenth
of interest or pleasure (DSM-5 and ICD-10), or Revision
decreased energy (ICD-10). DSM-5 and ICD-10
comprise similar criteria but may differ in the
identication of people fullling the criteria for
depression (Table 1). and ICD-10 have specic criteria for bipolar
A substantial proportion of older persons can depressive disorder, including different kinds of
have clinically important depressive symptoms mania as part of the depressive disorder. It is
but not fulll the DSM-5 or ICD-10 diagnostic important to keep in mind that DSM-5 and
criteria for depression. Only DSM-5 includes spe- ICD-10 have been developed mainly in younger
cic criteria for depressive episodes with insuf- populations without cognitive impairment or sub-
cient symptoms, also termed minor depressive stantial physical disease, and it has been argued
disorder or subsyndromal or subthreshold that this makes the classication systems less
depression. Subthreshold depressive symptoms valid in older people, particularly in the presence
persisting for more than 2 years may be diagnosed of cognitive impairment.
as dysthymia in both classication systems. In Depression in later life (DLL), also termed
DSM-5, persistent depressive disorder also late-life depression or geriatric depression, is tra-
includes persistent MDD. Finally, the DSM-5 ditionally dened as depression occurring in
persons older than 65 years, but other age cutoffs Depression in Later Life, Table 2 Depression and
have been suggested, such as 60 years and even dementia
55 years. Conversely, it has been suggested that Depression increases the There is an association
the DLL should use a higher age cutoff than risk of dementia between early-life
depression and risk for
65, because older people now experience better dementia. It is less clear
health and everyday function than they did in whether DLL is an
earlier times. Older persons can have DLL as independent risk factor for
part of a previously established mood disorder, dementia
or the depression can arise for the rst time in Depression and dementia Vascular disease, D
share biological pathways hippocampal atrophy,
late life. DLL is sometimes subdivided according pro-inammatory states,
to the age of the rst lifetime depressive episode. decreased neurotrophic
Studies have used different age cutoffs (e.g., factors are potential
50, 60, or 65 years) to distinguish between depres- biological mechanisms
linking depression and
sion beginning in early life (early-onset depres- dementia
sion [EOD]) and depression with the rst Depression as a Patients with depression
manifestation in later life (late-onset depression prodromal feature of and substantial cognitive
[LOD]). dementia impairment are at an
increase risk for
There is a complicated interplay between DLL
developing dementia
and dementia. Some important issues are summa- People with dementia are Almost one in four
rized in Table 2. at a higher risk of having individuals with dementia
depression experience signicant
depressive symptoms.
Epidemiology Depression is more
common in vascular
dementia or dementia with
Depressive disorders are debilitating health prob- Lewy bodies than in
lems and important causes of death for adults. Alzheimers disease
Depression among adults across the life span is Symptoms of dementia Diminished interest in
projected to be the leading cause of disability in and depression overlap activities that were once
middle and higher income countries by 2030. As enjoyed, sleep changes,
psychomotor changes, and
the population of those aged 65 and over grows, problems concentrating are
DLL will become a major health problem world- common symptoms in both
wide. The prevalence estimates of DLL vary depression and dementia
according to which diagnostic criteria have been Symptoms of depression Aphasia in dementia can
applied, but overall the prevalence rates do not can present different in impede reporting of
older adults with versus subjective depressive
seem to be higher in older persons than they are in without dementia feelings. Thus, provisional
younger age groups. However, in subgroups of diagnostic criteria for
older persons, the prevalence rates are consider- depression in dementia
ably higher. As in younger age groups, women are have been suggested,
which include observable
more likely to experience depression than men. symptoms such as
Compared to the younger group of old adults, withdrawal, irritability, and
depression seems to be more common among agitation
the oldest old, often dened as 85+, as most stud- Treatment of depression The efcacy of
with antidepressants is antidepressants for treating
ies nd an increasing prevalence of depression
less effective in patients depression in dementia is
with a higher age. However, the association with dementia uncertain suggesting
between depression and increasing age seems to different biological
disappear when adjusting for physical disease and pathways in depression in
patients with dementia
increased disability in older age. In
community-based samples, the point prevalence to consider in the etiology of DLL given that the
of MDD in older people has been reported to be rates of alcohol consumption have risen among
between 1 and 6%, but rates for subthreshold older adults, and it is well established that alcohol
depression seem to be two to three times higher use is linked to lower mood and depression. Older
(Meeks et al. 2011). Higher prevalence rates of individuals also use more medication more often
depression are found among old individuals in than younger individuals, and it has been
institutions, such as residential care or nursing suggested that polypharmacy may be associated
home care facilities. Depression is also more prev- with the risk of depression. However, empirical
alent in individuals with somatic disease, particu- evidence is not consistent, and the results are
larly brain disorders. Depression may occur in up difcult to interpret because the condition for
to half of those who suffer from Parkinsons dis- which the medication is taken often confers an
ease or in those who have had a stroke. The increased risk of depression. Finally, substance
prevalence estimates of depression in dementia dependence can also be a factor in the etiology
are high but vary widely, reecting the difculty of DLL and can be easily missed if not assessed in
in dening and diagnosing depression in the con- an older patient.
text of dementia. To improve the diagnosis of
depression in dementia, provisional diagnostic Brain Anatomy
criteria for depression have been suggested, but Research indicates that certain areas or circuits of
their validity remains uncertain. Overall, depres- the brain are relevant to the etiology of DLL
sive episodes in later life are more likely to be a (Naismith et al. 2012). These areas include the
recurrence rather than a rst-time episode. dorsolateral prefrontal cortex, orbitofrontal cor-
tex, anterior cingulate cortex, subcortical white
matter, basal ganglia (especially striatum), and
Etiology the hippocampus. Dysfunction in frontal-
subcortical neural networks involving these
Several biological, psychological, and social fac- areas seems to be associated with the onset and
tors can interact and thus contribute to the devel- prognosis of DLL.
opment of depression. A biopsychosocial model
of etiology seems to be particularly appropriate to Neurotransmitter Dysfunction
DLL, highlighting that the causes of DLL are The monoamines, namely, serotonin, noradrena-
multiple and range across all three domains line, and dopamine, are important modulating
(Blazer 2003). It is useful to consider both neurotransmitters for mood and behavior. Dys-
predisposing and precipitating factors when puta- function in serotonergic and noradrenergic neuro-
tive causes of depression in an individual are transmission and, to a lesser extent, dopaminergic
assessed. There is still limited knowledge about transmission has been demonstrated in DLL
why some older adults develop depression and (Thomas 2013). An association between abnor-
others do not, even though they seem to be malities in these neurotransmitters and depression
affected by the same set of risk factors. is also supported by the fact that antidepressant
medication targeting serotonin and noradrenaline
Biological Factors function improves depressive symptoms. Dys-
DLL regularly arises in the context of medical function in other neurotransmitters associated
illness. There are several well-established physi- with the occurrence of depression includes
cal risk factors like ischemic heart disease, chronic gamma-aminobutyric acid (GABA) and gluta-
obstructive pulmonary disease, diabetes, malig- mate. All of these neurotransmitters have wide-
nancy, chronic pain, and organic brain diseases. spread projections to the prefrontal cortex. Even
In addition, the use of drugs may play a central though dysfunction of monoaminergic transmis-
role in the development of depression in older sion is shown in DLL, it is not completely clear
adults. The role of alcohol is especially important how aging affects the neurotransmitters.
Some evidence suggests, however, that the explanation for the increased risk of dementia in
age-related changes of the neurotransmitters can people with depression, although ndings linking
make older persons more vulnerable to mood high glucocorticoid levels with hippocampus
disorders. atrophy are conicting.
Genetics Vascular Disease

Hereditary factors could predispose some older There is a well-established bidirectional associa-
persons to depression. There has been great inter- tion between vascular disease and depression.
est in genetic susceptibility across the life cycle, This includes coronary heart disease as well as D
but specic genetic markers for DLL have not cerebrovascular disease (i.e., stroke). The white
been identied. Heritability appears to be related matter of the brain is composed mainly by mye-
to multiple loci of the genetic material (DNA) linated nerve bers. Lesions to the white
with small effects rather than few loci with large matter identied on MRI, or white matter
effects. Genetic factors have been found to have a hyperintensities (WMH), have been studied
greater impact in DLL with EOD. Recent genetic extensively in relation to depression. It is pre-
research has focused on the serotonin transporter sumed that WMH are caused by chronic
(5HTTLPR) gene, apolipoprotein E (ApoE) gene, hypoperfusion of the white matter and the disrup-
brain-derived neurotrophic factor (BDNF) tion of the bloodbrain barrier. WMH are related
gene, and 5-methylenetetrahydrofolate reductase to vascular risk factors, the risk of depressive
(MTHFR) gene and has found that these genes episodes, poorer remission, and cognitive impair-
may be involved in the development and treatment. The strong relationship between cerebro-
ment response of DLL (Naismith et al. 2012). vascular disease and depression has led to the
vascular depression hypothesis, which postu-
Immune System lates that cerebrovascular disease can predispose,
Scientic knowledge regarding the interplay precipitate, and perpetuate depressive syndromes
among the nervous, endocrine, and immune sys- in later life by damaging frontal-subcortical cir-
tem has expanded immensely in recent years. It is cuits (Alexopoulos 2005). However, the concept
suggested that these systems should be regarded of a vascular depression has received some criti-
as a single network that gives rise to the new cism and it has proved difcult to reliably identify
discipline of psychoneuroimmunology (Thomas such a subgroup. Nevertheless, vascular disease is
2013). Research has shown that aging can lead likely to be an important factor in about 50% of
to an increased peripheral immune response, people with DLL (Thomas 2013).
impaired communication between the immune
system in the central nervous system (CNS) and Psychosocial Factors and Personality
peripheral nervous system (PNS), and a shift It is a common view that psychosocial factors are
toward a pro-inammatory state of the immune most important in mild to moderate depression,
system in the CNS. Raised levels of pro- whereas biological factors play a greater role in
inammatory cytokines, such as IL-1b, IL-6, and severe depression. The scientic evidence for this
TNF-a, have been reported in studies of DLL. It is view is rather limited, and the evaluation of pos-
probable that aging and comorbid diseases may sible psychosocial etiological factors should be
alter neuroinammation and predispose individ- part of the assessment regardless of the severity
uals to DLL (Alexopoulos and Morimoto 2011). of depression.
Dysregulation of the HPA (hypothalamic- Several psychological factors are associated
pituitary-adrenal) axis has been suggested as a with depression. Relatively little research on the
cause of depression in older and younger adults. association between personality and depression
The associated high glucocorticoid levels may has been done, and the interpretation of the results
have a toxic effect on the brain, particularly the is difcult. Most studies are cross-sectional or
hippocampus. This has been forwarded as an retrospective, and the recall of earlier personality
traits may be inuenced by the present situation. Social support may act as a buffer to stressful
It is also difcult to establish what came rst, the life events, and it is documented that impaired
depressive disease or the presumed personality social support is related to DLL. However, it is
trait. Furthermore, it is complicated to disentangle important to bear in mind that the majority of
the contribution of the personality traits from the people who experience signicant losses in old
social situation of the person as risk factors for age do not develop depression. Hence, the mean-
depression. ing of loss has to be interpreted in the context of
There is some evidence that a high level of the persons mastery style, social situation, and
neuroticism is linked to DLL. Neuroticism is a other predisposing factors (Aziz and Steffens
personality trait characterized by worry, fear, anx- 2013).
iety, guilt, and moodiness. People with a high
level of neuroticism can be sensitive to life
stressors and may interpret minor situations as Clinical Picture
threatening or hopelessly difcult. It has been
suggested that older persons with depressive syn- Several studies have shown that clinicians at var-
dromes can display cognitive distortions, where ious levels fail to recognize depression in older
they generally overrate their own mistakes and persons. There may be a tendency to attribute
exaggerate negative outcomes of life events and depressive symptoms to the normal aging process.
where loss and defeat are core themes. This may also explain the reluctance of some old
High levels of mastery of ones environment people to view their symptoms as signs of depres-
and self-efcacy have been shown to provide pro- sion. It is important to stress the fact that depres-
tection against DLL. A higher sense of control, an sive symptoms are not a consequence of normal
internal locus of control, and more active strategies aging. The most plausible reason for the low
have been found to be associated with fewer detection levels of depression is probably the
depressive symptoms (Bjorklof et al. 2013). rather complicated interplay between normal
Learned helplessness is the idea that individ- age-related changes, symptoms of somatic disor-
uals behave according to the expectation that act- ders and depressive symptoms. This may cause
ing in continually stressful situations has no clinicians to miss the diagnosis or also hinder
meaning. Older adults frequently encounter cir- insight by the person with depressive symptoms.
cumstances such as chronic physical illness and The ICD-10 criteria for depressive episode and
disability that may lead to learned helplessness, DSM-5 criteria for MDD are identical for both
and this notion has been linked to the occurrence younger and older patients (Table 1). The core
of DLL (Aziz and Steffens 2013). symptoms of depression are depressed mood,
loss of interest or pleasure, and decreased energy
Life Events (the latter only in ICD-10). Additional symptoms
Stressful life events can be seen as an integral dened in the diagnostic criteria are loss of
part of becoming old, but some types of condence, an excessive feeling of guilt or worth-
stressful life events, such as divorce or criminality, lessness, difculty concentrating, change in psy-
are less common in old age. It could also be argued chomotor activity, disturbance of sleep, change in
that stressful life events are more often expected in appetite with corresponding weight change, and
late life, making it easier to deal with them. suicidality.
As a person grows older, he or she will inevi- The clinical presentation of depression in old
tably deal with different types of loss. For exam- people differs from what is seen in younger age
ple, these losses include loss of position in society, groups. The aging process, cognitive impairment,
loss of a job, loss of nancial and functional reduced physical health, polypharmacy, and dis-
independence, and loss of a social network and ability can contribute to a more heterogeneous
loved ones. These losses may produce grief that presentation of a depression syndrome in older
develops into depression. individuals. Older adults may be less likely to
describe their suffering in ways that match up to from the diagnostic criteria in the ICD-10 and
common depressive symptoms. For instance, the DSM-5. Thus, provisional criteria for depres-
older persons with frank depression rarely sion in patients with Alzheimers disease have
describe experiencing feelings of sadness. This been suggested. These criteria require fewer
has led to the term depression without sadness. symptoms for a diagnosis of depression and the
More recent research, however, has challenged symptoms do not have to be present nearly every
the view that there is a specic phenotype in day. In addition to the depressive symptoms
depression among old people, suggesting that described in ICD-10 and DSM-5, the criteria for
the key symptoms of depression are the same, depression in Alzheimers disease also include D
irrespective of age (Thomas 2013). social withdrawal or isolation and irritability
However, it seems that some symptoms are (Olin et al. 2002).
more prominent in DLL, with cognitive impair-
ment being the most important. Various expres- Assessment of Depression
sions have been used to describe cognitive In addition to a thorough disease history that
impairment in depression, with pseudodementia considers biological and psychosocial risk factors,
being the most common. Pseudodementia refers the use of a structured assessment scale for depres-
to depression that is misdiagnosed as dementia sion is recommended. A few scales have been
due to marked symptoms of cognitive impair- developed for use in old people, such as the Geri-
ment. This term has fallen out of use, however, atric Depression Scale (GDS) and the Cornell
given the persistent nature of cognitive decits in Scale for Depression in Dementia (CSDD); the
depression, even after the depression has been latter is also used in people without dementia.
successfully treated and recent evidence Other well-known scales, such as the
suggesting that depression is a risk factor for Montgomery-sberg Depression Rating Scale
dementia (Butters et al. 2008). The characteristic (MADRS), the Hamilton Depression Rating
pattern of cognitive impairment in depression Scale (HAM-D), the Beck Depression Inventory
includes impaired attention and executive and (BDI), the Patient Health Questionnaire (PHQ),
amnestic impairment, whereas apraxia, visuospa- and the Hospital Anxiety and Depression Rating
tial impairment, and aphasia may indicate that the Scale (HADS), are frequently used, and the psy-
cognitive impairment stems from a comorbid chometric properties of most of these scales are
dementia disorder. People with a substantial cog- found to be acceptable in the assessment of
nitive impairment as part of their depressive epi- DLL. Reporting depressive symptoms may be
sode should be followed-up closely, even if the hampered by cognitive impairment and the assess-
cognitive impairment is reversed after the treatment may have to include a proxy-based assess-
ment of depression, because the risk of development, such as the CSDD. Given the large
ing dementia in the following year is higher in this proportion of people with DLL who experience
group. impaired cognition, a structured assessment of cog-
Other patterns of the symptom prole in nition should be included in the diagnostic process,
DLL are somatization or hypochondriasis, whether or not a dementia disorder is suspected.
psychomotor retardation, anxiety, and agitation.
It should be noted that some of these Suicidality
symptoms are also common in other diseases The suicide rates in older adults, particularly in
that frequently occur in old age, such as chronic men, have risen. Older men have few suicide
obstructive pulmonary disease and coronary heart attempts per completed suicide, i.e., they choose
disease. more lethal methods. An assessment of suicidality
Psychotic symptoms seem to be more common should be part of all assessments of DLL. As with
in DLL compared to depression in younger adults. any patient population, the older patient must be
There is evidence that for many patients with approached sensitively. Nevertheless, an explicit
dementia, the depression syndrome may differ and specic exploration of suicidal thoughts
should be carried out during the assessment. Older disorder may present itself for the rst time in
men who commit suicide often seek medical help old age. In that case, the diagnostic process may
prior to the attempt, but symptoms of depression be challenging due to the extensive medical
or suicidal thoughts are rarely mentioned. Practi- comorbidity. Medical comorbidity in bipolar ill-
tioners need to be aware of this and have ness is associated with a more disabling course of
suicidality in mind when older men seek advice the illness and a higher risk of suicide (Sajatovic
about other conditions, particularly issues and Chen 2011). Psychiatric comorbidity, such as
concerning pain management. Established risk anxiety disorders or substance use disorders, is
factors for suicide among old people are bereave- often less common among older people than
ment, social isolation, earlier attempts, chronic younger people with bipolar disorder. Patients
painful illness, disability or the threat of increas- with a late onset of bipolar disease tend to have
ing disability, drug or alcohol use, and sleep prob- less history of mood disorders in their family.
lems (Manthorpe and Iliffe 2010). Despite the About half of all older patients with bipolar dis-
concern about the high rate of suicide among old order have depression as their rst mood episode.
people, this issue has received little attention,
particularly when compared to the attention
toward suicidality in younger people. Practice Treatment
guidance on how to reduce the risk is lacking,
and intervention studies are scarce. Before starting treatment, a careful assessment
focusing on the biopsychosocial aspects of DLL
LOD and EOD is needed. The assessment should not be restricted
Some researchers suggest etiological and clinical to counting symptoms in order to establish a diag-
differences between EOD and LOD. EOD is asso- nosis; the meaning or the impact of the depressive
ciated more with a family history of depression, symptoms to the individual person needs to be
personality dysfunction, and severe disorders. taken into account. Functional limitations and
EOD is regarded as a risk factor for the later disability, disease history, and the duration of
development of dementia. LOD is associated symptoms are key issues to keep in mind when
more with WMH on MRI, prominent cognitive weighing the benets of treatment against risks.
impairment, and it relates more to systemic vas- Earlier treatment experiences and preferences of
cular risk and neurodegenerative disorders. There the patient should be taken into account. A careful
is a debate as to whether the symptom prole of explanation of the treatment plan involving the
depressive symptoms dened in the classication patient and if appropriate a family caregiver
systems is different in EOD and LOD patients. is mandatory for treatment success, as low treat-
ment adherence has been reported among old
people.
Bipolar Disorders in the Late Life A stepped care approach, identifying the least
restrictive and least costly intervention that will be
The number of people seeking care for bipolar effective for a persons presenting problems, is
disorders is increasing. Bipolar disorders can recommended (NICE 2010). People with sub-
develop early, i.e., onset before 50 years of age, threshold depression without a signicant impact
or can arise with a late onset, i.e., after 50 (different on everyday life should be offered supportive and
cutoffs between 50 and 65 have been used). Bipo- psychosocial interventions, but they should nor-
lar disorders in late life include both early and late mally not be offered medical treatment. In milder
onset. Due to the complexity and heterogeneity in forms of depression or persistent subthreshold
the classication of the disease, prevalence rates depression, more intensive psychotherapeutic
vary. Among older patients with bipolar disorder, approaches are advocated. Drug treatment should
most have their rst episode of mania or depres- still not be a rst-line treatment option, but should
sion early in life; in the minority, a bipolar be considered if other alternatives fail to produce
substantial improvement. In moderate or severe behavior and is often structured in sessions and
depression, drug treatment should be offered, length. CBT is widely studied and applied in DLL
often in combination with intensive psychothera- with mild to moderate severity. IPT is also based
peutic treatment. on here-and-now situations, but emphasizes inter-
In the treatment of depression, it is important to personal relationships. PST is based on CBT prin-
aim for remission (i.e., patients do not meet the ciples, but is a more focused treatment approach.
diagnostic criteria for depression or they have no PST aims to teach patients to better dene their
more than minimal depressive symptoms problems and goal, and the strategies to cope with
according to a depression assessment scale) and the problems, carry out the strategies, and then D
not merely for response (i.e., signicant symptom evaluate them. PST has shown strong results for
reduction), because residual symptoms after treat- depressed patients with executive dysfunctions.
ment are strongly associated with a risk for As a result, it has been suggested as a key treat-
relapse. Once in remission, a plan for the contin- ment approach in vascular depression, where it
uation of treatment should be established. There is has been implicated that the dysfunction of
reason to believe that maintenance therapy should frontostriatal circuits gives rise to executive
be offered more liberally in DLL than in younger impairment (Espinoza et al. 2014).
age groups, due to a greater risk of relapse. Psychotherapy, in combination with medical
treatment, may be more efcacious than any of
Psychosocial Interventions the two modalities alone in the treatment of DLL,
Older patients with minor or mild depression can both in the acute phase and as maintenance
benet from participating in various types of therapy.
social activities to prevent isolation and loneli-
ness, e.g., befriending services and attending day Medication
centers and local community events. Physical A number of issues need consideration when pre-
exercise includes bodily activity that enhances scribing antidepressive medication to older adults.
overall health and wellness. There is evidence As noted earlier, polypharmacy is common in
that structured exercise programs can help older older individuals. Medication with negligible
patients with milder depressive syndromes. Dif- side effects in healthy young people may cause
ferent kinds of exercises can be benecial, but serious side effects in older adults who take many
results are most consistent from aerobic exercise. prescribed drugs, especially when several of those
However, there are also studies that have failed to drugs could have direct effects on the brain. An
nd a positive effect of physical exercise in DLL. example is the rather weak anticholinergic effect
of a drug like paroxetine; in combination with
Psychotherapy other drugs with weak anticholinergic effects, it
Research indicates that psychotherapy can be an may cause confusion or delirium in susceptible
effective treatment for DLL even though the qual- individuals. Pharmacokinetic changes, such as
ity of studies is relatively low (Wilson et al. 2008). increased distribution volume, reduced hepatic
There is a variety of therapies that may be applied, metabolism, and reduced glomerular ltration
such as supportive therapy, life-review therapy, rates, may lead to higher plasma and brain levels
cognitive-behavioral therapy (CBT), interper- of the drug. However, there is great variation
sonal therapy (IPT), and problem-solving therapy among older adults in these changes. The slogan
(PST). Psychotherapy can be offered to individ- start low, go slow that was often voiced in
uals (in- or outpatients), couples, families, and as old-age psychiatry may be appropriate, but should
group therapy. Supportive treatment and adding not prevent older patients from being treated with
structure to the day can be effective in patients adequate doses. When evaluating dosing regi-
with minor depression syndromes. CBT focuses mens, the polymorphisms of key enzymes of the
on here-and-now situations as well as the link cytochrome P450 system involved in the
between negative thought patterns and mood and metabolism of several psychopharmacological
substances should be taken into account. A con- other antidepressants; combining SSRIs with
siderable proportion of individuals can have poly- mirtazapine or mianserin can be particularly use-
morphisms that may cause great variation in the ful for patients with sleeping problems and low
plasma level of a medication. In cases of unusual appetite. Serotonin and noradrenaline reuptake
side effects at low doses or treatment resistance, inhibitors (SNRIs) have adverse event proles
an analysis of P450 enzymes may be indicated. similar to SSRIs and are a useful second-line
Most studies regarding drug treatments for treatment option because of their somewhat
depression have been done in samples with MD- broader receptor prole. Because older adults
D. Hence, the results cannot readily be extrapo- with depression constitute a heterogeneous
lated to people with mild depression or group, the prescription of antidepressive medica-
subthreshold depression. The effect of antidepres- tion should be individualized based on the side
sants in treating DLL is well documented (Nelson effect prole of the drug, previous medication
et al. 2008). However, there is great variability history, somatic diseases, and the use of other
among studies. The older tricyclic antidepressants drugs.
(TCAs) have a comparable effect to the new Monotherapy is preferred, but in cases of treat-
ones but a higher prevalence of side ment resistance, augmentation therapy with other
effects particularly anticholinergic and drugs may be tried. The best evidence is for aug-
antiadrenergic effects that have made them less mentation with lithium, used for bipolar disorder
useful in treating DLL. (Cooper et al. 2011). However, lithium serum
Contrary to the positive treatment effect in levels have a very narrow therapeutic window
older adults without substantial cognitive impair- and require careful observation in order to avoid
ment, most of the studies concerning the use of potentially serious adverse events.
antidepressive treatment in patients with dementia
have failed to show an effect (Nelson and Electroconvulsive and Neuromodulation
Devanand 2011). This may be because of an Therapies
inability to dene homogenous patient groups Electroconvulsive therapy (ECT) is well tolerated
with depression and dementia. Symptoms of and efcacious in treating DLL (Riva-Posse
depression and dementia partially overlap and et al. 2013). It should be an option in people
cognitive impairment may prevent any verbaliza- with severe depression when other treatment alter-
tion of the depressive symptoms. Furthermore, natives have failed. In many countries, ECT is
people with dementia may be more susceptible reserved for severe depression with psychosis,
to adverse events. Taken together, there is not suicide risk, or life-threatening refusal of food or
enough evidence to suggest antidepressive ther- uids. Concerns about using ECT in DLL have
apy as a rst-line treatment in people with demen- been raised, especially the fear of precipitating
tia except in specic cases, such as very severe delirium or memory impairment. Recent studies
depressive symptoms or a history of earlier epi- demonstrate a faster remission in patients treated
sodes that have responded to treatment. with ECT than patients treated with antidepres-
There are a large number of antidepressive sants, without extra side effects. This suggests that
drugs to choose from, but selective serotonin the indication for ECT could be broader. The high
reuptake inhibitors (SSRIs) are the rst choice in relapse rate after ECT is a therapeutic challenge;
most instances, in line with most clinical guide- maintenance therapy may be indicated. Other
lines. These drugs are generally well tolerated and stimulation therapies, such as transcranial mag-
they have a predictable interaction prole. None- netic stimulation, vagal stimulation, or deep
theless, recent studies indicate that SSRIs may brain stimulation, have been tried out in selected
also be associated with serious adverse outcomes, patient groups, but these alternatives are not easily
such as increased QT interval, falls, and accessible and there is limited evidence to date to
hyponatremia. SSRIs may be combined with justify their use in clinical practice.
Prognosis risk of suicide, particularly in older men, warrants

special attention among all health workers provid-
DLL is associated with a number of negative outing care for older individuals.
comes, such as disability, cognitive impairment,
poorer outcomes of physical disorders, and an
increased risk of mortality. Remission rates of
Cross-References
DLL after treatment are not different from those
in younger age groups; however, relapse rates are
Anxiety Disorders in Later Life D
higher (Mitchell and Subramaniam 2005). The
Bipolar Disorder in Later Life
risk of relapse is highest for the rst 6 months. Cognitive Behavioural Therapy
Hence, it is important to continue treatment for at
Comorbidity
least 69 months. Even after the rst depressive
Dementia and Neurocognitive Disorders
episode in old age, the relapse rate is high after the Grief and Bereavement: Theoretical Perspectives
treatment has been discontinued. This has led
many to recommend lifelong maintenance treat-
Mild Cognitive Impairment
ment even if the rst depressive episode has a later Problem-Solving Therapy
onset, particularly if it was an episode of great
Psychological and Personality Testing
severity. This recommendation has to be weighed
Subsyndromal Psychiatric Disorders
against risks associated with polypharmacy, side Suicide in Late Life
effects, and other risk factors for relapse, such as
cerebrovascular pathology, other physical dis-
eases, and cognitive impairment. References
Alexopoulos, G. S. (2005). Depression in the elderly. Lan-

cet, 365, 19611970.
Conclusion Alexopoulos, G. S., & Morimoto, S. S. (2011). The inam-
mation hypothesis in geriatric depression. International
DLL is a disease with vast consequences for Journal of Geriatric Psychiatry, 26, 11091118.
affected individuals and society as a whole. The Aziz, R., & Steffens, D. C. (2013). What are the causes of
late-life depression? The Psychiatric Clinics of North
symptoms are well characterized and there is a America, 36, 497516.
huge knowledge base around epidemiology, etiol- Baldwin, R. C. (2014). Depression in later life (2nd ed.).
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the knowledge relates to younger age groups, Bjorklof, G. H., Engedal, K., Selbaek, G., Kouwenhoven,
S. E., & Helvik, A. S. (2013). Coping and depression in
which has been extrapolated to DLL. There is old age: A literature review. Dementia and Geriatric
reason to believe that there are important etiolog- Cognitive Disorders, 35, 121154.
ical and clinical issues that apply to DLL, which Blazer, D. G. (2003). Depression in late life: Review and
differ from what we see in younger age groups. commentary. The Journals of Gerontology. Series A,
Biological Sciences and Medical Sciences, 58, 249265.
Yet, there is probably greater diversity among Butters, M. A., Young, J. B., Lopez, O., Aizenstein, H. J.,
older versus younger age groups. This calls for a Mulsant, B. H., Reynolds, C. F., 3rd, DeKosky, S. T., &
careful assessment and consideration of biological Becker, J. T. (2008). Pathways linking late-life depres-
and psychosocial issues common with advancing sion to persistent cognitive impairment and dementia.
Dialogues in Clinical Neuroscience, 10, 345357.
age. Particular attention should be paid to comor- Cooper, C., Katona, C., Lyketsos, K., Blazer, D., Brodaty,
bid physical diseases, cognitive impairment, and H., Rabins, P., de Mendonca Lima, C. A., & Living-
distressing life events. The increased vulnerability ston, G. (2011). A systematic review of treatments for
of some older adults to depression in itself and refractory depression in older people. The American
Journal of Psychiatry, 168, 681688.
treatment side effects, the uncertain efcacy of Espinoza, R. T., & Unutzer, J. (2014). Diagnosis and
treatment in subgroups, and the high relapse rate management of late-life depression (UpToDate). Wal-
in DLL call for close follow-up. Lastly, the high tham, Wolters Kluwer.
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Manthorpe, J., & Iliffe, S. (2010). Suicide in later

life: Public health and practitioner perspectives. Inter- Disability and Ageing
national Journal of Geriatric Psychiatry, 25,
12301238.
Meeks, T. W., Vahia, I. V., Lavretsky, H., Kulkarni, G., & Fiona Kate Barlow1 and Nicole Walker2
1
Jeste, D. V. (2011). A tune in a minor can b major: School of Applied Psychology and Menzies
A review of epidemiology, illness course, and public Health Institute Queensland, Grifth University,
health implications of subthreshold depression in older
adults. Journal of Affective Disorders, 129, 126142. Brisbane, QLD, Australia
2
Mitchell, A. J., & Subramaniam, H. (2005). Prognosis of School of Psychology, The University of
depression in old age compared to middle age: Queensland, Brisbane, QLD, Australia
A systematic review of comparative studies. The Amer-
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Naismith, S. L., Norrie, L. M., Mowszowski, L., & Hickie,
I. B. (2012). The neurobiology of depression in later- Synonyms
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pathophysiological features. Progress in Neurobiology, Age-related disease; Age-related impairment;
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Nelson, J. C., & Devanand, D. P. (2011). A systematic Chronic disease; Functional change and loss;
review and meta-analysis of placebo-controlled antide- Impairment
pressant studies in people with depression and demen-
tia. Journal of American Geriatrics Society, 59,
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Nelson, J. C., Delucchi, K., & Schneider, L. S. (2008). Definition
Efcacy of second generation antidepressants in late-
life depression: A meta-analysis of the evidence. The Disability is a broad term that has multiple deni-
American Journal of Geriatric Psychiatry, 16, tions. The World Health Organization (World
558567.
NICE. (2010). Depression: The treatment and manage- Health Organization 2012) denes disability as
ment of depression in adults (Updated ed.). National encompassing:
Collaborating Centre for Mental Health, London.
Olin, J. T., Schneider, L. S., Katz, I. R., Meyers, B. S., 1. Impairments: a problem or problems with
Alexopoulos, G. S., Breitner, J. C., Bruce, M. L., Caine,
E. D., Cummings, J. L., Devanand, D. P., Krishnan, bodily structure or function
K. R., Lyketsos, C. G., Lyness, J. M., Rabins, P. V., 2. Activity limitations: a problem or problems
Reynolds, C. F., 3rd, Rovner, B. W., Steffens, D. C., experienced by an individual when attempting
Tariot, P. N., & Lebowitz, B. D. (2002). Provisional to carry out an action or task
diagnostic criteria for depression of Alzheimer disease.
The American Journal of Geriatric Psychiatry, 10, 3. Participation limitations: a problem or prob-
125128. lems in dealing with life situation (e.g., social,
Riva-Posse, P., Hermida, A. P., & McDonald, W. M. vocational)
(2013). The role of electroconvulsive and
neuromodulation therapies in the treatment of geriatric
depression. The Psychiatric Clinics of North America, The term disability, however, is not limited to
36, 607630. health conditions. In fact, the International Clas-
Sajatovic, M., & Chen, P. (2011). Geriatric bipolar disor- sication of Functioning, Disability, and Health
der. The Psychiatric Clinics of North America, 34, views disability as an umbrella term (World
319333.
Thomas, A. (2013). Depression in older people. In Health Organization 2012). In their denition,
T. Dening & A. Thomas (Eds.), Oxford textbook of disability is the interaction between environmen-
old age psychiatry (2nd ed., pp. 544569). Oxford: tal and personal factors (e.g., stigmatization,
Oxford University Press. access to healthcare, social support) and a health
Wilson, K. C., Mottram, P. G., & Vassilas, C. A. (2008).
Psychotherapeutic treatments for older depressed peo- condition (e.g., schizophrenia, cardiovascular dis-
ple. Cochrane Database of Systematic Review 23 (1), ease). This means that experiencing a disability is
CD004853. really the combination of both some health
Disability and Ageing 675
condition and how you are treated and/or limited disability are substantially higher in African and
as a result of it (World Health Organization 2012). Southeast Asian nations than they are in the
Disability is not an inevitable part of aging, but Americas or Europe (World Health Organization
the odds of experiencing a disability or living with 2012). International differences notwithstanding,
a disability increase with age. As this entry will with an expanding older population, globally,
show, many age-related changes are associated there are more people living with disability
with disability (e.g., age-related eye degeneration today than there have been in the past.
resulting in cataracts leading to visual disability) In general, part of the reason that we are living
(Hoyer and Roodin 2009). longer is because we are better at preventing and D
treating communicable disease. Communicable
diseases are those that can be spread between
The Nature and Causes of Disability for people or between people and animals. Vast
Older People reductions in infectious and parasitic disease
have resulted from effective and available immu-
As of 2010, approximately a billion people nization, attempts to manage poverty, and
(around 15% of the worlds population) were esti- improvements in diets and infrastructure. Thus,
mated to live with some form of disability. Among at present, in developed or high-income countries,
these, 24% were estimated to have severe dis- the leading causes of disability (as well as disease
ability that dramatically impaired functioning and death) are noncommunicable (e.g., arthritis,
(e.g., quadriplegia, blindness). Rates of disability cancer, mental health disorders). The same is true
(i.e., experiencing difculty in performing activi- of middle-income countries it is only in devel-
ties), and severe disability (i.e., being prevented oping countries that the leading cause of disease
from performing activities), increase with age and death remains communicable disease
(World Health Organization 2011). We can use (alongside maternal, perinatal, and nutritional
the USA as an example here. In the USA, fewer conditions). It is estimated that by 2030 this will
than one in ve people aged under 65 report a change noncommunicable disease will be the
disability (2010 US Census data) (Brault and leading cause of disability, disease, and death
United States. Bureau of the Census 2012). This worldwide (World Health Organization 2011).
increases to about 50% in adults aged 65 years and To some extent, this represents a challenge to
over. In this age bracket, one in two will report a the way that disability is traditionally conceptual-
disability. Over a third will live with a severe ized. When we think about disability in aging, we
disability. For people in their 80s, rates of disabil- often draw on standard stereotypes imagining
ity are close to 75% and severe disability 60% someone in a wheelchair or someone who is
(Brault and United States. Bureau of the Census vision impaired. The reality is that disability is
2012). varied, not only in its nature, but also in the extent
The way that disability is assessed and to which it affects or limits people.
recorded, however, differs country to country. The most common disability-related health
This means that it is hard to accurately estimate conditions in Australia and Canada are arthritis,
how many people are disabled, let alone how back problems, and hearing problems (World
many older people are disabled. According to Health Organization 2011, 2012; Australian
best estimates, however, approximately 30% of Bureau of Statistics 2012). Others include heart
adults aged 60 years and over in higher-income disease, hypertension, asthma, diabetes, stroke,
countries have a disability, and approximately depression, dementia, speech disorders, and
45% of adults over 65 in lower-income countries vision disorders. In the USA, rheumatism and
live with a disability. For example, the rates of heart problems represent the most common causes
of disability among adults 65 or older (World adverse lifestyle or environment can expedite dis-
Health Organization 2011; Centers for Disease ability in later life (World Health Organization
Control Prevention 2009). As of 2011, the most 2011, 2012). One of the most consistent predictors
common health conditions in developing coun- of disability is socioeconomic disadvantage. Poor
tries were heart disease, stroke, cancers (breast, nutrition, and inability to access healthcare,
prostate, and lung), sensory problems (cataracts increases the risk of developing a disability
and glaucoma), hearing loss, and musculoskeletal (World Health Organization 2012). At the inter-
impairment (osteoarthritis and osteoporosis) national level, rates of disability in the USA are
(World Health Organization 2011). high when compared to other developed coun-
Older people with disability can either enter tries. The reason for this is largely assumed to be
old age with a preexisting disability or develop a ready and equal access to healthcare provided by
disability in later life (either due to age-related governing bodies. Similarly, healthcare is often
factors or other factors such as communicable difcult to access in low-income countries. Just
disease or accident). As highlighted above, how- as there are higher rates of disability within
ever, rates of disability increase with age, in part low-income countries than within high-income
due to biological change. For example, as we age, countries, so too are there higher rates of disability
visual deterioration is common. This includes in people of low socioeconomic status (SES).
declines in accommodation (the ability of the Poverty has a cumulative effect, and this becomes
lens to focus), contrast sensitivity, and sensitivi- more evident in later life. Further, poverty is more
ties to glare (Hoyer and Roodin 2009). Changes in evident among the elderly (World Health Organi-
the eye give rise to visual pathologies. Approxi- zation 2011). Those born into poverty are more
mately 70% of adults aged 80 or over have cata- likely to develop a disability and if they survive
racts, with 20% and 7% of the same age group into old age, carry it with them. The prognosis and
experiencing age-related maculopathy and glau- quality of life for those with a disability who
coma, respectively (Resnikoff et al. 2004). Simi- experience poverty are worse than for those with
larly, with age comes a predictable breakdown of a disability who do not experience poverty. Thus,
cells in the inner ear (albeit at different rates for there appears to be a cycle of disability where
different people). This can result in hearing poverty breeds disability and also exacerbates
impairment, with approximately 35% of men it. Gender also interacts with poverty. As women
and 22% of women aged 7074 experiencing live longer than men, on average they are more
such impairment, and this rises to 58% of men likely to experience poverty in old age (Hoyer and
and 49% of women at 85 years or older (Mathers Roodin 2009).
et al. 2000). Taste, smell, and touch sensitivities
also decline. In the case of touch, this can be
particularly problematic as insensitivity to The Impact of Disability on Older Adults
touch and pain can lead to accidents and subse-
quent disability (Hoyer and Roodin 2009). The most obvious impact of disability on older
Finally, loss of bone density and muscle mass, adults is in the realm of self-care. Physical disabil-
circulation, and respiration are also part of the ity in older adults can prevent them from being
normal aging process (Deschenes 2004). As this able to independently move in and out of bed,
highlights, many factors contribute to disability leave the house, and engage in house maintenance
and all can hinder effective participation in many (Brault and United States. Bureau of the Census
activities of daily living (Hoyer and Roodin 2012). In fact, as of 2010, at least one in ten
2009). American adults aged 65 or older reported need-
ing assistance in leaving the house, with a similar
Factors Exacerbating Disability proportion reporting needing assistance with
While age increases the risk of developing dis- housework (Brault and United States. Bureau of
eases and disabilities, the cumulative effects of the Census 2012). When we consider the fact that
many people with disabilities require doctor or falls are the most common causal factor of restric-
hospital visits, as well as pharmacy medication, tions of activities of daily living (Rubenstein
any disability that prevents them from leaving the 2006). The more chronic health conditions an
house would exacerbate challenges associated elderly person reports, the more likely they are
with disability management should they not have to fall and fall recurrently (Tinetti et al. 1986).
access to assistance. Thus, we can see that disability in and of itself
Disability can impact on basic activities of self- puts people at the risk of future disability (World
care or activities of daily living. These include the Health Organization and Ageing Life Course Unit
ability to bathe, dress, and toilet independently. 2008). D
Instrumental activities of daily living like paying
bills, shopping and food preparation, and taking Participation in Society
medications appropriately require some degree Disability in the elderly often puts limits on their
of planning and intellectual engagement ability to live happy, fullled lives. This is not just
(Cavanaugh and Blanchard-Fields 2014). In the because of problems associated with activities of
USA, of Medicare enrollees 65 years or older, daily living (e.g., walking, getting dressed);
approximately 41% needed some assistance with rather, impairments can also impose barriers to
these activities. Twelve percent of adults aged social and vocational interactions. For example,
65 years or older needed help with instrumental difculties in vision can prevent older adults from
activities only, with the remaining 29% also driving (Hoyer and Roodin 2009). Mobility dif-
requiring assistance with at least one activity of culties can prevent catching public transport, as
daily living (Cavanaugh and Blanchard-Fields can the availability or affordability of public trans-
2014). The most common problems include dif- port (Gilhooly et al. 2002). Thus, disability can
culties in walking, bathing, dressing, using the lead older adults to withdraw from social activities
toilet, getting in and out of bed, and eating or cease attending gatherings or going on outings.
(Cavanaugh and Blanchard-Fields 2014). Impair- Physical and/or cognitive disability may also
ments in these areas increase with age. In the case prevent older adults from engaging in work-
of walking, approximately 15% of adults aged related activities. There are a number of reasons
6574 years are having difculty in doing so, for this. Firstly, physical disability may prevent
compared to almost 50% of adults aged 85 years someone from performing a job that they previ-
and older. Around 20% of adults aged 65 or over ously held (e.g., problems with walking may pre-
require either the use of a walking aid (e.g., cane, vent a farmer from farming). However, potent
walker, crutches) or wheelchair for mobility misconceptions about the disabled elderly
(Centers for Disease Control Prevention 2009). (including those held by the elderly themselves)
Importantly, when an older person becomes can also prevent older adults with disabilities who
restricted in some capacity, their decline is more desire employment from seeking and attaining it
rapid and recovery protracted, thus increasing the (World Health Organization 2012). For example,
likelihood of additional disability that further older adults with a disability are often excluded
limits their ability to live independently (World from disability services that aim to provide rights
Health Organization 2011; Hultsch et al. 1999) and opportunities to those living with a disability
Chronic disabilities are a robust predictor of (Jnson and Larsson 2009). In Sweden, for exam-
falls in the elderly (as can be assumed with over ple, a system of long-term support (personal assis-
50% of adults 85 and older reporting difculties tance) has been introduced for those living with a
walking). Further, in the USA, accidental injury is disability who are under the age of 65 (Jnson and
the fth leading cause of death in older adults after Larsson 2009). Researchers argue that ageism
cardiovascular disease, cancer, stroke, and pulmo- affects disability here whereby many conate
nary disease (Rubenstein 2006). Falls themselves disability and aging (i.e., assume that disability is
account for approximately 60% of these deaths. a normal and natural part of aging) (Jnson and
As a consequence, data in the USA reveals that Larsson 2009). Thus, older adults with a disability
often are not able to take advantage of programs nonprofessional care provided by family mem-
designed to support them in pursuing paid work, bers. In fact, the majority of older adults with a
among other things. disability do not live in aged care facilities. In
As prefaced above, older adults with disabilities Australia, one in ten people reports being a carer
are likely to face discrimination. Some researchers for a person with a disability (Australian Bureau
have argued that the recent focus on positive, of Statistics 2012). The majority of carers are
successful, or healthy aging has meant that female (70% of primary carers), and of carers
older adults with a disability are stereotyped as themselves, approximately a third have a disabil-
people who age badly or unsuccessfully ity. Labor force participation is lower for carers,
(Minkler 1990). When looking at specic preju- who often spend more than 40 h a week in their
dices, mental disabilities are stigmatized, and phys- caretaking roles (Australian Bureau of Statistics
ical disabilities are often assumed to extend to 2012).
cognitive impairment. Those with dementia are The cost of caring for older adults is not just
sometimes seen as less than human and conse- nancial; it is also emotional. Carers are typically
quently are not afforded time and companionship. overworked and often unpaid. They face substan-
Whether through physical barriers, or social tive stress, especially because their role often
exclusion, isolation can have a severe negative involves negotiating and managing the current
impact on older adults with a disability. A primary impairment and the future consequences of the
predictor of longevity is the strength and quality impairment (palliative care and death), which is
of our social relationships (often marriages often not recognized publically (Hoyer and
(Tucker et al. 1996)). Older adults with strong Roodin 2009).
social networks thrive especially when they The costs detailed above, both to societies and
enjoy close and meaningful relationships (Hoyer individuals, highlight the importance of looking at
and Roodin 2009). When disability limits this, disability in older adulthood at national, and
either through preventing socializing or through global, levels. When it comes to disability, gener-
increased incidents of discrimination, older adults ally, the World Health Organization recommends
with disability are likely to experience declines in that multiple environmental changes should be
health and quality of life. implemented to improve the lives of those with
disabilities (World Health Organization 2011,
2012). For example, it is recommended that poli-
Societal Impact and Management of cies concerning accessibility of education and
Disability in Aging healthcare be designed with specic reference to
meeting the needs of disabled people. Funding
Given the rising number of people with a disabil- and the provision of services for those with dis-
ity, there is a considerable burden experienced ability need to be increased. At a very basic level,
globally both in terms of health and nances. built environments should be designed to be
Financial costs are borne by the disabled them- accessible to all. Negative attitudes and poor stan-
selves, governments, and individual carers (and dards of care need to be combated. In each case, it
families). One report estimated that, in the period is recommended that extensive consultation with
between 2006 and 2015, the nancial cost of heart people with disabilities is undertaken and that any
disease, stroke, and diabetes in 23 low- and programs instituted are rigorously documented
middle-income countries approached $US100 bil- and evaluated (World Health Organization 2012).
lion (World Health Organization 2011). In 2009, When it comes to programs specically
the cost associated with new cancer cases in the designed to help older adults with disabilities,
USA was estimated at $US286 billion. The world- multiple successful examples can be found. For
wide cost of dementia in 2010 was estimated example, in Japan, free social exercise classes are
to exceed $US600 billion (World Health Organi- made readily available to older adults living in
zation 2011). Note that this gure includes large cities (Hoyer and Roodin 2009). Indeed,
exercise programs in the USA have been shown to and relatives who are often unpaid and under-
reduce disability and pain for older adults with resourced. Further, older adults with a disability
knee osteoarthritis (Ettinger et al. 1997). attract substantive discrimination. They are often
Community-based programs in the USA aimed treated as if they are childlike or impaired beyond
at preventing disability in older adults, as well as their disability. Increases in support to caregivers,
promoting disease self-management, have been better government and aged care services, as well
shown to reduce functional decline and length of as improvements in attitudes toward older adults
hospital stays (Wagner et al. 1998). with a disability would lead to improved quality of
On an individual level, managing disability in care and life for older adults with a disability D
older adulthood much like disability itself is (as well as their caregivers). Finally, while
complex. Several factors have been identied, avoiding disability in later life is probably unreal-
however, that reliably delay the onset of disability. istic, it can be delayed and managed more posi-
Most importantly, exercise is a factor that has been tively. Specically, regular exercise and social
shown to increase both physical health and mental interactions have both been shown to be protec-
health and is effective in delaying the onset of tive, as has income equality. Some changes can be
dementia (Cotman and Berchtold 2002) and made at a personal level, such as adherence to an
preventing physical disability (see above). Cogni- exercise program. Others will need to be tackled at
tive stimulation is also important. Older adults a societal level. Income inequality, for example, is
who remain in the workforce until later in life to a large degree a product of public expenditure,
display better cognitive integrity than those who taxation, laws, as well as government provision of
retire early, and it is likely that cognitive challenge healthcare and education. With an aging popula-
is protective (World Health Organization 2011). tion, it is clear that changes must be considered, if
Finally, a strong social network is vital. Older we are to reduce the global burden of disability.
adults do not necessarily benet from having a
large social group. Rather, they are most healthy
when they report close, developed, and deep
friendships (Hoyer and Roodin 2009). A reduc- Cross-References
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Roodin 2009; Cavanaugh and Blanchard-Fields Aging, Inequalities, and Health
2014). Loneliness and Social embeddedness in Old
Age
Social Cognition and Aging
Conclusion Social Connectedness and Health
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Distance-to-Death Research in Geropsychology 681
Distance-to-Death Research that unfold rapidly and accelerated aggravation

in Geropsychology or loss of functionality prior to death (i.e., drop)
from processes that run in a more steady and less
Across the past decades, research in accelerated way (i.e., decline). This distinction
geropsychology increasingly considered dis- has been grounded on theoretical considerations
tance-to-death as indicator of psychological regarding the causal processes driving the terminal
changes that unfold at the end of the human changes in psychological functioning: Terminal
lifespan. That is, this research is based on the decline reects a gradual accumulation of under-
rationale that crucial changes in psychological lying biological and environmental causes, D
functioning may occur in late life as individuals whereas terminal drop implicates a threshold
approach their death, meaning that the occurrence model with an acute precipitating mechanism
of these changes is closely related to biological (Bckman and MacDonald 2006, p. 227). How-
processes of deterioration that precede and will ever, both terms are often used interchangeably in
nally precipitate the death of the individual. His- distance-to-death research, supposedly because
torically, this approach was initiated in the eld of clear-cut empirical criteria to distinguish terminal
geropsychological research on cognitive function- decline from terminal drop in observations of time-
ing early in 1960s by Robert Kleemeier, who to-death-related changes are hard to establish. That
presented evidence of an association between is, any notion of changes that occur uniquely time-
late-life declines in intellectual function and mor- to-death-related at the end of individuals lifespans
tality, suggesting the existence of a factor, which implies some kind of acceleration, in that these
might be called terminal drop or decline, which changes occur after the onset of the terminal pro-
adversely affects intellectual performance and is cess, adding to ongoing normative age-graded
related to impending death of the aged person (or otherwise time-graded) changes or stability.
(Kleemeier 1962, p. 293). Such terminal change Therefore, the remainder of this chapter will not
might unfold late in peoples life over some time follow a strict distinction between slow-running
period before death, hence timely associated with and fast-running terminal changes, but rather deal
distance-to-death, rather than with calendar age with terminal change in general, including both
(i.e., distance-to-birth). To put this reasoning sim- dynamics of terminal decline and terminal drop.
ply, if humans are not hit by lethal developments Doing so, this chapter will mainly focus on
that unfold short termed (such as accidents or conceptual and theoretical aspects of distance-to-
severe acute illnesses), crucial changes driven by death research. Thus, only a brief overview on
end-of-life degradations may not occur norma- empirical ndings on terminal change will be
tively in terms of age related, but terminally in given rst. Second, methodological concepts that
terms of time-to-death related. are key constituents of distance-to-death research
Thus, in the broadest sense, geropsychological will be outlined. Third, the relevance and poten-
distance-to-death research includes all kinds of tials of distance-to-death research will be consid-
empirical studies that examine associations ered: Which insight about late-life development
between psychological functioning and time-to- does or could distance-to-death research pro-
death. In a narrower sense, however, the key vide to geropsychology?
objectives of such research refer to terminal
change. This distance-to-death research was Empirical Evidence: Terminal Decline
largely driven by the concepts of terminal decline in Cognition and Subjective Well-Being
and terminal drop. The latter term has been used Starting with Kleemeiers investigation, gerontol-
to differentiate time-to-death-related processes ogists interest in phenomena of terminal decline
has long been focused on cognitive functioning manifold hints toward proximal and distal inu-
(e.g., Kleemeier 1962; Riegel and Riegel 1972; ences across the lifespan that might impact on the
Siegler 1975; White and Cunningham 1988). This onset and speed of terminal declines (for review,
early research revealed manifold and strong see Bckman and MacDonald 2006; for more
evidence that (a) levels of cognitive function recent ndings, see, e.g., Gerstorf and Ram
predicted subsequent survival (for review Small 2013; Muniz-Terrera et al. 2013; Cadar
and Bckman 1999) and (b) intraindividual et al. 2015). Overall, terminal decline in cognitive
declines of cognitive performance were associ- functioning appears as developmental dynamic
ated with distance-to-death (for review, see not fully mediated by specic diseases, but a
Bosworth and Siegler 2002). Overall, these nd- phenomenon determined by multiple impacts,
ings suggested that terminal change accounts for a including some core of time-to-death-related
substantial portion of the differences in cognitive change that still could not be attributed to partic-
performance among older individuals, leading to ular causes and might be understood in terms of a
questions on the nature of the phenomenon, par- deterioration of global biological vitality
ticularly concerning the causal processes underly- (Bckman and MacDonald 2006, p. 225). Figure 1
ing terminal change and the pervasiveness of summarizes proximal and distal impacts of termi-
such distance-to-death-related changes across nal cognitive decline, adapted from Bckman and
different including also non-cognitive facets MacDonalds (2006) respective summary
of psychological functioning. With the terminal (leaving out predictive pathways from genes and
decline paradigm well established in aging early environment to childhood IQ and also
research, more recent investigations in the direct links from childhood IQ and normative
broadest sense dealt with these questions. age-graded inuences to death that were part of
The further progress of distance-to-death their gure). The original gure has been modi-
research up to the present may be summarized ed by adding potential causal pathways among
with respect to two predominant topics, namely, impacts, which Bckman and MacDonald did not
(a) increasing evidence of distance-to-death- include in their model, but may be considered at
related changes not only in cognitive functioning least hypothetically.
but also in indicators of subjective well-being Thus, keeping this chapters conceptual focus,
(SWB) and (b) the provision of more and empirical distance-to-death research up to the pre-
in-depth insights about the course and predictors sent might briey be characterized as a process
of terminal decline. Up to the present, a large body moving from mere evidence of terminal change in
of research provides massive evidence of terminal psychological functioning toward an understand-
decline in cognitive functioning, unfolding in a ing of these terminal changes as driven by proxi-
dedifferentiated manner across various cognitive mal and distal impacts across the individuals
abilities (Wilson et al. 2012). Moreover, broaden- lifespan. This course of the investigation of the
ing the distance-to-death perspective beyond the phenomenon from disclosure to causes seems
focus on cognitive functioning, SWB emerged as also implied in Gerstorf and Rams (2013, see also
important eld of terminal changes in recent for more review of empirical ndings) suggestion
years. An increasing body of studies provided to organize objectives for future research on ter-
evidence of changes in SWB associated with minal decline according to ve basic rationales
time-to-death showing patterns of terminal (Baltes and Nesselroade 1979), namely, (a) iden-
decline of cognitive (i.e., life satisfaction) and tication and description of terminal changes and
affective components of SWB (e.g., Gerstorf (b) the interindividual differences in terminal
et al. 2008a, b, 2010; Palgi et al. 2010; Schilling changes, (c) analysis of interrelationships
et al. 2013; Vogel et al. 2013; Windsor between terminal change in different attributes
et al. 2015). or multiple aspects of functioning, and
Given its historical forerun, in particular (d) identication of the causes of terminal change
cognitive distance-to-death research revealed and (e) of the interindividual differences in
Distance-to-Death Research in Geropsychology, MacDonald, European Psychologist 2006, 11(3), p. 229.

Fig. 1 Distal and proximal impacts on terminal cognitive Black arrows denote impacts considered originally by
decline (Note. Modied gure adapted from Bckman and Bckman and MacDonald)
terminal change. It could be expected, hence, that changes in the psychological functioning
ongoing and future distance-to-death research will observed at the end of the lifespan. However,
increasingly focus on the causes of terminal key to distance-to-death research, this rationale
change in psychological functioning. implies that unique statistical association of
However, crucial to such understanding of intraindividual change with time-to-death
causes, research on terminal decline in cognitive (controlling for age- and pathology-related time
functioning suggests that psychological changes metrics, such as time since diagnosis) means
preceding ones death are driven by impacts strong evidence for the effectivity of tertiary
which do not all unfold distance-to-death-related, aging processes.
but differentially timed within the individuals life
course. The classic distinction of primary, sec-
ondary, and tertiary aging processes also added Methodological Concepts of
in Fig. 1 to the model adapted from Bckman and Distance-to-Death Research
MacDonald (2006) has been suggested as con-
ceptual framework to disentangle this temporal Time-to-Death as Predictor of Change
overlay and interplay of the driving forces of in Psychological Functioning
late-life changes (Ram et al. 2010): Primary Across the past decades, distance-to-death research
aging denotes processes that are intrinsic to gained tremendous inspiration from appearance of
aging (i.e., unfolding regularly and irreversibly longitudinal growth curve methodologies (e.g.,
within individuals at certain ages), whereas sec- Curran et al. 2010). Growth curve modeling of
ondary aging refers to pathological changes that time-to-death-related trajectories mostly done
do not occur age-graded and may be preventable by means of longitudinal mixed/multilevel models
or reversible (Busse 1969), and tertiary aging employing time-to-death as within-subject predic-
denotes biological degradations that unfold tor (e.g., Vogel et al. 2013; Sliwinski et al.
under impending death (Birren and Cunningham 2003) is a suitable and effective tool to analyze
1985). Thus, processes that unfold normatively the association between intraindividual changes
age-related, or nonnormatively across some lim- and time-to-death, meaning evidence for terminal
ited time period in ones life, or uniquely distance- change in a strict sense. Since the 1990s, studies of
to-death-related might impact on terminal terminal change increasingly used longitudinal data
to model time-to-death-related trajectories of the transition point models, e.g., Cudeck and Harring
variable under study. 2007) have become a particularly relevant tool to
By means of time-to-death-related growth curve model time-to-death-related trajectories: As an
modeling, fundamental objectives concerning ter- implication of the concept of terminal change,
minal change can be addressed. For instance, the trajectories of psychological functioning in late
abovementioned objectives suggested by Gerstorf life might typically be shaped such that they mir-
and Ram (2013) can be linked to model parameters ror some kind of transition from a phase of preter-
of a time-to-death-related growth curve model minal change which might show only minor
(e.g., terminal change may be identied in terms change or change unfolding normatively age
of the xed level and slope effects and described by graded into the phase of increased terminal
the curvature of a growth curve model, whereas change prior to death. That is, the typical end-of-
interindividual differences in terminal change are life growth curves might appear as compound of
mirrored statistically in the random level and slope two pieces, namely, the preterminal trajectory
variances) or could easily be operationalized by showing relatively low rates of change and the
more elaborate growth curve model specications terminal trajectory showing higher, accelerated
(e.g., latent dual growth curve models may be used change. For illustration, Fig. 2 shows different
to analyze interrelationships between terminal widely used distance-to-death-related trajectory
declines in different attributes and potential causes functions, including a piecewise growth curve,
of terminal change might be included as predictors tted to the hypothetical values observed from
of time-to-death-related slopes; McArdle 2009). one individual at varying temporal distance-to-
By now, the longitudinal growth curve model- death. Piecewise growth curve models hence are
ing approach has become key to the analysis of the statistical translation of this implicit charac-
terminal change and therefore is essential for teristic of distance-to-death-related processes and
geropsychological distance-to-death research. have been used in many studies of terminal
However, a methodological drawback often pre- changes (e.g., Gerstorf et al. 2008a, b, 2010;
sent in these analyses of terminal change should Vogel et al. 2013; Wilson et al. 2003; Sliwinski
also be noted: In the typical scenario of distance- et al. 2006).
to-death research, using data from longitudinal An alternative to modeling piecewise trajecto-
samples to model time-to-death-related trajectories are growth curve models employing a
ries, only those participants can be included that nonlinear growth function that also may reect
had deceased (and those time of death had been the transition from a preterminal phase of moder-
recorded) when the analysis is conducted. Thus, ate changes into a terminal phase of accelerated
the participants still alive at the last mortality change for instance, curvilinear (quadratic) tra-
follow-up are excluded from these analyses. This jectories showing accelerating trends toward the
practice could lead to considerable selectivity of end of life, or exponential growth functions that
the subsample used for analysis, as participants could follow a pattern of high stability across a
from early birth cohorts that survived to very old period more distant from death, turning into rapid
age are excluded and/or only these from the youn- change as death comes close. These nonlinear
ger birth cohorts that died already at rather young functions may be more realistic in that they do
ages are included. Concerning, for instance, that assume a continuous transition from preterminal
the terminal processes of the long-living could to terminal change, instead of a sudden onset of
differ systematically from those that die at rather the terminal phase at a single point in time. How-
early ages, such selectivity could lead to biased ever, it is this coarseness of the piecewise
evidence of terminal change. growth curve model that makes it attractive for
research on terminal change: Fitting a series of
Trajectories of Terminal Change measures obtained at decreasing distance-to-death
Piecewise growth curve models (also referred to to a piecewise trajectory with a distinct change
as multiphase models, change point models, or point includes an estimation of the onset and
Distance-to-Death Research in Geropsychology, Fig. 2 Illustration of widely used time-to-death-related growth

curve functions
duration of the terminal process. That is, even if the choice of a growth function is relevant with
one does not assume that terminal change will respect to the distinction of terminal drop versus
start suddenly within a short temporal range (say, terminal decline. Piecewise or exponential growth
a day or a week), an estimate of the change point functions are better suited than the polynomial
in time provides valuable evidence of the timing functions (linear or quadratic) to t a terminal
of the terminal phase, indicating at about which drop pattern of sharp and steep decrease within a
time-to-death the terminal processes began to shorter time period before death.
evoke perceptible and observable changes in the
study variable. For example, for the individual Psychological Functioning as Predictor
depicted in Fig. 2, the onset of the terminal of Time to Death
phase would be estimated at about 3.2 years In contrast to the longitudinal approaches that
before death. employ time-to-death as predictor of psychologi-
Moreover, comparing the growth curves cal functioning, time-to-death is also a widely
depicted in Fig. 2 it should also be evident that used outcome variable mainly in epidemiological
research. These studies apply event history ana- regularity as humans approach and traverse the
lyses to predict time-to-death (Yamaguchi 1991), old age period of life. Therefore, analyses of
for instance, using cognitive abilities measured in age-related change had always played the impor-
a sample as predictor of survival. Thus, this tant role to provide gerontologists with basic
approach could be classied as cross-sectional, knowledge of such regularity, in terms of norma-
in that it models the statistical association between tive changes which are to be expected at certain
time-to-death and the interindividual differences ages, as well as the interindividual variability of
in the predictor at a given point in time (e.g., such changes, pointing at the plasticity of aging
White and Cunningham 1988; Smits et al. 1999). processes. A great deal of research interest in
Cross-sectional survival analytic ndings of time- psychological development in late life has
to-death-related variability in a variable under focused on the losses and hardships that accumu-
study might be taken as indirect evidence of late in old age, considering in particular how
time-to-death-related changes that could have psychological functioning such as cognitive
caused these differences. However, these analyses performance, subjective well-being, etc. gets
do not provide clear-cut evidence of terminal affected by fundamental biological degradations
changes, leaving it unexplored whether and that must occur in old age at least among those
when intraindividual changes did generate the that prevented acute lethal diseases and other
interindividual differences that are analyzed. causes of premature death. With regard to this
For example, interindividual differences in cogni- question, the analysis of age-related changes in
tive abilities that predict survival might have psychological outcomes could be understood as
persisted stably since early phases of the lifespan an application of chronological age as indicator of
(Deary et al. 2004). such accumulation of loss: The older, the worse
While it presents a weakness of the cross- the physical health and other objective living
sectional approach to distance-to-death research conditions; hence, age may predict decline in psy-
that survival analytic ndings cannot provide evi- chological functioning. However, distance-from-
dence of terminal change in a strict sense, it birth may not be the optimal predictor of old age
should also be noted that this procedure is not development driven by the biological degrada-
affected by the potential selectivity problems due tions and the losses that tend to accumulate toward
to the exclusion of study survivors (which may the end of the human lifespan. Taking into account
affect longitudinal analysis of terminal change, as that the occurrence, onset, and speed of such late-
explained above). In cross-sectional event history life aggravations are to some extent driven by
analyses, time-to-death can be treated as right- nonnormative developmental inuences, which
centered variable. That means that participants may or may not affect individuals development
that have not deceased until the last mortality more or less strongly at different times of their life
follow-up are included in these analyses, with course, a great deal of late-life development may
their time-to-death considered as unknown but come in old age, but not strictly age-graded
above the maximum value observed in the (Baltes and Nesselroade 1979). Thus, chronolog-
sample. ical age might be unreliable indicator of impacts
that promote changes in psychological function-
ing in old age.
Distance-to-Death Research In contrast, distance-to-death may do a better
in Geropsychology: What Is It Good For? job in indexing the accumulation of crucial bio-
logical degradations (and other kind of loss) late
Terminal Versus Age-Graded Changes in Late in an individuals life, considering that this accu-
life? mulation itself marks the process that will end up
In very general terms, gerontological research in the individuals death. That is, the health status
deals with changes in biological, psychological, of a 75-year-old who will not survive until age
and social functioning that unfold with some 80 could be expected worse compared to another
75-year-old who will live another 20 years, but across large parts of the old age period (noticing,
might rather resemble the health status of a however, reports of accelerated age-graded declines
90-year-old who will die before age 95. Following in the oldest-old ages; e.g., Pinquart 2001; Schilling
this reasoning, a focus on distance-to-death- 2005). Such apparent stability has been taken as
related changes seems promising to add to the evidence of old peoples overall high resilience
traditional age-related perspective in research on toward the losses they are confronted with in late
psychological late-life development in threefold life (e.g., Kunzmann et al. 2000; Charles and
respects, namely, (a) enabling the disclosure of Carstensen 2009). However, rather than paradoxi-
non-age-graded developmental late-life dynamics, cal stability of SWB, the absence of age-related D
(b) promoting insights in the nature of processes decline might mirror effects of differential survival,
that drive psychological late-life development, and in that those who suffer from severe health losses
(c) advancing geropsychological reasoning with that could aggravate their SWB will soon die or
paradigms of terminal phase of life and psycholog- otherwise be prevented from study participation.
ical terminality. Evidence of time-to-death-related decline in SWB
supports this latter interpretation. Thus, shifting the
Disclosure of Non-age-graded Late-life focus from age-graded to time-to-death-graded
Developments changes in SWB was instrumental in drawing a
The distance-to-death perspective can provide more clear-cut picture of SWB development toward
some instrumental value for the empirical the end of the human lifespan, disclosing late-life
detection of change dynamics unfolding at the change dynamics that imply a correction of a wide-
end of the human lifespan. That is, using time- spread notion of stability built on the age-related
to-death as a metric of time-graded changes in perspective.
psychological variables under study could reveal
changes that occur frequently and with some reg- Insights in Processes Driving Psychological
ularity in late life, which otherwise, grading Late-life Development
change to age or calendar time of measurement, Disentangling time-to-death-related changes
would not be detected. from age-graded developments (or other
Such added value gained from shifting the intraindividual changes that unfold neither age-
focus from an age-related to a distance-to-death- nor time-to-death-graded), could be essential to
related perspective became apparent in recent deepen the insights in the driving forces that
years from studies that examined longitudinal impact on late-life psychological functioning.
changes in subjective well-being (SWB) using Usually, the time metric used to index changes in
both time metrics, chronological age, and time- developmental studies is not considered a causal
to-death (Gerstorf et al. 2008a, b, 2010; Palgi et al. variable, but a proxy variable representing a set of
2010; Schilling et al. 2013; Vogel et al. 2013; processes covarying with the index time, consid-
Windsor et al. 2015). These studies reported ered causally linked with the change in the devel-
changes in SWB associated with time-to-death opmental variable under study. Interest in
showing patterns of terminal decline of life satis- distance-to-death-related changes in psychologi-
faction and affective components of SWB but cal functioning follows an inherent rationale that
weaker (or no such) associations with age. This these changes are driven by (or might even drive
evidence of time-to-death-related decline is reciprocally) those fatal processes that will end
inconsistent with the notion of a stability-despite- in the loss of the individuals biological capability
loss paradox of SWB in old age (e.g., Kunzmann needed to survive. Thus, psychological changes
et al. 2000): Age-graded longitudinal SWB trajec- that unfold in association with distance-to-death
tories or cross-sectional age-SWB associations are usually considered as linked with tertiary
showed no age-related decline or even some age- aging processes, denoting the biological degrada-
related improvement in many studies, suggesting tions that unfold under impending death (Ram
that SWB in general is maintained largely stable et al. 2010; Birren and Cunningham 1985).
Disentangling time-to-death-related change in a developmental trajectories. Obviously, mortality

given psychological study variable from changes and pathology risks increase with age, and sec-
that unfold age-related and or related with the ondary pathology processes might also increase
duration of some pathological conditions provides mortality risks. That is, the onset of tertiary aging
insight in the nature of the developmental process, processes cannot be considered independently
telling the researcher whether the respective psy- from the onset and course of secondary aging
chological changes are driven by terminal degra- processes, and both might depend on the course
dations or could be considered as consequence of of the primary aging (considering plasticity of
biological aging in a strict sense or of the individ- aging in terms of interindividual differences in
uals particular pathological conditions (Ram the severity of age-graded changes). Thus, an
et al. 2010; Sliwinski et al. 2003). interplay, rather than mere co-occurrence, of pri-
However, stressing such conceptual relevance mary, secondary, and tertiary aging processes
of the distance-to-death perspective, some princi- should be considered (for illustration see again
pal limitation of every time metric used to grade Fig. 1).
developmental changes should also be kept in Concerning statistical analyses that employ
mind. Regarding the study of age-related change, specic time metrics as proxy variables
Wohlwill stated that age is at best a shorthand for representing the impacts of these different pro-
the set of variables acting over time, most typi- cesses, this consideration should take into account
cally identied with experiential events or condi- the uniqueness of the separation of time-to-
tions, which are in a direct functional relationship death, age, or other time metrics effects on the
with observed developmental changes in behav- developmental outcome variable studied: Most of
ior; at worst it is merely a cloak for our ignorance the ndings on terminal decline in cognitive per-
in this regard (Wohlwill 1970, p. 50). This rather formance or SWB published over the past decades
critical view might also apply to the use of time- rested upon some kind of longitudinal analysis
to-death as time metric in developmental studies. of intraindividual differences in the outcome
That is, evidence of time-to-death-related psycho- predicted by time-to-death and/or chronological
logical changes such as terminal decline in cog- age (commonly done by running multilevel or
nitive performance or affective well-being latent growth models). Typically these studies
points at tertiary aging processes underlying focused on evidence of unique time-to-death-
such change, but of course it does not include an related change that may not be accounted for by
identication and conrmation of the particular normative age-graded development, by either
causal impacts that drive this terminal change. comparing separate models of age- versus time-
Thus, in the quest for an in-depth understanding to-death-related change in terms of model t or
of late-life psychological development, evidence intraindividual variance accounted for (e.g.,
of time-to-death-related change does not mark the Gerstorf et al. 2008a, b, 2010; Windsor
nal destination, but rather a stopover, directing et al. 2015), or by employing both time metrics
further scientic inquiry toward the specication simultaneously in one model in order to estimate
of and the causal interplay between particular their unique effects mutually controlled for
variables involved in the underlying process of the other time metric (e.g., Vogel et al. 2013;
tertiary aging. Sliwinski et al. 2003). If primary, secondary, and
Moreover, the clear-cut distinction of changes tertiary aging processes interact to some degree in
uniquely related with the timing of primary, sec- causing the interindividual changes in the psycho-
ondary, and tertiary aging processes by means of logical outcomes studied, the estimates of time-
statistical modeling with given longitudinal to-death-related variability obtained with these
data might be an ideal hardly met. In particular, statistical designs would not be perfectly freed
primary, secondary, and tertiary aging processes from primary age-graded or secondary patholog-
may not only co-occur and overlap but also inter- ical processes. The potential interplay between
act in determining the course of individual such differentially time-graded processes might
be modeled statistically by inclusion of respective specically related with impending death. The
interaction effects between different time metrics co-occurrence and interaction of these particular
in growth models (see, e.g., the statistical strategy dynamics might activate causal linkages which
proposed by Ram et al. 2010). are not effective at earlier stages of the human
However, regarding the conceptual meaning of life course, but particularly involved in the degra-
the statistical effects, the crucial point is that time- dation of the human system in the approach of
to-death-effects found in empirical data do not death.
strictly correspond with tertiary aging processes For instance, research on nutritional health
and hence do not strictly discriminate the impacts effects in very old subpopulations indicated a D
of terminal degradations on late-life development risk factor paradox, in that mortality risks
from those of normative aging and nonterminal implied by the nutritional status in the general
pathology. Thus, again, evidence of time-to- adult and young-old population were reversed
death-related psychological changes marks an (e.g., obesity seems protective against mortality
important stopover on the pathway to an and decline of physical function; Kaiser
in-depth understanding of end-of-life develop- et al. 2010), also adding to other ndings of
ment, pointing at terminal degradations of the so-called reverse epidemiology (Kalantar-Zadeh
human system that affect psychological function- et al. 2005). Though nonpsychological and not
ing, but proceeding further on this pathway will taken from distance-to-death research, this
need a specication and conrmation of the pro- denotes an exemplary case of specic causalities
cesses proxied by the time-to-death metric. different from those found in the healthy general
population that emerge under conditions of
Considering Paradigms of Terminal Phase aggravated physical health and biological degra-
and Psychological Terminality dations. Similarly, the severe physical and func-
In view of the so far massive evidence of intense tional loss conditions typically met in the terminal
changes in many domains of human functioning phase of life might interact in triggering conse-
that co-occur and accelerate over individuals quences that will reveal causal dynamics not only
nal years of life, the distance-to-death perspec- quantitatively more intense, but qualitatively dif-
tive in the study of late-life development may be ferent from those driving preterminal develop-
driven further theoretically, considering psycho- ment. Therefore, the terminal phase of life might
logical terminality and the terminal phase of the be viewed conceptually as a period of unique
human lifespan as theoretical paradigms that meaning, to be distinguished from age-graded
might inspire and enrich future research on late- segmentations of the lifespan such as the third
life development. and fourth ages.
As a basic conclusion drawn from the large Furthermore, a crucial aspect which could hold
body of distance-to-death research, individuals particular importance for psychological function-
approaching their end of life frequently undergo ing in this terminal phase is the individuals sub-
changes in psychological functioning along with jective perception of distance-to-death-related
physical health degradations, which did not accumulations and accelerations of degradative
unfold in some continuous manner across the changes. These might generate a sense of
adult lifespan, but occur specically over some impending death, provoking behavioral and affec-
limited time period preceding the end, at whatever tive responses which could be understood in terms
age it occurs. Therefore, the aging persons nal of psychological terminality. The self-regulatory
years might be considered distinct from previous reactions of individuals who feel it coming may
life phases: An individual might pass on to the at least to some extent be directed toward the
terminal phase of life when the accumulation of impending death, serving to facilitate the unavoid-
losses caused by primary and secondary aging able process of dying. Thus, criteria of successful
processes sum up to a critical mass, triggering preterminal adaptation such as maintenance or
dynamics of physical and psychological change restoration of goal achievement and primary
control capacities (Heckhausen et al. 2010), pro- health aggravations in the terminal phase of life
tection or optimization of positive SWB out- differently than to health problems experienced
comes, and so forth might no longer be earlier in a nonterminal life situation? Which
sufcient to understand end-of-life self- role do fears of death and dying play for such
regulation. Reasoning in such a way about psy- adaptation in the approach of lifes end?
chological terminality could inspire research on
late-life development, at least by creating para-
doxical views of adaptive changes, conicting Conclusions
with the motivational constructs assumed as driv-
ing forces of adaptation across the lifespan. For Up to the present, distance-to-death research in
instance, it might be asked whether terminal geropsychology has developed over a period of
declines of hedonic well-being could be adaptive more than ve decades, revealing a body of solid
in supporting the self-regulation of impending evidence on terminal decline of cognitive function-
death, in that individuals may easier disengage ing and, more recently, in SWB. Altogether, this
from life when it has become less hedonically research suggests that the end of life typically
rewarding. Similarly, one might even consider comes with intense and accelerated intraindividual
some cognitive declines adaptive in the terminal changes of psychological functioning, which
phase of life: For instance, reduced memory func- reect the degradation of the biological and psy-
tion might help to prevent too intense cognitive chological systems that drive these changes. In
processing of the loss of life, which otherwise such a way, the terminal phase of life appears as
might cause feelings of regret and despair. some kind of mirror image of the initial phase of
The arguments for such uniqueness of the ter- life, in that rapid changes unfold at both ends of the
minal phase of life and psychological terminality lifespan, driven by causal mechanisms related with
unfolding within are quite speculative at this stage the respective endpoint maturational processes
of distance-to-death research, as empirical unfolding after birth and terminal processes pro-
research ndings relevant to the particular matter moting the degradation of the organism.
of such uniqueness are barely present in the However, distance-to-death research at present
gerontological publication arena. Thus, these the- also appears as a still emerging eld of
oretical propositions should be understood as pro- geropsychological inquiry, far from any state of
spective paradigms for the further proceeding of completion. The manifold ndings of terminal
distance-to-death research (noticing also theoreti- changes reported so far inspire further questions
cal work that provided at least implicitly some concerning the interrelationships between time-
ideas of psychological terminality, such as Joan to-death-related changes in different psychologi-
Eriksons addition of a ninth stage of development cal domains and on the nature and specication of
to the Eriksonian psychosocial theory of lifespan the underlying processes. Also, the generality of
development, (Erikson 1997); and the thanato- the terminal change phenomenon has yet to be
psychological premise that knowing about explored (Gerstorf et al. 2013): Which other
their death impacts on humans attitudes and domains of psychological functioning in addi-
behavior, (Kastenbaum 2000)). That is, with sub- tion to cognitive abilities and well-being undergo
stantial evidence of time-to-death-related changes time-to-death-related changes? Finally, in view of
in key domains of psychological functioning the co-occurrence and interplay of terminal
established, future research might move toward changes in different psychological attributes, con-
distance-to-death-related changes of structural sidering the terminal phase of life as a distinctive
relationships and dynamic interactions, involving developmental segment of the human lifespan
these psychological domains. For instance, key might be a paradigm advancing research on late-
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Dual Sensory Loss 693
often restores functional vision. Diabetic retinop- atrophy and diminishing cochlea hair cells, and
athy usually affects both eyes and results in vestibular and neural changes (Nigam and Knight
blurred, distorted vision of the central visual 2008). Ear conditions that are prevalent in older
eld although laser surgery is sometimes success- people are cerumen (earwax) accumulation, con-
ful in restoring functional vision. Glaucoma ductive hearing loss (e.g., due to middle ear ossi-
results in loss of the visual eld and if controlled, cation), sensorineural hearing loss (e.g., due to
sight loss may be minimal. If uncontrolled, presbycusis, noise-induced hearing loss, or multi-
impaired vision or blindness often results. Finally, ple sclerosis). Central auditory processing disor-
age-related macular degeneration is the progres- der (CAPD) may occur due to neural changes in D
sive loss of reading vision and sharp distance the central auditory nervous system. Hearing loss
vision. This retinal disorder usually occurs bilat- is usually dened according to the corresponding
erally and affects the central part of the visual eld decibel loss consisting of mild, moderate,
frequently leaving peripheral vision unaffected. moderate-severe, severe, or profound hearing
According to the WHO ICD-10 (World Health loss categories. These acquired hearing disorders
Organization), the severity of visual impairment are often slow to deteriorate and difcult to iden-
ranges from moderate visual impairment (distance tify early due to the subtle changes that develop
visual acuity worse than 6/18 and equal or better gradually. The hearing loss is typically more
than 6/60), to severe visual impairment (distance severe in the high frequencies affecting the per-
visual acuity worse than 6/60 and equal or better ception of sounds (such as f, th, sh, and s speech
than 3/60), to blindness (distance visual acuity sounds) and speech reception or understanding
worse than 3/60 to no light perception). (particularly in poor listening situations or when
Age-related visual loss frequently results in there is high background noise or reverberation),
light sensitivity and reduced tolerance for glare. difculty with speech discrimination and the
Central or peripheral eld losses cause a multitude processing of auditory information.
of problems ranging from intolerance to variations Any combination of vision and hearing loss
in luminance to dependence on high levels (even when a mild loss occurs in both vision and
of luminance, reduced contrast sensitivity, the hearing) is termed DSL. The impact of DSL is
inability to see ne detail of large low contrast devastating for older people, having signicant
objects, difculty visualizing distant objects, dis- implications for their health care. These prevalent
criminating detail, adapting to darkness, and conditions (vision and hearing loss) need to be
distinguishing between colors. Additional visual recognized and considered by clinicians,
difculties include the reading of print even when researchers, and policy makers, particularly since
using visual aids (e.g., reading legal documents, the prevalence of these conditions is expected to
notices, magazines, or recipe books) and restricted rise in future years.
mobility which frequently interferes with a per-
sons ability to move around safely in the envi-
ronment. These difculties are disabling having Prevalence
severe psychosocial ramications, such as
decreased ability to participate in activities of In line with global population aging, there will be
daily living (ADLs) and independent activities of an increased number of older adults with vision
daily living (IADLs) independently, depression, and hearing loss. According to the WHO (2012a),
and decreased social interaction. amongst the 285 million people worldwide who
Likewise, ear changes associated with the are visually impaired, in the 50 year and over age
aging process occur and include: changes to the group, 65% are visually impaired and 82% are
external pinna (such as enlargement), loss of elas- blind. Similarly, of the 328 million adults with
ticity of the external auditory canal, thinning and disabling hearing loss worldwide, approximately
stiffening of the eardrum, calcication of the ossi- one-third is aged 65 years and over (World Health
cles, atrophy of the muscles of the middle ear, Organization 2012b).
Since the prevalence of vision loss and hearing associated with different phenomena in men com-
loss is high in the older adult population, it is a pared to women. In men, hearing loss is associated
rightful assumption that the prevalence of the com- with high triglyceride levels, high resting heart
bined sensory loss (DSL) would be high in this rate, and a history of smoking, while hearing
segment of the population and worthy of further loss in women is associated with high body mass
investigation and discussion. Research in the prev- index, high resting heart rate, fast pulse wave
alence of DSL, however, reects a relatively small velocity, and low Ankle-Arm Index (Helzner
body of work in comparison to other chronic con- et al. 2011).
ditions affecting older adults such as diabetes or A variety of vision and hearing measurement
dementia. Estimates of the prevalence of DSL vary methods (such as self-report, standardized mea-
greatly in the literature. This is primarily due to the sures or observation) have been used to investi-
different methodological approaches used to inves- gate DSL (Heine and Browning 2015). This use of
tigate DSL and the specic population investigated different measures as well as the above-mentioned
in studies of DSL. The following are two examples factors has made the comparison of studies
of studies that illustrate the disparity in prevalence difcult.
estimates: Caban et al. (2005) found that the prev-
alence of DSL in their sample of 1110 community
residing people in the USA was 7.3% in those Consequences of DSL
participants aged 6979 years and 16.6% for
those aged 80 years and over. Schneider DSL affects older adults everyday lives, func-
et al. (2012), however, obtained considerably dif- tioning and participation in activities, and has
ferent results in their longitudinal study of 2015 implications for their health and psychosocial
adults living in the Blue Mountains in Australia. well-being. In particular, difculty with commu-
Participants were aged 55 years and older at base- nication is frequently observed (Heine and Brow-
line. Results suggested that the prevalence of DSL ning 2002). Many older adults with severe visual
(termed DSI in this study) was 6% at baseline, loss cannot see their communication partners
increasing from 0% for ages <60 years to 26.8% face clearly and therefore cannot lip-read or per-
for participants aged 80 years and over. ceive cues such as gesture, facial expression, and
The type of cohort included in studies of DSL body posture and thus need to rely heavily on the
also produces different prevalence rates. While auditory modality for adequate speech reception
Smith et al. (2008) concluded that DSL ranged (Heine et al. 2002). For people with DSL, auditory
from 5.0% to 7.4% in the older adult veteran acuity is reduced and even if hearing loss is mild,
cohort, increasing to 20% in veterans aged the auditory modality cannot compensate for
85 years and over, Cacchione et al. (2003) found diminished visual acuity. Communication dif-
that 52.6% of their sample of older adults living in culties such as reduced conversational uency,
rural long-term care facilities were visually adequate reception of a verbal message, and
impaired; 44.1% were hearing impaired; 24.6% difculty with identication of verbal and nonver-
were dually impaired (had DSL); and 23.4% had bal cues result in communication misunder-
no sensory impairment. standings or breakdowns (Heine and Browning
Gender is also an important factor that inu- 2002). In turn, conversational difculty interferes
ences the prevalence of DSL. The literature shows with performance and condence in social-
that moderate and severe vision impairment and communication situations often resulting in
blindness have a higher prevalence rate in women diminished psychosocial functioning.
than men (West et al. 1997). However, men are at Many older adults with DSL are at risk for
a higher risk for developing hearing loss due to developing a multitude of difculties, including
their increased participation in the military (noise depression and decreased well-being. Kiely
exposure) or having worked in noisy occupations et al. (2013) investigated the association between
during their lifetime. Physically, hearing loss is DSL and mental health in 1611 adults aged
65103 years. They found an association exists lighting (e.g., by reducing the glare). Likewise, it
between depressive symptoms and DSL that was is essential for the vision specialist to accommo-
attributed to adults with DSL experiencing dif- date a clients hearing difculties by reducing the
culty with completing ADLs and having limited distance between conversationalists and using
social engagement. In line with these ndings, effective communication strategies such as speak-
Crews and Campbell (2004) also found that ing slower, clearer, and louder and repeating or
older adults with DSL had difculty with every- expanding utterances for clarication purposes.
day competence, experienced poorer health, and The lack of DSL clinical guidelines and profes-
had decreased social roles. sional education programs educating visual spe- D
The consequences of DSL are extensive as was cialists about hearing loss and audiologists about
evident in a study by Wallhagen and colleagues vision loss are signicant barriers to the early
(2001) who investigated the relationship between identication of DSL and is thus an area for fur-
DSL and several comorbidities in 2442 adults ther investigation.
aged 50102 years. These authors concluded
that DSL had a strong impact on physical and
social functional status. Management of DSL
This interdisciplinary area of practice requires the

Clinical Assessment collaboration of a number of medical and allied
health professionals including general physicians,
To date, there is no consensus regarding the iden- ophthalmologists, otolaryngologists, vision spe-
tication and assessment of DSL for either cialists (such as optometrists), audiologists and
research or clinical purposes. While self-report, speech-language pathologists (SLPs). Following
questionnaires, and tests such as the Snellen eye diagnosis, the vision specialist and audiologist
test (for vision) and pure-tone air audiometry for counsel and advise clients about their sensory
hearing have been commonly used in research acuity and provide rehabilitation or management
studies (Heine and Browning 2015), little litera- strategies, especially tting the necessary devices
ture exists regarding the identication of both (such as magniers to enlarge print for visual
disorders in one clinical setting. Service providers enhancement and hearing aids and assistive lis-
almost always identify vision and hearing disor- tening devices for amplication). The SLP is often
ders within separate contexts. That is, the vision included as a team member in the rehabilitation
specialists (such as the optometrist and ophthal- program and is in an ideal professional position to
mologist) assess vision and evaluate the clients provide clients with DSL strategies and practice to
perceptions about their visual loss, while audiol- improve their communication. Heine et al. (2002)
ogists assess hearing and appraise the clients conducted a cross-sectional study at a day center
perceptions about their hearing loss. The identi- for visually impaired people investigating the
cation of DSL clinically is therefore reliant on a communication, situational difculties and con-
collaborative approach between professionals, versational needs of older adults with sensory
which assumes that additional education loss, and their communication partners. Results
concerning DSL has been provided to all team suggested that older adults with DSL experienced
members working with older adults. For example, a range of functional vision and hearing and com-
the audiologist needs to take into account a cli- munication difculties and would benet from
ents visual difculties (such as blurry vision) specically devised training programs.
and conducts the audiological consultation by The management plan for those with DSL
considering the necessary accommodations that needs to take into account the clients unique
are required. These might include: reducing the sensory status, competencies, and barriers.
distance between conversationalists, accounting Again, the vision specialist, audiologist, and SLP
for mobility needs, and adjusting the room need to be educated in the area of DSL and its
management in order to delineate and implement environmental, situational, and conversational

an adequate rehabilitation program. For example, needs of the person with DSL (Heine et al.
as part of the rehabilitation program, when tting 2002). In these training programs, the clients and
a hearing aid for a client who has DSL, the audi- carers practice effective listening skills, situa-
ologist needs to consider the clients visual dif- tional management (such as being proactive and
culties and possible inability to manipulate small preselecting a quiet listening environment for a
objects such as the battery of a hearing aid or read conversation; reducing glare or background
written instructions. In these instances, visual noise), and the use and implementation of com-
accommodations such as the use of a magnier munication strategies (such as identication of
or enlarged font size may be warranted and from conversational breakdown and the use of
an audiological viewpoint a magnetic-tipped communication repair strategies). Communica-
device for battery removal may be useful. From tion training programs can enhance conversations,
a technological perspective, it is imperative that minimize communication breakdown, and
the audiologist considers that a client who has increase social condence thereby improving the
DSL has different audiological needs to a client social interaction, quality of life, and well-being
who has a hearing loss. Simon and Levitt (2007) of older adults with DSL.
discussed numerous audiological issues in rela- A complimentary unique model of interven-
tionship to DSL including specic recommendation is the biopsychosocial model discussed by
tions for amplication ttings. These authors Brennan and Bally (2007). This model focuses
proposed that hearing aid ttings should be on the coping and adaptation strategies that older
adjusted for people with DSL (e.g., consider the adults with DSL can use to improve their func-
use of directional microphones) to improve their tioning, independence, and well-being. Counsel-
sound localization and binaural processing which ing and assertiveness training are benecial
are of primary importance for speech perception especially since many older adults with DSL
and spatial orientation. often feel vulnerable and have decreased self-
Visual and hearing devices are one aspect of esteem and condence. This emotional reaction
the rehabilitation process. Other relevant clinical in turn often leads to social isolation, depression,
target areas include speech perception training, and decreased feelings of well-being.
communication programs for clients and carers Although DSL is a new eld of research and
(Heine et al. 2002), and the provision of informa- clinical practice, the diverse management pro-
tional counseling and psychosocial support grams show promising progress.
(Brennan and Bally 2007). Tye-Murray (2009)
has been instrumental in researching audiovisual
speech perception in people with vision and/or Future Directions
hearing loss. Outcomes of their research suggest
that audiovisual speech perception is related to Between 2000 and 2050, the number of people
auditory and visual word neighborhoods aged 80 years and over in major areas worldwide
(context) and multisensory integration. Thus for will more than quadruple (United Nations,
people with DSL, practice drills including these Department of Economic and Social Affairs. Pop-
concepts should be included in the intervention ulation Division 2004). With increasing longevity,
program. and the increase in the size of the older adult
Over the past two decades, communication population, the prevalence of DSL will increase
training has gained popularity as a valuable reha- dramatically.
bilitation method for people with DSL. In accor- While DSL in this segment of the population is
dance with a client-centered approach, the person still under-researched, gains have been made in
with DSL and if possible, their frequent commu- the recognition of DSL as a clinical entity that is
nication partner/s (family or carer) participate in a currently being researched more widely. Preva-
communication training program to address the lence studies are more common although they
still reect disparate ndings. Interventions such doi:10.2105/AJPH.94.5.823. PMid:15117707, PMCid:

as enhancing signal processing by modifying PMC1448344.
Heine, C., & Browning, C. J. (2002). Communication and
the dimensions of hearing aids, (Simon and Levitt psychosocial consequences of sensory loss in older
2007) multisensory integration (Tye-Murray adults: Overview and rehabilitation directions. Disabil-
2009), communication strategy usage, and psy- ity & Rehabilitation, 24(15), 763773. doi:10.1080/
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Heine, C., & Browning, C. (2015). Dual sensory loss in older
and discussed in the literature. Further research is, adults: A systematic review. The Gerontologist, 55, 913.
however, necessary to increase professional and Heine, C., Erber, N. P., Osborn, R., & Browning, C. J.
community awareness, knowledge and under- (2002). Communication perceptions of older D
standing of this groups communication and adults with sensory loss and their communication part-
ners: Implications for intervention. Disability and
psychosocial needs. In order to achieve an excep- Rehabilitation, 24(7), 356363. doi:10.1080/
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DSL, including methods of early identication Helzner, E. P., Patel, A. I., Pratt, S., Sutton-Tyrrell, K.,
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Hearing sensitivity in older adults: Associations with
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among researchers and professionals is required. composition study. Journal of the American Geriatrics
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promising as research continues. Promoting the Frontiers in Human Neuroscience, 7, 837. doi:10.3389/
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Risk for acute confusion in sensory-impaired, rural, United Nations, Department of Economic and Social
long-term-care elders. Clinical Nursing Research, Affairs. Population Division. (2004). World population
12(4), 340355. doi:10.1177/1054773803253917. to 2300. New York. http://www.un.org/esa/population/
PMid:14620691. publications/longrange2/WorldPop2300nal.pdf
Crews, J. E., & Campbell, V. A. (2004). Vision impairment Wallhagen, M. I., Strawbridge, W. J., Shema, S. J., Kurata,
and hearing loss among community-dwelling older J., & Kaplan, G. A. (2001). Comparative impact of
Americans: Implications for health and functioning. hearing and vision impairment on subsequent function-
American Journal of Public Health, 94(5), 823829. ing. Journal of the American Geriatrics Society, 49(8),
698 Dynamic Analyses to Optimise Ageing (DYNOPTA)
10861092. doi:10.1046/j.1532-5415.2001.49213.x. nine independently designed longitudinal studies

PMid:11555071. of aging, creating a large nationally representative
West, S. K., Munoz, B., Rubin, G. Z., Schein, O. D.,
Bandeen-Roche, K., Zeger, S., German, P. S., dataset of older adults in Australia. Aggregating
et al. (1997). Function and visual impairment in a data from a number of cohort studies has the
population-based study of older adults. The SEE pro- advantages of enhancing population coverage
ject. Investigative Opthalmology & Visual Science, (reducing coverage error), increasing sample size
38(1), 7282. PMid:9008632.
World Health Organization. (2012a). Global data on visual of underrepresented groups (such as the oldest old
impairment 2010. http://www.who.int/blindness/ or those with rare medical conditions), facilitating
GLOBALDATAFINALforweb.pdf instantaneous replication across studies, allowing
World Health Organization. (2012b). WHO global esti- cross-population comparisons, and investigating
mates on prevalence of hearing loss. Mortality and
burden of diseases and prevention of blindness and the impact of study idiosyncrasies on research
deafness. http://www.who.int/pbd/deafness/WHO_ ndings. The broad aims of the DYNOPTA pro-
GE_HL.pdf ject are to identify effective pathways to compress
World Health Organization. ICD-10 Version: 2015. http:// morbidity and optimize aging (Anstey et al.
apps.who.int/classications/icd10/browse/2015/en#/
H53-H54 2010a, 2011a).
The DYNOPTA dataset is rich including the
theme areas of cognitive functioning, sensory-
motor functioning, mental health, mobility, and
functional independence. The pooled dataset
Dynamic Analyses to Optimise also includes background variables that cover
Ageing (DYNOPTA) sociodemographics, health, lifestyle, medical
conditions, carers, and mortality. Within the
Kim M. Kiely, Richard A. Burns and DYNOPTA dataset, there are over 400 harmo-
Kaarin J. Anstey nized variables, which, when combined with indi-
Centre for Research on Ageing Health and vidual observations, results in excess of
Wellbeing, Research School of Population 18 million data points. DYNOPTA therefore pro-
Health, The Australian National University, vides some of the most comprehensive available
Canberra, ACT, Australia evidence on the health and well-being of older
Australians between the years 1990 and 2006.
Definition
Contributing Studies and Sample
The Dynamic Analyses to Optimise Ageing Composition
(DYNOPTA) project has harmonized and pooled
nine epidemiological studies of human aging to The target population for the pooled DYNOPTA
examine pathways to compressing morbidity and dataset is dened as all Australians born prior to
optimizing healthy aging in the Australian popu- December 1955, resulting in a baseline age range
lation. Research using the DYNOPTA dataset has of 45103. However, the target populations for the
focused on four main outcomes that contribute to individual studies vary by geography and demog-
disease and disability burden among older adults: raphy. There are study design differences in sample
cognitive function, sensory function, mental frame, random sampling procedures (simple, strat-
health, and mobility or activity limitations. ied, and clustered), data collection procedures
(clinical interview, postal, telephone and self-
completion questionnaire), baseline year (ranging
Project Background and Aims from 1990 to 2001), age range, sample size, time
intervals, and the number of follow-up waves. It is
DYNOPTA is a cross-institutional and multidis- therefore important that analyses account for study
ciplinary project that has harmonized and pooled design effects either through weighting and/or
Dynamic Analyses to Optimise Ageing (DYNOPTA) 699
Dynamic Analyses to Optimise Ageing (DYNOPTA), Table 1 Nine studies contributing to the DYNOPTA dataset
Baseline
Study Location N age range Waves Period
Australian Diabetes, Obesity and Lifestyle National 7,296 4595 2 19992005
(AusDiab) study
Australian Longitudinal Study on Womens
Health (ALSWH)
Middle-aged cohort National 13,706 4551 4 19962005
Older-aged cohort National 12,431 6876 4 19962005 D
Household, Income and Labour Dynamics in National 6,164 4590+ 5 20012006
Australia survey (HILDA)
Australian Longitudinal Study of Ageing Adelaide 2,087 65103 7 19922004
(ALSA)
Blue Mountains Eye Study (BMES) Blue 3,654 45100 3 19922004
Mountains
Canberra Longitudinal Study (CLS) Canberra, 1,134 70103 4 19902002
Queanbeyan
Melbourne Longitudinal Study on Healthy Melbourne 1,000 6594 11 19942006
Ageing (MELSHA)
Personality and Total Health (PATH) Through Canberra, 2,550 6066 2 20012006
Life Queanbeyan
Sydney Older Persons Study (SOPS) Sydney 630 7597 5 19912003
modeling adjustments. The contributing studies summary of policy-relevant ndings in the Aus-
include three nationally representative panel sur- tralasian Journal on Ageing (Anstey et al. 2011a).
veys and six regional studies that were representa-
tive of the local community (see Table 1). The
national surveys contribute 65% of participants. Variable Harmonization
The full DYNOPTA dataset is large and com-
plex, consisting of 50,652 participants who were Variable harmonization is the rescaling of func-
followed longitudinally, on up to 11 measurement tionally equivalent measurement instruments onto
occasions over a 15-year period. Over all studies, a common metric. While this process may result in
there was an average of 4.4 measurement occa- coarse-grained data (information loss), it has the
sions over a period of 9.4 years (SD = 2.9) and on advantage of providing a framework for the direct
average sample members participated in 3.1 mea- comparison of data obtained from independently
surement occasions. The mean age at baseline was sampled populations. Within DNOPTA, variables
61.7 years (SD = 12.4, range = 45103), and were primarily harmonized retrospectively using
77% of the sample were women, reecting the the by at method, which involves identifying
inclusion of the all-female cohorts from the common variables and, when necessary, recoding
ALSWH and womens greater longevity response categories onto the same scale where the
(excluding participants from the ALSWH, 53% possibility of disputing the recode is deemed triv-
were woman). Study participants were generally ial by a panel of experts. Modeling-based
community living, but ve studies did include approaches were used to standardize mental
adults who resided in institutions such as nursing health variables such as depression symptoms.
homes. Further information about each of the Table 2 shows a selection of variables harmonized
contributing studies, full description of the sam- in each of the content domains. Where possible,
ple, and project background can be found in a variables were harmonized to conform to Austra-
cohort prole published in the International Jour- lian national standards. Some measures were not
nal of Epidemiology (Anstey et al. 2010a) and a collected by all contributing studies, resulting in
Dynamic Analyses to Optimise Ageing (DYNOPTA), norms of those in older age. For example, popu-
Table 2 Selection of harmonized variables for each lation prevalence has been estimated for chronic
domain
disease and medical conditions (Bielak et al.
Domain Example measures 2012), probable dementia (Anstey et al. 2010b),
Cognitive function Mini-Mental State Examination hearing loss (Kiely et al. 2012a), depressive
(MMSE)
symptoms (Burns et al. 2012a), self-rated health
Sensory function Visual acuity, pure-tone
audiometry, self-reported vision (Anstey et al. 2007), and driving trends (Ross
and hearing difculties, hearing et al. 2009) in older Australians. Normative data
aid use, dual sensory loss that is representative of the older adult population
Mental health SF-36, probable depression, has been generated for common neuropsycholog-
psychological distress
ical tests and assessment scales including the
Mobility and Activities of daily living,
disability driving
National Adult Reading Test (NART) (Kiely
Mortality Date of death et al. 2011) and SF-36 (Bartsch et al. 2011). Pop-
General health and Diabetes, hypertension, ulation level norms have also been published for
medical conditions cardiovascular disease, stroke, health behaviors such as smoking and alcohol
arthritis, BMI, self-rated health consumption (Burns et al. 2013a) and engagement
Sociodemographics Age, sex, partner status, in physical activity (Sims et al. 2014). Burns and
education, career occupation,
colleagues (Burns et al. 2013a) examined period
labor force status, domicile
Health behaviors Alcohol consumption, smoking
effects by comparing patterns of alcohol and
status, physical activity smoking consumption during the years between
19901994 and 19962002. They reported a
decline in the proportion of adults who consumed
study censoring. For example, the Mini-Mental alcohol at high risk levels or currently smoked
State Examination (MMSE) was only collected tobacco over this period.
by the six regional studies. Mortality data were By mapping the demographic prole of a num-
obtained by linkage with the Australian National ber of longitudinal cohort studies, DYNOPTA
Death Index. Weights have been calculated to researchers have been able to reveal public health
account for design differences in sampling, selec- knowledge gaps by identifying subpopulations
tion, and response rates. Weighted estimates are with low participation rates. In particular, they
intended to reect the Australian estimated resi- have documented the poor representation of
dent population in 1996. Indigenous Australians in longitudinal studies of
aging (Anstey et al. 2011b).
Profiling the General Health and

Population Norms for Older Adults Cognitive Function
One of the main contributions of the DYNOPTA There are no existing prevalence data for dementia
project has been the estimation of population based on clinical diagnoses in Australia, and other
prevalence, national trends in behavioral patterns, national surveys have limited numbers of partici-
and calculation of normative data for older adults. pants in ages 75 years and older. To address this,
Population estimates derived from single studies DYNOPTA has provided the most recent national
are often restricted to reporting norms for broad prevalence estimates of cognitive impairment
age ranges (e.g., 75+) or may even exclude adults (probable dementia) (Anstey et al. 2010b). Cog-
aged older than 85 due to lack of recruitment nitive impairment was dened by an MMSE score
(Anstey et al. 2010b; Burns et al. 2013a). Of of 23 or less. A cut point of 23 on the MMSE was
particular importance, data pooling in DYNOPTA reported to have a specicity of 0.96 and 0.91 and
has increased the number of participants aged sensitivity of 0.75 and 0.60 for dementia diagno-
over 80, allowing for more robust and reliable ses in the Canberra Longitudinal Study (CLS) and
Sydney Older Persons Study (SOPS), respec- audiometry. To date, most DYNOPTA studies of
tively. Cognitive impairment was estimated to sensory function have focused on age-related
occur in 15.8% (95% CI: 14.017.7) of adults hearing loss. Notably, over 70% of adults aged
aged 75 years and older, increasing to 41.4% 80 years and older were estimated to have at least
(95% CI: 31.350.8) of adults aged 90 years and a mild degree of hearing impairment as dened by
older. These estimates were highly consistent with a pure-tone average of speech frequencies
results from meta-analyses of European studies. (0.54 kHz) greater than 25 dB in the better ear
There were no signicant sex differences in the (Kiely et al. 2012a). An evaluation of the utility of
prevalence of cognitive impairment, although self-reported hearing loss in comparison to hear- D
higher education was associated with higher ing loss dened by pure-tone audiometry demon-
MMSE scores. strated that the prevalence of hearing loss based
Healthy life expectancy research on cognition on self-report data was likely to be overestimated
had previously focused on social inequalities in for adults younger than 75, but underestimated for
cognitive impairment-free life expectancies, by older age cohorts (Kiely et al. 2012a).
demonstrating differentials in years lived with Another signicant study modeled longitudi-
cognitive impairment by level of educational nal trajectories of audiometric hearing thresholds
attainment. DYNOPTA data has been used to in 3,526 adults. Importantly, these analyses
extend this literature by investigating the effects examined an extensive range of risk factors for
of modiable risk factors for dementia. Multistate hearing loss not elsewhere investigated, including
models were used to estimate the impact of obe- sociodemographics, noise exposure, medical con-
sity, smoking, and sedentary behavior on cogni- ditions, and cognitive impairment. It was found
tive impairment-free life expectancies (Anstey that age, cognitive impairment, and hypertension
et al. 2014). Smoking was associated with the were associated with faster rates of decline in
largest reductions in total life expectancy and hearing thresholds. However, many other factors
years lived without cognitive impairment for commonly associated with differences in hearing
men and women, regardless of their education levels did not predict rates of decline in hearing
level. However, with the exception of obesity in thresholds (Kiely et al. 2012b). A currently active
men, all risk factors were also associated with stream of research on sensory functioning
fewer years lived with cognitive impairment. involves calculating sensory impairment-free life
The key conclusion from this analysis was that expectancies. These analyses demonstrate that in
although healthy lifestyle behaviors delayed the addition to being highly prevalent, hearing and
onset of cognitive impairment, they did not nec- vision impairment can affect older adults for sub-
essarily prevent it. Crucially, as age is the stron- stantial periods of their remaining life.
gest risk factor for dementia, and dementia risk
reduction also increases longevity, risk reduction
strategies may result in more years lived with Mental Health
cognitive impairment at a population level. This
nding has important implications for statistical The burden of psychological distress of older
modeling of the impacts of dementia risk reduc- adults, particularly those living in the community,
tion and projections of future dementia is unclear; some ndings purport an increase in
prevalence. depression risk with increasing age; others sug-
gest a decline in depression risk. However, many
of these ndings are confounded by increasing
Sensory Function heterogeneity with age and small sample sizes.
This is particularly the case for older men with
The DYNOPTA dataset includes measures of self- some suggestion that men are at greater risk of
rated vision and hearing loss as well as clinically reporting depression in late life. Analyses with
assessed measures of visual acuity and pure-tone DYNOPTA indicate a pattern of increasing
depression risk in men although this failed to Driving

reach a level of statistical signicance (Burns
et al. 2012a, 2013b). More robust evidence was DYNOPTA has been used to provide national
found for increasing levels of depressive symp- trends in driving rates and predictors of self-
tomatology among older men (Burns et al. reported driving and to investigate the proportion
2013b); this appears to mirror rates of suicide in of older drivers with low levels of cognitive
older Australian men. Gender differences in men- and/or sensory functioning (Ross et al. 2009). In
tal health in late life have also been reported when this study it was reported that 46% of adults over
examining terminal mental health decline. That is, the age of 65 were nondrivers. The proportion of
in both men and women, there is evidence that nondrivers was greater for women and for older
depressive symptoms increase substantially in the age groups, such that for those aged 85 years and
years preceding death. Findings from DYNOPTA older, 37% of men and 5% of women reported that
indicate this association is more strongly pro- they were current drivers. Discontinued driving
nounced in men and that most of the effect in was more likely to be reported by participants who
women can be accounted for by comorbid physi- were women, older, not married, had careers in
cal health states (Burns et al. 2013c). lower-skilled occupations, were living with
With increasing interest in dimensions of pos- impaired levels of visual acuity, and had poorer
itive mental health and well-being, DYNOPTA health. Although people with suspected cognitive
has provided substantial evidence of the need to impairment (MMSE < 23), and visual impairment
examine dimensions of psychological health and (visual acuity > 0.3 logMAR) did generally
well-being that are not necessarily captured in reduce or cease driving, there remained substan-
clinically relevant dimensions of psychological tial numbers of men who continued driving with
distress. For example, in contrast to measures of cognitive or visual impairments.
psychological distress, vitality a sense of vigor, By combining data from a number of state
energy, and engagement has been implicated as jurisdictions across Australia, Ross and col-
a stronger predictor of self-rated health (Burns leagues were able to evaluate the implications of
et al. 2014a), falls (Burns et al. 2012b), and mor- differing licensure policies for older adult driving
tality (Burns et al. 2014b, c). rates (Ross et al. 2011). They compared differen-
Another study examined age differences in high- tials in driving rates between state jurisdictions
and low-arousal positive and negative affect. Lower with and without mandatory age-based license
levels of negative affect and higher levels of testing. It was reported that mandatory age-based
low-arousal positive affect were reported by older testing for renewal of driving licenses was associ-
adults relative to those in midlife (Windsor ated with lower rates of driving, but was not
et al. 2013). Interestingly, physical function effective in reducing the proportion of older
suppressed the association of older age with drivers who had either a visual or cognitive
reduced high-arousal positive affect and lower neg- impairment.
ative affect. In other words, age differences in affect In summary, the pooling of existing datasets to
were amplied after additionally accounting for create DYNOPTA has produced the largest
covariation with physical function. These ndings dataset on aging in Australia. This resource has
were interpreted as being consistent with the notion enabled both population-based research of a
that older adults tend to restrain high-arousal emo- descriptive nature and developmental research
tions in order to avoid uncomfortable levels of on trajectories, trends, and patterns of characteris-
physiological arousal and provided further evidence tics at ages for which Australia previously lacked
that age differences in the expression of negative large datasets. The process of developing the
and positive affect are underpinned by lower levels pooled dataset has demonstrated the feasibility
of physical functioning among older adults. and utility of this approach.
Cross-References Burns, R. A., Butterworth, P., Luszcz, M., & Anstey, K. J.

(2013b). Stability and change in level of probable
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E
Early and Unplanned Retirement norms. Unplanned retirement refers to a retire-

ment process or decision that was not anticipated.
Gwenith G. Fisher1, Amanda Sonnega2 and Because retirement has been increasingly concep-
Dorey S. Chaffee1 tualized as a process rather than a discrete event, it
1
Department of Psychology, Colorado State has become more challenging to conceptualize
University, Fort Collins, CO, USA early and unplanned retirement. Early and
2
Health and Retirement Study, Survey Research unplanned retirement combines the timing of
Center, Institute for Social Research, University retirement as well as the extent to which the pro-
of Michigan, Ann Arbor, MI, USA cess of retirement was anticipated.
Synonyms Introduction
Early retirement age Given the rapid aging of the large baby boom
generation and global aging generally, under-
standing the retirement transition and its impact
Definition on retirement well-being is more important than
ever. A key factor in this transition is whether
Early retirement refers to the timing of leaving the retirement is planned or unplanned. Another
labor force, but the notion of early is relative, and important distinction is whether retirement occurs
therefore, there is not one single denition of what at an early age or a normal retirement age. What
constitutes early retirement. One denition of constitutes early retirement is relative. This
early retirement is economically driven (e.g., ear- entry addresses issues around early and/or
liest age of eligibility for pension plan benets). unplanned retirement. The study of early and
The exact age that denes early retirement varies unplanned retirement has implications for deter-
across countries due to differences in public pol- mining when and how workers may depart from
icies. In the United States, early retirement is the workforce, as well as for understanding con-
currently considered prior to age 62, because age sequences, including adjustment and well-being
62 is the earliest age of eligibility for Social Secu- postretirement.
rity benets. The second denition is early rela- A great deal of research in the 1980s and 1990s
tive to ones own expectations regarding the focused on retirement timing and particularly
timing of retirement. The third denition is decisions to retire early (e.g., Feldman 1994)
based on societal, cultural, or institutional because studies of labor force participation clearly
DOI 10.1007/978-981-287-082-7
706 Early and Unplanned Retirement
documented a trend toward increasingly younger ages of early eligibility and full Social Security
average age at retirement. For a variety of reasons, retirement benets) are evident (Gustman and
that trend now appears to have reversed, yet a Steinmeier 2005). This provides evidence that
signicant proportion of workers in their late 50s pension eligibility is a powerful retirement incen-
and early 60s continue to leave the labor force, tive. Although the early retirement age in the
both voluntarily and involuntarily. Therefore, United States currently remains at 62, the age of
understanding the antecedents and consequences eligibility for higher monthly benets has
of early and unplanned retirements remains an increased from 65 to older ages determined by
important research and policy focus. A variety of birth date, with additional incentives to delay
antecedents to retirement have received research retirement benet claims to age 70. In addition,
attention, including characteristics of workers the nancial penalty for continued work while
(e.g., health status, sociodemographics, prefer- receiving Social Security benets has decreased
ences), characteristics of their families (e.g., (Gruber and Wise 1998). Many other countries
spouses health status and other caregiving (e.g., Germany, Italy) have recently modied pub-
needs), and characteristics of the work environ- lic policies to increase the age of eligibility for
ment. Each of these is described below (see government pensions, thereby modifying the age
Antecedents). Other researches direct attention that constitutes early retirement (Gruber and Wise
to the consequences of early and unplanned 2007). In terms of private pensions, the shift from
retirement such as impacts on mental and dened benet plans to dened contribution plans
physical health, family, and nancial well-being beginning in the 1990s has provided stronger
(see Consequences). Lastly, a growing literature incentives to continue working (i.e., disincentives
addresses the variety of paths workers are now for early retirement).
taking as they exit the labor force. The traditional Other changes in public policy have changed
model of moving from full-time employment to the retirement landscape as well. For example, the
full and permanent retirement is growing less US Age Discrimination in Employment Act
common. Retirement is seen as a process rather (ADEA) was passed in 1967 to protect workers
than an abrupt transition (Shultz and Wang age 40 and older from discriminatory employment
2011). Implications for this trend on early and practices. In 1986 it was amended to eliminate
unplanned retirement are discussed (see Bridge mandatory retirement ages for all but a few occu-
Employment). pations (e.g., those involving public safety,
including airplane pilots and federal law
enforcement).
Background Even though policy has moved toward a focus
on extending working lives, a considerable num-
The concept of early retirement is relatively new ber of workers depart the labor force early for a
historically. As far back as 1850, approximately variety of reasons. Thirty percent of retirees indi-
75% of men age 65 or older were in the US labor cate that their retirement was forced (Szinovacz
force (Zickar 2013) When the US Social Security and Davey 2005). Others choose to leave the
program was introduced in 1933, approximately workforce at relatively young ages despite sub-
58% of men were still working at age 65 (Costa stantial work capacity. Here a range of factors that
1998). Combined with Social Security and other inuence both voluntary and involuntary early
pension incentives, most American workers work force departure have been described.
began retiring when they could afford to do so.
Retirement timing is driven to a large extent
by economic circumstances. This includes Theory
government- as well as employer-provided pen-
sions. For example, two notable peaks in retire- Psychologists studying retirement trends have
ment at ages 62 and 65 in the United States (the sought to provide theoretical grounding. Multiple
Early and Unplanned Retirement 707
theories have been offered in the psychological motivation among older adults. They developed
literature to facilitate understanding of retirement a person-centered approach, explaining goals for
behavior and retirement decisions. Theories rele- individuals at work, to work, and to retire. These
vant to early and unplanned retirement include goals take into account multiple reasons for work-
continuity theory (Atchley 1999), role theory ing or retiring, including nancial, social, per-
(Kahn et al. 1964), the life course perspective sonal, and generative, as well as uctuations in
(Elder 1994), and the push/pull model of retire- motivation to work and motivation to retire.
ment (Shultz et al. 1998; Barnes-Farrell 2003).
Continuity theory indicates that maintaining
continuity or stability is related to positive out- Antecedents E
comes. This theory would suggest a negative rela-
tionship between early and unplanned retirement While not an exhaustive review, this section high-
and outcomes because by its very nature early and lights major ndings from research exploring rea-
unplanned retirement may disrupt or signicantly sons for, or antecedents to, early and unplanned
modify ones life. retirement. Although each of these reasons is
Role theory proposes that life is comprised of described separately, reasons for retiring early
multiple sets of roles or expectations, such as interact in important ways. Many of the studies
work, family, and community (Kahn et al. 1964). mentioned investigate several retirement anteced-
Early and unplanned retirement involves a change ents simultaneously.
in roles in which an individual who worked must
now adjust to retirement, perhaps having more of Health
an opportunity to develop nonwork roles. One of the most widely studied potential reasons
Unplanned retirement in particular likely involves for early workforce departure is poor health.
a more abrupt role change, particularly as work Much of what is known about the impact of health
may provide an individual with a source of iden- on retirement decisions in the United States comes
tity with a work role, and one must adjust to no from studies using rich information from the
longer working. Health and Retirement Study (HRS) (see the
Related to role theory, the push/pull model of chapter Health and Retirement Study, A Lon-
retirement indicates that some workers will retire gitudinal Data Resource for Psychologists by
because they are pushed out of the work role, Sonnega and Smith, 2015). As a whole, these
whereas others will be pulled toward retirement studies reveal that health plays a large role in the
for nonwork reasons. Unplanned and early retire- timing of retirement (e.g., Aaron and Callan 2011;
ment may result from push factors (e.g., declines Cahill et al. 2013), especially in early and
in worker health, organizational incentives for unplanned labor force exit (Dwyer 2001) and
early retirement) or pull factors (e.g., caring for a perceptions of forced retirement (Szinovacz and
spouse, receiving a nancial windfall, or desiring Davey 2005). HRS data include widely used ques-
leisure more than work). Barnes-Farrell (2003) tions about expected age at retirement, which have
described four factors related to the retirement been shown to relate closely to actual retirement.
decision process beyond health and wealth: job McGarry (2004) studied how changes in health
attitudes, job conditions, organizational climate, affect retirement expectations, nding large
and societal pressures. Negative job attitudes effects of self-rated health on when workers
(e.g., low job satisfaction), poor job conditions, a expected to retire. Importantly, she also showed
negative or unsupportive organizational climate, that changes in retirement expectations were
and societal pressures (e.g., norms regarding affected to a much greater degree by changes in
retirement age or retirement timing) may lead to health status than by changes in income or wealth.
early retirement. Similar ndings emerge in other countries as
Recently, Kanfer et al. (2012) proposed an well. Studies in Canada (Park 2010) and Europe
organizing framework for understanding work (Garca-Gmez 2011; van Rijn et al. 2014)
revealed that a leading cause of early and Kim and Feldman (1998) found that individuals
unplanned retirement is poor health that results with an employed spouse are less likely to take
in a diminished capacity to work. Results from early retirement incentives compared to individ-
the well-known Whitehall II study showed that uals whose spouse is not working. Perceived pres-
health is a strong predictor of early retirement in sure from spouses (i.e., the antithesis of support)
British civil servants (Mein et al. 2000). More impacted individuals intentions to retire early. In
recently, the Survey of Health, Ageing and Retire- fact, perceived spousal pressure for early retire-
ment in Europe (SHARE) showed that poor self- ment was the strongest predictor of early retire-
reported health is a strong predictor of labor force ment (van Dam et al. 2009).
exit even after controlling for factors predictive of Men with a working spouse were much less
poor health such as obesity, problem use of alco- likely to exit the labor force themselves, account-
hol, job control, and effort-reward balance (van ing for health and other demographics (Ozawa
den Berg et al. 2010). Jones et al. (2010) examined and Lum 2005). How much spouses enjoy spend-
the effect of health on early retirement in 12 waves ing time together is a strong predictor of whether
of the British Household Panel Survey. In the sam- or not they time their retirement to coincide
ple of men age 5065 and women age 5060, (Gustman and Steimeier 2004). The timing of
health was a highly signicant risk for early retire- retirement among couples is also related to gender
ment. Interestingly, however, the relatively low and marital quality, with higher levels of marital
incidence of health problems in this age group conict taking place when one individual retires
means that relatively few retirements result from while the other is still working (Moen et al. 2001).
poor health. Other studies consider alternate paths
to retirement potentially affected by poor health. Family Caregiving
A recent meta-analysis of longitudinal studies In addition to early retirement due to ones own
found poor health is a major cause of workforce health, workers may also depart early to care for a
exit, especially through disability, unemployment, family member (Matthews and Fisher 2013). This
and early retirement (van Rijn et al. 2014). may take the form of caring for an inrmed family
Finally, research in this area distinguishes par- member or providing care to children or
ticular aspects of health that may affect the timing grandchildren.
of retirement. For example, although some
workers with chronic health conditions expect to Spousal Caregiving
retire at younger ages (Dwyer 2001), others may Pienta and Hayward (2002) found that women
experience an unexpected health event that causes were more likely to take their partners health
them to have to leave work (McGeary 2009). status into account when formulating a decision
Health conditions that commonly lead to early to retire than they are to consider their own health
retirement include musculoskeletal conditions status. In fact, personal health status was not a
(e.g., back pain or problems), cardiovascular con- signicant predictor of retirement decisions for
ditions (e.g., heart problems, stroke), circulatory women, but was for men.
problems, and mental illness (e.g., anxiety or Dentinger and Clarkberg (2002) found that
depression) (e.g., Karpansalo et al. 2004). when women were required to provide physical
care to their disabled husband, these women were
Marital Status signicantly more likely to retire early. Con-
The decision regarding whether and when to retire versely, though, men who were required to pro-
is often made collaboratively among spouses/part- vide physical care to their disabled wife were
ners, and research has shown that spouses often more likely to delay retirement. Such results
coordinate the timing of their retirement with one could be interpreted using a sex-role perspective
another (Gustman and Steinmeier 2000). wherein men may be more likely to perceive a
Although marital status and having children need to shoulder the nancial burden of having an
have not been shown to predict early retirement, ill spouse, whereas women more frequently
assume the caregiving role. The stress associated employment elsewhere. Layoffs are an example
with family care demands may be exacerbated by of an involuntary cause of retirement.
the suddenness with which such demands may Raymo et al. (2011) found that workers
develop. prior experiences with involuntary job loss
(unemployment) as well as working in jobs char-
Children and Grandchildren acterized by not offering retirement plans, health
Other caregiving responsibilities related to early insurance benets, and good wages were associ-
and unplanned retirement include taking care of ated with a lower likelihood of early retirement.
grandchildren (Matthews and Fisher 2013). Some
workers, and more likely women than men, may Economic Factors
E
be drawn to or pulled into early retirement in
order to care for grandchildren. A few studies Pension Plans
have found that early retirement is negatively As noted above, one of the more signicant
related to the number of children one has as well changes to retirement incentives has been the
as having nancial responsibility for children transition of both private and, to a lesser extent,
(Matthews and Fisher 2013). One explanation is public pensions from dened benet to dened
that women may enter the workforce because of contribution plans. Dened benet plans provide
the need to nancially support their children. a certain monthly dollar amount received during
Therefore, continued economic pressure may preretirement based on age, years of service, etc.
vent women from early retirement to ensure that Dened contribution plans (e.g., 401ks, 403bs)
children are supported. in the United States consist of nancial savings
and/or investment accounts to which employees
Job and Organizational Characteristics and sometimes employers contribute money, usu-
Characteristics of work and the work environment ally a percentage of wages. The value of accounts
are related to early retirement, though most of uctuates based on how money is invested. Gen-
these issues do not lead to unplanned retirement erally, longer work tenure means more retirement
and are therefore not discussed here in much savings. Dened benet plans produce economic
detail. Early and unplanned retirement may result incentives for workers to retire when they reach a
from organizational efforts to reduce the size of particular age or tenure with the organization,
their labor force. This may happen by offering offering little nancial benet for continued
wage, bonus, or health insurance incentives to work. Not surprisingly then, research demon-
entice workers to retire early (Zhan 2013) or strates a robust effect of the presence of a dened
forced layoffs, producing both voluntary and benet pension plan on earlier retirement
involuntary mechanisms by which workers may (Mermin et al. 2007; Aaron and Callan 2011;
retire early. In other words, an employee may Cahill et al. 2012)
retire earlier than he or she anticipated and without According to Butrica et al. (2009), employee
much advanced planning to accept an early retire- participation in dened benet pension plans was
ment incentive from their employer. Many reduced from 38% to 20% in the United States
employers are reducing longer-term healthcare between 1980 and 2008. Participation in dened
costs by reducing the amount of coverage or pro- contribution plans increased from 8% to 31%
portion of premiums paid to retirees. In an effort to during the same time period. This shift in pension
retain high-quality health insurance, workers may plan type provides some economic incentives for
opt to retire sooner than they originally planned in employees with a pension plan to remain in the
order to retain such benets during retirement. workforce to continue saving for retirement and
This example would constitute a voluntary early postpone spending down retirement savings.
unplanned departure. Early and unplanned Likewise, the decline of dened benet pension
retirement may also take place as a result of a plans means that this cause of early retirement is
layoff followed by not obtaining subsequent likely to diminish over time.
Health Insurance accounted for by the availability of public health

Prior to the Affordable Care Act of 2010 in the insurance. In other words, workers are more likely
United States, the link between employment and to retire early when public health insurance is
health insurance meant that those wishing to retire provided.
early or who were forced to leave the workforce
prior to the age of 65 (i.e., age of eligibility for Wealth
government-sponsored health insurance through Theoretical economic models of savings and labor
Medicare) could also risk going without health force participation posit that higher levels of
insurance. Most workers receive health benets wealth are associated with a higher probability
from their employers, but they often forfeit their of labor force exit (Gustman et al. 2011). In gen-
insurance when they retire. Not surprisingly then, eral, empirical results support this hypothesis:
health insurance provision has been shown to early retirement is more likely when individuals
affect retirement decisions. For example, potential have greater nancial resources. For example,
costs of health insurance reduced retirement rates among American workers between the ages of
in workers age 5161 (Johnson et al. 2003). 55 and 66, greater wealth was generally associated
Some work places offer health insurance as a with leaving the workforce (Aaron and Callan
benet to their retired employees, and this may 2011), although interestingly greater education
have an impact on early retirement. In a review of was associated with remaining at work. However,
the literature, Gruber and Madrian (2004) research demonstrating an empirical effect of per-
reported that the availability of retiree health sonal wealth on retirement reveals relatively mod-
insurance increases the odds of retirement by est effects, net of other factors (Bloemen 2011).
3080%. Others have shown that it substantially For example, Gustman et al. (2011) found that the
increases the probability of retirement by age recent economic recession, on average, had a
62 (French and Jones 2011). Nyce et al. (2013) modest effect on retirement. This is explained in
investigated this effect in a large data set part by the fact that a majority of Americans have
representing individual data from 54 US rms. no signicant stock market investments.
Presence of employer-provided health insurance It is important to note that economic resources,
has its biggest effects between ages 62 and including personal wealth, pension wealth, and
64, increasing the rate of retirement at 62 by health insurance, are dynamically interrelated and
6.3% and nearly 8% at age 63. Health status may decisions about work can unfold for many years
affect the value individuals place on employer- leading up to retirement. Poor health is often a
provided retiree health insurance. For example, reason for leaving the workforce, yet low economic
Blau and Gilleskie (2008) demonstrated that the resources often have the effect of delaying retire-
cost of health insurance has a modest effect on ment. Bound et al. (2010) followed men age 5161
retirement rates for men in good health but a large who were working in 1992 to evaluate the impact
effect on retirement decisions of men in poor of health and nancial resources on work choices.
health. Specically, having retiree health insur- Men in good health were not likely to retire without
ance available appears to provide a path to early fairly substantial economic resources behind them,
retirement for men in poor health. whereas men in poor health were likely to retire
Lastly, aspects of public and private insurance even without pension benets.
programs vary across countries, and thus effects
vary by country, as some nations have
government-sponsored health insurance that is Outcomes
provided independent of labor force status. For
example, Zissimopoulos et al. (2007) found that Retirement researchers have also extensively
the retirement rate is higher in England compared investigated outcomes of early and unplanned
to the United States, and the overall earlier age at retirement. This section summarizes some of this
retirement by age 55 and beyond is partly research.
Economic Methodological limitations, limited and cross-

Economic outcomes of early and unplanned sectional data, differences in cultural norms, labor
retirement are both macro- and microeconomics. markets and economic incentives, and failure to
At the macrolevel, early and unplanned retirement differentiate between voluntary and involuntary
results in additional use of government resources retirement have likely contributed to inconsis-
(e.g., disability pensions, less employee contribu- tencies in understanding the impact of retirement
tions to Social Security). At the microeconomic on health status. Dave et al. (2008) suggested
level, Munnell and Sass (2008) indicated that there are two primary complications when
many individuals do not save enough money for attempting to identify the causal effect of retire-
retirement and are therefore not likely to have the ment on health: unobserved selection effects (i.e.,
E
necessary nancial resources to maintain their a sample selection bias) and endogeneity biases,
standard of living in retirement based on low which results in the inability to determine which
savings rates. Early and unplanned retirement is comes rst. A few studies have examined the
likely to result in individuals spending down their effects of retirement on health. First, Dave
retirement savings compared to individuals who et al. (2008) adjusted for selection bias (e.g., life
remain in the workforce longer, because they have history, retirement time preferences) and used a
a longer amount of time on which to rely on their stratied sample, such that in waves prior to retire-
own nancial resources. To the extent that indi- ment individuals reported no major illness or
viduals retired at earlier ages and without antici- health problems and no worsening of health
pation of retiring, it is quite possible that they left between adjacent waves. Thus, any changes in
the workforce prior to attaining all the nancial health postretirement were likely due to factors
resources needed for nancial security during exogenous to health. They found that these
retirement. Munnell and Sass (2008) pointed out confounding biases accounted for the majority
that working two more years has a signicant (8090%) of the observed differences in health
impact on the preservation of retirement wealth. over time and that involuntary retirement was
associated with greater adverse health effects.
Health Second, Calvo et al. (2013) examined retirement
Research examining health consequences of early timing in relation to physical and mental health.
retirement emphasizes the need to distinguish They found that retiring early (i.e., exiting the
between voluntary and involuntary retirements. workforce at an earlier age than culturally and
Van Solinge (2007) suggested that retirement itself institutionally expected) can be problematic for
has no categorically harmful or benecial effect on both physical health and emotional health. Calvo
health. Instead, it is the degree of perceived control et al. (2013) assessed the potential for reverse
over the retirement process (i.e., voluntary causality in the relationship between retirement
vs. involuntary retirement) that adversely affects timing and health by adjusting for endogeneity
health and emotional well-being. A great deal of bias and controlling for confounding effects of
research has found higher levels of physical and unobserved factors (e.g., personality traits,
mental health associated with voluntary retirement genetic predispositions).
compared to involuntary retirement (Isaksson and Contradictory results were found by Jokela
Johansson 2000; Shultz et al. 1998). For example, et al. (2010) in a study of British social servants
research has shown that involuntary retirement over 15 years. Jokela et al. (2010) found that both
was associated with an increase in problem drink- on-time retirement and voluntary early retirement
ing behavior during retirement (Bacharach were associated with better physical functioning
et al. 2008). This study found that after accounting and mental health compared to those remaining in
for preretirement drinking behavior, having more the workforce. Moreover, results indicated that
control over the retirement decision was associated physical functioning and mental health prospec-
with less alcohol consumption and a lower risk of tively predicted retirement timing. Compared to
problem drinking behavior. continued employment or having left the
workforce due to reasons other than retirement, involuntary retirement) is related to lower levels
poor mental health was associated with increased of well-being, including life satisfaction (Isaksson
odds of subsequent voluntary early retirement, and Johansson 2000) and happiness (Quine
and those with poorer physical functioning were et al. 2007). From a life course perspective, the
more likely to retire at the statutory age. Jokela timing of retirement can have a signicant inu-
et al. (2010) suggested that these results support a ence on psychological well-being; specically,
causal relationship between statutory and early transitioning into retirement either earlier or later
voluntary retirement and positive health outcomes than expected or preferred is thought to be disrup-
because analyses of reverse causality (using tive and stressful, leading to greater difculty in
discrete-time survival analysis models) showed adjustment (Quick and Moen 1998; Isaksson and
poor health increased the probability of retire- Johansson 2000). For example, Wang (2007)
ment; thus it is unlikely reverse causality found that individuals who retired earlier than
accounted for improved health postretirement. expected experienced declines in health. Those
Further, longitudinal within-person analyses who were in unhappy marriages consistently
revealed that greater health benets were obtained experienced declines in well-being following
after retirement. Not surprisingly, both poor men- retirement.
tal health and physical functioning increased the Research indicates that psychological and
odds of ill health in retirement and were indicative nancial preparation is also important for individ-
of selection rather than causation. uals well- being in retirement (Bender 2012;
Noone et al. 2013). Although a substantial body
Psychological Well-Being of literature suggests that early retirement is det-
An individuals transition and psychological adjust- rimental to psychological well-being, Potonik
ment to retirement is a dynamic, multifaceted et al. (2010) found that retirees who acted in
process contingent upon many personal and contex- accordance with group norms favoring early
tual factors such as individual attributes, retirement and retirees who perceived low capac-
preretirement job-related variables, family-related ity to continue working were more satised with
variables, retirement transition-related variables, early retirement and reported higher levels of
and postretirement activities (Pinquart and Schin- well-being. Moreover, compared to retirees who
dler 2007; Wang et al. 2011). Because work is an entered retirement early by their own volition,
integral part of peoples lives, and is highly valued retirees who perceived their retirement as forced
in society, work roles can serve as a source of or involuntary experienced lower levels of both
psychological well-being by contributing to feelings satisfaction with early retirement and psycholog-
of self-worth, meaningfulness, and personal identity ical well-being. These results are consistent with
(Steger and Dik 2009). Further, work can provide other studies that found when individuals transi-
important social and nancial resources. Given the tion into early retirement voluntarily, they can
signicance of work, the loss of ones job through experience greater satisfaction with retirement
retirement can have adverse consequences for psy- and life and higher levels of psychological well-
chological well-being, especially when the event is being (Quick and Moen 1998; Isaksson and
unplanned, unexpected, or involuntary. Johansson 2000; Hershey and Henkens 2014;
Early and unplanned retirees are especially Noone, et al. 2013).
vulnerable to maladjustment to retirement. Although there is some heterogeneity in the
A major determinate of well-being among older empirical ndings concerning the impact of early
adults is perceived control over ones immediate retirement on the transition and psychological
environment (Lachman 2006). Similar to the adjustment to retirement, there is general agree-
empirical results regarding early retirement and ment that unplanned and involuntary retirement is
physical health outcomes, research has shown a detrimental to retirees well-being and adjust-
lack of perceived control over the timing or cir- ment. Further, it has been established that plan-
cumstances of retirement (e.g., unplanned or ning for retirement (both psychologically and
nancially) and having control over the timing and health factors play a large role in shaping the
and circumstances of retirement are benecial. timing of retirement as well as the degree to which
retirement may be planned or unplanned. Recent
Family changes to government pension plans have
Early and unplanned retirement may help address increased the age of eligibility to receive retire-
family caregiving needs, including the care of ment benets, thereby increasing the age that
ones spouse or partner or other family members. denes early retirement in economic terms. In
Increasingly, workers (more often women than general the age at which retirement benets rst
men) retire in order to have more time available become available is a strong predictor of retire-
to care for grandchildren (Matthews and Fisher ment timing. However, there are many additional
E
2013) (see Antecedents). antecedents of early and unplanned retirement,
including health status, marital status, kinship
and family caregiving roles, and organizational
Bridge Employment incentives that encourage employees to leave the
workforce. Early and unplanned retirement is
Bridge employment is an increasingly common associated with more negative than positive eco-
phenomenon, in which individuals continue work- nomic, physical, and emotional health outcomes.
ing after they retire from a career job (Beehr and Although retirement timing is important, the
Bennett 2014). Feldman (1994) rst highlighted extent to which the retirement process is voluntary
the importance of bridge employment in relation or involuntary is a strong determinant of health
to early retirement, and since then many and well-being among retirees, with much more
researchers have paid a great deal of attention to positive outcomes associated with voluntary
the topic of bridge employment (e.g., Shultz 2003; retirement and negative outcomes associated
Zhan et al. 2009). Bridge employment is relevant to with involuntary retirement. Bridge employment,
early retirement because workers who may be con- which refers to continued work after retiring from
sidered early retirees in terms of their career job ones career job, is an increasingly common work
may continue to work in bridge jobs prior to leav- arrangement particularly for early retirees.
ing the workforce altogether. (See other entries on
Bridge Employment.)
Bridge employment is increasing in preva-
Cross-References
lence. According to Cahill et al. (2005), half to
two-thirds of workers transition to bridge jobs
Parents Retirement Processes, Role of
before retiring completely. Maestas (2010)
Children
reported that 44% of workers in 2004 were only
Retirement and Continuity Theory
partially retired, and a growing proportion of
Retirement and Social Policy
workers (initially 25% but recently more than
Women and Retirement
33%) return to work after retiring. Bridge employ-
ment can serve as a mechanism for workers to
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Environmental Medicine, 71(4), 295301.
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Wang, M. (2007). Proling retirees in the retirement may signicantly impair physical health and psy-
transition and adjustment process: Examining the chosocial functioning in both men and women.
longitudinal change patterns of retirees psychological
well-being. Journal of Applied Psychology, 92(2), 455. According to the DSM-5 there are different types
Wang, M., Henkens, K., & van Solinge, H. (2011). of feeding and eating disorders: pica, rumination
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Zhan, Y. (2013). Designing early retirement incentive pro-
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retirement (pp. 449459). New York: Oxford Univer- lematic eating behaviors ranging from dieting and
sity Press. extreme weight control methods (i.e., fasting,
Zickar, M. J. (2013). The evolving history of retirement binge eating, and purging) to clinically diagnosed
within the United States. In M. Wang (Ed.), The Oxford
handbook of retirement (pp. 1021). New York: Oxford eating disorders (e.g., anorexia and bulimia
University Press. nervosa). Accompanying these behaviors is also
Zissimopoulos, J., Karoly, L., & Maestas, N. (2007). a range of disordered eating attitudes, such as the
Retirement transitions of the self-employed in the need to be thin as well as weight and shape fears.
United States and England. Ann Arbor, MI: Michigan
Retirement Research Center. The majority of research on eating disorders con-
centrates on adolescents or young adult women,
however, in the recent years data has emerged
focusing on middle-age and older adults who
may be experiencing eating disorders, namely
Eating Disorders and Eating anorexia nervosa, bulimia nervosa, and binge-
Disordered Behaviors eating disorder.
Viktoriya Samarina1, Susan Sharp2 and

Dawn La3,4 Eating Disorders as Defined by the
1
Barrow Neurological Institute, Phoenix, AZ, DSM-5
USA
2 The Diagnostic and Statistical Manual of Mental
Memphis Veterans Affairs Medial Center,
Memphis, TN, USA Disorders (American Psychiatric Association
3 2013) made several recent changes to the criteria
Palo Alto University/Pacic Graduate School of
Psychology, Palo Alto, CA, USA for feeding and eating disorders to better charac-
4 terize symptoms and behaviors of patients across
Sierra Pacic Mental Illness, Research Education
and Clinical Centers at the Veterans Affairs Palo the lifespan. Some of the changes included recog-
Alto Health Care System, Palo Alto, CA, USA nizing binge eating as a disorder, revising the
diagnostic criteria for anorexia nervosa and
bulimia nervosa, and including pica, rumination
and avoidant/restrictive food intake disorder
Synonyms (the latter three were originally included in the
Disorders Usually First Diagnosed in Infancy,
Dementia; Eating disordered behaviors; Eating Childhood, or Adolescence section of the
disorders; Older adults DSM-IV-TR).
Eating Disorders and Eating Disordered Behaviors 717
Anorexia nervosa is dened by a distorted further away from the cultural ideal of looking
body image, a pathological fear of gaining weight, young and thin.
and excessive dieting that leads to severe weight Binge eating disorder is characterized as recur-
loss. This disorder mostly affects adolescent girls ring episodes of eating signicantly more food in
and young women. Some of the changes that were a short period of time than most people would eat
made from the DSM-IV-TR include taking out the in the same circumstances. These episodes are
word refusal in terms of weight maintenance also dened by feelings of lack of control over
since that signies intention on the part of the eating (e.g., a feeling that one cannot stop eating
patient and is difcult to determine. In addition, or control how much one is eating). A person with
in the DSM-IV-TR a diagnosis of anorexia a binge eating disorder may eat more rapidly than
E
nervosa required amenorrhea, or the absence of normal whether he or she is hungry or not. The
at least three menstrual cycles. This criterion was individual may experience feelings of guilt,
taken out, because it cannot be applied to males, embarrassment, or disgust and may binge eat
premenarchal females, females taking oral contra- alone to cover the behavior. Marked distress is
ceptives, and postmenopausal females. Moreover, usually associated with binge eating. Addition-
some women may report some menstrual activity ally, this disorder occurs, on average, at least
but still show signs and symptoms of anorexia once a week over three months (American Psy-
nervosa (American Psychiatric Association chiatric Association 2013). Older adults suffering
2013). from binge eating disorder may feel lack of con-
It is important to understand that older adults trol or willpower. In addition, loneliness, depres-
may experience anorexia of aging, which is dif- sion, and other psychiatric or medical
ferent from anorexia nervosa. Anorexia is a med- comorbidities may impact older adults eating
ical condition that is characterized by reduced habits.
appetite or dislike of food therefore leading to
the inability to eat. Symptoms such as fear of
gaining weight or distorted body image, which Prevalence Rates of Eating Disorders
are key in anorexia nervosa, are absent in anorexia and Older Adults
of aging. Anorexia of aging, which is involuntary
weight loss and protein-energy malnutrition, Anorexia nervosa and bulimia nervosa are
includes the normal physiological changes that 10 times more common in females than males,
cause an increase in the proportion of body fat and binge-eating disorder is three times more
and decrease in lean muscle mass and extracellu- common (Treasure 2007). Though in recent
lar uid mass. This change in body makeup is years studies have shown that one in six males
usually a result of decrease in energy needs and also suffer from an eating disorder (Andersen
therefore a decrease in appetite and calorie intake 2002). Eating disorders have become a major
(Champion 2011). public health issue as it is the third most common
Bulimia nervosa is characterized by recurrent illness in adolescent females, and is affecting
episodes of binge eating followed by inappropri- more women of all ages worldwide. Research
ate behaviors such as self-induced vomiting to suggests that more than 20% of women aged
avoid weight gain, and self-evaluation that is dis- 70 and older were dieting and experiencing
proportionately inuenced by body shape and unhappiness with ones body image and the desire
weight. In contrast to the DSM-IV-TR criteria, to be thin; and these concerns do not disappear
which required the frequency of binge eating and with age (Fisher et al. 1995). Anonymous ques-
compensatory behaviors to occur twice a week, tionnaires were administered to 1,500 Austrian
the DSM-5 species that these behaviors must women between the ages of 40 and 60 assessing
occur once a week (American Psychiatric Associ- for eating disorders (as dened by the DSM-IV),
ation 2013). Older adults may especially engage subthreshold eating disorders, body image, and
in the inappropriate behaviors as they move quality of life. Subthreshold eating disorder was
dened by the presence of either binge eating with bulimia nervosa. Studies show a genetic predis-
loss of control or purging behavior, without position and a variety of environmental risk fac-
requiring any of the other usual DSM-IV criteria tors that contribute to eating disorders. Clinical
for frequency or severity of these symptoms. studies with twins show an agreement for
Of the 715 middle-aged to older adult women anorexia nervosa of 55% in monozygotic twins
that responded, 33 (4.6%) reported symptoms and 5% in dizygotic twins, and bulimia nervosa
meeting full DSM-IV criteria for an eating being 35% and 30%, respectively. In addition,
disorder. None indicated symptoms or behaviors much of the research focuses on the neurobiology
consistent with anorexia nervosa, possibly due of eating disorders, looking specically at neuro-
to the DSM-IV criteria of requiring amenorrhea. peptide and monoamine (especially 5-HT) sys-
Another 34 women (4.8%) displayed sub- tems, which are thought to play a central role in
threshold eating disorder (Mangweth-Matzek the physiology of eating and weight regulation.
et al. 2013). Studies incorporating functional imaging of
There are different patterns or categories into the brain show altered activities in the frontal,
which older adults may t with regard to eating cingulated, temporal, and parietal cortical regions
disorders. Some older adults have struggled with in both anorexia nervosa and bulimia nervosa, and
an eating disorder since adolescence and never there is some suggestion that these changes persist
received treatment. Others likely received treat- after recovery. Whether these changes are a result
ment in their younger years but relapsed later on in of the eating disorder or have somehow contrib-
life as a result of a stressful life event (e.g., death uted to the risk of developing an eating disorder is
or illness of family member or friend). Another not well researched (Lapides 2010; Kaye and
group may be older adults who were always pre- Strober 1999).
occupied with food and weight throughout their
lives but experienced limited consequences of
eating disorders when they were younger. Lastly, Eating Disordered Behaviors: Signs and
there is a small subset of older adults who devel- Symptoms in Older Adults
oped an eating disorder later in life (American
Psychiatric Association 2013). It can be difcult to determine or diagnose an
Similar to adolescents and younger adults, eating disorder in older adults. However, some
middle aged and older adults also face devastating signs and symptoms can be recognized as clues
physical and psychological consequences of eat- to changes in eating behavior in older adults. For
ing disorder. Issues such as social isolation, phys- example, signicant change in weight over a short
ical illness, bereavement, and minimal support are period of time; behavior changes such as
just a few factors that can impact the onset of late- disappearing after a meal or using the restroom
life eating disorder (Cosford and Arnold 1992). after eating; new use of laxatives, diet pills, or
Additionally, eating disorders in older adults are diuretics; wanting to eat alone rather than with
associated with anxiety, depression, and suicidal family; skipping meals; loss of concentration;
ideation and attempts (Hudson et al. 2007). Eating physical symptoms such as enamel loss, chronic
disordered behaviors may also increase the risk of sore throat, cracked lips, sensitivity to cold, exces-
medical morbidity, such as cancer and obesity sive hair loss, dental damage, or heart and gastro-
(Ng et al. 2013). intestinal problems (e.g., constipation); excessive
consumption of high-calorie foods that are sweet
(especially prominent in people with binge
Biology of Eating Disorders eating disorders). Furthermore, osteopenia and
osteoporosis are common symptoms of
Research on the biology of eating disorders longstanding anorexia nervosa and are associated
has primarily focused on anorexia nervosa and with an increased fracture risk in older adults.
Additionally, it is suggested that physicians com- Overall, stress is the most common trigger of
plete a physical for medical conditions and review eating disorders in both younger and older adults;
medications as medical conditions (e.g., thyroid stressors often change as one develops and
and gastrointestinal conditions), medications, and become more prominent. Eating disorders are
substance use can mimic symptoms of an eating usually not about weight or food, but a way of
disorder (e.g., nausea, weight gain or loss) coping with other stressors in life that the individ-
(Lapides 2010; Lapid et al. 2010). ual does not know how to handle. Disordered
eating behaviors are often a way to avoid and
numb emotions and feelings. If during adoles-
Contributing Factors to Eating Disorders cence or young adulthood the individual learned
E
in Older Adults maladaptive coping mechanisms to tolerate stress,
then the individual may utilize these unhealthy
Triggers of eating disorders may appear similar coping methods later in life as an older adult
for younger and older adults; however specic (Lapides 2010).
differences occur, as life stressors change as peo- In one study, 50 women who were treated in a
ple age. Body image issues and body dissatisfac- residential program and who eating disorder
tion are some of the common risk factors for symptoms began after the age of 40 were exam-
eating disorders and increase with age as the ined. On an eating disorder inventory, midlife
human body experiences natural changes (e.g., women scored higher than younger women on
wrinkles, graying hair, and weight gain). Addi- scales of ineffectiveness, perfectionism, interper-
tionally, the development of eating disorders in sonal distrust, and asceticism, but scored lower on
midlife can be due to other changes or transitions drive for thinness, bulimia, and body dissatisfac-
that occur as one ages. For example, loss of loved tion. Both midlife women and younger women
ones, widowhood, divorce, traumatic illness or reported moderately severe depression and anxi-
disability, children moving out of the house, ety symptoms. On the Minnesota Multiphasic
growing old and facing mortality, and loss of Personality Inventory (MMPI), midlife women
independence can all have an impact on eating indicated more denial than younger women.
behaviors of midlife or older adults (Lapides These midlife women also endorsed a higher
2010; Zerbe 2008). frequency of sexual abuse (63%) than reported
Certain medical conditions can also contribute by younger women with eating disorders.
to developing an eating disorder. For example, There was no signicant difference between mid-
older adults are at a higher risk for developing life and younger women in alcohol or other sub-
high cholesterol, diabetes, and other cardiovascu- stance use; however, midlife patients abused
lar diseases and may be advised by their primary cannabis much less and opioids more than
care physicians to be mindful of and careful with younger patients. Though not statistically
their diet. Some older adults may become anxious signicant, midlife patients more often abused
about their diets, but also lack knowledge about sedatives, hypnotics, and anxiolytics suggesting
proper nutrition that lower the risk for cardiovas- a higher tendency to abuse calming/sedating med-
cular diseases. They may begin restricting their ications. About 22% of older women reported a
diets and lose weight unintentionally. Their anxi- history of self-harm and 28% had attempted
ety may maintain their eating disordered behav- suicide. Though this study was limited to only
iors. Other contributing factors to eating disorders patients who were seeking treatment in a
for older adults may be lack of enthusiasm for life, facility, this suggests that older adults with
attempts to obtain attention from family members, eating disorders may under report some of their
nancial difculties, medical problems, and dis- distress and need serious consideration and treat-
satisfaction or objection of living situations (i.e., ment in the community (Cumella and Kally
nursing home, skilled facilities) (Lapides 2010). 2008).
Eating Disorders and Neurocognitive in visuoconstructional skills, social withdrawal,

Disorders and mood changes (symptoms of depression)
can occur. Eating changes in AD have been
Dementia is not one specic disease; rather, it is a shown to be less common. However, some
clinical syndrome characterized by a loss of cog- research indicated anorexia is more common in
nitive functioning that negatively impacts a per- AD (Ikeda et al. 2002). Research found more
sons abilities to complete day-to-day activities. signicant changes in eating behaviors in both
Dementia can affect many body systems and pro- bv-FTD and semantic dementia in contrast to
duce a variety of problems, such as poor or inad- Alzheimers disease. Individuals with semantic
equate nutrition. Individuals with dementia may dementia rst typically see a change in food pref-
decrease the amount of food they eat, forget to eat erence, whereas individuals with bv-FTD show
and drink, or believe they have already eaten. changes in food preferences as well as alterations
Changes in an older persons daily routine (e.g., in appetite (Ikeda et al. 2002).
such as meal time) or other distractions (e.g., how Though there is limited research on other types
the food smells or tastes, environmental issues of dementias (e.g., vascular dementia) and eating
such as too much confusion) may affect their disorders, overall, individuals with any type of
eating patterns. In some cases, people with dementia may suffer from a diminished interest
advance dementia may lose control of the muscles to eat or forgetting to eat. Changes in food intake
used to chew or swallow and this could put the can lead to malnourishment and dehydration,
person at risk of choking. Additionally, people increasing the risk of infections, abnormally low
with dementia may lose the feeling of hunger blood pressure, and other medical problems.
and the desire to eat. Other comorbid factors Proper nutrition does not necessarily prevent
such as depression, medication side effects, and weight loss in people who suffer from dementia,
constipation, can decrease the individuals interest nor will it slow down the progression of the neu-
in food (Ikeda et al. 2002). rodegenerative process, however continuing to
Frontotemproal dementia (FTD) encompasses maintain a healthy weight and diet can support
several clinical syndromes all sharing frontal overall health and better quality of life. Primary
pathology. The FTDs include behavioral variant care physicians, psychiatrists, psychologists, die-
FTD (bv-FTD), progressive nonuent aphasia ticians, family members and other caregivers play
(PNFA), and semantic dementia (SD). A variety an important role in some of the treatment options
of behavioral changes noted in bv-FTD, include for eating disorders in older adults.
loss of insight, disinhibition, impulsivity, apathy,
poor self-care, mood changes, mental rigidity, and
stereotypic behavior. Some research with bv-FTD Treatment Options for Eating Disorders
individuals has also found a high prevalence rate
of changes in food preferences, appetite, and eat- As people age, their interest in eating and
ing behaviors. Individuals with semantic demen- enjoying food changes. Individuals with dementia
tia characterized by anomia and impaired have pronounced changes in taste or food prefer-
comprehension, also show behavioral changes, ences as well as changes in mood, behavior, and
such as changes in appetite and food preferences physical functioning, which can impact eating.
that are similar to those observed in bv-FTD Some general treatment goals for eating disorders
(Ikeda et al. 2002). in individuals both with and without dementia are
One of the most prevalent dementia syn- to restore adequate nutrition, and weight to a
dromes, Alzheimers disease (AD), accounts for healthy level, reduce excessive exercise, and
about 35% of all dementia cases. AD is character- stop binging and purging behaviors. Additionally,
ized by early onset of memory impairment (poor individuals that suffer from dementia may benet
consolidation and recognition of information), from specic memory strategies (e.g., following a
poor confrontation naming (dysnomia), decits specic routine everyday or incorporating various
reminders or cues to remember to eat) or feeding disorder and set specic goals throughout the
tubes in later stages of the neurodegenerative dis- therapy. Three phases can occur over the course
ease. Multidisciplinary treatment teams such as a of cognitive behavioral therapy: behavioral phase,
primary care practitioner, psychiatrist, dentist, cognitive phase, and maintenance and relapse
nutrition specialist or dietician, and a mental prevention phase. During the behavioral phase
health care professional may be needed to manage the patient and therapist come up with a plan to
eating disorders (Fairburn 2010; Shapiro stabilize eating and eliminate symptoms. In the
et al. 2007). In addition, health care professionals cognitive phase, the therapist begins cognitive
treating patients with eating disorders have to be restructuring where the individual begins to rec-
mindful of different cultural and religious values ognize and change problem thinking patterns.
E
and practices patients may possess. Negative thoughts and beliefs (e.g., I will only
Several psychological theories have been probe happy if I can lose weight) are identied and
posed to account for the development and main- restructured. In addition, other concerns and
tenance of eating disorders, with cognitive issues such as relationship difculties, self-esteem
behavioral theory being one of the most promi- concerns, and emotion regulation are focused
nent with regard to treatment. Cognitive behav- on. The last stage of CBT focuses on minimizing
ioral theorists propose that there are two main triggers, preventing relapse, and maintaining pro-
origins for the restriction of food intake. The rst gress previously made (Fairburn 2010; Shapiro
is the need to feel in control of life, which transfers et al. 2007).
into the need to control eating. The second is over In addition to psychotherapy, psychotropic
evaluating ones shape and weight. In both cases, medications have also been shown to play a role
a dietary restriction is reinforcing. Following this, in treating eating disorders. Research on medica-
other processes such as social withdrawal, binge tion use for anorexia nervosa have not found
eating due to extreme and rigid dietary restraint, medication to promote weight gain, though some
and negative impact of binge eating or concerns studies suggested uoxetine as an option in
about shape and the sense of being in control, preventing relapse in patients after normal weight
begin to play a role and serve to maintain eating is restored. In contrast, uoxetine has shown to
disorders (Fairburn 2010; Shapiro et al. 2007). reduce binging frequency in bulimia nervosa, as
Cognitive and behavioral approaches have well as anxiety and depressive symptoms (Zhu
been shown to successfully treat eating disorders and Walsh 2002).
based on studies with younger and middle-aged While research demonstrates the benets of
women and men. In addition, antidepressant med- medication, the best results were seen with a com-
ications may also be effective for some eating bination of psychotropic medication and psycho-
disorders as well as treating comorbid anxiety or therapy (Zhu and Walsh 2002; Maine et al. 2010).
depression. Medical consequences of an eating Research shows that patients who received cogni-
disorder can be devastating and life threatening, tive behavioral therapy demonstrated more
however, the internal dialog within the person and improvement in symptoms than those who only
specic behavioral rituals that are constantly received medication. However, medication is ef-
repeated can cause suffering and pain. The con- cacious for patients who have not responded to
stant fear of judgment, self-imposing rules and psychotherapy. When patients who did not benet
demands can take over and cause negative emo- from cognitive behavioral therapy or interper-
tions and perpetuate negative behaviors. Individ- sonal therapy were administered a placebo or u-
uals with eating disorders often maintain negative oxetine, signicant results in favor of uoxetine
view of themselves and their bodies. These nega- were found (Walsh et al. 2000). While older adults
tive thoughts can cause feelings of shame or anx- have not been the focus of eating disorder ran-
iety that can then trigger behaviors to control domized control trials, interpersonal and cogni-
weight. Cognitive behavioral therapy can focus tive behavioral therapies were successfully used
on the specic factors that are maintaining the to treat other later-life psychiatric disorders, such
as depression (Hudson et al. 2007), which often but certainly possible, the eating issue could be a
co-occur with eating disorders. longstanding disorder or newly diagnosed condi-
In addition to psychotherapy and medication, tion. For these reasons, health care professionals
nutrition intervention, such as counseling by a reg- need to be cognizant of the possibility of eating
istered dietitian is an important aspect of multidis- disorders in the elderly, given the serious conse-
ciplinary treatment of eating disorders, and would quences of misdiagnosing or leaving them
certainly contribute to determining the course of untreated in any population.
treatment in older adults. The dietitian can perform
a nutrition assessment to identify nutrition prob-
lems related to the eating disorder and implement a
Cross-References
care plan that might establish healthy eating pat-
terns and restore the individual back to a healthy
Behavioral and Psychological Symptoms of
weight. In addition, the dietitian can monitor and
Dementia
re-assess the individuals progress with the plan
and jointly work with other health professionals
Comorbidity
to address the individuals needs. The trained die-
Stress and Coping Theory in Geropsychology
tician can recommend keeping a daily food, hydra-
tion, and exercise log and this information can help
identify if any new physical or medical problems References
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face between the female body and mental health
(pp. 5771). London: Routledge. A common denition is that stress occurs when a
Walsh, J. M., Wheat, M. E., & Freund, K. (2000). Detec-
tion, evaluation, and treatment of eating disorders: The person perceives a challenge to his or her internal
role of the primary care physician. Journal of General or external balance (homeostasis; De Kloet
Internal Medicine, 15(8), 577590. et al. 2005). Thus, a discrepancy between what
Zerbe, K. J. (2008). Integrated treatment of eating disorders: should be and what is induces stress.
Beyond the body betrayed. New York: WW Norton.
Zhu, A. J., & Walsh, B. T. (2002). Pharmacologic treatment A stressor can be physical (e.g., cold, hunger) or
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47, 227234. neighborhood violence, marital problems), as
well as acute or chronic. The subjective evaluation
of the stressor and of available coping resources
determines its impact on the individual (Lazarus
Effects of Stress on Memory,
1993). Something perceived as a threat by one
Relevance for Human Aging
person might be perceived as an exciting chal-
lenge by another. There is thus substantial
Oliver T. Wolf
interindividual variability in the vulnerability to
Department of Cognitive Psychology, Institute of
stress. As humans are social animals, a threat to
Cognitive Neuroscience, Ruhr University
the social self (social evaluative threat), in combi-
Bochum, Bochum, Germany
nation with uncontrollability of the situation, is
especially potent in prompting stress (Dickerson
Synonyms and Kemeny 2004). As further outlined below,
genetic susceptibilities, when combined with
Changes in stress vulnerability during aging: early adversity, render an individual more vulner-
Focus on the brain; Effects of stress on memory: able in adulthood.
724 Effects of Stress on Memory, Relevance for Human Aging
The Two Stress Systems: HPA and SNS This response is slower and constitutes the second
response wave (De Kloet et al. 2005). The two
Stress leads to neuroendocrine responses aimed at systems are illustrated in Fig. 1.
facilitating adaptation. In this context, the GCs are lipophilic hormones that can enter the
hypothalamic-pituitary-adrenal (HPA) axis and brain, where they inuence regions involved in
the sympathetic nervous system (SNS) play the cognitive functions (e.g., amygdala, hippocam-
most important roles. SNS activity leads to the pus, and prefrontal cortex). These effects are
rapid release of (nor)epinephrine from the adrenal mediated by the two receptors for the hormone:
medulla, which constitutes the rst response the mineralocorticoid receptor (MR) and the glu-
wave. Activity of the HPA axis on the other cocorticoid receptor (GR), which differ in their
hand leads to the release of glucocorticoids afnity for GCs and in their localization. While
(GCs; cortisol in humans, corticosterone in MR activation leads to enhanced neuronal
most laboratory rodents) from the adrenal cortex. excitability, GR activation causes a delayed
Effects of Stress on Memory, Relevance for Human hormone (CRH), which stimulates the secretion of adreno-
Aging, Fig. 1 Stress activates two neurohormonal sys- corticotropin (ACTH) from the anterior pituitary gland into
tems: the rapidly acting sympathetic nervous system (SNS) the blood stream. ACTH stimulates the adrenal cortex to
and the slightly slower hypothalamic-pituitary-adrenal release glucocorticoids (GCs, mostly cortisol in humans),
(HPA) axis. Activation of the hypothalamus stimulates which can easily pass the blood-brain barrier and modulate
the SNS to secrete (nor)epinephrine from the adrenal brain functions involved in learning and memory (see text).
medulla. These catecholamines cannot easily pass the GCs exert negative feedback effects (indicated by the
blood-brain barrier but can exert excitatory actions in the minus symbol) on the hypothalamus and the pituitary
brain by stimulating the vagus nerve (hence the dotted gland, leading to reduced activity of the HPA axis in the
line). The hypothalamus releases corticotropin-releasing aftermath of stress
suppression or normalization of the neuronal net- the HPA axis and, at the same time, a structure
work (Joels et al. 2008). Their activation further- of vital importance for episodic memory (see
more leads to an altered expression of responsive below).
genes. In addition, GCs can exert more rapid Longitudinal studies indicate that not all older
non-genomic effects which, in part, are mediated participants show an increase in basal cortisol
by membrane-bound MRs (Joels et al. 2008). levels over the years. A substantial interindividual
After acute stress, the HPA axis negative feed- variance exists, ranging from increasing or stable
back leads to GC levels returning to baseline to even decreasing levels (Lupien et al. 2009). To
values within hours (De Kloet et al. 2005; summarize, the existing data point to altered basal
Dickerson and Kemeny 2004). In periods of cortisol concentrations during the nocturnal
E
chronic stress on the other hand, persistent alter- trough, while cortisol levels remain mainly
ations of the HPA axis can occur, leading to con- unchanged or show only slight changes over the
tinuingly elevated cortisol levels. However, course of the day (Wolf and Kudielka 2008).
elevated cortisol concentrations, as typically During the past decades, several studies have
observed in major depression, are not always the investigated the reactivity of the HPA axis using
consequence of chronic stress (Wolf 2008). For psychosocial laboratory stressors such as the Trier
example, reduced cortisol levels occur in several Social Stress Test. In this test, participants have to
stress-associated somatoform disorders (Fries deliver a speech in front of an emotionally cold,
et al. 2005) as well as in post-traumatic stress nonresponsive committee. In addition, a difcult
disorder (Wolf 2008). mental calculation task has to be performed.
Based on observations made in rodents, older
participants were expected to show a more pro-
Age-Associated Changes in HPA Axis nounced and/or more prolonged stress response.
Activity/Reactivity Indeed, this is what several well-conducted stud-
ies observed, even though ndings are not
Since HPA axis alterations are a close correlate of unequivocal (Wolf and Kudielka 2008), espe-
or even a determining factor in the onset of differ- cially concerning some of the sex differences
ent diseases, the assessment of the integrity and observed.
functioning of HPA axis regulation is of major A different approach involves pharmacologi-
interest in older individuals in particular. cal stimulation of the HPA axis using, for exam-
Aging is accompanied by several distinct alter- ple, CRH (with or without pretreatment with
ations affecting basal HPA activity as well as the dexamethasone). The majority of these studies
systems response to stress or pharmacological have found evidence for an enhanced HPA reac-
manipulations (Lupien et al. 2009). Regarding tivity with aging, accompanied by an impaired
the circadian prole, several studies have revealed negative feedback. Interestingly, these alterations
an increase in nocturnal nadir levels with age, appear to be more pronounced in older women
meaning that older people are exposed to higher (Otte et al. 2005).
levels of cortisol during the night (Wolf and The factors causing the HPA axis hyperactivity
Kudielka 2008). A somewhat different picture observed during aging in some individuals remain
has emerged for the cortisol awakening response poorly understood. Possible candidates are early
(CAR), which occurs directly after awakening and adversity or chronic stress (Lupien et al. 2009).
is associated with a robust increase in cortisol However, metabolic alterations associated with
concentrations during the rst 30 min after wak- glucose intolerance or type 2 diabetes (Convit
ing up. During aging, this response appears to 2005) should also be considered. Alternatively,
become more blunted, a phenomenon which has degenerative processes in the central nervous sys-
been linked to atrophy of the hippocampus tem might be the starting point of the
(Pruessner et al. 2010), a structure critically age-associated HPA axis alterations, since it is
involved in the supra-hypothalamic control of known that degeneration of supra-thalamic
control centers of the HPA axis (e.g., the hippo- hippocampal formation and which is very well
campus) leads to HPA axis hyperactivity. Of documented in rodents. Studies have shown that
course, these explanations are not exclusive and an adrenergic activation in the basolateral amyg-
might interact at multiple levels. dala (BLA) appears to be a prerequisite for the
modulating effects of GCs on other brain regions
(e.g., the hippocampus). Lesions in the BLA as
Stress and Cognition: Acute Effects well as beta-blockade abolish the enhancing
effects of post-training GC administration
Stress affects the central processing of incoming (Roozendaal et al. 2009).
information at multiple levels. Early inuences on Comparable effects have been observed in
perception and attention have been documented, humans: Immediate post-learning stress has
as well as later effects on working memory and repeatedly been linked to enhanced memory
long-term memory. The present chapter will focus consolidation. Similar evidence comes from
on the inuence of stress on long-term memory pharmacological studies, while neuroimaging
because it is the area which has been best charac- studies have provided further evidence for a
terized in young adults and at least partially inves- stress-induced modulation of amygdala and hip-
tigated with respect to aging. pocampal activity (Wolf 2009). Pre-learning
Long-term memory can be subdivided into stress or cortisol studies have led to a somewhat
declarative or explicit and non-declarative or pro- less consistent picture. In this case, the exact
cedural (implicit) memory. Based on its content, timing of the stressor, the emotionality of the
declarative memory can be further subdivided learning material, and the relation of the learning
into episodic memory (recall of a specic event material to the stressor appear to be important
which can be located in space and time) and modulatory factors (Wolf 2009).
semantic memory (our knowledge of the world). While an enhanced memory consolidation is
The medial temporal lobe is critical for declarative adaptive and benecial, this process appears to
memory, with the hippocampus being especially occur at the cost of impaired retrieval (see
important for episodic memory (Wolf 2009). Fig. 2). Using a 24 h delay interval, researchers
Long-term memory can further be subdivided were able to show that stress or GC treatment
into different memory phases, namely, acquisition shortly before retrieval testing impairs memory
(or initial learning), consolidation (or storage), retrieval in rats in a water maze. Further studies
and retrieval (or recall). The literature regarding have revealed that, once again, an intact BLA and
the effects of stress on episodic memory was its adrenergic activation appear to be necessary for
initially somewhat divergent and confusing, with the occurrence of this negative GC effect
groups reporting both enhancing and impairing (Roozendaal et al. 2009). Roozendaal has sum-
effects of GCs on this form of memory. However, marized these ndings as indicative of stress put-
it has become apparent that this is largely due to ting the brain into a consolidation mode,
the fact that the different memory phases outlined accompanied by impaired retrieval. Such a reduc-
above are modulated by GCs in an opposing fash- tion in retrieval might facilitate consolidation by
ion (Wolf 2009). reducing interference (Wolf 2009).
GCs enhance memory consolidation, this pro- In humans, multiple studies have been able to
cess representing the adaptive and benecial side demonstrate a stress-induced retrieval impairment
of the action of GCs in the central nervous system using different stressors and different memory
(see Fig. 2). It has been conceptualized as the paradigms. Similar impairment has been induced
benecial effects of stress within the learning using pharmacological cortisol elevations (Wolf
context, or intrinsic stress. The terminology 2009). Interestingly, the benecial effects on con-
used emphasizes the fact that a stressful episode solidation and the impairing effects on retrieval in
is remembered better, an effect which is mediated humans are more pronounced for emotionally
by the action of stress-released GCs on the arousing material. This observation ts the
Effects of Stress on Memory, Relevance for Human enhanced memory retrieval hours, days, or weeks later. In
Aging, Fig. 2 Memory phase-dependent effects of stress contrast, stress shortly before memory retrieval impairs
on long-term memory. Immediate pre- or post-learning long-term memory by temporarily blocking the accessibil-
stress enhances memory consolidation, thus leading to ity of the memory trace
mentioned observation in animals that GCs can retrieval (see Fig. 2). Within this framework, emo-
only exert effects on memory in the presence of tional arousal and a nonlinear dose-response rela-
adrenergic activity in the amygdala. This arousal tionship are important modulatory variables (Wolf
can result from specics of the learning material 2009).
and/or specics of the testing conditions.
In a meta-analysis, time of day appeared as an
additional modulatory factor. Studies in which Age-Associated Changes in Acute Stress
cortisol was administered before initial acquisi- Effects
tion observed impairing effects on memory when
conducted in the morning, a time of high endog- Few studies have investigated age-associated
enous cortisol levels in humans. In contrast, stud- changes in the impact of stress or stress hormones
ies in the evening were more likely to observe on memory. Findings thus have to be considered
benecial effects (Het et al. 2005). This supports as somewhat preliminary. A pharmacological
the idea of an inverted U-shaped function between study observed a cortisol-induced memory
cortisol levels and memory in humans, with levels retrieval impairment in both young and old par-
too low as well as levels too high at the time of ticipants (Wolf 2009). Stress studies have
acquisition being associated with impairments, revealed a somewhat different picture, with older
especially when retrieval is tested while cortisol adults less impaired by the stressor. At the same
levels are still elevated (Het et al. 2005). time, stressed older adults appeared to be more
In sum, studies in animals and humans con- susceptible to distraction. Interesting correlational
verge on the idea that GCs acutely enhance mem- ndings have been provided by a neuroimaging
ory consolidation while impairing memory study. In young participants, increasing cortisol
concentrations were associated with more neural show increased corticosterone concentrations
activity in several memory-relevant brain regions. and lower GR density in the hippocampus in the
In older participants, the opposite pattern was offspring of stressed mothers. Also, postnatal
observed: Here, increasing cortisol concentrations maternal separation and poorer maternal care
were linked to less brain activity in the have been associated with reduced GR gene
hippocampus. expression in the hippocampus, which, in turn, is
In sum, the currently available literature indi- associated with reduced feedback sensitivity of
cates that the memory of older participants is in the HPA axis. Recently, a mechanism has been
some cases differently affected by acute stress discovered in rodents that explains how environ-
(Wolf and Kudielka 2008). Importantly, enhanced mental stimuli can impact gene expression. Per-
and reduced stress responsivities have been manent alterations of GR gene expression result
reported. It is therefore likely that the impact of from methylation/demethylation of specic GR
acute stress on aging is specic for certain pro- promoters, a process associated, among others,
cesses and brain regions. with variations in maternal care (Meaney 2001).
Initial evidence suggests that the human GR gene
is also subject to early life programming (Schlotz
Stress and Cognition: Chronic Effects and Phillips 2009). Moreover, elevated cortisol
concentrations have, for example, been reported
The following paragraphs will focus on the impact in association with reduced birth weight or pre-
of chronic stress on cognition in aging. First, the term birth.
long-term consequences of early life stress will be In the following, the consequences of chronic
summarized. These changes have an impact stress exposure throughout life on cognitive func-
throughout the lifespan leading up to old age. tioning will be described. It will become apparent
Next, the impact of chronic stress on memory in that individuals with an increased stress suscepti-
adulthood is reviewed, before specic bility (reecting genetic susceptibilities and/or
age-associated changes in the chronic stress early adversity) are especially vulnerable to
effects associated with aging are highlighted. stress-induced cognitive impairments in adult-
hood and aging (Lupien et al. 2009).
Long-Term Consequences of Early Life

Stress Chronic Stress During Adulthood: Effects
on Cognition
Several studies support the notion that early stress
exposure is associated with accelerated neurode- Animal research provides insights into the struc-
generative processes and early onset of memory tural alterations caused by chronic stress. One
decline in the course of aging (Lupien et al. 2009). main nding is that the integrity of the hippocam-
Neurodevelopmental impairments in association pus and the medial prefrontal cortex is
with early stress exposure may be one of the compromised, while, in parallel, the amygdala
factors explaining such cognitive disadvantages (the fear center of the brain) and parts of the
at an older age. Changes in stress susceptibility striatum (the habit center of the brain) become
programmed early on in life might account for hyperactive (Roozendaal et al. 2009). In the hip-
such decits (Schlotz and Phillips 2009). There pocampus, chronic stress leads to a retraction of
is evidence for pre- and postnatal stress exposure dendrites (dendritic atrophy), and similar effects
being associated with a chronically increased occur in the medial PFC (Lupien et al. 2009). This
reactivity of the HPA axis, potentially resulting atrophy is reversible after stress termination,
from a reduced expression of central glucocorti- pointing to substantial neuroplasticity. In addi-
coid receptors (Meaney 2001). Animal models tion, stress leads to reduced neurogenesis in the
dentate gyrus and the mPFC. Even though the Chronic Stress or Rising Cortisol Levels
function of these newborn neurons is discussed During Aging: Effects on Cognition
controversially, impairment of memory and learn-
ing resulting from reduced neurogenesis is likely. In older laboratory rodents, an increase in basal
At the behavioral level, impaired performance in corticosterone levels and a less efcient negative
hippocampal-dependent spatial memory tasks and feedback of the HPA axis can be detected. Studies
impaired PFC-dependent set-shifting capabilities have reported that enhanced HPA activity is asso-
can be observed (Roozendaal et al. 2009). ciated with poorer memory in those animals
In contrast to the hippocampus and the PFC, (Lupien et al. 2009).
the amygdala becomes hypertrophic in conditions As reviewed above, increases in basal cortisol
E
of chronic stress. Increases in dendritic arboriza- levels occur during human aging. In addition,
tion and spine density take place (Roozendaal pharmacological or behavioral challenge studies
et al. 2009). Moreover, activity of the CRF system observe an increased HPA response. Moreover,
in the amygdala, which is involved in anxiety, is HPA-negative feedback in older subjects is
enhanced. Chronically stressed animals show less efcient. These alterations might reect
enhanced fear conditioning and are characterized age-associated diseases, stress exposure over the
by a more habitual and less goal-directed response lifespan, genetic vulnerabilities, the long-term
style. Thus, the balance between brain regions consequences of exposure to early life adversity,
involved in cognition is altered by chronic stress or a combination of the above (Lupien
(Lupien et al. 2009). While analytic cognitive et al. 2009). In older adults, correlations between
functions mediated by the hippocampus and PFC elevated or rising cortisol levels and cognitive
are impaired, affective fear-related amygdala impairments have been reported (Lupien
functioning and habit-related striatal functioning et al. 2009). The association between rising corti-
are enhanced (Wolf 2008). sol levels and atrophy of the hippocampus is not
In humans, exposure to chronic stress (e.g., sufciently understood, and the current empirical
shift workers, airplane personnel, soldiers) is situation is heterogeneous. Similar associations
associated with cognitive decits in several with other GC-sensitive brain regions (e.g., PFC)
domains such as working memory and declarative have received less attention so far.
memory (Lupien et al. 2009; Wolf 2008). These Evidence for HPA hyperactivity has been
observed cognitive decits can, in part, be observed in patients with Alzheimers dementia
explained by GC overexposure in the presence (AD). This could reect the damage to HPA feed-
of chronic stress, a nding supported by studies back centers in the brain, but it might also be
administering GCs for days to weeks, resulting in causally involved in disease progression (Wolf
cognitive impairments. Further evidence comes and Kudielka 2008). Work in animals has
from studies with patients receiving GC therapy. documented that HPA hyperactivity can inuence
Whether the negative effects on memory reect amyloid metabolism as well as tau phosphoryla-
acute or chronic effects is sometimes hard to dis- tion, the two hallmarks of AD pathology. In
entangle, and at least one study showed a rapid human patients, treatment with prednisone
reversal of the decits after discontinuation of the resulted in exaggerated memory loss. Moreover,
GC treatment. Data from patients with Cushings a genetic susceptibility to AD could be linked to
disease point in the same direction, with cognitive the gene encoding 11beta-HSD, which inuences
impairments and hippocampal volume reductions local GC metabolism. In addition, at the self-
reported. Hippocampal atrophy might be revers- report level, evidence exists that enhanced stress
ible once successful treatment has occurred. This susceptibility is associated with a greater risk of
would be in line with the remaining plasticity of dementia (Wolf and Kudielka 2008).
this structure observed in animal studies (Wolf Another condition associated with HPA hyper-
2008). activity is the metabolic syndrome, as well as type
2 diabetes. There are close links between the stress and GR antagonists appear promising. In sum,
system and the glucoregulatory system. Several reinstating appropriate HPA signaling appears to
authors have suggested that chronic stress facili- be a promising treatment approach both in chron-
tates the occurrence of the metabolic syndrome by ically stressed animals and in human patients suf-
inuencing visceral fat deposition, impairing fering from stress-related psychiatric disorders
insulin sensitivity, or by changing eating habits (De Kloet et al. 2007).
toward unhealthier (comfort) food. Alternatively, Intervention strategies specically designed
the negative impact of glucose intolerance on the for older people could be developed based on
brain might lead to HPA hyperactivity and, in the following ndings. In rodents, behavioral
turn, elevated cortisol levels (Convit 2005). (e.g., neonatal handling) and pharmacological
(adrenalectomy with low-dose corticosterone
replacement) intervention strategies, leading to
Intervention Strategies stable HPA activity throughout life, prevent
age-associated cognitive decline. Similarly, a
In laboratory animals, stress-induced dendritic pharmacological reduction of active GC concen-
atrophy and reduced neurogenesis can be trations in the hippocampus (inhibition of 11beta-
prevented with antidepressants and anticonvul- HSD synthesis) is efcient in preventing memory
sants. Also, treatment with a glucocorticoid recep- impairments in aging mice. In humans, a pilot
tor antagonist is effective in preventing such study showed that the 11beta-HSD inhibitor
stress-induced changes in neurophysiology. Sim- carbenoxolone improved some aspects of mem-
ilarly, memory impairments can be prevented with ory in older men and in older patients with type
these drugs (Wolf 2008). 2 diabetes (Wyrwoll et al. 2010). Future studies
In humans, chronic stress without an associ- are needed to better investigate possible side
ated psychopathology could be alleviated by psy- effects of long-term treatment with these kinds
chological stress intervention strategies. Possible of drugs. Regarding treatment of the metabolic
examples are stress inoculation training and syndrome, lifestyle modications are often suc-
mindfulness-based stress reduction training. In cessful if started early enough. In addition, phar-
addition, social support is an effective stress- macological approaches are available. They
buffering factor. should be able to prevent or reduce memory
Pharmacological treatment with beta-blockers impairment and hippocampal atrophy associated
can prevent the effects of acute GC elevations on with diabetes and the metabolic syndrome (Convit
memory retrieval. It remains to be shown whether 2005).
similar approaches are effective in conditions of
chronic stress. In addition, GR antagonists and/or
CRF antagonists might be candidate drugs. More- Summary and Outlook
over, drugs that inuence the local GC metabo-
lism in the brain could also be effective. This chapter illustrates that chronic stress has a
Depression is often associated with HPA hyper- negative impact on cognition throughout life.
activity. Successful treatment with antidepres- A lifespan approach in research on stress and
sants leads to a normalized HPA axis. One study cognition emphasizes the long-lasting effects of
observed that treatment with a selective serotonin exposure to early life adversity. Genetic risk fac-
reuptake inhibitor (SSRI) improved memory per- tors, in combination with early life adversity, ren-
formance and reduced cortisol levels. More direct der an individual more susceptible to stress and
interventions targeting the HPA axis have been stress-associated diseases during aging.
tested in laboratory animals, and clinical trials By reducing early adversity, it would thus be
are on the way. In this context, CRF antagonists possible to support the development of a more
resilient phenotype less susceptible to stress- De Kloet, E. R., Derijk, R. H., & Meijer, O. C. (2007).
associated cognitive disturbances in later life. Therapy Insight: Is there an imbalanced response of
mineralocorticoid and glucocorticoid receptors in
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Memory Training Methods and Benets the central nervous system: Evidence from structural
Memory, Autobiographical and functional neuroimaging studies in human
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Memory Schlotz, W., & Phillips, D. I. (2009). Fetal origins of mental
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732 Elder Abuse and Neglect
older with some statutorily dened vulnerability)

Elder Abuse and Neglect may overlap with elder abuse but only when the
vulnerable adult is over the age of 60.
Shelly L. Jackson
Institute of Law, Psychiatry and Public Policy,
University of Virginia, Charlottesville, VA, USA Prevalence and Consequences of Elder
Abuse
Synonyms Nationally representative studies in the USA nd

that overall, one in 11 older adults experience
Elder maltreatment; Elder mistreatment; Mistreat- some type of elder abuse in a given year, although
ment of older adults; Victimization of older adults prevalence varies by the type of abuse involved:
nancial exploitation (5.2%), caregiver neglect
(5.1%), emotional/psychological abuse (4.6%),
Definition physical abuse (1.6%), and sexual abuse (<1%)
(Phelan 2013). However, between 30% and 40%
Elder abuse was rst publically recognized in the of reported abused older adults experience more
United Kingdom and the United States in the than one type of abuse simultaneously. Prevalence
1970s. It is now a recognized phenomenon studies conducted in the European Region nd
found around the world, led by the advocacy that about 2.7% of people age 60 and over have
work of the International Network for the Preven- experienced physical abuse in the preceding year,
tion of Elder Abuse. The denition of elder abuse 0.7% sexual abuse, 19.4% psychological abuse,
has expanded over time. However, across coun- and 3.8% nancial abuse (World Health Organi-
tries elder abuse is frequently dened as a single zation 2011). Throughout Asian countries, preva-
or repeated act, or lack of appropriate action, lence estimates vary wildly from 0.2% to 62%,
occurring within any relationship where there is although again, prevalence rates vary by the type
an expectation of trust which causes harm or dis- of abuse involved (Phelan 2013). In Portugal, it is
tress to an older person and typically encompasses estimated that 12% of older adults fall victim to
six types of abuse: physical abuse, caregiver elder abuse in a given year, although again prev-
neglect, nancial exploitation, psychological alence rates vary across types of abuse (Gil
abuse, sexual abuse, and (in some countries) abanet al. 2014). In Western Australia, the prevalence
donment (World Health Organization 2002a). of elder abuse is estimated to be 4.6% (Phelan
Since abandonment has received virtually no 2013). Due to methodological differences within
empirical attention, it is omitted from this review. and between countries, comparisons are impre-
The trust component of the denition serves to cise. However, it is generally accepted that the
distinguish elder abuse from other harms perpe- prevalence of elder maltreatment increases
trated against older adults. Abuse in later life, for among people with a disability, cognitive impair-
example, focuses on domestic violence and sexual ment, and/or dependence (World Health Organi-
assault of older adults (particularly women). zation 2011).
Although overlapping to a degree with elder There is evidence that elder abuse is
abuse, it is narrower than elder abuse and typically underreported, with only one in 24 cases reaching
espouses a very different theoretical position. the authorities, with rates of reporting differing
Crimes against older adults (e.g., burglary, nan- across types of abuse (Phelan 2013). Although
cial scams, assault) that are committed by elder abuse occurs in long-term care facilities
strangers are not typically considered elder (Payne 2011), the majority of elder abuse occurs
abuse, although homicide committed by a family in the community, where most (95%) older Amer-
member would be a form of elder abuse. And ican adults reside. However, residence varies tre-
abuse of vulnerable adults (ages 18 years and mendously in other parts of the world. In the
Elder Abuse and Neglect 733
European Region, for example, more afuent government agency guided by state statute,
countries have higher rates of paid caregiving although statutes vary considerably from state to
and institutional care compared to less afuent state (Jackson 2015). Albeit somewhat controver-
countries where care is provided primarily by sial, all but one state (New York) have some form
family members (World Health Organization of mandatory reporting. Australia, in contrast, has
2011). eschewed mandatory reporting. APS is guided by
The eld is recognizing the unique ways in the principle of self-determination and does not
which historically marginalized groups are compel compliance with the provision of services
impacted by the experience of elder abuse unless the older adult is incapacitated or in certain
(Teaster et al. 2014). Distinct ethnic/racial groups emergency situations and the court approves such
E
may perceive the experience of abuse differently, intervention. However, some states do compel
experience elder abuse in different ways, and even compliance with an investigation. In practice,
at different rates. Individuals who self-identify studies in the USA generally nd that approxi-
with certain groups (LGBT, veterans) may have mately a quarter of APS clients decline services,
unique vulnerabilities that place them at risk for some of which will have a subsequent APS report.
abuse, including nancial exploitation. For exam- Over the decades, elder abuse has shifted concep-
ple, threatening an LGBT older adult with outing tually to that of a crime, implicating the involve-
may be sufcient to produce silence. ment of law enforcement and prosecution,
The myriad consequences of elder abuse are although prosecution remains uncommon (Payne
not often recognized (Payne 2011). They include 2011).
psychological problems such as depression, emo- Concern over nancial exploitation (i.e., the
tional problems, disruptions in social and family illegal or improper use of an elders funds, prop-
relationships, compromised health, physical erty, or assets) has consumed much of the atten-
injury, hospitalization, and mortality, restrictions tion towards elder abuse (Factora 2014).
on and elimination of autonomy such as institu- Financial exploitation has captivated the federal
tionalization or imposition of a guardianship, and state responders in the USA and Australia,
changes in living arrangements, and loss of assets with the majority of new movement within this
including ones home. In some cases, there are dened area of elder abuse. As lawmakers bear
secondary victims as well. For example, family witness to older adults being nancially ruined,
members or the state may become physically they have responded in kind with increased leg-
and/or nancially responsible for the older adult, islation (albeit not funding). There are now
or those who stood to receive an inheritance will 39 states in the USA that criminalize nancial
not do so. The economic costs to society (direct exploitation (Jackson 2015). The primary form
costs to health, social, legal, police and other of nancial exploitation prevention has been
services) imposes a substantial nancial burden. education, but researchers are suggesting that
The consequences of elder abuse routinely lead to this may be ineffective for many older adults
a diminished quality of life for abused older adults (Payne 2011).
regardless of nationality. The eld of elder abuse has suffered from a
lack of theory (Payne 2011; Bonnie and Wallace
2003). However, the adoption of a lifecourse
Case Identification and Reporting approach is recommended for understanding
elder maltreatment (World Health Organization
Some countries (e.g., Israel, Brazil, South Korea, 2011). While still thin, there have been modest
United States) have implemented a system for empirical gains since the landmark release of the
responding to reports of elder abuse, typically Institute of Medicines Elder Mistreatment:
referred to as adult protective services (APS) Abuse, Neglect, and Exploitation in an Aging
(World Health Organization 2002b, 2011). Since America (Bonnie and Wallace 2003), depicting
the 1970s, all states in the USA have APS, a the deplorable condition of the elder abuse eld.
There is increasing recognition of the importance Risk Factors of Elder Abuse

of distinguishing among types of abuse (Payne
2011), while recognizing that sometimes types Consistent with a public health approach, much of
of abuse co-occur or that one type of abuse may the elder abuse research has focused on the iden-
be a risk factor for experiencing other forms of tication of risk factors (i.e., factors that increase
abuse. However, there is still relatively little the odds of some phenomenon such as elder
research that either increases basic knowledge or abuse). Researchers have identied over 50 risk
guides applied practice (Payne 2011). Further- factors for elder abuse, although only 13 are found
more, the research has been uneven, with less consistently across studies (Johannesen and
empirical attention to caregiver neglect and psy- LoGiudice 2013). However, risk factors are dif-
chological/verbal abuse compared to other forms ferentially associated with types of abuse. Other
of elder abuse. than co-occurring forms of elder abuse, little is
Detection of elder abuse remains challenging known about the ebb and ow of these risk factors
in all countries. In an effort to identify cases, elder or the interconnectedness among them. Also
abuse screens have been developed, although it is lacking from this literature is the identication of
unknown how widely they are administered in protective factors that buffer against elder abuse.
any country. The U.S. Preventive Services Task One risk factor that seems to cut across all
Force recently concluded, however, that there are types of elder abuse is dementia (Dong
no valid and reliable elder abuse screens and could et al. 2014). In 2002, the prevalence of dementia
not recommend their use (Moyer 2013). Consid- among American individuals ages 71 and older
erably more work is needed to develop psycho- was 13.9%, with another 22.2% having some
metrically sound screening instruments for elder form of cognitive impairment without dementia.
abuse. In the meantime, efforts in many countries However, it is important to remain cognizant that
(e.g., Canada) include public awareness cam- more people without dementia experience elder
paigns designed to encourage community mem- abuse. In response to the concern about identify-
bers to report suspected elder abuse. However, ing dementia among older adults, over 100 cogni-
detection and reporting are related but distinct tive screens have been developed and many are in
actions, with the decision to report considerably use in every day practice throughout the world.
complex. Regardless, communities implementing However, the US Preventive Task Force con-
public awareness campaigns must be prepared for cluded that . . .current evidence is insufcient to
the possible increase in maltreatment cases com- assess the balance of benets and harms of screen-
ing to the attention of those responsible for ing for cognitive impairment (Moyer and
responding. U.S. Preventive Services Task Force 2014).
With few exceptions, the eld suffers from a The risk factor that consumes the most real
lack of forensic markers, which is interesting estate in this eld is social isolation. However,
given the criminalization of elder abuse over the this concept is unrened in the context of elder
past couple of decades. Lack of forensic markers abuse, often being conated with network size,
hampers the ability of geriatricians and other loneliness, and living alone, and yet there are
health care providers to differentiate between important distinctions among these concepts.
aging and abusive behavior (Bonnie and Wallace The manner in which isolation manifests across
2003), especially when victims are reluctant to types of abuse appears to differ as well. Some
disclose. Furthermore, insufcient knowledge studies have found, for example, that while low
surrounds the differentiation between accidental social support was related to neglect, physical,
death and elder homicide. Forensic science also is sexual, and emotional abuse, it was not related to
being applied in the context of nancial exploita- family-perpetrated nancial exploitation. In con-
tion, with the utilization of forensic accountants in trast, other studies have found that living alone
nancial exploitation investigations. was related to nancial exploitation, but not to
Elder Abuse and Neglect 735
physical abuse (OKeeffe et al. 2007). Social To truly understand and predict elder abuse, the
isolation likely plays an important role in ecological model instructs that there are risk fac-
victimization, but requires greater conceptual tors at levels above and beyond the individual
clarity. It has been proposed, however, that social level (Payne 2011). For example, at the relation-
connectedness may play a prophylactic role in ship level, the quality of the relationship prior to
elder maltreatment (World Health Organization the occurrence of maltreatment may be an impor-
2011). tant predictive factor (World Health Organization
Gender has also been implicated in elder abuse, 2011). Although the literature is scant,
although scholars cogently argue that elder abuse neighborhood-level factors (unsafe neighbor-
is not a gendered phenomenon (Kosberg 2014). hoods, high unemployment, and negligible social
E
While the eld awaits the development of victim cohesion) have also been shown to be associated
proles for each type of abuse, it is important to with elder abuse. At the societal level, elder abuse
remember the heterogeneity that exists among may be impacted by social policy and public
older adults generally, and among elder abuse attitudes such as ageism (i.e., stereotyping and
victims specically. For example, the victimology discriminating against individuals or groups on
literature asserts that there is a range of culpability the basis of their age).
expressed by victims (Doerner and Lab 2015). It
may be more difcult for society to perceive an
older adult victimized by a family member as a Intervention
pure victim compared to an older adult victim-
ized by a stranger. The eld of elder abuse has placed very little
Offenders have historically been excluded effort into intervention development and even
from elder abuse research as well as the response less on the evaluation of interventions. Studies
to elder abuse. Elder abuse offenders can be any- nd little encouragement in this domain, with
one, but are frequently family members, relatives, some scholars questioning the underlying
friends, neighbors, and professional caregivers, assumptions of protective services legislation
although the predominant type of victim-offender (Payne 2011). It is becoming increasingly recog-
relationship appears to vary by abuse type nized that elder abuse cases range in complexity,
(Jackson 2014). Furthermore, in Spain the main with implications for interventions. Some cases
perpetrators for older people who are dependent are easily resolved, but many are not. It is clear
or have disabilities were adult offspring, whereas that cases involving older parents and their abu-
for independent older people the perpetrators sive adult children are often particularly challeng-
appear to be their partners (World Health Organi- ing cases in which to intervene due in part to
zation 2011). There are several offender risk fac- parents erce protection of their offspring and
tors that have substantial empirical support across entrenched patterns of behavior. Efforts are under-
studies from various countries (World Health way to identify and address high-risk victims.
Organization 2011; Payne 2011; Johannesen and Newer interventions have incorporated known
LoGiudice 2013). These include psychopathol- risk factors such as social isolation (World Health
ogy (substance abuse, mental illness, and/or crim- Organization 2011), conceding, however, that this
inal history), isolation, and nancial dependence type of intervention is time consuming. Some
upon the victim. As with victims, appreciating the offenders suffer from caregiver burden syndrome,
heterogeneity among elder abuse offenders is with programs developed to address this condi-
important. Prosecution has been the primary tion. However, a systematic review of respite care
form of intervention for elder abuse offenders, concluded that, although some evidence supports
and even that has been appallingly absent (Payne a positive effect on burden and depression among
2011). Development of offender interventions is caregivers, the evidence was limited and weak
urgently needed (Jackson 2014). (World Health Organization 2011).
In the United States and throughout Europe has existed since the 1950s, demonstration projects
there are examples of shelters offering support in the USA were funded in the early 2000s which
for women who have left an abusive relationship. served to raise awareness of the model. This model
In the USA, the Weinberg Center for Elder Abuse is expected to proliferate in the coming years,
Prevention has gained considerable prominence. although very few states have adopted this practice
However, little is known about the effectiveness legislatively. Unfortunately, the empirical valida-
of emergency shelters in reducing elder maltreat- tion of MDTs is woefully small.
ment. In general, there are insufcient evaluation
studies exploring the effectiveness of interven-
tions on elder maltreatment, both locally and glob- Conclusion
ally. One approach may be to identify strategies
for preventing violence in general as there may be Elder abuse is a pervasive problem that affects all
some underlying risk factors that cut across both societies and countries. Considerable gains have
of these elds. been made in the eld of elder abuse (research,
In the American context and in some European practice, and policy) since it was rst recognized
countries, even less is known about the practice of in the 1970s. Although the knowledge base is
APS caseworkers and the effectiveness of the growing, it remains underdeveloped. Very few
services they employ (Payne 2011). There is evi- interventions have been established, and far
dence that a report of abuse to APS increases the fewer have been evaluated. Practice continues to
likelihood of institutionalization as well as be based on experience rather than empirical evi-
mortality. However, APS caseworkers tend to per- dence. And while there are now governmental
ceive their interventions (e.g., institutionalization) policies of some kind in many countries (World
as effective. The eld has yet to identify and Health Organization 2011), they are fragmentary
dene successful outcomes beyond the cessation and largely unfunded. It is sometimes easy for
of abuse. APS caseworkers and older adults some- those in the eld to become discouraged. And
times hold different views of the underlying yet a look back over the past 35 years nds reason
causes of abuse (Payne 2011), suggesting they to be optimistic. For example, in 2002, the
might perceive outcomes differently. Victim sat- Toronto Declaration on the Global Prevention of
isfaction with an APS intervention is largely Elder Abuse called on all countries to take action
unknown. However, one study found that the ser- to prevent and ameliorate elder abuse. Many
vices most frequently offered (social services) countries recognize the plight of abused older
were not the type of service that had the greatest adults and are taking steps to respond. In the
impact (legal) on the abusive situation (Alon and USA, for example, the Elder Justice Act (Pub.
Berg-Warman 2014). In this evidence-based L. 111148, 124 Stat. 119) was passed in 2009,
driven world, APS is going to have to go under the rst federal legislation devoted exclusively to
the microscope. elder abuse.
One practice that is growing in prominence As recommended by the World Health Orga-
across countries is responding to elder abuse nization, the adoption of a public health approach
cases through multidisciplinary teams (MDTs) can facilitate a countrys ability to prevent and
(Brandl et al. 2007). Rooted in the biopsychosocial ameliorate elder abuse. However, in the absence
model, an MDT simply refers to a group of of a substantial investment in resources this edg-
people bound by a common purpose, typically ing eld will continue to falter. Whether elder
comprised of ve features: sharing, partnership, abuse has reached the level of a social problem
interdependency, power, and process. MDTs pro- in any country worthy of such investment remains
mote the inclusion of professionals historically dubious. However, in time society may look back
absent from societys formal response to elder and characterize this period as the turning point
abuse, for example, psychologists to conduct neu- for many countries in the development of the eld
ropsychological evaluations. Although the concept of elder abuse.
Eldercare and Work 737
Cross-References adults: U.S. Preventive Services Task Force recommen-

dation statement. Annals of Internal Medicine, 160(11),
791797.
Behavioral and Psychological Symptoms of OKeeffe, M., Hills, A., Doyle, M., McCreadie, C.,
Dementia Scholes, S., Constantine, R., Tinker, A., Manthorpe,
Caregiving and Carer Stress J., Biggs, S., & Erens, B. (2007). UK study of abuse
Social Support and Aging, Theories of and neglect of older people. Prevalence study report.
London: Kings College London and National Centre
for Social Research.
Payne, B. K. (2011). Crime and elder abuse: An integrated
References perspective (3rd ed.). Springeld: Charles C. Thomas.
Phelan, A. (2013). International perspectives on elder
Alon, S., & Berg-Warman, A. (2014). Treatment and pre- abuse. New York: Routledge. E
vention of elder abuse and neglect: Where knowledge Teaster, P. B., Harley, D. A., & Kettaneh, A. (2014). Aging
and practice meet A model for intervention to prevent and mistreatment: Victimization of older adults in the
and treat elder abuse in Israel. Journal of Elder Abuse & United States. In H. F. Ofahengaue Vakalahi,
Neglect, 26(2), 150171. G. M. Simpson, & N. Giunta (Eds.), The collective
Bonnie, R. L., & Wallace, R. B. (Eds.). (2003). Elder spirit of aging across cultures (pp. 4164). Dordrecht:
maltreatment: Abuse, neglect, and exploitation in an Springer Netherlands.
aging America. Washington, DC: The National Acad- World Health Organization (WHO). (2002a). Chapter 5.
emies Press. Abuse of the elderly. In World report on violence and
Brandl, B., Dyer, C. B., Heisler, C. J., Otto, J. M., Stiegel, health. Geneva: World Health Organization.
L. A., & Thomas, R. W. (2007). Elder abuse detection World Health Organization (WHO). (2002b). Missing
and intervention: A collaborative approach. New voices: Views of older persons on elder abuse:
York: Springer. A study from eight countries: Argentina, Austria,
Doerner, W. G., & Lab, S. P. (2015). Victimology (7th ed.). Brazil, Canada, India, Kenya, Lebanon and Sweden.
Newark: Lexis Nexis Matthew Bender. http://www.who.int/ageing/projects/elder_abuse/missing_
Dong, X., Chen, R., & Simon, M. A. (2014). Elder abuse voices/en/. Retrieved 2 Sept 2015.
and dementia: A review of the research and health World Health Organization (WHO). (2011). European
policy. Health Affairs, 33(4), 642649. report on preventing elder maltreatment. Geneva:
Factora, R. M. (2014). Aging and money: Reducing risk of World Health Organization.
nancial exploitation and protecting nancial
resources. New York: Springer.
Gil, A. P. M., Kislaya, I., Santos, A. J., Nunes, B., Nicolau,
R., & Alexandre Fernandes, A. (2014). Elder abuse in
Portugal: Findings from the rst national prevalence Eldercare and Work
study. Journal of Elder Abuse & Neglect. doi:10.1080/
08946566.2014.953659.
Jackson, S. L. (2014). All elder abuse perpetrators are not Lisa Calvano1 and Josie Dixon2
1
alike: The heterogeneity of elder abuse perpetrators and West Chester University of Pennsylvania, West
implications for intervention. International Journal of Chester, PA, USA
Offender Therapy and Comparative Criminology. 2
doi:10.1177/0306624X14554063.
London School of Economics and Political
Jackson, S. L. (2015). The vexing problem of dening Science, London, UK
nancial exploitation occurring in domestic settings.
Journal of Financial Crime, 21(1), 6378.
Johannesen, M., & LoGiudice, D. (2013). Elder abuse:
A systematic review of risk factors in community-
Synonyms
dwelling elders. Age & Ageing, 42(3), 292298.
Kosberg, J. I. (2014). Reconsidering assumptions regard- Elder care; Informal care; Parent care
ing men as elder abuse perpetrators and as elder abuse
victims. Journal of Elder Abuse & Neglect, 26(3),
207222.
Moyer, V. A. (2013). Screening for intimate partner vio- Definition
lence and abuse of elderly and vulnerable adults:
U.S. Preventive Services Task Force recommendation Eldercare is informal and unpaid care provided by
statement. Annals of Internal Medicine, 158(6),
478486.
family and friends that includes meeting a variety
Moyer, V. A., & U.S. Preventive Services Task Force of physical, emotional, household, and nancial
(2014). Screening for cognitive impairment in older needs. Caregiving can be divided into two broad
738 Eldercare and Work
categories: hands-on activities, such as feeding, (Bookman and Kimbrel 2011; Fine 2012; Kossek
transporting, and dispensing medication, and et al. 2010; Meng 2013; Yang and Gimm 2013).
managerial activities, such as planning, coordinat- With a growing number of women and men
ing, and supervising formal care provided by providing informal care worldwide and careers
others (Rosenthal et al. 2007). Care recipients and caregiving responsibilities peaking at roughly
may live in their own homes with their families the same time, eldercare has emerged as an impor-
or in residential facilities such as assisted living tant issue for employers. Although balancing
communities, nursing homes, or sheltered hous- caregiving and work can be stressful, employment
ing schemes. may provide a psychological buffer. Thus,
employers have a positive role to play by creating
supportive work climates and offering workplace-
Introduction based eldercare assistance. The following sections
will highlight recent research on the relationship
As populations age around the world, an increas- between eldercare and work with a special focus
ing number of adults are working and caring for on two of the most challenging caregiving
elders at the same time. In England and Wales, situations end of life care and dementia. The
11.9% of the female population and 9% of the general impact of caregiving on caregiver health
male population provide some level of unpaid and well-being, caregiver employment outcomes,
care with as many as 1.2% of the female popula- and workplace-based eldercare assistance will be
tion and 1% of the male population providing 50 h discussed.
or more while working full time (Ofce
for National Statistics 2013). In the United
States, approximately 17% of the population Impact on Caregiver Health
takes care of older family members or friends and Well-Being
while working full or part time (National Alliance
for Caregiving 2015). Data from Australia, From a theoretical perspective, caregiver health
Canada, Israel, and the European Union show and psychological outcomes can be understood
similar patterns of caregiving and employment through the lens of a social determinants of
(Cranswick and Dosman 2008; Fine 2012; Katz health model. This model suggests that a range
et al. 2011; Viitanen 2010). Overall, three times of individual and organizational factors, as well as
more people of working age are expected to care wider societal and cultural factors, inuence
for two billion aging family members worldwide health and psychological outcomes for caregivers
by 2050 (Carers UK 2013). (Mikkonen and Raphael 2010). Salient factors
In most parts of the world, elders traditionally include gender, income, and social status; work-
lived with their families in multigenerational ing conditions; health and social services; social
households and were cared for by female relatives support networks; culture; and personal health
who did not work outside the home (Gross 2011). practices and coping strategies. One example of
While women are still the primary caregivers in a culture factor is gendered expectations of who
most families, eldercare arrangements are chang- provides care (Williams et al. 2011).
ing due to social, economic, and public policy On a practical level, caregivers tend to develop
trends. These trends include more women in the more health problems than non-caregivers, but the
workforce, an increasing number of dual career effect is generally minimal (Pinquart and
households, delayed retirements, greater geo- Srenson 2003; Vitaliano et al. 2003). However,
graphic mobility, shrinking family sizes, reduc- they are much more likely to experience increased
tion of public spending on healthcare and social psychological strain (Duxbury et al. 2011) and
services, fragmented delivery of care to the aging, higher rates of depression (Pinquart and Srenson
and a growing desire on the part of the elderly to 2003). Some possible explanations for the nega-
remain in their own homes for as long as possible tive impact of eldercare on well-being include the
role reversal of children caring for parents, care- gains such as spiritual and personal growth and
givers confronting their own mortality, and the skills acquisition (Zarit et al. 2012; Sanders
emergence of unresolved family issues (Smith et al. 2005).
2004). In addition, strong negative emotions End of life care is also physically and emotion-
such as anger, helplessness, confusion, and guilt ally demanding because caregivers undertake
may surface when eldercare responsibilities occur physical tasks, manage complex symptoms, and
because of an emergency or escalate over time as provide emotional support to a dying person while
the health of the care recipient declines (Gross simultaneously managing their own, sometimes
2011). complicated, feelings of loss and grief (Williams
Research demonstrates that certain types of et al. 2011; James et al. 2009; Mangan et al. 2003).
E
eldercare produce more stress and strain than As a result, end of life care is associated with a
others, including caring for a spouse and/or wide range of negative health and psychological
co-residing with a care recipient (Duxbury impacts (Funk et al. 2010; Stajduhar et al. 2010).
et al. 2011; Pinquart and Srenson 2003). More- For example, a cross-country European survey
over, women and individuals with fewer nancial estimates that between 28% (Belgium) and 71%
resources experience poorer outcomes no matter (Italy) of end of life caregivers were physically
where they live or for whom they care (Austen and/or emotionally overburdened during the last
and Ong 2014; Carers UK 2013; Feinberg and 3 months of the care recipients life (Pivodic
Choula 2012; Lee et al. 2001; Schroeder et al. 2014).
et al. 2012). In addition, caregivers who live in
countries with weak social safety nets experience
more stress and strain (Hansen et al. 2013). Caregiver Employment Outcomes
The most physically and emotionally demand-
ing caregiving situations entail caring for some- Employed caregivers report higher levels of stress
one with dementia or at the end of life. Dementia and work-family conict than non-caregivers, and
patients require high levels of care and supervi- employers perceive that caregivers are less pro-
sion, particularly when the syndrome is in the ductive (Keene and Prokos 2007; Zuba and
moderate to severe stages (Wimo et al. 2013). Schneider 2013). While caregivers are more likely
People with dementia may also develop neuropsy- to experience disruption in their labor force par-
chiatric ailments, including personality changes ticipation than non-caregivers, it is debatable
and mood disorders, as well as associated problem whether the stress of eldercare results in negative
behaviors. These are symptoms that are particu- work outcomes for individuals who remain in the
larly associated with burden in dementia care- workforce (Zacher et al. 2012). Moreover, care-
givers (van der Lee et al. 2014; Chiao givers who continue to work may receive a psy-
et al. 2015; Ornstein and Gaugler 2012). Given chological boost from combining the two roles.
the signicant and cumulative losses associated Labor force participation. Research from
with the dementia disease trajectory, dementia around the world shows that caregiving impacts
caregivers may also experience anticipatory and labor force participation, especially for women
pre-death grief (Lindaur and Harvath 2014). (e.g., Austen and Ong 2014; Feinberg and Choula
Furthermore, dementia caregivers tend to provide 2012; Kotsadam 2011; Liu et al. 2010). Typical
more care each month and over a longer period responses to the demands of caregiving include
(Kasper et al. 2014). As a result of these multiple dropping out of the workforce permanently,
pressures, dementia caregivers experience high reducing work hours, taking leave without pay,
rates of burden, depression and anxiety, social or retiring early (Dembe et al. 2008). Women are
isolation, physical ill health, and feelings of guilt more likely than men to leave the workforce per-
and frustration (van der Lee et al. 2014; Chiao manently. Other factors that increase the likeli-
et al. 2015; Springate and Tremont 2014), hood of exit include age, poor health, and lower
although some authors have also documented socioeconomic status (Austen and Ong 2014;
Lilly et al. 2007; Meng 2013). There is also evi- that the UK public expenditure cost of caregivers
dence that employment status is a risk factor for leaving employment is 1.3 billion per annum,
unpaid caring. Individuals not working or work- covering 1 billion of lost tax revenues and 300
ing part time are more likely to be the ones to million in Carers Allowance.
provide care compared to those working full time Work-family conict. While research consis-
(Hutton and Hirst 2000). tently shows that eldercare affects labor force
Intensity of caregiving is another factor that participation, there is less evidence to support
affects labor force participation for both women assertions that the stress of eldercare causes neg-
and men. Research in the United Kingdom shows ative work outcomes for those who remain in the
that there is a threshold effect at 10 h a week, workforce (Zacher et al. 2012). For example,
such that becoming an unpaid caregiver for 10 or employers perceive that eldercare causes
more hours a week is associated with increased employees to miss work (Katz et al. 2011). All
odds of leaving employment (King and Pickard caregivers are absent more frequently than
2013). Similarly, a Canadian study shows that non-caregivers, but employees with children
higher intensity caregiving is associated with miss more days than those taking care of elders
being fully retired for men and women aged (Boise and Neal 1996). Moreover, all caregivers
5569. For women, high-intensity caregiving is experience higher levels of time- and strain-based
also associated with working part time and being a conict than non-caregivers, but there is no dif-
labor force nonparticipant (Jacobs et al. 2014). ference between those caring for children and
Type of caregiving also affects labor force par- those caring for elders (Lee et al. 2010). However,
ticipation. A large-scale nationally representative workers who take care of elders are likely to
survey conducted by the Alzheimers Association experience more frequent interruptions during
(2014) found signicant impacts on employment the workday, most typically to make phone calls
for dementia caregivers in the United States. Sev- and accompany care recipients to appointments.
enteen percent of workers gave up their jobs This phenomenon is known as presenteeism and
before or after assuming caring responsibilities, is a consequence of the fragmented delivery
8% took early retirement, and 13% moved from of services to the elderly, which require
full- to part-time employment. Parallel research in caregivers to coordinate care from multiple pro-
the United Kingdom estimates that 21% of people viders (Smith 2004). As with gendered outcomes
caring for someone with dementia leave their jobs for labor force participation, the impact of
and 29% reduce their working hours (Centre for eldercare on absenteeism and presenteeism is
Economic and Business Research 2014). End of greater for women, as well as workers in
life caregivers are nearly 5% more likely to reduce low-skill and low-status jobs (Austen and Ong
their work hours than individuals caring for elders 2014; Katz et al. 2011; Lee 1997; Zuba and
with a long-term, chronic condition (Williams Schneider 2013).
et al. 2014). Employees with the most challenging
Caregivers who reduce their hours or leave the caregiving responsibilities experience the most
workforce entirely incur long-term nancial pen- work-family conict and work disruptions. For
alties in terms of lost wages and benets and example, in the United States 54% of employees
reduced retirement savings (Feinberg and Choula taking care of dementia patients reported
2012). In addition, employers can incur costs unplanned absences from work, 15% took
because they will have invested resources to planned leave, and 8% saw their work perfor-
train and develop these employees. Many care- mance suffer to point of being worried about
givers who leave the labor market will have valu- dismissal (Alzheimers Association 2014). In the
able skills and experience because they are United Kingdom, as many as 6.6% end of life
concentrated in the 4564 age range (Carers UK caregivers missed full days at work compared
2013). Finally, there are public expenditure impli- those caring for someone with a long-term,
cations. For example, Pickard (2012) estimated chronic condition (Williams et al. 2014).
Work as a buffer. Employed caregivers gen- benets and the difculty measuring effectiveness
erally report better health than unemployed care- as hindrances to providing assistance (Katz
givers. This phenomenon may occur because et al. 2011).
employment is a protective factor or because the Workplace-based eldercare assistance can be
caregivers with the poorest health are those least divided into three broad categories: compliance
able to work (Cannuscio et al. 2004). Neverthe- with family leave laws, formal employer-
less, research indicates that work may be a pro- sponsored services and benets, and informal
tective factor because it bolsters a caregivers support from managers and supervisors. Legal
sense of efcacy, provides a sense of accomplish- compliance is the most basic level of assistance
ment, increases nancial resources, and expands that employers provide. If employers offer formal
E
support networks and opportunities for respite benets, they usually take the form of informa-
(Utz et al. 2012; Zuba and Schneider 2013). tion, education, and referral programs. In the
Two contrasting theories from the work-family United States, these would typically be available
literature explain how successfully (or not) individ- through Employee Assistance Programs (EAPs).
uals balance eldercare and work. Scarcity theory Some employers may go as far as offering exible
posits that an individual has a limited amount of hours and paid leave, as well as subsidies for
time and energy for which caregiving and work respite and emergency care (Dembe 2008). Flex-
compete (Marks 1977). On the other hand, role ibility is both the most desired benet and most
enhancement theory says that the benets of one benecial in terms of reducing caregiver burden,
role spillover into the other, creating a net gain but access varies greatly across countries, indus-
(Greenhaus and Powell 2006). Reid et al. (2010) tries, organizations, and job categories. For exam-
studied which of these theories more accurately ple, in the United States exible work hours are
predicts employee behavior and found that the available primarily to professional and managerial
results vary greatly from individual to individual employees (Sweet et al. 2014).
with some employed caregivers indicating that Even when employers offer eldercare benets,
work enhances their well-being while others saying employees frequently do not utilize them either
that it adds to their stress. Reid et al. (2010) con- because they are not aware of their existence or
clude that an individuals subjective perception of they worry about being stigmatized if they dis-
the degree to which eldercare interferes with work close their care duties (Dembe et al. 2008). Fear of
is more predictive of role conict and other nega- stigmatization is a particular concern for
tive outcomes than more objective measures. employees with the greatest caregiver burden.
For example, the lack of understanding that still
exists around dementia means that people may
Workplace-Based Eldercare Assistance feel uncomfortable about mentioning their care
responsibilities at work. This may prevent them
Although employer support has been shown to from seeking the support they need. Therefore,
reduce work-family conict and caregiver burden employers need to take active steps to ensure
(Zacher and Winter 2011), research on the avail- that all employees are made aware of workplace-
ability and effectiveness of workplace-based based assistance. Employers may also participate
eldercare assistance is sparse (Kelly et al. 2014). in dementia-friendly initiatives designed to
In general, a countrys public policy context is a reduce the stigma of dementia, including the
major determinant of how active private UKs dementia-friendly workplace initiative
employers are in this area. In countries with (Alzheimers Society 2015).
weaker family leave laws and welfare policies, End of life caregivers may require compassion-
private employers are more likely to provide assis- ate or family-friendly leave, in addition to
tance, but it is usually limited to the largest com- bereavement leave due to the intensity and trajec-
panies and certain employees (Dembe et al. 2008; tory of care (Vuksan et al. 2012). Psycho-
Yang and Gimm 2013). Employers cite the cost of educational interventions for end of life caregivers
may improve coping and help to reduce distress Boise, L., & Neal, M. B. (1996). Family responsibilities
and burden (Hudson et al. 2013). In turn, reducing and absenteeism: Employees caring for parents versus
employees caring for children. Journal of Managerial
caregiver burden and distress can support death at Issues, 8(2), 218238.
home rather than in hospital (Visser et al. 2004). Bookman, A., & Kimbrel, D. (2011). Families and
eldercare in the twenty-rst century. The Future of
Children, 21(2), 117140.
Cannuscio, C. C., Colditz, G. A., Rimm, E. B., Berkman,
Conclusion L. F., Jones, C. P., & Kawachi, I. (2004). Employment
status, social ties and caregivers mental health. Social
With populations aging around the world, more Science and Medicine, 58, 12471256.
and more adults will nd themselves juggling Carers UK. (2013). Supporting working carers: The bene-
ts to families, business and the economy. London:
eldercare and work responsibilities. In order to Author.
minimize stress, maximize well-being, and ensure Centre for Economic and Business Research. (2014). The
that caregivers can continue working as long as economic cost of dementia to english businesses.
they want, forward-thinking employers with the London: Author.
Chiao, C. Y., Wu, H. S., & Hsiao, C. Y. (2015). Caregiver
help of governments and the voluntary burden for informal caregivers of patients with demen-
sector should take the lead in developing crea- tia: A systematic review. International Nursing Review.
tive and effective eldercare policies and programs doi:10.1111/inr.12194.
to assist all employees. In order to create aging- Cranswick, K., & Dosman, D. (2008). Eldercare: What we
know today. Canadian Social Trends, 94, 4957.
friendly societies and workplaces, Bookman and Dembe, A. E., Dugan, E., Mutschler, P., & Piktialis,
Kimbrel (2011) argue that a large-scale, cross- D. (2008). Employer perceptions of elder care assis-
sector initiative is needed to coordinate tance programs. Journal of Workplace Behavioral
efforts. . .to support all citizens from diverse cul- Health, 23(4), 359379.
Duxbury, L., Higgins, C. & Smart, R. (2011). Elder care
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Feinberg, L., & Choula, R. (2012). Understanding the
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Definition
groups in Canada: End-of-life care, long-term care
and short-term care. Health and Social Care in the Electroconvulsive therapy (ECT) is a neurosti-
Community, 22(2), 187196. mulation intervention used to treat severe neuro-
Wimo, A., Jnsson, L., Bond, J., Prince, M., & Winblad,
psychiatric diseases, such as major depressive
B. (2013). The worldwide economic impact of demen-
tia 2010. Alzheimers and Dementia, 9(1), 111.e3. disorder, bipolar disorder, and schizophrenia. To
Yang, Y. T., & Gimm, G. (2013). Caring for elder perform ECT, while the patient is under anesthe-
parents: A comparative evaluation of family leave sia, controlled electrical stimuli are applied to the
laws. Journal of Law, Medicine and Ethics, 41(Sum-
brain via two electrodes that are placed on select
mer), 501513.
Zacher, H., & Winter, G. (2011). Eldercare demands, areas of the scalp to generate a therapeutic tonic-
strain, and work engagement. Journal of Vocational clonic seizure. The generated seizure tends to be
Behavior, 79, 667680. time limited and results in both motoric (typically
Zacher, H., Jimmieson, N. L., & Winter, G. (2012). Elder-
the foot) and electroencephalographic manifesta-
care demands, mental health, and work performance.
Journal of Occupational Health Psychology, 17(1), tions. To result in therapeutic efcacy, a typical
5264. ECT course includes on average between eight
Electroconvulsive Therapy 745
and fourteen sessions that are administered either Practice of Electroconvulsive Therapy
two to three times per week. There are no absolute
contraindications to ECT, but patients undergo Neuropsychiatric practices across the globe,
comprehensive medical and neuropsychiatric including the United States, employ ECT
examinations before undergoing treatment and (American Psychiatric Association 2008).
are monitored by an interdisciplinary care team Though there have been no formal epidemiologic
during and immediately after the treatment. studies on the use of ECT, it is estimated that
Though ECT tends to be medically safe, it can approximately one million people worldwide are
result in transient adverse effects including treated with ECT. In the United States, the number
headaches, body aches, and importantly cognitive of people treated with ECT is estimated to be
E
difculties. Regarding the latter, the cognitive approximately 100,000 annually. Across the
difculties include disorientation, decreased United States, the practice of ECT varies due to
processing speed, anterograde amnesia, retro- various mental health laws, as in certain states its
grade amnesia, verbal dysuency, and executive use is restricted to certain patients (e.g., patients
dysfunction. Despite these transient adverse aged 17 and older). A main factor that limits the
effects, ECT has been found to be one of use of ECT is the negative stigma associated with
the most effective neuropsychiatric treatments, it secondary to its associated side effects (e.g.,
particularly for major depressive disorder. Due retrograde amnesia, anterograde amnesia). Also,
to its usefulness when other neuropsychiatric after the publication of the National Institute for
treatments fail, modern neuropsychiatric practice Health and Care Excellence (NICE) guidelines
continues to employ ECT. (National Institute for Health and Care Excellence
2003), which resulted in more stringent practice
parameters, the use of ECT has decreased in the
Introduction United Kingdom. Nonetheless, ECT has a global
presence and its use may increase as more people
Introduced in the late 1930s, electroconvulsive are diagnosed with neuropsychiatric diseases, par-
therapy (ECT) is one of the oldest, most durable, ticularly when they are nonresponsive to other
and effective neurostimulation therapies in the treatments.
neuropsychiatric armamentarium (American Psy- Clinical indications (see Table 1) for ECT
chiatric Association 2008). Initially developed for include MDD, bipolar disorder, schizophrenia,
schizophrenia or other psychotic disorders based and catatonia (Mankad et al. 2010). For MDD,
on the false assumption that seizures and psycho- ECT tends to be reserved when other treatments
sis were unable to coexist, ECT has since been fail, and the illness is chronic, severe, and life-
found to be highly effective for major depressive threatening. For bipolar disorder, ECT is useful
disorder (MDD). Over the past two decades, for both the manic and depressive episodes and is
numerous clinical investigations sponsored by indicated when other treatments fail to abate the
the National Institute of Mental Health have
informed the development and renement of Electroconvulsive Therapy, Table 1 Neuropsychiatric
ECT (Fink 2014; Lisanby 2007). Such rene- indications for electroconvulsive therapy
ments have helped to minimize the side effects Behavioral disturbances of dementia (intractable to other
of ECT while maximizing the clinical benets treatments)
(McClintock et al. 2014). Indeed, despite the Bipolar disorder
introduction of other neuropsychiatric treatments Catatonia
including pharmacotherapeutics, psychotherapy, Epilepsy (intractable to other treatments)
and transcranial magnetic stimulation, ECT con- Major depressive disorder
tinues to be used in psychiatric practice as it tends Parkinsons disease (intractable to other treatments)
to be relatively safe and effective in cases where Schizoaffective disorder
other treatments fail. Schizophrenia
bipolar symptoms. For schizophrenia, ECT is Electroconvulsive Therapy, Table 2 Electroconvulsive

indicated when other treatments are ineffective therapy parameters
and may be useful for both the positive and neg- Domain Specic parameter
ative symptoms. For catatonia, ECT is indicated Stimulus waveform Sine wavea
as a rst-line treatment, though it tends to be Brief pulse
Ultra brief pulse
reserved until other treatments are determined to
Electrode conguration Bitemporal
be ineffective. Among these four clinical indica- Bifrontal
tions, ECT has been found most useful for MDD Right unilateral
and catatonia. Left unilaterala
Electrical dosage strategy Empirical dose titration
Age method
Half-age method
Administration of Electroconvulsive Pulse amplitude 500 mA
Therapy 600 mA
700 mA
An interdisciplinary healthcare team is needed to 800 mA
900 mA
administer ECT (American Psychiatric Associa-
mA milliamperes
tion 2008; Mankad et al. 2010). Such disciplines a
Sine wave pulse width is no longer used in modern ECT
include (in alphabetical order) anesthesiology, practice due to its associated adverse cognitive effects, and
clinical neuropsychology, clinical psychology, left unilateral electrode conguration is rarely used in
nursing, psychiatry, and social work. Before modern ECT practice
patients commence with ECT, they must undergo
a comprehensive medical and neuropsychiatric
examination to ensure that ECT is appropriate pulse, blood pressure, respiration, EKG, and elec-
and safe. Components of the examination include troencephalography (EEG)) by the treatment team
a general medical and physical work-up, anesthe- (American Psychiatric Association 2008; Mankad
siology work-up, neuropsychiatric history includ- et al. 2010).
ing prior and current treatments, and global To administer ECT, four treatment parameters
cognitive status examination. As needed, other (Table 2) can be adjusted to provide maximum
medical work-ups may be recommended includ- clinical outcome and minimize adverse effects.
ing electrocardiogram (EKG), x-ray (such as These parameters include stimulus waveform,
chest, spine, and head magnetic resonance imag- electrode conguration, electrical dosage
ing (MRI) or computerized tomography (CT)), (American Psychiatric Association 2008), and
and neurological examination. pulse amplitude (Peterchev et al. 2015). Although
Once a patient is cleared for ECT, the treatment the initial stimulus waveform was sinusoidal (sine
team will provide education to the patient (and wave), that waveform is no longer used and
his/her care partner) about the ECT treatment modern-day ECT devices no longer carry this
process, perform informed consent procedures option due to its adverse cognitive effects. Both
that will occur before the rst ECT session and brief and ultra-brief pulse waveforms have been
continue throughout the ECT course, and estab- found to be efcacious, and research suggests that
lish the ECT protocol to be used for the patient. the latter may have a more benign cognitive
During the provision of ECT, safety is a top pri- adverse effect prole (Tor et al. 2015). The initial
ority. Before initiation of each ECT session, the application of ECT employed bitemporal elec-
patient is administered anesthetic agents to cause trode conguration, and thus, it is sometimes
muscle relaxation (minimizes motoric seizure called the gold standard. However, research
expression) and sedation (minimizes the treatment has suggested that electrode placement along
experience), a bite block is placed in the mouth to with bifrontal and right unilateral electrode con-
protect the teeth and tongue, and the patient is guration when properly dosed is equivalent with
closely and continuously monitored (including regard to clinical outcome but that the latter two
placements may have less cognitive adverse take up to 8 or 12 weeks to achieve remission,
effects (Kellner et al. 2010). In another electrode ECT results in a rapid onset of action with remis-
conguration, left unilateral has rarely been sion on average being achieved in approximately
employed in clinical ECT practice due its adverse 34 weeks (Spaans et al. 2015). Such rapid rate of
cognitive effects particularly with verbal cogni- response and remission is critical for patients,
tive functions. particularly when the MDD is life-threatening
When providing the stimulus for the ECT ses- such as in cases of MDD with catatonia.
sion, two stimulus dosing methods are used The antidepressant effects of ECT apply to a
including the age and empirical dose titration broad range of depressive symptoms including
methods. For the age method, dose is adjusted melancholic and atypical features, psychosis, sui-
E
based on the age of the patient, with younger cidal ideation, and catatonia. Importantly, ECT is
and older patients treated with lower and higher safe and efcacious for populations in which med-
doses, respectively. For the empirical dose titra- ications may prove to be harmful. For instance,
tion method, a stimulus is applied at the lowest ECT is useful in elderly adults with MDD as there
dose necessary to produce a tonic-clonic seizure. are no medication-medication adverse interac-
While the age method tends to generalize the tions. Also, ECT can be useful for women with
stimulus dose across age groups and the empirical perinatal depression as research has found it to be
dose titration method individualizes the dosage, safe for both the woman and the developing fetus.
both have been found to be safe and efcacious Unfortunately, relapse after acute treatment
(Mankad et al. 2010). An ECT parameter that has can be high, especially in cases where there is no
received more recent attention is the pulse ampli- continuation or maintenance treatment protocol
tude. Current ECT devices usually have the pulse (Fink 2014; Lisanby 2007). Research continues
amplitude automatically set at 800 or 900 mA, and to be ongoing to nd optimal strategies to prolong
many clinics rarely adjust the amplitude. Some remission post the acute course including contin-
computational and pilot evidence suggested that uation ECT, continuation pharmacotherapy, con-
decreasing the pulse amplitude down to 500 mA tinuation combined ECT and pharmacotherapy,
could result in an efcacious treatment with continuation cognitive behavior therapy, and con-
benign cognitive adverse effects (Peterchev et al. tinuation depressive symptom-titrated ECT.
2015). However, the current evidence base is
lacking to justify altering pulse amplitude in clin-
ical practice. Efficacy in Elderly Adults
Electroconvulsive therapy is considered an impor-

Efficacy tant treatment in elderly patients with depression.
This is the case as elderly adults frequently require
While published rates of ECT antidepressant ef- treatment with a rapid onset as they may present
cacy have been found to vary with as low as 20% with greater depressive symptom severity (e.g.,
and as high as 80% remission rates due to vari- agitation, psychosis) and higher suicide risk and
ability in ECT practice and patient populations, potentially may respond more slowly to antide-
when judiciously employed following evidenced- pressant medication. Research has found that
based practices, ECT is a highly safe and efca- elderly adults with depression show rapid
cious treatment (Fink 2014; Trevino et al. 2010). response and remission with ECT. For example,
Indeed, among all neuropsychiatric antidepres- a study that compared outcomes from elderly
sant strategies and in cases where antidepressant patients who participated in a randomized con-
treatments have been ineffective, ECT has the trolled trial (RCT) for different antidepressant
highest efcacy rate with concordant large remis- medications with outcomes from another RCT
sion rates. Relative to psychotherapeutic and conducted in patients who received different
pharmacotherapeutic strategies that can at times forms of ECT found that both speed of remission
(mean time to remission for ECT group 3 weeks appropriate anesthetic and cardiovascular man-
vs. 4 weeks for medication) and remission rates agement, evidence suggests that ECT can be
(63% ECT group vs. 33% in the medication administered safely even in elderly adults with
group) were superior with ECT. After adjustment premorbid cardiovascular conditions when appro-
for clinical and demographic differences, the ECT priate precautions are put in place. For example, a
group was also eight times more likely to achieve retrospective review of the medical records of
remission compared to the medication group after 35 elderly patients with a history of heart failure
5 weeks of treatment (Spaans et al. 2015). and reduced ventricular heart function found that
ECT was safe, with no reported adverse effects
(Rivera et al. 2011). Similarly, a case report of the
Adverse Effects oldest person (100 years old) to receive ECT who
had severe aortic stenosis reported no cardiac
Electroconvulsive therapy is considered a safe complications over an extended period of ECT
procedure in the elderly, although not unlike any treatment that spanned 5 years (OReardon et al.
other medical procedure, there is the potential risk 2011).
for adverse effects (Table 3). These risks, how- An additional adverse effect relevant to the
ever, can be minimized through careful medical elderly is increased risk of falls from ECT.
work-up, optimally by a multidisciplinary team However, it is important to note that falls are
composed of different specialists (e.g., anesthe- common in psychiatric settings, particularly
tist, cardiologists, psychiatrist, etc.). This is par- among patients considered the older-old and
ticularly important for the elderly, who frequently those with medical comorbidities (e.g., motor
have medical comorbidities. Of these, preexisting dysfunction and cognitive impairment). A retro-
cardiac conditions pose the most signicant risk spective analysis of records from 1834 admissions
for adverse effects, including death. During ECT, to a psychogeriatric inpatient unit identied ECT
the cardiovascular system is placed under as a signicant risk factor after controlling for
increased stress due to activation of the sympa- other confounders, including age, medication
thetic autonomic system that results in tachycar- use, Parkinsons disease, and dementia (de Carle
dia, hypertension, and increased oxygen et al. 2001). Falls were additionally found to be
consumption. In modern ECT practice, with more common during the day, which was consid-
ered to be potentially associated with short-term
Electroconvulsive Therapy, Table 3 Adverse effects cognitive side effects. As such, it is recommended
associated with electroconvulsive therapya to use select ECT parameters to minimize cogni-
Neurocognitive adverse tive side effects in elderly patients, as well as
Medical adverse effects effects implementation of other precautions, such as
Headache Decreased processing speed increased surveillance.
Migraine Disorientation A less common adverse effect is dental and oral
Myalgia (e.g., body Executive dysfunction injury due to clenching of the jaw from direct
aches)
stimulation of the masseter muscles. These types
Inattention
Memory disruption
of adverse events are rare and typically mild. Risk
Anterograde amnesia is increased with dental pathology prior to treat-
Retrograde amnesia ment, which can be identied and potentially mit-
Verbal dysuency igated via pretreatment medical work-up.
a
Most adverse effects associated with electroconvulsive
therapy (ECT) tend to be transient. The medical
adverse effects tend to dissipate 2448 h after treatment
and can be managed with over-the-counter medication.
Medical Effects
The neurocognitive adverse effects tend to dissipate within
1 week after the last ECT session, though some effects have Other common medical effects associated with
been found to persist up to 6 months ECT include somatic discomfort (e.g., headache,
muscle soreness, nausea) and postictal delirium. Neurocognitive Effects

The most common medical side effect of ECT is
headache, which commonly occurs during and Cognitive side effects from ECT are frequently the
following postictal recovery. An audit of subjec- most signicant concern for patients and typically
tive side effects reported by 70 patients who manifest in short-term decits in orientation during
received ECT found that 11% of patients reported postictal recovery immediately following ECT,
experiencing a severe headache, while 44% memory (anterograde and retrograde), executive
reported a mild or moderate headache (Benbow function, and processing speed. Elderly patients
et al. 2004). Somatic complaints, including head- treated with ECT may have poorer baseline cogni-
ache, are however common in depressed tive functioning due to age and illness, which
E
patients prior to ECT, which therefore makes it potentially may confound the interpretation of cog-
difcult to determine their etiology. For exam- nitive side effects in this population (McClintock et
ple, a study conducted in elderly patients found al. 2011). In contrast to research on the cognitive
that approximately 20% of patients reported side effects of ECT in relatively younger adult
headache prior to treatment and that this propor- populations, research ndings to date have been
tion showed a nonsignicant increase following mixed in regard to the extent in which elderly
ECT treatment (Brodaty et al. 2001). Headaches patients experience cognitive side effects.
during ECT are typically managed through pro- Recovery of orientation immediately follow-
phylaxis with analgesic medications, or treated ing ECT, typically assessed at regular intervals
symptomatically. Muscle soreness/pain and nau- during recovery, has been identied as a predictor
sea are also common. Muscle pain due to ECT of retrograde memory side effects from ECT
is considered to be caused by the actions of the (Sobin et al. 1995). Monitoring of recovery of
muscle relaxant (succinylcholine) or alterna- orientation during the ECT course has therefore
tively through excessive convulsive movements been recommended to assist ECT practitioners
during treatment. In the case of the former, this with identifying patients at increased risk for
is managed with prophylaxis using analgesic these side effects. Importantly, increased age has
medications, while the latter can be addressed been associated with longer time to reorientate
through an increased dose of muscle relaxant. midway during the ECT course (Martin et al.
Nausea in contrast may occur as a side effect of 2015). Older age, therefore, may be a vulnerabil-
general anesthesia and is typically managed ity factor for increased memory side effects with
with antiemetics. increased number of ECT treatments.
Postictal delirium is also known to occur in a Research into other ECT-related cognitive side
minority of patients and is characterized by motor effects in elderly patients, however, has been
agitation, disorientation, and sometimes erratic mixed and shown stability, impairment, or
behavior. Correspondingly, it poses a risk for improvement in cognitive performance on mea-
injury for both patient and staff. A retrospective sures including tests of global cognitive function-
case-controlled study of 24 patients who experi- ing, memory, and executive function (Tielkes
enced postictal delirium and 24 controls failed to et al. 2008). For example, a recent study
identify any relevant clinical or treatment differ- conducted in 62 elderly patients (aged 6085
ences between groups, including age (Devanand years) found no signicant changes in perfor-
et al. 1989). A more recent study similarly was mance on measures of anterograde and retrograde
unable to identify any predictors, other than a memory, processing speed, and executive func-
potential association with seizure length (Reti tion following ECT compared to healthy elderly
et al. 2014). Thus, while older age is considered controls, although the ECT patients were found to
a risk factor for delirium in other settings, it perform poorer on a test of verbal uency at post
remains unclear whether elderly patients are sim- treatment compared to controls (Dybedal et al.
ilarly at increased risk for delirium after treatment 2014). In contrast, another recent study in
with ECT. 42 patients aged 5891 years found signicant
improvements in global cognitive function and Administration (FDA), it convened an advisory

anterograde memory but no changes on measures panel hearing in January 2011 to discuss the
of attention and executive function following reclassication of ECT. Following that advisory
ECT (Verwijk et al. 2014). panel meeting, the FDA released a draft of a
Potential reasons for these mixed results may guidance document (Center for Devices and
include heterogeneity in ECT treatment method- Radiological Health document number 1823) in
ologies (e.g., electrode montage, dosing method, December 2015 that outlined their recommenda-
pulse width, frequency of treatment, and choice of tions for ECT reclassication (US Food and Drug
anesthesia), cognitive assessment methods (i.e., Administration, 2015). Per the document, the
brief screening compared to more detailed neuro- FDA suggested that ECT should be reclassied
psychological assessment), and time of cognitive into Class II for patients age 18 and older with a
testing in relation to the last ECT treatment. The diagnosis of MDD or bipolar disorder. A device
latter is potentially important as cognitive side classied into Class II represents a high-risk
effects tend to resolve within a few weeks follow- device that requires special controls to ensure
ing treatment (Semkovska et al. 2010). It is also device safety and utility. While such reclassi-
possible that reported cognitive ndings in the cation will allow greater access to ECT for
elderly may be unduly biased due to the study patients age 18 and older with MDD or bipolar
cohorts. For example, elderly cohorts tend to disorder, it by default suggests that ECT will be
have relatively higher proportion of involuntary reclassied into Class III for all patients with other
patients who may be unable to participate in cog- diagnoses. A Class III device is considered to be
nitive testing. Moreover, research studies often of the highest risk and has the greatest level of
exclude patients who are at greater risk for delir- regulatory control. As such, patients younger than
ium (i.e., who are cognitively impaired at base- age 18 or those with neuropsychiatric diagnoses
line), which in turn may underestimate overall other than MDD or bipolar disorder in whom ECT
cognitive side effects. This is potentially impor- has been found to be safe and useful may nd it
tant, as patients with higher educational and occu- more difcult to be prescribed ECT.
pational attainment (i.e., increased cognitive The FDA also provided other recommendations
reserve) are less likely to show cognitive side in the guidance document. Regarding the practice
effects following ECT (Legendre et al. 2003). of ECT, the document suggested the use of brief
Thus, while the extent to which elderly patients pulse waveform, unilateral electrode conguration
experience cognitive side effects from ECT on the non-dominant hemisphere (e.g., right unilat-
remains unclear, given the vulnerabilities in this eral), decreased stimulus intensity particularly with
patient population (e.g., increased prevalence of bitemporal electrode conguration, and two ECT
cardiac comorbidities, cognitive impairment, sessions or less per week. As current ECT clinical
severe illness), it is recommended to implement practice has no mandated clinical neuropsycholog-
careful patient monitoring of cognitive side effects ical assessment, the FDA recommended that clini-
during ECT treatment. Also, use of ECT treatment cians monitor cognitive function before the
methods associated with lesser cognitive side initiation of and during the ECT course. The clin-
effects (e.g., ultra-brief pulse width, lesser fre- ical neuropsychological assessment should include
quency treatment) should also be considered for both patient self-report and observer-report of cog-
elderly patients who at potential increased risk. nitive function. As ECT has been found to produce
transient adverse cognitive effects, the FDA pro-
posed that the label for ECT devices include the
US Food and Drug Administration following warning: Warning: ECT device use
Recommendations may be associated with: disorientation, confusion,
and memory problems.
As ECT was grandfathered in and never formally As the guidance document is in review at this
approved or cleared by the US Food and Drug time and the FDA has invited comments from the
US community, it is unclear at this time which electroconvulsive therapy in elderly depressed patients.
recommendations, if any, in the guidance docu- The Clinical Neuropsychologist, 28(7), 10711090.
Fink, M. (2014). What was learned: Studies by the consor-
ment will be put into clinical practice. Given the tium for research in ECT (CORE) 19972011. Acta
safety and utility of ECT in patient populations Psychiatrica Scandinavica, 129, 417426.
where other treatments are intolerable or ineffec- Kellner, C. H., Tobias, K. G., & Wiegand, J. (2010). Elec-
tive, the restriction of its use could prove prob- trode placement in electroconvulsive therapy (ECT):
A review of the literature. Journal of ECT, 26,
lematic for the medical and neuropsychiatric 175180.
communities. Legendre, S. A., Stern, R. A., Solomon, D. A., Furman,
M. J., & Smith, K. E. (2003). The inuence of cognitive
reserve on memory following electroconvulsive ther-
Future Directions apy. The Journal of Neuropsychiatry and Clinical Neu- E
rosciences, 15(3), 333339.
Lisanby, S. H. (2007). Electroconvulsive therapy for
Being one of the oldest, though with modern depression. New England Journal of Medicine, 357,
technical and practice updates, most efcacious, 19391945.
and relatively safe neurostimulation interventions, Mankad, M. V., Beyer, J. L., Krystal, A., & Weiner, R. D.
(2010). Clinical manual of electroconvulsive therapy.
ECT has earned its place in the neuropsychiatric
Arlington: American Psychiatric Publishing.
armamentarium. With the recent recommenda- Martin, D. M., Galvez, V., & Loo, C. K. (2015). Predicting
tions from the US FDA, the practice of ECT retrograde autobiographical memory changes follow-
may change with new practice guidelines. ing electroconvulsive therapy: Relationships between
individual, treatment, and early clinical factors. The
Regardless of the nal US FDA recommenda-
International Journal of Neuropsychopharmacology,
tions, future research is warranted to understand 18(12).
the mechanisms of action underlying the efcacy McClintock, S. M., Staub, B., & Husain, M. M. (2011).
and side effects of ECT. Further, research is The effects of electroconvulsive therapy on
neurocognitive function in elderly adults. Annals of
warranted to integrate ECT with other neuropsy-
Long Term Care, 19, 3238.
chiatric interventions (e.g., psychotherapy, McClintock, S. M., Choi, J., Deng, Z. D., Appelbaum,
transcranial direct current stimulation) to mini- L. G., Krystalm, A. D., & Lisanby, S. H. (2014). Mul-
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cognitive performance associated with electroconvul-
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(2015). Speed of remission in elderly patients with levels (physiological, subjective-experiential,
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A review of continuation electroconvulsive therapy:
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and Radiological Health. (2015). Electroconvulsive
therapy (ECT) devices for class II intended uses. individuals general subjective well-being and
Draft guidance for industry, clinicians, and food and prominent indicator of successful aging, increas-
drug administration staff. Rockville: Food and Drug ingly thought to play a central role throughout the
Administration. life span in a wide range of areas involved in
Verwijk, E., Comijs, H. C., Kok, R. M., Spaans, H. P.,
Tielkes, C. E., Scherder, E. J., et al. (2014). Short- human functioning (Kahneman et al. 1999). Per-
and long-term neurocognitive functioning after electro- haps one of the most important ndings in psy-
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26(2), 315324.
of the adult life span and early old age, although
many individuals experience an increasing num-
ber of losses in cognitive, physical, and social
Emotional Development in Old Age domains. Prominent theories of emotional aging
have suggested that this discrepancy results from
Ute Kunzmann1 and Carsten Wrosch2 older adults high emotional competence, partic-
1
Life-Span Developmental Psychology ularly the effectiveness of their emotion regula-
Laboratory, University of Leipzig, Leipzig, tory strategies (Scheibe and Carstensen 2010). In
Germany recent years, however, at least three qualications
2
Concordia University, Montreal, QC, Canada to what has been called the stability-despite-loss
paradox of subjective well-being have been
reported. First, many aspects of subjective well-
Synonyms being, including affective components, become
increasingly likely to decline during very old age
Emotion and emotional reactivity; Emotion regu- beginning around age 80 (Baird et al. 2010;
lation and emotion control; Emotional compe- Kunzmann et al. 2000) and show normative
tence and emotional intelligence; Emotional decline several months or even years before indi-
understanding and cognitive-affective complexity viduals die (Gerstorf et al. 2010). Second, the
Emotional Development in Old Age 753
stability found in overall subjective well-being is positive and negative emotions has been thought
not necessarily evident for all its dimensions (e.g., to be one central aspect of emotional competence
the frequency of sadness remains stable and even (e.g., Scheibe and Carstensen 2010). In the
increases in very old age; Kunzmann et al. 2013). broadest sense, emotional competence can be
Third, certain subgroups of older individuals are understood as work with emotions in ways
at risk for low subjective well-being (e.g., individ- that help us to keep on track and make progress
uals who have been burdened by losses that affect with our immediate and longer-term goals. More-
many life domains; Lucas 2007). These qualica- over, three different dimensions of emotional
tions point to potential limits of emotion regula- competence can be differentiated: (a) regulating
tory processes in old age and the need for theories emotions so that they t situational affordances
E
of emotional aging that paint a balanced picture and facilitate our goals; (b) understanding and
about older adults strengths and vulnerabilities in sense making of emotions, including their causes,
maintaining long-term affective well-being. temporal dynamics, and consequences; and
Before discussing relevant theoretical and empir- (c) responding empathically to fellow humans
ical work on emotional aging, it might be useful to (i.e., being able to accurately infer others emo-
present denitions of the terms emotion and emotions, share their feelings, and experience sympa-
tional competence. thy with them). These three dimensions of
emotional competence have been thought to facil-
Defining Emotion and Emotional Competence itate long-term affective subjective well-being,
Emotions have been dened as fast and short- particularly in old and very old age (Kunzmann
lived reactions to events that are important to our and von Salisch 2009).
personal goals and well-being. Emotions are
manifested on different levels and typically char- Theories of Emotional Aging
acterized by certain cognitive appraisals, specic Socioemotional selectivity theory. Socio-
action tendencies, patterns of physiological activ- emotional selectivity theory (SST; Scheibe and
ity, congurations of facial expressions, and inner Carstensen 2010; Carstensen et al. 1999) is a
feelings (Levenson 2000). Many researchers have motivational theory of social and emotional
acknowledged the importance of both positive aging that has portrayed old age as a period during
and negative emotions for optimal functioning which individuals are particularly motivated to
(Levenson 2000; Wrosch and Miller 2009). shape their lives so as to maximize the occurrence
Although negative emotions may be unpleasant, of emotionally satisfying moments. More specif-
they signal the individual that there is something ically, according to SST, advancing age is natu-
wrong and motivate cognitive and behavioral pro- rally associated with endings and a limited
cesses that help regain a balance between the lifetime. As a consequence, older adults have a
person and the environment. Seen in this light, strong present orientation involving goals related
the capacity to spontaneously react to signicant to current feeling states, emotional meaningful-
and negative events with the appropriate emotion ness, and satisfaction. By contrast, younger
(e.g., fear to threat, anger to injustice) is an impor- adults, who typically have an extended future
tant contributor to longer-term emotional well- time perspective, prioritize longer-term goals
being. However, negative emotions may also be aimed at expanding breadth of knowledge and
signs of or contributors to low affective well- optimizing future resources. Thus, SST predicts
being if they become chronic and decoupled that people of different ages prioritize different
from concrete and immediate causes. types of goals. As people age and increasingly
Although emotions are often our best allies, perceive time as nite, they attach less importance
helping us to respond effectively to the opportu- to goals that expand their horizons and greater
nities and difculties we encounter, occasionally, importance to goals from which they derive
it is necessary to regulate our spontaneous immediate emotional meaning. Obviously, youn-
impulses and reactions. The ability to regulate ger people also sometimes pursue goals related to
meaning, just as older people pursue goals related is still in need of further investigation (Isaacowitz
to knowledge acquisition. However, the relative and Blanchard-Fields 2012).
importance placed on these two types of goals is Dynamic integration theory. According to
thought to change with increasing age. dynamic integration theory (DIT; Labouvie-Vief
In support of SSTs main predictions, a large 2003), high longer-term subjective well-being
body of evidence suggests that, in comparison encompasses processes of affect optimization but
with their younger counterparts, older adults are also processes of affect differentiation. Affect dif-
more selective in their choice of social partners ferentiation involves tolerance for and sense mak-
and prioritize familiar and close social partners ing of negative and ambivalent experiences and,
over unfamiliar and emotionally less important thus, ideally results in a deeper and more complex
persons (Carstensen et al. 1999). In addition, understanding of the self, others, and situations.
older adults report greater satisfaction and more DIT poses that diminishing cognitive resources,
positive experiences with members of their social particularly those referring to basic information
networks than do younger adults. When conicts processing functions (e.g., logical reasoning,
occur, older adults typically respond with fewer processing speed, or inhibition), will cause a
negative emotions than young adults (Luong decline in cognitive-affective complexity with
et al. 2011). Such age-related decreases in nega- age. As a consequence of their increasing dif-
tive feelings and facial expressions during culty to make sense of negative feelings, older
unpleasant social interactions concern particularly adults are thought to increasingly favor affect
relationship-damaging emotions such as anger, optimization over affect complexity. Indeed,
aggression, or disgust, but not necessarily sadness cognitive-affective complexity and affect optimi-
(Blanchard-Fields and Coats 2008; Charles and zation may mutually inhibit one another. On the
Carstensen 2008). Also consistent with SST, in one hand, in circumstances that involve reduced
comparison to young adults, older adults seem cognitive resources and, thus, cognitive-affective
to be more likely to appraise their partner posi- complexity, relatively effortless processes of
tively during a conict and to engage in affect optimization may prevail. On the other
deescalating conict management strategies hand, the more individuals use affect optimiza-
(Luong et al. 2011). tion and, thus, avoid or quickly downregulate
There is also substantial evidence for system- negative experiences, the less likely will they be
atic age differences in basic affective information able to acquire and maintain a complex and dif-
processing. Older adults appear to be generally ferentiated understanding of emotionally signi-
more sensitive to positive information and less cant phenomena that inherently encompass both
sensitive to negative information than young positive and negative aspects. Consistent with this
adults, a phenomenon termed the positivity idea is evidence from an age-comparative study
effect (Reed and Carstensen 2012). SST states that simultaneously assessed how individuals typ-
that this positivity effect results from an ically deal with marital conict and what they
age-related shift in motivational states (i.e., a know about marital conict. In comparison with
shift from goals related to knowledge acquisition their younger counterparts, older adults were
to goals related to emotional meaning) that causes more likely to avoid conicts with their partner
an age-related increase in the allocation of cogni- and, at the same time, possessed less complex and
tive resources toward emotion regulation (Mather elaborated knowledge about marital conict; age
2012). Given that the majority of studies inter- differences in conict avoidance were negatively
ested in affective information processing have associated with age differences in the complexity
not elicited emotions or systematically manipu- of knowledge about marital conict (Thomas and
lated emotion regulation strategies, however, the Kunzmann 2013). The age-related diminution in
idea that positivity effects serve emotion regu- the complexity of knowledge about marital con-
lation goals and lead to better emotional outcomes ict is further consistent with a large number of
studies interested in cognitive-affective complex- stressors with implications for multiple life
ity more generally (Labouvie-Vief 2003). domains, older adults may be at a greater risk for
According to DIT, optimal functioning dysregulation and, thus, lower subjective well-
involves an integration and exible coordination being than young adults. Findings from Wrzus
of affect optimization and affect complexity and colleagues (2013) are consistent with this
(Labouvie-Vief and Medler 2002). Seen in this idea. The authors found that older adults reacted
light, the age-related increase in affect optimiza- with greater unpleasantness to complex and
tion, as, for example, manifested in older adults demanding stressors than their younger counter-
positivity effects or avoidance of social conicts, parts, but this age difference was not evident when
is a double-edged sword: it promotes a positive the stressors were more circumscribed. In addi-
E
affect balance in the moment, but this effect is tion, in comparison with their younger counter-
caused by age-related decline in basic cognitive parts, older adults showed reduced heart rate
functions and, ultimately, comes at the cost of an variability, a sign of poor physiological regula-
increasingly less differentiated understanding of tion, when they encountered complex stressors,
emotionally signicant phenomena. In the long but there were no age differences in heart rate
run, a one-sided strategy to optimize affect may variability when stressors were circumscribed.
result in lower rather than higher levels of affec- According to SAVI, in complex and taxing situa-
tive well-being. tions, age-related biological vulnerabilities come
The strength and vulnerability integration to the foreground and make it difcult for older
model. The strength and vulnerability integration adults to mitigate negative reactivity. Also consis-
model (SAVI; Charles and Luong 2013) states that tent with this idea is work suggesting that older
understanding age-related stability and change in adults react to highly arousing negative stimuli
affective well-being requires considering interac- with greater unpleasantness than their younger
tions between older adults improved emotional counterparts, whereas this age difference is
competence on the one hand and their decreased reversed or nonsignicant if the stimuli are not
physical reserves on the other hand. Consistent particularly arousing (Streubel and Kunzmann
with SST, the model poses that older adults 2011). Finally, recent research demonstrated that
strengths lie in their high motivation and expertise older adults who exhibited high levels of chronic
to engage in effective emotion regulation. As an illness were at a greater risk of experiencing sharp
extension of SST, SAVI draws attention to older increases in feeling of loneliness over 8 years of
adults physiological vulnerabilities and states study, particularly if they were unable to cope
that these vulnerabilities may render regulating effectively with their health problems (Barlow
distress and other negative emotions difcult and et al. 2015). Together, the ideas put forward in
costly. For example, age-related changes in car- the SAVI model could imply that older adults have
diovascular and neuroendocrine systems can lead the least benet from their strengths when they
to greater blood pressure and cortisol reactions to need them most, namely, when age-related
stressors among older adults relative to younger stressors and critical life events are serious and
adults. Heightened and prolonged physiological long lasting rather than mild and circumscribed.
reactivity most likely impairs older adults ability The discrete emotion approach to affective
to use those emotion regulation strategies that aging. The discrete emotion approach to affective
typically would help them lower distress and aging (DEA; Kunzmann et al. 2014) is based on a
regain their typical level of affective well-being. program of research conducted over the past
Put differently, according to SAVI, because of decade (Kunzmann et al. 2013; Kunzmann and
their physiological vulnerabilities, some older Grhn 2005; Kunzmann and Richter 2009;
adults may not be able to successfully use their Kunzmann and Thomas 2014). DEA builds on
motivation- and experience-based strengths. Par- the assumption that each stage in the life cycle
ticularly if exposed to chronic and complex (e.g., young adulthood, midlife, or old age) is
characterized by a specic conguration of con- experienced. Thus, discrete emotions that indicate
straints and opportunities, each residing in the young individuals progress in developing their
environment, the person, or both (Baltes 1987; potential and that promote tenacious and assertive
Freund 2007; Heckhausen and Schulz 1995). behaviors in the face of obstacles should be par-
DEA states that these age-specic congurations ticularly salient. Anger serves as a prototypical
can change the salience and adaptive value of example: it is elicited by the appraisal that ones
particular positive and negative emotions. So far, goals are blocked by others, triggers a reactant
DEA has focused on two stages in the adult life moving against state of action readiness, pro-
span, that is, young adulthood and old age, and motes goal persistence, and facilitates assertive
posed that these two life stages are differentially behaviors (Kunzmann et al. 2014).
associated with the salience and adaptive value of In old age, by contrast, discrete emotions that
anger and sadness. indicate the individuals progress in dealing
Young adulthood has been described as a phase with losses (including the awareness of lifes
of growth during which individuals have great nitude) and that promote disengagement from
opportunities to develop their potentials. Thus, unattainable goals in socially responsible ways
processes of optimization rather than maintenance should be particularly salient. Sadness is a proto-
or compensation have priority in this life phase typical example: it is elicited by the appraisal of a
(Baltes and Baltes 1990). Young adults typically situation as an irreversible loss, triggers processes
pursue many long-term goals focused on acquir- of adaptive goal disengagement, and is compati-
ing new resources, such as knowledge, informa- ble with social closeness (Kunzmann et al. 2014).
tion, or competencies (Carstensen et al. 1999). In Corroborating evidence for DEAs assump-
young adulthood, individuals have a strong need tions stems from a growing body of research on
to accomplish their goals, and perceptions of high multidirectional age differences in sadness and
personal control as well as a tenacious pursuit of anger reactivity. Research has documented that
goals are highly prevalent and closely tied to well- older adults tend to react with less anger-related
being (Wrosch and Heckhausen 1999). As com- emotions to social conicts than their younger
pared to older adults, young adults also tend to be counterparts (Blanchard-Fields and Coats 2008;
more assertive and willing to engage in social Charles and Carstensen 2008). Age differences
conicts to accomplish their social goals (Luong in sadness reactions to social conicts, by con-
et al. 2011). trast, have been shown to be reversed (i.e., higher
In marked contrast, old age has been charac- among older adults) or nonsignicant (Blanchard-
terized as a phase during which social, cognitive, Fields and Coats 2008; Charles and Carstensen
and physical resources become increasingly lim- 2008). Other studies have investigated age differ-
ited and processes of maintenance and compensa- ences in emotional reactions to nonsocial stimuli.
tion gain importance (Heckhausen and Schulz In this line of work, older, as compared with
1995; Baltes and Baltes 1990). Given the limited younger, adults reported less anger in response
resources in old age, perceptions of low personal to anger-eliciting stimuli, but equal or higher sad-
control and goal adjustment processes become ness in response to sadness-eliciting stimuli
increasingly frequent and adaptive in this phase (Kunzmann and Grhn 2005; Kunzmann and
of life (Wrosch and Heckhausen 1999). In addi- Richter 2009; Labouvie-Vief et al. 2003; Seider
tion, the awareness of a limited lifetime and the et al. 2011; Haase et al. 2012). Although most of
fragility of life seem to promote a tendency among the evidence refers to age differences in subjective
older adults to relate to others in intimate and reactivity, at least two studies, using sad
caring ways (Luong et al. 2011). lms as stimuli, reported that the often
According to DEA, discrete emotions that indi- observed age-related diminution in physiological
cate and promote individuals progress in dealing activity (Levenson 2000) was not evident in
with age-typical challenges are particularly their research; that is, older adults showed
salient, that is, easily elicited and frequently similar (Kunzmann and Grhn 2005) or greater
physiological reactivity (Seider et al. 2011) than strategies (people may be hesitant to describe
young adults. It also deserves to note that similar themselves as emotionally incompetent), intro-
age differences in the experience of anger and spective limits (do we know how emotionally
sadness were reported in two studies measuring competent we are?), and implicit aging theories
the frequency of emotions during the past month (if older people believe that individuals should
(Kunzmann et al. 2013) and on a typical day using become better at regulating their emotions as
the day reconstruction method (Kunzmann and they age, they are likely to say that they do so).
Thomas 2014). Finally, there is preliminary sup- This is why we consider approaches that study
port for possible adaptive consequences of an emotional competence under standardized condi-
age-related experience of anger and sadness. tions and use performance-based tasks.
E
A laboratory study assessing affective responses Emotion regulation. Relatively few labora-
to neutral lms showed that anger predicted tory studies have investigated age differences in
higher long-term subjective well-being in young emotion regulation in vivo. In these studies, youn-
adulthood, but not in old age. Conversely, sadness ger and older adults have been instructed to regu-
was related to high subjective well-being in old late their emotional reactions (e.g., subjective
age, but not in young adulthood (Haase feelings or facial expressions) before or while
et al. 2012). they were presented with emotion-evoking stim-
Taken together, DEA addresses the role of dis- uli. The effectiveness of emotion regulatory
crete emotions in young adulthood and old age, attempts was operationalized as the difference in
which are two stages in the life cycle that differ emotion reactivity during no-regulation versus
markedly in terms of their proles on at least two regulation conditions. The theoretical framework
psychologically inuential dimensions: power con- for most of these studies has been provided by
trol (high in young adulthood and low on old age) Gross and colleagues process model of emotion
and afliation communion (high in old age and low regulation (Gross 1998). This model describes
in young adulthood). To the extent that discrete how different types of strategies aimed at regulat-
emotions are differentially compatible with these ing ones emotions are used before, during, and
age-typical proles and promote adaptive ways in after exposure to a negative event. Anticipatory
dealing with the challenges and opportunities that strategies such as attentional deployment or cog-
emerge, they should also differ in their age-related nitive reappraisal have been shown to be more
salience and potential adaptive value. Anger and effective than response-focused strategies (e.g.,
sadness appear to be two negative emotions that behavioral suppression). In fact, the latter strate-
clearly differ in both power control and afliation gies have more circumscribed effects and may
communion; additional discrete negative and pos- even be associated with physiological costs.
itive emotions that could serve age-related func- With respect to age differences in emotion
tions most likely include fear, disgust, pride, regret, regulation, several studies have shown that older
and compassion. and younger adults are similarly successful at
reducing outward expressions of emotion
Age Differences in Three Facets of Emotional (Kunzmann et al. 2005; Phillips et al. 2008). As
Competence to cognitive forms of emotion regulation, a grow-
The remaining part of this review will focus on ing number of studies indicate that older adults
studies that have assessed emotional competence regulatory strengths are associated with their use
in vivo by using performance-based tasks. Much of strategies that are relatively effortless. For
of what is known about age and emotional com- example, older adults are more successful at
petence has been based on self-report measures. using positive reappraisal compared to younger
Although these measures have their strengths adults, but are less successful at using detached
(e.g., they reveal peoples beliefs and judgments reappraisal (Shiota and Levenson 2009). In posi-
about how they deal with emotions), they are tive reappraisal the individual attends to the emo-
likely inuenced by impression management tional aspects of a situation and attaches a positive
meaning to these aspects; in detached reappraisal investigate the idea that age is associated with an
the individual thinks of the situation in a neutral or increasingly selective choice of those emotion
rational manner. Given that positive reappraisals regulation strategies that rely on intact resources
keep ones focus on the emotional aspects of the (Urry and Gross 2010).
situation, it arguably is less cognitively demand- Empathy. Empathy is fundamental to building
ing than detached reappraisal that requires a per- and maintaining satisfying social relationships
son to ignore all emotional aspects. Consistent and an important source of prosocial behavior
with this assumption, research has demonstrated (Davis 1994). Given the importance of social
that detached reappraisals have higher cognitive and emotional goals among older adults
costs than other major emotion regulation strate- (Carstensen et al. 1999), empathy may also be
gies, such as distraction (diverting attention from among the most inuential predictors of success-
an emotional situation; Sheppes and Meiran ful aging and particularly affective well-being.
2008). Corroborating the idea of age-related There is broad agreement that empathy is a
gains in cognitively undemanding emotion regu- multidimensional concept that involves both cog-
lation strategies, older adults were better at using nitive (e.g., the ability to accurately infer anothers
distraction (think about a positive memory) while emotions) and affective (e.g., the ability share
watching negative lm clips than young adults anothers feeling and to feel sympathy for him or
(Phillips et al. 2008). Studies interested in her) dimensions (Davis 1994). Age-comparative
age-related positivity effects in attention to posi- work on empathy underscores the usefulness of
tive and negative stimuli also deserve note. Evi- this distinction, by showing that cognitive and
dence from these studies suggests that temporarily affective facets of empathy exert multidirectional
decreasing cognitive resources through dual-task age differences: while the ability to accurately
paradigms eliminates older adults tendency to infer others emotions seem to decline with age
focus on positive stimuli and/or avoid negative (Ruffman et al. 2008), affective facets have been
stimuli. Although these studies have not elicited shown to remain stable or to increase with age
emotional reactions or instructed certain emotion (Richter and Kunzmann 2011; Sze et al. 2012b).
regulation strategies, they provide evidence for Although the underlying mechanisms for these
the idea that even age-related gains in arguably multidirectional age differences have to be further
less effortful processes of emotion regulation investigated, it is likely that the age-related
require a certain amount of cognitive resources decline in empathic accuracy is due to parallel
(Mather 2012). age-related declines in basic cognitive resources,
In sum, the reviewed evidence suggests such as logical reasoning, processing speed, or
multidirectional age differences in emotion regu- inhibition (e.g., Richter et al. 2010; Wieck and
lation. While the effectiveness of some strategies Kunzmann 2015). Emotional congruence and
may increase with age (positive reappraisal, atten- sympathy arguably rely less on such cognitive
tional deployment), the effectiveness of other resources and are more dependent on
strategies remains stable (behavioral suppression) age-friendly automatic and effortless processes
or declines (detached reappraisal). At rst sight, related to certain forms of emotion regulation.
this performance-based evidence is at odds with Much of the work interested in age differences
results from self-report studies, indicating that in the cognitive facets of empathy relied on tasks
older adults believe that they are generally more that require individuals to recognize emotions
effective in regulating their emotions than youn- depicted in decontextualized facial, vocal, or writ-
ger adults (Kunzmann et al. 2005). However, to ten material. Isaacowitz and Stanley (2011) con-
the extent that older adults use strategies that work sidered it possible that such tasks systematically
for them and avoid strategies that are more underestimate older adults empathic accuracy,
effective for young adults, overall gains in emo- which may be particularly dependent on the
tion regulation competence could be observed contextual richness of a task. For example, Sze
among older adults. Future research is needed to and colleagues (2012a) reported that age-related
decline in emotion recognition was less visible if (Isaacowitz and Stanley 2011). Although this
the tasks were based on dynamic, genuine, and may be the case, two ndings may contradict
contextualized stimuli. A problem with this this possibility and deserve note: (a) age
interpretation is, however, that the authors con- decits in empathic accuracy seem to not occur
textualized tasks required participants to make in contexts that are personally relevant to older
overall judgments of valence rather than specic adults and (b) relatively stable and high levels of
judgments pertaining to the intensity of discrete emotional congruence and sympathy may com-
emotions. Thus, the absence of age decits may pensate for potential weaknesses in empathic
be due to the lower difculty level rather than the accuracy.
contextual richness and ecological validity of the Emotional understanding. Evidence for age
E
task. In fact, an earlier study, manipulating differences in emotional understanding primarily
contextual richness and keeping the rating part stems from research by Labouvie-Vief and her
of the task constant across conditions, suggested colleagues. More specically, the authors repeat-
that contextual richness does not moderate age edly investigated cognitive-affective complexity
differences in empathic accuracy (Richter in several studies with individuals aged 1080
et al. 2010). In addition, there is evidence (and older) using cross-sectional and longitudinal
suggesting that the negative effect of emotionally designs (Labouvie-Vief 2003). In some of these
incongruent contextual information on empathic studies, the authors asked their participants to
accuracy becomes greater with age (Noh and think aloud about situations in which they felt
Isaacowitz 2013). Thus, the current evidence particular emotions (e.g., anger, fear, happiness)
speaks against the idea that age decits in or about their self and relations to signicant
empathic accuracy vanish in ecologically valid others. The answers were transcribed and later
tasks. In order to demonstrate what older adults evaluated by independent raters with a coding
can do under ideal conditions, additional factors scheme based on four levels of cognitive-affective
need to be taken into consideration. Recent work complexity (Labouvie-Vief et al. 1989). In this
suggests that task motivation is a promising scheme, a high level of cognitive-affective com-
candidate. With the presence of a strong task plexity is represented by a tolerance for negative
motivation, older adults have been shown to and conicting feelings, a clear differentiation
perform equally well in empathic accuracy between own and others feelings, a deep under-
tasks as young adults (Richter et al. 2010; standing of the dynamics and causes of emotions,
Wieck and Kunzmann 2015). This evidence is and an appreciation of the uniqueness of individ-
consistent with the selective cognitive engage- ual experiences. Findings consistently suggest
ment model, stating that older adults become that cognitive-affective complexity increases dur-
increasingly selective as their cognitive resources ing adolescence and young adulthood, peaks in
decline and that selective resource allocation is a early midlife, and begins to decline during late
key to maintaining performance in situations middle adulthood (Labouvie-Vief 2003;
that are particularly meaningful and relevant Labouvie-Vief and Medler 2002; Labouvie-Vief
(Hess 2014). et al. 1989). To the extent that cognitive-affective
In sum, the current evidence for age and empa- complexity contributes to individuals optimal
thy suggests multidirectional age differences. functioning, its age-related decline needs to be
Overall, older adults appear to have greater dif- considered a risk factor for low long-term affec-
culty in inferring other peoples emotions, but tive well-being.
emotional congruence and sympathy remain sta-
ble or even increase. Several researchers have
discussed the question of whether older adults Conclusions
decits in empathic accuracy have implications
for the quality of their social relationships and Empirical and theoretical work interested in emo-
ultimately their long-term affective well-being tional aging documents a complex picture of the
nature of emotion in old age. Older adults Cross-References

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Shiota, M., & Levenson, R. (2009). Effects of aging on Definition

experimentally instructed detached reappraisal, posi-
tive reappraisal, and emotional behavior suppression.
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Streubel, B., & Kunzmann, U. (2011). Age differences in memory and reasoning, but also cognitive
emotional reactions: Arousal and age-relevance count. appraisals and control processes are important in
Psychology and Aging, 26, 966978. our experience of emotions. Emotioncognition
Sze, J. A., Goodkind, M. S., Gyurak, A., & Levenson, R. W.
(2012a). Aging and emotion recognition: Not just a interactions are the interface between these differ-
losing matter. Psychology and Aging, 27, 940950. ent aspects of mental experience.
Sze, J. A., Goodkind, M. S., Gyurak, A., & Levenson, While cognitive and affective psychology have
R. W. (2012b). Greater emotional empathy and long been considered as two relatively indepen-
prosocial behavior in late life. Emotion, 12, 11291140.
Thomas, S., & Kunzmann, U. (2013). Age differences in dent subareas in aging research, there has been a
wisdom-related knowledge: Does the age-relevance of recent surge of interest in investigating the inter-
the task matter? The Journals of Gerontology Series B: action between cognition and emotion. While
Psychological Sciences and Social Sciences, 69, many cognitive functions decline with age, emo-
897905.
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before and after passing a developmental deadline: nemotion interactions? Do emotional processes
Activation and deactivation of intimate relationship place different loads on cognitive function in
goals. Journal of Personality and Social Psychology,
77, 415427. younger and older adults? The present essay will
Wrosch, C., & Miller, G. E. (2009). Depressive symptoms present research on emotioncognition interac-
can be useful: Self-regulatory and emotional benets of tions in aging from different perspectives. First,
dysphoric mood in adolescence. Journal of Personality the socioemotional selectivity theory (Carstensen
and Social Psychology, 96, 11811190.
Wrzus, C., Mller, V., Wagner, G. G., Lindenberger, U., & 2006) will be introduced, and it will be described
Riediger, M. (2013). Affective and cardiovascular how valenced task material and current mood
responding to unpleasant events from adolescence to states inuence cognitive performance in younger
old age: Complexity of events matters. Developmental and older adults. Second, age differences in the
involvement of cognitive control in dealing with
emotional challenges are discussed. Finally, age
differences in specic functions combining cog-
nitive and affective processes will be considered.
EmotionCognition Interactions The essay ends with a conclusion and brief
outlook.
Katharina M. Schnitzspahn1 and
Louise H. Phillips2
1
School of Psychology, University of Aberdeen, Socioemotional Selectivity Theory
Aberdeen, UK and Effects of Emotional Task Material
2
University of Aberdeen, Aberdeen, UK on Cognition in Younger and Older
Adults
Synonyms The idea that cognitionemotion interactions may

be inuenced by adult aging has been suggested
Cognition = thinking, reasoning, memory; Emo- by theories from lifespan developmental psychol-
tion = affect, mood, feelings; Emotioncognition ogists, providing the conceptual framework for
interplays; Emotioncognition links the majority of empirical work. The most
EmotionCognition Interactions 763
prominent framework is the socioemotional selec- example, in incidental learning tasks where par-
tivity theory, a lifespan theory of motivation, ticipants do not know that their memory will
which assumes that the subjective sense of subsequently be tested.
remaining time has profound effects on basic Another moderator of age changes in emo-
human processes, including cognition and emotional biases suggested by a second meta-analysis
tion (Carstensen 2006). More precisely, when (Murphy and Isaacowitz 2008) is type of cogni-
time is perceived as open ended as in youth, tive task assessed. Specically, memory para-
gathering information, experiencing novelty, and digms yielded overall stronger effects than
expanding breadth of knowledge are prioritized attention paradigms, and within memory mea-
goals. When time is perceived as constrained, as surements, emotional effects in older adults were
E
in old age, goals tend to emphasize current feel- stronger in recall paradigms compared to recog-
ings and emotion states, particularly regulating nition paradigms. While most studies examined
emotional states to optimize psychological well- emotion effects on retrospective memory for past
being in the moment. As people age and increas- events, some recent studies have looked at
ingly perceive time as nite, the theory predicts whether emotion inuences age-related differ-
that they ascribe greater importance to goals from ences in prospective memory, which is the crea-
which they derive emotional meaning. The tion and enactment of an intention, such as
age-related shift in goal priorities should effect remembering to attend an appointment at a spe-
cognitive functioning, as it changes the focus of cic time. For example, age differences in the
attention and memory. inuence of positive and negative compared to
Socioemotional selectivity theory predicts that neutral target cues indicating the right moment
older adults should favor processing of informa- to initiate an intended action on its correct fulll-
tion likely to maintain or enhance well-being, ment have been examined (Schnitzspahn
which will often mean a bias toward positive et al. 2012). Results did not support a specic
information. This hypothesis motivated many positivity bias in old age but instead indicated an
studies manipulating the emotional valence of age-related emotional salience effect: older adults
cognitive task material. Results often showed an were better at carrying out the intention in
age-related increase in the preference for positive response to both negative and positive words
over negative information in attention and mem- compared to neutral. Similar ndings from other
ory, the so-called positivity effect. A clear studies of ageemotion interactions in prospective
age-related shift in emotioncognition interac- memory, using different tasks and materials, sup-
tions was conrmed by a recent meta-analysis port the idea of enhanced emotional salience for
(Reed et al. 2014), which showed that younger both positive and negative material in remember-
adults tend to show a negativity bias: that is pref- ing intentions in old age.
erential processing of negative over positive mate- These ndings underline the importance of
rial, while older adults show instead a positivity examining valence effects across different cogni-
bias. The majority of the studies reported look at tive abilities to test the generalizability of the
age differences in memory for positive and nega- positivity effect. Information processing and
tive information, nding that older adults remem- encoding may be inuenced differently by emo-
bered more positive information than negative, tion valence depending on the specic require-
while younger adults showed the opposite pattern ments of the examined cognitive function.
of bias. However, this review combined studies Besides task type, general cognitive resources
which varied substantially in the tasks used to seem to play a critical role in the positivity effect
look at emotional biases, and the authors point (Reed and Carstensen 2012). The positivity effect
out the importance of testing for possible moder- emerges when resources are relatively available
ators. They found that age-related positivity and undivided but is absent when resources are
biases are strongest when the memory task does rather poor or divided. Further, positivity emerges
not impose specic instructions on encoding, for during controlled stages of information
processing, but not for relatively automatic may automatically and more effectively regulate
processing. These ndings led to the conclusion their emotions during mood induction than the
that positivity reects top-down motivational con- young, resulting in less impairment in a cognitive
trolled cognition in older adults that can be task following a mood induction. This could lead
inuenced by situational and contextual factors to reduced age effects in positive/negative mood
(Reed and Carstensen 2012). conditions compared to neutral ones. Also, in line
with widely reported positivity biases, there might
be different effects of positive and negative mood
The Influence of Mood States states in old age.
on Cognition in Younger and Older Results to date have been mixed and indicate
Adults that age differences in the effect of mood on
cognition may be inuenced by task demands. It
Research motivated by the socioemotional selec- has been found that negative mood disrupts older,
tivity theory examined emotioncognition inter- but not younger, adults planning performance
actions by experimentally manipulating the (Phillips et al. 2002) but fails to inuence either
valence of the task material and its inuence on age groups recall memory performance (Emery
cognitive performance in the respective task, et al. 2012) or working memory (Scheibe and
while the participants mood is assumed to be Blanchard-Fields 2009). In contrast, negative
neutral. A second line of research addresses mood impaired the performance of delayed inten-
emotioncognition links by using neutral cognitions in younger but not older adults
tive task material after inducing a positive or (Schnitzspahn et al. 2014). Concerning positive
negative mood and compares subsequent perfor- mood, an impairing effect on planning in younger
mance to a neutral mood condition. Thus, the adults was found (Phillips et al. 2002), which was
emotional state of the participant instead of the even more pronounced in older adults. Further-
valence of the task material is varied. These more, positive mood exacerbated false memories
manipulations are of interest because it is known in older but not younger adults, whereas correct
that mood states can inuence cognitive perfor- recall was not inuenced (Emery et al. 2012). In
mance in younger adults: for example, being contrast, the performance of delayed intentions
induced into a positive or negative mood may was impaired under positive compared to neutral
cause more heuristic processing, which can mood in younger but not older adults
improve performance on some creative tasks but (Schnitzspahn et al. 2014). Thus, results range
impair performance on constrained tasks which from reduced age effects of mood state on cogni-
demand concentration and detailed processing. tion to no age differences in moodcognition
Only very few studies examined age-by-mood interactions and to exacerbated age-related mood
interactions in inuencing cognitive performance. effects on cognitive performance.
In general, two possible but contradictory out- The studies outlined above differed in the
comes can be predicted. On the one hand, age nature of mood manipulations used and cognitive
effects in cognition may be exacerbated when tasks investigated. Clearly the understanding of
participants have to deal with a cognitive task how mood and cognitive functioning interact in
and an acute mood state in parallel. As suggested aging is still in its infancy, and more research is
by the socioemotional selectivity theory, older needed to better understand age differences in
adults are assumed to focus on the regulation of mood effects on cognitive performance. More
their emotional state which may compete with the information is needed, through specic task
ongoing cognitive activity and requires manipulations on the pattern of age differences
processing resources which are already limited in moodcognition interactions. It is possible
in older adults. On the other hand, dealing with that the interaction is similarly moderated by mea-
emotions may be a better practiced, more stream- surement type and cognitive resources as the pos-
lined process in old age. Accordingly, older adults itivity effect. Depending on the brain areas
associated with different cognitive functions and control, it has been suggested that emotion regu-
their overlap with the brain regions required dur- lation could be less costly in a cognitive sense in
ing emotion regulation, cognitive performance in older adults compared to younger ones as they
tasks measuring the respective functions may be have more experience, and therefore emotion reg-
more or less inuenced. Besides qualitative dif- ulation may become more effectively and autom-
ferences between cognitive tasks, quantitative dif- atized. This prediction was tested (Scheibe and
ferences in their difculty and hence requirement Blanchard-Fields 2009) by asking younger and
of cognitive resources may also inuence mood older adults to perform a working memory task
effects. Relatively easy cognitive tasks may still after a neutral or a negative mood induction.
be performed well under certain mood states, Importantly, instructions were varied between
E
while performance in difcult tasks should be participants in the negative mood group. Some
disturbed. However, task type and difculty can- participants were asked to try to maintain the
not explain the differential age effects observed in intensity of their negative feelings, while others
some of the studies described above. The most were asked to change the negative feelings as fast
promising candidate here may be age benets in as possible into positive ones. While the instruc-
emotion regulation processes which will be tion to regulate the negative mood after its induc-
presented in more detail in the following section. tion did not affect older adults performance in the
subsequent working memory task, it impaired the
performance among the young. This occurred
Aging, Cognition, and Emotional Skills despite evidence of a strong mood induction in
both age groups and successful ability to follow
The rst part of this review focused on the inu- emotion regulation instructions in both groups.
ence of emotional factors (i.e., valence of the task This nding indicates that intentional
material and mood) on cognitive performance and downregulation of negative emotions may be
thus considered emotions as one possible factor less costly in older age. Indeed, the allocation of
inuencing cognition in general and age differ- cognitive resources needed to effectively regulate
ences in cognitive performance in particular. emotions seems to vary by age.
However, emotioncognition interactions have Another research question that has attracted
also been examined in the eld of emotional attention concerns cognitive mechanisms under-
aging. The main research questions in this area lying differences between younger and older
are the lifespan development of emotional skills adults emotion regulation and their predictive
and the involvement or necessity of cognitive value for mood outcomes. Specically, it has
resources. The following paragraphs will focus been suggested that age-related positivity effects
on emotion regulation and emotion recognition, in attention and memory that has been described
their development in aging, and the role of above actually reect motivated cognition operat-
cognition. ing in the service of emotion regulation
Emotion regulation skills are involved in mon- (Isaacowitz 2012). Focusing on positive informa-
itoring and controlling our inner experience of tion while paying less attention to or remembering
emotional states. There is substantial evidence of fewer negative aspects of stimuli could plausibly
age-related improvements in emotion regulation help to achieve or maintain well-being. This
skills to downregulate negative affect and pro- hypothesis has been addressed in several studies
mote positive affect (Kryla-Lighthall and Mather using eye tracking in order to examine differences
2009). As already briey mentioned above, suc- between younger and older adults in visual atten-
cessful emotion regulation requires active use of tion to emotional material. Their ndings show a
cognitive control strategies or executive function- greater preference for positive looking in older
ing and leads to an attentional shift toward ones adults, resulting in a viewing behavior toward
emotional state and away from other ongoing positive and away from negative material
activities. Given reported age benets in emotion (Isaacowitz 2012). These age differences in
preferences have been replicated using different be conrmed in emotion recognition. It seems
materials and seem strongest when participants that older adults do not prot from their benets
are in negative mood state or are explicitly in emotion control and their strong motivational
instructed to regulate their emotions. Positive focus on emotions and well-being in this specic
looking has been found to help some older adults domain. Recent studies indicate that older adults
regulate their mood, but these effects were mod- poorer performance in recognizing emotions may
erated by individual differences in attentional be ameliorated by manipulations which improve
abilities. Thus, older adults with good attentional the ecological validity, personal relevance, or
abilities were able to use attentional deployment motivational context of emotion recognition
in the form of positive looking to successfully tasks. For example, it has been reported (Sze
regulate their mood. These ndings conrm that et al. 2012) that age-related declines in recogniz-
positivity effects reect top-down processes ing emotions from traditional stimuli such as pho-
requiring cognitive resources when used to regu- tographs of facial expressions are reversed to
late their emotions by older adults. result in age-related improvements when rating
Another important emotional skill is the ability emotions online using more naturalistic stimuli,
to recognize the emotions of others. We use nonin this case videos of dyadic interactions which
verbal cues from facial expressions, vocal tone, included contextual information.
and body posture to decide whether other people
are angry, sad, or happy. Meta-analyses on age
effects in emotion recognition suggest an overall Functions Combining Cognitive
age-related decline (Ruffman et al. 2008). This and Emotional Aspects and Their
nding is true across modalities (faces, voices, Development in Aging
bodies/contexts, matching of faces to voices) and
different basic emotions (anger, sadness, fear, sur- After considering the inuence of emotional fac-
prise, happiness). Some emotions (anger and sad- tors on cognition and the involvement of cogni-
ness) and some modalities (facevoice matching) tive factors in emotional abilities, the nal section
create particular difculties, while a trend for will present the development of empathy and
older adults to be better than younger adults at wisdom in aging. Both constructs involve cogni-
recognizing disgusted facial expressions was tive and affective processes and thereby allow the
reported. It has been suggested that general cog- study of emotioncognition interactions and pos-
nitive decline might account for the age-related sible age differences within the same ability.
changes in emotion recognition. However, this Empathy requires the cognitive understanding
seems unlikely because the pattern of age effects of another persons feelings as well as an appro-
did not match the difculty levels of the emotions, priate affective response. The latter concerns the
as younger and older adults showed difculties in affective facet of empathy that comprises the
different emotions. degree to which one shares the feelings of another
Reviewing the literature, the authors (Ruffman person and the capacity to experience and express
et al. 2008) conclude that there is no consistent sympathy or emotional concern. Results
evidence that general cognitive decline accounts concerning age differences in empathy are mixed
for older adults pattern of emotion recognition but suggest differential age effects for the different
difculties. Instead, it is suggested that specic components. As reviewed above, older adults are
neuropsychological changes in frontal and tempo- often reported to perform worse than young on
ral volume and neurotransmitters may cause the tasks of emotion recognition, which can be con-
observed age-related impairments (Ruffman sidered part of cognitive empathy. However, these
et al. 2008). Interestingly, a positivity effect in age effects may depend on the motivational nature
terms of absent or reduced age effects in labeling of the task. In one of the few experimental studies
positive emotions and clear age impairments to directly look at age differences in cognitive and
when recognizing negative emotions could not affective aspects of empathy within the same
paradigm (Richter and Kunzmann 2011), age strong connection with an expertise approach but
effects in understanding another persons emo- expand classical cognitive ability measures by
tional state (cognitive empathy) were no longer including emotional and motivational aspects. In
observed when the person was talking about a a typical paradigm, participants are presented with
topic of high relevance to older adults. difcult and existential life problems and are
Concerning the affective facets of empathy, older asked to give advice. Responses are recorded
adults competencies remain stable or even and evaluated according to prespecied wisdom
improve across adulthood: older adults report criteria. In general, older adults perform as well as
and express greater sympathy for others than younger adults in such tasks. Age benets were
younger adults (Richter and Kunzmann 2011). observed on typical dilemmas of old age and
E
Taken together, cognitive facets of empathy may when age has been combined with wisdom-
be more vulnerable to age-related decline than related experiential contexts (e.g., professional
emotional facets. Accordingly, age differences in training as clinical psychologist), while younger
empathy may vary between studies depending on adults performed better on typical dilemmas of
the type of measurement used and in how far it young adulthood (see Staudinger and Glck
focuses more on the cognitive or affective facet. 2011 for an overview). Performance is best
Wisdom integrates several facets in terms of predicted by measures located at the interface of
psychological functioning. The deep insight into cognition and personality, such as a judicial crea-
self, others, and the world comprises the cognitive tivity and moral reasoning, but not by uid and
facet. Complex emotion regulation allowing the crystallized intelligence or personality alone. The
tolerance of ambiguity represents the emotional different age effects found depending on the mea-
facet. The assumption of a positive association surement type assessing wisdom suggest that
between wisdom and age is very common in the required cognitive resources may play an impor-
general population as experience cumulates with tant role. Negative age effects may arise when
age, although most people consider old age as measures heavily relying on complex cognition
neither necessary nor sufcient for wisdom are used, while no age effects or even benets can
(Staudinger and Glck 2011). Empirical ndings be expected in tasks allowing older adults to make
can be distinguished according to the type of use of knowledge and heuristics about life prob-
wisdom measured. Personal wisdom refers to lems acquired through experience and practice.
individuals insight into their selves and their
own lives and describes an ideal end point of
personality growth. This approach is based in the Conclusion and Outlook
tradition of personality research and mostly uses
self-report measures. Studies do not report a linear Younger and older adults differ in the way that
positive relationship between personal wisdom emotion and cognition combine. The empirical
and age and sometimes even observed negative ndings summarized above all seem to support
relations (Mickler and Staudinger 2008). Declin- the claim that age moderates emotioncognition
ing cognitive resources may make abstract think- interactions as age differences were the rule rather
ing, which is required to satisfy some wisdom than the exception. Importantly, many studies
criteria such as self-relativism, more difcult for observed age benets which may seem surprising
older adults. In addition, lower levels of openness given the general cognitive decline accompanying
to experience and societal restrictions of growth aging. Better emotion control and a strong focus
opportunities in old age may hinder the further on emotional well-being in older adults seem to
development of self-insight. make it easier for older adults to work on tasks
General wisdom describes individuals requiring cognitive and emotional processes.
insights into life in general. Approaches to the Older adults seem to prot more than young
empirical study originated from cognitive from valenced task material, are generally cogni-
research and are performance based. They have a tively less impaired by current mood states, and
are superior in emotion regulation skills: indeed structure, remains stable with age, emotion and
emotion regulation seems less cognitively cognitive control regions of the brain including
demanding for older people than young. Other the prefrontal cortex deteriorate signicantly. First
age-related benets include good performance in ndings suggest that healthy older adults can still
tasks requiring complex abilities such as empathy maintain their emotional well-being to some
or wisdom, when the tasks allow them to use their extent by recruiting additional cognitive resources
emotional strengths and knowledge. These nd- and thereby compensate for their losses by
ings are very encouraging, as they show how exerting more cognitive effort (Kryla-Lighthall
motivational and emotional strengths can be and Mather 2009).
used to compensate for age-related cognitive The theoretical model of strength and vulnera-
decline. However, there is clearly a limit for com- bility integration (Charles and Luong 2013)
pensation, and as mentioned in several examples adopts a broader, more applied perspective. In
above, age benets diminish or turn into line with the socioemotional selectivity theory, it
age-related impairments when the (cognitive and suggests that across adulthood, expertise and
emotional) tasks get too difcult or older adults do motivation to regulate ones emotions increase.
not have sufcient cognitive resources available. However, it is further suggested that certain situ-
This pattern is predicted by the dynamic integra- ations that increase in prevalence with age (i.e.,
tion theory (e.g., Labouvie-Vief et al. 2014), social isolation, neurological dysregulation, and
which emphasizes that emotional gains in old chronic stress) preclude the use of these emotion
age may be reversed where the demand on avail- regulation strategies on a daily level. It is further
able information processing is exceeded. For argued that these situations will lead to equal or
example, older adults show greater interference even lower levels of emotional well-being and
between mood states and cognition where the greater physical consequences in the cardiovascu-
cognitive task is very demanding, and older adults lar and the neuroendocrine systems in older com-
perform worse than young when decoding other pared to younger adults as a result of their
peoples emotions in situations devoid of context. physiological vulnerabilities.
Accordingly, recent conceptual developments To sum up, while old age is often characterized
build on the socioemotional selectivity theory as a period of cognitive decline, there are also
and expand it by dening the limits of age bene- emotional gains during this time of life. Older
ts. Two of them will be outlined in the following. adults are better at using their emotions to focus
The cognitive control framework of aging and cognitive resources on the key aspects of a situa-
emotional well-being (Kryla-Lighthall and tion which will enhance mood. Older adults are
Mather 2009) posits that older adults will experi- also good at effectively and efciently regulating
ence emotional enhancement to the extent that their emotions in a way which might mean less
they are capable of exerting cognitive control to impact of mood uctuations on cognitive perfor-
direct attention and memory in ways that help mance. These skills of managing emotions and
satisfy emotional needs. Thus, cognitive control cognition likely have positive impact on well-
is suggested as the key mechanism underlying the being in old age.
transformation of age differences in goals into
differences in emotional well-being. In line with
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three facets of empathy: Performance-based evidence.
tion, that contributes to the preservation of the
Ruffman, T., Henry, J. D., Livingstone, V., & Phillips, L. H. natural environment by reducing harm to, or
(2008). A meta-analytic review of emotion recognition strengthening, the ecosystem.
770 Employee Green Behavior and Aging
Employee Green Behavior at Work double from 12% in 2010 to 25% in 2050 as the
and Aging baby boomers exit the workforce. Organizational
success in the twenty-rst century will be deter-
Environmental sustainability is emerging as a mined in part by the ability of organizations to
driver of human activity in the twenty-rst cen- respond effectively to signicant issues (Ones and
tury. Evidence of this can be seen in global emis- Dilchert 2012), such as environmental sustain-
sions targets and the investment in technology ability and an aging population. The focus of
intended to enable societies to grow without this entry is to integrate research on aging and
compromising the natural environment or jeopar- employee green behavior and provide insights
dizing the livelihood of future generations (World into whether or not employees become greener
Commission on Environment and Development as they gray.
1987). It is likely, however, that to forestall or
avoid the worst effects of human activity How Are Aging and Environmental
(anthropogenic climate change), human activity Sustainability Interrelated?
itself will need to change (Ones and Dilchert As should be expected with concurrent issues of
2012). such magnitude, the issues of an aging population
Scientic evidence points to human economic and environmental sustainability are interrelated.
activity as the key driver of environmental degra- On the one hand, climatic changes pose health
dation (Ones and Dilchert 2012). Many organiza- risks for older people who are more vulnerable
tions and industries have therefore taken it upon to changes in the environment. For example,
themselves to address their role and to attenuate research has shown that periods of extreme heat
their negative environmental impact while at the are associated with increased mortality rates
same time accentuating their positive impact among the elderly (strm et al. 2011). Moreover,
(Robertson and Barling 2015). When we consider and as the Intergovernmental Panel on Climate
the amount of time many people spend at work Change (2014) has now established, periods of
throughout their lives (Terkel 1974), organiza- extreme heat are likely to become both more fre-
tional efforts to increase employee activity that quent and more extreme in future years.
contributes to environmental sustainability (i.e., At the same time, the members of an aging
employee green behavior; Ones and Dilchert population and workforce have evolving needs
2012) might well be a vital cog in the machinery (e.g., mobility, health; Klein et al. 2012) that
of a sustainable society. place increased demands on natural resources,
Environmental sustainability is one of several thereby incurring environmental costs. Although
signicant issues with implications for organiza- there is reason to believe that an individuals over-
tions. In addition to economic activity, climate all CO2 emissions should decrease slightly above
change is also being driven by changes in global the age of 65 (Zagheni 2011), there are three
population (Intergovernmental Panel on Climate additional important considerations that need to
Change: 2014). In this regard, a contemporaneous be appraised and that bring into question these
issue facing many countries is an aging popula- presumptions.
tion, caused by increased longevity, a decline in First, the business sector uses considerably
fertility, and the procession of the baby boomer more energy and produces vastly more waste
bulge into old age (McDaniel and Zimmer 2013). than the domestic sector (Davis and Challenger
According to the Bureau of Labor Statistics 2011). As a consequence, workplace activity is
(2015), over 67 million employees in the United going to be the largest contributor to global emis-
States are aged 55 or over, representing approxi- sions and a signicant contributor to employees
mately 43% of the total labor force. Looking to the carbon footprints (Goodall 2010). Second, gov-
future from a more global perspective, Kuenen ernments are raising retirement ages to cope with
et al. (2011) estimate that the dependency rate the nancial burden of supporting such a large
(number of people over 65 per 100 workers) will cohort (Hertel and Zacher 2016). Third, while
overall emissions may trend downward, they are environmental sustainability through increased
still expected to remain well above the minimum social, regulatory, and normative pressure
threshold (5.5 t per person) that MacKay (2009) (Klein et al. 2012), it is likely that companies
suggests is necessary to avoid a worst-case sce- will increasingly embed green behaviors
nario (i.e., concentration of CO2 in the atmosphere into employees required tasks. Accordingly,
exceeding 450 parts per million, which is associ- reviews on green behavior at work have a focus
ated with a 2 C increase in average global tem- on constructs and processes unique to the
perature; Intergovernmental Panel on Climate workplace.
Change: 2014). In response to an increase in organizational and
With these issues in mind, and taking into academic interest in environmental sustainability
E
account that many employees today work beyond (Ones and Dilchert 2012), several researchers
what was once accepted as the traditional retire- have conducted reviews of employee green
ment age (65 years; Hertel and Zacher 2016), it behavior (e.g., Norton et al. 2015). These reviews
seems reasonable to conclude that estimates of document the role of contextual factors such as
individuals emissions decreasing after age policies and goals and person factors such as
65 might not be as robust as currently thought. environmental attitudes and perceived green orga-
Moreover, even in the event that estimates of nizational climate in the green behavior of
declining emissions after the age of 65 turn out workers in general.
to be correct, any decreases (while nominally
positive) would be supercial because it would Employee Green Behavior Among Older
still exceed the proposed per person threshold for Workers
emissions by some 200% (Mackay 2009). In Although our understanding of aging and
acknowledgment of the contribution of workplace workplace behavior in general is relatively
activity to greenhouse emissions, and assuming mature (Hertel and Zacher 2016), the impact of
that the longer a person works, the larger their aging on employee green behaviors is in its
own carbon footprint, the question of how an infancy. Although the aforementioned reviews
aging workforce engages with environmental sus- on employee green behavior have not investigated
tainability becomes vitally important. We next age specically, subsequent analysis of the studies
provide an overview of the current state of included in the largest and most recent review
research in relation to this question. (Norton et al. 2015) does serve to highlight rela-
tionships between age and employee green behav-
Employee Green Behavior ior. Broadly, these studies form four categories:
Employee green behavior refers to individual (1) report the effects of age, (2) control for age but
actions in the workplace that contribute to envi- do not report any effects, (3) report age as a
ronmental sustainability (Ones and Dilchert demographic variable, and (4) do not measure
2012). The need to dene these behaviors in the age. Of the 69 studies included in the review, the
context of the workplace arises because of the majority (37) fell into the fourth category, while
extent to which an individual has autonomy over 13 fell into the third category and 3 are included in
his or her behavior. Whereas the decision to be the second. Moreover, of the 16 studies that did
environmentally friendly at home is largely voli- report effects, ndings were mixed. Nine studies
tional and driven by psychological (i.e., person) reported no relationship between age and
factors (Bamberg and Mser 2007), in the work- employee green behavior, two reported negative
place it may be either encouraged or discouraged effects, and ve reported positive ndings. It
by social norms, expectations, and task demands should be noted, however, that most studies report
(Ones and Dilchert 2012). Ones and Dilchert bivariate correlations only. In short, there seems to
(2012) indicate that as much as 29% of green be a lack of evidence regarding the specic rela-
behavior at work is required by the organization. tionship between age and green behavior in the
Considering the normalization of organizational workplace.
Why Employees Might/Might Not Become behavior as they age. In doing so, older employees
More Green as They Gray might be seen to be attempting to limit their envi-
In light of a paucity of data from which to draw ronmental impact, the costs of which future gen-
conclusions about aging and employee green erations would incur. This also taps into a central
behavior, it is necessary to consider explanations belief at the heart of most denitions of environ-
for how these two constructs might relate based on mental sustainability which is to preserve the
data from related areas. The following positions ecosystem for the benet of future generations
are drawn from the broader literatures on aging, (World Commission on Environment and
general work behavior, and green behavior Development: 1987).
at home. Another argument for why employees might
become greener as they gray draws on positive
Arguments for a Positive Relationship relationships of age with conscientiousness and
On the one hand, there is evidence that environ- agreeableness (Hertel and Zacher 2016; Wiernik
mental values strengthen as people age, and green et al. 2013). First, conscientious employees are
behaviors at home therefore become more preva- more likely to engage in citizenship behavior
lent (Whitmarsh and ONeill 2010). In this regard, (Hertel and Zacher 2016; Wiernik et al. 2013),
stronger environmental attitudes in older people which encompasses approximately two-thirds of
may be explained from a cohort perspective. employee green behavior (Ones and Dilchert
Research suggests that environmental attitudes 2012). Second, and relatedly, older workers might
(as a predictor of employee green behavior; Nor- be more agreeable to the idea of environmental
ton et al. 2015) are relatively stable after early sustainability if the organization demonstrates a
adulthood (Inglehart 1990). Thus, the predisposi- value toward it (e.g., by announcing a shift to
tion to green behavior among contemporary older purchasing renewable energy). Both of these argu-
employees might be explained by the emergence ments implicate the important role of organiza-
of an environmental discourse during their early tional values toward the natural environment.
adulthood (Wiernik et al. 2013). These establish a need within the organization for
Conversely, there is also evidence of a environmental initiatives, to which older adults
U-shaped relationship between environmental might be more agreeable, and provide cues toward
behavior at home and age (Klein et al. 2012), areas where citizenship behavior might be appreci-
suggesting that the effect might not necessarily ated. For example, older employees in organiza-
be straightforward. Specically, green behavior tions with prominent environmental values might
at home is more prevalent in early and late adult- be more inclined to align their behavior to these
hood, but less common during middle adulthood. values, including performing citizenship behaviors
This effect may be attributed to the prioritization that contribute to the organizations environmental
of family-oriented rather than environmental mission.
values as people raise their children in middle Finally, older adults are more inclined to value
adulthood (Hertel and Zacher in press). frugality by being economical and avoiding waste
In this regard, a life span perspective may be (Wiernik et al. 2013). This is relevant to environ-
particularly helpful. Consider, for example, the mental sustainability as environmental initiatives
concept of generativity, which refers to one of often focus on recycling, avoiding waste, and
the motivations in Eriksons (1950) stages of psy- conserving resources (Ones and Dilchert 2012).
chosocial development. In this respect, Curtailing the consumption of resources is often
generativity describes an individuals desire to an early step toward environmental sustainability,
help guide the next generation. From this perspec- as reducing costs associated with waste provides
tive, and in light of omnipresent environmental direct nancial benets to organizations (Kane
issues, there might be justication to hypothesize 2015). Pursuing frugal environmental behavior
that individuals should engage in more green may also be a source of intrinsic satisfaction
(Lee et al. 1995). Thus, for older employees who engage in behavior that prioritizes convenience
value frugality, engaging in green behavior at above environmental interests (e.g., printing doc-
work may have benecial outcomes and contrib- uments to read instead of reading them on the
ute to overall job satisfaction. screen). Alternatively, older employees may
A positive relationship between aging and engage in non-green behavior out of necessity to
green behavior would also provide organizations optimize declining personal resources such as
with three additional opportunities to benet physical ability (Baltes and Baltes 1990). For
simultaneously from an aging workforce and example, an older employee might print a docu-
move toward environmental sustainability. First, ment to review with one page to a sheet because
a positive effect of aging on environmental values s/he wants a larger size print.
E
might be effectively utilized by having older A life span perspective also supports a negative
employees lead the way in communicating relationship between age and green behavior.
and championing green initiatives (Wiernik According to this perspective, older adults might
et al. 2013). Second, if older adults are in fact be less motivated by future consequences. Given
more conscientious than their younger colleagues, that climate change is an intergenerational issue
they might be more predisposed to prosocial (Intergovernmental Panel on Climate Change:
activity such as making environmentally friendly 2014), reduced sensitivity toward long-term con-
suggestions or leading green teams. Third, older sequences removes a signicant motivation to
employees possessing a greater appreciation for behave in an environmentally conscious way
frugality might in effect serve as environmental (Klein et al. 2012). Accordingly, older employees
advisors to purchasing ofcers, emphasizing a might be less affected by environmental cam-
need to resupply resources only when necessary paigns in the workplace that focus on future con-
and suggesting environmentally friendly alterna- sequences of their behavior. This may be
tives. Such roles may have positive outcomes for particularly relevant for initiatives with goals
older employees as well, such as intrinsic satis- that extend into the future beyond the expected
faction derived from frugality (Lee et al. 1995). retirement age of older employees.
Alternatively, organizations might nd that Another argument for a negative relationship
campaigns that emphasize the nancial cost of draws on the hypothesis that habits crystallize
leaving lights on are especially effective for over a persons life span, and accordingly individ-
older employees, who have a heightened appreci- uals become more resistant to change, including
ation for being economical. Thus, a positive rela- efforts to move to more environmentally sustain-
tionship between aging and green behavior could able ways of work. According to this argument,
make older employees valuable assets for organi- older employees would be less likely to replace
zations seeking to engage with environmental old practices (e.g., traveling for meetings) with
sustainability. new practices that incorporate environmental
interests (such as teleconferencing). The empirical
Arguments for a Negative Relationship evidence does not support this stereotype, how-
On the other hand, the idea that green behavior at ever. In fact, there is evidence that resistance to
home decreases with age is supported by the argu- change can even decrease with age (Hertel and
ment that, as people age, they have greater dis- Zacher 2016). In this regard, evidence that people
posable income and therefore become less willing become more agreeable and conscientious as they
to sacrice comfort and convenience (Wiernik age suggests that people become more open to
et al. 2013). For example, whereas younger indi- change as they age (Hertel and Zacher 2016).
viduals might be more willing to open a window Nonetheless, there are valid reasons to conclude
on a hot day, older adults may be more inclined to that people become less likely to engage in green
use air conditioning (Klein et al. 2012). Applied behavior as they age and that older employees
to the workplace, older workers might prefer to may demonstrate fewer green behaviors at work.
If in fact employees become less likely to improvement, as messages utilizing social norms
engage in employee green behaviors as they age, are particularly effective for older employees
organizations might need to install contingencies (Wiernik et al. 2013).
to mitigate such an effect. First, organizations
could address the issue of convenience by Research Recommendations
(a) making green behavior more convenient and With the emerging signicance of an aging popu-
(b) reducing the impact of non-green behavior. An lation and the need for organizations to become
example of making green behavior more conve- environmentally sustainable, there is a real need
nient is for managers to provide information for research on how older employees might better
and/or training on how to schedule computers to engage with green behaviors. At the very least,
turn off and start up in order to avoid drawing researchers should report employee age as a var-
power overnight and during weekends. Another iable in research on employee green behavior.
example would be for organizations to provide Beyond this, it would be interesting to investigate
tablet computers with styluses to allow people to the potential for cohort effects on environmental
make handwritten notes on documents without attitudes and behavior. In this case, the effect of
having to print them rst. An example of a miti- aging on employee green behavior may be mod-
gating tactic would be to dedicate a printer for erated by an individuals experience of the
draft documents that uses recycled paper and ink prevailing social attitudes during early adulthood,
cartridges and a default setting that saves ink and which have changed over time (Wiernik
prints double-sided. et al. 2013). In this regard, the environmental
To address issues from a life span perspec- message individuals receive in early adulthood
tive, organizations might consider reframing might be more important than the effects of
environmental goals and messages to be more aging. Alternatively the effects of aging might be
inclusive of older employees who see themselves moderated by personality traits (e.g., conscien-
close to retirement. Options for this strategy tiousness, agreeableness) or the degree of concern
include creating short-term goals for projects for future generations (i.e., generativity). In effect,
that are likely to extend beyond older employees the effects of aging on employee green behavior
tenure. Alternatively, listed companies could may vary from one person to the next.
offer stock options as part of retirement packages In this entry, we have outlined theoretically
so that older employees can maintain a grounded arguments for why aging might have
vested interest in the companys performance positive and/or negative effects on employee
beyond their employment. Another intervention green behavior. Only empirical evidence can elu-
targeting the life span perspective is to cidate the extent to which, and under what cir-
tailor environmental messages to encompass cumstances, these positions are true. Research
the broader effects of environmental sustainabil- providing insights in this area is likely to have
ity for the general community and future signicant practical implications for how organi-
generations. zations respond to the challenges of an aging
Where environmental sustainability will working force and environmental sustainability.
require the adoption of new behaviors, organiza- Should evidence support the argument for a pos-
tions will likely need to implement interventions itive effect of aging on employee green behavior,
to change non-green habits. This could manifest a next step might be to investigate the effects of
in training programs that challenge assumptions such behavior on older employees job satisfac-
about habitual behavior (e.g., that shutting down tion and work motivation. Conversely, evidence
and powering up a computer uses more electricity for a negative effect of aging on employee green
than leaving it on or is bad for the device) and behavior would shift the focus of research toward
explain and demonstrate green alternatives. Such interventions designed to overcome an emerging
a strategy could be integrated with organizational resistance in older adulthood to employee green
values and norms for innovation and continuous behavior.
Conclusion behaviour. Journal of Environmental Psychology, 27,

1425.
Bureau of Labor Statistics. (2015). Bureau of Labor Sta-
Aging and environmental sustainability are sig- tistics: Labor force statistics from the current popula-
nicant and contemporaneous issues with impli- tion survey. Department of Labor. Retrieved 7 Sept
cations for organizations. In spite of the reality of 2015, from http://www.bls.gov/cps/cpsaat03.htm.
an aging workforce and the need for organizations Davis, M. C., & Challenger, R. (2011). Environmentally
sustainable work behaviors. Wiley encyclopedia of
to operate in environmentally sustainable ways, management Organizational behavior (3rd ed, vol.
there is practically no research to date that has 11, pp. 13). John Wiley & Sons: New York
studied the effect of age on employee green Erikson, E. (1950). Childhood and society. New York:
behavior. What empirical evidence does exist is W. W. Norton.
Goodall, C. (2010). How to live a low-carbon life (2nd ed.). E
insufcient in both quantity and consistency to New York: Earthscan.
infer any conclusions. From a broader perspec- Hertel, G., & Zacher, H. (2016). Managing the aging
tive, there appear to be valid arguments for both workforce. In C. Viswesvaran, N. Anderson,
positive and negative relationships between age D. S. Ones, H. K. Sinangil (Eds.), The SAGE handbook
of industrial, work, & organizational psychology (2nd
and employee green behavior. When interpreting ed, Vol. 3). Sage: London
existing research on aging and environmental Inglehart, R. (1990). Cultural shift in advanced industrial
behavior more generally, it is important to society. New Jersey: Princeton University Press.
acknowledge the possibility for cohort effects. Intergovernmental Panel on Climate Change. (2014).
Intergovernmental Panel on Climate Change: Climate
Specically, our current understanding is derived change 2014 synthesis report. Geneva: IPCC.
using data from a cohort who may not have been Kane, G. (2015). The green executive Corporate
exposed to the same environmental messages as leadership in a low carbon economy. New York:
generations that will be entering older adulthood Earthscan.
Klein, R. M., DMello, S., & Wiernik, B. M. (2012).
in coming decades. Nonetheless, from our under- Demographic characteristics and employee sustainabil-
standing of aging and workplace behavior more ity. In S. E. Jackson, D. S. Ones, & S. Dilchert (Eds.),
generally, older employees may be particularly Managing human resources for environmental sustain-
useful to organizational initiatives that promote ability (pp. 155186). San Francisco: Jossey-Bass.
Kuenen, J. W., Osselaer, J. V., Berz, K., Kaye, C., Sander,
green behavior. A., Schouten, W. J., & Tsusaka, M. (2011). Global
aging How companies can adapt to the new reality.
Boston: Boston Consulting Group.
Cross-References Lee, Y.-J., De Young, R., & Marans, R. W. (1995). Factors
inuencing individual recycling behavior in ofce
settings A study of ofce workers in Taiwan. Envi-
Age, Organizational Citizenship Behaviors, ronment and Behavior, 27, 380403.
and Counterproductive Work Behaviors Mackay, D. J. C. (2009). Sustainable energy Without the
hot air. Cambridge: UIT.
McDaniel, S. A., & Zimmer, Z. (2013). Global ageing in
the twenty-rst century An introduction. In
References S. A. McDaniel & Z. Zimmer (Eds.), Global ageing
in the twenty-rst century Challenges, opportunities
strm, D. O., Forsberg, B., & Rocklv, J. (2011). Heat and implications (pp. 112). Surrey: Ashgate.
wave impact on morbidity and mortality in the elderly Norton, T. A., Parker, S. L., Zacher, H., & Ashkanasy, N. M.
population A review of recent studies. Maturitas, 69, (2015). Employee green behavior A theoretical frame-
99105. work, multilevel review, and future research agenda.
Baltes, P. B., & Baltes, M. M. (1990). Psychological per- Organization & Environment., 28, 103125.
spectives on successful aging The model of selective Ones, D. S., & Dilchert, S. (2012). Environmental sustain-
optimization with compensation. In P. B. Baltes & ability at work A call to action. Industrial and Orga-
M. M. Baltes (Eds.), Successful aging Perspectives nizational Psychology: Perspectives on Science and
from the behavioral sciences (pp. 134). New York: Practice, 5, 444466.
Cambridge University Press. Robertson, J. L., & Barling, J. (2015). Introduction. In
Bamberg, S., & Mser, G. (2007). Twenty years after J. L. Robertson & J. Barling (Eds.), The psychology of
Hines, Hungerford, and Tomera A new meta-analysis green organizations (pp. 311). New York: Oxford
of psycho-social determinants of pro-environmental University Press.
776 Employment of Older Workers
Terkel, S. (1974). Working People talk about what they challenges of rapid population aging (Sonnet
do all day and how they feel about what they do. New et al. 2014). In some countries this is a reversal
York: Parthenon Press.
Whitmarsh, L., & ONeill, S. (2010). Green identity, green of earlier policy aimed at early exit of older people
living? The role of pro-environmental self-identity in from the labor force, when developed countries
determining consistency across diverse responded to recessionary times in the 1980s by
pro-environmental behaviours. Journal of Environ- pushing older workers out of the labor market
mental Psychology, 30, 305314.
Wiernik, B. M., Ones, D. S., & Dilchert, S. (2013). Age through redundancies and early retirement.
and environmental sustainability A meta-analysis.
Journal of Managerial Psychology, 8, 826856.
World Commission on Environment and Development. Definition
(1987). World Commission on Environment and Devel-
opment: Our common future. New York: Oxford Uni-
versity Press. The denition of an older worker varies from
Zagheni, E. (2011). The leverage of demographic dynam- country to country and from context to context.
ics on carbon dioxide emissions Does age structure For example, to take chronological age as a start
matter? Demography, 48, 371399.
point, the OECD older workers scorecard uses the
ages of 55 years to 64 years. Others use the age of
50 to begin discussions about older workers,
and in some cases older workers are deemed to
Employment of Older Workers start from 45 years old. In the USA the Age
Discrimination in Employment Act (ADEA) for-
Judy McGregor bids age discrimination against people from the
AUT University, Auckland, New Zealand age of 40 years, which many might regard as the
start point of middle age.
Whatever the chronological denition used, it
Synonyms is clear, however, that in many countries there is
now a difference between the young old (those
Aging labor force; Mature employees up to 65 years of age) and the old old those who
may be in their seventies, eighties or even nineties
and still in paid employment. It is startling to note
Older Workers the projection that in 35 years time, Japan is
likely to have 550,000 people over the age of 100.
The growing number of men and women who are Clearly, too, thousands of older people are
working longer and the aging of many labor mar- involved in work that is unpaid, particularly
kets are global phenomena without precedent. women who are often caring for older partners
More older people are working, despite large and other dependents. In some cases women are
country differences (OECD 2014). Many people caring for both children and dependents. How-
in the world will live an additional 30 years after ever, whether older workers are paid for their
they have reached the traditional age of retirement labor or not, responses to older workers are
from paid work, and this is forcing a reenvisioning impacted globally by social attitudes and eco-
of the future of work and what retirement nomic growth and stability. For example, policy
means. A complex array of factors, such as in developed countries relating to the category of
increasing longevity, declining fertility rates, older worker is often indexed to a nominal age
changing labor market dynamics, and retirement of retirement where individuals receive universal
policies and practices, are creating a new demog- state or privately funded pension payments.
raphy of work. Looking at the markers of age for older
Many countries are carrying out reforms to workers, it is clear that some regard workers as
encourage longer working lives, to incentivize old when their physical capacities decline and
worker retention, and to respond to the looming their stamina retreats impacting on job
Employment of Older Workers 777
productivity. Others suggest an older worker is The Diversity of Older Workers

marked by declines in cognitive or intellectual
capacities impacting on performance. For others While extending working lives will maximize
chronological age alone marks out an individual older adults income security, not all older people
as an older worker particularly if that is linked to want to work or can access jobs. There are many
incentives for early exit from the labor market. reasons why people work longer including both
There is evidence, too, that perceptions of age positive and negative factors, often referred to as
differ by gender. either push or pull elements or supply- and
demand-side factors. It is a mistake to assume that
older workers are a homogeneous group and
E
Population Aging and Work therefore one policy size will t all.
Many women, in particular, are more likely to
The number of people worldwide aged 60 years be forced to work longer because they have earned
and older is expected to triple by 2050, according less over their working lives and they are living
to projections by the United Nations Population longer. Their earning potential may be inuenced
Division. Not only that, the share of the population by womens traditional occupational segregation
in older age groups is increasing. At least four in lesser-paid work (such as cleaning, clerical, and
trends are apparent in population aging that impact caring work) and/or because of work interruption
on the employment of older workers in general. when bearing and raising children and having
First, population aging is not conned to some primary or sole responsibility for family and
countries only but is everywhere, including the domestic life. The global nancial crisis also
youngest countries and developing nations. For disproportionally impacted on older adults and
example, the six Gulf countries, which have tradi- saw many lose signicant portions of their retire-
tionally relied on expatriate workforces, acknowl- ment assets at a time of intensied competition for
edge that their two main demographic challenges jobs and resources. However, it has been shown
by 2050 will be population aging and a slowdown that irrespective of age, women usually face dim-
of the increase in national workforces. Second, mer job prospects than men.
population aging is a major life force and impacts Older workers are a multifaceted and diverse
not only on employment in terms of job demands group. Categories of older workers include those
but also health, economic security, and social cohe- who are retained in paid employment beyond the
sion. Third, population aging is occurring quickly conventional retirement age when an employer
and the pace is accelerating, and, fourth, it is taking needs their skills, older people who reenter the
place at different rates around the world. For exam- labor market for job satisfaction and feelings of
ple, in Asia, while Japan was the rst country to self-esteem that the structure of work gives them,
face the age wave, South Korea and China fol- and those who downscale to different, lesser-paid
low and then India and Pakistan (Hayutin 2009). jobs. The majority of older workers are part-time
The supply and demand of jobs in a global by choice or by demand, and many are employed
labor market is characterized increasingly by job on temporary contracts only because that is all that
mobility and migration to nd work. Older is available to them. Increasingly, too, there are
workers are not immune from these trends. They thousands of older people who are self-employed
are also crucial to vital sectors where worker including farmers in agricultural sectors and in
shortages are profound. The World Health Orga- small businesses around the world, including
nization in 2013 estimated that there would be a some older workers who buy themselves a job
shortage of 12.9 million healthcare workers by through self-employment.
2035. In areas of great need like sub-Saharan The different types of older work have
Africa, shortages are particularly acute. Nursing, prompted new terms such as job shifting,
for example, is an occupation which is aging which can mean moving from a highly paid and
rapidly (Graham and Dufeld 2010). full-time position to a lesser-paid, part-time job as
an older worker, and encore career, a term cov- published in 2006 Live Longer, Work Longer
ering thousands of Americans in particular who (OECD 2006) which implicitly suggests that
have shifted in the second half of their lives to extending a working life will increase life span.
second careers in areas like the environment, non- Often this perspective is referred to as positive
prot sectors which blend income and social aging or active aging, and it is a policy framework
impact (Freedman 2007). used by Western governments in particular to
place working longer in a favorable social context.
In the positive aging context, older workers are
Motivations for Working Longer seen as productive, contributing economically
(Butler 2009) and increasing their own self-
Some people want to work longer at an older age. esteem and self-efcacy through the structure of
In some cases this aspiration is made easier by the work. In this optimistic scenario, the choice to
general shift over time from manufacturing and continue on working as an older person is charac-
service industry jobs, which required sustained terized by individual autonomy and the human
physical labor and took a toll on older bodies, to rights of older people (Ofce of the Human Com-
the knowledge economy where physical body missioner for Human Rights 2012). Humorist and
demands are less onerous. It is no surprise, for writer George Bernard Shaw once said, A per-
example, that in many countries, such as South petual holiday is a good working denition of
Africa, Australia, Canada, and the United King- hell.
dom, the education sector is one area which older The second perspective suggests that older
workers nd attractive in terms of retention of people may be more likely to be in precarious
their skills and labor. work (International Labour Organization 2012)
Others are compelled to work longer at an as opposed to decent work. Precarious work
older age than their parents, for example, to is characterized as uncertain, risky, and
increase their nancial security. There is less cer- unpredictable, sometimes without employment
tainty that some countries can absorb the full costs protections in the law, often casual work without
of their aging populations especially where there certainty of hours from day to day or week to
are limited existing retirement income schemes or week, and mostly low paid and contingent
state pensions. (Sargeant and Frazer 2009). The idea has been
It is clear that education matters. Across OECD popularized by Guy Standings work in which he
countries, well-educated people are more likely to describes the precariat as the new dangerous
work longer than the less skilled. This gap, class (Standing 2011). He states that old agers
though, probably cannot be separated from the have become a source of cheap labour, paid low
deepening inequality divide between those who wages, given few benets, easily sacked. This is
are well educated and better-off and those who are undoubtedly true of some older workers only,
poor and unskilled with low educational attain- particularly women, ethnic minorities, and
ment, irrespective of age. migrant workers, who are often in precarious
work that creates greater economic inequality,
insecurity, and instability.
Perspectives About Working Longer
It is clear that there are both challenges and oppor- Social Attitudes, Discrimination,
tunities associated with older workers. Two per- and Older Workers
spectives have traditionally dominated discussion
about working longer. First, there is the perspec- Ageism, which constitutes negative societal atti-
tive that sees working longer as benecial to indi- tudes about age, and age discrimination at work
viduals, families, communities, and society. This are of concern throughout the world. Age discrim-
is reected in the title of a major OECD report ination means older people are disadvantaged in
Employment of Older Workers 779
individual or cumulative aspects of work such as or the need for health and safety considerations, or
job hiring, pay and reward systems, promotions, the need to recruit and appoint young people.
job assignments, training opportunities, and The mass media, and the news media in partic-
fringe benets. This is despite different cultural ular, have been criticized for promoting the cult of
contexts in which older people are revered for youth as celebrities in sport, leisure, and fashion
their wisdom and knowledge and regarded as and in the world of work. This led to the comment
elders with dignity and respect in family struc- that the mass media has powerfully and negatively
tures and communities. inuenced both public opinion generally, and
Age discrimination is often invisible and covert employers attitudes specically, on the subject of
and often not easy to prove despite statutory prohi- older workers (McGregor 2005). Concern has
E
bition in many countries. The emphasis on age also been expressed consistently at the way older
discrimination is not necessarily because of a new workers are stereotyped in print advertisements and
appreciation of the need for fairness. Fredman commercials and online marketing, despite the
(2011) says it gains its chief impetus from macro- potential purchasing power of older workers in
economic imperatives, but this should not obscure paid employment (Treguer 2009).
the fact that it is unjust. The impacts of exclusion
from the labor market of older people on the basis
of age should not be underestimated in terms of Changing Employer Practices
poverty, ill-health, and depression, as well as self-
esteem and social isolation. A variety of human resource strategies are neces-
Experiments in Spain, Sweden, Scotland, Ger- sary to attract, retain, and accommodate older
many, Norway, New Zealand, and Australia, among workers, in addition to labor market and pension
other countries, have shown that if matching appli- policies. Companies need to retain and transfer
cations from job candidates with equal qualica- institutional knowledge, for example. They also
tions are presented to employers, the younger need older workers to mentor and coach younger
applicant will be preferred. Older applicants were and intermediate workers. Corporates, compa-
not preferred, not on the basis of merit or compe- nies, and small businesses need to manage diverse
tencies, but simply on the discriminatory basis of workforces that are representative of their own
their age (Wilson et al. 2007). However, employers client and customer bases, and they need to be
seldom identify chronological age as the criterion able to keep older workers productive.
on which they have preferred one candidate over Many transnational corporations and multina-
another. It is often very difcult for a mature job tional companies can afford enlightened and pro-
seeker to establish that old age was the grounds on gressive employer policies and practices that
which they did not get a job. balance their workforces by age. Companies
Age discrimination laws usually include the around the world, such as Singapore Health Ser-
whole employment cycle starting from job adver- vices Ltd., with 20% of its 15,000 workforce
tisements which are expected not to refer to the above 50 years of age, have innovative human
age of applicants through to exiting from the labor resource policies (Tan 2009). These include
market through retirement or redundancy. Laws reemploying retirees, exible work arrangements
prohibiting age discrimination have been used by such as exitime, project work and part-time work
specic occupational groups such as airline pilots, and customized employment contracts, job shar-
judges, and university teachers, among others, to ing, and telecommuting.
challenge mandatory retirement ages in various However, a challenge for many smaller orga-
countries with mixed success. In the European nizations is that older workers are often the most
Union, for example, the courts can say that an expensive. Higher pay has often been linked to
objective justication for not employing older seniority and job tenure. Some employers wish to
people is the need for intergenerational fairness rationalize both succession planning and wage
or to balance the age structure of an organization, costs, without breaching age discrimination
legislation. Whether older workers, especially workforces are impacting on economic growth.
middle-class baby boomers, would accept or can Global research shows that older workers often
afford lesser wages as retirees or be attracted to feel they are discriminated against in selection for
different jobs for less money is a moot point. training opportunities (McGregor and Gray
However, tailoring wage and benet systems 2002).
accordingly may become urgent in some sectors.
Future Trends
Employability of Workers
There is much research on or about older
Many older workers, who have choice about workers. Comparatively little is known about the
whether to work or not, make an individual deci- perceptions and experiences of older workers
sion about job retention, on their own personal themselves, and their voices have become the
sense of employability. This could include con- missing voices in policy frameworks around
sideration of their currency in the skills, knowl- older workers, aging, and employment. It is criti-
edge, and technology required by their cal that future research addresses this omission. It
occupational choice. Sometimes this is profes- is also essential that older workers are not viewed
sional registration, sometimes it is new software, by legislators, policy makers, and employers as
and sometimes it is the inability to be productive one homogeneous grouping. No other population
and keep up in a factory environment. In some groupings, such as children, or young people, or
cases the decision is health related. Older workers the middle aged, span 3040 years of life. A single
may develop age-related illnesses or disabilities description whether it be old age or older worker
that curtail working longer and prompt exit from is insufcient. It is therefore imperative that
the labor market. national statistical collections, censuses, and
In other cases, inadequate workplace design international data collections allow for disaggre-
such as insufcient lighting or inadequate ergo- gation past the age of 65 years to develop a more
nomic support (making computers easier to see, sophisticated mapping of older people. This will
hear, and use) pushes an older worker out of the help governments, policy agencies, employers,
labor market. An English study showed older and older people themselves plan for the future.
workers found it difcult to work in open-plan The idea that older workers are taking jobs
environments because of noise, light, and cold from young people and that this could provoke
temperatures and older workers say they want to or incite intergenerational tensions with younger
learn new technology at their own pace, in face-to- people has been largely discredited. The idea of a
face situations rather than in environments where xed number of jobs with winners and losers is a
they are expected to either rely on Internet pack- variation of what economists call the lump of
ages or compete with tech-savvy, younger labor fallacy. Research shows that there is no
workers (Myerson 2009). Work intensication evidence that increasing the employment of
and job creep in areas like aged care, where older persons reduces either the job opportunities
more is expected in less time along with increas- or wage rates of younger workers (Munnell and
ing employer expectations, are other reasons older Wu 2013). Global problems of youth unemploy-
workers give for exiting. ment have many patterns and complexities that
An issue of increased salience to older workers are different to those inuencing older worker
is lifelong learning to sustain employability. Adult unemployment and access to employment.
learning for job training either to refresh or renew However, an under-researched area requiring
job-related knowledge and skills and nancial future scholarship and debate concerns the
incentives to encourage it are not necessarily intergenerational transfers and accommodations
mainstream policy even in countries where older that will have to take place in workplaces of the
Encephalopathy 781
future. As the aging population increases and as OECD. (2006). Live longer, work longer. Paris: OECD
the labor market gets older, how will older people Publishing.
OECD. (2014). Labour Market Statistics. Labour force
work? What incentives will they require not to statistics by sex and age. OECD Employment and
retire? Only some of the answers to these signif- Labour Market Statistics (database). doi:10.1787/
icant questions are known today. data-00309-en.
Ofce of the Human Commissioner for Human Rights.
(2012). Normative standards in international human
rights law in relation to older persons: Analytical out-
Cross-References come paper. Geneva: United Nations.
Sargeant, M., & Frazer, A. (2009). Older workers as vul-
nerable workers in the new world of work. In: 15th
Organizational Strategies for Attracting, world congress of the international industrial relations E
Utilizing, and Retaining Older Workers association (IIRA), Sydney.
Recruitment and Selection of Older Workers Sonnet, A., Olsen, H., & Manfredi, T. (2014). Towards more
inclusive ageing and employment policies: The lessons
Stress and Well-Being: Its Relationship to Work from France, The Netherlands, Norway and Switzerland.
and Retirement for Older Workers De Economist. 162.315-339. doi:10.1007/s10645-014-
Technology and Older Workers 9240-x.
Standing, G. (2011). The precariat: The new dangerous
class (p. 140). London: Bloomsbury Publishing.
References Tan, S. K. (2009). Human resources strategies for engaging
and retaining older workers. In: Re-inventing retire-
ment Asia: Employment and active engagement beyond
Butler, R. N. (2009). The longevity revolution: The benets
50. AARP and Council for Third Age, Singapore. Jan
and challenges of living a longer life. New York: Public
89. 40.
Affairs.
Treguer, J. P. (2009). Media and messaging: Changing atti-
Fredman, S. (2011). Discrimination law. Oxford: Oxford
tudes and perceptions. In: Reinventing retirement Asia:
University Press.
Employment and active engagement beyond 50. AARP
Freedman, M. (2007). Encore: Finding work that matters
and Council for Third Age, Singapore. Jan 89. 84.
in the second half of life. New York: Public Affairs.
Wilson, M., Parker, P., & Kan, J. (2007). Age biases in
Graham, E., & Dufeld, C. (2010). An ageing nursing
employment: Impact of talent shortages and age on
workforce. Australian Health Review, 34, 4448.
hiring. University of Business Review, 9(1), 3341.
Hayutin, A. (2009). Four pillars of economic security. In:
Reinventing retirement Asia: Employment and active
engagement beyond 50. AARP and Council for Third
Age, Singapore. Jan 89.
International Labour Organisation. (2012). From precari-
ous work to decent work: Outcome document to the Encephalopathy
workers symposium on policies and regulations to
combat precarious employment. Geneva: International
Labour Organisation.
Sarah Borish1, Hannah Brunet1,
McGregor, J. (Ed.). (2005). Lifeswork: Celebrating older Victoria Liou-Johnson2,3 and Joel Kramer1
1
workers in New Zealand. Wellington: Dunmore University of California, San Francisco, San
Publishing. Francisco, CA, USA
McGregor, J., & Gray, L. (2002). Stereotypes and older 2
workers: The New Zealand experience. Social Policy University of California, San Francisco, CA,
Journal, 18, 163177; Loretto, W., White, P. (2006). USA
3
Employers attitudes, practice and policies towards Sierra Pacic Mental Illness Research Education
older workers. Human Resource Management Journal, and Clinical Center, VA Palo Alto Health Care
16(3), 313300.
Munnell, A. H., & Wu, A. Y. (2013). Do older workers System, Palo Alto, CA, USA
squeeze out younger workers? Stanford Institute
for Economic Policy research, discussion paper
no. 13-01. Synonyms
Myerson, J. (2009). workplace design for the aging work-
force. In: Re-inventing retirement Asia: Employment
and active engagement beyond 50. AARP and Council Autoimmune Disease; Encephalitis; Infections;
for Third Age, Singapore. Jan 89. 56. Neuroinammation; Prion Disease
782 Encephalopathy
Definition predominant psychiatric and cognitive symptoms.

These syndromes are more likely to present with
Encephalopathy is a broad term for any brain subacute delirium that may not be immediately
disease that affects brain functioning. obvious. Unlike a classic delirium, subacute pre-
sentations are marked by cognitive changes over
Encephalopathy refers to a broad category of con- days and weeks rather than a more rapid, 24-h
ditions that disrupt normal brain functioning. Like window (Flaherty 2011). As such, these
many broadly dened conditions, etiology and conditions are frequently misdiagnosed as neuro-
clinical presentation vary extensively. Etiologies degenerative diseases or psychiatric illnesses.
can include vascular conditions, autoimmune dis- Practitioners who work with older adults must be
orders, infectious and viral agents, cancer, familiar with these diseases in order to make
paraneoplastic syndromes, hypoxia, systemic appropriate referrals for diagnosis and treatment,
medical illness, neurodegenerative disorders, especially given that so many of these disorders
prion disease, medications, metabolic conditions, are treatable and reversible.
traumatic brain injury, and toxins. Symptoms may This entry will give a brief overview of several
include delirium, altered mental status, seizures, types of encephalopathies that are more likely to
cognitive decits, motor impairment (e.g., weak- present outside of traditional acute care settings or
ness), psychosis, personality changes, and other neurology clinics. First, this entry will review
psychiatric symptoms (Roos and Brosch 2012). anti-NMDA receptor encephalopathy (ANRE),
The average age of onset for these conditions which presents with predominant psychiatric fea-
varies somewhat according to etiology; however, tures. Next, the entry will review voltage gated
older age is almost universally a risk factor for the potassium channel encephalopathy, Hashimotos
development of encephalopathy, with the majority encephalopathy, herpes simplex encephalopathy,
of patients presenting over the age of 50 (Paterson and spongiform encephalopathy (i.e., prion dis-
et al. 2012). Risk for developing encephalopathy ease) all of which often present with marked cog-
increases with age, such that as adults move into nitive changes. Notably, both cognitive and
their 40s, 50s, and 60s, risk for onset of these psychiatric changes are common among individ-
conditions intensies. uals with these encephalopathies and understand-
The most common forms of encephalopathies ing core symptom proles may be helpful in
present with clear changes in mental status and/or making appropriate referrals.
delirium. For example, hepatic encephalopathy
presents in the context of liver failure with confu-
sion, altered consciousness, and ultimately coma Anti-NMDA Receptor Encephalopathy
and/or death. Similarly, uremic encephalopathy
can develop in patients with acute or chronic N-methyl-D-asparate (NMDA) receptors are glu-
kidney failure. Subdural hematomas, most often tamate receptors found throughout the central ner-
secondary to traumatic brain injury, can cause an vous system and are thought to be involved in
encephalopathy marked by headaches and cognitive functioning and psychiatric illness, par-
changes in consciousness. Wernickes encepha- ticularly psychosis. Anti-NMDA receptor
lopathy (WE), caused by a thiamine deciency encephalopathy (ANRE) is an autoimmune dis-
secondary to chronic alcohol use, HIV/AIDS, ease, a condition in which the body mounts an
and malnutrition, is marked by confusion, ataxia, immune response against itself. In the case of
and weakness (Weathers 2013). These acute med- ANRE, the immune system develops antibodies
ical disturbances are typically treated in primary to attack NMDA receptors in the brain. ANRE is
medical settings and are unlikely to be seen by characterized by acute psychiatric and neurologi-
most geropsychologists. cal symptoms including psychosis, seizures,
However, several encephalopathies can pre- fatigue and/or reduced consciousness, breathing
sent with a more insidious onset and with difculty, and abnormal movements (Vitaliani
Encephalopathy 783
et al. 2005). While the median age of onset is common. Diagnosis is conrmed by testing the
24, cases of ANRE have been reported in older cerebrospinal uid (CSF) for antibodies to the
adults up to 76 years of age (Dalmau et al. 2008). NMDA receptor (Sansing et al. 2007). For
ANRE is often associated with a type of tumor, an Calahan, it took over a month to receive an accu-
ovarian teratoma, which is found in almost 59% of rate diagnosis (Cahalan 2012). Accurate diagnosis
patients with the disease. In the subset of cases is critical because ANRE is responsive to treat-
that are associated with malignancies, the immune ment, which usually involves immunotherapy,
response to the tumor also attacks parts of the such as corticosteroids or plasma exchange, as
central nervous system, which is known as a well as surgical tumor removal (Dalmau
paraneoplastic syndrome. In a case series by et al. 2008). Many patients achieve full recovery
E
Dalmau et al. (2008) the median age of onset or exhibit only mild lasting decits; however,
was 23 and predominantly female (91%). The some patients experience severe lasting effects
symptom presentation is often dominated by psy- and the disease can be fatal (Dalmau et al. 2008).
chiatric symptoms including psychosis. In a pop-
ular book published in 2012, author Susannah
Cahalan provides a rst-hand account of her expe- Voltage Gated Potassium Channel
rience with this disease. Her initial symptoms Antibody Associated Encephalopathy
included psychosis and emotional lability, and
providers diagnosed her with an alcohol use dis- Voltage gated potassium channel encephalopathy
order and schizoaffective disorder (Cahalan (VGKC) is an autoimmune condition that is par-
2012). This is not uncommon for patients with ticularly common in adults over 50 and presents
ANRE; many have gone undiagnosed for months more often in males than females. In healthy
because they were thought to have primary psy- adults, voltage gated potassium channels regulate
chiatric disorders. Other features include seizures neurotransmitter release but with abnormal
(76%), reduced alertness or unresponsiveness expression of these antibodies, an encephalopathy
(86%), autonomic dysfunction, such as difculty may develop.
breathing and slowed heart rate (69%). Ulti- The clinical prole of VGKC is marked
mately, Cahalan (2012) was transferred to an inpa- by acute cognitive changes, seizures, and
tient neurology department in response to onset of hyponatremia (Bettcher et al. 2014). Some
seizures. Many patients also exhibit abnormal research suggests that seizure activity may repre-
movements, often orofacial dyskinesias such as sent the rst symptom of VGKC, although they
grimacing or chewing movements, or limb pos- may not be clinically obvious if they are focal
turing, which can sometimes be mistaken for sei- temporal seizures that do not generalize and pre-
zures (Dalmau et al. 2008). Nonspecic u-like sent with tonic-clonic movements. In a compre-
symptoms (e.g., fever, headache) are also com- hensive literature review, Radja and Cavanna
mon just before the onset of the acute neurological (Radja and Cavanna 2013) found that seizures
and psychiatric symptoms (Sansing et al. 2007). were present in 85% of patients diagnosed with
While many patients exhibit seizures as part of VGKC; seizures often preempted subsequent cog-
the ANRE clinical syndrome, most patients will nitive changes. Severe episodic memory impair-
exhibit abnormalities on electroencephalogram ment is a core feature of VGKC; over 97% of
(EEG) monitoring, including slowing without patients present with memory impairment (Radja
overt epileptic activity (Dalmau et al. 2008). and Cavanna 2013). Changes in executive func-
Approximately half of patients exhibit abnormal- tioning and language have also been observed.
ities on magnetic resonance imaging (MRI), Neuropsychological tests measuring verbal u-
which most commonly consist of hyperintensities ency and set-shifting appear to be particularly
observed on T2 and FLAIR images in medial sensitive to the language and executive function-
temporal structures and the cerebellum (Sansing ing changes associated with VGKC (Bettcher
et al. 2007). Impairments on cognitive testing are et al. 2014). Finally, psychiatric symptoms are
784 Encephalopathy
also common in this population, affecting approx- associated with Hashimotos thyroiditis (HT), an
imately 33% of patients (Radja and Cavanna autoimmune disorder in which antibodies attack
2013). Specic symptoms include agitation, the thyroid gland. In rare instances, the autoim-
insomnia, hallucinations, and depression. In mune reaction may cause an inammatory
case studies, patients have presented with response in the thyroid receptors of the brains
schizophrenia-like syndromes that progress to limbic system. Although the autoimmune reaction
delirium, stressing the presence of affective symp- is not limited to the limbic system, it is nonethe-
toms in this disorder (Parthasarathi et al. 2006). less referred to as a limbic encephalopathy. Only a
MRI ndings among patients with VGKC are small fraction of Hashimotos thyroiditis patients
consistent with the neuropsychological prole; in may develop HE; it is estimated that HE occurs in
particular, the medial temporal lobes appear to be only 2.1/100,000 people (Ferracci et al. 2004),
hyperintense on imaging in approximately 80% of while HT occurs in approximately 1/1000 people.
patients (Bettcher et al. 2014; Radja and Cavanna Hashimotos encephalopathy may present in
2013). This is consistent with a limbic encepha- patients of all ages, including older adults, with a
lopathy in which autoimmune diseases primarily mean age of onset in the mid 40s (Chong
target the limbic system. Phenotypically, limbic et al. 2003). Approximately 80% of reported
encephalopathies are associated with neuropsy- cases are female. Due to the heterogeneity of
chiatric symptoms (e.g., psychosis, anxiety), sub- presentation, subtypes have been proposed:
acute behavioral changes, cognitive decline, steroid-responsive encephalopathy associated
seizures, and uctuating course. Neuroimaging with autoimmune thyroiditis (SREAT) (Castillo
in limbic encephalopathy cases can present with et al. 2006) and nonvasculitic autoimmune inam-
abnormalities in the medial temporal lobes, matory meningoencephalitis (NAIM) (Caselli
although this is not identied in all cases et al. 1999). Regardless of type, a dening trait of
(Paterson et al. 2012). These conditions rarely HE is that it is steroid-responsive. High serum
affect the medial temporal lobes in isolation, and antithyroid antibody must be present in order to
for VGKC, additional involvement of the lateral diagnose HE, while other diagnostic tests may vary
frontal lobes, basal ganglia, and white matter (Wood-Alum and Shaw 2014).
structures has been identied. Patients who present with HE may display a
VGKC is highly responsive to treatment with wide range of symptoms, which can make the
immunosuppresants (Radja and Cavanna 2013). syndrome difcult to identify. Older adult patients
Over time, cognition typically improves mark- often present with more subtle symptoms, such as
edly, and patients report subjective improvements anxiety or cognitive impairment, but they may
in all cognitive domains and psychological also exhibit other psychiatric symptoms including
domains, as well as remission of seizures (Radja psychosis, uctuating states of consciousness and
and Cavanna 2013). However, longitudinal evi- attention. Many patients may present with stroke-
dence suggests that some patients continue to like symptoms such as aphasia, hemiparesis,
have cognitive difculties in one or more domain weakness, blindness, headache, gait unsteadiness,
even after treatment (Bettcher et al. 2014). and seizures can also occur (Weathers 2013;
Chong et al. 2003; Wood-Alum and Shaw 2014).
Because of these varying characteristics, patients
Hashimotos Encephalopathy presenting with these symptoms may be
misdiagnosed and thus treated inappropriately.
Hashimotos encephalopathy (HE) is a rare con- Additionally, elevated antithyroid antibodies
dition that was rst characterized by Brain may be present with other nonthyroid related
et al. (1966) in a 48-year-old male who presented autoimmune disorders; therefore, blood labs
with stroke-like symptoms of aphasia and right alone cannot diagnose HE. Other diagnostic tests
hemiplegia (Brain et al. 1966). The causes of HE may include electroencephalography and/or neu-
are not clearly understood, but it is thought to be roimaging (Wood-Alum and Shaw 2014).
Encephalopathy 785
The treatment of HE is varied due to the rarity but cases have been documented with focal
of the disorder; therefore optimal dosage, lesions in the brain stem rather than the cortex
duration, and course of treatment is unknown. (Tyler et al. 1995). At present, the particular trig-
The initial case identied by Brain and gers for onset of HSE remain unclear. Researchers
colleagues (1966) reported symptomatic remis- hypothesize that HSV-1 targets the cortex through
sion with levothyroxine treatment alone (Brain the olfactory bulbs, thereby leaving the
et al. 1966). Subsequent studies have reported orbitofrontal and medial frontal lobes particularly
an approximate 65% effectiveness with vulnerable to the deleterious effects of the disease
levothyroxine alone, while steroid treatment (Widener and Whitley 2014). However, others
alone has yielded an estimated 98% effectiveness have argued that the trigeminal nerve serves as
E
(Wood-Alum and Shaw 2014). Additional treat- the primary pathway through which the virus tar-
ments may include a combination of medications gets the CNS (Tyler et al. 1995).
and/or intravenous immunoglobulin therapy or Initial symptoms associated with HSE include
plasmapheresis for more resistant cases. Despite changes with cognition including altered mental
the lack of clear diagnostic and treatment criteria, status and speech decits as well as concurrent
steroidal treatment generally yields good progno- fever and headache (Berk and Myers 2010).
ses and remission of symptoms. Given the vulnerability of temporal regions in
HSE, patients frequently show neuropsychological
decits in language, (e.g., naming and semantic
Herpes Simplex Virus Encephalitis knowledge) as well as episodic memory. As with
other types of encephalitis, early symptoms are
Encephalitis caused by the herpes simplex virus frequently psychiatric. In cases of HSE, acute per-
(HSE) is the most common form of sporadic and sonality change and olfactory hallucinations are
fatal encephalitis in the world (Whitley common. The presence of olfactory hallucinations
et al. 1998). Unlike HE, VGKC, and ANRE and nasal eld defects are important potential indi-
which are caused by autoimmune disorders, HSE cators for HSE (Berk and Myers 2010). Addition-
is caused by viral infection. Approximately 1250 ally, patients with this diagnosis often experience
cases are diagnosed annually, half of the cases are temporal lobe seizures and hemiparesis.
diagnosed in adults over 50 (Tyler 2004), and In addition to carefully reviewing symptoms,
HSE affects men and women equally (Berk and diagnosis can be conrmed by CSF analysis,
Myers 2010). Typically, the herpes simplex virus- EEG, and imaging. Early in infection, CSF will
type I (HSV-1), commonly known to cause show elevated lymphocytes and red blood cells
orofacial lesions, causes HSE. The HSV-2 variant suggestive of hemorrhage and/or damage to the
associated with genital lesions and neonatal infec- bloodbrain barrier (Berk and Myers 2010; Wid-
tions is the source of only 10% of documented ener and Whitley 2014). EEG pattern is typically
HSE cases. Patients with compromised immune abnormal with slow waves most notable in the
systems appear to be particularly vulnerable to temporal lobes; occasional lateralization is also
HSE. Primary HSV-1 infections among individ- highly suggestive of HSE. Finally, MRI scans
uals with no previous history of HSV-1 antibodies are highly sensitive to HSE-related brain changes,
are responsible for approximately 1/3 of HSE particularly in early stages of the disease. Early
cases, while recurrent infections cause the MRI changes reveal edema and hyperintensities
remaining 2/3 of HSE cases (Widener and in the orbitofrontal and medial temporal lobes.
Whitley 2014). Additionally, early imaging often identies
In HSE, HSV-1 produces inammation in the changes in the insula and external capsula with
CNS that leads to hemorrhage and necrosis of later involvement of the cingulate (Widener and
brain tissue (Widener and Whitley 2014). HSE Whitley 2014). Although brain biopsy used to be
most frequently affects the medial temporal the only denitive diagnostic mechanism of HSE,
lobes and the orbitofrontal regions of the brain, polymerase chain reaction (PCR) now represents
786 Encephalopathy
the gold standard for both assessing the presence patients do not survive past 1 year. The disease
of HSV in the CNS and monitoring treatment most often affects older adults with the typical age
response in patients with HSE (Widener and of onset falling between 55 and 75. Patients in this
Whitley 2014). age group presenting with a rapid decline in cog-
Early diagnosis and treatment with acylcovir nitive functioning should raise concern for CJD or
for HSE is imperative. Without treatment, the another spongiform encephalopathy (Geschwind
mortality rate for HSE is over 70% (Berk and 2015).
Myers 2010; Widener and Whitley 2014). Even The clinical syndrome for CJD includes behav-
among patients who receive treatment, long-term ioral symptoms, gait abnormalities, extrapyrami-
cognitive consequences are frequent; only 2.5% dal symptoms such as dystonia and Parkinsonism,
of patients diagnosed with HSE ultimately and myoclonus (muscle twitching). Initial symp-
recover normal neurological and cognitive status toms most commonly include cognitive symp-
(Ward and Roizman 1994). Prognosis is directly toms, characterized by memory loss, language
related to prompt treatment as level of conscious- dysfunction, executive functioning difculties,
ness at treatment onset is correlated with out- and confusion. Other early symptoms that occur
comes (Berk and Myers 2010). Additionally, in about one third of patients include fatigue,
worse prognosis is associated with older age at headache, dizziness, and changes in appetite and
onset and symptom duration longer than 4 days sleep. Almost half of patients experience behav-
prior to treatment initiation (Widener and Whitley ioral symptoms at some point during the disease
2014). course, which include agitation, depression,
aggression, apathy, or personality change, and
are therefore often misdiagnosed with psychiatric
Prion Diseases disorders. One third of patients experience lan-
guage dysfunction (aphasia), difculty with
Prion diseases, also referred to as spongiform motor planning (apraxia), neglect, and difculty
encephalopathies, are responsible for a variety of with arithmetic calculations. CJD affects vast
rapidly progressive dementias. Normal prion pro- areas of the brain and because of the variability
teins are found in the membranes of cells. Prion in symptom presentation it can be challenging to
diseases are caused by misfolded prion proteins accurately diagnose (Geschwind 2015).
that propagate throughout the central nervous sys- Diagnostic tests include EEG, MRI, and
tem. Prion diseases can occur spontaneously, as a CSF. EEG abnormalities may not appear until
result of an inherited genetic mutation, or acquired later in the disease course. MRI, particularly
through infection or other mechanism of transmis- uid-attenuated inversion recovery (FLAIR) and
sion. In the USA, the incidence rate of prion diffusion-weighted imaging (DWI) sequences,
disease is about 1 in 1 million, and sporadic reveals abnormalities in the deep gray matter
Creutzfeldt-Jakob disease (CJD) comprises most nuclei as well as hyperintensity in the cortical
of the diagnosed cases. As it represents the most gyri, known as cortical ribboning. CSF tests may
common form of prion disease, and often presents not always reveal abnormalities in patients with
with cognitive, motor, and behavioral symptoms, CJD but a minority of patients may have elevated
CJD will be discussed in more detail. Geschwind proteins found in CSF (Geschwind 2015).
(Geschwind 2015) described the clinical syn-
drome and diagnostic considerations in CJD and
other prion diseases (Geschwind 2015). Wernickes Encephalopathy
Many dementias caused by neurodegenerative
conditions, such as Alzheimers disease, progress Wernickes encephalopathy (WE) results from
slowly and gradually over many years. In contrast, thiamine (vitamin B1) deciency often secondary
CJD is characterized by a very rapid course; the to poor nutrition and poor vitamin absorption in
median length of survival is 5 months and most those who chronically abuse alcohol. In addition
Encephalopathy 787
to poor diet and alcohol misuse, other risk factors until later in the disease course (Sechi and Serra
include bariatric surgery, chronic vomiting or 2007). Unfortunately, this syndrome does not
diarrhea, and chemotherapy in those undergoing improve even with treatment to correct thiamine
treatment for cancer (Sechi and Serra 2007; Zahr deciency (Butters 1980).
et al. 2011). Some individuals also have a genetic WE is important to identify correctly because if
susceptibility for reduced thiamine afnity untreated, it can lead to coma and death. WE can
(Guerrini et al. 2005). Thiamine is involved in be differentiated from more commonly seen neu-
important neurological processes such as the rodegenerative disorders in older adults based on
production and maintenance of myelin, commu- the rapid onset. In addition to the clinical signs,
nication between neurons, and producing neuro- blood tests to determine thiamine levels and MRI
E
transmitters such as GABA. Lesions in brain areas ndings have the most diagnostic utility (Lough
most vulnerable to thiamine deciency can be 2012). However, the nonspecic nature of the
observed after as little as 3 weeks of thiamine symptoms make it easy to misdiagnose. Early
depletion (Schenker et al. 1980). symptoms often include headache, fatigue, and
WE is rare with 2% prevalence rates in the irritability and can present differently across indi-
USA, and it affects men almost twice as often as viduals. Furthermore, symptoms can be difcult
women. The classic triad of WE symptoms to differentiate from acute alcohol intoxication
includes altered mental status, eye movement when patients present to medical settings
changes, and unsteady gait, although these symp- (Thomson 2002).
toms are not universal. Altered mental state sec-
ondary to WE includes confusion, slowed
thinking, apathy, reduced awareness, and concen- Conclusions
tration difculties (Sechi and Serra 2007). Eye
movement abnormalities occur in approximately Encephalopathies are varied in etiology and pre-
one third of patients and can include gaze palsy sentation. Despite this variability, there are certain
and involuntary quick jerking of the eyes known categories of symptoms that are common across
as nystagmus. Motor and gait abnormalities most these syndromes. Cognitive changes, uctuations
often present with poor coordination and unsteady in consciousness, and psychiatric symptoms are
gait. Gait ataxia in WE patients is typically char- highly prevalent in encephalopathies, regardless
acterized by a wide stance with short, unsteady of specic etiology. With disease progression,
steps (Lough 2012). Psychiatric symptoms such seizures are common. Given that patients with
as agitation and hallucinations have also been these symptoms may present in primary care
reported (Zahr et al. 2011). clinics, geriatric medical clinics, as well as psy-
WE can occur with or without Korsakoffs chiatry and psychology departments, it is impor-
syndrome, although the majority of patients with tant that providers outside the scope of neurology
untreated WE will develop Korsakoffs syn- practices are familiar with potential presentations
drome. Patients with Korsakoffs syndrome of these disorders. Additionally, older adults are at
exhibit profound anterograde amnesia with rela- increased risk for encephalopathy, and it is impor-
tively preserved implicit learning and general tant for providers to be aware of the varied etiol-
intelligence. Confabulation often accompanies ogies and symptoms that are associated with these
the memory impairment, particularly in the earlier conditions. Symptoms that indicate any alteration
stages of the syndrome. Executive functioning in brain functioning, such as cognitive and psy-
decits are also common (Zahr et al. 2011). chiatric changes, should raise suspicion for
Korsakoffs syndrome is associated with atrophy encephalopathy. Notably, onset of encephalopa-
of the thalamus, mammillary bodies, and frontal thy symptoms is typically acute rather than grad-
lobes, which can be observed on imaging. CSF is ual. However, the onset of a subacute delirium
usually normal in patients with WE/Korsakoffs with more gradual symptom onset (i.e., over
syndrome, and EEG abnormalities do not appear days and weeks rather than hours) is common
788 Encephalopathy
among the atypical encephalopathies described 7(12), 10911098. doi:10.1016/s1474-4422(08)

here. The presence of seizures often triggers a 70224-2.
Ferracci, F., Bertiato, G., & Moretto, G. (2004).
referral to a neurologist, but this symptom often Hashimoto's encephalopathy: Epidemiologic data and
manifests later in disease progression. Patients pathogenetic considerations. Journal of the Neurologi-
with encephalopathy, particularly those pres- cal Sciences, 217(2), 165168. doi:10.1016/j.
enting with cognitive and behavioral changes, jns.2003.09.007.
Flaherty, J. (2011). The evaluation and management of
may go undiagnosed for many months. Immediate delirium among older persons. Medical Clinics of
treatment is associated with the best outcomes, North America, 95(3), 555577. doi:10.1016/j.
therefore recognizing early signs and symptoms mcna.2011.02.005.
of these disorders in older adults is imperative. Geschwind, M. (2015). Prion diseases. Continuum, 21(6),
16121638.
Guerrini, I., Thomson, A., Cook, C., et al. (2005). Direct
genomic PCR sequencing of the high afnity thiamine
Cross-References transporter (SLC19A2) gene identies three genetic
variants in Wernicke Korsakoff syndrome (WKS).
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Behavioral and Psychological Symptoms of Lough, M. (2012). Wernickes encephalopathy: Expanding
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Parthasarathi, U., Harrower, T., Tempest, M., et al. (2006).
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Tyler, K. (2004). Herpes simplex virus infections of the The end of life can occur at any age, though it
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Tyler, K., Tedder, D., Yamamoto, L., et al. (1995). Recur- nesses that compromise physical health. The end
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psychiatric symptoms, and hypoventilation in ovarian tations, fears, and wishes. In its most clinical
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doi:10.1002/ana.20614. logical decline that leads to a complete cessation
Ward, P., & Roizman, B. (1994). Herpes simplex genes: of vital bodily functions such as respiration and
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9525(90)90009-u. protracted; of a single cause or multifactorial;
Weathers, A. (2013). Encephalopathy (delirium) due to painful or relatively peaceful; brought about by a
systemic disease. In S. Lewis (Ed.), Neurological dis- persons own hand, by anothers hand, or by acci-
orders due to systemic diseases (2nd ed., pp. 2950).
Oxford: Wiley-Blackwell. dent; a result of internal processes or external
Whitley, R., Kimberlin, D., & Roizman, B. (1998). Herpes forces; and wished for or fought against. Clearly,
simplex virus. Clinical Infectious Diseases, 26, dying is a multifaceted experience, with biologi-
541553. cal, psychological, and social elements. Death,
Widener, R., & Whitley, R. (2014). Herpes simplex virus.
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neurology (1st ed., Vol. 123, pp. 251263). Oxford: the process, death the result.
Elsevier. End-of-life care refers to the wide range of
Wood-Alum, C., & Shaw, P. (2014). Thyroid disease and services and supports that can be provided not
the nervous system. In M. Aminoff, F. Boller, &
D. Swaab (Eds.), Handbook of clinical only to an individual who is dying but also to
neurology, volume 120, neuerologic aspects of systemic family members and friends. It also involves a
disease part II (3rd ed., pp. 703735). Amsterdam: variety of professionals who provide the care,
Elsevier. but of course have thoughts and feelings about
Zahr, N., Kaufman, K., & Harper, C. (2011). Clinical and
pathological features of alcohol-related brain the experience themselves. This care has many
damage. Nature Reviews Neurology, 7(5), 284294. facets and attributes, such as its intensity, location,
doi:10.1038/nrneurol.2011.42. scope, and nancing. Those facets and attributes
often evolve in response to the specic reasons
why a person is dying. For instance, acuity of the
situation calls for different interventions: a person
who has a sudden, massive heart attack will need
End of Life Care
different things than someone experiencing grad-
ual decline associated with a slow-growing tumor.
Brian D. Carpenter
The cause of the situation might also demand
Department of Psychology, Washington
different interventions: dying as a result of a nat-
University, St. Louis, MO, USA
ural disaster will involve a different experience
than dying as a result of a common, age-related
disease. Timing also matters: dying while still in
Synonyms early childhood is vastly different from dying past
age 100.
Death; Dying; Hospice care; Palliative care; Across these facets, the goal of end-of-life care
Terminal illness is, in general, to enhance the quality of life near
790 End of Life Care
the end of life for people with a life-limiting children are very young, if the children are
illness and their care partners. There are, of young adults launching their own lives, if the
course, many ways to achieve that quality, which children are middle aged with their own growing
themselves span biological, psychological, and family, and if the children are old and might even
social strategies. In practice, end-of-life care predecease their parent. In all these scenarios, the
usually (and optimally) includes a collection of parent is still a parent, but the family itself is in a
strategies and interventions, designed and different developmental place. Consequently the
implemented by a team of caregivers, all striving parents dying will affect the family in different
to enhance a persons experience in this important, ways, just as the family will affect the parent in
ultimate developmental milestone. different ways.
The third important context is the culture. This
context incorporates specics about the nation,
Life Span Developmental and region, state, province, principality, neighbor-
Biopsychosocial Perspective hood, community, and at the most minute level,
perhaps even the building where a person lives.
Dying and death can occur at any point in the life Broadly speaking, the location in which a person
span, and the timing of those events matter. It is is dying inuences the experience, with its unique
useful to consider three different contexts in order structure, resources, and systems. So too do the set
to gain a comprehensive understanding of a per- of norms and values that characterize the group of
sons dying and death. The rst is to recognize that people in which the dying person is situated. This
dying and death occur at a particular time in the context also incorporates the particular point in
development of the individual. As a person pro- history at which a person is dying. Dying and
gresses through life, she grows in many different death in the late 1800s were different processes
domains physiological, psychological, social, than dying will be in 2050: changing technology,
and spiritual and the point of her development medical advances, mores and values, legislative
inuences her experience of dying and death. For policies, reimbursement structures, and other fea-
example, the psychological resources available to tures all inuence a persons journey through
a person who is dying are likely to be different for dying.
a younger person than an older person. Not only To return to the original point, dying is a
do basic cognitive functions (e.g., insight, reason- unique experience for that person, in that family,
ing, judgment) evolve and change across a per- in that culture, and at that place in time.
sons life span, but so too does their perspective on
life, based on the accumulation of experiences
they have had and their relative place in their Mental Health at the End of Life
own history. Likewise, from a social perspective,
death is more expected, more of an on-time People near the end of life grapple with a variety
event, for an older adult than it is for an adoles- of challenges that could have an impact on their
cent. Therefore, the death of any 16-year-old, mental health. These include serious medical con-
regardless of circumstances, can seem more tragic ditions that bring a host of symptoms such as pain,
than the death of a 90-year-old who has had a fatigue, dyspnea, nausea, and constipation; intru-
lengthy life. sive treatments that often have side effects as
The second important context is that of the debilitating as the disease they are meant to treat;
family, the most central social network for most functional limitations that interfere with activities
people. When an individual begins to die, she of daily living and prompt increased dependence
does so within a family network that is itself on others for assistance; the sheer amount of time
changing over time, with its own developmental spent in organizing and attending appointments
history and milestones. When a parent is dying, with health-care providers, requiring a person to
the family will experience it differently if the step out of the routine most people follow and live
instead according to other peoples schedules and disorders (e.g., major depressive disorder), anxi-
availability; nancial obligations related to treat- ety disorders (e.g., panic disorder, specic pho-
ments and short or long stays in institutional set- bias), trauma- and stressor-related disorders (e.g.,
tings; and, of course, living with the knowledge of posttraumatic stress disorder), substance-related
ones foreshortened future and the uncertainty of disorders (e.g., alcohol-use disorder), sleep-wake
what that future might bring. It is no wonder, then, disorders (e.g., insomnia disorder), and, perhaps
that people who are dying are vulnerable to sad- more rarely, eating disorders (e.g., anorexia
ness, worry, and dread. Still, not every person who nervosa, bulimia nervosa). These are the syn-
is dying is distressed. dromes listed and described in taxonomic systems
The World Health Organization denes mental such as the International Classication of Dis-
E
health as, A state of well-being in which every eases (ICD) and the Diagnostic and Statistical
individual realizes his or her own abilities, can cope Manual of Mental Disorders (DSM-5). Equally
with the normal stresses of life, can work produc- inuential to quality of life is the presence of
tively and fruitfully, and is able to make a contri- subsyndromal symptoms that, though less severe,
bution to her or his community (World Health are nonetheless distressing. Examples of those
Organization 2001). Note that this denition does symptoms include apathy that leads to unhelpful
not focus on the absence of signicant psycholog- social isolation, restlessness that depletes energy
ical distress, but instead the presence of activities that could be spent on more afrmative activities,
that promote continued engagement with life, even and rumination that distracts from important con-
as death nears. Therefore, psychological assess- templation. Subsyndromal symptoms are com-
ment and intervention should focus on classic men- mon and deserve equal attention and intervention.
tal health symptoms, such as depression and Mental health considerations are relevant to
anxiety, but they should also address ways to family and friends as well. Even before death,
enhance psychological well-being more broadly. symptoms of grief may appear in a caregiver,
People who are dying also may benet from inter- and that sadness may be a natural response to an
ventions that help them clarify their goals and impending death. For example, in the case of a
values, adopt useful coping skills, use effective patient with advanced dementia, caregivers may
communication strategies, maximize remaining begin to grieve as the disease follows its natural
abilities, and grapple with questions about identity course, sometimes years before death. After
and meaning in the face of mortality. death, grief is also a natural response. Although
Moreover, to assume that dying is an entirely some experiences are common during bereave-
negative experience overlooks the varied positive ment (disbelief, sadness, longing, guilt), they are
outcomes that some people experience. That not ineluctable in sequence or duration. Variations
includes an incentive, however unintended, to in the experience are likely depending on the
review ones life and to reach a level of under- circumstances of the death, nature of the relation-
standing and appreciation of what one has accom- ship with the person who died, and the time since
plished. An enhanced depth of relationship with death, among other factors. However, there is a
friends and family is also possible, as is achieving difference between expected grief and prolonged
a clarity of purpose necessitated by limited time grief disorder. The former is a natural emotional
remaining. Getting ones house in order can reaction to loss that does not impair a persons
lead to reconnection, reconciliation, and renewal functioning to any great extent and typically
in unexpected ways. resolves with time. The latter, on the other hand,
Signicant psychiatric problems do occur as is a more severe form of grief with a distinct
people are dying, however, and their detection symptom pattern that can include intense yearning
and treatment should be pursued with the same for the deceased, bitterness over the loss, and
diligence as would be the case in any other group. difculty accepting the loss. Prolonged grief dis-
Frank clinical syndromes are common in people order also appears to have a different response to
with severe illnesses. These include depressive treatment (Prigerson et al. 2008).
Psychological Assessment and symptoms are well managed) are to the

patients benet.
Caring for people at the end of life requires know- When a person is dying, there are likely urgent
ing how they are thinking and feeling about their or at least proximate medical needs that dominate
experience. Therefore, astute psychological the situation, but it would be a mistake to overlook
assessment is the linchpin of care. When learning the role that frank psychopathology may play in
about a person with serious illness, psychologists the quality of a persons life at the end of life. The
will want to investigate traditional mental health prevalence of psychiatric symptoms is quite high
symptoms, such as current and past anxiety and in people with life-limiting illness, and clinicians
depression, but a comprehensive assessment will should investigate their presence as they would in
extend far beyond those symptoms. It is equally any referral. Although studies vary widely in their
important to know about a range of topics covered estimates, mood and anxiety disorders may be
in a usual clinical interview a persons educa- present in more than a third of patients (Solano
tional and work history, social support network, et al. 2006), and disorders based on DSM-5 or
nancial concerns, and spiritual philosophy but ICD-10 diagnostic criteria should be fully inves-
also other features of a persons psychology that tigated. Self-report questionnaires can be used to
may matter to their current circumstances, pre- assess symptom severity (as well as progress in
ferred learning style, past coping strategies, and treatment). Well-validated instruments include the
personality. Of course, extensive knowledge Hospital Anxiety and Depression Scale (HADS),
about a persons medical circumstances represents the Patient Health Questionnaire (PHQ-9), the
an important foundation for many, if not most, General Health Questionnaire (GHQ-12), the
conversations. That includes asking patients Geriatric Depression Scale (GDS), and the Geri-
about their understanding of their disease, prog- atric Anxiety Inventory (GAI).
nosis, and current treatment regimen (and com- One overarching suggestion in any kind of
paring that to information provided by the assessment is to remain mindful of the overlap
patients health-care team, noting any discrepan- between physical and psychiatric symptoms. It
cies). A comprehensive psychological assessment can be difcult, but very important, to tease
involves multiple methods that may include apart symptoms that are due to a disease or its
interviews, questionnaires, and observations. treatment from symptoms due to a psychological
Moreover, a comprehensive psychological process. Indeed, the two may be interrelated. For
assessment is multimodal and may involve input instance, low energy may be a symptom of
from patients themselves but also family, friends, depression or an effect of chemotherapy, or both.
medical records, and an array of health-care Dyspnea may be a symptom of anxiety or related
providers. to chronic obstructive pulmonary disease, or both.
Given that some people who are dying may be Consequently, focusing on cognitive symptoms
quite limited in their ability to provide information (e.g., hopelessness, worthlessness, guilt, fear,
themselves, due to cognitive or physical limita- dread, rumination) may be more useful when
tions, thought and care need to be given to how determining the reason for a patients symptoms
and when to obtain assessment details. Clinicians (American Psychological Association 2007).
will need to consider the impact of sensory limi- A nal consideration has to do with the chal-
tations, speech and language abilities, stamina, lenge of measuring constructs that are manifestly
and consciousness that may uctuate due to dis- important when talking with patients who have
ease, treatments, and the dying process. Maximiz- serious illnesses but that defy the tools we have
ing a patients communication abilities means available. Patients (and caregivers) talk about for-
understanding these factors and managing the giveness, acceptance, peace, dignity, and readiness
assessment, so tools (e.g., reading glasses, large- to die, but scale development and assessment inno-
print materials) and timing (e.g., at the patients vation have not been as important to the eld as
best time of day, when there are few distractions those concepts are to patients.
Psychological Interventions (Chochinov et al. 2005) uses a set of facilitated

questions posed by the therapist to help patients
Psychological challenges appear throughout the identify past accomplishments, values, and goals.
experience of living with serious illness. Psycho- Themes that are addressed include generativity,
logical support can be useful throughout the expe- the continuity of self, role preservation, the main-
rience as well. Beginning with the point at which a tenance of pride, hopefulness, and concerns about
life-limiting diagnosis is made, psychologists can the aftermath of ones death. DT sessions can be
help patients understand their diagnosis, manage recorded, and a transcript can be used to create a
emotional reactions, communicate treatment pref- legacy document that captures the patients life
erences, and mobilize supports. As illness pro- in a form that can be shared and retained by family
E
gresses, psychologists can offer both supportive members. Patients and family member report that
and change-oriented interventions to promote DT is helpful, although its impact on anxiety,
adaptation to shifting circumstances. Following depression, and quality of life is less clear.
death, psychologists can provide services to the Meaning-Centered Group Therapy (MCGT)
bereaved. Psychological interventions are rele- (Breitbart et al. 2004) combines existential and
vant not only to patients but also to their informal cognitive-behavioral techniques to help very ill
caregivers and to their health-care providers, who patients restore meaning to their life. MCGT
may from time to time seek opportunities to help involves eight, weekly group sessions, 90 min in
them cope with the stress of working in end-of- length that include didactics, discussion,
life care. and experiential exercises to help patients under-
Selecting a treatment approach depends on the stand their illness and sustain hope and meaning.
goals of the patient and targets for intervention. Recent evaluations of MCGT have found signi-
Treatments for psychopathology or subsyndromal cant improvement in sense of meaning, faith, and
symptoms that have been validated in other spiritual well-being and signicant decline in
patient populations are reasonable alternatives to symptom-related distress and a desire for death.
consider: evidence-based cognitive-behavioral,
interpersonal, and brief psychodynamic approa-
ches may be useful, though those treatments have Competence in Diversity and Inclusion
not been validated in patients with serious illness,
and modications may be needed in end-of-life People arrive at the end of their life having trav-
circumstances (Kasl-Godley 2011). Other eled many different paths. Therefore, although
approaches may contain elements with obvious dying ends in the same, universal cessation of
face validity for people who are dying. Accep- basic biological functions, how it happens, and
tance and Commitment Therapy (ACT) (Hayes how people feel about it, vary widely. Each person
et al. 2012), with its focus on acknowledging has a unique developmental history that shapes
symptoms rather than trying to change or dismiss his/her experience at the end of life, and health-
them, may help patients whose symptoms may, in care providers need to consider how individual
reality, not improve. Likewise, existential thera- differences might matter. Moreover, differences
pies that concentrate on meaning making in the across nations, regions, and cultures can affect
face of mortality have obvious application (Spira how an illness is experienced, how choices are
2000). weighed, how the health-care system operates,
Recently, several new types of psychotherapy and the dynamics of personal and professional
have been developed that are specically relationships. Generalizations about how racial
designed to address the psychological well-being or ethnic groups approach end-of-life issues may
of patients near the end of life. The two with be a starting point, but only a starting point. It may
the most empirical data so far regarding their be more useful to pay attention to cultural scripts,
efcacy are Dignity Therapy and Meaning- but recognize variability within groups based on
Centered Group Therapy. Dignity Therapy (DT) socioeconomic status, acculturation, spiritual
beliefs, and other factors likely to vary from per- and with any type of severe disease. Palliative care
son to person (Smith et al. 2009). generally involves a holistic, interprofessional
In the usual domains of psychological approach to care that can benet both patients
practice assessment and intervention several and family members. A growing body of research
considerations are important. Norms on many suggests that not only does palliative care improve
common assessment instruments are rarely avail- quality of life, but it also extends life for
able for particular groups based on age, gender, some patients while at the same time reducing
race/ethnicity, and socioeconomic status, and they costs (Higginson and Evans 2010; Morrison
are even more rare for people within those groups et al. 2011).
who are dying. Consequently, there is relatively Hospice, by contrast, is a particular type of
little information about what is normal at the palliative care. This service adopts a palliative
end of life in terms of psychological constructs in care philosophy when supporting patients very
the domains of emotion (e.g., variations in posi- near the end of life. Like palliative care, hospice
tive and negative affect), cognition (e.g., decision- can be offered to any type of patient, with any type
making processes), and personality (e.g., locus of of life-limiting illness, and can be provided at
control). In terms of evidence-based psychologi- home or in a residential or institutional setting.
cal treatments, interventions designed for the end In the United States, hospice has included a suite
of life are so edgling that there have been virtu- of services, reimbursed by the Medicare Hospice
ally no systematic evaluations of their effective- Benet, as a complement to other health-care
ness in subgroups of diverse patients. Therefore, services a patient might receive. Traditionally,
providers will have to be exible and open- patients are eligible to receive hospice care when
minded in their practice, making sure to inquire a physician certies that a patient has fewer than
about the background, experience, beliefs, and 6 months to live. In addition, hospice is offered if
preferences of the particular patient and family patients are no longer pursuing curative treat-
with whom they are working. ments. In recent years there has been some move-
ment to reduce these restrictions, with some pilot
programs testing more relaxed eligibility criteria.
Palliative Care and Hospice In general, however, hospice is reserved for
patients very close to death, whereas palliative
One common point of confusion among the pub- care is appropriate, and perhaps most benecial,
lic, and even some health-care professionals, is when initiated early in the course of a disease.
the relationship between palliative care and hos-
pice. Palliative care is a broad category of care
designed to help people coping with serious ill- Interprofessional Collaboration
ness. This type of specialty care is, according to
the World Health Organization, an approach that Because end-of-life care aims to enhance quality
improves the quality of life of patients and their of life broadly, it addresses patient needs in many
families facing the problems associated with life- domains. A biopsychosocial-spiritual approach to
threatening illness, through the prevention and care recognizes the complex interplay among a
relief of suffering by means of early identication patients medical condition and treatments, psy-
and impeccable assessment and treatment of pain chological adaptation to serious illness, the social
and other problems, physical, psychosocial and context in which the experience of illness occurs,
spiritual (http://www.who.int/cancer/palliative/ and a persons spiritual interpretation of their cir-
denition/en/). As such, palliative care is pro- cumstances. As a result, a team of professionals is
vided to people throughout the disease trajectory, typically involved in providing end-of-life care.
from diagnosis to death; in a variety of care set- That team can include a broad range of profes-
tings, from home to outpatient and inpatient; to sionals from many disciplines, all of whom have
any type of patient, from children to older adults; something important to add to a patients care.
A typical palliative care team, for instance, and a genuine challenge for providers is nding a
includes a physician, nurse, social worker, and way to manage it. Without doing so, burnout is
chaplain. In some settings, end-of-life care is also likely. Signs of burnout include emotional
provided by psychologists, psychiatrists, occupa- exhaustion, pessimism, cynicism, and self-doubt
tional therapists, physical therapists, speech- (Maslach 2001). Providers who are burned out
language pathologists, pharmacists, dieticians, may nd themselves disengaging from patients,
aides, and homemakers. Hospice also utilizes vol- maintaining a more safe emotional distance in
unteers for peer support. Of course the most essen- order to avoid any disappointment or sadness.
tial members of the team are the patient and the Risk factors for burnout include occupational
family, who bring their own perspective, expertise, time pressure, frequent exposure to suffering,
E
expectations, and needs. interprofessional team conicts, and uncertainty
The concept of collaborative care has evolved in about ones professional competence. At the same
recent years, as the importance of an integrated time, protective factors include having ample time
effort has become more apparent. Teams were to spend with patients and families, receiving
rst known as multidisciplinary, with profes- adequate training about communication princi-
sionals from different disciplines developing their ples, stable personal and professional relation-
own independent treatment plans for patients that ships, and positive professional appraisal
were later shared among team members. The ter- (Pereira et al. 2011). In the face of burnout, effec-
minology changed to interdisciplinary teams tive interventions involve obtaining peer consul-
when team members from different disciplines tation and supervision, seeking continuing
were encouraged to assess and develop a treatment education, establishing a satisfying work-life bal-
plan collaboratively. More recently, the term ance, and recognizing when down time is needed
interprofessional team has come into widespread and taking it (Vachon 2006).
use, with an even greater emphasis on team mem- One role that psychologists can play in end-of-
bers understanding and appreciating the contribu- life care is supporting other providers in their
tions of each discipline. Therefore, a true work. With expertise in the interplay among
interprofessional team that provides end-of-life thoughts, emotions, and behavior, psychologists
care would concentrate its efforts on sharing infor- are in a unique position to educate and intervene
mation and expertise to develop an integrated care to help individuals and teams manage the chal-
plan that involves several disciplines, each contrib- lenges of the intensity of end-of-life care. As they
uting unique expertise that dovetails with that of educate staff about the mental health needs of their
other disciplines. Effective interdisciplinary care patients, so too can they educate staff about how
depends on several factors, including timely and to promote their own mental and physical health.
comprehensive communication among team mem- Psychologists also may be called in to facilitate
bers, a shared philosophy about care, transparent support or process groups to help teams work
decision-making, a clear delineation of roles, more effectively.
respect for the competencies each discipline brings
to the care plan, and provision of mutual support
(Hanks et al. 2009). This model of care is likely to Ethical Issues
become even more preeminent as its benets
become more widely substantiated. That so many ethical issues arise in end-of-life care
is perhaps an indication of the importance of this
moment in a persons life. It brings to a close every
Supporting Formal Caregivers other chapter of life that preceded it, and it is
therefore invested with great meaning for individ-
Emotions run high in much of end-of-life care uals, families, and cultures. At the same time, eth-
because the decisions are complex, time is lim- ical issues arise in end-of-life care because it is a
ited, and the stakes are high. Stress is unavoidable, nexus for complicated, fast-moving, multifaceted
situations that involve many people and many dif- Cognitive Behavioural Therapy
cult decisions. Broadly, many of these ethical Decision Making
issues center on autonomy: the extent to which an Distance-to-Death Research in Geropsychology
individual has the opportunity (and ability) to live Family Therapy
and die when, where, and how they wish. People Grief and Bereavement: Theoretical
have strong preferences regarding the end of their Perspectives
lives, and those preferences intersect with beliefs Interpersonal Psychotherapy
within the family, proscriptions dictated by faith Mental Health and Aging
traditions, and guideposts articulated by legal doc- Mindfulness Approaches
trine and public policy. Ethical quandaries arise Palliative Care
when there is tension between opposing beliefs or Psychodynamic and Humanistic Approaches
ideas. For example, ethical principles are in conict Subsyndromal Psychiatric Disorders
when deciding whether a patient who is in severe
pain should be treated with morphine (respecting
the ethical principle of benecence), even though
that treatment might lead to the patients extreme References
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American Psychological Association. (2007). End-of-life
principle of nonmalecence). Many health-care
issues for mental health providers. Washington, DC:
organizations have in place trained ethics commit- Author.
tees to help patients, family, and staff weigh com- Breitbart, W., Gibson, C., Poppito, S. R., & Berg,
plex decisions, though these decisions are A. (2004). Psychotherapeutic interventions at the end
of life: A focus on meaning and spirituality. Canadian
rarely easy.
Journal of Psychiatry, 49, 366372.
Chochinov, H. M., Hack, T., Hassard, T., Kristjanson, L. J.,
McClement, S., & Harlos, M. (2005). Dignity therapy:
Conclusion A novel psychotherapeutic intervention for patients
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55205525.
Dying and death are universal human experi- Hanks, G., Cherny, N. I., Christakis, N. A., Fallon, M.,
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sity Press.
true within the eld of psychology as well,
Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (2012).
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Indeed, as science reveals the increasingly Guilford Press.
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interconnected nature of the body and the mind,
dence that palliative care teams improve outcomes for
and as health-care adopts integrated, interpro- cancer patients and their families? The Cancer Journal,
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& J. Kasl-Godley (Eds.), End-of-life issues, grief, and
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bereavement: what clinicians need to know
butions, even if they are in their edgling stages of (pp. 85115). New York: Wiley.
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present at the zenith of life.
Morrison, R. S., Dietrich, J., Ladwig, S., Quill, T.,
Sacco, J., Tangeman, J., & Meier, D. E. (2011).
Palliative care consultation teams cut hospital costs
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Prigerson, H. G., Vanderwerker, L. C., & Maciejewski, of men and woman aged 50 and over who are
P. K. (2008). A case for inclusion of prolonged grief living in England. Repeated measures covering
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H. Schut, W. Stroebe, & E. Van den Blink (Eds.), health, economics, psychology, lifestyle, and
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Washington, DC: American Psychological study the dynamics of the aging process.
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Smith, A. K., Sudore, R. L., & Perez-Stable, E. J. (2009).
Palliative care for Latino patients and their families.
JAMA, 301, 10471057. The ELSA Sample and Study Design
Solano, J. P., Gomes, B., & Higginson, I. J. (2006).
A comparison of symptom prevalence in far advanced E
cancer, AIDS, heart disease, chronic obstructive pul- ELSA is sampled from the Health Survey for
monary disease, and renal disease. Journal of Pain and England (HSE), a large annual cross-sectional sur-
Symptom Management, 31, 5869. vey on the health of the population of England
Spira, J. (2000). Existential psychotherapy in palliative (Mindell et al. 2012). Sample members recruited
care. In H. M. Chochinov & W. Breitbart (Eds.), Hand-
book of psychiatry in palliative medicine at wave 1 (2002/2003) were individuals who
(pp. 197214). New York: Oxford. had previously taken part in 1 of 3 years of the
Vachon, M. (2006). Avoiding burnout and compassion HSE (1998, 1999, and 2001) and were aged 50 or
fatigue: Feeding ones soul. Edmonton: Pallium Project over at the time of the wave 1 interview. Subse-
Development Ofce.
World Health Organization. (2001). Strengthening mental quent ELSA data collection waves have taken
health promotion (Fact sheet no. 220). Geneva: Author. place biennially, in 2004/2005 (wave 2), 2006/
2007 (wave 3), 2008/2009 (wave 4), 2010/2011
(wave 5), 2012/2013 (wave 6), and 2014/2015
(wave 7). The eighth and ninth waves of data
collection are planned for 2016/2017 and 2018/
English Longitudinal Study of Aging 2019, respectively.
(ELSA) New study participants are recruited during
some waves in order to compensate for the
Nina T. Rogers1, James Banks2,3, James Nazroo3 aging sample population and to refresh the
and Andrew Steptoe1 younger age groups. This serves to maintain
1
Department of Epidemiology and Public Health, representation of all ages 50 and over in
University College London, London, UK ELSA. Refreshment sampling to date has
2
Institute for Fiscal Studies, London, UK recruited members aged 5052 at wave 3 (HSE
3
School of Social Sciences, University of 200104), aged 5074 at wave 4 (HSE 2006),
Manchester, Manchester, UK aged 5055 at wave 6 (HSE 200911), and aged
5051 at wave 7 (HSE 201112), with plans to
continue to recruit new sample members aged
Synonyms 5051 at future waves.
The core members of the ELSA sample are
Aging cohort; Health; Lifestyle; Retirement; individuals aged 50 and over, living in private
Panel studies residences, who were recruited through HSE at
either the rst wave of ELSA or at any of the
subsequent refreshment samples. The data also
Definition includes interviews with young partners, who
are individuals under the age of 50 whose partners
The English Longitudinal Study of Ageing are core members and new partners in the cor-
(ELSA) (Steptoe et al. 2013a) is a multidis- rect age range who entered relationships with core
ciplinary panel study that collects a comprehen- members after those members were recruited
sive array of measures on a representative sample to ELSA.
798 English Longitudinal Study of Aging (ELSA)
Mode of Interview consequence of this, researchers now have the

opportunity to study the circumstances that sur-
Data are collected from respondents in their round a respondents move from a private resi-
own home, every 2 years and by means of a dence to an institution. In situations when study
computer-assisted personal interview (CAPI) participants have been unable to consent to an
that is delivered by a trained interviewer. The interview for themselves, because of a physical,
CAPI includes questions on the respondents mental, or cognitive disability, a proxy informant,
demographics, household membership, work and usually a close family member or friend, has been
retirement activities, economic circumstances, asked to complete a 20-min interview on the par-
health, and behavior. A self-completion question- ticipants behalf. The proxy interview focuses
naire includes questions on well-being, social par- mainly on key demographic information and gen-
ticipation, quality of life, and social networks, eral health status, omitting attitudinal questions
along with questions considered to be sensitive. that a third person is unlikely to be able to answer.
The main interview takes approximately 85 min to Prior contact with a respondent who later requires
complete for an individual interview and around or requests interview-by-proxy gives opportunity
2 h when two people within the same household to researchers to ascertain what factors and mech-
are interviewed concurrently. anisms might contribute to later life disability or
At waves 2, 4, and 6, core members who com- impairment.
pleted a main interview were offered a visit from a An end of life (EOL) interview was introduced
qualied nurse, where a blood sample was taken into ELSA at wave 2. The EOL interview aims to
and a series of performance and biomedical tests capture important information about how a
were conducted. The nurse visits took place soon deceased study members life might have changed
after the main interviews and were of similar in the years before their death and how their assets
duration to the main interviews. were distributed after their death. Like proxy
Unless they expressly ask to leave the study, all interviews, EOL interviews are generally under-
participants who decline to be interviewed in a taken with a close family member or friend and
given wave are offered a full interview at each include questions on the health of the deceased,
future wave. From wave 3 onward, individuals any care or support they had received, their mood
electing to leave the study, or those who had and memory, problem behavior and nancial
declined to take part in two consecutive face-to- questions such as funeral expenses, inheritances,
face interviews, were offered a telephone inter- and private health care. EOL interviews have
view as an alternative to the standard interview. taken place at waves 2, 3, 4, and 6 with a response
The telephone interviews were approximately rate of 66% (n=135), 54% (n=375), 58%
10 min long and respondents were asked a small (n=242), and 74% (n=242) from all issued
number of questions about their health, work and cases, respectively.
benets, marital status, and accommodation. As
well as providing limited information in their own
right, these telephone interviews are also a useful Response Rates
strategy for retaining sample members who might
otherwise leave the study, with some agreeing to a Cross-sectional response rates at a given wave of
full interview at future waves. ELSA are calculated by dividing the total number
Individuals at wave 1 were not recruited if they of respondents by the total number of individuals
lived in institutions such as retirement homes, deemed eligible for that wave. Response rates are
elderly care facilities, hospices, or prisons. From based on core members and not on those who
wave 3 onward, any respondent who had previ- have died, who have moved to an institution or
ously taken part in a main interview at wave 1 but care home, or who are living outside the
had later transitioned into a care home or other UK. Waves 1, 2, 3, 4, 5, 6, and 7 have achieved
institution was deemed eligible for interview. As a response rates of 66%, 82%, 73%, 74%, 80%,
78%, and 77%, respectively. These response rates respondents to that of the population represented
include both those who were eligible for wave by the Census 2001. Wave 2 weights were calcu-
1 and refreshment sample members who joined lated to adjust for differential nonresponse
the study at later waves. By wave 6, 56% of all between waves 1 and 2 and population represen-
eligible wave 1 core members had given an inter- tativeness. From wave 3, refreshments were
view at every wave of ELSA. added to the main sample, requiring the need for
Much like other panel studies, the success of separate cross-sectional and longitudinal weights.
ELSA is dependent on the retention of respon- Separate weights have been produced to address
dents for follow-up interviews. Loss to follow- differential nonresponse for interview comple-
up can occur because respondents are no longer tion, completion of the self-completion question-
E
eligible for interview, and for ELSA, this includes naire, participating in a nurse visit, and giving a
those who have died or who have moved outside blood sample at waves 2, 4, and 6. A detailed
of the UK. The majority of respondents who are description of the weights can be found in the
deemed ineligible to participate in ELSA are par- user guides and technical reports that can be
ticipants who have died: 23.5% (n=2680) of the accessed at http://www.elsa-project.ac.uk/.
core sample members at wave 1 (n=11,391) had Linkage to administrative data: Since
died by wave 6. There is strong evidence to sug- ELSAs inception, respondents have been asked
gest that within the ELSA sample, participants to give their permission to link their survey data
with higher numeracy are less likely to drop out to National Health Service (NHS) Hospital Epi-
of the study compared with their less-numerate sode Statistics (HES) data, which contain details
counterparts. Higher levels of education also of diagnosis, treatment, length of stay, and type
appear to predict lower levels of attrition, but of discharge. Respondents have also been asked
this association appears to be limited to younger to give permission to link their records to the
respondents (i.e., those aged 5064) (Banks NHS Central Register mortality data and cancer
et al. 2011). Lower retention rates have also registration data. Year and age of death informa-
been reported in ELSA compared with HRS, tion for deceased respondents is available. Ana-
but the mobility of respondents, maturity of lysts who wish to utilize the detailed mortality
the study, interviewer quality, and sampling data, HES, or cancer data are able to request
methods were not found to be sufcient to special permission to access this data. Permis-
explain the gap in attrition between the two sion from respondents was also obtained to link
studies; rather it was suggested that higher survey data to ofcial records of national insur-
incentivization in HRS compared with ELSA ance contributions, welfare and benet receipt,
and cultural differences in the willingness of the and details of any tax credits they may be
two populations to take part and remain in scien- claiming, and these data will be available to
tic surveys might explain the difference (Banks analysts shortly.
et al. 2011).
Weighting: Cross-sectional and longitudinal
weights are produced to minimize any bias Data Access
resulting from differential nonresponse and to
ensure that the respondent sample is representa- Anonymized archived data from ELSA are avail-
tive of the population of interest (adults aged able from the UK Data Service (UKDS, https://
50 and over living in private households in www.ukdataservice.ac.uk/). The main dataset is
England). At wave 1, a weight was derived to made available to bona de researchers on sub-
minimize any unrepresentativeness of the sample mission of a request to UKDS. The archive data
population due to nonresponse at HSE, refusal to are used primarily by academics and government
be interviewed post-HSE, and nonresponse at departments. Requests for restricted data
wave 1. Derivation of the weight involved cali- (geographically more detailed and/or relating to
bration of the age-sex prole of core member administrative data linkages) can be made by
application to the ELSA Linked Data Access Content of Waves 17

Committee; an application form can be found at
www.ifs.org.uk/elsa. Respondents are not always subject to the same
questions at every wave of ELSA. Instead some
questions are rotated on and off successive waves
International Comparisons of Health at of the study, often to allow time to include new
Older Ages questions. The information in Table 1 provides a
broad overview of the content included in
To enable cross-country comparisons, ELSA has ELSA. The primary content of the survey is
been developed with close consideration of its two arranged in separate modules that broadly focus
sister studies, the Health and Retirement Study on health, work, nancial circumstances, cognitive
(HRS; USA) and the Survey of Health, Ageing function, and psychosocial measures. A number
and Retirement in Europe (SHARE; 20+ Euro- of substudies are also ongoing and each primary
pean countries and Israel). HRS, ELSA, and module and substudy is briey detailed below.
SHARE have also been used as models for the
development of other aging studies such as the Health Module
Irish Longitudinal Study on Ageing (TILDA), the The health module includes self-report measures
Northern Ireland Cohort for the Longitudinal of general health and physician-diagnosed condi-
Study of Ageing (NICOLA), the China Health tions including mental illnesses, longstanding ill-
and Retirement Longitudinal Study (CHARLS), ness/disability, symptoms indicative of particular
the Korean Longitudinal Study on Ageing health conditions and health behaviors. There are
(KLoSA), the Mexican Health and Aging Study also objective measures relating to gait speed,
(MHAS), the Japanese Study of Aging and Retire- physical performance, anthropometrics, and bio-
ment (JSTAR), and the Brazilian Longitudinal logical markers. During wave 6, a module on
Study of Health, Ageing and Well Being (ELSI- sexual relationships and activities was introduced
Brasil). Understanding which factors drive to the study. A report covering sexual activity,
national differences in factors such as retirement, problems with sexual functioning, and concerns
chronic disease, and mortality is pivotal for about sexual health has subsequently been
informing policies aimed at improving health published (Lee et al. 2016). Information on drug
and well-being. For example, comparison of dis- prescription and adherence data was rst collected
ease rates in ELSA and HRS populations revealed during the nurse visit at wave 6 and will be
that at every wealth level the English population repeated at wave 8, with the aim of producing a
in late middle age has lower levels of diabetes, unique national longitudinal dataset on medica-
hypertension, heart disease, myocardial infarction use in an aging population. The name of each
tion, stroke, lung disease, and cancer and lower prescribed medicine was recorded and allocated a
mean levels of C-reactive protein, high-density code number corresponding to the British
lipoprotein, and cholesterol levels than their US National Formulary (BNF) listing. Collection of
counterparts (Banks et al. 2006). Although older polypharmacy data should provide an opportunity
adults in the USA appear to suffer higher burdens for a deeper understanding of the factors that
of chronic disease, they have been reported as contribute to successful use of prescribed drugs
being cognitively healthier than older adults in in older people. At wave 7, an objective measure
England (Langa et al. 2009), and when health is of hearing ability was introduced to the study to
operationalized into functional domains that further complement the self-reported hearing
include measures of pain, cognition, disability, questions that were already present in the survey.
depression, and physical performance rather than The HearCheck device, developed and produced
dened by absence of disease, English adults were by Siemens (Munich, Germany), is a handheld
found to be only slightly healthier than US adults device with an ear cup that is held against
(Cieza et al. 2015). the respondents ear (Parving et al. 2008).
English Longitudinal Study of Aging (ELSA), Table 1 Information collected in the ELSA, waves 17. For measures
not administered at every wave, the brackets denote the wave of data collection
Demographic data Consumption
Household membership Housing (rent and mortgage)
Living relatives Vehicle and durables ownership
Marital status Fuel, leisure, clothing (27), food, health insurance
Ethnic group and country of birth Transfers, charitable giving/child trust funds (2,47)
Educational qualications Expectations
Age completed full-time education Mortality, employment, inheritances, and bequests
Occupation of main carer when respondent was 14 years Income
old Adequacy
Parents age and cause of death Ability to work E
Income and assets Movement into nursing home (2, 6, 7)
Earnings Perceived nancial position (25)
State benets Future housing and care needs (6,7)
Sources of income Paying for care and knowledge of care funding (7)
Financial and physical assets Health
Primary housing wealth and mortgage debt Self-reported health
Business wealth Disability and mobility; aids, sources of help, who pays
Debt Eyesight and hearing (self-report)
Life insurance Objective HearCheck hearing test (7)
Lifetime receipt of inheritance and gifts (6,7) Dental health (3,5,7)
Pensions Physician-diagnosed conditions (self-report)
Current pension plan and past pension details Falls, fractures, pain and joint replacements
Current contributions Urinary incontinence and bowel incontinence (6,7)
Accrued pension wealth (self-reported) Menopause (47)
Knowledge of female state pension age (37) Sexual function and attitude (6)
Knowledge of male state pension age (6,7) Cancer screening (5, 6,7)
State pension deferral (47) Polypharmacy (6)
Employment Psychiatric and emotional problems
Job details, normal pay and hours General health questionnaire (GHQ-12)
Health and work disability (27) CES-D depression scale
Age and reasons for retirement if retired Health behaviors
Employer name and permission to contact Physical activity in general and at work
Desired, offered, and requested workplace adaptions Alcohol consumption
(27) Smoking status and history
Social and civic participation Consumption of fruit and vegetables (37)
Provision of unpaid help Sleep duration and disturbance (4,6)
Informal caregiving and volunteering Cognitive function
Civic, social, and cultural participation Memory: word list recall, immediate and delayed recall
Accessing local amenities and services (12,47) Memory: prospective (15)
TV watching (46) Executive function: letter cancelation accuracy and
Social networks and support speed of mental processing (15)
Social isolation and loneliness Executive function: word nding (15 and 7)
Transport Numerical ability (1,4,6,7)
Social capital (1, 3,7) Literacy (2,5,6,7)
Perceived discrimination (5) Fluid intelligence (6)
Religiosity (5) Backward counting from 20 (7)
Digital inclusion (6.7) Serial 7s counting backward from 100 (7)
Psychosocial factors Naming objects (7)
Control and demand Quality of cognitive interview (interviewers assessment)
Effortreward balance (27) Proxy interview of cognitive function IQCODE scale
Subjective social status (27)
Age at which middle age ends and old age begins (1,3,7) Physical examination and performance
Self-perceived age (2,4,6,7) and desired ages (2,4) Walking speed (for ages 60 and over)
Experience and perceptions of aging () Height and weight; waist and hip circumference (2,4,6)
Sense of collectiveness (4) Blood pressure
Altruism (4) Lung function
Pet ownership (5) Chair stands; balance, leg raises, and grip strength (2,4,6)
(continued)
English Longitudinal Study of Aging (ELSA), Table 1 (continued)

Psychological and social well-being Blood assays
Quality of life (CASP-19) DNA extraction and storage (2,4,6)
Satisfaction with life scale (27) Total LDL and HDL cholesterol and triglycerides (2,4,6)
Ryff well-being scale (2 subsample) C-reactive protein, brinogen (2,4,6)
Positive affect (5) 6? Glucose, glycated hemoglobin (2,4,6)
Personality (5) Hemoglobin and ferritin (2,4,6)
Time use and affect (6,7) White blood cell count (4,6)
ONS well-being questions (6,7) IGF-1, DHEAS (4)
Vitamin D (6)
Biological samples:
Cortisol from hair (6), from saliva (2,4)
The participant is asked to indicate when they hear required to carry out a current job. It is not only
a beep, and a detection threshold is recorded. through paid work that older adults contribute to
society as many partake in productive activities
Financial Circumstances Module such as volunteering and caring and details of
ELSA captures detailed information on all aspects these activities are also captured in ELSA.
of the household budget and on economic circum- In recent years, there has been an increasing
stances including wealth holdings, household focus on the wealth holdings of older people,
income, pensions, consumption, future expecta- especially with respect to different types of costs
tions, employment, and retirement and work disabil- that older adults will face, such as funding their
ity (see Table 1). In an aging world, where future retirement needs and payment for long-
individual pension provision is becoming an term care. To help understand these issues, a
increasingly important issue and more complex new set of questions on perception of social care
decisions need to be made at increasingly older were added to the existing social care questions at
ages, it is vital that individuals are able to understand wave 7 and included questions on whether
the nancial choices available to them in terms of respondents expect to need formal social care at
savings, annuitization, insurance, and other related home, whether they expect to pay for it, and their
choices. Using these data, it has been shown that knowledge of care funding.
numeracy levels are strongly correlated with knowl-
edge and understanding of pension arrangements, Cognitive Function Module
perceived nancial security, measures of retirement The cognitive measures in ELSA are designed to
saving, and investment portfolios, even after con- assess cognitive ability across a number of dimen-
trolling for factors such as cognitive ability and sions, including learning and memory, word-
educational qualications. This suggests that simple nding ability, executive function, speed of
retirement planning information could be benecial processing, and numerical ability. At wave 7, the
to low-numeracy and low-education adult groups cognitive function questions were adapted to tem-
(Banks and Oldeld 2006). porarily remove a measure of uid intelligence and
Engagement of older adults in paid work is to add questions to identify early signs of dementia.
becoming a policy issue of major importance, in New measures of cognitive function, taken from
part because of the economic pressures of an the minimental state examination were added at
aging population. ELSA captures details on wave 7, which involved asking the respondent to
many aspects of employment including current count backward in ones from 20, to count back-
work status, types of work performed, and reasons ward in sevens from 100, and to name items and
for remaining in or for leaving work. The study people from a standardized description. Cognitive
also contains questions on whether health prob- test scores used in ELSA have been demonstrated
lems limit the respondents ability to carry out to indicate risk of death from a number of chronic
paid work and the level of physical activity diseases (Batty et al. 2016).
Psychosocial Measures Module were older, less wealthy, and more educated
ELSA includes a signicant number of measures and who had retired were more vulnerable to
related to psychological well-being, including this type of perceived discrimination (Rippon
scales for determining depression (CES-D), satis- et al. 2014).
faction with life (SWLS), and quality of life
(CASP-19). Notably, these scales have been
used in conjunction with other markers of health Substudies
and physical performance in an attempt to under-
stand the complex relationship well-being forms Objective Physical Activity
with physical health. High levels of well-being are Self-reported measures of physical activity have
E
a signicant contributor to healthy aging, but been used to demonstrate that taking up physical
maintaining positive well-being can present a activity in later life is associated with reduced risk
challenge in older adults who are experiencing of developing major chronic disease, depressive
ill health, caring for a sick or disabled spouse, or symptoms, and physical and cognitive impair-
suffering from bereavement. Higher levels of hap- ment (Hamer et al. 2014). Physical activity mea-
piness and enjoyment have been found to be asso- sures based on self-report are limited because they
ciated with reduced later life disability and rely on accurate recall and accurate reporting.
mobility (Steptoe et al. 2014a), and increased Respondents often fail to take into account the
pleasure and enjoyment of life have been linked totality of their activity throughout the day, thus
to a reduced risk of incident frailty in ELSA the need for objective data. During wave 6, a
participants (Gale et al. 2014). A sense of purpose subsample of 330 respondents were given wrist-
and meaning in life has also been linked to worn accelerometers for 7 days so that objective
increased survival (Steptoe et al. 2014b). It is measures of physical activity could be recorded.
clear that determinants of well-being in older The data are currently being analyzed.
adults extend beyond health concerns and higher
levels of well-being have been reported in respon- Risk Preferences
dents who participate in social activities such as A risk module aimed at measuring participants
volunteering and paid work, providing that they willingness to take risk and to delay reward was
felt adequately appreciated for their contributions carried out in wave 5 on a subsample of 1060
(McMunn et al. 2009). ELSA respondents. The module involved two
In addition, ELSA contains questions on social incentivized tasks and the chance to win small
activities such as going to the museum, theater, amounts of real prize money. The risk module
cinema, and eating out and participation in orga- was designed as a computer-assisted self-
nizations such as social clubs, religious groups, or administered interview but with a computer-
committees. Data on the emotional closeness and assisted personal interview (CAPI) for those who
amount of contact with a spouse or partner, chil- wanted, or needed, the interviewer to assist them
dren, and friends are also collected. It has been with operating the laptop.
demonstrated that higher levels of social isolation,
dened in terms of contact with family and friends Dementia
and partaking in civic participation, is an indepen- The inclusion of an assessment of dementia in the
dent predictor of survival (Steptoe et al. 2013b). sample is vital if ELSA is to contribute to the
ELSA collects information on the use of the Inter- better understanding of cognitive impairment at
net and email, and these measures have been older ages. ELSA will conduct interviews in 2017
linked to reductions in cognitive decline in older with about 1,000 ELSA participants aged 65 and
adults (Xavier et al. 2014). Questions on per- older who have previously participated in four to
ceived discrimination were introduced to ELSA eight waves of data collection. Respondents will
at wave 5. A recent study using data on perceived be asked to complete additional cognitive tests
age discrimination revealed that individuals who that will provide accurate information about
cognitive abilities applicable to the diagnosis of for a hypothetical person with the same back-
dementia and the identication of mild cognitive ground and age as the respondent. Differences
deterioration. The tests will match those adminis- between the ways respondents rated hypothetical
tered in HRS and which are themselves derived persons compared with themselves were then
from the Aging, Demographics, and Memory examined. Anchoring vignettes have recently
Study (ADAMS). been used to show that cultural differences in
terms of mental health norms explain some of
the differences in self-reported depressive symp-
Retrospective Life History Interview toms between respondents in ELSA, SHARE, and
HRS (Mojtabai 2015).
At wave 3, data from 7,855 participants were ELSA Genome-Wide Association Study: It
collected on upbringing, early life adversity, fam- is seldom that large-scale population studies pos-
ily structure, schooling, employment and earn- sess both genome-wide genotyping data as well as
ings, parity and reproductive history, living a large array of phenotypic data. The inclusion of
conditions in residences at different stages of such information in ELSA has great potential to
life, relationship with parents when they were a augment what is already known about how geno-
child, childhood health, smoking, and other mic variation is linked to disease risk and how
important events in their lives. To aid recall of certain characteristics interact to modify genetic
past events, a Life History Calendar was used susceptibility. In 2013/2014, we used the Illumina
to help individuals remember past circumstances Omni 2.58 chip (Illumina Inc, San Diego, Ca.,
more accurately. The aim of the interview was to USA) to perform genome-wide genotyping of
collect data to understand the life course of around 2.5 million single nucleotide polymor-
respondents and to analyze associations between phisms (SNPs) and related genomic features for
earlier life experiences and well-being, health, and approximately 7,400 ELSA participants. The
economic circumstances in later life. A recent same genotyping chip had previously been used
study that utilized these measures revealed that in HRS, enabling direct comparisons of the ELSA
material poverty in childhood is linked to higher and HRS samples to be carried out without the
levels of depression, poorer memory, and slower need for imputation-based meta-analysis. The
walking speed in later adult life (Tampubolon ELSA GWAS data have been deposited in the
2015). A separate study has reported associations European Genome-phenome Archive (EGA) and
between early parenthood, larger family size, and are available to bona de researchers. Data access
poorer health outcomes in older adults (Grundy & is regulated by the ELSA Genetic Data Access
Read 2015). Committee (EGDAC). Applicants can request
access to the ELSA GWAS data with or without
linkage to phenotypic information or can apply to
Anchoring Vignettes commission genotyping, because not all the SNPs
have been genotyped.
Interpretation of measures across different groups Ethics: All participants gave written informed
within a population sample, or across national consent at the recruitment wave to participate in
contexts, is problematic because different groups the study and have given separate written permis-
may interpret similar situations differently. To try sions to allow linkage of their data to administra-
and circumvent this problem, respondents were tive data sources. At each subsequent wave, the
asked in wave 3 to complete supplementary self- participants consent to participate was reafrmed
completion questionnaires on health or work dis- in writing. Telephone interviewees gave verbal
ability that contained anchoring vignettes. consent to participate.
Respondents were rst asked to rate, on a ve- Ethical consent for the study was granted by
point scale, various aspects of their own circum- the NHS-REC and by the University College
stance; they were then asked to do the same thing London Research Ethics Committee.
Management of ELSA Banks, J., Muriel, A., Smith, J. P. (2011). Attrition and
health in ageing studies: Evidence from ELSA and
HRS. Longitudinal Life Course Studies, 2.
From inception until 2014, the principal investiga- doi:10.14301/llcs.v2i2.115.
tor of the study was Professor Sir Michael Marmot. Batty, G. D., Deary, I. J., & Zaninotto, P. (2016). Associ-
In 2014, Professor Andrew Steptoe took over this ation of cognitive function with cause-specic mortal-
role and is the current principal investigator and ity in middle and older age: Follow-up of participants in
the English Longitudinal Study of Ageing. American
Professors James Banks and James Nazroo have Journal of Epidemiology, 183, 183190. doi:10.1093/
been co-PIs of the study since its inception. Dr aje/kwv139.
Nina Rogers manages the study. ELSA is a collab- Cieza, A., Oberhauser, C., Bickenbach, J., et al. (2015).
oration between the Department of Epidemiology The English are healthier than the Americans: Really?
International Journal of Epidemiology, 44, 229238. E
and Public Health at University College London, doi:10.1093/ije/dyu182.
the Institute for Fiscal Studies, the University of Gale, C. R., Cooper, C., Deary, I. J., et al. (2014). Psycho-
Manchester, and NatCen Social Research. The logical well-being and incident frailty in men and
study has been supported in specialist areas by women: The English Longitudinal Study of Ageing.
Psychological Medicine, 44, 697706. doi:10.1017/
expert groups at the University of East Anglia, S0033291713001384.
the University of Cambridge, the University of Grundy, E., & Read, S. (2015). Pathways from fertility
Exeter, and the University of Nottingham. history to later life health: Results from analyses of
the English Longitudinal Study of Ageing 324.pdf.
Demographic Research, 32, 107146. doi:10.4054/
DemRes.2015.32.4.
Funding Hamer, M., Lavoie, K. L., & Bacon, S. L. (2014). Taking
up physical activity in later life and healthy ageing: The
Around half of ELSAs funding since wave 1 has English Longitudinal Study of Ageing. British Journal
of Sports Medicine, 48, 239243. doi:10.1136/bjsports-
come from the US National Institute on Ageing 2013-092993.
(NIA). Various UK government departments have Langa, K. M., Llewellyn, D. J., Lang, I. A., et al. (2009).
provided substantial amounts of funding to ELSA Cognitive health among older adults in the United
and current sponsors include the Department for States and in England. BMC Geriatrics, 9, 23.
doi:10.1186/1471-2318-9-23.
Work and Pensions, the Department of Health, and Lee, D. M., Nazroo, J., OConnor, D. B., et al. (2016).
the Department for Transport. Previous funders of Sexual health and well-being among older men
the ELSA include the UK Department of Educa- and women in England: Findings from the English
tion and Skills, the Department for the Environ- Longitudinal Study of Ageing. Archives of Sexual
Behavior, 45, 133144. doi:10.1007/s10508-014-
ment, Food and Rural Affairs (DEFRA), Her 0465-1.
Majestys Treasury, the Department of Trade and McMunn, A., Nazroo, J., Wahrendorf, M., et al. (2009).
Industry, Her Majestys Revenue and Customs Participation in socially-productive activities, reciproc-
(formerly the Inland Revenue), the Ofce of the ity and wellbeing in later life: Baseline results in
England. Ageing and Society, 29, 765. doi:10.1017/
Deputy Prime Minister, and the Ofce of National S0144686X08008350.
Statistics (ONS). The Economic and Social Mindell, J., Biddulph, J. P., Hirani, V., et al. (2012). Cohort
Research Council currently coordinate funding prole: The health survey for England. International
between the UK government funders and ELSA. Journal of Epidemiology, 41, 15851593. doi:10.1093/
ije/dyr199.
Mojtabai, R. (2015). Depressed mood in middle-aged and
older adults in Europe and the United States:
References A comparative study using anchoring vignettes. Jour-
nal of Aging and Health, 28, 95117. doi:10.1177/
Banks, J., & Oldeld, Z. (2006). Understanding pensions: 0898264315585506.
Cognitive function, numerical ability and retirement Parving, A., Sorenson, M. S., Christensen, B., et al. (2008).
saving. London: Institute for Fiscal Studies. Evaluation of a hearing screener. Audiological Medi-
Banks, J., Marmot, M., Oldeld, Z., et al. (2006). Disease cine, 6, 115119.
and disadvantage in the United States and in England. Rippon, I., Kneale, D., de Oliveira, C., et al. (2014). Per-
JAMA, 295, 20372045. doi:10.1001/jama.295.17. ceived age discrimination in older adults. Age and
2037. Ageing, 43, 379386. doi10.1093/ageing/aft146.
806 Entrepreneurship and Aging
Steptoe, A., Breeze, E., Banks, J., et al. (2013a). Cohort rates, and the aging baby boom generation lead
prole: The English Longitudinal Study of Ageing. to a rising proportion of older people. By 2050,
International Journal of Epidemiology, 42,
16401648. doi:10.1093/ije/dys168. people aged 65 and above will constitute over
Steptoe, A., Shankar, A., Demakakos, P., et al. (2013b). 26% of the population in developed countries
Social isolation, loneliness, and all-cause mortality in (Cohen 2003). The increase in older people
older men and women. Proceedings of the National will affect how and to what extent older people
Academy of Sciences of the United States of America,
110, 57975801. doi:10.1073/pnas.1219686110. remain active participants in the workforce.
Steptoe, A., de Oliveira, C., Demakakos, P., et al. (2014a). A growing number of older people will stay in
Enjoyment of life and declining physical function at their jobs or remain economically active through
older ages: A longitudinal cohort study. CMAJ, 186, other means (Kautonen et al. 2011). An interest-
E150E156. doi:10.1503/cmaj.131155.
Steptoe, A., Deaton, A., & Stone, A. A. (2014b). Subjec- ing aspect of this changing involvement of older
tive wellbeing, health, and ageing. Lancet, 385, people in the economy is the phenomenon of the
640648. doi:10.1016/S0140-6736(13)61489-0. older entrepreneur (de Bruin and Dupuis 2003),
Tampubolon, G. (2015). Growing up in poverty, growing also known as gray entrepreneur, senior entrepre-
old in inrmity: The long arm of childhood conditions
in great Britain. PLoS One, 10, e0144722. doi:10.1371/ neur, third age entrepreneur, elder entrepreneur,
journal.pone.0144722. and second career entrepreneur (Weber and
Xavier, A. J., dOrsi, E., de Oliveira, C. M., et al. (2014). Schaper 2004).
English Longitudinal Study of Aging: Can internet/e-
mail use reduce cognitive decline? The Journals of Ger-
ontology. Series A, Biological Sciences and Medical
Sciences, 69, 11171121. doi:10.1093/gerona/glu105. Definition of Older Entrepreneurs
Entrepreneurship is dened as the discovery, eval-

uation, and exploitation of opportunities to create
Entrepreneurship and Aging future goods and services (Shane and
Venkataraman 2000). This denition implies that
Rebecca Funken and Michael M. Gielnik entrepreneurship is a process with different phases
Institute of Strategic HR Management, Leuphana of discovering, evaluating, and exploiting rather
University of Lneburg, Lneburg, Germany than a single event (Baron and Shane 2008). Out-
comes of entrepreneurship include new busi-
nesses (i.e., new venture creation) but also
Synonyms business growth and innovations when managing
the business. Entrepreneurship can thus be a con-
Elder entrepreneur; Gray entrepreneur; Second tinuous, lifelong process.
career entrepreneur; Senior entrepreneur; Third There is no agreement in the literature about
age entrepreneur what age the term older comprises (Weber and
Schaper 2004). A possible cutoff point could be
the retirement age, which is around 65 in many
Definition countries (Weber and Schaper 2004). However,
many issues that confront older people in the
Older entrepreneurship is the discovery, evalua- workforce are also relevant for people in their
tion, and exploitation of future goods and services fties (de Bruin and Dupuis 2003). Some authors
when in age 50 and above. include people as young as 45 years of age,
whereas for others the term older includes peo-
ple of 60 years and above (Weber and Schaper
Introduction 2004). Most scholars opt for a midpoint and dene
older entrepreneurship as starting a new business
The worlds population will age dramatically. or being self-employed with age 50 and above
Increased life expectancy, declining fertility (Ainsworth 2015).
Entrepreneurship and Aging 807
Older entrepreneurship can thus be dened as inverse U-shape (Kautonen et al. 2014). Start-up
the discovery, evaluation, and exploitation of future activity gradually increases up to middle age and
goods and services when in age 50 and above. then decreases (Reynolds et al. 2004). The age
It is important to distinguish older entrepre- group of 2544 is more likely to start a business
neurs from older business owner. Older entrepre- than any other age group (Reynolds et al. 2004).
neurs recognize and evaluate business Consistently, the interest in becoming an entrepre-
opportunities and then exploit or implement neur decreases with age (Blanchower 2001).
these opportunities to create something new Even though older people possess more human,
(Shane and Venkataraman 2000). They can do social, and nancial capital to start a business than
this in the start-up phase to create a new business younger people (Kautonen et al. 2011; Weber and
E
or within an existing business to grow and Schaper 2004; Rogoff 2007; Singh and DeNoble
develop this business. Older business owners, in 2003), they are less interested in self-employment
contrast, are dened as owning and managing a (Blanchower 2001). Hence, older people do not
business, but they do not necessarily act entrepre- lack the skills or requirements for entrepreneur-
neurially in the sense of identifying, evaluating, ship but are less interested in entrepreneurship
and exploiting new business opportunities. Older than younger people. Among workers in employ-
business owners own the business because they ment aged 5075, only 14% would prefer to be
have either founded the business themselves or self-employed (Curran and Blackburn 2001). The
gained ownership through purchase or inheritance main reasons against self-employment are no
of the business. When the business owners have guarantee of income (65%), to late/feel to old
founded the business themselves, they have acted (60%), and no job security (50%) (Curran and
entrepreneurially at that time. Business owners Blackburn 2001).
who do not continue to identify and exploit new
opportunities are not considered to be entrepre-
neurs. Thus, the tasks of the older entrepreneur Research on Motivation and Older
differ from the tasks of the older business owner. Entrepreneurship
The older entrepreneur deals with the identica-
tion and exploitation of new opportunities, It is important to distinguish between research on
whereas the older business owner manages an older entrepreneurship as an outcome and
operating business. The difference between the research on older entrepreneurship as a predictor.
concept of older business owner and older entre- The rst line of research seeks to understand fac-
preneur is also evident in data on the prevalence of tors that drive or inhibit older people to engage in
older entrepreneurship. entrepreneurship. The second line of research
examines older entrepreneurship as a predictor
for performance measures. This paragraph
Prevalence of Older Entrepreneurship describes the rst line of research on older entre-
preneurship as an outcome. The subsequent para-
In general, the probability of being a business graph describes the second line of research on
owner increases with age (Blanchower 2001). older entrepreneurship as a predictor.
People are gradually more likely to become a
business owner through founding, buying, or Time Allocation Model
inheriting a business and thus ow into entrepre- The time allocation model posits that the decreas-
neurship (Blanchower 2001). Once being self- ing interest in entrepreneurship is the result of an
employed, many business owners manage their age effect (Zacher and Gielnik 2014). The model
businesses until retirement or at least for a time suggests that the relative return of a business
of several decades. reduces as people become older. People allocate
In contrast, the probability of being an entre- their time between income generating activities
preneur and starting a new business follows an and leisure time to maximize the expected utility.
Waged labor results in an immediate income. In 2014). Thus, starting a business might be a viable
contrast, starting a new rm requires spending a option for older people to stay economically
certain number of weeks or months to exploit the active and have an income.
opportunity. It takes time before a new rm is According to the opportunity argumentation,
established and generates revenue. Consequently, older people have characteristics that are favor-
the resulting income is delayed to some point in able for entrepreneurship (Curran and Blackburn
the future. As people age, the amount of time left 2001). During their working lives, older people
is decreasing. As a result, people depreciate the gain experience, acquire knowledge, build profes-
value that is given to delayed income from entre- sional networks, and accumulate nancial assets
preneurship. Furthermore, with age the income (Singh and DeNoble 2003). These factors facili-
from waged labor is increasing due to accumu- tate discovering and exploiting opportunities.
lated work experience. Thus, as people age, the
opportunity costs to engage in entrepreneurship Early Retirement: Self-Employment Model
rise. Taken together, the delayed income from Scholars describe in a deductive model the moti-
entrepreneurship and high opportunity costs com- vation of older workers who chose entrepreneur-
pared to waged labor make it less attractive for ship as a transition into (or out of) retirement
older people to start a business. (Singh and DeNoble 2003). Entrepreneurship
offers exibility that makes it an attractive form
OpportunityNecessity Model of bridge employment for older workers. Entre-
The opportunitynecessity model seeks to distin- preneurs can more easily vary their hours and
guish between different pathways that lead to conditions of involvement (de Bruin and Dupuis
entrepreneurship at older age (Rogoff 2007). 2003) and thus balance demands from personal
According to the model, there are two different life and work (Ainsworth 2015). Three types of
pathways why older people engage in entrepre- early retirees that start a business are differentiated
neurship. Older people engage in entrepreneur- (Singh and DeNoble 2003). The constrained
ship because they either have to (necessity) or entrepreneur always wanted to become self-
want to (opportunity) (Rogoff 2007). The two employed but was not able to follow this dream
different pathways are important to understand because of established or perceived constraints
older peoples underlying motivation for entrepre- (e.g., liquidity, family). The rational entrepre-
neurship. There are economic and social reasons neur compares his or her current career options
that make it necessary for older people to engage with self-employment. This comparison is often
in entrepreneurship (necessity pathway). One of based on nancial reasoning but can also include
the main economic reasons for older people to non-monetary aspects (e.g., respect, fulllment).
engage in entrepreneurship is that retirement The reluctant entrepreneur becomes self-
funds shrink with negative effects on older peo- employed because of a lack of employment
ples wealth. To compensate for the shrinking opportunities on the traditional labor market.
retirement funds, older people remain motivated
to earn a salary (de Bruin and Dupuis 2003). Self- Contingency Model
employment then becomes an attractive option The contingency model posits that the assumption
when older people are not able to stay in their of a general decline of entrepreneurial activity
jobs or nd a new job. One of the main social with increasing age is too simplistic (Kautonen
reasons is that aging is often seen as a time of et al. 2014). Rather, older peoples engagement in
decline. Negative stereotypes against older entrepreneurship is dependent on contingency
workers are thus common in the population factors like perceived age norms (Kautonen
(de Bruin and Dupuis 2003). Age discriminatory et al. 2011) and type of business (Kautonen
practices in recruitment make it difcult for older et al. 2014).
people to remain in or enter the traditional labor Age Norms. Perceived age norms inuence
market (Kautonen et al. 2011; Zacher and Gielnik entrepreneurial intentions of older people
Entrepreneurship and Aging 809
(Kautonen et al. 2011). These age norms refer to growth-oriented businesses to low-risk busi-
perceiving entrepreneurship as socially accept- nesses, such as simple forms of self-employment.
able at any age and especially at the third age.
Three mechanisms transfer the effect of perceived
age norms on entrepreneurial intentions Research on Older Entrepreneurship and
(Kautonen et al. 2011). The effect of perceived Performance
age norms inuences entrepreneurial intentions
via how positive individuals attitudes toward Research on older entrepreneurship as a predictor
entrepreneurship are, how the individual per- of performance suggests that the performance of
ceives the amount of support from family and older entrepreneurs differs from the performance
E
friends, and how the individual perceives their of younger entrepreneurs (Weber and Schaper
own ability to become an entrepreneur 2004). Being an older entrepreneur might be
(Kautonen et al. 2011). advantageous but can also be a possible constrain.
Business Type. The relationship between age Whether older entrepreneurs outperform younger
and the engagement in entrepreneurship depends entrepreneurs (or vice versa) depends on the per-
on the type of business people pursue (Kautonen formance measure like survival rate, growth, or
et al. 2014). Scholars identied three different family succession. It is important to note that in
types of businesses that differ regarding the risk entrepreneurship research, all these performance
involved and regarding the prevalence in different measures are considered to be relevant.
age groups (Kautonen et al. 2014). First, Survival Rate. In general, survival rates
ownermanagers are growth-oriented and have among new businesses are relatively low with
ambitions to hire others. Being growth-oriented 63% of rms surviving after 4 years (Robb
and ambitious requires having a higher-risk pro- et al. 2010). The likelihood of success in the rst
pensity. With age, the risk propensity declines and 4 years signicantly increases if the primary busi-
with it the willingness to engage in entrepreneur- ness owner is older than age 45 (Robb et al. 2010).
ship as an ownermanager. In accordance with the Entrepreneurship scholars argue that older people
model of Lvesque and Minniti (2006), the rela- possess human, social, and nancial capital favor-
tionship between age and entrepreneurship fol- able for the survival of a business (Weber and
lows an inverse U-shape for ownermanagers. Schaper 2004; Ainsworth 2015). During their
Second, self-employers want employment for working lives, older people gained professional
themselves but are not intending to invest in the knowledge and build up formal and informal net-
business or hire others. Similar to waged labor, works that can increase the likelihood of survival
self-employment involves a low-risk propensity (Weber and Schaper 2004). In addition, older
and prot is distributed rapidly. The relationship people are more likely to have accumulated nan-
between age and entrepreneurship for self- cial assets through prior employment which can
employers is signicantly different from that of be invested into the business (Singh and DeNoble
ownermanagers. The close resemblance to 2003).
waged labor and the human capital of older people Growth. Even though businesses of older
lead to an increase in self-employment with age entrepreneurs have a higher survival rate (Robb
even for people in their 60s. Third, reluctant et al. 2010), these businesses are less likely to
entrepreneurs are pushed into entrepreneurship grow (Autio 2007; Gielnik et al. 2012). The age
because of a shortage of other employment group of 1834 years starts 45% of growth-
options. They mostly engage in low-risk forms oriented start-ups compared to 22% in the age
of self-employment and have a shorter investment group of 4564 years (Autio 2007). Furthermore,
horizon. Research shows that for reluctant age is negatively related to business growth in
entrepreneurs, the effect on entrepreneurship is terms of sales, prot, transaction volume, income,
relatively unaffected by age. In summary, and number of employees (Gielnik et al. 2012).
with increasing age, entrepreneurs shift from Scholars argue that the negative effect of age on
business growth is a result of a decrease in peo- means that they direct their focus to generative
ples focus on opportunities (Gielnik et al. 2012). motives (Zacher et al. 2012). Older family busi-
Focus on opportunities is a cognitivemoti- ness owners focus less on their own career goals,
vational construct that describes how many new occupational gains, or accomplishments and
goals, plans, options, and opportunities people direct their focus to developing and guiding mem-
believe to have in their personal future (Gielnik bers of the younger generation (e.g., their children
et al. 2012). Research showed that companies or grandchildren) in the family business (Zacher
with CEOs high in focus on opportunities et al. 2012). Older business owners generativity
increased their number of employees on average is an important mechanism in the family succes-
by 2.24 employees over a period of 4 years, while sion process. Generativity explains why older
companies with CEOs low in focus on opportuni- family business owners are more successful in
ties remained with the same number of employees nding a successor and in smoothly managing
over this time period. Similarly, companies with the succession process (Zacher et al. 2012).
CEOs high in focus on opportunities increased
their sales level by 38% percent over 4 years,
while companies with CEOs low in focus on Conclusion
opportunities did not change their sales level
over this period (Gielnik et al. 2012). With The topic entrepreneurship and aging gains more
age several individual and contextual factors and more attention because of the ongoing
negatively inuence peoples focus on opportuni- sociodemographic changes in our society. There
ties. Individual capabilities (e.g., information is no clear-cut relationship between age and entre-
processing capabilities), which are important to preneurship, but peoples ontogenetic develop-
maintain a focus on opportunities, decrease ment has benets as well as drawbacks for
with age. In addition, contextual factors like entrepreneurship. Factors that inuence whether
age-related norms and environmental constraints or not age positively affects entrepreneurship can
may lower peoples focus on opportunities. How- be found on the cultural/societal level, the rm
ever, the decline in focus on opportunities and level, and the individual level. Thus, a compre-
venture growth is not inevitable (Gielnik hensive approach taking into account all levels is
et al. 2012). Mental health buffers the negative necessary to fully understand the relationship
effect of age on peoples focus on opportunities. between age and entrepreneurship.
This means that for business owners who remain
in good mental health, age does not have a nega-
tive effect on their focus on opportunities and Cross-References
business growth.
Family Succession. With age, family succes- Age Stereotypes in the Workplace
sion becomes more important for business owners Age Stereotyping and Discrimination
(Zacher et al. 2012). Age is often seen as a general Aging, Inequalities, and Health
time of decline and withdrawal (de Bruin and Attitudes and Self-Perceptions of Aging
Dupuis 2003). According to the socioemotional Distance-to-Death Research in Geropsychology
selectivity theory (Carstensen et al. 1999), age is Early and Unplanned Retirement
not simply a matter of decline but can be consid- Job Attitudes and Age
ered in terms of shifting goal priorities. With Late Life Transitions
increasing age, people are more aware that time
is limited. As a consequence, goal priorities shift
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Environmental Influences on Aging and Behavior, Theories of 811
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Autio, E. (2007). Global entrepreneurship monitor: 2007 tionship between business owners age and family suc-
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Babson College, London Business School, and Global
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Latent entrepreneurship across nations. European Eco-
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(1999). Taking time seriously: A theory of Department of Psychological Aging Research,
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opportunities as a mediator of the relationship between
aging
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Kautonen, T., Tornikoski, E. T., & Kibler, E. (2011). Entre-
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Lvesque, M., & Minniti, M. (2006). The effect of aging on
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147164. tal idea that contexts (and not merely genes,
Zacher, H., & Gielnik, M. M. (2014). Organisational age
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and attitudes toward younger and older employees. tors) may drive aging processes and outcomes has
International Small Business Journal, 32, 327349. a long-standing tradition in social gerontology
812 Environmental Influences on Aging and Behavior, Theories of
and its emphasis on social relations and the social experiences her home, neighborhood, and spatial
contexts of aging. However, the role of the imme- infrastructure for the rst time in life as a barrier:
diate physical, spatial, and technical environment She now has anxiety when using the staircase, the
put forward by Lawton and Nahemows work has bathroom, and the kitchen. The garden no longer
largely been neglected in geropsychological is her garden and indeed is now unused, and
research (e.g., Wahl 2001; Wahl et al. 2012). driving the car evokes feelings of insecurity and
This is surprising, because in child and adolescent incompetence, but driving is necessary to
psychology (Bronfenbrenner 1999), as in life span maintaining independence. Dealing with her
developmental science at large, co-construction, physical-spatial living situation over the next
the assumption that developing individuals are 2 years increasingly impacts her daily routine
shaped by contexts and vice versa, always has and negatively affects her well-being and feelings
been a widely accepted view (Valsiner 1994; of autonomy, with the latter belonging to the
Youniss 1987). Going further, it is important to things she always was very proud of in her life.
argue that particularly in its early and late It also becomes increasingly difcult to keep her
phase the human life span is highly sensitive if informal support network going, and due to ongo-
not vulnerable to environmental input and P-E ing cognitive decline, she is now entering a phase
interactions, including the physical component in life in which full control in some necessary
of the environment. tasks is no longer possible. One question becomes
Research targeting the relationship between an intrusive one: How long will I be able to
the environment and the aging individual has tolerate this struggle with my place and indeed
had a strong link with psychology from the begin- survive the struggle mentally in good shape? At
ning (e.g., Lawton 1977; Lawton and Nahemow the age of 93 years, she will have arranged,
1973; Wahl 2001), although it has also been seen together with her daughter, relocation to a nursing
as an important interdisciplinary area. Therefore, facility located 20 miles from her hometown.
terms such as environmental gerontology and Her place and long-standing and highly valued
ecology of aging used in this entry are intended day-to-day social interactions are left behind.
to emphasize the strong behavioral component of One may ask what would have happened to
the eld and its role within geropsychology. Ms. A in another physical setup (e.g., no large
distance to next shopping mall, staircase, optimal
housing modications, installation of a computer
A Case History: When Aging with Skype and e-mail possibilities, etc.). One
in Place Fails may also ask what it likely meant to Ms. A to
undertake this relocation and spend her last years
Ms. A is an 89-year-old woman who lives in her at a different place than the one in which she lived
medium-sized house in a small, urban community for decades. These are key questions of an envi-
in Kansas. She had been married for 66 years to ronmental perspective on aging, as well as of late-
her husband Will, who passed away 3 years ago. life development at large. Lets follow these ques-
Ms. A has a daughter living with her family near tions based on a treatise of a number of P-E
NYC, which is rather far away; no other relatives concepts and theories and a selection of empirical
live closer than 4 h away by car. However, social ndings.
support conditions are working well; her neigh-
bors and some friends provide help when needed.
Although Ms. A has good health overall, signi- Fundamental Principles of Psychological
cant cognitive decline started about 2 years ago, Aging and the Environment
during which substantial mobility and vision
impairment have occurred. Ms. A increasingly Three principles build the cornerstones of envi-
has to struggle with her place and enjoys it as ronmental perspectives on aging: (1) importance
her place in the world. For example, she now of P-E transaction and developmental
co-construction, (2) importance of explicitly con- For example, a certain space infrastructure (e.g.,
sidering the environment with a focus on the distance between rooms) in a nursing home may
physical-spatial dimension, and (3) importance provoke or hinder social communication (see
of optimizing ecological validity in research. already Lawtons environmental docility hypoth-
First, the classic formula dating back to German esis; Lawton 1977, 1982). Third, environmental
psychologist Kurt Lewin that behavior is a func- gerontology always put much emphasis on the
tion of the persons as well as the environments need to enhance ecological validity in psycholog-
characteristics (B = f[P,E]) has found a central ical aging research (e.g., Wahl 2001). Focusing on
place in the social and behavioral sciences; aging issues such as under which conditions older adults
is no exception. Environmental gerontology also are feeling at home (Oswald and Wahl 2005) or
E
has close afnity with environmental psychology, offering a detailed description of the role of envi-
in which the concept of person-environment ronmental barriers in the home or immediate sur-
transaction has been promoted as a key issue rounding directly brings research to the daily
(Altman and Rogoff 1987). A major assumption ecology of old age. More generally put, environ-
is that it is difcult if not impossible to separate mental gerontologys argument is that older adults
P from E and that the understanding of an ongoing always operate in naturally occurring physical-
complex and mutual shaping of P and social environments; therefore, reconstructing
E throughout the life span is adequate. Moreover, daily ecologies of aging must have a high priority.
it may be that this intimate intertwining of P and It is interesting to mention in this context that the
E grows along the life span and may indeed reach issue of ecological validity seems to have
its climax in old and very old age (Zingmark increased in importance at large in
et al. 1995). Furthermore, life span development geropsychology in the past two decades or so,
is seen as a never-ending sequence of ecological via event-sampling in situ research strategies and
transitions in which new P-E territories are con- ambulatory-assessment strategies (Hoppmann
tinuously conquered, while other P-E territories and Riediger 2009).
are left behind. A major transition in late life (see
again Ms. A) is the transition to a sheltered envi-
ronment, such as a nursing home. Mission of Environmental Gerontology
Second, Powell M. Lawton (1977), a key g- within Geropsychology
ure in the psychology of aging and the inaugura-
tion of environmental gerontology, has dened In light of the three principles outlined in the
the environment in the rst edition of the Hand- previous section, the overarching aim of environ-
book of the Psychology of Aging very broadly; this mental gerontology is to describe, explain, and
denition includes social others and social modify/optimize the relationship between the
groups, as well as all its physical components aging person and his/her physical-social environ-
(the natural or man-made ones). However, the ment. With regard to description, environmental
predominant contribution of environmental ger- gerontology puts strong emphasis on day-to-day
ontology to geropsychology can be seen in its contexts of aging individuals, reinforcing the
emphasis on the physical and spatial environment notion that daily ecology settings deserve strong
(Wahl 2001; Wahl et al. 2004, 2012) such as attention in gerontological research. A major rea-
features of the objective home environment (e.g., son for this emphasis is that older people spend
lighting in kitchen, barriers in bathroom) and dis- most of their time (i.e., about three-quarters of
tance between ones home and public transport. their daytime) in the home and immediate home
Wahl and Gitlin (2007) have suggested the term environment (Baltes et al. 1999; Oswald and Wahl
physical-social environment to address the issue 2005). Furthermore, older individuals tend to live
that the physical component of the environment is in the same place for a long period of time, typi-
hard to separate from its social component cally for decades, not for years (Oswald and Wahl
and vice versa (see also Wahl and Lang 2004). 2005). Such long-term living and aging at the
same location seems to evoke rich cognitive and Thus, older people need to react to environmental
affective ties to the place one lives, known in pressure in order to remain independent and feel
German as Heimat (homeland) or, put in schol- well in terms of high positive affect and low
arly language, addressed as place identity and negative affect (Lawton 1982). The ETA was crit-
place attachment to the very specic genius loci icized for portraying the role of the aging individ-
of my place. ual as too passive. Consequently, in a later
The phenomena to be explained in environ- extension of the ETA (Lawton 1989), the environ-
mental gerontology are classic outcomes in mental proactivity hypothesis was introduced,
aging research and gero-epidemiology, such as which assumes that older adults are not simply
positive and negative affect (Lawton 1977), pressured by their environments but that they
well-being (Oswald et al. 2011), and autonomy also strive to change proactively environmental
(Oswald and Wahl 2005; Oswald et al. 2007). conditions according to their own needs and goal
Furthermore, there is a set of specic variables priorities in order to maintain independence and
addressed by environmental gerontology theories well-being. For example, new cohorts of older
and empirical studies, such as the emergence of individuals seem to increasingly make goal-
feelings of being at home, place attachment (and directed P-E transitions, such as moving to an
detachment) processes, place identity, usefulness assisted-living facility or closer (but not too
of ones physical environment, and housing- close) to their families, in order to prevent being
related control beliefs (Oswald et al. 2007). overwhelmed by environmental pressure in the
Also, explaining the experience and outcome foreseeable future.
related with enduring change of space/place, The ETA has since gained considerable,
such as transitions to long-term institutions and though not consistent, empirical support (Scheidt
assisted living (but also from home to home), has and Norris-Baker 2004; Wahl and Oswald 2010).
been a classic area of environmental gerontology For example, Wahl et al. (2009) provided a liter-
(e.g., Wahl and Oswald 2010). ature analysis of all studies published between
Striving for optimization reects the ambition 1997 and 2006 in peer-reviewed journals, which
of environmental gerontology to improve aging addressed relationships between the physical
by means of place improvement or, as it also has home environment and endpoints such as activi-
been coined, place therapy (Wahl and Weisman ties of daily living, amount of help and support
2003). Major examples include evidence-driven needed, and falls. A total of 21 studies found
home modications, adding to the development of supportive or at least partially supportive evidence
new housing solutions for the diversity of aging for substantial linkages between environmental
individuals, or designing public spaces and age- barriers and hazards in the home and disability-
friendly environments at large. related outcomes, while only four did not. The
subset of studies also considering the t or lack
of t between the aging persons functional limi-
Established Theoretical Accounts and a tations and the given physical barriers revealed
Selection of Empirical Findings the strongest relative linkages with disability-
related outcomes. The drawback of the available
Impact of Physical Environments body of empirical work is that most studies have
A classic view has been the Ecological Theory of been cross-sectional, thus not allowing any causal
Aging (ETA; Lawton 1982, 1989; Lawton and interpretation.
Nahemow 1973; Scheidt and Norris-Baker
2004). The basic assumption of this theory has Role of Perceived Physical Environments
been that the capacity to adapt behaviorally to Major concepts in this area include place attach-
existing physical-social environmental pressure ment, place identity, and the meaning of home.
profoundly decreases as people age, due to an Theories on place attachment and place identity
increasing number of functional limitations. (Altman and Low 1992; Brown and Perkins
1992; Stedman 2002) point to a gamut of environment, such as environment-related cogni-

processes operating when people form affective, tion and perceived control over the environment.
cognitive, behavioral, and social bonds to These behaviors include reactive and proactive
the environment (Burholt and Naylor aspects of using, compensating, adapting,
2005) transforming by this means space into retrotting, creating, and sustaining places,
place (Altman and Low 1992; Rowles and which is especially important in old age because
Watkins 2003). Often, these aspects of physical, of decreasing functional and cognitive capacity.
social, and personal bonding are assessed by The model also assumes that both P-E belonging
global attachment evaluations e.g., on indoor and P-E agency must be considered in any qual-
versus outdoor place attachment (Oswald ication of P-E relations in later life.
E
et al. 2005) but there are also efforts using qual- Emerging empirical evidence for the model
itative methodology to empirically approach place came from the ENABLE-AGE project, in which,
attachment and identity (Oswald and Wahl 2005). for the rst time, a maximum of indicators regard-
Empirical research in this area, for example, ing P-E belonging as well as P-E agency have
supported the age-related increase of place attach- been assessed in parallel in advanced old-age
ment and place identity (Zingmark et al. 1995). individuals in a range of European countries
Similarly, the work of Burholt and colleagues (Iwarsson et al. 2007). As has been found, for
(e.g., Burholt and Naylor 2005), Scharf and col- example, P-E t processes and housing-
leagues (2005), and Peace (2005) provided related control processes speaking to objective
evidence conrming that attachment to place constellations of remaining competence and
is an important feature of quality of life in respective objective physical-social home
old age particularly in old and very old environments as well as P-E belonging
individuals underpinning core elements of the processes contributed to the prediction of end-
aging person such as self, identity, and quality of points such as autonomy, well-being, and depres-
life. Aspects of meaning of home have gained sion (Oswald et al. 2007).
particularly strong attention in the now-classic Most recently, Golants model of residential
work of Rowles (1983) and Rubinstein (1989; normalcy highlights subjective environmental
see also Oswald and Wahl 2005). experiences of residential comfort and mastery
as well as related adaptive coping strategies to
Need for Simultaneous Consideration of maintain or achieve residential normalcy in
Objective and Subjective Person-Physical existing objective physical environments (Golant
Environment Relations 2015). According to the model, if older people
At the core of the framework suggested by Wahl feel comfortable and in control of their environ-
et al. (2012) is the assumption that two processes, ment at home, they have achieved residential nor-
experience-driven P-E belonging and behavior- malcy and may no longer feel the need to change
driven P-E agency, help to better understand and anything. However, if there is a perceived incon-
integrate existing P-E interchanges as people age. gruence on the behavioral or experiential level,
P-E belonging reects a sense of positive connec- they perceive themselves as being out of their
tion with the physical-social environment (e.g., mastery and/or comfort zone. Consequently, they
Bakan 1966; Baumeister and Leary 1995), while will try to re-achieve residential normalcy by
P-E agency refers to the process of becoming a ways of assimilative or accommodative coping
change agent in ones own life by means of inten- strategies (Brandtstdter and Greve 1994) with
tional and proactive behaviors imposed on the respect to the immediate home environment.
physical-social environment (e.g., Bandura
1991). Technology as a Major New Environment
In contrast, processes of P-E agency include of Aging
the full range of goal-directed behaviors related to The Internet, the automation of everyday tech-
making use of the objective physical-social nology (e.g., teller machines, ticket machines,
computer and telephone voice menus, car technol- most optimized environment. In a sense, the situ-
ogy), and sensor- or GPS-based assistance are ation of many older individuals, particularly those
rapidly changing the way older people organize in advanced old age, appears in environmental
and experience their everyday life (e.g., Schulz gerontology terms as an ongoing struggle with
et al. 2014). Future cohorts of older adults will place. In future cohorts, agency and proactive
benet from a full range of technology products dealing with this struggle may be expected to
designed to support them as they stay connected increase, for example, via increased competencies
and age well, despite accumulated loss experi- to use all kinds of technology and accept a smart
ences. This requires a full new set of empirical home environment. This may indeed also allow
research including outcome studies that are cur- individuals to stay put, even in the face of major
rently only available to a limited extent (see again cognitive impairment.
Schulz et al. 2014). It is a limitation that most ongoing longitu-
dinal studies of aging only measure the physical
and technical environment in which aging
Reconsidering the Case of Ms. A and an individuals live to a minor extent. Such a ten-
Outlook dency toward decontextualization of aging
seems problematic and hinders the empirical
Environmental perspectives on aging can be con- testing of environmental theories based on
sidered a major part of geropsychology, able to longitudinal data.
add the role of the physical-social environment to
the understanding of aging processes and out-
comes. Furthermore, there is the need in many
Cross-References
areas of geropsychology to pay full attention to
technology environments (such as those dealing
with social relations (e.g., social interaction via
Contextual Adult Life Span Theory for
the Internet)), in the experience of vulnerable
Adapting Psychotherapy (CALTAP) and
phases late in life (e.g., care robotics), as
Clinical Geropsychology
well as in developmental regulation at large
Gerontechnology
(i.e., technology as a means to exert control over
Stress and Coping Theory in Geropsychology
ones environment; see again Valsiner 1994).
Environmental gerontology may become an
important helper in order to enrich these key
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environment (pp. 3359). New York: Springer. ontologist. Online published. doi:10.1093/geront/
Lawton, M. P. (1989). Environmental proactivity in older gnu07.
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course of later life (pp. 1523). New York: Springer. place. Predicting behaviour from place-based cogni-
Lawton, M. P., & Nahemow, L. (1973). Ecology and the tions, attitude and identity. Environment & Behavior,
aging process. In C. Eisdorfer & M. P. Lawton (Eds.), 34(5), 561581.
Psychology of adult development and aging Valsiner, J. (1994). Irreversibility of time and the construc-
(pp. 619674). Washington, DC: American Psycholog- tion of historical developmental psychology. Mind,
ical Association. Culture, and Activity, 1, 2542.
Oswald, F., & Wahl, H.-W. (2005). Dimensions of the Wahl, H.-W. (2001). Environmental inuences on aging
meaning of home in later life. In G. D. Rowles & and behavior. In J. E. Birren & K. W. Schaie (Eds.),
H. Chaudhury (Eds.), Home and identity in later life. Handbook of the psychology of aging (5th ed.,
International perspectives (pp. 2146). New York: pp. 215237). San Diego: Academic.
Springer. Wahl, H.-W., & Gitlin, L. N. (2007). Environmental ger-
Oswald, F., Hieber, A., Wahl, H.-W., & Mollenkopf, ontology. In J. E. Birren (Ed.), Encyclopedia of geron-
H. (2005). Ageing and person-environment t in dif- tology (2nd ed., pp. 494502). Oxford: Elsevier.
ferent urban neighbourhoods. European Journal of Wahl, H.-W., & Lang, F. (2004). Aging in context across
Ageing, 2, 8897. doi:10.1007/s10433-10005-10026- the adult life course: Integrating physical and social
10435. environmental research perspectives. In H.-W. Wahl,
818 Ergonomics and Demographics
R. Scheidt, & P. Windley (Eds.), Annual review of Definitions

gerontology and geriatrics (Aging in context: Socio-
physical environments, Vol. 12, pp. 133). New York:
Springer. The implications of the demographic change have
Wahl, H.-W., & Oswald, F. (2010). Environmental per- long been known. Falling birthrates and a steady
spectives on aging. In D. Dannefer & C. Phillipson increase in life expectancy lead to considerable
(Eds.), The SAGE handbook of social gerontology changes in the age structure of the workforce. Older
(pp. 111124). London: Sage.
Wahl, H.-W., & Weisman, J. (2003). Environmental employees will be more numerous in the future, and
gerontology at the beginning of the new they will have to remain in employment for longer.
millennium: Reections on its historical, empirical, The purpose of designing workplaces for older
and theoretical development. The Gerontologist, 43, employees is to give consideration to age-related
616627.
Wahl, H.-W., Scheidt, R., & Windley, P. (Eds.). (2004). impairments in their performance, whilst at the same
Annual Review of Gerontology and Geriatrics (Aging time exploiting and fostering their particular abilities.
in context: Socio-physical environments, Vol. 23). New Following analyses of the physiological changes and
York: Springer. identication of the specic hazards faced by older
Wahl, H.-W., Fnge, A., Oswald, F., Gitlin, L. N., &
Iwarsson, S. (2009). The home environment and people, design measures for workplaces for older
disability-related outcomes in aging individuals: What employees were developed and implemented in prac-
is the empirical evidence? The Gerontologist, 49, tice for demonstration purposes at a selection of
355367. model workplaces. Work ability of older employees
Wahl, H.-W., Iwarsson, S., & Oswald, F. (2012). Aging
well and the environment: Toward an integrative model can moreover be retained and enhanced through well-
and research agenda for the future. The Gerontologist, planned personnel development.
52, 306316. doi:10.1093/geront/gnr154. In the end it is important not to focus especially
Youniss, J. (1987). Social construction and moral develop- on older employees. Each age or generation has its
ment: Update and expansion of an idea.
In W. M. Kurtines & J. L. Gewirtz (Eds.), Moral devel- own capabilities and challenges which have to be
opment through social interaction (pp. 131148). New considered in order to preserve a healthy work-
York: John Wiley. force with high work ability.
Zingmark, K., Norberg, A., & Sandman, P.-O. (1995). The Demographics is currently a buzzword, with its
experience of being at home throughout the life span.
Investigation of persons aged from 2 to 102. Interna- impact upon both the private lives of individuals
tional Journal of Aging and Human Development, and the world of work. Older people are becoming
41(1), 4762. more numerous as a group, younger people less
numerous. Two main trends are driving this devel-
opment. Firstly, average life expectancy is rising;
secondly, the birthrate is falling. For the world of
work, this means that the average age of work-
Ergonomics and Demographics forces is rising, and younger personnel are becom-
ing increasingly hard to recruit. What are the
Susan Freiberg1, Rinat Saifoulline2 and consequences of this for preventive occupational
Hanna Zieschang1 safety and health activity? How can work be orga-
1
Institute for Work and Health of the German nized such that it can be performed equally well
Social Accident Insurance, Dresden, Germany by younger and ageing workforces?
2
Faculty of Business Administration, University
of Applied Sciences, Dresden, Germany
What Changes Can Be Seen
in the Performance of Older Workers
Synonyms Over Their Working Lives, and What Are
the Impacts of These Changes?
Human factors and ergonomics; Work design and
aging; Personnel development in an aging Views of older and ageing workers performance
workforce. differ widely. Old and wise was a phrase that
Ergonomics and Demographics 819
1.2 3500
1 3000
2500
0.8 Accidents per
1000
2000
0.6 Days of incapacity
1500 for work per 100
0.4
1000
0.2 500 E
0 0
< 25 years 25-34 35-44 45-54 >55
of age
Ergonomics and Demographics, Fig. 1 Incapacity for full-time workers (data from the Holz-BG, 2007). The
work in days (data from the German Social Accident intention here is not to compare the absolute gures
Insurance Institution for the woodworking industry (which are from different years), but to illustrate the trends
(Holz-BG), 2006) and accidents per 1,000 equivalent within each of the two curves
reected the value attached at one time to the It is evident that older workers are an issue
wisdom and experience of age. By contrast, mod- for the social insurance systems. The statistics
ern society is strongly biased towards youth, show that although older people are ill less fre-
whether in advertising, in the recruitment of quently, when they do fall ill they are incapaci-
labour, or in the desire to remain young or at tated for work for longer periods than their
least to appear to be so. younger counterparts (Fig. 1). This pattern also
Who exactly are these older workers? At applies to absences from work owing to illnesses
what age does one become older: 45, 50, 60? unrelated to work and to occupational accidents.
And what actually changes? Absences from work by older employees thus
give rise to higher costs for both the health and
Who Exactly Are the Older People? accident insurance institutions.
Many publications or studies dene older people
as persons aged 45 (or 50) and over. By contrast, What Changes Occur as People Get Older?
the gerontologist Andreas Kruse of the Univer- Any individual will notice for themselves that
sity of Heidelberg asserted in 2006 that ageing is ageing is accompanied by numerous changes.
a lifelong process beginning at birth and ending Often, only characteristics or abilities that deteri-
at death. Since this process is continual, and orate are considered (decit model; see for exam-
changes take a somewhat different form and ple (Landau and Weiert-Horn 2007)):
occur at different times from one person to the
next, it is virtually impossible, and also not con- Age-related hearing loss
structive, to dene a calendar age above Age-related hearing loss primarily affects
which one belongs to the older demographic. the higher frequencies, which older persons
A denition proposed by the Organisation for are no longer able to discern as clearly as
Economic Co-operation and Development before.
(OECD) has gained currency, according to Presbyopia
which older workers are persons in the second Even people with good eyesight typically
half of their working lives, not yet in retirement begin to need glasses when they reach the age
and in good health. of around 45. The useful eld of vision that can
Ergonomics 100
Force in % of the maximum force

and Demographics, Men
Fig. 2 Mean values of the
80
physical forces exerted by
men and women, plotted
against age. Data from 60
strand, Bengtsson, Burke, Women
Dementjeff, Hettinger,
40
Mller, Lehmann, Qutelet,
Reindell, Reys, Rodahl,
Rutenfranz, and Schochrin. 20
According to (Hettinger and
Wobbe 1993), p. 99
0
0 10 20 30 40 50 60 70
Age in years
be viewed without movement of the head also order of milliseconds. The question therefore
drops with increasing age (Boyce 2003). arises as to what work situations exist in which
Need for more light the longer reaction time is actually relevant.
Generally speaking, it is assumed that at the Deterioration in mental performance
lower end of the illuminance range, older peo- Different age groups exhibit differences in
ple require approximately twice the illumi- terms of memory and the ability to retrieve
nance at their workplaces than younger people. stored information. However, older people do
Decrease in physical performance not always perform less well than their youn-
This includes several aspects. Firstly, gen- ger counterparts. Older people are often better
eral agility deteriorates with rising age. Beyond than younger people at retrieving consoli-
that, muscular performance and maximum dated knowledge stored in the long-term
physical force also decrease. The cardiovascu- memory. Other abilities, such as the capacity
lar system is also no longer as t as it was in for coping with stress and condence in
younger years. decision-making are also frequently better
However, Fig. 2 shows clearly that the among older people.
decrease in physical force is not limited to older
age. Human physical force peaks at the age of Some of these abilities can be trained. It is
2025. If a person does not then train, their known, for example, that regular training of mus-
physical force deteriorates continuously. The cles enables their performance to be maintained at
average force values for women are consistently a high level even as a person ages. Well-trained
around 30% lower than those for men. There is male athletes aged between 65 and 70 can still
therefore no clear point at which a person attain peak oxygen uptake values a measure of
becomes old in terms of physical performance. the muscles endurance capacity that exceed the
Increase in recovery time average values for women across all ages
This increase is a direct consequence of the (Hollmann and Hettinger 2000, p. 315).
deterioration in physical performance: when Not every aspect of deteriorating physical per-
the performance of the cardiovascular system formance can be compensated for by training.
is reduced, the body takes longer to reach the Sensory performance in particular is improved
rest state (resting heart rate) following physical only marginally by training. It can, however, be
exertion. supported by technical aids. In addition, the per-
Increase in reaction time formance curves differ widely from one person to
Researchers have demonstrated that older the next. The values shown in Fig. 2 are average
peoples reactions are slower in certain situa- values. A range of factors are at play here that
tions. The differences are, however, in the assist in compensating for decits in old age and
Factors influencing performance

Personal and professional:
Intelligence and innate ability
Constitution
Mental and physiological performance
Lifestyle (nutrition, exercise, smoking patterns, alcohol consumption, etc.)

Socialization, education
Self-concept, concept of others
Jobs to date (stresses, training)
Required performance at work and in private life
Motivation from work and hobbies for learning
E
Personal
differences
Age
Ergonomics and Demographics, Fig. 3 Changes in the characteristics of human beings as they age occur at different
points in time and vary strongly from one individual to the next (Modied in accordance with (Buck et al. 2002))
also in strengthening or developing new abilities. experience can often be linked or are mutually
This shows that ageing has a strong biographical benecial.
component and is also linked to an individuals Regained exibility in use of time
employment history (Fig. 3). As a rule, older employees no longer have
Abilities that are enhanced in older age or are children at home to look after. They can there-
more and more attained until then include fore often manage their time more exibly than
(competence model, refer for example to (Maintz young parents. Their commitments to caring
2003)): for family members can, of course, restrict this
exibility.
Interpersonal skills
Company loyalty
Older people have more experience in deal-
Surveys have shown this to be a character-
ing with other people. This includes dealing
istic particularly valued by employers: where
with customers, as well as colleagues.
employees have had the opportunity to work
Effective communication
continuously for a company over a long
Owing to their greater social competence,
period of time and to experience recognition
older workers are often more successful in
within it, their loyalty to their employer is also
discussions with customers. Firstly, they are
very strong. This can make them more
more familiar with their companys products
reliable.
or services; secondly, their long experience
makes them more familiar with frequently
recurring customer needs. Strategies for Corporate Action Against
Experience the Backdrop of Demographic Change
Older people can deal with vocational chal- Analysis of the deteriorating and improving abil-
lenges better owing not only to their occupa- ities of ageing employees reveals key areas in
tional experience but also to their life which companies or employers can take measures
experience as a whole. Occupational and life to support and assist their staff. According to
Ilmarinen and Tempel (2002), companies can Deterioration in general agility

address the following four elds of action: Reduction in muscle performance, i.e., loss of
physical strength
1. Promotion of good health Reduction in the performance of the cardiovas-
2. Training and skills development cular system
3. HR management and corporate culture
4. Work design and organization Should vision deteriorate, poor or uneven
lighting, for example, may lead to hazards and
Design of workplaces suitable for older workers a higher accident risk (Zieschang and
is not sufcient on its own. It is important that Freiberg 2006). Should the work require the exer-
ageing be understood as a process. A corporate tion of substantial muscle force, the worker may
strategy that merely reacts to decits as they arise be able to perform it only with restrictions, or
is not effective. Mental and physical tness in old not at all.
age is the result of a lifelong process. Both the
accident and health insurance institutions are on Ergonomic Workplace Design: Model
hand to provide expert advice to companies. Workplaces
The example below from the eld of action of Ergonomically, sound design of workplaces can
work design and organization addresses the area mitigate or even fully compensate for
of workplace design. age-related loss of performance. Good ergo-
nomic design and the necessary adjustments to
specic workplaces for the minimization of
Design of Workplaces health risks also benet younger coworkers at
the same workplaces, since they increase occu-
In order for the health and performance of older pational safety in general. Special workplaces
workers to be retained within the work process for older workers, or sheltered workplaces,
and beyond, ergonomic measures at the work- which are also more likely to be rejected by
place are absolutely essential. Firstly, attention older workers owing to their special status,
must be paid to the optimum design of tools and then become superuous.
work equipment; secondly, however, the proper The workplaces should be designed in the rst
use of these elements and health-conscious behav- instance according to the following principles:
ior on the part of the workers are relevant.
Inherently sound workplace design in accor-
Constraints and Hazards at the Workplace dance with human engineering and ergonomic
Section What Changes Can Be Seen in the Per- criteria results in only a small number of addi-
formance of Older Workers Over Their Working tional special measures being required in order
Lives, and What Are the Impacts of These for workplaces to be adapted to the needs of
Changes? showed that human beings change as older employees.
they age. Many abilities remain virtually unaf- Younger employees also benet from good
fected by the ageing process or mature only in the ergonomic workplace design.
course of an individuals life. Some skills, how- The aim is not for special workplaces for
ever, are largely or even completely lost. Examples old people or sheltered workplaces to be
of changes in old age that tend to make coping with created. Younger workers are also to be able
the ow of work more difcult or that can lead to to work at the redesigned workplaces. Social
additional health risks include the following: exclusion resulting from age is thus
prevented.
Deteriorating vision Wherever possible, consideration should be
Changes in the perception of noise and deteri- given to the particular abilities of each individ-
orating hearing ability ual employee.
Good ergonomic design and productivity

should not and need not be mutually exclusive
(Zieschang and Freiberg 2006). Various design
elements are explained below with reference to
model assembly and video display unit
workplaces.
Model Workplace for an Assembly Task

The workplace was rst to be designed according
to good human engineering practice and equipped
E
with basic elements. These include:
An adequately dimensioned and nonreective

work surface
Assembly trays located appropriately for the
task within the workers reach
A height-adjustable work chair
An adjustable footrest
Adequate lighting
In order for materials and the corresponding

tools to be matched more easily, it is advanta- Ergonomics and Demographics, Fig. 4 Model work-
geous for the assembly trays for the screws and place for an assembly task (Source: IAG)
the corresponding screwdriver bits to be color
coded.
Various elements were then adapted (Fig. 4)
that are geared to the needs of older workers and The combination of two lamps at the model
facilitate performance of the work or indeed make workplace did not give rise to glare.
it possible in the rst instance (Hoffmann and Design of the legibility
Zieschang 2005): An illustrated description of the individual
assembly steps, with clearly structured dia-
Design of the lighting grams, assists in understanding and learning
Older workers require up to 100% more the procedure and avoiding mistakes. High
light. In order to meet this requirement, two legibility was attained by means of a suf-
lamps were installed for supplementary use as ciently large font, clear contrast, and large
needed. The European standard EN 12464-1 images.
(2003) requires a maintained illuminance value Reducing the physical stress
of 300 lx for moderately ne assembly tasks in In order to relieve the locomotor system, a
the metal manufacturing and processing indus- holding xture was used for the power screw-
tries and of 500 lx for other industrial sectors. driver, and trolleys provided for the delivery of
The lamp employed at the model workplace materials to the workplace and roller conveyor
yields an average illuminance of 1,200 lx in the belts for dispatch of the assembled workpieces.
working area on the assembly bench. If possible, the weight of the loads to be manip-
Switching on an additional lamp of the same ulated was to be kept low.
type approximately doubles the illuminance to A forearm rest provides relief and improves
2,300 lx. Since older workers are more sensi- ne-motor performance. These rests can be
tive to glare, it must be ensured that this is not tted to the table and removed from it quickly
caused by the installation of additional lamps. and easily as required by the individual.
A holder, tted to the edge of the assembly If an ergonomic sitting posture necessitates an
bench and removable at any time, into which adjustable footrest, one must also be provided.
the workpiece subassembly can be inserted The issue most frequently raised regarding the
during assembly, prevents the parts from slip- design of video display unit (VDU) workplaces
ping out of the workers hand. Less stress is for older employees is the relationship between
thereby placed upon the workers motor func- age-related deterioration in vision and VDU work.
tions, and assembly can be performed more Conditions in the work environment, such as
quickly. Should no holder be present, a rubber noise, the climate, and the space requirement,
surface can be used as an alternative to assist must also be considered.
the worker in gripping small parts. The color With increasing age, the lens of the eye
selected for the surface should provide a clear becomes less elastic, resulting in a deterioration
contrast to the parts to be handled. in its accommodative ability. The continual
An assembly bench with electrical height change in focus between screen, keyboard, and
adjustment enables each worker to adjust the documents used for the work increases the strain
bench to the working height most suitable for upon the eyes, consequently leading to premature
them. Where permitted by the task, the worker fatigue. Workers suffering from complaints such
should alternate between a seated and standing as impaired vision may attempt to compensate for
position, thus preventing imbalanced posture them by adopting unfavorable sitting and head
and muscle tension. Should budgetary con- postures. Optical aids such as reading glasses,
straints or other reasons rule out purchase of a varifocal glasses, or contact lenses often fail to
height-adjustable bench, other measures must meet the particular requirements posed by a VDU
be taken to ensure movement and variation in workplace. Under certain circumstances, presby-
activity at the workplace. opia (age-related vision impairments) can be
Further organizational tasks such as collec- corrected by means of suitable spectacles spe-
tion of the components and transport of the cially designed for use for work at video display
nished subassembly to a location a few units. In this case, the working conditions and
meters away also have the function of promot- viewing distances for the individual at the work-
ing more movement at the workplace. The place must be determined beforehand, in addition
worker is forced to stand up in order to put to the examination by an eye specialist. The cor-
the workpiece aside. Although this entails rect relationship between VDU work and recov-
additional time, the resulting movement at the ery time or task alternation can also prevent
workplace counters the onset of fatigue, which excess strain upon the eyes.
in turn has a positive inuence upon The model workplace is adapted to the needs of
productivity. older workers as follows (Fig. 5):
Model Workplace for VDU Tasks Design of the lighting

This workplace was also designed in the rst Presbyopia and deteriorating ability to
instance with consideration for ergonomic adapt to lighting conditions can be compen-
aspects and equipped with basic elements. These sated for in part by increased illuminance.
include: The European standard EN 12464-1 requires
a maintained illuminance of 500 lx for VDU
A nonreective desktop of adequate area and ofce work (EN 12464-1 2003). A mean
An ofce chair with height adjustment and illuminance of 850 lx was measured at the
armrests adjustable for height and width model workplace with general room lighting.
An LCD display The value was increased to 1,600 lx by means
A light-colored keyboard with dark characters of an additional asymmetrical workplace lamp
A standard mouse suitable for VDU work. The glare effects
Adequate general lighting caused by high illuminance values were
Ergonomics
and Demographics,
Fig. 5 Model workplace
for VDU tasks (Source:
IAG, Floss)
avoided by suitable design of the display In order to ensure sufcient movement dur-
(character display in positive video). ing sitting, swivel ofce chairs are
Noise abatement recommended that ensure active sitting, i.e.,
Older people are more easily disturbed by alternation between sitting in forward, middle,
background noise than are young people. and rearward positions.
Where possible, sources of noise (such as
printers, photocopiers, and fax machines) Preventive Activity for All Age Groups
should be kept away from the workplace. The purpose of designing workplaces for older
Where several workplaces are located in a sin- workers is to give consideration to age-related
gle room, telephone calls and conversations impairments in their performance, while at the
may constitute sources of noise. These can be same time exploiting and fostering their particular
controlled by sound-absorbing elements such abilities. Following analysis of the physiological
as acoustic ceilings, front panels of cabinets, or changes in older people and identication of the
suitable partitions. specic hazards facing them, the design measures
Reducing the physical stress described in section Ergonomic Workplace
Asymmetric stress and a lack of movement, Design: Model Workplaces for workplaces
caused, for example, by a seated work position for older employees were developed and
at a video display unit, accelerate the natural implemented in practice for demonstration pur-
age-related wear of joints, intervertebral disks, poses at various model workplaces. In the process,
and the spine. In order to promote movement, it was frequently observed that once a workplace
the model workplace was equipped with an had been designed with consideration for good
electrically powered desk that permits work ergonomic practice, only minor further adjust-
in either a seated or standing position. Alterna- ments to the particular needs of older employees
tively, a high-level desk, either free-standing or were then needed. Workers in all age groups ben-
adapted to the existing desk, can be used. et from the preventive health benets of ergo-
Organizational measures, such as locating nomic design. That all age groups benet has also
the printer in an adjacent room or placing the been shown by a study in which persons of differ-
telephone at a higher level in the immediate ent ages performed assembly tasks at a model
working area, for example on a side table, force workplace. The evaluation revealed no signicant
the worker to stand up and exercise. differences between the older and younger
workers. In other words, the workplace is equally must be taken. The second approach involves the
well suited to persons of any age. timely provision of advice and training for a
The model workplaces illustrate the need for change in task or occupation. The consulting con-
ergonomic design, and can therefore be used for cept developed for this purpose is based upon a
the purpose of training on the subject, and also in number of empirical studies (Ulbricht and Jahn
the context of consulting with companies. 2010; Jahn and Ulbricht 2011; Rahnfeld and Jahn
However, good ergonomic design of work- 2012; Seibt and Seidler in press; Saifoulline and
places also has its limits. Some occupations pre- Jahn 2015). In these studies, a comprehensive risk
sent considerable physical or mental stresses analysis was performed for the model occupations
when performed over a long period of time and of nurse, cleaner, construction worker, teacher,
cannot be performed through to the statutory and metal caster. Experts with many years voca-
retirement age. How the work ability and health tional experience, individuals who had success-
of the affected workers can be retained despite this fully changed vocation, occupational physicians,
is described in the next section. and managers with responsibility for personnel
were interviewed in the course of these studies.
The consulting concept essentially comprises
Personnel Development for Occupations four steps:
of Limited Duration: How Can
Employability Be Assured Through 1. Identication of early-warning indicators
a Change in Occupation? 2. Analysis of the risk factors in the current
occupation
Construction worker, metal production worker, 3. Requirements for a follow-on occupation
nurse, forester in many sectors of the economy, 4. Provision of advice on a switch to a suitable
occupations are found that can be performed only occupation
for a limited duration. According to Behrens
(1994), occupations of limited duration are those Identification of Early-Warning Indicators
that, primarily for health reasons, cannot be The effects of occupational stresses are often not
performed by the majority of workers through to recognized until an advanced stage and some-
the statutory retirement age and often not even to times not until it is already too late. It is important
the age of 50. that they be recognized and addressed early in
In the long term, the high stresses in these order for retention of employability to be assured.
occupations lead to premature attrition and high The early-warning indicators are a sign of occu-
levels of strain upon the workers. Older workers pational health hazards and risks that could lead to
are particularly affected by the cumulative effects the employee leaving his or her occupation
of the stresses in occupations of limited duration. prematurely.
They are often unable to work through to the
statutory retirement age and must instead leave Early Warnings from Superiors
the occupation prematurely. Often, it is direct superiors who realize at an early
Two approaches are conceivable by which the stage that a workers health and performance are
workers employability can be assured. The rst suffering. A drop in work performance or more
approach involves all measures for extending the frequent absences from work may be indicators.
time spent working in the occupation in which the The task of the workers superior is to discuss with
individual was trained (see section Design of the worker what the reasons could be for the
Workplaces). This should always be the pre- impaired work performance and health. Together
ferred approach. These measures may, however, with the worker, the superior examines whether
not sufce, in which case the second approach the impairments could be counteracted by
changes in the organization or design of the work. the employees skills and his or her career develop-
It is then the superiors responsibility to implement goals are determined by a skills analysis.
ment these changes.
Such discussions with personnel can be Requirements for a Follow-On Occupation
conducted as part of the regular annual interviews, The outcome of the requirements and skills anal-
after 10 years employment at the company, fol- ysis is a denition of the criteria to be met by an
lowing changes in a workers family situation, in alternative job or occupation which eliminate the
the event of variations in performance, or when a critical stresses associated with the existing job
worker indicates a need for them. and which best match the employees skills.
E
Early Warnings from Occupational Physicians Provision of Advice on a Switch to a Suitable
During occupational medical prophylaxis, Occupation
occupational physicians are in a position to Based upon the results of the analysis, the
identify early-warning indicators of health employee is advised on possible alternative jobs
impairments of occupational origin. A relation- or alternative occupations. Alternative career
ship based upon trust between the physician paths are rst developed in conjunction with the
and the employee and between the physician employee. Following the decision for a particular
and the company is a criterion for sound diag- career, an integral part-time training concept is
nosis and for effective, early consultation when developed for preparation for the follow-on
a risk of work-related disease rst becomes job/occupation. Career matrices can be used for
apparent. this purpose. These include:
The following diseases may be early-warning
indicators in a metal production worker aged A vertical career path within the company
under 45: A sideways career move within the company
A change to a job or occupation outside the
Degenerative diseases of the musculoskeletal company
system (e.g., signs of attrition in the spine
region) An example of a career matrix is shown in
Rheumatic diseases Table 1 with reference to the metal sector.
Coronary diseases, vascular changes Vertical career paths leading to management
Diseases of the respiratory tract (such as positions are forms of personnel development
asthma) that, where permitted by the employees perfor-
Mental disorders (such as depression) mance, exploit his or her knowledge and experi-
Sleep disorders ence and counteract health risks before health
impairments arise. Such career paths should be
Analysis of the Risk Factors in the Current opened to middle-aged employees in the company
Occupation in particular.
If early-warning indicators are diagnosed during Sideways career moves channel the vocational
occupational medical examinations, the employee knowledge and experience and permit their trans-
is offered a consultation. Responsibility for the confer between different departments, thus beneting
sultation can be assigned to the occupational physi- the company. The purpose of the change in job is
cian, the employees immediate superior, the human often to prevent or minimize health risks. For
resources department, the staff council, or the dis- large companies in particular, it is the easiest
ability manager. The demands of the present job and way of bringing about a change.
sources of stresses in the family and social context Figure 6 shows by way of example how this
are analyzed during the consultation. In addition, consulting approach is implemented.
Ergonomics and Demographics, Table 1 Vertical career paths and sideways career moves in companies with
reference to the example of the metal sector
Change in job Change in occupation
In the company Vertical career path Vertical career path
For example, as a foreman: For example, in occupational medicine:
Shift foreman Paramedic in the emergency services
Day foreman Employee in occupational medicine
For example, as a technical employee: Sideways career move
Quality assurance employee To early shift
Production planning employee For example, as a mold builder in the mold
Sideways career move workshop
To early shift As an employee in the logistics department
For example, as a metal caster in
continuous casting
Outside the Vertical career path Sideways career move
company For example, as a technical employee: Return to previous occupation (e.g., truck driver,
Self-employment (own production cook)
company) In a new occupation (e.g., caretaker, metalworker,
Engineering degree media designer)
Ergonomics
and Demographics,
Fig. 6 A strongly
simplied example of
careers advice for a change
of occupation (Saifoulline
and Jahn 2015)
Example experience in the casting plant and his

close afnity to the occupation:
No shift work
1. The occupational medical examination Flexible working hours, in order to rec-
of a metal caster in a casting plant identied oncile work and family life
sleep disorders as an early-warning An additional qualication building
indicator of signicant impairments to upon existing vocational knowledge
well-being and in particular to cognitive and experience
performance. 4. An alternative career in this case is training
2. The requirements analysis revealed the as a metalworker.
most critical factor for stress to be shift
work against the background of the
employees family obligations and his A Digital Guide for a Sideways Career Move
10-year history of shift work. In the Horizontal career changes project, the
3. The following requirements were dened approach described here for identication of a
for the follow-on occupation, in consider- suitable occupation for a possible career change
ation of the employees many years of was extended to all skilled vocations. A digital
guide was developed in this project that provides Cross-References

companies with assistance in suitable personnel
planning. Taking the form of an information Age Diversity at Work
portal, it supports affected individuals in the Age-Related Changes in Abilities
search for an alternative occupation that is as Human Resource Management and Aging
equivalent and as suitable as possible. An inte- Personality Disorders in Older Adults
grated ICT instrument contains a database of Technology and Older Workers
occupational proles of all skilled vocations. Work Design and Aging
A person looking for an alternative occupation
creates their own personal prole by complet-
E
ing an electronic questionnaire. A specially
References
developed algorithm compares the properties of
the personal prole with those of the occupa- Behrens, J. (1994). Der Prozess der
tional proles. The properties considered in the Individualisierung das demographische Ende eines
proles can be divided into three categories: historischen Bndnisses. In Frhinvaliditt ein Ventil
qualications, preferences, and health. The result des Arbeitsmarktes? Berufs- und Erwerbsunfhigkeit
(pp. 105 ff). Berlin: DZA.
is a list of suitable alternative occupations, Boyce, P. R. (2003). Lighting for the elderly. Technology
ranked by match level. The ICT instrument and Disability, 15, 165180.
also permits detailed analysis of the results. Buck, H., Kistler, E., & Mendius, H. G. (2002).
The alternative occupations proposed by the Demographischer Wandel in der Arbeitswelt. Chancen
fr eine innovative Arbeitsgestaltung (Series of bro-
ICT instrument constitute preliminary informa- chures: Demographie und Erwerbsarbeit, 8). Stuttgart:
tion that cannot and should not replace a per- Fraunhofer IRB Verlag. http://publica.fraunhofer.de/
sonal consultation. Rather, the digital guide is eprints?urn:nbn:de:0011-n-96996.pdf. Accessed 20
intended to draw attention to the problem of Feb 2015.
EN 12464-1. (2003). Light and lighting Lighting of work
occupations of limited duration and to generate places Part 1: Indoor work places.
interest in a change of occupation. It is impor- Hettinger, T. H., & Wobbe, G. (Eds.). (1993). Kompendium
tant that this then be followed by a personal der Arbeitswissenschaft: Optimierungsmglichkeiten
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Ludwigshafen (Rhein): Kiehl.
The digital guide is available for use free of Hoffmann, M., & Zieschang H. (2005). Arbeitsplatz-
charge on the Internet (in German only) at http:// gestaltung fr ltere Arbeitnehmer No: 3016, Issue
wegweiser-berufsumstieg.de. 1. In Aus der Arbeit des BGAG. Berufsgenos-
senschaftliches Institut Arbeit und
Gesundheit BGAG, Dresden loose-leaf. http://
www.dguv.de/bgia/de/pub/ada/pdf/bgag3016.pdf
Conclusion Hollmann, W., & Hettinger, T. (2000). Sportmedizin.
Grundlagen fr Arbeit, Training und
Owing to the demographic shift, the proportion Prventivmedizin. Stuttgart/New York: Verlag
Schattauer.
of older workers has been rising rapidly for Ilmarinen, J., & Tempel, J. (2002). Arbeitsfhigkeit 2010:
some years and will continue to rise in the Was knnen wir tun, damit Sie gesund bleiben? Ham-
future. This increasingly shifts the focus to burg: VSA-Verlag.
the retention of work ability. Through knowl- Jahn, F., & Ulbricht, S. (2011). Mein nchster
Beruf Personalentwicklung fr Berufe mit
edge of the performance criteria for older begrenzter Ttigkeitsdauer. Part 1: Modellprojekt in
employees, ergonomically optimized design of der stationren Krankenpege. Revised and extended
workplaces, and well-planned personnel devel- edition. iga.Report 17. http://www.iga-info.de/
opment, work ability can be retained and veroeffentlichungen/iga-reporte/iga-report-17.html
Landau, K., & Weiert-Horn, M. (2007). ltere
enhanced. The beneciaries are ultimately not Arbeitnehmer. In K. Landau (Ed.), Lexikon
only the ageing workforces but also younger Arbeitsgestaltung (pp. 3639). Stuttgart: Gentner-
employees. Verlag.
830 Event-Related Potentials
Maintz, G. (2003). Leistungsfhigkeit lterer Overview

Arbeitnehmer Abschied vom Dezitmodell. In
B. Badura, H. Schellschmidt, & C. Vetter (Eds.),
Fehlzeiten-Report 2002 (pp. 4355). Berlin/Heidel- Event-related brain potentials (ERPs) represent
berg: Springer. the synchronized activity of populations of corti-
Rahnfeld, M., & Jahn, F. (2012). Mein nchster cal neurons measured noninvasively at the scalp
Beruf Personalentwicklung fr Berufe mit that are time-locked to some event of interest (e.g.,
begrenzter Ttigkeitsdauer. Part 3: Modellprojekt
Reinigungsberufe. iga.Report 17. http://www.iga-info. the onset of a stimulus or a button press) (Luck
de/veroeffentlichungen/iga-reporte/iga-report-17.html and Kappenman 2012). ERPs provide excellent
Saifoulline, R., & Jahn, F. (2015). Neue Wege bis 67 temporal resolution to examine the unfolding of
gesund und leistungsfhig im Beruf. Modellprojekt in information processing over time that is superior
der Metallindustrie. Hamburg: Wachholz.
Seibt, R., & Seidler, A. (in press). Im Lehrerberuf gesund to hemodynamic measures such as functional
und motiviert bis zur Rente Wege der Prvention und magnetic resonance imaging (fMRI) or near-
Personalentwicklung. Mein nchster Beruf infrared spectroscopy (NIRS). In contrast, the
Personalentwicklung fr Berufe mit begrenzter spatial resolution of ERPs is inferior to that of
Ttigkeitsdauer.
Ulbricht, S., & Jahn, F. (2010). Mein nchster fMRI, although distributed source analysis in
Beruf Personalentwicklung fr Berufe mit begrenzter combination with multivariate statistical tech-
Ttigkeitsdauer. Part 2: Modellprojekt im Straen- und niques may provide a reasonably precise method
Tiefbau. iga.Report 17. http://www.iga-info.de/ for estimating the cortical generators of the ERPs.
veroeffentlichungen/iga-reporte/iga-report-17.html
Zieschang, H., & Freiberg, S. (2006). Model work- The ERP technique has been widely used to study
places for older employees. 9. Internationales information processing related to perception, cog-
Kolloquium der IVSS-Sektion Forschung. Integra- nition, emotion, and action (Luck and
tion des Faktors Mensch in die Planung von Kappenman 2012).
Arbeitssystemen: Basis fr ein erfolgreiches
Unternehmen. 13 Mar 2006. ERPs have been used extensively to examine
age-related differences in neural recruitment
related to topics of interest to cognitive and social
neuroscientists including age-related variation in
the automaticity of sensory processing, the slowing
Event-Related Potentials of processing speed, the encoding and retrieval of
episodic memories, and the monitoring of response
Robert West conict and errors (Friedman 2012). The direct
Department of Psychology, Iowa State University, measure of neural activity makes the technique
Ames, IA, USA well suited for studies of neurocognitive aging as
issues related to age-related variation in the cou-
pling of the vascular and neural systems inherent in
fMRI are not an issue for ERP researchers. This
Synonyms
entry provides an overview of the effects of aging
on a number of ERP components related to cogni-
Electroencephalogram; Evoked potentials
tive information processing. For those interested in
the effects of aging on ERPs associated with early
sensory or perceptual processing, Freidman
Definition (Friedman 2012) provides an excellent review of
this literature.
Event-related brain potentials (ERPs) represent
the synchronous activity of populations of cortical
neurons measured at the scalp. This entry con- The P3s
siders age-related differences in ERPs related to
language, episodic memory, and outcome The P3 or P300 is the most extensively studied
processing. ERP component that represents at least two
Event-Related Potentials 831
distinct components (i.e., P3a and P3b) that can be ERPs. Consistent with the speed of processing
dissociated based upon their psychological char- theory of cognitive aging, the latency of the P3
acteristics, neural generators, and neuropharma- increases in a fairly linear fashion from 20 to
cological underpinnings (Polich 2007). The 80 years of age (Polich 1996). This effect may
components contributing to the P3 are most com- be somewhat stronger for auditory than visual
monly observed in the oddball task that compares stimuli, increase as target frequency decreases,
the ERPs elicited by a frequent standard stimulus and be greater for oddball tasks requiring counting
relative to a lower-frequency target stimulus (i.e., responses relative to button presses. The
oddball) and/or a task-irrelevant distractor stimu- age-related slowing observed for the P3 is greater
lus. The P3a/P3b components are both observed and more consistently observed than the effect of
E
with auditory, visual, and somatosensory stimula- aging on earlier ERP components related to sen-
tion, indicating that they reect information sory processing (Polich 1996), which may high-
processing beyond the primary sensory systems. light differences between sensory and cognitive
The amplitude of the P3a is maximal over the aging (Friedman 2012).
frontal midline, while the amplitude of the P3b is In addition to the age-related increase in the
maximal over the centralparietal midline (Polich latency of the P3, a number of investigators have
2007). The P3a commonly peaks between reported that the distribution of the P3 becomes
250 and 400 ms after stimulus onset, while the more anterior in older adults relative to younger
P3b can peak from anytime time between 300 and adults, reecting an anterior shift in the oddball
600 ms after stimulus onset depending upon task task (Fabiani et al. 1998). The anterior shift
demands. The P3a is thought to reect stimulus- appears to be stronger for older adults with
driven attentional orienting, and the P3b is lower executive function than those with higher
thought to reect the allocation of attention to executive function. The reason for the anterior
stimulus categorization that facilitates subsequent shift has been debated in the literature. It appears
memory processing (Polich 2007). A P3a-like that the effect may at least partially result from the
component has been described in a number of greater contribution of the P3a to the ERPs
different paradigms resulting in various labels elicited by target stimuli in older adults than in
being applied to this component of the ERPs younger adults, while the P3b distinguishing tar-
including the P3a, the novelty P300, and the get from standard stimuli may be relatively pre-
no-go P300. Systematic comparison of the ERPs served in later adulthood. Age-related differences
elicited in various paradigms using multivariate in the contribution of the P3a and P3b elicited in
statistical techniques demonstrates that these three the oddball task and other paradigms highlight the
components in fact reect the same phenome- potential importance of using carefully designed
non (Polich 2007). In complex tasks used in the paradigms in combination with appropriate statis-
cognitive aging literature, the ERPs measured at tical techniques to gain a clear understanding of
the scalp often reect a mixture of the P3a, P3b, the effects of aging on the latent ERP components
and other components that share temporalspatial that are manifest in the scalp-recorded ERPs.
overlap. This makes it important to carefully con-
sider aspects of paradigm design and/or utilize
statistical techniques that allow one to tease apart The Medial Frontal Negativities
the contribution of different components during
study design and data analysis. Over the last two decades, there has been an
The P3 has been used extensively in studies explosion of interest in transient negativities
examining the effects of aging on information observed over the medial frontal region of the
processing (Friedman 2012). The underlying scalp in a number of different paradigms
topography of the P3a and P3b appears to be (Friedman 2012; Cavanagh and Frank 2014).
similar in younger and older adults, although this These include the error-related negativity (ERN)
may be obscured in the manifest scalp-recorded that distinguishes errors from correct responses in
a variety of tasks, the N2 and medial frontal neg- amplitude of the ERPs elicited by errors in older
ativity (MFN) that distinguish incongruent trials adults, although some evidence indicates that
from congruent trials in the anker and Stroop aging can also be associated with an increase in
tasks, and the feedback negativity (FN) or the amplitude correct-related negativity (CRN) in
feedback-related negativity (FRN) that distin- older adults that thereby reduces the difference in
guishes gains from losses in gambling and rein- amplitude between errors and correct responses.
forcement learning tasks. Each of these Potential moderators of the effect of aging on the
components has been linked to neural generators ERN have not been extensively explored, with
in the anterior cingulate cortex (ACC) in studies some limited work demonstrating that the effect
using both dipole source modeling and distributed of aging is not sensitive to individual differences
source analysis. Consistent with these ndings, in physical tness. Together, the results of the
converging evidence from studies using fMRI in extant literature lead to the suggestion that aging
humans and single-unit recording in primates has is associated with a decrease in the efciency of
revealed neural activity related to choice errors, the endogenous error monitoring system that
response conict, and negative feedback in the involves the ACC and is reected by the ERN.
ACC (Cavanagh and Frank 2014; Gehring The MFN is elicited in a variety of
et al. 2012). stimulusresponse compatibility tasks and reects
The ERN represents a transient negativity over greater negativity for incongruent (incompatible)
the medial frontal region of the scalp that in than congruent (compatible) trials that can be
healthy younger adults is greater in amplitude observed when the ERPs are locked to either
for errors than correct responses (Gehring stimulus or response onset (Friedman 2012). In
et al. 2012). The ERN typically peaks between the anker and Simon tasks, the MFN or N2 tends
50 and 100 ms after an error is committed and to be greatest in amplitude between 200 and
reects the activity of an endogenous error mon- 300 ms after stimulus onset, while in the Stroop
itoring system, as feedback indicating the pres- and Stroop-like tasks, the component is greatest in
ence of the error is not required to elicit the amplitude between 300 and 500 ms after stimulus
component. The ERN is typically followed by onset. The difference in the timing of component
the error positivity (i.e., Pe) that can extend from across tasks is likely related to variation in the
the frontal to the parietal region of the scalp and time course of information processing, as the
last for 300500 ms after the response. The psy- anker or Simon tasks tend to produce substan-
chological processes represented by the ERN and tially shorter response times than the Stroop task.
Pe have been extensively debated, and current The effect of aging on the MFN is less consis-
consensus appears to be that the ERN is related tent than the effect of aging on the ERN, but there
to the detection and possibly correction of have also been fewer studies (Friedman 2012). In
the error or the restoration of goal-directed studies using a Simon-like task wherein the ERPs
processing, while the Pe is related to conscious were locked to the response, the amplitude of the
awareness that an error has occurred. MFN was similar in younger and older adults
The effect of aging on the ERN has been stud- (Friedman 2012). In contrast, in studies using the
ied in a variety of paradigms including choice color-word or counting Stroop tasks wherein the
response tasks, response compatibility tasks ERPs were locked to stimulus onset, the ampli-
(e.g., anker or Stroop task), and reinforcement tude of the MFN was attenuated in older adults
learning tasks (Friedman 2012). In almost all relative to younger adults (West and Schwarb
cases, the amplitude of the ERN is reduced in 2006). Given the existing literature, it is difcult
older adults relative to younger adults when mea- to know whether variation in the effect of aging
sured as the difference between errors and correct observed across studies results from differences in
responses. The effect of aging on the ERN most the cognitive processes measured by the tasks that
commonly appears to result from a decrease in the were utilized in the various studies or the method
of data processing. There is some evidence that Episodic Memory

individual differences in executive function may
moderate the effect of aging on the MFN observed ERPs have been used extensively to examine the
in the Stroop task and that the presence of neural correlates for encoding and retrieval pro-
age-related differences in the MFN is sensitive to cesses related to episodic memory in studies of
the amount of interference that is encountered in item recognition and source memory (Wilding
the task (Friedman 2012; West and Schwarb and Ranganath 2012). Successful encoding is com-
2006). Gaining a greater understanding of how monly associated with slow-wave activity over the
individual differences and task-related factors frontal and parietal regions of the scalp that can be
inuence the effect of aging on the MFN is clearly greater in amplitude over the left than right frontal
E
one avenue for future research. regions. The left frontal slow-wave activity has
The FN represents a transient negativity over been associated with semantic retrieval and inte-
the frontal central region of the scalp that is greater grative processing that facilitates episodic
in amplitude following negative outcomes (i.e., encoding. The ERP correlates of successful
losses or negative feedback) than positive out- retrieval are somewhat dependent upon the task
comes (i.e., gains or positive feedback) in gam- that is used to probe episodic memory. In recogni-
bling and reinforcement learning paradigms tion memory paradigms, there are three compo-
between 250 and 350 ms after feedback is nents that consistently distinguish remembered
presented (Cavanagh and Frank 2014). Studies items (hits) from forgotten (misses) or new
examining the effect of aging on the FN have (correct rejections) items; these include the
consistently revealed that the amplitude of this FN400, the left parietal oldnew effect, and the
component is smaller in older adults than in youn- right frontal slow wave. The NF400 is greatest in
ger adults and that this results from a reduction in amplitude over the medial frontal region of the
the amplitude of the ERPs elicited by negative scalp and has been associated with item familiarity,
outcomes (Hmmerer et al. 2011). In various stud- being similar in amplitude for recognized old items
ies, the reduction in the amplitude of the FN in regardless of whether or not the memory includes
older adults has been associated with a mild dec- source information or recollection. The left parietal
rement in associative learning, a tendency to oldnew effect represents greater positivity for old
switch following gains and losses, and a tendency items than for new items between 400 and 600 ms
to be more conservative than younger adults. after stimulus onset that is typically greater in
These ndings may indicate that an age-related amplitude when recognition is associated with
reduction in the efciency of feedback processing source information or recollection. The right fron-
could have widespread effects on efcient infor- tal slow wave is observed less consistently than the
mation processing. other two components and has been associated
In summary, aging is associated with a reduc- with monitoring or meta-memory processes. In
tion in the amplitude of medial frontal ERP activ- paradigms requiring source judgments or cued
ity related to error monitoring and feedback and recall, successful retrieval is commonly associated
conict observed in a variety of paradigms. At with slow-wave activity that can be broadly dis-
the neurobiological level, these data may indi- tributed over the scalp from the frontal to the pari-
cate that aging is associated with a decrease in etal regions. As will become clear in the paragraphs
the functional integrity of the ACC and related that follow, the effect of aging on ERPs related to
neural structures; at the psychological level, the successful encoding and retrieval in episodic mem-
effect of aging on the MFNs and the ACC may ory has been quite mixed with some studies
contribute to an age-related reduction in degree revealing minimal age-related differences in ERP
to which negative or undesirable outcomes guide activity related to episodic memory, while others
future information processing or decision reveal dramatic reductions in amplitude in older
making. adults or ERP components that are seemingly
unique to older adults (Friedman 2012; Friedman successful memory judgment relative to when
et al. 2007). individuals could rely on familiarity to support
ERPs measured at encoding reveal slow-wave successful recognition (Friedman 2012). Another
activity that distinguishes between stimuli that are possibility is that the mixed results result from
later remembered relative to those that are later variation in the characteristics of the older adults
forgotten (Hmmerer et al. 2011). The amplitude included in the samples across studies. Supporting
of slow-wave activity associated with encoding this idea, limited work has demonstrated that indi-
verbal stimuli can be attenuated in older adults vidual differences in memory performance, edu-
relative to younger adults, and this appears to be cation, and executive function may moderate the
one source of age-related declines in episodic effect of aging on parietal ERPs related to episodic
memory (Friedman 2012). Age-related differ- memory.
ences in ERPs related to successful encoding In addition to examining the effect of aging on
may reect the failure of older adults to spontane- the FN400 and left parietal oldnew effect that are
ously utilize processing that promotes recollection related to recognition memory in younger adults,
or to engage in sustained integrative semantic some studies have also reported ERP components
processing that facilitates later memory. Consis- over the frontal region of the scalp associated with
tent with this idea, the amplitude of the subse- successful recognition that may be limited to older
quent memory effect in the ERPs is similar in adults (Friedman 2012). There are not a sufcient
amplitude when individuals encode natural scenes number of studies that have examined ERPs
that are thought to foster relational processing unique to older adults to draw rm conclusion
during encoding. regarding the functional signicance of this neural
There is considerable variability in the effect of activity. The frontal ERP activity may be greater
aging on the ERP correlates of episodic memory in amplitude for low-performing individuals rela-
in studies examining recognition (Hmmerer tive to high-performing individuals, leading to the
et al. 2011). A number of studies have reported suggestion that it likely does not reect compen-
that the amplitude of the FN400 is similar in satory recruitment that underpins preserved epi-
younger and old adults, a nding that converges sodic memory in later adulthood.
with the behavioral literature in demonstrating Studies using ERPs consistently reveal two
that familiarity is preserved in later adulthood effects of aging on the neural correlates of source
(Friedman 2012). However, in other studies, the memory (Li et al. 2004). In younger adults, the
amplitude of the FN400 was reduced in older retrieval of source information is associated with
adults relative to younger adults, or there was no left parietal activity that resembles the oldnew
difference in the amplitude of the ERPs elicited by effect and slow-wave activity over the right fron-
hits and correct rejections in the time window tal region. The amplitude of both of these compo-
where the component was observed in younger nents is attenuated in older adults, and in some
adults (Wang et al. 2012). A similar pattern has studies the amplitude of the ERPs does not differ
been observed for the left parietal oldnew effect. between old and new items in older adults. These
In some studies, the amplitude of the component ndings are consistent with the age-related
is similar in younger and older adults when source decline in source memory that is commonly
information or recollection is associated with observed in behavioral studies. In older adults,
memory retrieval; however, in other studies the there is slow-wave activity extending from the
amplitude of the left parietal oldnew effect is frontal to parietal regions that reects greater neg-
attenuated in older adults, or there is no difference ativity when source information is retrieved rela-
between hits and correct rejections. One possible tive to new items. This slow-wave activity is
explanation for variation across studies is related generally absent in younger adults. Some investi-
to the demands of the memory test, as age-related gators have suggested that age-related differences
differences appear to be reduced or absent when in the ERP correlates of source memory may
recollection or source information is required for a reect variation in the type of information that
younger and older adults rely upon when making between 20 and 80 years of age (Kutas and Iragui
source judgments. Consistent with this idea, the 1998). The effect of aging on the latency of the
left hemisphere ERP activity was reduced or elim- N400 may be reduced or eliminated with auditory
inated in older adults when participants were presentation of connected speech. Importantly, this
instructed to use self-referential processing during method of presentation does not eliminate the
encoding that presumably focused individuals to effect of aging on the amplitude of the N400.
rely on a source of information known to promote Understanding the nature of the effects of aging
episodic memory (Dulas et al. 2011). on the N400 may provide insight into the develop-
ment of age-associated neuropathology, as varia-
tion in the amplitude of the N400 and P600 has
E
Language been shown to predict conversion from mild cog-
nitive impairment to dementia over a 3-year period
Since the discovery of the N400 in 1980, this and (Olichney et al. 2008).
other ERP components (e.g., P600 and late frontal The reason for the age-related decrease in the
positivity) have been widely used to study various amplitude of the N400 has been examined in a
aspects of information processing related to lan- number of studies (Wlotko et al. 2010). There is
guage comprehension (Friedman 2012; Kutas and general agreement that the effect of aging on the
Federmeier 2011). ERPs provide an excellent tool N400 does not result from an age-related decline
for investigating relatively natural language pro- in semantic memory (Friedman 2012). In contrast,
cess without the imposition of articial response the results of a number of studies lead to the
demands that are required when using some suggestion that an age-related decline in the use
behavioral measures. The N400 represents a neg- of contextual information to form expectations or
ativity in the ERPs over the central to parietal make predictions during online comprehension
midline that varies in amplitude with the degree may account for the effect of aging on the N400
of t between the meaning of a stimulus (i.e., (Wlotko et al. 2010). Also, other research demon-
word, picture) and the prior semantic context. strates that the effect of aging on the N400 may
Like the N400, the late frontal positivity is also result from the coordinated recruitment of the left
sensitive to semantic aspects of information and right hemispheres to support processing of
processing. This component may be related to multiple meanings of words (i.e., dominant versus
ambiguity resolution as it is most pronounced nondominant) or to integrate different features
when a word is inconsistent with a highly (i.e., concreteness versus imagery) of words
constrained semantic context. In contrast to the (Wlotko et al. 2010). Consistent with this idea,
N400, the P600 represents a later positivity over the amplitude of the late frontal positivity related
the parietal region that is more sensitive to varia- to ambiguity resolution is attenuated, or this com-
tion in syntactic variables rather than semantic ponent is absent, in older adults. This effect of
features of the stimulus or linguistic context. The aging on the late frontal positivity would be con-
effect of aging on the P600 has only been inves- sistent with the idea that older adults generally do
tigated in a few studies, which appear to demon- not activate multiple meanings of ambiguous
strate that aging has little effect upon syntactic words during online comprehension, thereby
processing related to this component (Friedman reducing the need for ambiguity resolution.
2012). The effect of aging on language comprehen-
The effects of aging on the N400 and the lin- sion and particularly ambiguity resolution may be
guistic variables that contribute to the generation of sensitive to individual differences in verbal u-
this component have been intensely investigated ency, an important executive function (Wlotko
(Friedman 2012; Wlotko et al. 2010). With visual et al. 2010). Two studies have demonstrated that
or auditory + visual stimuli, the latency of the N400 individual differences in verbal uency are corre-
increases by about 1.5 ms per year, and its ampli- lated with ERP amplitude over the frontal region
tude decreases by .05-.09 microvolts per year of the scalp when individuals are required to
resolve ambiguity related to homographs or Dulas, M. R., Newsome, R. N., & Duarte, A. (2011). The
semantic incongruity, with high-uency older effect of aging on ERP correlates of source memory
retrieval for self-referential information. Brain
adults being more similar to younger adults than Research, 1377, 84100.
low-uency older adults. This effect appears to be Fabiani, M., Friedman, D., & Cheng, J. C. (1998). Individ-
relatively limited to frontal processes as it does not ual differences in P3 scalp distribution in older adults,
extend to the N400. and their relationship to frontal lobe function. Psycho-
physiology, 35, 698708.
Friedman, D. (2012). The components of aging. In
S. J. Luck & E. S. Kappenman (Eds.), The Oxford
handbook of event-related potential components
Conclusions (pp. 513535). New York: Oxford.
Friedman, D., Nessler, D., & Johnson, R., Jr. (2007). Mem-
The literature reviewed in this entry clearly dem- ory encoding and retrieval in the aging brain. Clinical
EEG and Neuroscience, 38, 27.
onstrates the utility of using ERPs to examine the
Gehring, W. J., Liu, Y., Orr, J. M., & Carp, J. (2012). The
effects of aging on neural activity related to vari- error-related negativity (ERN/Ne). In S. J. Luck &
ous aspects of cognition. In some instances, the E. S. Kappenman (Eds.), The Oxford handbook of
ERP data converges nicely with the cognitive event-related potential components (pp. 231291).
New York: Oxford.
aging literature (e.g., the linear effect of aging on
Hmmerer, D., Li, S.-C., Mller, V., & Lingenberger,
the latency of the P3 and N400 components) U. (2011). Life span differences in electrophysiological
(Polich 1996; Kutas and Iragui 1998). In other correlates of monitoring gains and losses during prob-
instances, the ERP data reveal qualitative differ- abilistic reinforcement learning. Journal of Cognitive
Neuroscience, 23, 579592.
ences in neural recruitment between younger and
Kutas, M., & Federmeier, K. D. (2011). Thirty years and
older adults that may not be expected within the counting: Finding meaning in the N400 component of
context of a cognitive behavioral perspective the event-related brain potential (ERP). Annual Review
(e.g., age-related variation in left and right frontal of Psychology, 62, 621647.
Kutas, M., & Iragui, V. (1998). The N400 in a semantic
slow-wave activity related to source memory)
categorization task across 6 decades. Electroencepha-
(Li et al. 2004). Also, there is growing evidence lography and Clinical Neurophysiology, 108, 456471.
that various individual differences may moderate Li, J., Morcom, A. M., & Rugg, M. D. (2004). the effects of
the effect of aging on neural recruitment reected age on the neural correlates of successful episodic
retrieval: An ERP study. Cognitive, Affective, & Behav-
by ERPs (West and Schwarb 2006; Wlotko
ioral Neuroscience, 4, 279293.
et al. 2010) and that understanding these differ- Luck, S. J., & Kappenman, E. S. (2012). The Oxford
ences may provide insight into the development handbook of event-related potential components. New
of age-associated neurodegenerative disease York: Oxford.
Olichney, J. M., Taylor, J. R., Gatherwright, J., Salmon,
(Olichney et al. 2008).
D. P., Bressler, A. J., Kutas, M., & Iragui-Madoz, V. J.
(2008). Patients with MCI and N400 and P600 abnor-
malities are at very high risk for conversion to demen-
tia. Neurology, 70, 17631770.
Cross-References Polich, J. (1996). Meta-analysis of P300 normative aging
studies. Psychophysiology, 33, 334353.
Polich, J. (2007). Updating P300: An integrative theory of
Cognitive Control and Self-Regulation P3a and P3b. Clinical Neurophysiology, 118,
Executive Functions 21282148.
Language, Comprehension Wang, T. H., de Chastelaine, M., Minton, B., & Rugg,
M. D. (2012). Effects of age on the neural correlates
Memory, Episodic of familiarity as indexed by event related potentials.
Journal of Cognitive Neuroscience, 24, 10551068.
West, R., & Schwarb, H. (2006). The inuence of aging
References and frontal function on the neural correlates of regula-
tive and evaluative aspects of cognitive control. Neu-
Cavanagh, J. F., & Frank, M. J. (2014). Frontal theta as a ropsychology, 20, 468481.
mechanism of cognitive control. Trends in Cognitive Wilding, E. L., & Ranganath, C. (2012). Electrophysiolog-
Sciences, 18, 414421. ical correlates of episodic memory processes. In
Everyday Cognition 837
S. J. Luck & E. S. Kappenman (Eds.), The Oxford problem-solving, which is characterized by cog-
handbook of event-related potential components nitively complex real-world problems typically
(pp. 373395). New York: Oxford.
Wlotko, E. W., Lee, C.-L., & Federmeier, K. D. (2010). drawn from domains of instrumental daily func-
Language of the aging brain: Event-related potential tioning such as medication use, nancial manage-
studies of comprehension in older adults. Language ment, or food preparation. These types of
and Linguistics Compass, 4, 623638. problems typically have one correct answer,
and therefore, the focus is on objective
performance.
Another subdomain of practical or everyday/
Everyday Cognition real-world problem-solving focuses on socio-
E
emotional or affective problems that older adults
Jason C. Allaire1 and Alyssa A. Gamlado2 might face in their daily lives (Blanchard-Fields
1
Department of Psychology, North Carolina State 2009). Studies examining these socially and/or
University, Raleigh-Durham, NC, USA emotionally laden real-world problems typically
2
School of Aging Studies, University of South focus on identifying the coping strategies
Florida, Tampa, FL, USA employed in response to these problems. While
socioemotional problem-solving is an important
area of research, only everyday cognition is
Synonyms discussed here.
Everyday problem-solving
Theoretical Underpinnings
Definition The study of everyday problem-solving in general

and everyday cognition specically began, in part,
Everyday cognition refers to the ability of indi- by questioning whether psychometric tests of cog-
viduals to solve cognitively complex real-world nition were appropriate assessments of older
or everyday problems. Specically, studies of adults cognitive functioning (Denney 1989;
everyday cognition focus on assessing the real- Willis and Schaie 1986). Some argued that despite
world manifestation of basic cognitive abilities signicant and normative age-related declines in
such as memory, reasoning, knowledge, and many cognitive abilities, the majority of older
processing speed by testing older adults ability adults retained their ability to effectively function
to solve problems using ecologically valid stimuli in their daily lives. In addition, psychometric tests
such as a medication label or food nutrition label. were designed for and validated in samples of
children and young adults in an academic setting.
Thus, for older adults, who are many years
Everyday Cognition and Everyday removed from school environments, psychomet-
Problem-Solving ric tests may not be sensitive measures of cogni-
tive competence. In addition, context-free
Terms such as practical problem-solving or psychometric tests might underestimate older
everyday/real-world problem-solving are used adults ability because they do not allow them to
interchangeably, and both are often applied to call upon a lifetime of accumulated knowledge to
studies of everyday cognition. However, practical solve the problem. That is, in their everyday lives,
or everyday/real-world problem-solving refers to older adults can draw upon domain-relevant expe-
the larger domain of research focused on examin- riences to support and/or enhance their cognitive
ing the ability of older adults to solve any kind of performance, and so relatively a-contextual
real-world problem. Everyday cognition refers to laboratory-based assessments of cognition may
a subdomain of practical or everyday/real-world produce an underestimation of true performance
838 Everyday Cognition
competencies. These concerns with psychometric self-report. Though some interesting ndings
tests led some researchers to propose that mea- have come from subjective measures of everyday
sures comprised of real-world problems and stim- cognition (Farias et al. 2013; Marshall
uli that older adults might face in their daily lives et al. 2014), such assessments are often unrelated
might be a more accurate way to assess cognitive to objective performance (Tucker-Drob 2011).
competency (Denney 1989; Willis and Schaie
1986).
The early everyday problem-solving research Sources of Individual Differences
focused on identifying the kinds of problems older in Everyday Cognition
adults experienced in their everyday lives. These
studies found that the everyday problems older Over the past 25 years, research on everyday
adults often experienced fell into one of two over- cognition has primarily focused on identifying
arching categories: socioemotional or instrumen- sources of individual differences in older adults
tal. Early studies assessing individual differences performance. Not surprisingly, given the early
in performance included both problem types, such rationale for studying everyday cognition, much
as the seminal work by Denney (1989). However, of the research has centered on the mapping of age
as the eld matured studies tended to focus on differences as well as understanding the underly-
examining problem-solving either within instru- ing role basic cognitive abilities play in everyday
mental domains of functioning (Willis and Schaie cognitive performance.
1986) or socioemotional domains (Blanchard- Age-related Differences and Changes. As
Fields 2009). previously mentioned, the study of everyday cog-
nition was, in part, predicated on the idea that
psychometric measures of cognition might under-
Measuring Everyday Cognition estimate older adults true cognitive competency.
Furthermore, performance on real-world mea-
There are a number of different measures used to sures of cognition might be preserved because
assess everyday cognition. An excellent overview elders can call upon domain-specic knowledge
of the various measures is provided by Law and when solving real-world problems. Unfortunately,
colleagues (2012). Assessments of everyday cog- there has been very little evidence to support this
nition tend to have at least four things in common. assumption, with many cross-sectional studies
First, as previously mentioned they generally reporting a negative relationship between age
focus on instrumental tasks of daily living which and everyday cognition (Allaire and Marsiske
older adults must be able to solve effectively in 1999; Burton et al. 2006; Diehl et al. 2005). In
order to remain independent. Items describe a fact, results from a meta-analysis of over
real-world problem such as You woke up this 33 age-comparative studies indicated that older
morning and your refrigerator is not working adults performed signicantly worse than
and/or present real-world stimuli, such as a bank middle-age and younger adults on measures of
statement, and ask participants to solve problems everyday problem-solving, particularly on items
based on those stimuli. Second, the real-world drawn from the instrumental domains of daily
problem is clearly dened, so older participants living (e.g., nancial and medication manage-
know exactly what they are supposed to solve. For ment) (Thornton and Dumke 2005).
instance, there is little ambiguity as to what is the In addition to negative age differences, a num-
real-world problem in the following statement: ber of longitudinal studies have found evidence of
You woke up this morning and your refrigerator long-term decline in everyday cognitive function-
is not working. Third, the desired goal or end ing (Tucker-Drob 2011; Yam et al. 2014; Gross
state is also apparent from the problems (e.g., you et al. 2011). Tucker-Drobb reported that three
want your refrigerator to work). Fourth, most different measures of everyday cognition
measures are performance based rather than exhibited signicant and negative decline over a
5-year period (Tucker-Drob 2011). In a follow-up (e.g., inductive reasoning, memory, processing
to that study, Yam and colleagues reported that speed) is associated with lower everyday cognitive
everyday cognition exhibited a quadratic over a functioning (Allaire and Marsiske 1999; Burton
10-year period (Yam et al. 2014). Specically, an et al. 2006; Diehl et al. 2005). In fact, Allaire and
early increase in everyday cognitive performance Marsiske reported that as much as 80% of the
due to practice effects was overshadowed by sig- individual differences in everyday cognition were
nicant declines in performance over time. accounted for by basic cognitive abilities, particu-
Taken together, these ndings suggest that larly memory and inductive reasoning ability
older adults ability to solve cognitively complex (Allaire and Marsiske 1999). Yen and colleagues
everyday problems is, in general, compromised reported that inductive reasoning and a factor
E
with age. However, it is possible that in some representing learning and memory were both sig-
situations, perhaps where tacit knowledge for the nicantly related to everyday cognitive function-
problem or context is strongly age-related, differing, while processing speed was not related to
ences may be minimized. For instance, Artistico everyday cognition (Yen et al. 2011). Informant-
and colleagues reported that older adults based subjective everyday cognition functioning is
performed better than younger age groups on also signicantly negatively related to neuropsy-
everyday problems set within an older adult con- chological clinical assessments of memory and
text (Artistico et al. 2010). Presumably, older executive functioning (Farias et al. 2013).
adults beneted from their familiarity with the Evidence of the association between basic cog-
context of the problem and their domain- specic nitive abilities and everyday cognition also comes
knowledge of the problem. Unfortunately, the from more recent longitudinal studies (Tucker-
authors did not adequately assess domain-specic Drob 2011; Gross et al. 2011; Yam et al. 2014).
knowledge. It is important to note that age is not Yam and colleagues found that 10-year decline in
an explanatory variable but merely an index of everyday cognition was not as dramatic as the
chronological time. That is, an individuals age decline observed for memory and speed (Yam
does not cause declines in everyday cognition, but et al. 2014). However, the negative trajectory for
instead a more proximal predictor(s) associated everyday cognition was greater than what was
with age is driving the declines. Additional observed for verbal ability and was signicantly
research is still needed to understand what factors similar to that of reasoning ability. In fact, reason-
can explain the age-related differences and ing accounted for 85% of the intercept and 96% of
age-related declines in everyday cognitive func- the slope variance in everyday cognition. Tucker-
tioning. One such explanatory construct is basic Drob reported that decline over 5 years in three
cognitive functioning. different measures of everyday cognition was sig-
nicantly related to decline in basic ability mea-
sures assessing reasoning, processing speed, and
Basic Abilities memory (Tucker-Drob 2011). In fact, a single
latent change factor could signicantly account
Given that everyday cognition is characterized by for change in each of the basic ability and every-
the ability to solve cognitively complex real-world day cognition tests, suggesting that these declines
problems, it should come as no surprise that basic are the manifestation of a common underlying
cognitive abilities provide the foundation for every- process. Further evidence of this common under-
day cognitive performance. That is, everyday cog- lying process comes from Farias and colleagues
nition can be considered the application of basic (2013), who reported that lower total brain and
cognitive abilities to real-world problems such that hippocampus volume were related to worse
an amalgam of basic abilities is responsible for everyday cognition (Farias et al. 2013).
cognitive performance within everyday contexts. Other Sources of Individual Differences.
Evidence from cross-sectional studies suggests While the lions share of research has focused
that lower performance on basic ability tests on everyday cognition as it relates to age
and/or intellectual ability, some researchers have assessments of everyday cognition in addition to
explored other sources of individual differences. basic cognitive ability tests. It is important to note
For instance, markers of health such as blood that when everyday cognition is used as a predic-
pressure and number of chronic conditions have tor, there should not be an assumption of causality.
been associated with everyday cognition. For That is, everyday cognition does not necessarily
instance, Whiteld and colleagues found that the cause the outcome, but it is related to explaining
number of chronic conditions and perceived individual differences in the outcome.
change in health status were signicantly related One such outcome is mortality, where lower
to lower everyday cognitive performance even performance on measures of everyday cognition
after controlling for demographic characteristics is uniquely related to a greater likelihood of death
(Whiteld et al. 2004). In addition, lower blood (Allaire and Willis 2006; Weatherbee and Allaire
pressure is associated with worse everyday cog- 2008). For instance, Weatherbee and Allaire
nition ability even after controlling for age and reported that performance on a measure of every-
performance on tests of basic cognitive abilities. day knowledge was a signicant and unique pre-
In addition to indices of physical health, higher dictor of death even after controlling for a number
levels of depression have been shown to be of basic cognitive abilities (Weatherbee and
directly and indirectly (through basic cognitive Allaire 2008). In another study, everyday cogni-
abilities) associated with lower everyday cognition was a signicant and unique predictor of
tive performance (Yen et al. 2011). There is also nearness to death (Allaire and Willis 2006). Per-
evidence that depression is related to everyday haps related to morality, older adults who
cognition (Paterson et al. 2015). Higher scores performed better on measures of everyday cogni-
on a standard measure of depression were signif- tion were more likely to remember to take their
icantly related to worse everyday cognitive func- medications even after controlling for perfor-
tioning in older adults. The predictive salience of mance on basic cognitive ability tests (Neupert
depression remained even after controlling for et al. 2011). Thus, performance on everyday cog-
age, gender, and education. nition may be an indirect indicator of mortality
risk, in that it can identify older adults who are
likely to adhere to their health providers pre-
Predictive Outcomes of Everyday scribed medication and/or treatment plan, which
Cognition can sustain their health and quality of life and
reduce their mortality risk. Not surprisingly,
As previously discussed, early research on every- everyday cognition also serves as a unique pre-
day cognition focused on cataloguing the prob- dictor of older adults self-reported instrumental
lems older adults faced in their day-to-day lives. functioning (Allaire and Marsiske 2002; Allaire
As the eld developed, studies turned to exploring et al. 2009), accounting for all individual differ-
age differences and the association between basic ences in subjective instrumental functioning asso-
cognitive abilities and everyday cognition. More ciated with basic abilities and also adding unique
recently, a growing group of researchers have explanatory power (Allaire and Marsiske 2002).
turned to examining the extent to which everyday Cognitive Impairment. Everyday cognition is
cognition predicts meaningful outcomes. If every- also used as a predictor of mild cognitive impair-
day cognition is thought to assess cognition in the ment (MCI) which is considered the transitional
real-world, then it should be strongly related to period between normal cognition and dementia.
real-world outcomes. Moreover, everyday cogni- Cross-sectional studies of community-dwelling
tion was, in part, originally designed as an alter- elders report that performance on various mea-
native to traditional measures of intelligence or sures of everyday cognition signicantly predicts
cognitive functioning. Therefore, if it does not impairment or MCI status even after controlling
provide added value beyond basic cognitive abil- for performance on cognitive screening or basic
ities, then there may be no need to include cognitive ability measures (Allaire et al. 2009;
Burton et al. 2009; Allaire and Willis 2006). everyday cognition functioning. For instance,
Allaire and colleagues reported that older adults results from the ACTIVE study have suggested
with MCI performed signicantly worse on the that while improvements in trained abilities are
three instrumental subdomains of an everyday evident, these gains do not consistently transfer to
memory test and that performance on the measures of everyday cognition (e.g., Rebok
subdomain assessing of nancial management et al. 2014).
was a signicant and unique predictor of MCI Given this lack of transfer, some studies have
status even after controlling for a battery of basic examined whether everyday cognition is amena-
cognitive ability tests (Allaire et al. 2009). ble to direct intervention. For example, Thomas
Thomas and Marsiske reported that everyday cog- and Marsiske (2014) examined the outcome of
E
nitive performance was worse in older adults with providing simple verbal instructions or prompts
amnestic MCI, then nonamnestic, and then such as look harder or try again when a par-
unimpaired (Thomas and Marsiske 2014). ticipant was unable to correctly answer a question
Studies from the clinical literature have also on an everyday cognition test. The results
found that everyday cognition plays a central role suggested that prompts signicantly improved
in differentiating between impaired and performance. Promoted performance did not
nonimpaired older adults. For instance, a study exhibit signicant age-related decline like
using an informant and proxy subjective assess- unprompted performance. Moreover, participants
ment of everyday cognition, while not ideal, found with MCI benetted the most from prompts with
that items such as remembering a few shopping prompted performance similar to that of the
items or balancing a checkbook signicantly unprompted performance of non-MCI partici-
discriminated MCI from non-MCI older adults pants. Another study adapted the strategies used
(Marshall et al. 2014). In addition, this same to train inductive reasoning ability and applied
study also found that older adults with poorer them to real-world or everyday problems
everyday cognition were more likely and (Williams et al. 2014). Participants from assisted
more quickly to progress from normal to living facilities that received this training experi-
impaired status. However, this study did not con- enced signicant gains in everyday cognitive per-
trol for basic cognitive abilities. Other studies have formance relative to participants that did not. In
also reported that differences between MCI and addition, these gains were maintained 3 months
non-MCI older adults are particularly salient later.
when the everyday task is memory laden (Farias
et al. 2013).
Conclusion
Interventions With the burgeoning older adult population, there

will be an increasing concern among older adults
Since the late 1970s, a considerable amount of about experiencing cognitive impairment and,
research has focused on the extent to which older subsequent, loss of functional independence.
adults basic cognitive functioning is amenable to Understanding the antecedent of and outcomes
intervention. As part of this research, measures of associated with an older adults ability to perform
everyday cognition have been used as outcome cognitively demanding real-world tasks is at the
variables. Their use in outcome batteries is to deter- core of everyday cognition. Even though every-
mine if the cognitive training intervention impacts day cognition is correlated with basic abilities, it
domains related to but still unique from the basic remains sufciently distinct enough to warrant
abilities which are the focus of the intervention. additional research. While studies have begun to
However, there is little evidence that interventions point out that everyday cognition is a salient and
focused on improving basic cognitive abilities have unique predictor of important real-world out-
a robust or reliable impact on older adults comes, additional research is warranted to identify
modiable determinants of impaired everyday Farias, S. T., Park, L. Q., Harvey, D. J., et al. (2013).
cognition. Such research can be useful in design- Everyday cognition in older adults: Associations with
neuropsychological performance and structural brain
ing successful interventional protocols to improve imaging. Journal of the International Neuropsycholog-
cognitive functioning and well-being. ical Society, 19(4), 430441. doi:10.1017/
S1355617712001609.
Gross, A. L., Rebok, G. W., Unverzagt, F. W., Willis, S. L.,
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cult to clearly establish. However, over the past
Executive Functioning two decades, a great deal of progress, using psy-
chometric methods, has been made toward iden-
Stephen Rhodes1 and Mario A. Parra1,2,3,4 tifying core processes underlying executive
1
Department of Psychology, Centre for Cognitive functioning. The emerging view is that there are
Ageing and Cognitive Epidemiology, and Human separable but interdependent components under-
Cognitive Neuroscience, The University of lying performance of complex executive tasks.
Edinburgh, Edinburgh, UK This approach has also been used to assess the
2
Department of Psychology, HeriotWatt effect of healthy aging on specic processes in
University, Edinburgh, UK order to better characterize the decline of execu-
3
Alzheimer Scotland Dementia Research Centre, tive functioning with age. Given the pervasive
The University of Edinburgh, Edinburgh, UK effect of age on cognition, much of this work has
4
UDPINECO Foundation Core on also attempted to establish whether the effect of
Neuroscience (UIFCoN), Diego Portales age on specic functions is greater than would be
University, Santiago, Chile expected given age-related decline in speed of
processing. This entry does not aim at providing
a comprehensive review of the topic; for such
Synonyms reviews see MacPherson et al. (2015), Jurado and
Rosselli (2007) and Phillips and Henry (2008).
Central executive; Controlled processing; Its aim is to briey touch upon state-of-the-art
Response inhibition; Set-shifting; Working mem- issues in this eld with emphasis on current the-
ory updating ories of cognitive aging.
Definition Fractionating Executive Functioning
Executive functioning is an important concept in In their highly inuential paper, Baddeley and
neuropsychology and broadly refers to our ability Hitch (1974) made the distinction between
to plan and coordinate complex behavior. The low-level storage buffers for verbal and visuospa-
term is used widely in describing performance tial information and a higher-level controlling
on cognitive tasks that require planning, strategy mechanism they termed the central executive.
use, self-regulation, focused attention, inhibition, This executive component was said to coordinate
and other supervisory functions. the action of the slave storage systems and
844 Executive Functioning
allow exible behavior in the face of constantly necessitates that the appropriate rules for a
changing goals. Whether executive functioning given task are maintained and engaged/disen-
reects the action of a single general-purpose gaged as required. Measures of shifting
control system or multiple separable processes, typically compare performance between con-
working in concert, has since proven controver- ditions in which participants characterize stim-
sial. Neuropsychologists have developed a wide uli according to a single rule, to conditions in
array of measures to assess executive functioning, which there are two or more rules to shift
and Table 1 provides a selective list of commonly between (see Table 1). These measures of
used tasks. These measures are inherently com- task switching are considered important indi-
plex, and, given this problem of task impurity, ces of cognitive control.
there is widespread disagreement as to what 3. Inhibition: Much of our behavior is automatic
underlying abilities these tasks actually assess and based on well-learned responses to stimuli.
(MacPherson et al. 2015; Jurado and Rosselli However, it is often desirable to inhibit these
2007). Consequently, psychometric methods prepotent responses if the automatic reaction is
have proven useful in identifying potential core inappropriate. Typical assessments of this
processes that support executive functioning. construct require speeded responses that run
These methods assess patterns of shared variance counter to well-learned stimulusresponse
between conceptually similar tasks and attempt to mappings, for example, naming the color font
explain performance on an array of measures in in which the word BLUE is presented (see
terms of underlying, latent variables. The emerg- Table 1). Inhibition may also refer to the ability
ing view from this line of research is that the to ignore irrelevant information or the ability to
central executive can be fractionated into separa- resist the distracting effects of no-longer-
ble but highly interdependent executive processes relevant information, also known as proactive
(Jurado and Rosselli 2007; Miyake et al. 2000; interference (Miyake and Friedman 2012).
Miyake and Friedman 2012).
In their review of the literature, Miyake and Having identied these core executive func-
colleagues (2000) identied three executive functions in the literature, Miyake et al. (2000) admin-
tions, or processes, that are commonly referred to istered a range of simplied executive functioning
when explaining performance on measures of measures to a group of young, college-aged
executive functioning. These three executive adults. Using latent variable modeling, they then
functions are as follows: assessed patterns of association between the dif-
ferent measures to examine whether their three
1. Updating: When information currently stored proposed executive functions could be separated.
in working memory the small amount of A model separating the contributions of updating,
material that can be actively maintained in the shifting, and inhibition to performance on mea-
face of concurrent processing is no longer sures of executive functioning gave a better
relevant to current goals, the space must be account of their data than a model with a single
freed up via the removal of irrelevant items. component. However, in the favored model, the
This ability to clear and update working mem- correlations between the three components were
ory is crucial for the efcient use of this limited moderate to large (0.420.63) suggesting that,
capacity workspace. Updating is typically while the three functions are separable, they are
assessed with tasks that require simultaneous interconnected. What underlies this unity is very
storage and processing of information (see much up for debate, although it has been noted
Table 1). that the requirement to actively maintain task
2. Shifting: In day-to-day life, it is rarely the case goals is a basic feature of all executive processes
that one task can be completed without atten- (Miyake and Friedman 2012).
tion being diverted to another. This ability to The idea of separating updating, shifting, and
switch between different mental sets inhibition has gained support from subsequent
Executive Functioning, Table 1 Commonly used measures of executive functioning

Measure Description Outcome measure(s) Putative domains tapped
Wisconsin Participants arrange cards, one at a The number of incorrectly sorted Shifting (Miyake et al. (2000)
card time, into four piles. Cards can be cards following a rule change. found their shifting factor
sorting sorted on the basis of multiple Referred to as the number of predicted performance on the
test features (color, shape, number) perseverative errors WCST), inhibition, sustained
(WCST) but only one is the correct rule at attention
any one time. Feedback is given
after each card and the sorting rule
changes without warning
Go/no-go Participants make a response (e.g., Reaction time Inhibition, goal maintenance
press a button) as quickly as The number of hits (responses on (no-go rule) E
possible if a certain condition is go trials) and false alarms
met (go trial; e.g., when an X is (responses on no-go trials)
presented) but not otherwise
(no-go trial; e.g., any other letter is
presented). No-go trials are
infrequent
Verbal Generate as many different words The number of words produced. Inhibition, working memory
uency possible in a given time period. In The number of repeated words updating, access to long-term
the most common variants, (perseverative errors) memory (see Miyake and
participants generate words Friedman 2012)
beginning with the same letter
(phonemic uency) or words
belonging to the same category
(semantic uency)
Working This refers to a selection of tasks The total number of items (e.g., Working memory updating,
memory requiring simultaneous processing words) recalled, or if an adaptive shifting
span and storage of information. In method is used the last level at
operation span participants verify which the participant met a
an equation (e.g., (3 * 4)7 = 3?) criterion (e.g., two out of three
and then are given a word to store trials correct)
for later recall. Reading span is
similar except that participant
veries a sentence then
remembers the last word
The In the most common variant of this Reaction time difference between Inhibition, cognitive control
Stroop task, participants must name the incongruent trials (the font
task color font that a color label (e.g., matches the color label) and
BLUE) is presented in. This is incongruent (mismatch) trials
compared to a baseline condition Difference between incongruent
in which the participant either trials and baseline trials
names the color of meaningless
units (e.g., #####) or names color
labels presented in black font
Trail- These tasks are typically paper- Difference between baseline and Shifting, speed of processing
making and-pencil and require switching tests in terms of time
task participants to connect randomly taken to complete or number of
(TMT) arranged dots. In a baseline errors made
version (Part A), the dots are
connected in order of numeric
label. In the comparison task (Part
B), dots are connected by
alternating between numeric and
alphabetic labels (e.g., 1 ! A !
2 ! B. . .)
See Jurado and Rosselli (2007), Baddeley and Hitch (1974), and Lezak et al. (2012) (and the references therein) for more
detail on each task and for additional tasks commonly used to assess executive functioning
studies using a similar individual differences further light on the neural correlates of executive
approach (see Jurado and Rosselli 2007; Miyake functioning (Collette et al. 2006).
and Friedman 2012 for reviews). Of course this Early neuroimaging studies of executive func-
list is an oversimplication, and there are other tioning compared tasks presumed to pose some
important processes that likely contribute to mea- executive demand to baseline tasks without such
sures of executive functioning (see, e.g., Fisk and demand and, in general, found activation of a
Sharp 2004; Lezak et al. 2012). In fact, a three- wide-ranging network including both anterior
factor model would be insufcient to account for and posterior areas (Collette et al. 2006). How-
the large number of behavioral responses we can ever, as multiple processes contribute to perfor-
observe and measure either in healthy individuals mance of executive tasks (Miyake et al. 2000), it is
or in those affected by brain diseases, which are difcult to identify activation involved in, say,
thought to result from the function of an executive shifting with a single-task measure. Conse-
system (e.g., planning, selective attention, moni- quently, one notable study in the eld used PET
toring, decision-making, and others) (Lezak to measure regional cerebral blood ow (rCBF),
et al. 2012). Thus while conceptualizing executive while participants performed a range of tasks
functioning in terms of these separable but inter- selected to place primary demand on updating,
related components is clearly a simplication, it shifting, or inhibition (Collette et al. 2005). Con-
provides a useful focus for discussing studies of sistent with earlier ndings, Collette and col-
the neural correlates and age-related decline of leagues (2005) found activation of a large
executive functions. frontoparietal network common to all tasks that
they assessed. This network included the left
superior parietal gyrus and right intraparietal sul-
Neural Correlates of Executive cus along with regions of the dorsolateral prefron-
Functioning tal cortex.
As well as assessing common activation, the
Damage to the frontal lobes has long been associ- use of multiple measures allowed them to perform
ated with profound behavioral changes. Patients interaction analyses to identify areas dispropor-
with frontal lobe lesions can exhibit a range of tionately associated with one function relative to
decits including an impaired ability to initiate the others. This method of analysis suggested that
goal-directed action and socially inappropriate, the hypothetical processes of shifting, updating,
impulsive behavior (MacPherson et al. 2015; and inhibition do exhibit separable patterns of
Lezak et al. 2012). Historically this has led to the activity. Performance of tasks involving the
suggestion that the frontal lobes, particularly pre- updating of working memory representations
frontal cortex, are the seat of executive control was associated with the activity in inferior frontal
(see MacPherson et al. 2015 for a historical over- and frontopolar cortices as well as the intraparietal
view). However, further evidence from neuropsy- sulcus. Activity associated with inhibiting prepo-
chology and neuroimaging studies has shown that tent responses was found in the orbitofrontal cor-
this mapping of executive functions purely onto tex along with middle and superior frontal gyri.
the frontal lobes is highly misleading. While mea- Finally, shifting was associated with greater rCBF
sures of executive functioning are sensitive to to the left intraparietal sulcus.
frontal lobe lesions, they are certainly not specic While it is difcult to make strong conclusions
as lesions to other areas have also been associated on the basis of neuroimaging data, these ndings
with impaired performance (MacPherson complement the behavioral data nicely. There
et al. 2015; Jurado and Rosselli 2007; Lezak appear to be separable patterns of activity associ-
et al. 2012). Studies assessing executive tasks ated with the performance of tasks primarily
along with neuroimaging measures, such as func- assessing updating, shifting, and inhibition, as
tional magnetic resonance imaging (fMRI) or well as a large frontoparietal network engaged
positron-emission tomography (PET), have shed regardless of task demand.
Aging and Executive Functioning age, is whether the performance of older adults on
complex measures of executive functioning
Healthy adult aging is associated with reduced reects the operation of the same underlying abil-
performance across a range of cognitive variables, ities as in younger adults. That is, is it still possible
and measures of executive functioning are no to separate out the contributions of shifting,
exception. For example, on the Wisconsin Card updating, and inhibition components or do abili-
Sorting Test (WCST; see Table 1), older adults ties become dedifferentiated (i.e., less distinct)
show an increased number of perseverative with age? Several studies have adopted an indi-
errors relative to younger adults (MacPherson vidual differences approach to assess the latent
et al. 2015; Phillips and Henry 2008). That is, factor structure of executive functioning measures
E
following a change to the sorting rule, older adults in older groups. In contrast to the idea of dediffer-
are more likely to erroneously use the old rule to entiation, many of these studies have found that
sort the cards and take longer to discover the new the three-factor solution gives a good account of
rule. Similarly, studies using the go/no-go task performance in groups of healthy older adults
tend to nd that older adults produce a greater (Fisk and Sharp 2004; de Frais et al. 2009;
number of errors (e.g., responses on no-go trials) Vaughan and Giovanello 2010).
and slower response times relative to younger It should also be noted, however, that other
groups (MacPherson et al. 2015; Phillips and investigators have found two-factor solutions. For
Henry 2008). Further, structural neuroimaging example, Hull and colleagues (2008) found that a
studies have found evidence of pronounced dete- two-factor model, with no distinction between
rioration of the frontoparietal network implicated updating and inhibition but with a separate shifting
in performance of many executive tasks. The component, tted their data just as well as the more
frontal lobes in particular appear to be greatly complex three-component model. On the other
affected by the aging process. Gray matter volume hand, Hedden and Yoon (2006) found a separable
in the prefrontal cortex exhibits pronounced inhibition factor in their group of older adults but
decline relative to other areas, and white matter were unable to separate shifting and updating fac-
hyperintensities are observed with greater fre- tors (see also Androver-Roig et al. 2012). While
quency in the frontal lobes (Raz and Rodrigue these studies may suggest some degree of dediffer-
2006). entiation with age, it is the case that even in
However, as highlighted above, multiple pro- college-aged adults, the existence of a distinct inhi-
cesses underlie performance on complex mea- bition factor, that can be separated from the shared
sures of executive functioning, and older adults variance between the other executive processes, is
may take longer or make more errors for many a matter for debate (Miyake and Friedman 2012).
different reasons (Phillips and Henry 2008). Thus, The choice of measures used to construct the fac-
in attempting to understand the effect of healthy tors is likely to be an important reason for this
aging on executive functioning, it is important to discrepancy.
take a broad range of measures to separate out Interestingly, ndings from the large-scale Vic-
age-related decline in executive processes. Fur- toria Longitudinal Study suggest that, in fact, the
ther, it is important to disentangle change to spe- separability of different executive components
cic executive processes, such as a reduced ability may be a good indicator of general cognitive
to update the contents of working memory, from functioning in old age (de Frais et al. 2009).
more general changes associated with age, such as That study assessed the structure of executive
reduced information processing speed (Albinet functioning in over 500 participants aged between
et al. 2012). 53 and 90. On the basis of a broad cognitive
battery assessing speed, reasoning abilities, as
Fractioning Executive Functioning in Old Age well as episodic and semantic memory the group
An important starting question, before discussing was split into high performers (termed cognitive
the decline of specic executive functions with elites), those performing at a normal level and
those who showed a mild level of cognitive speed were accounted for in the statistical model,
impairment. At the baseline assessment, the the amount of variance in executive functioning
three-factor model, with separable updating, inhi- accounted for by age was greatly reduced. This
bition, and shifting components, t the data from reduction of age-related variance in executive
the high and normally performing older adults. functioning when accounting for measures of
However, the three-factor model did not t the speed has been found many times (Albinet
data from the cognitively impaired group; their et al. 2012; Androver-Roig et al. 2012;
pattern of performance was explained by a single Sylvain-Roy et al. 2014). However, despite the
component, consistent with dedifferentiation of overall reduction in age-related variance, this
executive functions. Further, the cognitively study found that a signicant relationship
healthy groups (high and normal performers) remained between age and the component
showed stability in their underlying abilities over representing the ability to shift between mental
a 3-year follow-up period. sets, suggesting that age may impair shifting
Thus, much of the extant literature suggests ability over and above the reductions seen in
that in groups of healthy older adults, it appears information processing speed.
to be possible to separate the contribution of dif- Similar conclusions have also been reached in
ferent underlying executive processes to complex a recent series of meta-analyses of the executive
measures of executive functioning, just as can be functioning and cognitive aging literature
done for younger adults. (Verhaeghen 2011). The estimated age effects on
many measures of inhibition were no greater than
Does Age Differentially Affect Executive that predicted by age differences in matched base-
Functions? line measures (i.e., tasks with similar structure but
Given that the contributions of shifting, updating, without the requirement of executive control).
and inhibition appear to remain largely separable This analysis did, however, reveal a dispropor-
with age, the question becomes: does healthy tionate effect of age on task switching and was
aging affect all executive processes equally or do able to probe further into the possible origin of this
some processes exhibit a disproportionate decit. The cost of having to switch between two
age-related effect? The nature of executive func- sets of task rules can be expressed as the differ-
tioning measures makes this an inherently dif- ence in performance (in this case RT) between
cult question to answer. As noted above, blocks of trials in which a single-task rule must
performance on a measure like the WCST may be applied as opposed to blocks in which partici-
be impaired for a number of reasons, such as pants must switch between rules. The resulting
reduced speed of processing, failure to inhibit contrast gives the global task-switching cost.
overlearned responses, an impaired set-shifting Alternatively task-switching costs can be calcu-
ability, or a mixture of these factors. However, lated as the difference in performance between
some have adopted the multivariate approach of trials on which a switch was required (i.e., the
Miyake and colleagues (Miyake et al. 2000) to previous trial used a different rule) versus trials
assess the effects of age on the separable but where no switch was required (i.e., the previous
interconnected executive processes. These studies trial used the same rule). Here the resulting score
have also attempted to disentangle specic change is referred to as the local task-switching cost. The
from the more general age-related change to speed meta-analyses revealed that older adults exhibited
of processing. a disproportionate global task-switching cost,
One study assessing healthy adults (aged whereas the local cost was no greater than
2081) performance on a range of executive func- expected from matched baseline measures. This
tioning tasks found a signicant relationship global task-switching decit was interpreted as a
between age and the factors reecting updating, reduced ability to simultaneously maintain two
inhibition, and shifting ability (Fisk and Sharp sets of task rules, whereas the lack of a dispropor-
2004). However, when measures of processing tionate effect of age on local switching suggests
that the ability to engage the relevant task rules (Fisk and Sharp 2004; Albinet et al. 2012;
when a switch is required is well preserved (see Androver-Roig et al. 2012; Sylvain-Roy
also Phillips and Henry 2008). Thus the increased et al. 2014). While this may suggest that much of
number of perseverative errors exhibited by older the decline in executive functioning is accounted for
adults on tasks such as the WCST (MacPherson by senescent decline at a lower level in the
et al. 2015; Phillips and Henry 2008) would be processing hierarchy, this should be interpreted
interpreted as a failure to maintain and retrieve the with caution. It is often assumed that measures of
new appropriate rule, rather than a failure to initi- processing speed capture a more primitive aspect
ate rule following. of cognition; however, many commonly used mea-
There is additional evidence that performance sures of speed appear to require controlled
E
on measures of set shifting may be an important processing (Phillips and Henry 2008; Albinet
determinant of day-to-day functioning in old age et al. 2012). It is reasonable to suspect that slower
(Vaughan and Giovanello 2010). This study speed of processing leads to poorer performance on
extracted shifting, inhibition, and updating factors executive functioning measures, but nevertheless it
from the performance of 100 older adults (aged is also conceivable that speed of processing could be
6090) on a range of measures. They also slowed by poor executive control; for example,
included self-report and performance-based mea- older adults could take longer to process information
sures of instrumental activities of daily living, because they are less able to inhibit prepotent
which give an indication of a persons ability to responses. Thus a more thorough theoretical analy-
live independently. While none of the executive sis of the mutual relationship between speed of
processes predicted self-report measures of daily processing and different executive functions is
functioning, the shifting component signicantly required to gauge their relative contributions to
predicted performance-based measures. The age-related decline on complex behavioral measures
authors conclude, given that self-report measures (Albinet et al. 2012).
are prone to overestimation, the ability to shift
between different mental sets appropriate to cur-
rent goals may be an important determinant of an Further Fractionation of Executive
older adults ability to manage daily life. Functioning
In summary, studies adopting a psychometric
approach to assessing executive functioning While focusing on three core executive processes
across the life span and meta-analyses of the liter- is useful for guiding discussion, further fraction-
ature suggest that the ability to shift between ation of executive functioning seems inevitable.
mental sets, and more specically concurrently For example, the concept of inhibition as
maintain two sets of task rules, may exhibit dis- discussed above was specically framed around
proportionate decline with age. However, it is avoiding inappropriate but automatic responses,
important to note that ndings are mixed as but this term may also apply to reducing the inter-
other groups have found evidence for a dispropor- fering effects of previously encountered material
tionate effect of healthy aging on the ability to (proactive interference) or to preventing task-
inhibit prepotent responses (Sylvain-Roy irrelevant information from distracting task per-
et al. 2014) or a more general effect of age across formance (Miyake and Friedman 2012). The sug-
the subprocesses, even after accounting for gestion that older adults have a specic decit in
age-related slowing (Albinet et al. 2012). Much of inhibiting distracting information is highly inu-
this ambiguity may be attributable to different stud- ential in the cognitive aging literature (Hasher and
ies using different measures of the underlying con- Zacks 1988). Indeed research does suggest that
structs and of processing speed. Further it appears older adults are less able to ignore task-irrelevant
that when these studies control for measures of distractors, and neuroimaging work has begun to
processing speed, the variance in executive func- shed light on the mechanisms underlying this.
tioning attributable to age is greatly reduced One fMRI study presented younger and older
adults with a series of images of faces and scenes that AD patients have a specic decit in dual
to remember over a brief interval (Gazzaley tasking.
et al. 2005). Their task involved selectively In fact, recent work with a familial form of AD
attending to one of these categories; for example, has suggested that a decit in dual tasking may
participants would have to attend to faces while signify early changes associated with the disease
ignoring the scenes presented. Looking at a spe- (MacPherson et al. 2012). Carriers of a genetic
cic scene-selective region of interest in the left mutation exhibited a pronounced decit when
parahippocampal gyrus, the authors found the performing the digit recall and tracking tasks con-
expected suppression of activity when younger currently, whereas noncarrier family members did
adults were ignoring scenes relative to trying to not. Crucially, these carriers did not meet diag-
encode them. Their older adults, on the other nostic criteria for AD and, given the typical age of
hand, did not exhibit the same suppression effect. onset in this cohort, would not be expected to for
In fact this seemed to be driven by the very lowest approximately 12 years. This raises the intriguing
performers in the older group, as high performing clinical possibility that measures of dual tasking,
older adults exhibited the suppression seen in the properly titrated, may differentiate between
younger adults. Thus inhibition appears to be healthy and pathological aging at an early stage.
multifaceted itself (Miyake and Friedman 2012),
and it may be that age has a differential effect on
its subcomponents. Neuroimaging of Executive Functioning
Further, there is evidence that the ability to in Older Adults
coordinate two tasks at once may be a distinct
executive function. The latent variable study of There have been many neuroimaging studies that
Miyake et al. (2000) found that a measure of dual have assessed age differences in activation pat-
tasking did not load highly onto any of their three terns during the performance of executive func-
core executive processes, suggesting the possibil- tioning tasks. However, these studies are subject
ity that dual tasking reects a somewhat distinct to the caveat mentioned many times above;
function (see also Fisk and Sharp 2004). While namely that single tasks do not give sufcient
performance on many measures of executive insight into the processes underlying executive
functioning changes with age, it appears that, functioning. Future imaging studies assessing
under certain circumstances, the ability to coordi- age-related activation differences across a wide
nate two tasks at once is relatively unimpaired. range of tasks (as was done in the study of Collette
For example, Logie and colleagues (2004) et al. (2005) described above) would be highly
required participants to retain a sequence of informative establishing whether age has a gen-
digits while they tracked a moving stimulus with eral effect on the neural substrates of executive
a stylus on a computer screen. Crucially, however, functioning or whether specic differences occur.
they measured participants performance when However, one clear nding from many neuro-
completing these tasks in isolation, in order to titrate imaging studies across a broad range of tasks is
the demand of each task (i.e., the number of digits that older adults exhibit patterns of overactivation
given and the speed of the tracking stimulus) in the relative to younger adults. This overactivation
dual-task condition. The small cost associated with appears to be more extensive for tasks requiring
performing the tasks concurrently was no greater in executive control relative to tasks assessing mem-
their older group compared to their younger group. ory or perceptual function and is primarily found
However, a group of patients with Alzheimers in the dorsolateral prefrontal cortex (Spreng
disease (AD) showed a large reliable performance et al. 2010). The nding that this hyperactivity is
cost. Given that each task was performed usually exhibited by better performing older
within procient single-task levels, this suggests adults has contributed to the suggestion that it is
in some way compensatory and acts as a scaffold performance best in their group of older adults.
supporting less efcient brain areas (Park and If we accept that age disproportionately affects
Reuter-Lorenz 2009). However, this over- shifting ability although as discussed above the
recruitment could represent a non-specic degra- evidence is mixed it may be the case that more
dation of brain function or dedifferentiation of intact executive processes can be called upon to
cognitive processes with age (see Spreng support less well-preserved functions in the per-
et al. 2010 for a review). formance of multifaceted executive functioning
Interestingly, a meta-analysis of 24 functional tasks.
imaging studies covering a range of executive
functioning tasks and 22 studies assessing
E
age-related change to gray matter volume has Conclusion
recently shown considerable overlap between
areas overactivated by older adults and regions In summary, a great deal of progress has been
exhibiting disproportionate gray matter loss with made in recent years toward understanding the
age (Di et al. 2014). The clusters were found in the core processes underlying executive functioning.
bilateral dorsolateral prefrontal cortex, and Studies adopting a multivariate approach have
overactivation of this region was not associated identied separable but highly interconnected fac-
with poorer task performance relative to younger tors representing the ability to inhibit prepotent
controls. These ndings could be leveraged in responses, shift between mental sets, and update
support of either the compensatory or general the contents of working memory. Contrary to the
inefciency/dedifferentiation views. That areas predictions of dedifferentiation, these diverse
showing the greatest volumetric decline were functions appear to remain largely separable in
also those exhibiting overactivation is certainly healthy old age although this may break down in
reconcilable with the argument that the additional mild-cognitive impairment.
recruitment is a product of degradation and neural However, whether or not executive processes
inefciency. However, that this activation was not exhibit differential decline is unclear. The studies
associated with any gain or loss in performance discussed above suggest some reason to suspect
could also suggest that hyperactivation serves to that older adults have specic difculty in shifting
compensate for structural decline (Park and between tasks or maintaining multiple task rules.
Reuter-Lorenz 2009). The compensation account Nevertheless, ndings are mixed, and this likely
is clearly very exible, and it will take large lon- depends on the precise measures used to establish
gitudinal studies to establish the functional signif- the underlying constructs. Further, it appears that
icance of hyperactivation during executive much of the impairment exhibited by older adults
functioning and other tasks (Spreng et al. 2010; on complex measures of executive functioning
Di et al. 2014). may attributable to more general decline, such as
While more work needs to be done to link reduced speed of processing. Although it is
neuroimaging measures to behavioral measures important to note that commonly used measures
of executive functioning in old age, it is interest- of processing speed may include an element of
ing to note that there may be behavioral evidence executive control, therefore the effect of control-
for the compensation hypothesis from complex ling for processing speed measures in analyses
executive functioning tasks. In younger adults, should be interpreted with caution. It seems likely
Miyake et al. (2000) found performance on the that the substrates of executive functioning will be
WCST was best predicted by the shifting factor fractionated even further through the use of
from their latent variable model. On the other theory-driven tasks that aim to better isolate exec-
hand, Hull et al. (2008) found that their working utive processes. Finally, the assessment of tasks
memory updating factor predicted WCST which rely on executive functions which are age
insensitive, such as dual tasking, can open new working memory impairment in normal aging. Nature
diagnostic opportunities for the early detection of Neuroscience, 8, 12981300.
Hasher, L., & Zacks, R. T. (1988). Working memory,
abnormal variants of aging, such as Alzheimers comprehension, and aging: A review and a new view.
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motivation (Vol. 22, pp. 193225). New York:
Academic.
Hedden, T., & Yoon, C. (2006). Individual differences in
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Working Memory in Older Age Lezak, M. D., Howieson, D. B., & Tranel, D. (2012).
Neuropsychological assessment (5th ed.). New York:
Oxford University Press.
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A. D. (2004). Is there a specic executive capacity for
Albinet, C. T., Boucard, G., Bouquet, C. A., & dual task coordination? Evidence from Alzheimers
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Baddeley, A., & Hitch, G. (1974). Working memory. & Iveson, M. H. (2015). Handbook of frontal lobe
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ping, 25, 409423. unity and diversity of executive functions and their
Collette, F., Hogge, M., Salmon, E., & Van Der Linden, contributions to complex frontal lobe tasks: A latent
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Di, X., Rypma, B., & Biswal, B. B. (2014). Correspon- tal lobes: A lifespan perspective (pp. 5779). New
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Sylvain-Roy, S., Lungu, O., & Belleville, S. (2014). Nor- the service of adaptive, goal-directed behavior.
mal aging of the attentional control functions that Executive control is especially required in novel,
underlie working memory. The Journals of Gerontol-
ogy. Series B-Psychological Sciences and Social Sci- ambiguous, or complex situations, when there are
ences. doi:10.1093/geronb/gbt166. E-pub ahead of no well-learned routines for action selection
print. (Baddeley 2000; Jurado and Rosselli 2007). Exec-
Vaughan, L., & Giovanello, K. (2010). Executive function utive abilities allow us to think divergently and
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Verhaeghen, P. (2011). Aging and executive control: overcome it. They help us to maintain a goal and
Reports of a demise greatly exaggerated. Current focus our attention in the face of distraction, while
Directions in Psychological Science, 20, 174180. E
staying exible enough to adjust our behavior
quickly to unpredicted changes in the environ-
ment. We need executive skills to resist tempta-
tion and to suppress inappropriate habitual
Executive Functions behaviors. Executive functions enable us to plan
ahead, to juggle multiple pieces of information in
Kerstin Unger1 and Julia Karbach2 our mind and make new connections between
1
Department of Neuroscience, Brown University, them. It is thus not surprising that executive con-
Providence, RI, USA trol is a strong predictor for various life outcomes,
2
Goethe-University Frankfurt, Frankfurt, such as academic achievement, socioeconomic
Germany status, and physical health.
There is a fundamental debate as to whether
executive functions can be best described as a
Synonyms unitary or multidimensional construct. While the
former view holds that a single ability or common
Cognitive control; Executive control cognitive mechanism underlies all aspects of
executive functioning (unity), the latter view
assumes that executive functions involve related,
Definition but separable, components (diversity). The unity
framework includes inuential concepts such as
Executive functions are higher-level cognitive the supervisory attentional system in the model of
control functions supporting the exible adapta- attention for action by Norman and Shallice
tion to changing environmental demands. They (1986) or the central executive in Baddeleys
include abilities such as updating, shifting, and working memory model (Baddeley 2000). Fur-
inhibition, which are subject to signicant ther, it has been suggested that perceptual speed
age-related changes. These age differences are and/or basic reasoning skills may form a common
associated with age-related changes in the neural basis for executive control operations (Salthouse
substrate supporting executive processes. How- 2005).
ever, the brain is plastic up to very old age, and In line with the idea of a unitary control sys-
executive functions can be improved by intensive tem, studies using conrmatory factor analysis
cognitive and physical training in adulthood. and structural equation modeling have typically
revealed substantial correlations between the
latent constructs underlying performance in exec-
The Concept of Executive Functions utive control tasks (e.g., Friedman et al. 2011;
Miyake et al. 2000). These studies, however,
Executive control is an umbrella term for a broad also showed that the latent factors explained
set of higher-order cognitive processes supporting unique variance and thus may represent separable
the exible regulation of thoughts and actions in abilities. Miyake and colleagues (2000), for
854 Executive Functions
instance, demonstrated that interindividual differ- review, Adrover-Roig et al. 2012). Importantly,
ences in executive functions in young adults are single-factor models did not seem to provide an
better accounted for by a three-factor model with appropriate description of executive functioning
the latent variables shifting, working memory in either of the abovementioned studies. Overall,
(updating), and inhibition than by single- or it has been concluded that aging is associated with
two-factor models. Generally considered as core changes in the relative contribution of the differ-
components of executive control, these factors ent subcomponent processes to performance on
describe the ability to (i) exibly switch between executive control tasks rather than with a funda-
different tasks, goals, or mental sets (shifting); mental reorganization of executive functions.
(ii) update or monitor task-relevant information
to be maintained in working memory (working
memory/updating); and (iii) withhold prepotent Age-Related Changes in Executive
responses and suppress attention to irrelevant Functions
stimuli as well as interfering thoughts and emo-
tions (inhibition). The three main latent factors Compared to other cognitive domains, such as
have been found to contribute differentially to procedural and semantic memory, language, or
more complex executive functions, such as plan- emotion regulation, executive control seems to
ning or concept formation. be particularly affected by aging, with a sharp
Notably, more recent work has shown that only drop occurring after the age of 60 (Jurado and
the shifting and updating factors captured unique Rosselli 2007). Consistent with the unity/diversity
variance that was separable from a higher-order view, both global and component-specic mech-
unity factor (common executive function; anisms have been shown to account for declines in
Friedman et al. 2011). Further support for a executive functions with advancing age. Promi-
hybrid unity/diversity framework comes from nent examples for global mechanisms that are
neuroscientic studies showing that different thought to impact all components of executive
executive control processes rely on overlapping control are reduced information processing
but separable networks of neural activity (Jurado speed (Salthouse 2005) and impaired goal main-
and Rosselli 2007; Collette et al. 2006). tenance (e.g., Braver and West 2008; Miyake and
A fundamental cognitive mechanism that might Friedman 2012). Specically, Salthouse and col-
underlie the common factor of executive control is leagues suggested that the apparent diversity of
the ability to stably maintain task goals in working age-related cognitive decits can be explained by
memory (Braver and West 2008; Miyake and a generalized slowing of cognitive processing.
Friedman 2012), whereas updating and shifting This argument is based on their observation that
have been linked to the ability to efciently (i) measures of executive functions, reasoning,
gate goal-relevant information into working and processing speed were highly correlated and
memory (updating) and to quickly remove con- (ii) controlling for processing speed eliminated or
tents from working memory when they are no strongly diminished age differences in executive
longer needed (shifting; Miyake and Friedman functioning (Salthouse 2005). However, other
2012; Herd et al. 2014). studies found age-related decits in executive
Convergent evidence indicates that the basic control when differences in speed of processing
organization of executive functions is similar in were taken into account (e.g., Albinet et al. 2012).
younger and older adults. While some studies Moreover, commonly used measures of
replicated Miyake et al.s three-factor structure processing speed, such as the Digit-Symbol Sub-
in healthy elderly populations, others revealed stitution Test, are impure in that they also tap
two-structure solutions with the subcomponents inhibition, shifting, and working memory, which
(a) shifting and updating or (b) shifting/updating may explain their shared variance with executive
and resistance against proactive interference (for control tasks. Using hierarchical regression
analyses, Albinet and colleagues (2012) demon- effects in younger and older seniors. While youn-
strated that despite sharing common variance, ger seniors performance did not differ between
processing speed and the three main control com- the two delay conditions, older seniors showed
ponents are independently affected by chronolog- worse BX but better AY performance with longer
ical age. This nding argues against the view that delays.
age-related decrements in executive functions are Based on these ndings, Braver and Barch
exclusively mediated by generalized slowing. (2002) concluded that the younger seniors decits
Several theoretical frameworks contend that in BX trials result from their difculties with
the ability to actively maintain behavioral goals updating rather than maintenance of the rule
or task sets in order to bias task-appropriate context. Thus, updating mechanisms might be more
E
response selection plays a pivotal role in execu- vulnerable to advancing age than maintenance,
tive functioning (e.g., Braver and West 2008; which shows impairments only at older age or
Miyake and Friedman 2012). An elegant para- under more challenging conditions (e.g., distrac-
digm to examine age differences in the integrity tion). In line with this assumption, complex work-
and robust maintenance of goal representation is ing memory tasks that require updating and
the AX-Continuous Performance Test (AX-CPT; monitoring, such as reading or operation span, usu-
Braver and Barch 2002). In this paradigm, partic- ally reveal more substantial age differences than
ipants are presented with different cues (A simple span tasks. In further support of a particu-
vs. non-A) that specify the appropriate rule for larly high susceptibility of updating skills to cogni-
responding to a subsequent probe stimulus (X tive aging, previous work identied updating as the
vs. non-X). When an A cue is followed by an most important predictor of older adults perfor-
X probe (AX trials), a target response must be mance on tasks tapping complex executive func-
given, while X probes preceded by non-A tions, such as Tower of Hanoi (TOH) and
cues (BX trials) as well as all non-X probes Wisconsin Card Sort Test (WCST) (cf. Adrover-
(AY and BY trials) require a non-target response. Roig et al. 2012). In younger adults, by contrast, the
Since AX-trials are presented more frequently Miyake et al. study (Miyake et al. 2000) found
than other trial types, X probes elicit a strong inhibition and shifting to be the best predictors for
tendency to make a target response. Thus, failures TOH and WCST performance, respectively.
to maintain a stable representation of the rule While the ability to update and maintain infor-
context (A vs. non-A) should lead to higher mation in working memory is characterized by a
error rates when X probes are preceded by constant age-related decrease, the ability to exi-
non-A cues (BX trials) but lower error rates bly shift between tasks seems to be less affected
when A cues are followed by non-X probes by age. One frequently used experimental task to
(AY trials). Consistent with the goal maintenance measure this skill is the task-switching paradigm
account, Braver and colleagues observed exactly including conditions in which participants are
this error pattern when comparing younger and required to shift back and forth between two or
older adults performance on the AX-CPT. Older more tasks (mixed-task blocks) and conditions
adults produced more BX than AY errors, while that do not require task switches (single-task
the opposite was true for younger adults. Notably, blocks). Shifting skills are measured as the differ-
these age differences were even more pronounced ence in performance between task-switch and
when distractors were presented during the task-repeat trials within mixed-task blocks
cue-probe delay. This latter nding indicates that (specic switch costs). Further, by contrasting
older adults are more susceptible to distraction, mixed-task blocks with single-task blocks, this
most likely due to their weaker maintenance abil- paradigm allows to determine performance costs
ities. Interestingly, increasing maintenance due to the greater maintenance demands in the
demands by manipulation the length of the dual-task situation (general switch costs). When
cue-probe delay (1 vs. 5 s) resulted in differential the general age-related slowing of processing
speed is controlled for, age differences are usually (Braver and West 2008) found that older partici-
only found for general switch costs but not for pants showed disproportionally higher rates of
specic switch costs (e.g., Verhaeghen and intrusion errors (i.e., naming the word instead of
Cerella 2002). the ink color) when color and word naming alter-
It is interesting to note, however, that the com- nated in a trial-by-trial rather than block-wise
mon component of executive control and the fashion. Notably, this effect was separable from
shifting-specic subcomponent often tend to be the switching demand itself and has been
negatively correlated (e.g., Friedman et al. 2011). argued to reect a weaker representation of the
In a recent study, Herd and colleagues (2014) used currently relevant task goal. Similarly, Mayr and
neural network modeling to show that this might colleagues (2014) suggested that older adults
reect opposite effects of stable maintenance on higher susceptibility to irrelevant memory traces
the two factors. Specically, the authors demon- in interference tasks results from their difculties
strated that stronger goal representations led to an to reestablish a stable maintenance mode after any
overall decrease in reaction times for both task- kind of interruptions (e.g., conict, task switch).
switch and task-repeat trials in mixed-task blocks More consistent age-related impairments have
relative to single-task blocks, resulting in a reduc- been observed in tasks that require participants
tion of general switch costs. This effect was to withhold their responses upon intermittently
smaller for task-switch trials, where participants presented stopping signals (i.e., stop-signal
needed to overcome the stronger goal representa- tasks, go-nogo tasks) or tasks that require the
tions, resulting in an increase of specic switch inhibition of the automatic orienting response to
costs. Thus, spared shifting abilities in old age salient visual distractors (anti-saccade tasks;
might actually be a byproduct of impaired cf. Buitenweg et al. 2012).
maintenance skills. Further research is needed to It is important to note that not all individuals
determine how the putative shifting-specic are equally affected by cognitive aging. Indeed, in
processes removal of no-longer-relevant infor- some older adults, executive functions are
mation from working memory and automatic remarkably spared. Correlational data indicate
persistence of those contents change with that greater engagement in intellectual, social,
advancing age. and physical activities is associated with stronger
Robust goal maintenance is particularly impor- resilience to cognitive decline in later life (for
tant in the face of strong interference from com- review, Reuter-Lorenz and Park 2014). Most the-
peting response tendencies or goal-irrelevant ories of cognitive aging share the assumption that
information and usually considered to be a key at least two mechanisms contribute to the protec-
determinant of inhibition (Miyake and Friedman tive effect of those environmental variables. First,
2012). Indeed, the abovementioned neural net- an enriched lifestyle could directly counteract
work simulations by Herd et al. (2014) revealed age-related changes in brain anatomy and physi-
that in the Stroop color-word interference task, ology, thereby promoting brain health and
strong goal representations particularly benetted increasing the threshold for cognitive decits.
incongruent trials and hence were associated with Second, environmental enrichment is thought to
reduced interference effects. Interestingly, enhance the ability to adapt to age-related brain
age-related impairments do not reliably occur for pathology and to preserve cognitive function, for
all types of inhibitory control. In particular, a instance by compensatory recruitment of addi-
number of ndings have suggested that older tional brain regions and alternative neural circuits.
adults decits in inhibitory processing as mea- Conversely, depleting genetic and environmental
sured by the Stroop task or negative priming variables, such as vascular risk factors, head
reect global changes in processing speed or trauma, or low socioeconomic status, have detri-
impaired sensory processing (e.g., Verhaeghen mental effects on brain health and aggravate the
and Cerella 2002). However, in support of the effects of aging on executive and other cognitive
goal maintenance account, West and colleagues functions.
Neurobiological Underpinnings Reductions in grey matter volume in PFC

of Executive Control and Cognitive have been found to predict performance on
Aging age-sensitive executive control tasks such as the
WCST or TOH. Further, there is evidence indicat-
Executive control is inextricably linked to the ing that changes in synaptic connectivity (e.g.,
functioning of the frontal lobes, especially pre- reduced synaptic and dendritic density) might
frontal cortex (PFC). Evidence from neuroimag- play a more important role in explaining cognitive
ing and lesion studies revealed, though, that decline in old age than white and grey matter
executive functions are supported by a distributed disruption as such.
neural network, involving prefrontal and parietal It is important to note that age-related changes
E
areas as well as subcortical structures, such as in brain structure are not restricted to frontal cor-
basal ganglia, thalamus, or cerebellum (Duncan tex but occur throughout the brain. In fact, brain
and Owen 2000). The results of these studies are aging has been shown to progress along an
largely in accordance with the view that both anterior-to-posterior gradient rather than being
shared and unique mechanisms underlie executive specic to PFC. Moreover, it is well established
functioning. Specically, it has been shown that that decits in dopamine (DA) function contribute
shifting, updating, and inhibition tasks elicit an to many of the cognitive impairments observed in
overlapping pattern of activation in frontal (e.g., old age (Bckman et al. 2000). DA levels decline
dorsolateral PFC, anterior cingulate cortex) and monotonically with increasing age (at a rate of
parietal regions (e.g., superior and inferior parietal about 10% per decade), and markers of advanced
lobe, precuneus). Component-specic activations DA depletion predict age-related decits in exec-
have been found in distinct prefrontal, occipital, utive functions, processing speed, episodic mem-
and temporal areas as well as subcortical regions ory, reward-based learning, and decision making.
(e.g., Collette et al. 2006). Consistent with the Braver and colleagues (Braver and Barch
neuroimaging ndings, data from lesion studies 2002) provided an integrated theoretical frame-
revealed that patients with brain damage to differ- work for the role of frontal and dopaminergic
ent frontal regions show both common and unique dysfunction in cognitive aging. According to
performance decits on executive control tasks. this account, dorsolateral PFC (dlPFC) contrib-
There are similarities between certain aspects utes to executive control by maintaining goal rep-
of aging-related neurocognitive changes and the resentations and other task-relevant context
neuropsychological decits displayed by frontal- information and to use this information to bias
lobe patients, especially those with lateral frontal (or contextualize) lower-level information
damage. The idea that cognitive impairments in processing in posterior cortical regions. The neu-
older adults are strongly linked to frontal dysfunc- rotransmitter DA is thought to play a key modu-
tion (frontal lobe hypothesis) has received sub- latory role over dlPFC function by regulating
stantial support from neurophysiological studies maintenance and updating (gating) of goal rep-
demonstrating that aging is associated with vari- resentations. Age-related deterioration in PFC and
ous changes in prefrontal structure and physiol- DA function, thus, are assumed to result in a
ogy, such as white matter integrity, grey matter specic impairment in the ability to actively
volume, metabolic markers of neural integrity, update goal/context information into working
and neurovascular factors (Raz and Rodrigue memory and to maintain this information robust
2006). Although disruption of white matter integ- against interference. Consistent with the idea of a
rity has been primarily associated with the gener- frontostriatal functional dissociation between
alized age-related decrease in processing speed, a maintenance (PFC) and updating (striatum), accu-
number of studies demonstrated more specic mulating evidence points to complementary roles
correlations between separable white matter sys- for DA in PFC and basal ganglia, with higher
tems and age-related impairments in task- prefrontal DA levels promoting stabilization of
switching, working memory, and inhibition. goal representations and higher striatal DA levels
exible updating (Cools and DEsposito 2011). control tasks, older adults showed a separable
Thus, the loss of dopaminergic function with nor- pattern of effects, involving stronger recruitment
mal aging may contribute to both increased dis- of right (but not left) inferior frontal gyrus and left
tractibility (i.e., impaired maintenance) and presupplementary motor area. Nonetheless, the
updating decits that have been observed in overall spatial distribution of working-memory
older adults. In support of this notion, Raz and versus inhibition-specic brain activation proles
colleagues (Raz and Rodrigue 2006) found a pro- was largely comparable in younger and older
nounced age-related decline in frontostriatal DA adults.
activity and striatal volume.
Functional neuroimaging studies have pro-
vided ample evidence that brain aging is not Plasticity of Executive Functions
only reected structural changes but also differ- in Older Age
ences in brain activity. Common aging-specic
patterns of brain activity include over- and Given that executive functions decline with
underactivation, a loss of functional selectivity increasing age, there has been growing scientic
of neural responses in different regions and net- interest in interventions designed to improve
works (dedifferentiation), and altered functional them. Recent studies have applied a wide range
connectivity among different brain areas. Most of of cognitive and physical training interventions,
these effects are thought to reect compensatory revealing that cognitive plasticity (i.e., the poten-
mechanism that accompany neurocognitive tial modiability of a persons cognitive abilities
decline. Compensatory strategy changes, in turn, and brain activity) is considerable up to very old
might initiate changes in brain structure, resulting age (for reviews, Karbach and Verhaeghen 2014;
in a complex interplay between structural and Ballesteros et al. 2015).
functional effects. A typical example of compen- Cognitive interventions can be divided into
satory neural scaffolding is the posterior to three major categories: (i) strategy-based train-
anterior shift in functional brain activity with ings, (ii) process-based trainings, and (iii)
advancing age, which has been interpreted as an multimodal interventions. Strategy-based train-
overrecruitment of frontally mediated control pro- ings aim to improve specic cognitive
cesses in response to the reduced distinctiveness operations typically those that are most impaired
of neural representations in posterior regions. in older age by teaching participants an explicit
Moreover, older adults often show greater and strategy on how to solve the given task or prob-
more bilateral PFC activity at lower levels of lem. For example, the so-called method of loci
task demand than younger adults a domain- helps individuals to improve their memory perfor-
general pattern known as hemispheric asymmetry mance by associating the to-be-remembered items
reduction. Interestingly, both patterns also seem to with a sequence of specic physical locations
be reected in age-related changes in functional along a mental route in a familiar place such
connectivity. as their apartment. Although strategy trainings
Despite the well-documented generality of have been shown to result in considerably large
compensatory neural mechanisms, a recent meta- and sustained performance gains, improvements
analysis provided evidence for dissociable pat- are often limited to the trained task, with little
terns of age differences in brain activity during evidence of transfer to untrained functions. Train-
working memory and inhibitory control tasks ing regimes that involve a combination of multi-
(Turner and Spreng 2012). Specically, the ple strategies or focus on more complex functions,
authors found that working memory tasks were such as reasoning, problem solving, or goal man-
associated with more bilateral activation of dlPFC agement, seem to yield a more generalized bene-
as well as greater activation of left supplementary cial effect on untrained measures of executive
motor area and inferior parietal lobule in older function as well as indicators of daily life
compared to younger adults. During inhibitory functioning.
Process-based cognitive intervention programs functions and intelligence are most commonly
aim to improve specic cognitive processes, such reported for adaptive trainings, i.e., when task
as speed of processing or working memory, by difculty is individually adjusted over the course
training participants on tasks that are thought to of training to match participants performance
heavily tax these functions. Only a relatively levels. Even though transfer effects of updating
small number of studies have examined the effects practice have often been found to be absent or
of set-shifting in older adults (Buitenweg considerably smaller in older participants, a num-
et al. 2012). Available evidence indicates that ber of recent meta-analyses found small, but reli-
relatively short shifting practice (less than 10 train- able, transfer effects of working memory and
ing sessions) can yield signicant performance executive function training to untrained cognitive
E
improvements, particularly in terms of general skills, particularly uid intelligence. Interestingly,
switch costs. Most importantly, training-induced these studies revealed that overall the magnitude
gains have been shown to transfer to untrained of training-induced performance gains is compa-
tasks and abilities, such as inhibition, attention, rable in younger and older adults. It should be
and reasoning. Specically, several studies dem- noted, however, that not all meta-analytic studies
onstrated that shifting practice results in reduced found evidence for benets of training on execu-
Stroop interference effects, better performance on tive functions. These inconsistencies might be
verbal and spatial working memory tasks, and attributable to methodological factors such as the
increased uid intelligence scores in both younger total number of included studies, criteria for study
and older adults. Transfer effects have been attrib- exclusion, heterogeneity of trained tasks and
uted to the fact that task-switching paradigms put populations, as well as the specic coding of
high demands not only on shifting but also on transfer measures.
maintenance and interference control and hence Only a very small number of training studies
tap into multiple subcomponents of executive that have been conducted with older adults
control. Additionally, transfer to more complex focus directly on inhibition. As reviewed in
functions (e.g., reasoning skills) might derive Buitenweg et al. (2012), practice on tasks tapping
from the requirement to efciently coordinate inhibition, such as Stroop or Simon task,
multiple tasks. Despite promising initial improved inhibitory control in elderly but the
ndings, some studies have failed to obtain training-induced gains did not generalize to
practice-induced transfer effects to untrained untrained tasks. A notable exception is a recent
tasks after set-shifting training in older adults. study by Mishra and colleagues (2014) that used
Thus, more research is needed to determine the an adaptive distractor-suppression training to
conditions under which shifting practice may enhance interference control in healthy aging.
compensate for age-related decline in executive The training did not only affect behavioral and
control and associated impairments in daily neural indicators of interference effects in the
functioning. trained task but also had benecial effects on
Working memory updating trainings in healthy unrelated measures of working memory and
older populations revealed substantial perfor- sustained attention.
mance improvements on the trained as well as Given that a general decrease in information
structurally similar tasks (Karbach and processing speed is thought to play an important
Verhaeghen 2014). In terms of transfer to other role in the age-related decline of executive func-
dimensions of executive control, intelligence, or tions, several interventions have targeted speed of
reasoning, however, the ndings are less consis- processing in older adults. Speed of processing
tent. Studies that have systematically assessed the trainings have been shown to induce large and
potential of working memory updating training to sustained improvements in speed scores. While
improve executive control functions in the elderly some studies reported transfer to untrained func-
are scarce. In younger adults, generalization of tions such as visual-spatial abilities, attention, and
performance gains to other measures of executive everyday speed measures, training gains did not
generalize to executive control measures. Another training task and the transfer task engage
relatively recent approach to improve executive overlapping cognitive processing components
control and other aspects of cognition in older and brain regions.
populations are video game trainings. Results, Aside from cognitive training interventions,
thus far, show that video game playing can physical training, especially from the domain of
enhance several age-sensitive cognitive functions, cardiovascular training, can improve cognitive
including visuospatial attention, memory, and functions. These positive effects of physical exer-
speed of processing, but training gains do not cise were particularly pronounced in the domain
seem to transfer to executive functions. of executive control (Ballesteros et al. 2015).
In recent years, some progress has been made They have been reported for healthy older adults
in identifying neural substrates of training- as well as for individuals with cognitive and phys-
induced plasticity in older age (Brehmer ical impairments and have been accompanied by
et al. 2014). Training-related changes in brain changes in cerebral blood ow and the modula-
structure (e.g., grey and white matter volume) tion of activity in task-relevant brain areas. Hence,
have been observed in task-relevant areas rather both cognitive and physical activity in older age
than globally throughout the brain. Performance may be effective ways to support executive func-
gains on executive control tasks were associated tioning in the aging brain. Indeed, multimodal
with activation increases, decreases, or a combi- training approaches that combine various types
nation thereof, in frontoparietal control regions as of interventions, including social engagement,
well as subcortical areas. While activation cognitive trainings, and physical stimulation,
increases are thought to reect compensatory have yielded promising results in terms of
strategies, activation decreases are usually improving executive functions and daily life func-
interpreted as an indicator of increased neural tioning. The complexity of multimodal interven-
processing efciency. In general, neural activation tions, however, entails methodological challenges
changes can be classied as functional redistribu- that have not been fully resolved yet. For instance,
tion or functional reorganization, with the former it is often difcult to determine to what degree
denoting quantitative changes in activation levels single components and/or interactions between
within the same or similar brain regions and the different components contributed to training
latter denoting qualitative changes in the spatial gains.
pattern of brain activation. Cognitive interven-
tions often induce a reduction of age-related acti-
vation differences, such that after training, brain Summary and Conclusion
activation in the elderly approximated that in
younger adults. Executive control functions include a number of
Interestingly, a number of working memory processes such as updating, shifting, and inhibi-
training studies revealed a pattern of activation tion, all of which are subject to signicant
decrease in frontoparietal regions in association age-related changes across the adult life span.
with activation increase in the striatum. This pat- These age differences have been linked to struc-
tern might reect faster and less effortful updating tural and functional alterations in the neural sub-
of working memory representations due to more strate supporting executive processes. Consistent
efcient information processing in corticostriatal with the frontal lobe hypothesis of cognitive
circuits, e.g., as a consequence of more salient aging, the greatest change in brain anatomy and
striatal updating (gating) signals. In younger but physiology is evident in anterior brain regions.
not in older adults, the training-related increase in However, research on cognitive aging has also
striatal activation predicted transfer effects to a shown that the brain is plastic up to very old age
structurally similar untrained task that also acti- and that executive control can be modulated by
vated the striatum. The latter nding is consistent lifestyle factors as well as intensive cognitive and
with the idea that transfer is increased if the physical training in adulthood. Environmental
enrichment, including intellectual, social, and References

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memory work: A meta-analysis of executive-control performance necessary to attain expert status
and working memory training in older adults. Psycho-
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Mayr, U., Kuhns, D., & Hubbard, J. (2014). Long-term like writing or driving a car sufced for expert
memory and the control of attentional control. Cogni- status in earlier times, but they are minimum
tive Psychology, 72, 126. requirements for most jobs nowadays. Expert
Mishra, J., de Villers-Sidani, E., Merzenich, M., & Gazzaley,
A. (2014). Adaptive training diminishes distractibility in swordsmanship has come out of fashion while
aging across species. Neuron, 84, 10911103. excelling in web design was unknown to our
Miyake, A., & Friedman, N. P. (2012). The nature and ancestors. In aging societies the question if and
organization of individual differences in executive how expert levels of performance can be
functions four general conclusions. Current Directions
in Psychological Science, 21(1), 814. maintained into later adulthood has gained central
Miyake, A., Friedman, N. P., Emerson, M. J., Witzki, signicance. Workforces in most OECD (Organi-
A. H., Howerter, A., & Wagner, T. (2000). The unity sation for Economic Co-operation and Develop-
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tions to complex frontal lobe tasks: A latent variable
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Norman, D. A., & Shallice, T. (1986). Attention to action: 2006, and between 1980 and 2006, the median
Willed and automatic control of behavior. In age of the American workforce increased from
R. J. Davidson (Ed.), Consciousness and self- 35 to 41 years (Ng and Feldman 2008). Fewer
regulation (pp. 118). New York: Plenum Press.
Raz, N., & Rodrigue, K. M. (2006). Differential aging of the young people enter the workforce and those who
brain: Patterns, cognitive correlates and modiers. Neu- do have nowadays enjoyed longer periods of
roscience and Biobehavioral Reviews, 30, 730748. training. A main factor is the increasing employ-
Reuter-Lorenz, P. A., & Park, D. C. (2014). How does it ment rate of older employees, which is largely the
STAC up? Revisiting the scaffolding theory of aging
and cognition. Neuropsychology Review, 24, 355370. result of reductions in the traditional safety nets of
Salthouse, T. A. (2005). Relations between cognitive abil- funded (early) retirements even in European wel-
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Turner, G. R., & Spreng, R. N. (2012). Executive functions
and neurocognitive aging: Dissociable patterns of brain perspective on levels of functioning in older
activity. Neurobiology of Aging, 33, 826.e113. adults. Tests measuring the speed and accuracy
Verhaeghen, P., & Cerella, J. (2002). Aging, executive of basal processes like visual search or compari-
control, and attention: A review of meta-analyses. Neu- son operations are referred to as performance IQ
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(Intelligence Quotient) or uid intelligence in the
literature, and performances on these tests show
considerable age-related declines (Kaufman
Expertise and Ageing 2001). Due to the age-referenced denition of
IQ, the average 50-year-old has to perform at
Ralf T. Krampe roughly 8590% the speed of a 25-year-old to
Brain and Cognition, University of Leuven, obtain the same IQ score. Adults in their 60s
Leuven, Belgium typically take 1.62 times as much time compared
with 20-year-olds to perform speeded tests or
experimental tasks a phenomenon called gen-
Synonyms
eral age-related slowing (Salthouse 1996). Meta-
analytic reviews also point to age-related declines
Skill maintenance; Exceptional performance
in working memory and reasoning (Verhaeghen
and Salthouse 1997), the ability to perform two
Definition tasks simultaneously (Verhaeghen et al. 2003),
and cognitive control (executive functions)
The concept of expertise refers to individuals (Rhodes 2004). Cognitive control comprises
superior levels of performance in specic planning complex actions, the maintenance of
Expertise and Ageing 863
task-relevant information (task sets), inhibition of Expertise research differs from both cognitive
irrelevant task sets, and switching task sets when aging and organizational psychology with respect
performance conditions change. Onsets are later to the type and the levels of performances studied.
and rates of age-related declines are much Expertise research focuses on domain-specic
shallower for crystallized intelligence, that is, rather than domain-general functions. The broad
abilities based on knowledge, experience, and varieties of job performance studied by organiza-
culturally transmitted skills (Li et al. 2004). tional psychologists do not correspond to the
Studies from organizational psychology narrower concept of expert-level performance.
appear to defy the negative implications from While the boundaries between expert and novice
cognitive aging research. In what has been the performance are far from well dened, authors
E
most comprehensive meta-analysis of studies on (Ericsson and Smith 1991; Salthouse 1991)
the relation of age and job performance to date, agree on dening expertise as a stable individual
Ng and Feldman (Ng and Feldman 2008) found attribute. This attribute should not be based on
that core task performance on the job and creativ- experience (seniority) or social judgment, but on
ity was largely unrelated to age. In additional the actual level of performance. Expert perfor-
analyses Ng and Feldman found that the age x mance must be replicable and measurable taking
core performance relation followed an inverted the requirements of a certain domain into account.
U-shape function: performance in core skills Extant models of expertise posit that experts
improved with age in younger workers have developed specic mechanisms, which
(<40 years), presumably because of growing allow them to circumvent the process limitations
job-related experience, and it became slightly constraining normal (i.e., novice) performance
negative in employees age 40+. Related effects (Chase and Ericsson 1981; Ericsson et al. 1993).
wee small however, and the authors concluded This metaphor implies that experts do things dif-
that here is little to suggest from the meta-analytic ferently and that their brains also differ from nov-
reviews that older workers or employees cannot ice brains. Examples of cognitive mechanisms are
function in their jobs, lack creativity, or that their chess players memory for game positions, the
other performance aspects deteriorate noticeably advance coordination of ngers in rapid typing,
relative to young adults. One reason for this appar- and hand-independent timing in pianists. Evi-
ent contradiction with ndings from cognitive dence for expertise-specic adaptations at the
aging research may be the denition of older neural level comprises enlarged hippocampal
traditionally applied in organizational psychology regions in expert taxi drivers (Maguire
(Ng and Feldman 2008). For pragmatic reasons et al. 2000) or enlargements in sensorimotor cor-
(early retirement age, low workforce participation tices in musicians (Amunts et al. 1997; Elbert
rates), the authors considered older to be indi- et al. 1995). These examples illustrate that expert
viduals of age 40+. In standard textbooks of life mechanisms are not tricks of the trade one can
span developmental psychology (Berk 2014), the pick up in a crash course. Ericsson and colleagues
period 4065 years corresponds to middle adult- argued that attaining international-level expertise
hood, and participants in cognitive aging studies in any domain typically requires 10 years or at
typically are in their late 60s or older. A second least 10,000 h of deliberate practice (Ericsson
reason is that cognitive aging studies for the most et al. 1993). Deliberate practice is goal-directed
part use psychometric tests and experimental tasks learning, which requires careful monitoring of
with unfamiliar materials and they compared ones own performance and the continuous search
young and older individuals performances in for ways to improve. At least during the initial
novel and untrained settings. Arguably, the spe- acquisition phase, this occurs ideally under the
cic skills, which have been acquired and auspices of a coach, who is an expert herself/
exercised for considerable amounts of time in himself. The deliberate practice model depicts
professional contexts, show a friendlier expertise development as a long-distance race,
age-related development. during which the individual has to negotiate
effort, motivational, and resource constraints. to exist for older experts when compared with
Because its practice is inherently effortful, nature age-matched controls. For theoretical reasons
deliberate practice activities can only be sustained such age x expertise studies try to address three
for limited amounts of time, and they call for other questions: (1) do experts, who excel in their
sufcient recuperation. What distinguishes delib- domains also differ from normal individuals
erate practice from leisurely exercise is the moti- when it comes to domain-general abilities such
vation to improve and to overcome weaknesses in as general intelligence (processing speed, work-
ones own performance. Resource constraints ing memory) or cognitive control (monitoring and
relate to external (teachers, parental support) and controlling attention, suppressing irrelevant infor-
internal (physical health, concentration) types of mation, updating information in working mem-
support or limitations. Discussions in the litera- ory, switching between task sets and plans)?
ture abide as to whether deliberate practice is only (2) Does domain-specic expertise also convey
a necessary or a sufcient prerequisite of attaining an advantage in near-transfer domains that are
expert-level status (Hambrick et al. 2014; subject to age-related decline in the general pop-
Macnamara et al. 2014; Meinz and Hambrick ulation (e.g., are older chess masters also better in
2010); however, all theoreticians agree that it is a reasoning tests?)? (3) Does the level of expert
critical factor. Several authors have argued for performance maintained depend on older experts
inherited individual differences or gene- investments into certain activities (e.g., practice)?
environment correlations, which determine, for Depending on the answers to these questions, we
example, adult levels of musical accomplishment can distinguish four different accounts of expert or
(Hambrick and Tucker-Drob 2015). A related exceptional performance in later adulthood in the
question is whether individual differences in literature.
domain-general cognitive abilities (i.e., intelli- The preserved differentiation or a priori dispo-
gence) determine only initial progress in learning sition account maintains that (experts) have
(Ackerman 1988; Fox et al. 1996) or if they con- always been superior in skill-relevant abilities,
tinue to constrain accomplishments at superior or such that their advantages at any age could be
expert levels of performance (Hambrick and attributed to interindividual differences with
Engle 2002; Wai 2014). Controversies and long-term stability that already existed prior to
answers to these questions depend to a large expertise acquisition. For example, a predisposi-
degree on how the type and level of performance tion for visual imagery might nurture interest in
necessary to be considered an expert is dened and a professional choice for graphic design or
(Ericsson 2014). Whatever the precise perspective architecture. The second position, expertise-driven
on the precursors of expertise, maintaining exper- general ability account emphasizes transfer to
tise into later adulthood amounts to a considerable broader cognitive abilities. The idea is that acquir-
extension of the long-distance race because age ing expertise involves gradual improvements in
changes the nature of effort, motivational, and some, though not necessarily all, domain-general
resource constraints. functions. For example, daily professional chal-
lenges to keep complex facts in memory might
foster increases in working memory span. Differ-
Accounts for High Levels ential preservation or selective maintenance
of Accomplishment in Older Experts accounts emphasize the role of specic over
broad abilities. Accordingly, expertise at any age
The primary goal of the experimental study of rests on specic mechanisms, which age more
expert performances is to demonstrate reliable gracefully than general mechanisms, presumably
differences between experts and novices in tasks because experts actively maintain them through
reecting accomplishment in a specic domain. In continued use or deliberate practice. Finally, the
the context of aging, the key questions are compensation account posits that older experts
whether these performance advantages continue actively acquire specic mechanisms when
experiencing age-related decline of those mecha- investigating experts activities revealed a clear
nisms supporting their expertise. relation between levels of expert performance
and the amount of practice that went into acquisi-
tion (Ericsson et al. 1993). Deliberate practice
Experimental Studies of Expert seems to be as important when it comes to
Performance in Young and Older Adults maintaining expertise into later adulthood
(Charness et al. 1996; Krampe and Ericsson
Expert performance has been studied under labo- 1996). In particular, the study by Krampe and
ratory conditions with age-comparative samples Ericsson suggests that it is not years of experience,
for such diverse domains as typewriting, games starting age, or practice during young ages, but the
E
(chess, bridge, GO, mastermind), piloting, and air amount of practice invested during recent years,
trafc control, management skills, visual search in which determines the degree of maintenance.
medical assistants, ne motor control in mechan- The specicity of the expertise advantage in
ics, memory for numerical information in accoun- older experts is in line with the assumptions of
tants, auditory processing in musicians, and limited transfer to other skills or to general dimen-
musical performance (for a review, see Krampe sions of cognitive abilities (Hambrick et al. 1999;
and Charness 2006). Across studies experts in Owen et al. 2010). Individual differences in cog-
their late 50s and 60s typically perform at levels nitive abilities (Ackerman 1988) correlate with
comparable to or slightly below those of experts in learning rates in early stages of skill acquisition,
their late 20s. Even for experts of more advanced but these correlations weaken once learning pro-
ages, studies have reported at least reduced ceeds to expert levels. These ndings are at odds
age-related decline compared with age-matched with the expertise-driven general ability account,
novices. At the same time, older experts showed which posits that the acquisition of a specic skill
the typical reductions in measures of domain- leads to improvements at the level of general
general processing, which were similar to those abilities. One specic version of this account con-
observed in age-matched controls. This pattern of tinues to enjoy enormous popularity in science
results strongly suggests that older experts rely on and the media, namely, the assumption that
domain-specic mechanisms to circumvent the music lessons boost intelligence in children. Two
processing constraints of domain-general func- intervention studies indeed found small but reli-
tions just like young experts do. In line with this able benets of music training for broader intel-
assumption, benets are the highest in the most lectual abilities in preschool children and 6-year-
complex skill-related tasks, where experts can olds. Surprisingly, these advantages are smaller in
bring their most adapted specic processes to adults and absent in professional musicians. Some
bear. As an example, professional pianists have a authors argued for medium transfer of skills such
higher single-nger tapping rate compared with that cognitive control (executive functions) or
novices and amateur musicians; however, their language processing rather than broad mental
advantages are magnied when complex sequenc- abilities benet from musical training in adults.
ing of multiple ngers is required. In turn, age In the aging context, it is next to impossible to
effects in the novice group are the largest in the distinguish whether group differences in general
most complex conditions because they related abilities reect expertise-driven mitigation or pre-
tasks require increased engagement of domain- served differences, which existed prior to skill
general functions like working memory or cogni- acquisition. For example, two studies found supe-
tive control. These functions are known to be most rior performances on tests of broad visuospatial
affected by age-related decline (West 1996). abilities in architects (Salthouse et al. 1990) or
It is hardly feasible that such highly specic graphic designers (Lindenberger et al. 1992). At
adaptations reect a priori (e.g., innate) disposi- the same time, age-related differences were simi-
tions. Instead, the pattern agrees best with lar in experts and novices ruling out experience-
the selective maintenance account. Studies related mitigation. The authors argued that the
preserved difference account provided the best et al. 2001; Meinz and Salthouse 1998) or private-
explanation for these ndings. licensed pilots (Morrow et al. 1993) were found to
Evidence for the compensation account show normal age-related declines even in tasks
remained suggestive. Charness (1981) proposed related to their hobbies. On the other hand, even
that older chess experts compensate for slower top performers in their domain, who are highly
search rates by relying on rened, knowledge- motivated to maintain their levels of performance,
based processes of move selection. Other authors are not immune to the effects of aging. In his
(Bosman 1993; Salthouse 1984) have speculated longitudinal analyses, Simonton (Simonton
that older expert typists compensate for slower 2012) showed that creative experts in their 60s
reaction time and reduced dexterity by increasing and 70s were more productive than young experts
their eye-hand span (the amount of text they look starting their careers; however, peak productiv-
ahead during transcription typing). An inherent ities were at younger ages (late 30s and early
problem of the compensation account is that it is 40s, depending on domains).
difcult to determine whether older experts
indeed acquired specic mechanisms in reaction
to (as compensation for) age-related declines they Summary and Implications
experienced or whether these mechanisms were
better preserved than other component functions Expertise denotes domain-specic skills the
found in young experts. development of which can be described as a grad-
ual decoupling of expert mechanisms from
domain-general functions. The available evidence
Limitations on Selective Maintenance gives reasons for cautious optimism that specic
of Expertise skills can be maintained at high levels into late
middle adulthood or even old age. Naturally the
A key factor determining experience-related mit- typical cross-sectional studies in the age x exper-
igation is how closely experimental tasks relate to tise domain are subject to cohort and selection
the expertise under investigation. However, even effects. Arguably, older experts in these studies
if tasks are closely related to the expertise under could represent the survivors of an age-graded
investigation, skill maintenance is typically not winnowing process by which individuals with
perfect if young expert performance is taken as a pronounced age-related declines in relevant
benchmark. Studies on highly demanding profes- capacities or insufcient motivation to maintain
sions like piloting or air trafc control (Nunes and their skills have dropped from the eld (or have
Kramer 2009; Taylor et al. 2007) found that spar- been promoted to positions where more social
ing from age-related decline is frequently limited skills matter). A second methodological con-
in scope. In particular, these studies showed that straint is that all evidence related to capacities
some component skills are more easily assumed to moderate age-related changes in
maintained than others with speed or working expert performance is correlational, and this is
memory demands marking those components equally true for estimates of practice intensity.
more sensitive to aging even in experts. Obvi- Decoupling of expert from domain-general
ously domains of expertise differ with respect to mechanisms goes a long way, and experts, who
how many of such components they comprise, continue to strive for their best performances,
how sensitive they are to aging, and whether com- show remarkably little age-related decline. How-
pensatory mechanisms are effective to prolong ever, expertise is not immune to aging. When
high levels of performance into late adulthood. experimental tasks cover a broad range of compo-
Several studies also suggested that solid reduc- nent skills, maintenance in older experts is rarely
tions of age-related declines in specic skills perfect, and some component skills are more dif-
require a certain level of expertise or accomplish- cult to maintain than others. This has important
ment. For example, amateur musicians (Krampe implications for certain professions as the studies
of air trafc controllers and pilots illustrate. The Amunts, K., et al. (1997). Motor cortex and hand motor
degree of decoupling of expert mechanisms from skills: Structural compliance in the human brain.
Human Brain Mapping, 5(3), 206215.
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with age. Theories of life span intellectual (6th ed.). Boston: Pearson. Allyn and Bacon.
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differentiation-dedifferentiation (Li et al. 2004). motoric aspects of transcription typing skill. Psychol-
ogy and Aging, 8, 87102.
Dedifferentiation means that at advanced ages Charness, N. (1981). Search in chess: Age and skill differ-
acquired specic skills and their neural underpin- ences. Journal of Experimental Psychology: Human
nings become vulnerable, and we have to default Perception and Performance, 7, 467476.
to domain-general processes again. The implica- Charness, N., Krampe, R. T., & Mayr, U. (1996). The role
of practice and coaching in entrepreneurial skill E
tion is that expertise can certainly buffer domains: An international comparison of life-span
age-related decline, but this effect does not extend chess skill acquisition. In K. A. Ericsson (Ed.), The
endlessly into very old age. road to excellence: The acquisition of expert perfor-
Expertise does not rest on mere experience lest mance in the arts, sciences, sports, and games
(pp. 5180). Mahwah: Erlbaum.
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Krampe, R. T., & Charness, N. (2006). Aging and expertise. Psychology: Applied, 15(1), 1224.
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Krampe, R. T., Engbert, R., & Kliegl, R. (2001). Journal of Experimental Psychology: General, 113,
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F
Family Therapy tasks) and emotional support ow in multiple

directions within the family across the lifespan.
Sara Honn Qualls As older adults develop illness, disability, or
Gerontology Center, University of Colorado, frailty, family support often increases in intensity,
Colorado Springs, Colorado Springs, CO, USA frequency, or style in a pattern termed family
caregiving. Transitions in family life can disrupt
familiar patterns in ways that disrupt the well-
Synonyms being of older adults or other family members as
well as in families with long-term decits. Family
Family caregiving; Family intervention therapy focuses on relationships within which
older adults live and make their meaning as key
opportunities for improving their well-being.
Definition
Therapeutic interventions that change interper- Conceptual Foundations

sonal processes among family members alter the
structure or functioning of families with the goal Family development and family systems theories
of improving the familys abilities to meet the posit that families engage a variety of processes to
developmental needs of all members; aging fam- support the development of members (Walsh
ily therapy focuses specically on the needs of 2011), and those processes are inuenced by
families in which the key concerns center around structural characteristics of families (McGoldrick
the well-being of elderly members of the family et al. 2008). Age-related changes in biological,
(Qualls 1995, p. 475). psychological, or social functioning can alter fam-
ily structures or processes in ways that lead fam-
ilies to seek assistance.
Background Basic family structures include marriage, part-
nership, and parenting that are often depicted in a
Families are a key social context for older adults, diagram of a family tree called a genogram
with family members making up more of the (McGoldrick et al. 2008). Intragenerational struc-
social network in later life than at any other time tures include marriage or partnership, siblings,
in adulthood. The salience of families makes them and cousins. Intergenerational relationships are
particularly inuential to the well-being of older represented in vertical lines that illustrate parent-
adults, and vice versa. The instrumental (aid with child relationships across multiple generations.
DOI 10.1007/978-981-287-082-7
870 Family Therapy
The entry and exit of members are dening char- older adults are likely to live as singles, with men
acteristics of stages of the family life cycle more likely to live in partnership or marriage than
because they represent structural changes that women, especially in advanced age (Davey and
inuence functioning. Ambiguity in family struc- Takagi 2013). Historical cohorts vary in number
tures is particularly stressful on families (Boss of children, leading to variation in the number and
2007). An example of ambiguous structure in complexity of intragenerational as well as
later life occurs when a member has dementia intergenerational relationships. When plotted in
that renders him or her incapable of independent a genogram, or family tree, the older adults fam-
participation in family interaction. ilies clearly have more intergenerational relation-
Basic family processes include child-rearing, ships than within-generation relationships.
parent care, and partnership for pleasure and eco- The diversity of structures in aging families is
nomic sustenance among many other functions great, especially when compared with younger
family members perform for each other. Processes families. In child-rearing families, the parent and
involve communication, verbal and behavioral, child roles have relatively prescribed denitions,
that cues family members to act, feel, or think in with variations across cultures in the timing of
ways that become highly predictable circular transitions, contexts of development, and rules
cycles of prompts and responses. The recursive about specic aspects of family roles. Child-
cycles of behavior among members of a family rearing families experience role ambiguity pri-
can be articulated as rules of the family system. marily during periods of signicant transition
Anticipation of the familiar sequence shapes the from one status to another (e.g., child to adult) or
timing and selection of behaviors in particular when membership status is ambiguous such as
relationships in ways that appear rule driven. occurs when someone is missing in action in war
Observers can name the rules that describe the and thus is not dead, but not participating in the
sequences and interrupt the automatic pattern in family roles (Boss 2007). Aging families, how-
order to open the opportunity for novel responses ever, are composed of primarily adult members,
that meet members needs far better. with no clear role denitions supplied by the
Life stressors may alter family structures or culture for the important distinctions between
processes in ways that interrupt support patterns adults as children of independently aging versus
for one or more members. Stressors may result very frail or cognitively compromised aging par-
from historical events such as war or economic ents. Similarly, there is no clear signal point when
depression; from normative life events such as a marital or intimate partnership shifts from mutu-
employment, the onset or termination, or relation- ally autonomous to one dened by caregiving and
ships; or from nonnormative events such as house care receiving. Structural ambiguities add stress to
re. The individuals coping responses to stressors the family, especially in times of intensive role
are communicated in behaviors that impact other demands (Boss 2007).
family members, sometimes altering structural or Age-related chronic illnesses can alter family
functional characteristics of the family system. relationships by shifting roles, with long-term
The chronological aging of members in a fam- shifts into caregiver and care recipient as being
ily may impact family structures or processes, one variation. Families may adapt roles, commu-
primarily through changes in functional abilities nication patterns, and decision-making structures
to participate in family activities or self-care. In from those used in the early adult phases. Later-
addition, cultural rules about roles for aging fam- life family challenges and adaptations occur
ily members also inuence family structures and within the context of many decades of interaction
processes if elders are imbued with particular patterns, cultural norms, and expectations and
roles or values within the culture. Illnesses or particular intergenerational structures that offer
deaths that alter or remove members from the strength, resilience, and challenges (Walsh 2011;
structures often provoke shifts in roles related to Davey and Takagi 2013). Although most families
instrumental or emotional support. By later life, adapt well to aging-induced transitions, some fail
Family Therapy 871
to adapt effectively or experience stress during the decision-making structures). Disruptions in the
period of adaptation; intense or protracted stress life of the mid-life generation can challenge the
can undermine the well-being of one or more older members of the family system. Transitions
members. Perhaps the best-documented example in the lives of mid-life family members that can
is the impact of the transition to care for a member affect the older generation include divorce, incar-
with dementia on the primary caregiver (see entry ceration, geographic relocation, or signicant
on caregiving/carer burden). changes in lifestyle. Although these transitions
Families may enter later life with little prepara- can be navigated with minimal disruption to fam-
tion for the challenges or the contexts of aging. In ily patterns, they often require some shifts in
recent centuries, each generation must learn the communication style and frequency, nurturance,
health, housing, social, and legal service structures or problem-solving style, ultimately affecting the
for their own aging experience, because what was regular structures or processes of family life. F
observed in the previous generations offers little Chronic disease, sensory impairment, func-
guidance due to rapid rates of cultural change. tional disabilities, and/or cognitive impairments
Family therapy often includes education about in later life intrude upon families, often altering
aging processes or age-related diseases or difcul- structure, function, and meaning. Families play
ties, as well as about the formal service systems key roles in delivering health services to older
available to support older family members. family members, partner with them in manage-
ment of daily life when illness or disability con-
strains independence, and negotiate transitions
Problems Addressed by Family Therapy across the healthcare system repeatedly (e.g.,
from home to hospital to rehabilitation to home
In later life, family therapy can assist families with with home health to family support to complete
life stresses, health transitions, or relationship prob- independence). Not surprisingly, some transitions
lems in the older or younger generations. The are accomplished poorly, with disruptions
biopsychosocial model that has been embraced by in needed care (emotional or instrumental).
healthcare points to the multiple domains of human Although current models of health service deliv-
well-being that have reverberating effects in others, ery increasingly recognize the importance of
so interventions with families may be key to empowering older adults and their families as
supporting health interventions (e.g., changes in key participants in the service delivery model,
diet or activity patterns), psychological interven- very few health systems can accommodate family
tions (e.g., dementia or depression), or other social members participation on health teams.
interventions (e.g., increasing the rate of social
contact or addressing a conicted relationship
with another family member). Models of Family Therapy Applied
Social transitions in later life can disrupt long- to Geropsychology
term patterns of family life in ways that alter
support to members (old and young) and impact Among the earliest adaptations of family interven-
other domains of functioning. Retirement gener- tion approaches for aging families was the appli-
ally is experienced as a positive transition, but cation of family systems approaches to later life
when the retiree lacks control over the timing or families by Herr and Weakland in what they
conditions of the retirement, or loses signicant described as a counseling approach (Herr and
resources with the retirement, other members of Weakland 1979). Grounded in family systems
the family may be impacted. Remarriages and theory, they advocated the use of problem-solving
other intimate partnerships in later life can bring techniques with aging family challenges as con-
great joy and meaning to the couple, even as they ceptualized by systems theory. The contextual
may disrupt other aspects of family function (e.g., approach to family therapy was applied to aging
blending family holiday activities, assets, and families by Hargrave and Anderson (1992) who
872 Family Therapy
emphasized the importance of addressing obliga- Alzheimers Caregiver Health) study and its
tions and expectations that require forgiveness in extension, REACH II (Belle et al. 2006).
order to repair family functioning from the effects Although intervention research with family care-
of previously painful experiences. Structural fam- givers has been conducted around the world,
ily therapy (Minuchin 1974) informs the approach family-level interventions have not been the
to family therapy for caregiving families who are focus outside the USA.
experiencing signicant role shifts by Qualls Reviews of the literature on interventions with
(1995) and Qualls and Williams (2013). dementia caregivers found that education and sup-
Medical family therapy has evolved in the past port groups alone produce poorer outcomes than
two decades to offer substantial guidance to more intensive interventions, including family
geropsychologists whose work with later-life counseling interventions (Coon et al. 2012). Inter-
families often involves illness-related challenges ventions often include training in specic strategies
and transitions (McDaniel et al. 2013). Medical for communicating with persons with dementia,
family therapy applies the principles of family problem-solving approaches to addressing behav-
development and family systems to families in ior problems, and strategies for enhancing social
which one or more members have signicant support for the primary caregiver(s).
health challenges. This approach addresses the General models for intervention with family
changes in structure and function that illness can caregivers can be applied to a wide range of situa-
impose on families as well as the meaning of tions. A strong assessment is key to planning inter-
illness in the family system (McDaniel ventions for caregiving families (Zarit and Heid
et al. 1997) and thus is directly applicable to 2015). As with any family faced with signicant
work with later-life families who are most likely health problems, aging families require assessment
to seek help for health-related challenges. of the care recipient and caregiver and the broader
context for care (Zarit and Heid 2015).
Family interventions may also be helpful for
Family Therapy Research problems other than dementia, including elder
abuse within families and challenges experienced
The research literature on family therapy with aging by grandparents rearing grandchildren. Families of
families is limited. Reviews of the literature show a persons within other populations who require fam-
stable pattern of approximately 3% of articles in the ily support also benet from variations on these
major marriage and family journals that focus on interventions (e.g., traumatic brain injury, develop-
aging over recent decades (Lambert-Shute and mental disabilities, or serious mental illness).
Fruhauf 2011), a rate far lower than expected if Culturally diverse populations require strate-
research productivity matched the demographic gies that are aligned with cultural frameworks on
representation. Low rates of curriculum content on the roles of families and the acceptability of
aging within marital and family therapy programs nonfamily members understanding the inner
offer little opportunity for marriage and family ther- workings of the family system (Knight and
apy trainees to learn about practice with aging fam- Sayegh 2010). Furthermore, deliberate outreach
ilies (Barber and Lyness 2001). approaches are needed in order to reduce dispar-
Outcome research on interventions with aging ities in access to services.
families has focused heavily on families in care-
giving situations. Family-level counseling was a
key component of successful intervention for Future Directions
dementia caregivers in two programs that have a
substantial evidence base: the New York Univer- Today, family therapy for aging families is based
sity (NYU) Caregiver Intervention (Mittelman on the limited conceptual scholarship, with very
et al. 2004) and the multisite REACH little empirical data, primarily from the USA.
(Schulz et al. 2003) (Resources for Enhancing Looking forward, conceptual scholarship needs to
Family Therapy 873
elaborate the foundational constructs for adapting professionals in family therapy approaches to
family therapy interventions into strategies and work with older adults will add to the demand
protocols for particular problems faced by diverse for policy shifts in reimbursement structures for
family constellations. The elaboration of the con- family-level interventions in countries where
ceptual frameworks provides the foundation upon health and social service reimbursement regula-
which delity of interventions in outcome research tions constrain payments to particular family con-
can be investigated. Randomized clinical trials are stellations (e.g., care recipient must be present).
challenging to conduct with aging families due to
the heterogeneity in family structures, processes,
and problems, yet rigorous empirical investiga- Cross-References
tions need to inform providers about which inter-
ventions work for which populations in which Caregiving and Carer Stress F
settings to achieve which outcomes. Clinical Issues in Working with Older Adults
Descriptive research on help seeking by aging Intergenerational Relationships
families is also needed. Aging families are often
geographically dispersed, with highly varied
References
membership and member participation in inter-
ventions. When not recruited for research studies, Barber, C., & Lyness, K. P. (2001). Gerontology training in
exactly who seeks intervention, in what family marriage and family therapy accredited training program:
constellations, for which problems, and from Prevalence of aging issues and later-life family concerns.
what sources? Feasibility questions are also key: Gerontology and Geriatrics Education, 22, 112.
Belle, S. H., Burgio, L., Burns, R., Coon, D., Czaja, S. J.,
how are families engaged in intervention, by Gallagher-Thompson, D., & Zhang, S. (2006). Enhanc-
whom, for what purposes, with what value, to ing the quality of life of dementia caregivers from
what members of the family, and the service deliv- different ethnic or racial groups. Annals of Internal
ery network. How does integrated care offer Medicine, 145, 727738.
Boss, P. (2007). Ambiguous loss theory: Challenges for
opportunities for engaging families? scholars and practitioners. Family Relations, 56(2),
Cultural variation in the processes of engage- 105111.
ment (which families seek services in which set- Coon, D. W., Keaveny, M., Valverde, I. R., Dadvar, S., &
tings, and accept services from which types of Gallagher-Thompson, D. (2012). Evidence-based psy-
chological treatments for distress in family caregivers
providers) is critical to reduce the disparities in of older adults. In F. Scogin & A. Shah (Eds.), Making
access, services, and outcomes. Careful mapping evidence-based psychological treatments work with
of the types of problems that families bring to older adults (pp. 225284). Washington, DC: Ameri-
service settings and the interpersonal dynamics can Psychological Association.
Davey, A., & Takagi, E. (2013). Adulthood and aging in
within which those problems are embedded families. In G. W. Peterson & K. R. Bush (Eds.),
would lead the eld far toward understanding Handbook of marriage and the family (pp. 377399).
where interventions can be targeted effectively. New York: Springer.
Variations in families due to the nature of the Hargrave, T. D., & Anderson, W. T. (1992). Finishing well:
Aging and reparation in the intergenerational family.
stressors being experienced, communication New York: Brunner/Mazel.
styles and processes, and cultural contexts all Herr, J. J., & Weakland, J. H. (1979). Counseling elders
need far more investigation. The eld knows little and their families: Practical techniques for applied
about the cost to family members, older adults, or gerontology. New York: Springer.
Knight, B. G., & Sayegh, P. (2010). Cultural values and
society of the failure to support families with caregiving: The updated sociocultural stress and coping
interventions. model. The Journals of Gerontology: Series
Research is needed on training strategies for B. Psychological Sciences and Social Sciences, 65B,
building skill in geropsychologists to assess and 513.
Lambert-Shute, J., & Fruhauf, C. A. (2011). Aging issues:
intervene with aging families and with marriage Unanswered questions in marital and family therapy
and family therapists to address the distinctive literature. Journal of Marital and Family Therapy, 37,
challenges presented by aging families. Training 2736.
874 Filial Responsibility
McDaniel, S. H., Hepworth, J., & Doherty, W. J. (1997). Definition

The shared experience of illness. New York: Basic
Books.
McDaniel, S. H., Doherty, W. J., & Hepworth, J. (2013). Filial obligation is the obligation of children to
Medical family therapy and integrated care. Washing- defer to parental wishes and meet a parents
ton, DC: American Psychological Association. needs. This role not only includes contact with
McGoldrick, M., Gerson, R., & Petry, S. (2008). parents, having shared living arrangements, and
Genograms: Assessment and evaluation (3rd ed.).
New York: Norton. providing routine care, but also involves providing
Minuchin, S. (1974). Families and family therapy. Cam- physical, informational, and emotional support and
bridge, MA: Harvard University Press. nancial help, especially when parents reach old
Mittelman, M. S., Roth, D. L., Coon, D. W., & Haley, W. E. age. This responsibility also includes more compre-
(2004). Sustained benet of supportive intervention for
depressive symptoms in caregivers of patients with hensive efforts to ensure a parents safety, health,
Alzheimers disease. American Journal of Psychiatry, emotional well-being, sociability, and continued
161, 850856. integration in society through contact with the out-
Qualls, S. H. (1995). Clinical interventions with later life side world (Schorr 1960; Caro 2014; Whyte 2004).
families. In R. Blieszner & V. Bedford (Eds.), Hand-
book of aging and the family (pp. 474494). Westport:
Greenwood Press.
Qualls, S. H., & Williams, A. A. (2013). Caregiver family What Is Filial Responsibility?
therapy. Washington, DC: American Psychological
Association.
Schulz, R., Burgio, L., Burns, R., Eisdorfer, C., Gallagher- Families provide psychological, social, and physi-
Thompson, D., & Gitlin, L. N. (2003). Resources for cal resources to family members throughout their
Enhancing Alzheimers Caregiver Health (REACH): lives, and family is especially important in an older
Overview, site-specic outcomes, and future direc- adults later life. When physical, cognitive, or men-
tions. Gerontologist, 43, 514520.
Walsh, F. (2011). Normal family processes: Growing diver- tal functions decline, family can provide assistance
sity and complexity (4th ed.). New York: Guilford. with ADL (activities of daily living) and IADL
Zarit, S. H., & Heid, A. R. (2015). Assessment and treat- (instrumental activities of daily living); medical
ment of family caregivers. In P. A. Lichtenberg & and long-term care information; emotional, affec-
B. T. Mast (Eds.), APA handbook of clinical
geropsychology (Vol. 2, pp. 521551). Washington, tive, and psychological support; and nancial aid.
DC: American Psychological Association. The terms lial responsibility, lial norm, lial
piety, and lial obligations are often used inter-
changeably. Some studies use the term lial respon-
sibility expectations to reect what parents expect
Filial Responsibility from their offspring instead of the adult childrens
perspective or normative obligation beliefs.
Tomoko Wakui1 and Sheung-Tak Cheng2,3 Different theoretical approaches, including
1
Tokyo Metropolitan Institute of Gerontology, societal, familial, attitudinal, and psychological
Tokyo, Japan perspectives, shed light on the development and
2
Department of Health and Physical Education, maintenance of lial responsibility (Donoro and
The Education University of Hong Kong, Hong Sheehan 2001). From the societal perspective,
Kong, China cultural expectations and values inuence the
3
Department of Clinical Psychology, Norwich nature and expectations of parental care, and lial
Medical School, University of East Anglia, obligations are culturally regulated duties based
Norwich, UK on kinship. Familial perspectives refer to the fam-
ily norms that ensure that certain functions are
performed to maintain and protect the health and
Synonyms safety of older family members. These norms and
expectations vary across families, races, ethnici-
Filial norms; Filial obligation; Filial piety; Filial ties, socioeconomic statuses, and geographic
responsibility expectations locations. Attitudinal perspectives refer to the
Filial Responsibility 875
attitudes assumed by adult children toward normative obligations or societal beliefs

intergenerational support, interaction with par- (Ganong and Coleman 1999). Norms of lial
ents, visiting, and caregiving. Psychological responsibility refer to the recognized duties
perspectives posit lial responsibility as a devel- and obligations that dene the social role of
opmental stage or task confronting middle-aged adult children with respect to their aging par-
children. Filial responsibility is also viewed as a ents. These norms have been described as more
process in which children face a developmental than an expectation of ones own behavior
crisis called lial maturity (Marcoen 1995). Filial (Gans and Silverstein 2006). They are socially
maturity requires adult children to accept that their dened norms with regard to family obligations
aging parents are becoming weaker and more vul- and are also described as rights and duties that
nerable and are no longer reliable support resources. specify the ways in which any pair of
Adult children must renegotiate their relationship kin-related persons is expected to behave toward F
with their parents during this crisis before coming to each other (Rossi and Rossi 1990). From this
accept their responsibilities for parents. perspective, lial obligations or lial responsi-
Previous studies have universally sought to bility expectations are used to label normative
establish the rationale and motive for lial obliga- beliefs on adult childrens obligations to their
tion (Ganong and Coleman 1999). For instance, aging parents. Personal feelings or attitudes of
lial responsibility has been explained as a form obligation, however, are dened as the individ-
of altruism based on kinship ties, involving a uals self-perceived responsibilities. In this per-
genetic predisposition to care for those to spective, personal obligations are changeable
whom one is genetically related. A norm of beliefs, and they may change as the relationship
intergenerational transmission of reverence has and the contexts shift. Hence, a sense of lial
also been used to explain lial responsibility; responsibility may represent internalized norms
when children support their parents, they will like- of the society or may arise from personal affec-
wise receive support when they reach old age. tion for the parent and hence a genuine concern
A feeling of gratitude also explains why children for the parents welfare. In most cases, chil-
reciprocate their parents help; parents raised their drens lial responsibility has both elements.
children or helped their children establish their own A close examination of the general literature
families, and so children help their parents in return on lial responsibility, including lial obliga-
when needs arise. Filial attitudes may also be tion, lial piety, lial norms, and lial responsi-
inuenced by moral duty if one believes that bility expectations, may reveal that authors face
good people show lial responsibility. Children difculty conceptualizing lial responsibility
may also be motivated by emotional attachments and even simply understanding the expansive
to their aging parents. Intergenerational solidarity idea of that responsibility. The value has been
is another model that explains lial responsibility, dened in various ways depending on the
and this model proposes that children support their authors interests and the purposes of the stud-
aging parents because of familistic norms, affec- ies, resulting in a variety of measurements of
tion for parents, an opportunity structure that facil- lial responsibility (Sung 1995). The measure-
itates interactions, and perceptions that exchanges ments include individual feelings, attitudes
between generations have been reciprocal toward specic behaviors such as coresidence,
(Ganong and Coleman 1999). and the frequency of supportive behaviors
toward aging parents. Some are limited to
care-related behaviors toward parents with dis-
Personal Feelings of Obligation ability, and others include more comprehensive
and Normative Obligations support for protecting aging parents and defer-
ring to them. Consequently, systematic develop-
Filial responsibility includes an individuals ment of measurement for the different
sense of obligation to assist parents and components of lial obligation is needed.
Life Course, Age, Gender, Race, support to their aging parents due to the rising
and Cohort Variations in Filial cost of living, especially in urban areas. The grow-
Responsibility ing nancial pressure in many economies world-
wide put families in a difcult situation if they
Research has shown that lial obligations may have to provide support to older family members
be subject to change throughout the course of a and younger children at the same time (Aboderin
lifetime. In general, younger generations show 2004).
relatively stronger sense of lial obligation than On the other hand, an opposite cohort effect
older generations (Gans and Silverstein 2006), has been found in previous studies in that those
suggesting a weakening of normative beliefs born in the 1950s and 1960s showed stronger lial
with increasing age. One explanation is that the beliefs at midlife than their parents generation
younger generation, because of inexperience, tend (i.e., the later-born generation reported stronger
to hold idealistic views about caregiving without lial obligation than the earlier-born generation).
considering its practical implications and conse- This seemingly confusing may be explained by
quences. In contrast, older generations may have the fact that the pro-familism trend, which existed
already been exposed to these situations, either as simultaneously with a historical trend of weaken-
caregivers to their parents or because they have ing lial responsibility, peaked in 1970s and
needed help, and may also have observed these 1980s but diminished subsequently (Gans and
situations among their family or friends. Exposure Silverstein 2006).
to these experiences may change individuals per- Previous research has identied several per-
ceptions of lial piety (Gans and Silverstein sonal and family characteristics that explain vari-
2006). ations in lial responsibility (Burr and Mutchler
A lower expectation reduces the likelihood of 1999). Gender differences have been found, with
lial discrepancy (i.e., seeing childrens lial women consistently showing stronger beliefs of
behaviors as less than desirable), thus enhancing lial obligation than men across cultures. Gender
satisfaction with childrens support and avoiding also affects how responsibilities to aging parents
strain in the relationship (Cheng and Chan 2006). are realized. Women tend to provide more house-
As excessive demands may discourage children work and personal care for family members than
from offering support when future needs arise, men do. However, in Asian countries, it has been
lowering lial expectation is adaptive in the observed that older parents tend to prefer children
long run. of the same sex to perform care activities that
From a sociological perspective, moderniza- involve personal privacy such as bathing (Cheng
tion and aging theory has attempted to explain et al. 2015). Moreover, nancial assistance to
the decline of status and family support for older older parents is generally believed to be the
parents in developing as well as industrialized responsibility of adult sons.
countries. Modernization and aging theory Economic class is another factor that deter-
explains the decline as a result of extended fami- mines how lial piety is manifested. Middle-
lies giving way to the modern nuclear family, class families prefer the transfer of money and
which is related to urbanization and industrializa- goods rather than the provision of actual support,
tion. The emphasis on the bonds between young whereas the latter is preferred by the working
parents (i.e., adult children) and their dependent class. Consequently, working- and lower-class
children within the reduced family structure, ulti- families show stronger beliefs of lial obligation.
mately, causes a decreased willingness on the part Geographical area is another factor. Family ties
of adult children to provide for their aging parents are stronger among those living in rural areas,
(Aboderin 2004). The role of material constraints, who report a greater sense of lial responsibility
however, provides an alternative explanation, than those in more urbanized areas (Lee et al.
which emphasizes the incapacity of adult chil- 1994a). This may be a reection of geographical
dren, rather than unwillingness, to provide location; family members usually need to
cooperate with each other in economic produc- mobilize their resources to meet the needs. How
tion, such as on farm, in rural areas. When actual adult children fulll their roles as caregivers in the
in-kind help is needed, geographical proximity family is contingent on the family situation.
becomes an important consideration, with dis- Studying the whole family that includes all the
tance between parents and children found to be adult children, their interrelationships, and their
associated with the amount and type of help chil- relationships with aging parents (instead of just
dren provide (Rossi and Rossi 1990). Coresidence one parentchild dyad removed from the family
or geographical proximity increases help context) is needed to understand the behaviors
exchange. However, no type of help increases that help parents. For example, when a family
compensatory as the result of fewer in-kind help has multiple children, each sibling expects sup-
due to the greater distance. port to parents from the others. While siblings
Filial responsibility also varies by cultural may not provide care in exactly the same ways, F
background. In the United States, attachment to the distribution of lial responsibility is partly
the norm of lial responsibility is generally stron- determined by family structure, family history,
ger among minority families, including African- and affective ties (Matthews and Rosner 1988).
Americans, Hispanics, and Asian-Americans than Gender also determines the type of care adult
among non-Hispanic whites. African-Americans, children provide to their parents. Female siblings
for example, who have long struggled for eco- are more likely to be involved in providing care
nomic and social equality, may have developed than male siblings when there are both male and
extensive generational support networks among female siblings in a family, although sons do help
family and friends (Burr and Mutchler 1999). when asked. Sons may feel obliged to provide
Hispanics and Asian-Americans may experience care, as daughters do; however, some types of
similar circumstances as the African-Americans, caregiving tasks are more traditionally provided
and their traditional lial attitudes may be by females. As a result, female children are more
maintained by strong family ties, even though likely to engage in routine care (e.g., housework
impacts of immigration and acculturation, which and personal care) than male children. When male
likely undermine traditional values, cannot be children are the caretakers, their wives are also
overlooked. Yet, results were not always consis- usually involved, either in an assisting or a prin-
tent. A lower sense of lial obligation among cipal capacity, although fewer and fewer
African-Americans, compared with Caucasians, daughters-in-law are willing to assume the pri-
has also been reported (Hanson et al. 1983). mary caregiving role (Zhang et al. 2014; Cheng
Future research should recruit larger and more et al. 2013). In families with multiple children,
representative samples of different ethnic groups siblings share caregiving roles; some siblings
and examine the longer- and short-term impacts of coordinate routine care, whereas others are
immigration and acculturation on lial responsi- involved sporadically or help nancially. The
bility, in order to reach more denitive conclu- birth order of siblings is an important factor in
sions about cultural inuences and variations in care provision decisions in Asia and sometimes in
lial attitudes. Western countries; for example, the oldest sibling
may be expected to be involved in routine care
(Cheng and Chan 2006).
Filial Responsibility for Caregiving The effects of lial responsibility on family
Behavior caregiving have been examined in several studies.
On the one hand, lial responsibility may reduce
As parents age, lial responsibility increasingly the negative impacts of caregiving. Several stud-
emphasizes physical assistance, emotional sup- ies have reported that lial piety is related to a
port, and nancial support to address parents lower level of the caregiving burden (Khalaila and
needs. In particular, once parents are perceived Litwin 2011). On the other hand, a strong sense of
to have dependency needs, adult children lial obligation may place undue pressure on the
caregiver, leading to feelings of guilt when one simply reect that those who need help expect
seems to perform below self-expectations (Cheng more from adult children. Although parental
et al. 2014). The benets of lial responsibility expectations of lial responsibility appear to
may also differ according to culture (Funk vary by race, the ndings are far from being
et al. 2013), and more studies are required to conclusive. For example, whereas a study has
elucidate how cultural values moderate the rela- reported stronger lial responsibility expectations
tionship between lial piety and caregiving bur- among African-Americans than among Cauca-
den. It also has to be mentioned that the sians, even when sociodemographic, health, and
relationship between the attitude of lial respon- support factors were statistically controlled for
sibility and actual caregiving behavior is not clear. (Lee et al. 1998), others have found the reverse
Attitudes of lial responsibility are not necessarily or a lack of difference between the two ethnic
translated into enacted social support (e.g., groups (Lee et al. 1994b). Moreover, parents
personal care) (Chappell and Funk 2012). Unfor- expectations of lial obligation do not determine
tunately, research on the impact of lial responsi- the actual amount of support received from adult
bility on caregiving is limited by inconsistent children, although parents aid to children does
denitions and measurements of lial responsibil- positively affect the amount of aid adult children
ity. Thus, future research should clarify the rela- provide to their parents (Lee et al. 1994b).
tionships between feelings of lial responsibility,
adult childrens helping behaviors, the selection
and usage of public long-term care service, and Filial Responsibility in the West
caregivers mental health outcomes. and the East
In the United States and some other Western

Filial Responsibility Expectations countries, lial responsibility has become a grow-
ing issue in view of the number of older adults
Although the foregoing discussion has focused on with different degrees of dependency. Actual help
childrens lial attitude and its relationships with from offspring is typically provided only after the
caregiving behaviors, the role of older parents parents have ceased struggling to maintain their
lial responsibility expectations should not be independence and self-sufciency, as individuals
ignored. The concept of intergenerational solidar- taking responsibility for themselves are culturally
ity suggests that caregiving behaviors are more valued in these countries (Cheng and Chan 2006;
likely to be executed in an appropriate manner Silverstein et al. 1996). An ideology that people
when the two generations share similar lial are responsible for themselves and their depen-
responsibility norms and make decisions collec- dents is the result of a long history of autonomy
tively (Bengtson and Roberts 1991). Otherwise, orientation or individual rights in the United
there may be negative impacts on older adults States and elsewhere. Yet, ideas about individual-
personal well-being when their expectations are ism have existed alongside the assumption that
unrealistic or are not met by their children (Cheng women will be available, able, and willing to
and Chan 2006; Seelbach and Sauer 1977). assist and support family dependents in the house-
Some studies have focused on the perspective hold. However, this assumption is increasingly
of the older parents on lial responsibility expec- challenged due to changing family structure,
tations. These studies measure lial responsibility including the downsizing of the family, women
expectations as the extent of support to which working outside the home, or the reconstruction
aging parents feel entitled to receive from chil- of families through divorce or remarriage, uni-
dren. Women, unmarried, those in poorer health, formly closed relationships, or the unavailability
and those of lower economic class and education of family members to provide services for aging
are more likely to hold stronger lial responsibil- parents. How such changes in the family affect the
ity expectations (Lee et al. 1994a). This may provision of care to aging parents in the context of
the traditional emphasis on personal autonomy marital relations or reconstructed family networks
remains to be seen. erode familial responsibility and make family
In Asian societies, the concept of lial respon- members unavailable as a future resource for
sibility is commonly believed to derive from supporting aging parents.
Confucianism. Filial piety is a dominant idea in The traditionally important role of the family in
Confucian teachings and guides the relationship supporting aging parents has been well
between children and parents. This belief system documented, and even societies that have intro-
prescribes such behaviors as showing respect, duced long-term care programs retain this funda-
being obedient, and honoring or promoting the mental assumption. It is generally recognized that
public prestige of ones parents and ancestors. the role of the state in care provision will become
Filial piety, in the traditional sense, also empha- increasingly indispensable, along with the rapid
sizes the value of producing an heir, carrying on increase of the older adult population, but whether F
the family line, and caring for the parent, whether that will diminish family responsibility in provid-
healthy or sick (Cheng and Chan 2006). Children ing for the needs of older family members is
in Asian countries are taught from an early age to debatable. Nevertheless, the state can never
show courtesy and respect to older adults replace the familys support functions entirely, as
(Bengston et al. 2000). Having lial children is a certain support functions, such as conding and
source of pride and major support resource, so affectionate exchanges, cannot be reliably repli-
much so that childlessness poses a risk for cated by formal care services, though some of the
ill-being in Asian older adults (Cheng 2014). traditional family caregiving tasks could be
However, it has been argued that the value of lial replaced by the expansion of public services.
piety has been changing in Asian countries such However, current aging policies in most coun-
as China, Korea, and Japan because of industrial- tries face the limitation of the competing roles
ization and urbanization. Nevertheless, lial piety between family and states. Most studies support
has remained a core value, and rapidly aging the idea of complementarity rather than substitut-
societies have continued to rely on family support ing family with the state (Bengtson and
with fewer children to provide it. In this context, Lowenstein 2003). Complementarity is based on
formal social services and long-term care pro- the idea that the family would provide care by
grams are expanding to meet the needs that fam- using services when the service reduces the
ilies cannot provide. Thus, the undependability of familys burden. In this way, public services
family support has led to modications of the could contribute toward practical and material
methods used to support older adults. support so that the family can focus more on
emotional support. Additionally, the generous
pension system in some countries allow older
Filial Responsibility and Aging Policy adults to reciprocate via nancial support to the
younger generation, thus sustaining adult chil-
One major issue in societies with aging drens in-kind support to parents (Bengtson and
populations and declining fertility is how to pro- Lowenstein 2003). How state involvement
vide care for the elderly. The reduction in the changes concepts of lial piety and adult chil-
number of potential caregivers vis--vis the drens responsibility to parents remains to be seen.
increasing number of frail older adults places
strain on the states health care and support
resources. The combined effects of increased Conclusion
longevity, fewer kin ties, and womens social
advancement in rapidly aging societies lend Filial piety is a multidimensional concept. It
greater importance to the balance between family includes normative expectations, actual expecta-
and state responsibility in care provision for the tions at the personal level, and enacted behaviors.
aged (Cheng et al. 2015). However, weakened When it comes to expectations and normative
beliefs, there could be intergenerational differ- References

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882 Financial Planning for Retirement
retirement. The absence of adequate retirement Theoretical Frameworks

preparation poses a real concern (at the individual
as well as at the policy level) about individuals Research on retirement has adopted varying
ability to adequately nance their retirement, with approaches to understanding the dynamics of
the concomitant risk of falling into poverty in later when and why people retire, how they approach
life. Calls for concerted national efforts to foster preparing for their retirement, and how they adjust
long-term investments in income and old-age pen- to life in retirement. A recent review (Wang and
sion systems are being made amid concerns that Shi 2014) depicts three particular psychological
retirees across the globe run the risk of becoming models for understanding retirement: the temporal
poorer relative to the rest of society. process model encapsulating retirement planning,
retirement decision-making, and retirement tran-
sition and adjustment; the multilevel model of
Importance of Financial Planning retirement which institutionally embeds retire-
for Retirement ment and individual decisions and plans into a
social, cultural, and organizational milieu; and
Our understanding of retirement has been the resource model which focuses on retirement
informed by a well-developed body of research adjustment as a uctuating process dependent on a
evidence that has described retirement as an iden- range of individual resources. Resources here are
tiable stage during an individuals life cycle. understood to include an individuals total capa-
Much of the early research on retirement focused bility required to fulll a valued need, and there-
on the experience of transitioning out of the work- fore comprise a combination of income, health,
force and in particular on the loss of job role. This and social support resources (Kim and Moen
literature evolved to consider factors associated 2002; Donaldson et al. 2010). A more recent
with the physical and psychological effects of no six-factor resource model (Wang and Shultz
longer being employed and the attendant loss of 2010) extends beyond the resource categories of
structure, focus, purpose, and social connection physical (health), nancial (income), social
that many retirees wrestle with. More recent resources (relationships and activities) to include
research has focused attention on unearthing a emotional resources (positive emotions), cogni-
range of antecedent factors that may help predict tive resources (including self-esteem, mastery,
positive adjustment to retirement, and here, nan- and optimism), and motivational resources (goal
cial planning is recognized as one critical activity clarity and tenacity). Together, this resource per-
which may facilitate both a successful transition spective suggests that resources determine retire-
into retirement and satisfaction with ones retirement well-being in terms of retirement adjustment
ment lifestyle, and consequently, an activity that and retirement satisfaction. It is suggested (Heraty
facilitates successful aging in retirement. and McCarthy 2015) that this resource perspec-
While research has shown that higher income tive could also be used to explain preretirement
promotes better retirement adjustment, and that behavior. Since the accumulation (and depletion)
inadequate income and nancial stress are associ- of resources occurs across the life span, it is likely
ated with dissatisfaction and more negative retire- that the valence of particular resource types
ment experiences (Heraty and McCarthy 2015), it (at critical points in time) will be associated with
is almost a certainty that many retirees could have certain preretirement behaviors, including nan-
set aside savings while they were working but cial planning for retirement.
failed to do so. Given the centrality of nancial Focusing on nancial preparation for retire-
planning for adjustment and well-being in retirement here, we can trace the use of a range of
ment, there is a growing debate that the stumbling perspectives to understand the dynamics of indi-
block for many people is a widespread uncertainty vidual nancial planning behavior. Early work
about how to go about nancial planning for the (Ando and Modigliani 1963) used life cycle eco-
future. nomic theory to explain individuals as rational
economic maximizers who make decisions that explanatory power in helping to predict nancial
will afford them the highest net benet, and so planning behavior generally and nancial plan-
will make investment decisions that will yield ning for retirement specically. These will be
higher returns over the longer run. The theory of considered in turn.
planned behavior (Ajzen 1991), based on earlier Turning rst to demographic predictor vari-
work on reasoned action, has emerged as one of ables, it has been shown that the nature and
the most inuential frameworks for the study of amount of preparation people engage in changes
human action. This theory suggests that human (i.e., increases) as they draw nearer to the retire-
behavior is guided by three particular kinds of ment event (Hershey et al. 2007; Phua and
considerations: attitudes about the likely conse- McNally 2008). This life stage view of planning
quences or other attributes of the behavior can be understood through the Life Course Per-
(behavioral beliefs), attitudes about the normative spective (Elder 1995), which presents our lives as F
expectations of other people (normative beliefs), a series of key transition events, during which
and attitudes about the presence of factors that individuals reect on their own development and
may further or hinder performance of the behavior interpret their aging as they move across the life
(control beliefs). In consort, behavioral beliefs span. The closer one gets to retirement age, the
produce a favorable or unfavorable attitude more readily individuals can conceptualize them-
toward the behavior; normative beliefs result in selves as being retirees, and the more likely they
perceived social pressure or subjective norm; and are to plan for that more immediate life stage.
control beliefs give rise to perceived behavioral There is also some evidence (Moen et al. 2001)
control, which is the perceived ease or difculty of to suggest that those with higher overall levels of
performing the behavior. In general, the more education are more likely to engage in nancial
favorable the attitude and subjective norm is planning behavior. This may be related to better
toward a certain behavior and the greater the per- nancial literacy or higher incomes linked with
ceived behavioral control over that behavior, the better job opportunities overall.
stronger an individuals intention to perform the Gender appears to have some explanatory
behavior under consideration (Ajzen 1991). The power when it comes to predicting nancial plan-
relative importance of these three determinants is ning. Specically, men are more likely than
expected to vary across behaviors and situations. women to engage in nancial planning (Moen
This suggests that nancial planning for retire- et al. 2001; Glass and Kilpatrick 1998). Women
ment is a function of the degree to which people appear to have lower occupational pension cover-
feel they need to make adequate provision and age and lower pension income than men, due at
have the capability to make such provision now. least partially to interrupted work histories
A number of additional features have been iden- because of occupational segregation, childbirth,
tied in this regard and are explored next. child-rearing, and other caring responsibilities.
Given that women have a higher life expectancy
than men and so are more likely to have longer life
Predictors of Financial Planning in retirement, they may run a higher risk of
for Retirement income poverty in retirement.
Financial literacy has been consistently found
The possibility of being able to predict who will to be a strong predictor of nancial planning for
most likely engage in nancial planning behaviors retirement (Lusardi and Mitchell 2011). Although
is intuitively appealing at several different levels nancial knowledge and nancial literacy in gen-
and remains an area of considerable research eral populations is considered to be low (Lusardi
interest, especially in terms of retirement plan- and Mitchell 2011; Babiarz and Robb 2013), it
ning. To date, research has unearthed a com- becomes a key concern as individuals consider
bination of demographic, dispositional, and when and how to plan for their retirement. In
psychological variables that have some particular, a working knowledge of the basic
884 Financial Planning for Retirement
fundamentals of nance and economics, includ- There is some evidence to suggest that individuals
ing understanding compound interest, ination with higher levels of self-efcacy when it comes
risk, and risk diversication, provides individuals to saving for retirement are more likely to partic-
with some objective knowledge of what may be ipate in pension plans and for this to be
required for pension purposes. Evidence (Lusardi reinforcing (Lusardi and Mitchell 2011; Wiener
and Mitchell 2011) suggests those who actively and Doescher 2008).
plan for their retirement tend to arrive close to A link between individuals self-perceptions or
retirement with much higher wealth levels and self-concept and nancial planning behavior has
display higher nancial literacy than those who also been established (Hira and Mugenda 1999)
fail to plan. suggesting that nancial behaviors are as likely to
The temporal perspective explores how indi- be inuenced by sociopsychological needs as
viduals adopt a long or short time perspective practical and nancial ones. A recent study of
when considering nances. The ability to engage self-perceptions of aging as psychological predic-
in and commit to planning over a longer time tors of nancial planning behavor (Heraty and
perspective has been shown to explain variations McCarthy 2015)) among older workers (aged
in individual savings patterns (Van Dalen 50 year +) found that, after controlling for age,
et al. 2010), such that those who adopt a longer gender, employment contract type, and industry
time horizon are more likely to engage in active sector, self-perceptions of aging signicantly pre-
planning for their retirement. dict the likelihood of nancial planning behavior.
Risk tolerance has been found to partially Specically, older workers with more positive
explain nancial planning behavior. In this con- beliefs about their ability to control aspects of
text risk tolerance provides an indication of the their aging were more likely to nancially plan
amount of nancial uncertainty someone is will- for retirement, while those with a less consistent
ing to accept. Risk propensity is thus an individ- awareness of their own aging were less likely to
uals attitude and behavioral tendency toward plan for their retirement.
taking or avoiding risks. Financial risk tolerance
has been described as an individuals willingness
to engage in nancial behaviors in which the out- Future Directions
comes remain uncertain and possibly even nega-
tive (Grable et al. 2009); it has been shown that In the last 20 years, people all over the world have,
those with a higher propensity to plan for their on average, gained 6 years of life expectancy. This
retirement are more risk tolerant. Those who have increasing longevity means that people can expect
a tendency to avoid risk have been found to have to live for longer in retirement, and therefore, the
more conservative investment patterns in retire- pressure escalates to ensure that individuals can
ment savings and therefore lower income replace- create and maintain the means to ensure their
ment in retirement. There is also some indication nancial independence as they enter into retire-
of a lower preference for risk taking among ment. This is particularly important where the
women when compared with men. evidence shows that inadequate income predicts
Self-efcacy is a well-established construct in dissatisfaction and maladjustment in retirement.
the psychological literature that describes an indi- However, while recent work demonstrates the
viduals perception of his or her ability to perform signicance of a combination of demographic,
a certain behavior in response to a particular threat dispositional, and psychological predictors of
or challenge (Bandura 1977). In terms of nancial nancial planning behavior, there is still much to
planning, self-efcacy inuences the perceived be learned about the particular mechanisms that
amount of control and ability one feels when underlie nancial planning for retirement. Indeed,
considering and dealing with nancial plans since aging itself is characterized by large
the extent to which one feels capable of develop- interindividual variabililty, planning for retire-
ing plans and following through with them. ment is likely to vary as a function of many
contextual and psychological predispositions. The Ando, A., & Modigliani, F. (1963). The life cycle hypoth-
recognition that dispositional and psychological esis of savings: Aggregate implications and tests.
American Economic Review, 53, 5584.
factors may be more salient than several demo- Ajzen, I. (1991). The theory of planned behavior. Organi-
graphic variables should facilitate a more nuanced zational Behavior and Human Decision Processes,
understanding of how retirement itself may be 50(2), 179211.
internalized by the individual and allow for dif- Babiarz, P., & Robb, C. A. (2013). Financial literacy and
emergency saving. Journal of Family and Economic
ferent strategies to be employed to cater for indi- Issues, 35, 111.
vidual needs. In particular, they may help to Bandura, A. (1977). Self-efcacy: Toward a unifying the-
identify those at more risk of failing to adequately ory of behavioral change. Psychological Review, 84(2),
prepare for retirement and who consequently run 191215.
Donaldson, T., Earl, J. K., & Muratore, A. M. (2010).
the risk of pensioner or retiree poverty. This sug- Exploring the inuence of mastery, planning and con-
gests a key role for career councilors, organiza- ditions of workforce exit on retirement adjustment. F
tional psychologists, those who are responsible Journal of Vocational Behavior, 77, 279289.
for managing the transition into retirement, and Elder, G. H., Jr. (1995). The Life Course Paradigm: Social
change and individual development. In P. Moen,
those involved in designing training and develop- G. H. Elder Jr., & K. Lscher (Eds.), Examining lives
ment programs on career planning, pensions, and in context: Perspectives on the ecology of human devel-
retirement planning in the workplace. While opment (pp. 599618). Washington, DC: American
research continues to explore variations in nan- Psychological Association.
Glass, J. C., & Kilpatrick, B. B. (1998). Gender compari-
cial planning behaviors, there is an interest in sons of baby boomers and nancial preparation for
exploring patterns of behavior over time and on retirement. Educational Gerontology, 24, 719745.
a longitudinal basis. Such a dataset would allow Grable, J. E., Roszkowski, M. J., Joo, S.-H., ONeill, B., &
for a more patterned exploration of individual Lytton, R. H. (2009). A test of the relationship between
self-classied nancial risk-tolerance and investment
differences in nancial planning over time. It is risk-taking behavior. International Journal of Risk
suggested that our understanding of successful Assessment and Management, 12, 396419.
aging generally would benet considerably from Hershey, D. A., & Mowen, J. C. (2000). Psychological
the use of multiple data sets from longitudinal determinants of nancial preparedness for retirement.
The Gerontologist, 42(6), 687697.
research studies (Zacher 2015). Hershey, D. A., Jacobs-Lawson, J. M., McArdle, J. J., &
Echoing recent policy-level discourse in both Hamagami, A. (2007). Psychological foundations of
the European Union and in the United States on nancial planning for retirement. Journal of Adult
how to reform and restructure pension systems to Development, 14, 2636.
Heraty, N., & McCarthy, J. (2015). Unearthing psycholog-
facilitate retirement planning, it is suggested that ical predictors of nancial planning for retirement
research that makes comparisons across national among late career older workers: Do self-perceptions
contexts may be particularly helpful, with the of aging matter? Work, Aging & Retirement, 1(3),
potential to advance theory on nancial planning 274283.
Hira, T. K., & Mugenda, O. M. (1999). The relationships
for retirement, especially where different national between self-worth and nancial beliefs, behavior, and
pension systems are in operation. satisfaction. Journal of Family and Consumer Sciences
Education, 91(4), 7682.
Kim, J. E., & Moen, P. (2002). Retirement transitions,
Cross-References gender, and psychological well-being: A life-course,
ecological model. Journal of Gerontology: Psycholog-
Quality of Life in Older People ical Sciences, 57B, 212222.
Lusardi, A., & Mitchell, O. S. (2011). Financial literacy
Retirement Planning and Adjustment around the world: An overview. Journal of Pension
Economics and Finance, 10(4), 497508.
Moen, P., Kim, J. E., & Hofmeister, H. (2001). Couples
References work/retirement transitions, gender, and marital qual-
ity. Social Psychology Quarterly, 64, 5571.
Adams, G. A., & Rau, B. L. (2011). Putting off tomorrow Phua, V., & McNally, J. (2008). Men planning for retire-
to do what you want to do today: Planning for retirement: Changing meanings of preretirement planning.
ment. American Psychologist, 21(February), 113. Journal of Applied Gerontology, 27, 588608.
886 Five-COOP Study
Van Dalen, H. P., Henkens, K., & Hershey, D. A. (2010). among very old people. The 5 Country Oldest
Perceptions and expectations of pension savings ade- Old Project (5-COOP) aims to study these ques-
quacy: A comparative study of Dutch and American
workers. Aging and Society, 30, 731754. tions by pooling and comparing representative
Wang, M., & Shultz, K. (2010). Employee retirement: samples of subjects aged 100 years in Denmark,
A review and recommendations for future investiga- France, Japan (including Okinawa), Sweden, and
tion. Journal of Management, 36, 172206. Switzerland. A theoretical sample size of 1250
Wang, M., & Shi, J. (2014). Psychological research on
retirement. Annual Review of Psychology, 65, 209233. (5* 250) subjects has been initially set. In the
Wiener, J., & Doescher, T. (2008). A framework for pro- rst phase, each sample is analyzed at the country
moting retirement savings. The Journal of Consumer level. In the second phase, comparisons among
Affairs, 42, 137164. countries will be performed by merging the ve
Zacher, H. (2015). Successful aging at work. Work, Aging
and Retirement, 1, 425. standardized data sets. The 5-COOP project will
increase knowledge about the age trajectory of
several functional and geriatric conditions
(mobility, difculty in activities of daily living,
cognitive disorders) and about the relationships
Five-COOP Study between longevity and health (i.e., risk of depen-
dence as well as medical and social needs). This
Jean-Marie Robine understanding of mortality selection and health
INSERM & EPHE, Paris and Montpellier, France status will help us to plan care resources and
make better population forecasts.
Synonyms
Background
100 years old people; People having reached the
age of 100 years; Studies of centenarian people One of the most important changes in modern
societies is the (slow at rst and then rapid) emer-
gence of a new age group of population, the
Definition oldest-old people, beyond the usual elderly peo-
ple. Actually, very little is known about the nona-
The 5 Country Oldest Old Project (5-COOP) is the genarians and the centenarians. Their numbers
rst study which analyzes the relationship and their speed of accumulation greatly vary
between the level of mortality selection, the between developed countries even if life expec-
speed of accumulation of oldest old, and their tancies at birth are quite close. Even less is known
functional health status. The 5-COOP project about their health status. Data from Denmark sug-
will provide the prevalence of the main functional gest that the functional health of the Danish cen-
limitations and geriatric conditions, at the age of tenarians improved, especially for females,
100 years, in the ve geographic settings between 1995 and 2005, while data from Japan
(Denmark, France, Japan, Sweden, and Switzer- suggest a signicant decline in the functional
land) as well as the level of independence in health status of the Japanese centenarians since
activities of daily living. 1973. In Denmark life expectancy at age 65 for
The number of oldest old is increasing dramat- females increased from 17.8 in 1985 to 19.0 in
ically. However, the health status of nonagenar- 2005 (1.3 years increase), while the number of
ians and centenarians remains controversial: some females aged 100 years increased from 66 to
studies show that they are healthy, while others 233 (250% relative increase). In Japan, life
suggest relatively poor health. Few studies have expectancy at age 65 for females increased from
been able to explore how the mortality selection 19.0 in 1985 to 23.2 in 2005 (4.1 years increase),
and the rate of increase of the oldest old are while the number of females aged 100 years
associated with cognitive and physical status increased from 536 in 1985 to 7892 in 2005
Five-COOP Study 887
Female Centenarian Rates

160
140
120
100
80
60
40
20
0
France
Iceland
Spain
Italy
Switzerland
Sweden
England & Wales
Denmark
Norway
Netherlands
Belgium
Lithuania
Scotland
Portugal
Ireland
Germany
Austria
Finland
Estonia
Latvia
Poland
Luxemburg
Hungary
Slovakia
Czech Rep
Bulgaria
F
Five-COOP Study, Fig. 1 Centenarian rate in 26 European countries in 2006 (for females)
(1300% relative increase). This discrepancy in of people being interested and who volunteer to
longevity increase suggests the existence of a participate in scientic studies exploring their
trade-off between the level of mortality selection, extreme longevity. This often leads to the per-
the speed of accumulation of oldest old ception that centenarians are healthy people, free
(centenarians or nonagenarians), and their func- of most of the aging-related impairments, espe-
tional health status. cially of cognitive disorders. In reality, the few
In the mid-1990s, James Vaupel and Bernard representative or quasi-representative studies of
Jeune demonstrated that the number of centenar- nonagenarians and centenarians have demon-
ians had doubled on average every 10 years since strated that they are in relatively poor health with
1950 in half a dozen Western and Nordic Euro- a signicant proportion being bedridden and/or
pean countries (Vaupel and Jeune 1995), however, demented (Andersen-Ranberg et al. 2001).
starting with very small numbers. Since that time, According to Gondo and colleagues, less than
the increase in the number of centenarians has 2% of the Japanese centenarians are in perfect
been meticulously described in Japan (Robine health, dened as having no sensory problem, no
et al. 2003) and in a handful of European countries cognitive decit, and being fully independent in
such as Denmark (Jeune and Skytthe 2001), basic activities. Most of them should be consid-
England and Wales (Thatcher 2001), Belgium ered as frail or fragile people (Gondo et al. 2006),
(Poulain et al. 2001), France (Vallin and Mesl conrming a previous study showing that only 1%
2001), and Switzerland (Robine and Paccaud of Italian centenarians were fully independent
2005). More recently, Robine and Saito analyzed (Motta et al. 2005).
the emergence of the centenarians in 27 European
countries (Robine and Saito 2009), disclosing sig-
nicant differences in the probability of becoming Relationships Between the Mortality
centenarian: For instance, French females, born in Selection and the Health Status
1906, had an about ten times higher chance to of Centenarians
reach 100 years alive than Bulgarian females
(see Fig. 1). However, studies have also suggested that these
On the other hand, little is known on the health extremely old people were in relatively good
status of the oldest old, nonagenarians or cente- health 5 or 10 years before reaching age 100. For
narians. Most published nonagenarian and cente- instance, among the 1905 Danish cohort, the great
narian studies consist of small convenient samples majority of those who became centenarians in
888 Five-COOP Study
2005 were physically independent when they to better characterize the cognitive status of cen-
were 92 years old. As only a modest decline in tenarians. Indeed, the literature provides a very
the proportion of independent individuals has large range of prevalence of dementia among cen-
been observed within this cohort between the tenarians, from 50% to 100% (Calvert et al. 2006).
ages of 92 and 100 (Christensen et al. 2008), dif- The 5-COOP project has made an important effort
ferential mortality risk must have eliminated the in collecting comparable data on the cognitive
frailer and more dependent nonagenarians. functional status of the centenarians, and the
Indeed, nonagenarians and centenarians are merging of the ve samples should help to better
strongly selected people, and the current spectac- understand the dementia development in the very
ular increase in their numbers in many countries old. Combining information on health and cogni-
creates new concerns. For instance, in Japan the tion, the 5-COOP project will not only estimate
number of centenarians increased from 154 people how many centenarians suffer from dementia or
in 1963 to more than 50,000 in 2013. This phe- are dependent in the ve studied countries but will
nomenal increase is mainly due to a reduction in also estimate how many can be considered as frail
mortality above the age of 80 years. Are older or as successful according to various denitions of
people more likely to become centenarians frailty and successful aging (Nosraty et al. 2012).
because they are in better health or because they For all these objectives it is of the utmost
are better cared for or, more generally, because it importance to get representative, or at least
is much easier to survive today than before? In unbiased, samples of centenarians. This method-
Denmark, where the number of oldest-old people ological issue was central since the beginning
increased relatively slowly compared to most of of this study, and the 5-COOP project did the
the Western European countries, over the recent maximum of what was possible in each country
decades, the functional health status of female to maximize the representativeness of the
nonagenarians and centenarians signicantly samples. Data collection shows that not only it is
improved (Christensen et al. 2013; Engberg more and more difcult for the researchers
et al. 2008). On the other hand, in Japan, where to contact the oldest-old people and their
the number of centenarians has increased more families because of the newly established privacy
than threefold every decade since the 1970s, occa- and ethical rules, but even when the families
sional centenarian surveys demonstrated signi- are contacted the rate of participation in social
cant declines in the functional health status of surveys tends to decrease. For these reasons,
Japanese centenarians. For instance, the preva- the participation rates in 5-COOP are much
lence of female centenarians being bedridden lower, except in Sweden, than expected or expe-
increased from 21.9% in 1973 to 41.1% in 2000 rienced in previous surveys in Denmark and in
(Gondo 2008). The rst objective of the 5-COOP France.
project is to clarify the existence of a possible
trade-off between the speed of increase in num-
bers of oldest-old individuals and their functional The 5-COOP Consortium
health status.
The 5-COOP Study is a joint effort of the Institute
of Public Health, University of Southern Den-
The Cognitive Status of the Centenarian mark, in Odense in Denmark (http://www.sdu.
People dk); the research team Biodemography of Lon-
gevity and Vitality (INSERM U1198) of the
Besides specifying the prevalence of the main French National Institute of Health and Medical
functional limitations and geriatric conditions in Research in Montpellier in France (http://www.
the ve geographic settings as well as the level of inserm.fr); several Japanese research groups in
independence in activities of daily living, the sec- Keio University, Nihon University, Osaka Univer-
ond important objective of the 5-COOP project is sity, and Okinawa International University
Five-COOP Study 889
coordinated by the Advanced Research Institute quality of life). The second workshop focused on
for the Sciences and Humanities of Nihon Univer- the general study design and broadly discussed
sity in Tokyo (http://www.nihon-u.ac.jp/intldiv/ sample characteristics, questionnaires, physical
en/academics/graduates/arish.html) and the tests, clinical and cognitive assessment, blood sam-
School of Human Sciences of Osaka University ples, data management, statistical analysis, and eth-
(http://www.hus.osaka-u.ac.jp); the Aging ical issues. New working groups related to these
Research Center (ARC) of the Karolinska Insti- issues were set up. Eventually, the study protocol
tute at the Stockholm University (http://ki-su-arc. and the various questionnaires were ne tuned dur-
se); and the Department of Internal Medicine, ing the third workshop in the summer of 2010.
Rehabilitation and Geriatrics, Geneva University The data collection, funded by AXA Research
Hospital (http://www.hug-ge.ch) as well as the Fund, started in the different countries as soon as
Institute of Social and Preventive Medicine of each national team got the legal permission to start F
University Hospital of Lausanne (http://www. the 5-COOP project. This phase took a few
iumsp.ch/) in Switzerland. All together, these months in Denmark which was the rst country
ve economically advanced countries present starting to collect the data in May 2011, but it took
three levels of mortality selection among the more than 2 years in Switzerland which started to
oldest-old people which will allow the various collect the data only in August 2013. The three
research questions to be explored (Robine other countries started to collect the data in fall
et al. 2010). 2010. Getting legal permission involves up to
three kinds of committees as in France (privacy
committee, ethical committee, scientic commit-
The 5-COOP Timeline tee) and may have to be obtained from several
regional or local committees as in Switzerland. In
The 5-COOP project has been prepared through Demark, the 5-COOP survey beneted from the
three international workshops held in Geneva/ staff of the Danish oldest-old surveys, and several
Archamps in November 2008, August 2009, and specially trained interviewers collected the data
August 2010. At least two researchers per country throughout Denmark in a little bit more than
participated in each workshop. The rst workshop 1 year. In Sweden, the 5-COOP survey was
examined and discussed (i) the data availability embedded in the SWEOLD survey, and the data
(including ethical and privacy issues) in each was nationally collected by lay interviewers in
country, (ii) the historical background (i.e., health about 8 months. In Japan, the data was collected
events and transitions, diet, tobacco consumption, in ves prefectures evenly distributed from the
etc.), (iii) the more general sociodemographic north to the south of the archipelago: Aomori,
background, (iv) the functioning and disability Tokyo, Hyogo, Fukuoka, and Okinawa. The data
data, and (v) the usefulness of the clinical exam collection lasted about one year and a half in
and biomarkers. The opportunity of a common Japan. In France, the data was collected in only
study design were also discussed and working one region, namely, the Languedoc-Roussillon,
groups prepared proposals for the second work- by the same interviewer who visited during two
shop, as well as an Internet discussion on the years and a half each new centenarian who
general study design. The working groups exam- accepted to participate in the 5-COOP project. In
ined four main issues (i) functioning (mobility, Switzerland, the data was collected in Western
difculty in activities of daily living ADL, French-speaking cantons by trained nurses
vision and hearing, physical tests), (ii) geriatrics between August 2013 and December 2014.
(symptoms, fatigue, sleep, pain, mood; clinical The response rates in the 5-COOP project were
assessment; cognitive functioning and biomarkers), lower than expected, except in Sweden where the
(iii) health care consumption (health care and social participation was exceptionally high for a cente-
services uses), and (iv) demography and back- narian survey with a participation rate of 85.6%.
ground (sociology, economy, anthropology and The response rate reached only 30.4% and 31.6%
890 Five-COOP Study
Five-COOP Study, Table 1 The 5-COOP project: Summary of the data collection
Denmark France Japan Sweden Switzerland Together
Starting date 05/05/2011 01/09/2011 20/02/2012 24/10/2011 21/08/2013 05/05/2011
Ending date 05/07/2012 31/03/2014 26/09/2013 27/06/2012 31/12/2014 31/12/2014
Sample size 504 756 1067 360 428 3115
Interviews 251 211 337 274 168 1241
Deceased before 63 40 13 116
interviewed
Males 56 (22.3%) 36 (17.0%) 58 (17.2%) 75 (18.2%) 23 (13.7%) 248 (20.0%)
Females 195 (77.7%) 175 (83.0%) 279 (82.8%) 199 (81.8%) 145 (86.3%) 993 (80.0%)
Response rate* 49.8% 30.4% 31.6% 85.6% 40.5% 41.4%
*The response rate, in percentage, is obtained by dividing the number of conducted interviews by the number of
centenarians contacted minus the number of centenarians who deceased before the date of the interview
in France and Japan, respectively, 39.8% in Kruskal-Wallis nonparametric tests, ANOVAs and
Switzerland, and 49.8% in Denmark. The impact multiple regression). The rst elements to be com-
of these low response rates on the representative- pared are the participation rates, the reasons why
ness of the samples will be carefully studied (see data could not be collected, and the prevalence of
Table 1). geriatric conditions, including dementia and cog-
nitive disorders. The results of the 5-COOP project
will be publically available through scientic pub-
National and Common Analyses lications in several disciplines: anthropology,
demography, epidemiology, geriatrics/gerontol-
The 5-COOP samples are rst analyzed at the ogy, sociology, and public health.
national level before being merged in the common
5-COOP database at the Geneva University under
the responsibility of Franois Herrmann.
Cross-References
Data cleaning and national analyses started in
2013 for Denmark and Sweden. Various results
Health in Centenarians
have been already presented in several national
Hong Kong Centenarian Study
conferences. The 5-COOP project organized a
Korean Centenarian Study, Comprehensive
rst symposium at the annual scientic meeting
Approach for Human Longevity
of the Gerontological Society of America in Wash-
New England Centenarian Study (NECS)
ington in November 2014 (Robine and Saito
Okinawa Centenarian Study, Investigating
2014). Data cleaning is under way in France,
Healthy Aging among the Worlds Longest-
Japan, and Switzerland. All data will be merged
Lived People
in 2015 and the rst common analyses will follow.
Sydney Centenarian Study
A theoretical sample size of 1250 subjects had
Well-Being in Centenarians
been initially set for allowing the simultaneous
analysis of up to 125 variables in multiple regres-
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892 Flexible Work Arrangements
remain longer in paid work are increasingly rec- and also, through taxation, help to meet the costs
ognized in academic literature and in policy state- of an aging population. Older workers represent a
ments (Carnegie Trust 1993; OECD 2006). There valuable and often untapped source of increased
is considerable evidence that meaningful and productivity. Retaining older workers provides
appropriate work is benecial to the well-being important benets to employers in meeting skill
of older people. Remaining in or reentering the shortages; retaining the valuable skills, experi-
workforce has been shown to have a positive psy- ence, and the accumulated knowledge of older
chological impact for older people; the habits of workers; and encouraging them to act as mentors
work routine are benecial to a sense of well-being to younger staff. Firms which understand the
and accomplishment and are linked to self-worth as implications of aging will be better placed to
opposed to retirement, which may be viewed as a address its challenges. Population aging itself
non-role (Jaworski 2005; Hinterlong et al. 2007). can be a signicant source of innovation and
Remaining in paid work provides people with business opportunity.
social contact and mental stimulation. Productive If these benets are to be realized and potential
engagement can lead to improved health and disbenets are to be avoided, older people will
functioning for older people (Humphreys require appropriate and acceptable working
et al. 2003). Participation in paid work will also arrangements. Working conditions and experi-
increase the incomes of older people, improving ences can be very inuential in decisions about
their material well-being in later life. retirement from the paid workforce. These factors
There are potential disbenets to individuals. include the availability or otherwise of exible
Retirement is now seen as a legitimate phase of conditions, access to training to keep up and pre-
life, a right that has been earned by a lifetime of vent obsolescence of skills, the quality of working
paid work and something to look forward to conditions, feeling valued by employers and col-
(Phillipson 1998). Low levels of job satisfaction leagues, and having a sense of control and of
and low morale resulting from unsatisfactory purpose in their job (McNair et al. 2004; Smeaton
working conditions can lead to a deterioration of and McKay 2005).
both physical and psychological well-being, at a
time when age-related health problems may be
beginning to affect some people. The quality of Elements of Flexible Working
work in later life is therefore important. Arrangements
There are also social benets. Society would be
worse off if older people are not given the oppor- Alternative work options for older people are var-
tunity to contribute their skills and experience as ied. They include permanent or semipermanent
role models and mentors in workplaces, helping to part-time work, sometimes linked to phased
break down ageism and negative stereotypes. This retirement with reduced work schedules, prorated
will also contribute to intergenerational solidarity. salary, and benets; adjustment of responsibilities
A World Economic Forum report expresses this in and time at work (variations to starting and
terms of releasing accrued social capital among nishing times, number of hours worked per
the older population and facilitating the process day, and part-week, -month, or -year arrange-
of adaptation to an aging population (Biggs ments); contract work on a fee for service
et al. 2012). basis; relieving pools (for temporary full-time or
Demographic trends suggest that labor and part-time assignments); temporary or seasonal
skill shortages will become more pressing in the work, telecommuting, or home-based work
future as younger people entering the workforce (working a portion of usual hours regularly at
do not balance the numbers retiring. The economy home or working from home or an emergency or
therefore benets from having an economically casual basis); and extended leave and the
active older population, which will contribute to exible use of annual leave and long service
growth and the maintenance of living standards leave (Morrison 1986; Government of Western
Australia 2010). Self employment will provide the retirement and positive aging (Hegewisch 2009;
opportunity for exible work arrangements as Lissenburgh and Smeaton 2003; Australian Insti-
these can be set by the people themselves. tute of Management 2013). They allow older peo-
Such measures, which seek to enhance the ple to exercise a preference to sacrice income for
functional capacity of older workers, have been more control over their time without giving up
brought together in a process called reciprocal paid employment entirely. If older workers are
adaptation, in which the individual seeks to unable to balance their chosen activities, capabil-
establish a t with the job, and the job is mod- ities, and responsibilities with the demands of
ied to suit the needs, values, and interests of the their paid work, and employers are unwilling to
older worker (Yeatts et al. 2000). This aims to provide exibility, then many older workers may
produce job modications acceptable to both be forced out of the workforce, removing valuable
workers and employers in a win-win situation. skills and signicantly impacting on their future F
Work Ability, a concept developed in Finland, nancial and personal well-being.
aims to establish a proactive, preventative, and Deteriorating physical and mental health
holistic approach to working lives, through better among older people may be a barrier to continuing
age management at the enterprise level (Maltby workforce participation. Flexible work arrange-
2011). It balances personal factors health, skills, ments will be helpful to people with declining
motivation with the job and how it is managed physical stamina and sensory impediments, espe-
and aims to encourage employers to tailor work to cially when accompanied by ergonomic and other
individuals as they age. forms of job adaptation.
At the same time, the human resource approach Flexibility in work arrangements may also be
needs to shift from a depreciation model, where a required to accommodate caring responsibilities,
workers value to the organization peaks early in especially eldercare. As life expectancy increases,
their career, reaches a plateau mid-career, and then many working people in their 50s, 60s, and even
steadily declines (Yeatts et al. 2000). Instead, there 70s have living parents in their 80s and 90s, often
is benet in fostering a conservation model in in need of care and support. At the same time as
which all employees, regardless of age, are viewed governments are intensifying their efforts to delay
as renewable assets that can continue to yield a retirement, many are also pursuing policies to
high rate of return if they are adequately managed, support aging at home with reliance on informal
educated, and trained and given appropriate work- care. Middle-aged women are frequently expected
ing conditions. The similar age management and frequently do take on eldercare responsibili-
approach aims to ensure that workforce aging is ties and also caring for grandchildren and other
managed well and that age does not become a dependent relatives. Yet this group has increased
barrier to employment (Naegele and Walker its level of participation in paid work and this is
2006; Brooke and Taylor 2005). likely to continue. As a result they may experience
difculties in juggling caring responsibilities
with paid work. Lack of exibility in the work-
The Value and Importance of Flexible place may lead to their withdrawal as work
Work Arrangements becomes incompatible with the service they wish
to offer their families (Johnson 2011). Consider-
Flexible work arrangements are the means able attention has been focused on family-friendly
whereby older people can achieve their prefer- working arrangements with respect to child
ences and aspirations in the paid labor force and rearing, but less has been given to workers in
retain levels of participation which provide job midlife with other family responsibilities, ranging
satisfaction, income to supplement pensions and from social contact to personal care. Combining
superannuation, and time to pursue recreational paid employment with eldercare is an emerging
and family activities, including caring, and volun- issue in New Zealand and internationally (Phillips
tary work, which are seen as part of a healthy et al. 2002).
Flexible working conditions also provide a extending these provisions to all workers. In
means of phasing into retirement. Many older New Zealand, the Employment Relations
people switch to part-time work for a few years (Flexible Working Arrangements) Amendment
before full withdrawal from the paid labor Act came into effect in 2008. This provides
force. While most people still expect to retire, an employees, who have worked for the same
abrupt break between working full time and not employer for at least 6 months and are responsible
working at all is becoming much less likely. for the care of any person, with the right to request
Rather than seeing retirement as a one-off con- exible working arrangements (i.e., a variation to
cept, it would be more productive to see people their hours of work, days of work, or place of
negotiating moves in and out of work, not related work). After a review, these provisions are being
to chronological age, but based on their skills, extended to all employees. Employers can refuse a
abilities, and life experiences (Allen et al. 2004). request on reasonable business grounds, which
This might develop into a transitional decade, include inability to reorganize work among
during which people select how and when they existing staff or to recruit additional staff, the
wish to retire, with the option of gradually wind- burden of additional costs, and/or a detrimental
ing down by adopting more exible work effect on ability to meet customer demand.
practices. Reviews of exible working arrangements in
International research suggests that the major- Australia and New Zealand found that the pro-
ity of workers would prefer a gradual transition to visions were working effectively and were being
retirement and that there are benets for both taken seriously by employers and employees, and
workers and employers (Department of Labour the vast majority of requests were being granted
2011). For workers, reduced participation in paid (Department of Labour 2011). In New Zealand the
work allows them time to pursue leisure and majority of employee-reported requests were
family activities and adjust and prepare for the accepted by employers without recourse to the
nancial changes which retirement brings. For formal legislative process, but only 56% of
employers, retaining older workers allows valued requests related to caring responsibilities; a sig-
knowledge and experience to remain with the rm nicant proportion were for other reasons. The
and be used to mentor and train less-experienced conclusion was that employers and employees
workers. have been independently developing formal and
informal exible work arrangements that suit their
particular needs. However, even where legislation
Policy Initiatives on Flexible Work exists, many workers are not aware of their rights
Arrangements to request exible work arrangements and
employers also are often not well informed.
Facilitating participation in the labor market by Awareness appears to be higher in larger busi-
people with caring responsibilities has been a nesses and among higher-income employees.
focus of policies relating to exible work, but
other considerations include providing opportuni-
ties for employees to pursue education and train- The Availability of Flexible Work
ing, assisting older workers to transition to Arrangements
retirement, and increasing labor force participa-
tion through part-time work. Flexible work practices are already widespread in
Several countries, including New Zealand, many countries and also are very popular with
Australia, the UK, and Northern Ireland, have older workers. As already noted, a high proportion
legislation providing the right to request exi- of organizations, in New Zealand and elsewhere,
ble work arrangements. This legislation may con- provide exible work arrangements in some form
ne the right to employees with caring for all employees (Hudson 2004). Such practices
responsibilities, although some countries are are more likely to be offered in large businesses
than smaller rms. In New Zealand, they are most coworkers, leading to guilt about reducing
prevalent in government agencies, professional working time.
services, and IT rms, and manufacturing, Recent surveys in New Zealand, the UK, and
construction, property, engineering, and whole- Northern Ireland show that employers widely per-
sale distribution rms are the least likely to offer ceive exibility as delivering positive business
exibility. It is more common for employees benets (Heathrose Research 2010). Their expe-
working in highly skilled occupations to have rience in this area has been largely unproblematic;
exible hours than those working in other few have encountered the costs, increased litiga-
types of occupations and employees with no tion, or ood of requests anticipated prior to the
qualications. introduction of exible working legislation. Ben-
Research shows that exible working arrange- ets include better employee retention, reduced
ments are being taken up by both men and turnover, improved recruitment through widening F
women, and a signicant proportion of these the talent pool, increased employee motivation
employees have no caring responsibilities. Bene- and loyalty, and improved productivity and
ts to employees arising from better work-life protability.
balance include higher levels of motivation and Support for exible work arrangements was
commitment to their jobs, lower levels of stress also expressed in recent research among New
and higher productivity, better relationships with Zealand employers and representatives of public
their families, and better health outcomes and private sector organizations involved with
(Heathrose Research 2010). workforce issues (Davey 2015). The unanimous
opinion was that exibility could be consistent
with business efciency and could pay a dividend
Assessment of Flexible Working in employee engagement and loyalty and being
Arrangements seen as an employer of choice. There was
acknowledgment, however, that exibility might
A gradual reduction in hours over a number of not be appropriate in all jobs, such as assembly
years leading up to retirement is the most pre- line, retail, reception, and hospital work. Part-time
ferred exible work arrangement among older work may not be easy to t in to schedules that
workers, and one of the most common barriers require eldwork and teamwork. In some cases,
to working beyond the age of eligibility for super- respondents reported that senior management
annuation/pensions is the inability to access may resist moves toward exibility, at least on a
greater exibility in work arrangements. But formalized basis. If greater exibility was
despite these demonstrated benets, there are bar- extended only to senior workers, this could bring
riers to their extension. Some groups of workers accusations of unfairness from other staff who do
may have little or no access to exible work due to not have such freedom.
limited bargaining power, the culture of the work- Some managers may fear that exible working
place, and operational constraints within some conditions which suit the preferences of older
workplaces (EEO Trust 2006; Department of people may not be consistent with business ef-
Labour 2006). There may also be attitudinal bar- ciency. For example, part-time workers can
riers to accessing exible working arrangements increase administration costs and exible working
on the part of workers themselves. These include can be harder to manage. Nevertheless, problems
perceptions that using exible work will hamper with exibility can be tackled; increased over-
career progression and involve a reduction in heads related to part-time workers can be over-
income; that exibility is only available to highly come with creative thought using hot desks or
valued employees in particular occupations or off-site work. Work from home can save the cost
industries; and that workplace cultures were not of ofce space. One respondent commented:
supportive, including the attitudes of managers or Having the best person 80% of time is often
employers and the views of colleagues and better than having another 100%.
Conclusions Biggs, S., Carstensen, L., & Hogan, P. (2012). Social

capital, lifelong learning and social innovation. In
J. Beard, S. Biggs, D. Bloom, L. Fried, P. Hogan,
The social, economic, and individual benets of A. Kalache, & S. Olshansky (Eds.), Population ageing:
extended participation in the paid workforce Peril or promise (pp. 3941). Geneva: World Eco-
among older people are now widely accepted, nomic Forum.
and in many countries policies are being promul- Brooke, L., & Taylor, P. (2005). Older workers and
employment: Managing age relations. Ageing and
gated to encourage this trend. There are a wide Society, 25, 415429.
range of work arrangements which can be applied Carnegie Trust. (1993). Life, work and livelihood in the
to facilitate older peoples working arrangements third age. Research paper: Carnegie inquiry into the
while taking into account the possibility of third age. Dunfermline: Carnegie UK Trust.
Davey, J. (2015). Paid employment. In P. Koopman-
reduced physical or sensory capacity and allowing Boyden, M. Cameron, J. Davey, & M. Richardson
them to participate and contribute in other areas of (Eds.), Making active ageing a reality: Maximising
life, including voluntary work, family activities participation and contribution by older people
(and informal care), recreation, and leisure. Flex- (pp. 4481). Hamilton: University of Waikato.
Department of Labour. (2006). Quality exible work:
ible work arrangements can facilitate the transi- Increasing availability and take up in New
tion to retirement and the adjustments social and Zealand. Discussion paper. Wellington: Department
nancial which this entails. of Labour.
Initiatives to encourage and facilitate exible Department of Labour. (2011). The ndings of the review of
Part 6AA of the Employment Relations Act 2000.
working conditions may come from government Wellington: Department of Labour.
policies. These include legislation on access to EEO Trust. (2006). Equal employment opportunities trust
exible work, employment regulations and agree- work and age survey report. Auckland: Equal Employ-
ments, antidiscrimination law, and provisions ment Opportunities Trust.
Government of Western Australia. (2010). A guide to man-
around retirement income support (e.g., whether aging an ageing workforce: Maximising the experience
a work test is applied for pension entitlement). of mature-age workers through modern employment
However, the main decisions about allowing ex- practices. Perth: Public Sector Commission, Govern-
ible work arrangements are made at the individual ment of Western Australia.
Heathrose Research. (2010). Report to the National Advi-
business level. Therefore the attitudes of man- sory Council on the Employment of Women. Welling-
agers and employers and the prevailing business ton: Heathrose Research.
culture are of fundamental importance in whether Hegewisch, A. (2009). Flexible working policies:
or not exible work arrangements for older people A comparative review. Equality and Human Rights
Commission Research report series, Manchester.
are offered and supported. Hinterlong, J., Morrow-Howell, N., & Rozario, P. (2007).
Productive engagement and late life physical and men-
tal health: Findings from a nationally representative
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population Implications for employers. Australia/
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Jaworski, B. (2005). Aging workers, changing value.
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Maltby, T. (2011). Extending working lives? Employabil-
ity, work ability and better quality working lives. Social The Fordham Centenarian Study is a population-
Policy and Society, 10(3), 299308. based study which aims at describing life circum-
McNair, S., Flynn, M., Owen, L., Humphreys, C., & stances in very advanced age and characteristics
Woodeld, S. (2004). Changing work in later life: of near-centenarians and centenarians. A mixed-
A study of job transitions. Guildford: Centre for
Research into the Older Workforce, University of methods designed was used to investigate individ-
Surrey. uals aged 95107 years old with respect to person
Morrison, M. (1986). Work and retirement in an older characteristics (e.g., health, cognition, well-being,
society. In A. Pifer & L. Bronte (Eds.), Our aging psychological strengths), their immediate social
society: Paradox and promise (pp. 341365). New
York: W.W. Norton. network (e.g., family and friends, informal sup-
Naegele, G., & Walker, A. (2006). A guide to good practice port, relationship to advanced age children), and F
in age management. Dublin: European Foundation for societal-cultural features that may play a role for
the Improvement of Living and Working Conditions. successful aging in these very old individuals.
OECD. (2006). Live longer, work longer. Paris: Organisa-
tion for Economic Cooperation and Development. Findings conrm poor health conditions and lim-
Phillips, J., Bernard, M., & Chittenden, M. (2002). Jug- ited social networks, while maintaining rather
gling work and care: The experiences of working high levels of mental health and well-being.
carers of older adults. York: Joseph Rowntree Future analysis comparing the Fordham Centenar-
Foundation.
Phillipson, C. (1998). Changing work and retirement: ian Study data with data from the Second Heidel-
Older workers, discrimination and the labour market. berg Centenarian Study and the Oporto
In M. Bernard & J. Phillips (Eds.), The social policy of Centenarian Study will help to better understand
old age: Moving into the 21st century (pp. 7692). specic vs. global mechanisms of successful
London: Centre for Policy on Ageing.
Smeaton, D., & McKay, S. (2005). Working past state aging.
pension age: Quantitative analysis. London: Depart-
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adaptation to a changing workplace: Employment
issues for the 21st century. Educational Gerontology,
26, 565582. Living an exceptionally long life is wished for by
many individuals, and this wish is likely to
become reality for more and more people. The
older adult population is growing rapidly in indus-
trialized countries around the world, as life expec-
Fordham Centenarian Study tancy increases due to advances in medicine and
healthier lifestyle, as well as the aging of large
Daniela S. Jopp1,2 and Stephanie Hicks3 cohorts such as the baby boomers (Christensen
1
Institute of Psychology, University of Lausanne, et al. 2009; Ortman et al. 2014; Robine
Lausanne, Switzerland et al. 2010). The group of the population that
2
Swiss Centre of Competence in Research shows the strongest increase is very old individ-
LIVES, Overcoming Vulnerability: Life Course uals. In the USA, for example, the number of
Perspectives, Lausanne, Switzerland centenarians increased by 66% between 1980
3
Psychology Department, Fordham University, and 2010, resulting in a total of 53,364 individuals
Bronx, NY, USA aged 100 or older, as documented by the 2010
CENSUS (Meyer 2012). This trend will continue
and is likely to accelerate, resulting in population
Synonyms projections of between 600,000 and 1 million cen-
tenarians in the USA by 2050. Given that half
Centenarians; New York oldest-old; Population- of all children born after the year 2000 are
based; Successful aging expected to reach their 100th birthday
898 Fordham Centenarian Study
(Christensen et al. 2009), this global trend will lived; (b) to determine support needs of the very
change the life perspectives in many countries old and create a knowledge base that will help to
and poses various challenges at the individual, develop well-suited care and service structures.
family, and societal levels. To better evaluate the As very old age comes with unique challenges
challenges to be expected and to plan for the and service needs, identifying those is essential
future, it is important to learn more about what for the individual, the family, and society in plan-
characterizes life at age 100. ning for the future; (c) to determine individual,
Despite currently increasing numbers and societal, and cultural characteristics that contrib-
future projections, centenarians represent an ute to successful aging and enhance and foster
understudied and underserved group to date. As those in current and future generations.
most centenarian studies have concentrated on The Fordham Centenarian Study has a key
demographic, medical, and genetic research ques- interest in identifying personal factors that may
tions, with the overarching aim of enhancing the enable successful aging and a specic focus on
understanding of what may be responsible for psychological characteristics such as psychologi-
increase in life expectancy and what contributes cal strengths (e.g., self-efcacy, optimistic out-
to exceptional longevity, only few studies have look, meaning in life, and will to live). At the
addressed what it actually means to live to age same time, expanding on classic approaches of
100 (Jopp et al. in press a, b). As a consequence, successful aging and in line with lay perspectives
views on very old age described in the media are on successful aging (e.g., Jopp et al. 2015), the
rarely realistic but polarizing: individuals of very Fordham Centenarian Study considers the imme-
advanced age are either depicted very positively, diate social context (e.g., social network and
by showing for example outstanding centenarian informal support system) as well as the wider
and supercentenarian individuals who are aging societal and cultural context (e.g., laws and regu-
extremely well, or they are depicted very nega- lations as well as attitudes towards aging) as
tively, for instance by describing a tsunami of important features that shape life in younger
very old people who, bedridden and plagued by years but particularly in very old age. It is our
dementia, endanger our social welfare systems. In long-term goal to ascertain the person factors,
the absence of a solid empirical knowledge base, social network characteristics, and cultural
life in very old age is still poorly understood in aspects that are of key importance for quality of
terms of its unique characteristics and challenges. life in very advanced age and to examine their
Moreover, as reaching very old age becomes a interplay to better understand mechanisms of suc-
topic of personal interest for more and more indi- cessful aging. This will be a major step toward
viduals, questions about quality of life at this age developing prevention and intervention programs
urgently need to be addressed. Also, as those that enable more very old individuals and their
demographic changes do not only affect the indi- families to age successfully.
vidual, but their families and societies, additional
challenges arise. To handle these successfully,
information about care needs is important in Methodology
order to develop support structures that could
enable the very old to maintain their independence Participants. Participants included individuals
for as long as possible. aged 95 years and older from the three most
The Fordham Centenarian Study has three key diverse boroughs of New York City (i.e., Manhat-
goals: (a) to create a realistic, more balanced, and tan, Brooklyn, the Bronx). Participants did not
more differentiated picture of very old age. Fol- need to be fully cognitively intact to be eligible
lowing a population-based recruitment approach, for the study, but they had to be able to reliably
it aimed at gaining representative information respond to questions about themselves, as the
about the limitations to be faced in very old age, studys goal was to capture the very olds experi-
as well as the strengths possessed by the very long ence of their very advanced age, well-being, and
depressive symptoms, as well as other psycholog- question for him/her when read by the interviewer.
ical constructs. In order to ensure a population We also checked items for double negations and
basis of the study, recruitment was primarily other complicated formulations were replaced.
accomplished by inviting individuals aged We furthermore reduced the answering options
95 years and older for study participation who to a maximum of 5, as more options caused dif-
were listed in the New York Voters Registry. culty to the centenarians. The open answers were
The recruitment approach resulted in 103 inter- later coded using clustering or open coding tech-
views, of which 95 were included in the study niques usually applied in qualitative research.
(80% of the total sample). As this main recruitment In line with our key research questions, the
approach made it slightly more difcult to reach following areas of functioning were investigated:
individuals living in nursing homes, we recruited basic demographic aspects (including life
an additional 23 participants via ve collaborating achievement such as education and work history, F
health care providers. Finally, one additional cen- marital status), health (including common dis-
tenarian was recruited by word of mouth. The nal eases, subjective health, sensory impairment,
sample consisted of 119 adults aged 95107 years pain, activities of daily living, walking speed,
(Mage = 99.25 years; 78% females), including and grip strength), cognitive status (including a
57 near-centenarians (9599 years old; MAge = shortened version of the Mini-Mental State Exam-
97.11; 71.9% females) and 62 centenarians ination, Folstein et al. 1975; and the Global Dete-
(100107 years old; MAge = 101.22; 83.9% rioration Scale; Reisberg et al. 1982), social
females). Of these, 92 (77.3%) were White, network and living arrangements (including
23 (19.3%) were Black, and 4 (3.4%) were social contact, informal support, loneliness, living
Hispanic. Thus, the Fordham Centenarian Study in a private household, living with whom), well-
included similar proportions of both gender and being aspects (including life satisfaction, happi-
ethnic groups as documented within the US CEN- ness, depressive symptoms), and psychological
SUS for the city of New York (Meyer 2012). strengths (including self-efcacy, optimistic
Measures. The assessment included a compre- outlook, meaning in life, will to live, self-
hensive interview, for which a mixed methods determination, coping, and life management strat-
approach was used, combining qualitative and egies). Key constructs that were assessed with
quantitative data collection techniques. Speci- open coding procedures were everyday chal-
cally, both standard questionnaires with a Likert- lenges, relationship between centenarians and
type answering format and questions with an open their advanced age children, and centenarians
answering format were applied; the former views about what had contributed to their success-
allowing to compare the centenarians with youn- ful aging.
ger age groups and the latter allowing the very old Procedures. Participants were interviewed in
to describe less investigated aspects in their own person at their residence (private home or institu-
words. In line with our experience in prior studies tion). Specically, interviews were divided into
and during the studys pilot phase, we adjusted the two sessions of 1.5 h each to minimize fatigue.
measures to reduce their cognitive load as much as Study procedures were approved by three institu-
possible. Due to age-related reduction in sensory tional review boards. Data collection was
capacity and potential restriction in cognitive conducted between 2010 and 2012.
function, all centenarians were interviewed in
person at their home by well-trained interviewers.
To facilitate the interview procedures, we Results
reformulated statement items often used in self-
report questionnaires (I feel satised with my Health and Physical Functioning
life) into questions (Do you feel satised with Whether centenarians are prime examples of suc-
your life?) to ensure that the centenarian under- cessful aging has been long discussed, given that
stood right away that an item was meant as a they have outlived almost all their peers. Yet, life
at age 100 seems nevertheless characterized by Nevertheless, regarding specic PADL activities,
illness. In line with ndings from prior studies about half of the sample mentioned having dif-
on health in very old age, many Fordham cente- culty in taking a bath (55%), getting dressed (52%),
narians were affected by multimorbidity, and moving in and out of bed (48%). Centenarians
reporting an average of 4.85 (SD = 2.32) medical had increased levels of impairment in instrumental
conditions (Jopp and Hicks 2016). The health activities of daily living, which were slightly more
issue reported most often, mentioned by over impaired, with an average score of 8.89 (SD = 4.05)
80% of the sample, was sensory (vision, hearing) from the IADL scale; however, 17% of the sample
conditions. This was also the top one condition reported no difculty. The instrumental activities
mentioned in the Second Heidelberg Centenarian causing difculty most often were light housework
Study (Jopp et al. 2016d), which is notable as (77%), shopping (76%), preparing meals (65%),
sensory issues can be expected to have a high and getting around/traveling (64%;
prevalence at this age, but they have received Jopp et al. 2016c). Compared to prior studies, levels
limited attention in prior studies on health in of PADL and IADL in our sample were higher than
centenarians. Heart/circulation conditions and previously reported.
muscular-skeletal conditions were both men- Sensory impairments were assessed via self-
tioned by about two thirds of the sample, rated vision and hearing capacity. Participants
representing the second highest prevalence. rated each on a 5-point scale ranging from
Mobility issues were on rank 4 with a slightly 1 (Poor) to 5 (Excellent). Many centenarians
lower prevalence. In the Second Heidelberg Cen- reported impairments in vision and hearing: spe-
tenarian Study, we had, however, found mobility cically, 17% indicated to have only poor or fair
issues to be the condition mentioned second most ability for vision and 18% had poor or fair ability
often (Jopp et al. 2016d). Possibly, the slightly for hearing, while 38% had poor or fair function in
younger age of the Fordham Centenarian sample both vision and hearing concurrently (Cimarolli
is responsible for this nding. Another notable and Jopp 2014). Thus, while vision and hearing
difference was the nearly doubled prevalence of impairment only were reported at similar rates as
conditions related to the respiratory system in the in younger samples, prevalence of dual sensory
Fordham sample compared to the Second Heidel- impairment was particularly high in this age group
berg Centenarian sample, which was particularly and substantially higher than in younger ages
due to reports of pneumonia (Jopp and Hicks (compared to, for example, 20% of a sample
2016). with average age of 78 years, Brennan
Despite high multimorbidity, self-rated health et al. 2005). At the same time, it is notable that
was fairly high, with 67% reporting their health as more than a quarter of the sample reported no
good or excellent. Centenarians also showed good sensory impairments, which was an unexpected
functional health, as indicated by low levels of nding that deserves future attention. Conrming
restriction in personal activities of daily living. the importance of vision and hearing for everyday
Functional health was assessed with reported dif- functioning, vision impairment only and dual sen-
culty in seven personal activities of daily living sory impairment were found to be strong predic-
(PADL) and seven instrumental activities of daily tors of functional disability and these effects
living (IADL) as measured within the Older Amer- remained signicant when controlling for depres-
icans Resources and Services Multidimensional sive symptomatology, health limiting desired
Functional Assessment Questionnaire (Fillenbaum activities, and living in a nursing home.
1988). Specically, ndings indicate that functional Explaining independent amounts of variance in
capacity was high for PADLs, with an average of functional ability, namely, 6.6% (vision impair-
10.41 (SD = 3.67) out of 14 from the PADL scale. ment only) and 4.8% (dual sensory impairment),
Twenty-eight percent of the sample had the highest indicates that these impairments have a substantial
score of 14, 21% had difculty with only 1 activity, role in determining the extent to which a person
and 19% had difculty with only two activities. is able to live independently. Notably, these
impairments had about the same size effects as 16.45 (SD = 4.04) out of 21, indicating high levels
other factors (e.g., living in an institution or of functioning. Although study participation had
depressive symptoms), yet, the importance of sen- not been possible with a shortened MMSE score of
sory impairment is often overlooked. Findings 4 or less, in order to ensure that centenarians were
further suggest that individuals with dual sensory able to reliably talk about their lives and inform
impairment had the highest level of depressive about subjective well-being and psychological
symptoms, compared to the other impairment strengths, there was still substantial variability as
groups. indicated by a range of 521. Based on the observer
An additional set of analyses revealed which rating of the Global Deterioration Scale (1 = no
specic basic or instrumental activities of daily memory decit evident from interview, to 7 = very
living were inuenced by vision or hearing severe cognitive decline; Reisberg et al. 1982), par-
impairment. Specically, vision impairment had ticipants had a mean score of 1.44 (SD = .9, range: F
a signicant inuence on taking care of ones 37), denoting only little memory impairment.
appearance, eating, taking medications, writing Ninety-three individuals (93%) had no or little
checks, and using a telephone, while hearing cognitive limitations (scores of 1 to 3), and seven
impairment had a signicant inuence on travel- individuals (7%) had moderate limitations (scores
ling only (controlling for age, gender, minority of 4 and 5), which indicates that the sample was
status, cognitive function, depression, and the somewhat more positively selected, but in line with
other [vision or auditory] impairment; Cimarolli our study goal of assessing reliable self-reports
et al. 2016). Thus, vision impairment seems to among this age group.
have an effect on more specic activities com-
pared to hearing, which is likely to be related to Living Arrangements, Marital Status,
the nature of these activities and the extent to and Social Network and Support
which visual and auditory senses are involved in Despite the substantial health issues mentioned
accomplishing them successfully. above, a large majority of the Fordham centenar-
ian study participants lived in the community
Education and Cognitive Functioning (74%), while only 26% lived in an institution
Participants of the Fordham Centenarian Study (i.e., 6% assisted living, 19% nursing home, and
were relatively well educated, with one third 1% other). Of those living in the community, 66%
(n = 40, 34%) having a bachelors or higher lived alone, 3% lived with their spouse, 19% with
degree and another third having a high school children, and 3% with other family. The propor-
diploma or some college (n = 38, 32%). Another tion of near-centenarians and centenarians living
third had middle school education or completed alone was substantially larger than in other stud-
some high school (n = 36, 30%). Very few (n = ies, and comparing both age groups, centenarians
3, 3%) had received only primary school educa- were even more likely to live alone than
tion. Participants also exhibited relatively high near-centenarians (Jopp et al. 2016b). One could
levels of cognitive functioning. To assess cogni- speculate that this is due to the fact that living in a
tive functioning, we used the following subscales city like New York comes with more services,
from the Mini-Mental State Examination (MMSE; ranging from a doorman, food delivery services
Folstein et al. 1975): Orientation (range: 010 to various levels of professional care supports,
points), Registration (range: 03 points), Attention which could allow for residing in the community
(05 points), and Recall (03 points), resulting in a longer. Furthermore, considering marital status,
maximum total of 21 points. Doing so, we we found that most of the sample (75%) was
followed the recommendations by Holtsberg widowed, but 7% were still married. Eight percent
et al. (1995), who proposed using items that were were divorced/separated and 9% had never
unlikely to be biased by the poor sensory function- married.
ing highly prevalent in centenarians. Our ndings In comparison to studies with younger individ-
indicate an average shortened MMSE score of uals, social functioning of the near-centenarians
and centenarians was poor: Participants reported demographic development, namely, that for the
having an average of three relatives to talk to at rst time, two generations within one family
least once a month, two relatives as condants, reach old and very old age together. Of those
and two relatives as emergency contacts. In com- who had children, 76% reported having a child
parison to family contacts, the number of friends living close.
available to talk to at least once a month was In-depth assessment of the quality of the rela-
smaller, namely, about two, and the number of tionship was delivered by a subgroup of very old
friends being condants and emergency contacts and their children (n = 29). Qualitative coding of
were between one and two on average. the relationship description indicated that most
A combination of these indicators of social con- centenarians and their children experienced their
tact and support (as measured by the relationship as positive (90% of the very old and
six-item Social Network Scale (Lubben 1988)) 70% of the children). It was, however, notable that
underscored the impression that the very old had the very old gave much more positive reports and
substantially smaller social resources than indi- rarely mentioned issues, while the children were
viduals of younger old age. Although most partic- somewhat less positive and were more open to
ipants had at least one person for communication/ talk about difcult aspects of their relationship.
social support, their overall support score of Positive features mentioned were feeling a close
12 was substantially lower than that of young- bond, sharing activities, and having important
olds (7080 years old), who scored between conversations. Negative features included having
16 and 18 (Lubben 1988; Lubben et al. 2006). day-to-day frictions and having different views.
Using 11 or less as a cutoff for the total score and Only few mentioned serious frictions. Children,
5 or less for the family and friends score (Lubben however, also mentioned old wounds that made
1988; Lubben et al. 2006), we found that, when the relationship difcult (Jopp et al. 2016a).
considering their total network, half of the sample Considering the amount of informal support
(51%) was at risk for social isolation. Considering that near-centenarians and centenarians receive
family support, the percentage at risk was smaller in everyday life (e.g., help with care, household,
(34%), but for friendship support, the risk was but also socializing), the children had a particu-
double (58%), indicating that a large proportion larly important role. In most cases, the child was
of near-centenarians and centenarians were at risk the main go-to person: they were the primary
for social isolation (Jopp et al. 2016). contact involved in providing day-to-day help
Given our particular interest in social factors mentioned by 31% of the sample (Jopp et al.
enabling very old individuals to age successfully, 2016b). We were furthermore surprised to nd
one focus of the Fordham Centenarian Study was that individuals other than immediate family
to examine more closely the nature and quality of played a much smaller a role: friends were men-
the relationship between the centenarians and tioned as providing help by 15% and other rela-
their children, who themselves have reached tives by 9% of the participants. Furthermore,
advanced age. Study participants had a mean those with a living child had substantially more
number of living children of 1.36 (SD = 1.31). help than those without children, indicating that
It is notable that about 39% had lost one or more having a child does apparently not only come
children, which represents one of the most dif- with help from the child him/herself but also
cult life experiences of centenarians. The average seems to facilitate help from other individuals.
age of the living children was 66 years. The range Nevertheless, it is of note that only 51% of the
of the childrens ages was 4283, and about one near-centenarians and 40% of the centenarians
fourth of the children were older than 70 years old indicated receiving any help at all. Although
and 10% were older than 75 years old, highlight- study participants residing in the community
ing a new phenomenon associated with the current received more help (52%), only one fourth of
those living in an elder facility indicated receiving was challenging for them. Responses were coded
any informal help. using open coding and clustering methods in
order to identify common challenges among
Well-Being and Mental Health these centenarians.
Participants of the Fordham Centenarian Study Allowing the very old to indicate in their own
had relatively high levels of mental health words what they found challenging in their every-
(Jopp et al. 2016c). Using the Geriatric Depres- day life revealed a multidimensional concept of
sion Scale (GDS; Sheikh and Yesavage 1986), challenges at this very advanced age. Although
with higher scores indicating more depressive near-centenarians and centenarians most com-
symptomology (theoretical range = 015), mean monly reported functional challenges (76%),
depression score was 4.10 (SD = 3.41), and 72% such as restrictions in activities of daily living,
of participants had few or no depressive symp- disability, health, and sensory impairment, they F
toms (i.e., GDS scores 04). Over 80% of the also indicated other types of challenges, including
sample did not meet the criteria for clinical psychological and social. Psychological chal-
depression (GDS scores 8 and higher). Life satis- lenges (40%) were commonly mentioned, includ-
faction, measured by the Satisfaction with Life ing loss of independence and loss of enjoyable
Scale (Pavot and Diener 1993), was moderate activities. Social challenges (20%) were also com-
considering the mean level (M = 2.07, monly reported, involving, for example, social
SD = 1.14). About 66% reported moderate to loss and leaving loved ones behind. It should
very high life satisfaction. About 25% were a also be noted that a small proportion of centenar-
little satised and only 9% were not satised ians mentioned having no challenges at all.
with their lives. Regression analysis indicated Regression analysis further revealed that differ-
that individual differences in depression were ences in aging satisfaction were predicted by
related to subjective health and IADL function- functional and psychological challenges, with
ing, as well as support from the family. For life functional challenges being negatively associated
satisfaction, subjective health as well as PADL and psychological challenges being positively
functioning and number of children were sig- associated. The latter, somewhat unexpected,
nicant predictors (Jopp et al. 2016c). In a effect could indicate that those very old reporting
second set of analyses, in which we considered psychological challenges are more sensitive to
not only basic personal resources but also psy- age-associated challenges and see the potential
chological strengths, we found that optimistic of these to grow and develop. A regression
outlook and will to live were the strongest pre- predicting loneliness furthermore revealed that
dictors of life satisfaction, besides ADL func- functional challenges were related to higher levels
tioning and number of living children of loneliness. In addition, more social challenges
(Jopp 2016), suggesting that psychological were marginally related to higher levels of loneli-
aspects play an important role in the wellness. Interestingly, none of the specic challenge
being of the very old. types was associated with depressive symptoms.
In sum, ndings suggest that perceptions of chal-
Common Challenges and Beliefs about lenges are not only specic and varied but that
Successful Aging they are also differentially associated with mental
Centenarians reported everyday challenges were health outcomes.
assessed with two open-ended questions. The rst To assess centenarians views on successful
was, Please think now for a moment about the aging, participants were asked two open-ended
things that you nd challenging. Are there things questions. The rst was, A lot of people are
that you nd challenging or difcult? Partici- very fascinated that one can reach a very old age
pants were then asked how the difcult instance and wonder how this comes about. Since you are
one of the few people who have reached their ability to adapt to age-associated challenges.
100th birthday, or are close to it, what do you Findings further indicated that perceived chal-
think are the reasons for it? The second question lenges were related to mental health outcomes,
was, And if you think about your life, did you which indicates that centenarians are not ignoring
have a certain theme, a guideline, after which you their issues but apparently have ways of dealing
lived and maybe still live? Responses were with these in a positive way. Future analysis will
coded using open coding or content-based clus- further highlight the role of psychological factors
tering to identify recurrent themes. Findings indi- that seem to be responsible for this successful
cate that most centenarians believed that adaptation.
psychological aspects (e.g., taking good care of Findings further highlight the importance of
yourself, letting others help you) had helped them social partners. The Fordham Centenarian Study
reach age 100. The two most commonly men- is the rst to provide information about the rela-
tioned themes after psychological aspects were tionship of centenarian parents and their advanced
social aspects (e.g., family background, children, age children, a dyad that is the result of recent
friends) and lifestyle (e.g., living life in modera- demographic changes. How old children and very
tion, healthy diet). Other themes mentioned old parents experience their relationship will be
include faith, health, luck, work, leisure (having further investigated, also taking into account how
hobbies), and aging experience (e.g., forget about the nature of the relationship may inuence phys-
aging). Thus, results suggest that, in line with ical and mental health outcomes in both dyad
more recent ndings on laypeoples views on partners. So far, it is already clear that the children
successful aging, near-centenarians and centenar- become the most important go-to people and that
ians have a multidimensional view of aging and the relationship is mostly experienced positively,
that psychological aspects are quite important, but that difcult interactions with substantial bur-
maybe even more important than in other age den do occur. More research is necessary to iden-
groups. tify the unique care needs and to provide guidance
for the development of well-suited services for
this very old population.
Conclusion That a large proportion of the sample lived in
the community, and that this proportion was much
In line with the main goals of the Fordham Cen- higher than in other studies, seems to be in line
tenarian Study, its ndings to date give important with the very olds desire for leading an autono-
insights about what characterizes life in very old mous life, which may have been facilitated by
age and help to increase our understanding of the New York service culture. The impact of the
common challenges at this age, as well as levels of wider societal and cultural environment will be
functioning and strengths of near-centenarians further investigated by considering data from
and centenarians. Findings indicate that all study the Second Heidelberg Centenarian Study
participants had health challenges, yet they per- (Jopp et al. 2013) and the Oporto Centenarian
ceived their health as good. The cognitive status Study (Ribeiro et al. in press), which were
of the sample was high, which was in line with the designed in large parts as parallel studies to
goal of the study to talk directly to individuals of the Fordham Centenarian Study (Jopp et al. in
that age, rather than gaining information by proxy press b). The comparison of person, social, and
informants. Findings also demonstrate that the societal-cultural factors among the parallel studies
social resources of the sample were low and will help to identify which factors are responsible
many of them were at risk for isolation. Despite for successful aging in specic cultures and which
reduced levels of physical functioning and social are responsible across countries, in order to shoul-
resources, very old participants were in good men- der the global challenge of very old age at indi-
tal health suggesting high resilience and the vidual, family, and societal levels.
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906 Frailty and Cognition
This consensus has also stated that the syndrome

Frailty and Cognition can be prevented and treated by interventions
which include exercise, protein-calorie supple-
Mnica Sanches Yassuda1 and mentation, vitamin D supplementation, and
Ivan Aprahamian1,2 reduction of polypharmacy; it can be identied
1
University of So Paulo, So Paulo, SP, Brazil with rapid screening instruments, and that
2
Jundia Faculty of Medicine, Jundia, Brazil individuals 70 and older or with signicant
weight loss due to disease should be screened for
frailty.
Synonyms for Frailty An inuential model (Walston et al. 2006) has
proposed that frailty is related to oxidative stress,
Fragility; Vulnerability to stressors mitochondrial dysfunction, DNA damage, genetic
factors, and inammation. These processes may
lead to decrease in key hormone levels, such as
Definition of Frailty estrogen, testosterone, and dehydroepiandroster-
one (DHEA) and increase in cortisol levels,
An age-associated syndrome linked to diminished increase in inammatory markers (TNF-alpha,
physiological reserves and lower resistance to IL-6), and loss of lean muscle mass.
stressors. This syndrome is associated with According to Rodriguez-Maas and Fried
increased risk for negative health outcomes, such (2015), the prevalence of frailty in people older
as immobility, hospitalization, and death. than 65 years is high, ranging from 7% to 16.3%
in most studies. The prevalence increases with age
and it is greater in women than in men. In older
Introduction samples, 85 years and older, it may reach 28%
(Collard et al. 2012). Prevalence estimates depend
Definitions and Models of Frailty on sample origin and may be higher in clinical
In recent decades, the frailty syndrome has samples.
received different denitions. Earlier studies There is a productive debate about the best
equaled frailty to multiple comorbidities, depen- approach and criteria to identify frailty in clinical
dency, mobility limitations, institutionalization, and research settings. Three recent strategies have
failure to thrive, and predeath (Hogan et al. been most frequently used for that purpose.
2003). In the past 15 years, the concept has gained Fried et al. (2001) have proposed a frailty
more precise denitions. Frailty can be considered phenotype which emerged from the Cardiovascu-
a biologic age-associated syndrome linked to lar Health Study (CHS) including data from 5,317
diminished physiological reserves and lower men and women 65 years and older. The pheno-
resistance to stressors (Fried et al. 2001). It results type associated with negative health outcomes in
from cumulative declines across multiple physio- this study comprised three or more of the follow-
logic systems due to age and diseases. Frailty ing characteristics: unintentional weight loss
increases the risk for negative health outcomes, (10 pounds in the past year), self-reported exhaus-
such as immobility, falls, hospitalization, and tion, weakness (assessed by grip strength),
death. slow walking speed, and low physical activity.
An international consensus has dened physi- Reaching frailty criteria at baseline was associated
cal frailty as a medical syndrome with multiple 3 or more years later with incident falls, worsen-
causes and contributors that is characterized by ing mobility or ADL disability, hospitalization,
diminished strength, endurance, and reduced and death. Presenting one or two of such charac-
physiologic function that increases an individuals teristics was regarded aspre-frailty, and it was
vulnerability for developing increased depen- associated with intermediate risk for the condi-
dency and/or death (Morley et al. 2013). tions described above.
Frailty and Cognition 907
The frailty phenotype has generated a very Several issues remain open to debate regarding
signicant body of research, spanning several frailty. It has been challenging to reach consensus
aspects of the syndrome from epidemiology and regarding the essential characteristics of the syn-
early diagnosis to treatment and prevention strat- drome and ways to operationalize its assessment.
egies (Rodriguez-Maas and Fried 2015). The In addition, there has been prolonged debate
phenotype has been helpful to identify a high- whether cognitive impairment should be included
risk subgroup of seniors for negative outcomes in frailty criteria. Some research groups (Fried
with higher predictive value than chronic disease. et al. 2001) have excluded older adults with cog-
Researchers from the Study of Osteoporotic nitive impairment from study samples justifying
Fractures (SOF) have proposed the use of a the need to study frailty in general and not frailty
simplied strategy to identify the frailty associated to dementia. In the risk index perspec-
syndrome the SOF index. This index includes tive, the inclusion of cognitive problems has been F
weight loss, inability to rise from a chair ve times recommended as it may represent an important
without using arms, and reduced energy level decit that accumulates with others to determine
assessed with one question from the Geriatric frailty thresholds (Mitnitski et al. 2015). In the
Depression Scale. One criterion should indicate next sections, the evidence linking frailty and
pre-frailty status and/or two frailty status. Studies cognition will be revisited with the aim to support
from this group (Ensrud et al. 2009) have shown the view that frailty and cognitive impairment are
that the SOF index predicts risk of falls, disability, associated phenomena and may be subsided by
fracture, and mortality as well as the CHS criteria. similar biological processes.
Alternatively, the Canadian Study of Health
and Aging has dened frailty as a risk index.
According to this group, frailty can be evaluated Frailty and Cognition: Evidence from
by the number of health decits that individuals Cross-Sectional and Longitudinal
accumulate. Therefore, the frailty index is calcu- Studies
lated as the ratio of the decits present in a person
to the total number of potential decits evaluated. Cross-sectional studies from different regions of the
In many epidemiological and clinical studies, the world have reported that frail and pre-frail older
FI has successfully graded the degree of risk of individuals tend to have lower scores in global-
adverse outcomes, such as mortality, health ser- and domain-specic cognitive tests compared to
vice use, hospital-acquired complications, wors- non-frail seniors (Chen et al. 2015). In addition,
ening health, and loss of independence (Mitnitski cross-sectional studies have reported that individual
et al. 2015). markers of frailty are associated to cognition. As an
In addition to the phenotype and the risk index example, one previous study tested the association
perspectives, several different instruments and of the ve CHS frailty criteria individually with
questionnaires have been proposed to detect cognitive scores and found that grip strength and
frailty. Such instruments might capture some of gait speed were signicantly correlated to cognitive
the core aspects of frailty maintaining predictive performance (Yassuda et al. 2012).
validity for adverse outcomes (Pialoux et al. Longitudinal investigations have reported that
2012). However, this approach has been frailty is a signicant predictor of future cognitive
questioned, as the use of frailty screening instru- decline. Samper-Ternent et al. (2008) followed up
ments may only identify the presence or absence 1,370 older Mexican Americans for 10 years,
of frailty. Such instruments most likely cannot without cognitive impairment at baseline. They
identify the level of risk or gradients of frailty in reported that frailty was an independent predictor
order to predict specic outcomes accurately, and of cognitive decline assessed by the Mini-Mental
they may be limited in their contribution to the Status Examination (MSSE). In another longitu-
device of individualized care plans (Rockwood dinal study, vila-Funes et al. (2008) classied a
et al. 2015). community-based sample into seniors who were
frail, pre-frail, and robust according to the pheno- calculated a frailty index based on 19 decits not
type model and further classied all participants known to predict dementia. Their results indicated
into those who were cognitively impaired and that dementia and AD incidence increased expo-
those who were intact. They reported that cogni- nentially with the increase in this frailty index.
tively impaired frail elderly had higher risk for These results suggest that frailty and general
functional impairment, mobility limitations, and health are associated with the risk for dementia.
hospitalization than those frail individuals who In a longitudinal study, including 750 seniors
were cognitively intact. These ndings suggest without cognitive impairment, with follow-up
that the presence of cognitive impairment among assessments of up to 12 years, Boyle
frail elderly may increase the predictive value of et al. (2010) showed that frailty was associated
frailty to determine negative outcomes. with a higher MCI incidence risk and a faster rate
Other studies have suggested that changes in of cognitive decline.
individual frailty criterion may predict cognitive A previous study in Japan (Shimada
decline. Alfaro-Acha et al. (2006) reported that et al. 2013), which included 5,104 community-
older Mexican Americans with reduced grip dwelling seniors, investigated the prevalence of
strength at baseline, after 7 years, demonstrated frailty, MCI, and both conditions concomitantly.
signicant decline in the MMSE, whereas seniors Results indicated that 11.3% of participants were
with high grip strength tended to maintain cogni- frail, 18.8% were diagnosed as having MCI, and
tive performance. Mild physical impairment has 2.7% had both conditions. More importantly,
also been associated with greater risk for cognitive there was a signicant relationship between frailty
decline and dementia (Wilkins et al. 2013). and MCI.
Few studies have investigated the frailty syn-
Frailty Increases the Risk for MCI and AD drome among patients with MCI. McGough
Most importantly, previous studies have revealed et al. (2013) assessed a sample of 201 sedentary
that physical frailty is associated with higher risk seniors previously identied as having amnestic
for mild cognitive impairment (MCI) and MCI for three frailty criteria (gait speed, grip
Alzheimers disease (AD). Buchman et al. strength, and physical activity level) and cognitive
(2007), in a 3-year follow-up study of 823 seniors, performance in the ADAS-Cog, Trail Making
found that baseline frailty scores and annual rate A and B, and WMS-R Logical Memory I.
of change in frailty were associated with an Among participants, the majority reached criteria
increased risk of incident Alzheimers disease for frailty, 57.3 for low gait speed, 64.2 for low grip
(AD). In a recent study of this group, Buchman strength, and 58.2 for low physical activity. In a
et al. (2014) reported that in 6 years, frailty and linear regression model, gait speed was signi-
cognition declined in similar proportions. Most cantly associated with all cognitive measures,
individuals showed worsening frailty and cogni- whereas activity level was associated with Trail
tion (82.8%). In addition, rates of change in frailty Making B and ADAS-Cog Word Recall, and grip
and cognitive scores were strongly correlated. strength was associated with scores for the Trail
Brain tissue analyses revealed that AD pathology, Making A. These results lend support to the notion
macroinfarcts, and nigral neuronal loss showed that there is a signicant relationship between
independent associations with the rate of change frailty dimensions and cognitive performance in a
in both frailty and cognition. These results sample of older adults with cognitive decits. Most
strongly support the hypothesis that frailty and importantly, MCI patients who reach certain frailty
cognition may be caused by the same biological criteria, particularly gait speed, may be at a higher
mechanisms. risk for conversion to dementia and may require
Using data from 7,239 cognitively healthy, more assistance.
community-dwelling older adults from the Cana- In a longitudinal study of 12 months, Alencar
dian Study of Health and Aging, who had 5- and et al. (2013) followed up 207 cognitively intact
10-year follow-up data, Song et al. (2011) seniors. After 1 year, there was an incidence of
Frailty and Cognition 909
4.9% of cognitive impairment among the physi- presence of frailty, presence of MCI (CDR = 0.5),
cally robust participants, 8.9% among the pre-frail, and absence of AD or other dementias. In other
and 13.3% among the frail seniors. The latter group words, the condition should describe cognitive
had lower scores in the MMSE in both evaluation decline not associated with neurodegeneration.
points. This study suggests that even in a short- The cognitive frailty concept has faced some
time period, an association between frailty and challenges, such as ruling out the presence of
cognitive decline can be observed. neurodegenerative processes. It is known that
Frailty among the oldest old has been less fre- healthy seniors may also present a signicant
quently studied. Using data from 840 community- degree of atrophy and AD markers, in the pres-
dwelling seniors 85 years and older from the ence of intact cognition. Therefore, the criteria for
Jerusalem Longitudinal Cohort Study, with 5-year cognitive frailty might need to include a temporal
follow-up assessment, Jacobs et al. (2011) reported aspect; that is, the presence of frailty may need to F
that frailty and cognitive impairment were signi- precede the onset of cognitive decits (Canevelli
cantly associated. Mortality rates were higher for and Cesari 2015). According to these authors, the
frail and pre-frail than for robust participants. How- concept of cognitive frailty needs to be further
ever, mortality among frail subjects with or without investigated in epidemiological and clinical stud-
cognitive impairment was equivalent. Also, frailty ies so that its operational denition may be
alone was more predictive of mortality than cogni- improved as well as the understanding of its bio-
tive impairment alone. logical mechanisms.
Taken together, cross-sectional and longitudi-
nal studies have provided support for the hypoth- Interventions Geared Toward Improving
esis that frailty is a clinical condition associated Frailty
with worse cognitive performance, faster cogni- Currently, there is considerable interest in identify-
tive decline, and higher risk for MCI and demen- ing interventions that might prevent or delay frailty;
tia. The initial implication for these ndings is that yet there is a lack of well-designed frailty trials.
frail seniors should be screened for cognitive Cesari et al. (2015) reported ndings from the Life-
impairment in order to improve early dementia style Interventions and Independence for Elders
detection. In addition, individualized care plans Pilot (LIFE-P) study. In all, 424 community-
for frail elders may need to include cognitive dwelling persons (mean age = 76.8 years) with
stimulation and/or cognitive training programs. sedentary lifestyle and at risk of mobility disability
Considering that frailty and cognitive decits were randomized into the 12-month physical activ-
may be subsided by similar biological processes, ity or successful aging interventions. The CHS
seniors with MCI or dementia might also benet frailty syndrome criteria were assessed at baseline,
from frailty screening and interventions aiming to 6 and 12 months. At 12 months, there was a reduc-
minor or delay frailty. It is plausible that frail tion in frailty prevalence in the physical activity
seniors with MCI might be at a greater risk for group compared to the active control group. How-
conversion to dementia and may benet from ever, when individual frailty criteria were analyzed,
multimodal interventions targeting both physical the authors observed that low physical activity was
and cognitive impairments. the criterion most affected by the key intervention.
The other criteria, such as gait speed and grip
The Concept of Cognitive Frailty strength, were not altered by the physical activity
The evidence linking frailty and cognitive impair- intervention. The authors hypothesized that to alter
ment has compelled a panel of specialists to propose other frailty dimensions, multimodal interventions
a condition called cognitive frailty (Kelaiditi may be needed. In other words, physical activity
et al. 2013). This condition should describe the may need to be offered along with nutritional sup-
deleterious effects of frailty on cognition in plementation, for instance.
the absence of dementia. The tentative criteria pro- A recent review with a focus on studies which
posed by this panel for cognitive frailty are the offered physical activities to frail elders has
documented the large methodological variability Alfaro-Acha, A., Snih, S. A., Raji, M. A., Yong-Fang, K.,
among the studies (de Labra et al. 2015). Among Markides, K. S., & Ottenbacher, K. J. (2006).
Handgrip strength and cognitive decline in older Mex-
other ndings, the authors documented that ve ican Americans. Journals of Gerontology Series A:
out of seven studies reported signicant increases Biological Sciences and Medical Sciences, 61A,
in muscle strength in frail seniors. 859865.
The literature on interventions to improve or Avila-Funes, J. A., Helmer, C., Amieva, H., Barberger-
Gateau, P., Le Goff, M., Ritchie, K., Portet, F.,
delay frailty is diverse, and several studies have Carrire, I., Tavernier, B., Gutirrez-Robledo, L. M.,
investigated specic outcomes, such as falls, or & Dartigues, J. F. (2008). Frailty among community-
instead included in their sample seniors with cer- dwelling elderly people in France: The three-city study.
tain clinical characteristics, such as cardiologic Journals of Gerontology Series A: Biological Sciences
and Medical Sciences, 63(10), 10891096.
diseases. So far, most clinical trials have not Boyle, P. A., Buchman, A. S., Wilson, R. S., Leurgans,
used well-established models to assess frailty at S. E., & Bennett, D. A. (2010). Physical frailty is
baseline and follow-up, and they have failed to associated with incident mild cognitive impairment in
show convincing evidence of effectiveness community-based older persons. Journal of American
Geriatrics Society, 58, 248255.
(Rodriguez-Maas and Fried 2015). Well- Buchman, A. S., Boyle, P. A., Wilson, R. S., Tang, Y., &
designed intervention studies addressing frailty Bennett, D. A. (2007). Frailty is associated with inci-
and cognition simultaneously have not been iden- dent Alzheimers disease and cognitive decline in the
tied in recent searches. elderly. Psychosomatic Medicine, 69, 483489.
Buchman, A. S., Yu, L., Wilson, R. S., Boyle, P. A.,
Schneider, J. A., & Bennett, D. A. (2014). Brain pathol-
ogy contributes to simultaneous change in physical
Future Directions frailty and cognition in old age. Journals of Gerontol-
ogy Series A: Biological Sciences and Medical Sci-
ences, 69(12), 15361544.
Frailty is now widely regarded as a relevant med- Canevelli, M., & Cesari, M. (2015). Cognitive frailty:
ical condition associated with adverse health out- What is still missing? The Journal of Nutrition, Health
comes. There is debate regarding the ideal criteria & Aging, 19(3), 273275.
to dene this condition and the best strategy to Cesari, M., Vellas, B., Hsu, F. C., Newman, A. B., Doss, H.,
King, A. C., Manini, T. M., Church, T., Gill, T. M.,
operationalize its assessment. There is agreement Miller, M. E., Pahor, M., & LIFE Study Group. (2015).
that frailty and cognitive decits may co-occur, A physical activity intervention to treat the frailty syn-
and that the presence of frailty increases the risk of drome in older persons-results from the LIFE-P study.
MCI and dementia. Larger and well-designed Journals of Gerontology Series A: Biological Sciences
and Medical Sciences, 70(2), 216222.
intervention studies are needed to offer insights Chen, S., Honda, T., Narazaki, K., Chen, T., Nofuji, Y., &
regarding the best strategies to delay or prevent Kumagai, S. (2015). Global cognitive performance and
frailty. Such interventions may play an important frailty in non-demented community-dwelling older
role in dementia prevention as well. adults: Findings from the Sasaguri Genkimon Study.
Geriatrics and Gerontology International.
doi:10.1111/ggi.12546.
Collard, R. M., Boter, H., Schoevers, R. A., & Oude
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912 Frailty in Later Life
An Aging in Place Population as their home itself. As a consequence, the resi-

dential area is not restricted to the home itself but
In our modern society, the older population is also to the environment where the home is situated
growing rapidly. The World Health Organisation and to the people who live in the neighborhood
estimates in their fact sheet 404 that between 2015 (Satariano et al. 2012). This shift of mind is
and 2050, the proportion of the worlds population prompted by the prevailing belief among
over 60 years will nearly double from 12% to policymakers that an aging population inevitably
22%. This aging process is unprecedented, uni- means increasing demands on health care
versal, sustainable, and far-reaching. Several resources, social support, informal networks,
explanations for this aging process are proposed. etc. (Bond and Cabrero 2007). Moreover, aging
First, a continuous increase in life expectancy in place is considered to be less expensive than
over the last decades results in a situation where institutionalization (Marek et al. 2012).
more people attain very old ages. Mainly due to
initiatives in the domain of public health and
supported by enhanced nursing and medical care Conceptualization of Frailty
for older people, mortality rates are declining.
Moreover, as birth rates are declining, an addi- A major challenge for European governments
tional increase of the proportion of older people with regard to this aging in place policy lays in
will take place (Grundy 2006). the early detection of frail or vulnerable older
In order to cope with the challenges of an aging people so that appropriate and often preventive
population and to meet the preferences of older support can be provided as early as possible and
people themselves with regard to the place where unnecessary adverse outcomes may be prevented.
they age, in Europe, governments have changed Indeed, when aging in place, older people are
their vision towards health care provision confronted with the limits of their own resources,
(de Gooijer 2007). This policy mainly reects a their informal and formal care framework, and of
deinstitutionalization of long-term care services in their living environment. If there is an imbalance
order to provide opportunities for older people to between resources and demands, people can
stay in their own environment for as long as pos- become frail or vulnerable (Grundy 2006). In
sible, also known as Aging in place. Several order to identify these limits and to ensure that
studies demonstrated that this is the most pre- adequate care is provided to the right persons in
ferred way of aging by older people themselves time, detection of these limits seems essential, but
and addressed the impact of it on an individuals not straightforward.
quality of life (Mitzner et al. 2014). It is more than Although recognized as a syndrome for some
a symbol of quality of life as it covers a basic need time (Weindruch et al. 1991), frailty is now a fast
(accommodation) and has benets on both phys- growing research area in gerontology and geriatric
ical and psychological health. It is also the place medicine focusing on its causes, risk factors, and
where intimate relationships with family mem- adverse outcomes (Gobbens et al. 2010). Within
bers, relationships with friends/relatives, and lei- Western welfare policy and practice, frailty is
sure take place (Rojo Perez et al. 2001). increasingly used for classication of older people
Clearly, aging in place creates opportunities to (Nicholson et al. 2012). The term frailty is
bind people. Indeed, older people are often reluc- derived from the Latin word Fragilitatem
tant to leave their community dwellings, even which means being weak or aw. The Federal
when it is difcult for them to manage the house- Council on Aging (USA) proposed the rst de-
hold chores, mostly because the familiar home nition of frailty (see Denition), and since 1991,
environment provides them with a strong sense frailty is also a Mesh term (Medical Subject Head-
of meaning and belonging (Costa-Font et al. ing) and dened as: Older adults or aged individ-
2009). Older peoples experience with their neigh- uals who are lacking in general strength and are
borhood and neighbors may be just as important unusually susceptible to disease or to other
inrmity. The initial purpose of the Federal consultations to institutionalization. As a conse-

Council on Aging was to make an inventory quence, prevention becomes very meaningful.
about the care needs, but later on, frailty was
recognized as an interventionist concept
(Weindruch et al. 1991; Hertogh 2010) not in the
Frailty: Paradigm Shift
least because the aging process is stereotyped as a
period of losses and decline in physical and men-
In literature, new debates are going on about the
tal functioning. Some researchers consider frailty
frailty concept. One debate explores the
as a clinical syndrome, a pure biomedical
multidimensionality of frailty. According to
problem.
(Hertogh 2010), psychological and social factors
Fried, one of the leading scholars regarding
are overlooked in frailty. Additional some
frailty, developed the phenotype approach (Fried
researchers also point to environmental factors asso- F
2001), which has received international attention
ciated with frailty (Markle-Reid and Brown 2003).
and has been extensively validated in research
According to (Romero-Ortuno et al. 2010, p. 1)
literature. Criteria used by Fried to dene frailty
frailty is
are: weight loss, endurance, inactivity, gait speed,
and hand grip strength. Over the years, a wide loss of independence, vulnerability and impairs the
quality of life and psychological well-being of
range of other physical problems have been linked
many older people; it also poses an enormous chal-
to frailty: gait speed, a 3 m walk test, a stand-up lenge on families, carers and other structures of
test, endurance, weakness, reduced physical activ- social care and social support. In the face of the
ity, weight loss, mobility, exhaustion, cardiac rapid population ageing occurring in Western Soci-
functioning, grip strength, balance, strength, eties, frailty is set to reach epidemic proportions
over the next few decades.
slowness, neuromotor performance, sarcopenia,
etc. Thus, in this respect, frailty is considered as As the number of older persons increases in
a medical/clinical syndrome in which the under- society, the prevalence of frailty in the population
lying physiological and biological processes will consequently also increase. The interest in
result in multiple clinical manifestations. frailty lies in postponing the decline in health
However, other scholars recommend giving and quality of life of frail older persons in order
more attention to the psychological aspects of to improve their chances of living a longer and
frailty. Conceptualizing frailty as a pure medical healthy life. Frailty is therefore frequently concep-
problem is neglecting both the capacities of older tualized as an antonym for successful aging, and
people themselves to withstand stress and their some researchers state that frailty can be
experiences (Hertogh 2010). As a consequence, prevented, delayed, and eventually reversed
psychological indicators (cognition, mastery, (Lang et al. 2009). Because of the shift in focus
depression, anxiety, sadness, and management towards prevention and risk reduction, some
capacities) were introduced in frailty assessments frailty conceptualizations neglect other critical
in addition to biomedical indicators. This aspects of aging (Hertogh 2010).
bio-psychological approach was criticized for A second debate is about the way frailty is
neglecting the interplay of bio-psycho-social factors conceptualized. When older women were asked
in frailty (Nicholson et al. 2012). As a consequence, how they perceive frailty, most of the answers
social indicators like social support or social net- were not only linked to physical descriptions,
work were also introduced in frailty assessment. but also to contextual, social, and emotional prob-
Although a consensus about an operational lems, suggesting that older people themselves
denition of frailty is still lacking, one aspect is have other denitions about frailty than clinicians
gaining consensus: frailty is an entity that can be (Grenier 2007). Gustafsson and colleagues inves-
distinguished from disability or comorbidity tigated frailty from a health care professionals
(Gobbens et al. 2010) and is associated with perspective. Seven dimensions were consistent
excess of healthcare costs ranging from medical with frailty: being bodily weak and ill, being
negatively inuenced by personal qualities, of frailty in the primary care setting are still in the
lacking balance in everyday activities, being preliminary stages of development.
dependent in everyday life, not being considered Moreover, different existing approaches of
important, being hindered by the physical milieu frailty are criticized because they are often based
and defective community service, and having an on a negative and stereotypical view of aging
inadequate social network. These results point to associated with becoming disabled (Markle-Reid
the fact that health care professionals view of and Brown 2003) and loss or declining abilities
frailty in older persons differed from the current (Kaufman 1994). These instruments neglect the
state of knowledge on frailty (Gustafsson lived experiences of each individual (Grenier
et al. 2012). As a consequence, a paradigm shift 2007), assuming that aging is a uniform process
regarding frailty is needed. (Kaufman 1994). According to Gobbens and col-
leagues (2010), addressing frailty exclusively on
physical components jeopardizes the attention for
Measuring Frailty in the Community the individual as a whole. Markle-Reid points to
the fact that frailty is a multidimensional non-age-
In most Western societies, frailty has been rec- related concept that must consider the interplay of
ognized as a major challenge the world is facing various physical, psychological, social, and envi-
today for both formal health services and infor- ronmental factors. The fact that much biomedical
mal caregiving (Ceci and Purkis 2011). As a research on frailty demonstrates great variations
consequence, detecting frailty in primary care is in frailty according to gender, socio-economic
a major challenge for primary care physicians. The status, education, etc., points to the social produc-
I.A.G.G. (International Association of Gerontol- tion of frailty (Markle-Reid and Brown 2003).
ogy and Geriatrics) and the G.A.R.N. (IAGG While some authors have developed a mea-
Global Aging Research Network) have already surement instrument for frailty aiming to meet
taken initiative in this domain and pointed to the the aforementioned critiques (e.g., Groningen
need to concentrate on aging in place in order to Frailty indicator, Tilburg Frailty Indicator), they
prevent premature nursing home placement. ignore the environmental aspects of frailty. In
According to Romero-Ortuno and colleagues such an approach, however, frailty shifts from a
(2010), the problem with the extant frailty instru- microlevel analysis focusing on the individual
ments is that they are not readily applicable in only to a macrolevel analysis, where frailty is
primary care practice. The aforementioned phe- seen as a result of numerous intersecting factors,
notype of frailty has the advantage that it only many of which are external to the individual.
requires the measurement of ve variables, but Additionally, some scholars (Grenier 2007) sug-
while this is affordable from a primary care point gest to take the subjective perceptions of an indi-
of view, the problem arises with the construction vidual into account, the so called lived experience.
of the measure as it requires considerable statisti- For example, social isolation, inadequate care and
cal expertise to dichotomize criteria measured on support, and living arrangements are risks associ-
a continuous scale (e.g., grip strength) (Romero- ated with aging, but all these factors can have both
Ortuno et al. 2010). Other scholars, however, state mutual and individual antecedents and are expe-
that using the extant screening instruments in rienced in different ways.
community-dwelling frail people is impractical, Beside the criticism on the operational deni-
because the assessment methods are complex tion of frailty, some scholars like Robertson
and time-consuming and the results are difcult (1997) expressed their concerns about the medi-
to report. calization of aging due to the use of frailty mea-
Altogether, if primary care providers need to surements. For Robertson, the biomedicalization
screen for frailty, user-friendly instruments are and gerontologization of old age are being
required (De Lepeleire et al. 2008), but compre- reconceptualized as a new medical space requir-
hensive tools to identify multidimensional aspects ing new supporting ideologies which protect the
new created space, with over servicing as a con- Development of the Comprehensive
sequence, and requiring new customers. As a con- Frailty Assessment Instrument
sequence, the socially constructed dependency of
older adults serves those structural interests. In order to answer the aforementioned critiques,
Using functional and ill-health variables tends to the Comprehensive Frailty Assessment Instru-
a medical construction where older people are ment (CFAI), which assesses the physical, social,
placed into classes (e.g., nonfrail, pre frail, frail, psychological, and environmental domain of
severely frail), and the distinction between normal frailty, was developed and validated (De Witte
and not normal is made. Those assigned with the et al. 2013a, b). Each domain received equal
status of frail become eligible for public and attention. This self-administer instrument (CFAI)
home-care services (Grenier 2007). contains 23 indicators and demonstrates a high
Not only does this approach overlook the social overall internal consistency and high consistency F
and emotional experiences, it also places older of its scales, thus supporting the validity and
people in competition with each other for the scarce reliability of the instrument and highlighting the
resources. In 1994, scholars like Kaufman already multidimensionality of frailty as described by
argued that frailty, constructed from within a health Markle-Reid and Browne (2003). Indeed, in a sam-
care context, transforms the older peoples lived ple of 33,629 community-dwelling older people,
and experienced problems to diagnosis, then to the CFAI has been proven to be internally consis-
treatment plans and rules about what ought to be tent, with a Cronbachs a of 0.812, explaining
done, leading to negotiated compliance. This view 63.6% of the variance in frailty (De Witte
ignores the role of the broader environment and et al. 2013b). In a second study (N = 181), the
neglects the cumulative disadvantages build up CFAI was cross-validated with the Tilburg Frailty
during the lifespan (Grenier 2007). The implemen- indicator. The internal consistency of the CFAI
tation of frailty has no preventive aims but corre- was 0.759. The correlation between the CFAI
sponds with an increased professionalism and and TFI was 0.590. Correlations between the
efforts to ration care and thereby neglecting gov- physical, psychological, and social domains of
ernment initiatives to include older people in the both scales were good, and the environmental
society. Problems of aging are reduced to an indi- domain showed weak correlations with all other
vidual level, moving responsibility from the gov- domains, pointing to convergent and divergent
ernment to the individual. As a consequence, the validity (De Witte et al. 2013a).
problem of frailty is depoliticized. The CFAI assesses frailty on four domains
Some scholars point to the social construction of and all contribute to frailty, conrming the
frailty (Lustbader 2000). In order to remain in the results of several studies have already addressed
community, older individuals also rely on aspects that frailty is more than just a purely physical
in their social, psychological, and physical phenomenon. Environmental indicators include
resources. Consequently adjusting the frailty mea- the bad condition of the house, the house being
sures for home-care clients to a biopsychosocial or uncomfortable, problems with heating the house,
more integrative approach may prove valuable. and aversion against the neighborhood. These
Furthermore, although social science literature factors are in line with scholars like Costa-Font
acknowledges the merits of the frailty measure- and Wahl (Costa-Font et al. 2009; Wahl
ments in order to identify patient problems, it also et al. 2009), who all highlighted the importance
points at a conict between the biomedical concep- of the spatial context and environmental
tualization and the older peoples experiences. On resources on which an individual depends when
the other hand, it was found that when clinicians aging. As expected, social support also contrib-
were asked to rate the different factors related to uted to frailty.
frailty, they rated mobility, stamina, and activities The psychological domain added the most to
of daily living as most important and social and the respondents overall frailty score. This is a new
psycho-emotional factors as least important. insight, which, to the best of our notion, has not
been addressed in earlier research. Therefore, lit- References

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Frontotemporal Dementia (FTD) 917
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adults in different living environments. International decits in behaviour and cognition. Three main
Journal of Social Robotics, 6, 213227. clinical entities as well as overlaping syndromes
Nicholson, C., Meyer, J., Flatley, M., & Holman,
C. (2012). The experience of living at home with frailty affecting the young subject (< 65 years old) are
in old age: A psychosocial qualitative study. Interna- described here on a clinical, neuropsychological
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Robertson, A. N. N. (1997). Beyond apocalyptic demog-
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Rojo Perez, F., Fernandez-Mayoralas Fernandez, G., Pozo Introduction F
Rivera, E., & Manuel Rojo Abuin, J. (2001). Ageing in
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elderly. Social Indicators Research, 54(2), 173208.
Romero-Ortuno, R., Walsh, C. D., Lawlor, B. A., & Kenny, neurodegenerative disease characterised by pro-
R. A. (2010). A frailty instrument for primary care: gressive decits in behaviour and cognition. FTD
Findings from the Survey of Health, Ageing and Retire- is a common type of dementia, particularly in
ment in Europe (SHARE). BMC Geriatrics, 10(1), 57. patients younger than 65 years. It is the second
Satariano, W. A., Ory, M. G., & Lee, C. (2012). Planned
and built environments: Interactions with aging. In most common form of younger-onset dementia
T. R. Prohaska, L. A. Anderson, & R. H. Binstock after Alzheimers disease (AD) (Ratnavalli
(Eds.), Public health in an aging society. Baltimore: et al. 2002). Despite such prevalence, FTD has
The Johns Hopkins Press. received far less recognition compared to other
Wahl, H.-W., Schilling, O., Oswald, F., & Iwarsson,
S. (2009). The home environment and quality of life- dementias. This is surprising considering the
related outcomes in advanced old age: Findings of the overlap FTD shares clinically and pathologically
ENABLE-AGE project. European Journal of Ageing, with many other dementias, making it a challeng-
6(2), 101111. ing condition in terms of diagnosis and treatment.
Weindruch, R., Hadley, E. C., & Ory, M. G. (Eds.). (1991).
Reducing frailty and fall-related injuries in older per- Currently, three different FTD subtypes are
sons. Springeld: Charles C Thomas. clinically recognized: behavioral variant FTD
(bvFTD) and two FTD subtypes with progressive
aphasia (PPA) semantic variant primary pro-
gressive aphasia (sv-PPA) and nonuent variant
Frontotemporal Dementia (FTD) PPA (nfv-PPA) (Hodges 2011). All three subtypes
have specic but overlapping clinical, pathologi-
Maxime Bertoux1,2, Claire OCallaghan3, cal, and neuroimaging features which will be
Emma Flanagan1 and Michael Hornberger1 discussed in detail shortly. First, we will give a
1
Norwich Medical School, University of East brief historical and general introduction to FTD
Anglia, Norfolk, UK before discussing the main subtypes as well as the
2
Department of Clinical Neurosciences, most prominent overlap syndromes.
University of Cambridge, Cambridge, UK FTD was rst described by Arnold Pick in
3
Behavioral and Clinical Neurosciences Institute, 1892 (Pick 1892). Pick published a series of
University of Cambridge, Cambridge, UK patient cases which all showed signicant behav-
ioral and language changes. Importantly, postmor-
tem examinations of the patients showed atrophy
Synonyms macroscopically in the temporal and frontal lobes
and microscopically ballooned cells, called
Behavioural variant frontotemporal dementia; Pick bodies. The disease has been historically
Frontal dementia; Semantic Dementia; Progres- known as Picks disease, however was renamed
sive non-uent aphasia; Pick disease frontotemporal dementia in the 1980s by
918 Frontotemporal Dementia (FTD)
researchers in Lund and Manchester (Neary comprehensive interview with informants cru-
et al. 1986), according to the prominent macro- cial to establish symptoms. In that perspective,
scopic atrophy seen in these patients. Diagnostic the use of carer questionnaires (such as the
criteria for FTD were rst published in the 1980s Cambridge Behavioural Inventory CBI,
with revisions in the 1990s (Neary et al. 1998). Bozeat et al. 2000) to identify and quantify
The most recent diagnostic criteria split the behavioral changes is particularly useful.
behavioral variant (Rascovsky et al. 2011) from Apathy is observed in many, if not all, bvFTD
the aphasic (Gorno-Tempini et al. 2011) subtypes patients. A striking reduction of motivation and
to allow more detailed phenotyping of the interest in others, work, hobbies, and hygiene
variants. may be observed, resulting in social withdrawal
Over the years, FTD has moved from being and a signicant reduction of premorbid activi-
considered a condition that only occurred occa- ties (Chow et al. 2009) that could be mistaken for
sionally to a more prominent role. In particular, depression (Woolley et al. 2011). Importantly,
the genetic connection of amyotrophic lateral although loss of libido may be commonly
sclerosis (ALS) and FTD has highlighted that observed, patients generally do not report the
FTD pathology and associated symptomology other key symptoms that characterize depression,
are more common than previously assumed. The such as feeling of worthlessness or guilt, sleep
following book chapter will allow the reader to disturbances, and recurrent sad thoughts. Behav-
gain an insight into the FTD spectrum which will ioral disinhibition is also an early symptom of
hopefully trigger further clinical and research bvFTD and usually coexists with apathy (Le Ber
interest in the FTD eld. et al. 2006; Seelaar et al. 2011). Patients can act
impulsively without taking into account the con-
sequences of their actions and thus make poor
Behavioral Variant Frontotemporal nancial decisions and reckless purchases, or
Dementia (bvFTD) engage in pathological gambling (Manes
et al. 2010). Another key symptom of bvFTD is
Clinical Symptoms inappropriate social conduct, manifesting as
bvFTD is the most frequent subtype of FTD. abnormal intimacy with strangers, loss of man-
The median survival (from rst assessment) is ners, and embarrassing or tactless personal
about 3.04.5 years (Piguet et al. 2011a), with remarks (Lu et al. 2006). Such socially awkward
a disease onset usually around 60 years old, behaviors are further aggravated by a lack of
although younger and older cases have been empathy and a decreased ability to decode
frequently described. The clinical symptomatol- others thoughts and beliefs. This leads to
ogy of bvFTD is dominated by progressive and decreased interest and concern for others, includ-
dramatic changes in patients social behavior ing closest relatives, which is a major cause of
and personality that become gradually evident carer and family distress (Baez et al. 2014;
to their relatives, often to great distress. Apa- Lough et al. 2006). Stereotyped behaviors are
thy, behavioral disinhibition, inappropriate commonly observed, with simple repetitive
social conduct, lack of empathy, stereotyped movements such as grunting, humming, food
and rigid behaviors, as well as changes in eat- tapping, or lip smacking being frequent as well
ing behavior are the clinical hallmarks of as the repetitive verbalization of words or phrases
bvFTD (Piguet et al. 2011a; Rascovsky et al. (Snowden et al. 1996, 2001). Mental rigidity is
2011). Patients also exhibit a loss of insight also habitually observed, manifesting as a rigid
that complicates their engagement and referral adherence to everyday routine, a lack of creativ-
to the clinic (Hornberger et al. 2014; Eslinger ity, and, sometimes, compulsive ritualistic behav-
et al. 2005), as they do not recognize either iors (Snowdmeen et al. 2001; de Souza et al.
their decits or the relevance of a medical 2010). Change in eating behavior is also an
consultation. These insight problems make a early symptom of bvFTD. Patients can be
gluttonous, which can cause signicant weight Impairments in decision-making and reward
gain. A deterioration of table manners, impulsiv- processing have also been documented in bvFTD
ity to start eating before everyone else, snatching (Rahman et al. 1999). Patients exhibit a decreased
food from others and stufng it into the month all sensitivity to reward (Fletcher et al. 2015), reduced
at once are frequently observed symptoms aversion to losses (Chiong et al. 2016), an
(Ahmed et al. 2014; Piguet et al. 2011b; Woolley increased discounting of future reward (Bertoux
et al. 2007). et al. 2015c), and striking difculties in reversing
It should be noted that some patients differ in the selection of a previously rewarding item that
their progression, showing hardly any change becomes punishing (Bertoux et al. 2013).
over a decade (Davies et al. 2006) while Poor episodic memory has only recently been
still exhibiting the behavioral symptoms of recognized as a possible cognitive symptom of
bvFTD. Comparative investigations between bvFTD (Hornberger et al. 2010) and can be F
these phenocopy patients and the patients who observed in 50% of bvFTD patients (Bertoux
progress suggest that an absence of brain atrophy, et al. 2014) although spatial orientation appears
normal or sub-normal executive functioning, and to remain relatively preserved (Tu et al. 2015).
preservation of everyday living activities allow The language prole of bvFTD is character-
for accurate identication of these nonprogressors ized by diminished spontaneous speech and de-
(Hornberger et al. 2009). cits in noun and verb naming as well as impaired
single word comprehension, but to a lesser extent
Neuropsychology than in sv-PPA (Snowden et al. 1996; Hardy
Apart from the neuropsychiatric symptoms, the et al. 2015).
neuropsychological prole of bvFTD is domi- Praxis disturbances can be observed after the
nated by decits in all aspects of social cognition, earliest stages of the disease, particularly difcul-
including empathy, theory of mind, and emotion ties imitating face postures (Johnen et al. 2015).
recognition (Lavenu et al. 1999; Gregory
et al. 2002; Bertoux et al. 2013). Carer question- Neuroimaging
naires such as the Interpersonal Reactivity Index Structural imaging such as magnetic resonance
(IRI Davis 1983) can be useful to measure a imaging (MRI) scans show a typical pattern of
decrease in empathic concern. Faux pas and sar- atrophy that is ideally seen in coronal orientation.
casm detection are among the most sensitive It is characterized by predominant frontal, fronto-
assessments to capture theory of mind impair- insular and/or anterior temporal atrophy, which is
ments in bvFTD (Bora et al. 2015; Henry sometimes asymmetrical (Agosta et al. 2012).
et al. 2014). Finally, emotion recognition tests Because atrophy can be very subtle in the early
show difculties in identifying negative emotions stages of the disease, a normal MRI should not
(Bertoux et al. 2015a). exclude the diagnosis of bvFTD. Regions that are
Dysexecutive symptoms, such as impaired more likely to be atrophied in the earliest stages
organization and planning, decreased verbal are the medial prefrontal and orbitofrontal corti-
uency, difculties in verbal and nonverbal con- ces, as well as the anterior insula (Perry et al.
ceptualization, inhibition dysfunctions, and work- 2006; Seeley et al. 2008). In the temporal lobe,
ing memory decits are commonly observed, the amygdala and hippocampus are also affected
although they can be absent or subtle in the earli- (Seeley et al. 2008; de Souza et al. 2013). Subcor-
est stages of the disease (Lindau et al. 2000; Greg- tical structures such as the striatum (Bertoux
ory and Hodges 1996; Rahman et al. 1999: et al. 2015b), thalamus (Hornberger et al. 2012),
Harciarek and Jodzio 2005; Perry and Hodges and hypothalamus (Piguet et al. 2011b) are also
2000; Hornberger et al. 2011). It should be noted involved, as well as white matter tracts such as the
that these symptoms have a poor discriminative paracallosal cingulum bundle, corpus callosum,
value between bvFTD and AD or depression uncinate fasciculus, and fornix (Hornberger
(Libon et al. 2007; Stopford et al. 2012). et al. 2012; Mahoney et al. 2015).
Functional imaging such as single photon- less obvious in conversation than during testing
emission computed tomography (SPECT) shows because of the critical importance that contextual
important hypoperfusion in the fronto-insular and cues have in a discussion. Similarly to what is
polar tempolar regions (Le Ber et al. 2006; Jeong observed with anomia, factors such as familiarity
et al. 2005). As amyloid deposition is not a neu- and prototypicality (e.g., dog for the category
ropathological feature of FTD, amyloid tracer animal) inuence performance (Rogers et al.
can efciently distinguish bvFTD from AD 2015). The progressive deterioration of concep-
(Rabinovici et al. 2011). tual knowledge leads to an impairment of object
knowledge and use, although patients should
function normally with everyday objects at home
Semantic Variant Primary Progressive (also reecting an effect of familiarity for objects).
Aphasia (sv-PPA) Surface dyslexia and dysgraphia are also
observed, where irregular words (e.g., pint) are
Clinical Symptoms pronounced or written as if they were regular (e.g.,
Sv-PPA, also called semantic dementia (Snowden mint). Although symptoms and complaints
et al. 1989; Hodges et al. 1992), is a progressive preferentially focus on language impairment
disorder of language. It is a presenile disease with less emphasis on behavior, behavioral
with onset commonly ranging between 66 and symptoms are common and can mimic the
70 years. Anomia and single-word comprehen- changes observed in bvFTD (Kamminga et al.
sion decits are the core features of the disease. 2015; Seeley et al. 2005), particularly for
Although these symptoms, particularly anomia, sv-PPA with predominant right-sided atrophy.
may be observed in other FTD variants or neuro- Therefore, apathy, behavioral disinhibition,
degenerative conditions such as AD, these distur- changes in eating behavior (e.g., restriction of
bances are especially severe in sv-PPA. The food preferences and bizarre food choices), and
disease involves a gradual degradation of concep- emotional withdrawal are commonly observed.
tual knowledge (thus affecting all modalities), Patients also often present with an abnormal ego-
which impairs object knowledge and object use centric behavior (Snowden et al. 2001; Belliard
after the earliest stages. Behavioral changes sim- et al. 2007), extreme rigidity, and compulsions
ilar to those observed in bvFTD are also common such as repetitive playing of puzzles (Hodges
symptoms of sv-PPA (Hodges and Patterson and Patterson 2007). Finally, newfound religios-
2007; Bang et al. 2015; Gorno-Tempini et al. ity, collectionism, and eccentricity of dress are
2011). Finally, prosopagnosia can be observed, also reported (Edwards-Lee et al. 1997; Snowden
most commonly in sv-PPA with right predominant et al. 2001). Insight abilities in sv-PPA are mostly
atrophy, which accounts for one third of sv-PPA impaired for behavioral changes but, by contrast,
cases and shares many behavioral similarities with patients show only a mild anosognosia regarding
bvFTD (Thompson et al. 2003; Evans et al. 1995; language decits (Hornberger et al. 2014; Savage
Kamminga et al. 2015). et al. 2015).
Anomia is a key symptom of sv-PPA, occur-
ring in the spontaneous speech that, by contrast Neuropsychology
with other PPA variants, is not marked by phono- Alterations of language are the main causes of
logical or grammar difculties. This symptom is complaint and functional impairment in sv-PPA,
obvious during language assessment (e.g., picture as well as being the core features for its diagnosis.
naming test) but less noticeable in spontaneous Anomia is especially salient during picture-
speech, as patients compensate for their difcul- naming tests, where specic terms tend to be
ties with the use of circumlocutions (Hodges and replaced by more prototypical words or by the
Patterson 2007). A single-word comprehension superordinate category name (e.g., dog or ani-
decit is also a hallmark of the disease. It is also mal instead of wolf) or, in latest stages, by no
answer (Hodges and Patterson 2007; Belliard occurring mostly on verbal tasks, with a relative
et al. 2007; Savage et al. 2013). Phonological preservation of day-to-day memory (Irish
cues such as pronouncing the rst letter or the et al. 2016; Hodges and Patterson 2007) and auto-
rst phoneme of the word to help its production biographical memory (Irish et al. 2011) as well as
have little or no effect (Jefferies et al. 2008). spatial navigation (Pengas et al. 2010).
Semantic uency is dramatically impaired, Visuospatial abilities are well preserved
reecting a severe difculty to generate words in (Desgranges et al. 2007; Perry and Hodges
a particular category, while phonemic/letter u- 2000) with normal copy of complex gures
ency is relatively preserved during the early stages (Hodges and Patterson 2007). Prosopagnosia
(Hodges and Patterson 1996; 2007). After the appears predominantly in right-sided sv-PPA and
earliest stages, identication of objects in any can be its principal symptom at presentation, help-
modality is also impaired and reects a central ing to differentiate these cases from bvFTD. By F
semantic decit (Golden et al. 2015; Luzzi contrast, it is rarely observed in cases with left-
et al. 2015; Hodges and Patterson 2007; Savage side predominant atrophy (Thompson et al. 2003;
et al. 2013). Consequently, object use may also be Kamminga et al. 2015).
altered (Hodges and Patterson 2007). Similarly to Social cognition decits can be seen in both
anomia, patients with sv-PPA invariably have an left- and right-sided sv-PPA. Facial and musical
impaired comprehension of single words, which emotion recognition is altered (Hsieh et al. 2012)
is strongly modulated by word familiarity as well as empathy and theory of mind. In partic-
(Hodges and Patterson 1996, 2007; Savage ular, nonverbal sarcasm detection has been shown
et al. 2013). Therefore, while patients may be to be impaired (Rankin et al. 2009) as well as
able to repeat words without errors, difculties false-belief, mental-state inference, and attribu-
arise when they have to provide denitions: def- tion of intention (Irish et al. 2014; Duval
initions lack in detail at rst and, in the most et al. 2012).
severe stages, can be impossible. When the patient
is asked to read or write, typicalization errors Neuroimaging
are observed: irregular words are pronounced or Structural imaging examinations show character-
written as if they were regular, including verbs istic focal and bilateral, though asymmetric, atro-
(e.g., drinked instead of drank), which is typ- phy of the temporal lobe, involving the polar,
ical of surface dyslexia and dysgraphia (Hodges lateral, and inferior surface (including fusiform
and Patterson 2007; Savage et al. 2013). gyrus) with relative preservation of the superior
Executive functions in sv-PPA are overall rel- temporal gyrus (Chan et al. 2001; Galton et al.
atively preserved in left-sided presentations of 2001). This atrophy is typically left-sided (the
sv-PPA and impaired in right-sided sv-PPA. right-sided atrophy is observed in one third of
Digit or visuospatial spans are well preserved, cases) and ideally appreciated in coronal orienta-
and semantic decits may explain day-to-day tion. Medial temporal structures are also involved,
working memory impairment as well as verbal with the amygdala and hippocampus being
uency decits (Laisney et al. 2009; Jefferies severely atrophied as well, particularly anteriorly
et al. 2008; Desgranges et al. 2007; Hodges (Galton et al. 2001; La Joie et al. 2013). Involve-
et al. 1999). While alteration of cognitive exibil- ment of the ventromedial frontal cortex and insula
ity may be observed in left-sided sv-PPA, it is is also frequently observed (Agosta et al. 2012;
more often seen in right-sided sv-PPA as part Gorno-Tempini et al. 2004; Rosen et al. 2002).
of a more general dysexecutive syndrome Functional imaging shows hypoperfusion/
(Desgranges et al. 2007; Kamminga et al. 2015). hypometabolism in anterior temporal regions as
Although many patients complain of memory well as in the hippocampus and orbitofrontal cor-
problems, this does not reect a true amnesia. tex, which is more marked on the left side
Memory decits in sv-PPA are modality-specic, (Rabinovici et al. 2008; Agosta et al. 2012).
Nonfluent/Agrammatic Variant Primary words within a sentence (Leyton et al. 2011). Trial
Progressive Aphasia (nfv-PPA) and error processes often accompany this speech
output where the patient gropes for the correct
Clinical Profile sound or mouth formation. Apraxia of speech
Consistent with other syndromes on the FTD spec- (AOS), which refers to disordered articulatory
trum, nfv-PPA is a younger-onset condition with an planning and speech sound coordination, is a
average age of 60 years and equal prevalence in prominent mechanism underlying the labored
male and female patients (Johnson et al. 2005). speech in nfv-PPA (Josephs et al. 2006). Slowed
Survival is approximately 7 years after symptom rate and effortful speech are apparent in sponta-
onset (Hodges et al. 2003; Kertesz et al. 2005). neous speech output. On more standardized
According to current diagnostic criteria, hallmark assessment, when nfv-PPA patients are asked to
features of nfv-PPA are agrammatism and slow, provide a description of a series of pictures or a
effortful speech, typically with accompanying def- visual scene, their rate of speech is less than
icits in syntax comprehension in the context of one-third the speech rate of healthy control sub-
spared single-word comprehension and object jects and slower than other FTD variants (Ash
knowledge (Gorno-Tempini et al. 2011). Speech et al. 2009; Wilson et al. 2010b; Grossman
production in nfv-PPA contrasts with the uid, 2012). Formal assessment tools for this include
syntactically correct, but meaningless speech pro- describing the Picnic Scene from the Western
duction seen in sv-PPA, and patients are usually Aphasia Battery (Kertesz 1982) or the Cookie
aware of their speech output decits (Hodges and Theft picture from the Boston Diagnostic Apha-
Patterson 1996). Speech becomes increasingly sia Examination (Goodglass and Kaplan 1983).
effortful over the disease course and typically These tools can also be used to quantify the fre-
ends in mutism. Communication via writing has quency of agrammatic errors. Severely reduced
been anecdotally reported as better preserved com- uency in nfv-PPA is also evident on classical
pared to speech output; however, formal assess- tests of phonemic and semantic uency (Nestor
ment can reveal equivalent impairments in both et al. 2003; Wilson et al. 2010b).
domains (Graham et al. 2004). Prominent behav- Agrammatism in nfv-PPA is reected in the
ioral disturbance is uncommon early in the course reliance on short, simplied phrases; omissions of
of nfv-PPA; however, apathy, agitation, and depres- grammatical morphemes such as function words
sion have been documented (Rohrer and Warren or inections; and errors in word arrangement
2010) and more profound personality changes and (i.e., syntax) (Gorno-Tempini et al. 2011; Leyton
decits in social functioning can emerge with dis- et al. 2011). Frequency of grammatical errors also
ease progression (Grossman 2012). Neurological contributes to the reduced rate of speech produc-
examination in nfv-PPA patients is often tion (Gunawardena et al. 2010). Related to this are
unremarkable, although the presence of extrapyra- decits in syntax comprehension, where patients
midal features is suggestive of an FTD overlap have difculty understanding the syntactic
syndrome such as ALS or corticobasal degenera- aspects of speech (Hodges and Patterson 1996;
tion (CBD). Thompson et al. 1997). Agrammatism can be
observed in spontaneous speech or tested infor-
Neuropsychology mally by asking the patient to follow sequential
Slow, effortful speech in nfv-PPA is marked by commands that increase in their syntactic com-
errors, with abnormal prosody and a slowed rate plexity (e.g., put the pen on the watch before
of speech (Gorno-Tempini et al. 2004, 2011; Ogar giving me the scissors). Standardized assessment
et al. 2007). Errors can include distortions (lack of of complex sequential commands reveals impair-
accurate articulation), deletions, substitutions, ments relative to healthy controls (Gorno-Tempini
insertions, or transpositions of speech sounds. et al. 2004). Tasks that assess syntactic compre-
Changes in prosody can reect the incorrect hension, such as responding to questions about a
placement of stress or intonation on syllables or complex sentence (e.g., The friendly boy that the
girl chased was nice. versus a simple sentence, are documented, as well as more diffuse white
The nice, tall girl chased the friendly boy.) show matter changes outside the language network
pronounced decits relative to controls, sv-PPA, (Galantucci et al. 2011; Schwindt et al. 2013).
and bvFTD (Peelle et al. 2008). Matching syntac- Fluency impairment has been directly related to
tically complex sentences with the correct line gray matter volume in the left inferior frontal
drawing using the Test for Reception of Grammar regions, insula, and superior temporal area (Ash
(Bishop 2003) also reveals signicant impairment et al. 2009), whereas apraxia of speech is associ-
in nfv-PPA patients (Nestor et al. 2003). ated with changes in the premotor and supplemen-
Repetition of multisyllabic words (e.g., stetho- tal motor cortices (Josephs et al. 2006). Posterior
scope) is particularly sensitive to nfv-PPA, and regions of the inferior frontal cortex show func-
impaired repetition seen in the context of spared tional abnormalities related to processing of
naming and comprehension supports a break- syntactically complex sentences during fMRI F
down in grammatical processing or articulatory (Wilson et al. 2010a).
planning (Leyton et al. 2014). Testing of repeti-
tion can be done informally or using standardized
repetition tests contained in language assessment Neuropathology of FTD Variants
batteries such as the Sydney Language Battery
(SYDBAT) (Savage et al. 2013) and the Western Neuronal loss, gliosis, and microvacuolar changes
Aphasia Battery. characterize frontotemporal lobar degeneration
In contrast to the striking language decits, (FTLD). Specic patterns of abnormal protein
performance is better preserved in other cognitive deposition are observed in FTLD, such as
domains, such as episodic memory, visuospatial microtubule-associated protein tau (MAPT),
skills, and nonverbal reasoning (Graham et al. TAR DNA-binding protein with molecular
2004). However, measures of working memory weight 43 kDa (TDP-43), and fused-in-sarcoma
(e.g., digit span) are reliably impaired in nfv-PPA protein (FUS). Ubiquitin-only, p62-only positive
(Nestor et al. 2003; Wilson et al. 2010b) consis- inclusions, or no inclusions are sometimes
tent with a decit in phonological rehearsal abili- observed, but in many fewer cases (Mackenzie
ties (Leyton et al. 2014). Impairments in et al. 2010; Bang et al. 2015).
attentional set-shifting are also observed on the FTLD-MAPT or tau accounts for 3650% of
trail making test (Savage et al. 2013; Brambati all FTLD cases, almost equally distributed
et al. 2015). between Picks disease, CBD, and PSP cases
(Josephs et al. 2011; Sieben et al. 2012; Dickson
Neuroimaging et al. 2011). FTLD-TDP accounts for about 50%
Structural MRI in nfv-PPA reveals gray matter of all FTLD cases, with three major subtypes
atrophy in the inferior frontal region of the left (A, B, and C) accounting for about half of the
hemisphere, which can extend to the anterior nfv-PPA cases (FTLD-TDP-A), two-thirds of
insula, frontal operculum, dorsal prefrontal cortex, FTD-MND cases (FTLD-TDP-B), and the major-
and superior left anterior temporal lobe (Gorno- ity of sv-PPA cases (FTLD-TDP-C) (Josephs et al.
Tempini et al. 2004; Peelle et al. 2008; Rogalski 2011; Sieben et al. 2012; Mackenzie et al. 2011;
et al. 2011; Grossman 2012). Progression of gray Le Ber 2013). Deposition of TDP-43 pathology in
matter loss in the left frontal regions is evident in the hypoglossal nucleus and in the anterior cingu-
longitudinal studies, accompanied by involvement late cortex has been found to have high value to
of subcortical regions (Brambati et al. 2015). respectively identify MND and bvFTD patients
Metabolic abnormalities in left hemispheric (Tan et al. 2015). FTLD-FUS accounts for about
regions are also documented by PET imaging 10% of all FTLD cases and is characterized by
(Grossman et al. 1996; Nestor et al. 2003). Local early-onset FTD with severe behavioral and psy-
white matter abnormalities in the dorsal language chiatric abnormalities without linguistic and
network (e.g., superior longitudinal fasciculus) motor impairments (Mackenzie et al. 2011).
Finally, AD pathology is observed at autopsy et al. 1996a). Cognitive impairment occurs in the
in 1530% of patients with a diagnosis of FTD majority of patients and is characteristically
(Hodges et al. 2004; Grossman et al. 2007; Alladi fronto-subcortical, with mental slowing and
et al. 2007), mostly in bvFTD and nfv-PPA. executive dysfunction (especially attention and
verbal uency) and inefcient memory recall
(Brown et al. 2010). PSP patients also exhibit
Overlap Syndromes (ALS, AD, signicant levels of apathy and disinhibition
Logopenic, PSP, CBD) (Litvan et al. 1996b; Aarsland et al. 2001). The
combination of executive dysfunction and neuro-
A number of syndromes overlap with the classical psychiatric features supports a clinical overlap
FTD spectrum, with shared clinical, pathological, with FTD, and one case series identied over
and genetic characteristics. Overlap syndromes 30% of pathologically conrmed PSP cases met
include ALS, progressive supranuclear palsy clinical criteria for possible bvFTD (Kobylecki
(PSP), CBD, AD, and logopenic aphasia. et al. 2015). Pathologically, PSP is characterized
by accumulation of tau protein and neuropil
Amyotrophic Lateral Sclerosis (ALS) threads primarily in the basal ganglia and
ALS is dominated by motor symptoms caused by brainstem (Hauw et al. 1994; Williams and Lees
lower and upper motor neuron dysfunction. These 2009). Tau pathology represents a common sub-
symptoms include weakness, spasticity, muscle strate underlying PSP, which is also present in
wasting, dysarthria, and swallowing difculties nearly half of FTD cases (Josephs et al. 2011).
(Mitchell and Borasio 2007; Kiernan et al. A PSP-FTD subtype has been proposed to iden-
2011). Cognitive and psychiatric changes are tify those patients with a prominent FTD cogni-
increasingly recognized in ALS and 2050% of tive/behavioral syndrome. Those patients show
patients meet diagnostic criteria for FTD more extensive cortical pathology compared to
(Ringholz et al. 2005). A proportion of FTD PSP without prominent cognitive/behavioral
patients also go on to develop ALS motor features changes (Dickson et al. 2010).
(Lomen-Hoerth et al. 2002). Cognitive dysfunc-
tion in ALS is characterized by executive impair- Corticobasal Degeneration (CBD)
ment, personality changes, poor insight, and CBD is characterized by tau pathology and a
behavioral changes that include disinhibition and combination of motor and cognitive/behavioral
apathy (Flaherty-Craig et al. 2006; Phukan features related to frontoparietal neuronal loss
et al. 2007). Clinically, this presentation overlaps and basal ganglia degeneration. Numerous diag-
considerably with bvFTD (Lillo et al. 2012b). Neu- nostic criteria and terminologies have been pro-
roimaging in ALS patients with cognitive and posed (Riley et al. 1990; Boeve et al. 2003; Bak
behavioral dysfunction reveals frontotemporal and Hodges 2008; Armstrong et al. 2013). The
atrophy (Lillo et al. 2012a; Mioshi et al. 2013). clinical motor syndrome commonly associated
Consistent with the clinical overlap, FTD and with CBD is parkinsonism, asymmetric rigidity,
ALS also share overlapping pathology and genetic and corticobasal dysfunction evidenced by limb
susceptibility. TDP-43-positive inclusions are pre- or oculomotor apraxia, cortical sensory decits,
sent in half of the patients with FTD and in the and alien limb or dystonic limb posturing (Kouri
majority of ALS patients (Neumann et al. 2006) et al. 2011). The cognitive/behavioral syndrome is
and expansions in the C9 or f72 gene are a common characterized by language and visuospatial dys-
cause of both familial FTD and ALS (DeJesus- function and changes in behavior and personality
Hernandez et al. 2011; Renton et al. 2011). (Burrell et al. 2014). Visuospatial dysfunction is
typically striking and may include Balints syn-
Progressive Supranuclear Palsy (PSP) drome (simultanagnosia, oculomotor apraxia, and
PSP is characterized by vertical gaze palsy, pos- optic ataxia) (Graham et al. 2003). Language fea-
tural instability, and cognitive decline (Litvan tures overlap with nfv-PPA (Kertesz et al. 2000;
McMonagle et al. 2006) and behavioral symptoms linked to a core phonologic short-term memory
mirror those seen in bvFTD, particularly apathy decit (Gorno-Tempini et al. 2008, 2011).
and disinhibition (Kertesz and McMonagle 2010; Although the slowed speech overlaps with the
Bruns and Josephs 2013). nfv-PPA presentation, logopenic aphasics do not
exhibit the same degree of motor speech errors or
Alzheimers Disease (AD) agrammatism (Grossman et al. 1996). The con-
AD is pathologically distinct from FTD; however, frontation naming impairment is typically less
shared clinical features can make these diseases severe than in sv-PPA and characterized by pho-
difcult to distinguish. AD is characterized by nological errors as opposed to semantic errors
impaired ability to retain newly learnt information (Gorno-Tempini et al. 2004). Compared with the
(anterograde episodic memory) (Kopelman 1985; two other progressive aphasias, logopenic aphasia
Butters et al. 1987; Perry et al. 2000). Progression is associated with a more rapid progression F
sees decline in other aspects of memory (i.e., toward a global dementia that encompasses non-
semantic knowledge and remote memory), verbal domains (Leyton et al. 2013). Imaging
accompanied by attentional, executive, and visuo- abnormalities in the left temporoparietal junction
spatial decits (Hodges 2006). Cognitive decline and dorsal language network are found in
in AD is associated with early hippocampal and logopenic aphasia (Rohrer et al. 2010; Leyton
medial temporal pathological changes and later et al. 2012). Amyloid imaging and neuropatho-
frontal and parietal changes, which are apparent logical studies conrm that Alzheimer pathology
on structural, functional, and metabolic imaging is the most common underlying cause of
(Jack 2012). Episodic memory impairment was logopenic aphasia (Mesulam et al. 2008;
previously considered a distinguishing feature to Rabinovici et al. 2008; Rohrer et al. 2012).
separate AD from FTD as it was presumed to be
intact in FTD (Neary et al. 1998). However, mem-
ory impairment in FTD, in particularly bvFTD, Conclusion and Outlook
can be equally severe as seen in AD (Hornberger
et al. 2010; Bertoux et al. 2014). Atypically The current chapter gave an overview of the FTD
presenting AD may also manifest a frontal spectrums as well as the most prominent overlap
behavioral syndrome characterized by behavioral syndromes. As evident from the chapter, FTD is a
abnormalities and executive dysfunction (Warren complex and multifaceted disease, which covers
et al. 2012). The potential overlap between mem- different cognitive, neuroimaging, and pathologi-
ory impairment and behavioral change means in cal domains. More specically, FTD patients can
certain cases AD and bvFTD might only be dis- not only present with behavioral and language
tinguished postmortem. AD pathology involves problems but can also show social cognition and
the accumulation of beta-amyloid plaques and neu- memory decits as well as motor symptoms. Sim-
robrillary tangles beginning in the transentorhinal ilarly, brain regions affected by structural and
cortex and hippocampus, before progressing to functional changes can be widely distributed or
adjacent medial temporal regions and later neocor- focal. Finally, the admixture of tau and TDP-43
tical association regions (Braak and Braak 1991). pathology adds the last level of complexity for this
disease spectrum.
Logopenic Aphasia Such multifaceted complexity might at rst
Sv-PPA and nfv-PPA were the prototypical pri- seem daunting for any clinician or researcher.
mary progressive aphasias prior to identication However, FTD is therefore emerging often as a
of a third variant known as logopenic aphasia critical disease to determine pathological specic-
(Gorno-Tempini et al. 2004). Word retrieval and ity. More specically, comparisons between FTD
sentence repetition decits, accompanied by and other dementias allow to delineate cognitive,
slowed speech with frequent word-nding pauses, neuropsychiatric, and neuroimaging biomarkers
are hallmark features of logopenic aphasia and specic to each conditions. This is particularly
relevant for phenotypological variability across lobar degeneration spectrum of disorders. Cortex,
dementias, i.e., where patients can show 48(4), 389413.
Ahmed, R. M., Irish, M., Kam, J., van Keizerswaard, J.,
overlapping cognitive symptoms. Bartley, L., Samaras, K., Hodges, J. R., & Piguet,
Taken together, our overview shows the O. (2014). Quantifying the eating abnormalities in
importance of FTD as a syndrome within the frontotemporal dementia. JAMA Neurology, 71(12),
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ferent dementia pathologies on a cognitive and (Pt 10), 26362645.
neuropsychiatric level. Clearly future investiga- Armstrong, M. J., Litvan, I., Lang, A. E., Bak, T. H.,
Bhatia, K. P., Borroni, B., et al. (2013). Criteria for
tions are needed to explore this further via novel the diagnosis of corticobasal degeneration. Neurology,
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as outcome measures in disease modifying trials. Ash, S., Moore, P., Vesely, L., Gunawardena, D., McMil-
Finally, the longitudinal trajectories of cognitive lan, C., Anderson, C., et al. (2009). Non-uent speech
in frontotemporal lobar degeneration. Journal of
and neuropsychiatric changes are still virtually Neurolinguistics, 22(4), 370383.
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G
Gender Differences in Memory somewhat contradictory ndings reported in

and Cognition cross-sectional and longitudinal studies will be
highlighted.
Agneta Herlitz1, Serhiy Dekhtyar1, Martin In this review, the following main conclusions
Asperholm1 and Daniela Weber2 are drawn: There is little evidence to suggest that
1
Division of Psychology, Department of Clinical the rate of decline in cognitive performance over
Neuroscience, Karolinska Instituet, Stockholm, the life span is different for men and women.
Sweden However, cross-sectional studies, comparing indi-
2
World Population Program, Wittgenstein Centre viduals of different ages, suggest that the magni-
for Demography and Global Human Capital, tude of gender differences may change over time.
International Institute for Applied Systems Improvements in living conditions and better edu-
Analysis, Laxenburg, Austria cational opportunities are factors that may lead to
increased gender differences favoring women in
some cognitive functions and decreased or elimi-
Synonyms nated differences in other cognitive abilities.
These changes in gender differences seem to
Ageing and retirement in Europe (SHARE); take place due to a general increase in cognitive
Cohort effects; Gender differences; Longitudinal performance over time, associated with societal
assessment; Mathematics; Memory: episodic; improvements, where women improve more
Verbal ability; Visuospatial ability than men.
Age and gender are variables that have been found

to inuence cognitive performance. In the follow- Gender Differences in Cognitive Abilities
ing entry, ndings of gender differences in cogni-
tive functions will be reviewed, with a specic Not all cognitive tasks give rise to differences in
focus on examining to what extent the pattern test scores between men and women, but some do
and magnitude of these differences change over and have consistently been shown to do so. The
the adult life span. First, results on gender differ- focus in this entry will be on tasks assessing
ences found in memory and cognition tasks in visuospatial, verbal, numerical, and episodic
childhood and young adulthood are presented. memory abilities cognitive abilities that typi-
This is followed by a discussion of the extent to cally yield differences between men and women.
which these differences change over the life Visuospatial ability. Most research indicates
span and/or over geographical regions. Lastly, that men perform at a higher level than women
DOI 10.1007/978-981-287-082-7
936 Gender Differences in Memory and Cognition
when it comes to visuospatial ability. The most (Hyde and Linn 1988) showed an overall modest
recent meta-analysis on the topic (Voyer advantage for women over men (d = .11). How-
et al. 1995) concluded that men perform at a ever, different tasks yielded different effect sizes,
substantially higher level than women on most with the largest differences found in speech pro-
visuospatial tasks, with the overall gender differ- duction tasks (d = .33). In anagram solving,
ence in visuospatial ability being d = .37 womens advantage was smaller (d = .22), in
(effect size, d = (Mwomen Mmen) / Sdtotal). vocabulary it was nonexistent (d = .02), and in
Although men outperform women, the size of verbal analogies men had a slight advantage over
the difference may vary depending on the task women (d = .16). Further, in verbal production
being assessed. The largest difference is found in tasks, such as category uency, an advantage
mental rotations (d = .56; the ability to rapidly favoring women is most often found
rotate two or three dimensional gures in mind), (Maylor et al. 2007), but depending on the topic
while it is somewhat smaller for spatial perception that the participants are asked to generate words
(d = .44; the ability to determine a spatial rela- from, no gender differences are sometimes
tion regardless of distracting information) and found (Weber et al. 2014). Similarly to visuospa-
considerably smaller in spatial visualization tial abilities, studies examining the development
(d = .19; the ability to manipulate complex of verbal abilities, specically concerning verbal
spatial information when several steps are production tasks, nd gender differences favoring
required to arrive at the correct solution). girls as young as 5 years of age (Hyde and
The differences in visuospatial ability have Linn 1988). In line with this, another study
also been examined in children. For example, (Herlitz et al. 2013) has found that the magnitude
studies conducted on 3- to 4-month-old (Quinn of the gender differences is similar for 12- to
and Liben 2008) and 5-month-old babies (Moore 14-year-olds.
and Johnson 2008) have shown that male infants Episodic memory. Episodic memory refers to
are able to differentiate between rotated the conscious recollection of unique personal
(compared to the orientation it had during the experiences in terms of their content (what), loca-
encoding phase) familiar gures and novel ones. tion (where), and temporal occurrence (when). It
In both of these studies, male infants displayed a is typically assessed by rst presenting some
novelty preference for the new gure, indicating information (e.g., episodes, words, objects, or
that they recognized the familiar gure and there- faces) and then asking the person to recall or
fore spent less time viewing it. This was not found recognize the earlier-presented material.
for the female infants, who divided their attention Although the rst comprehensive review of
between the two items equally. Others (Levine gender differences in cognition did not nd any
et al. 1999) have demonstrated that 4.5-year-old differences between men and women when it
boys display the same kind of male advantage comes to memory (Maccoby and Jacklin 1974),
when it comes to spatial visualization and mental many more recent studies have found gender dif-
rotation tasks. The edge that boys have over girls ferences favoring women in episodic memory
at this age also persists into adolescence, as dem- tasks (see Herlitz and Rehnman 2008 for an over-
onstrated by Herlitz and colleagues (2013) who view). Women consistently outperform men on
found that these differences also exist around tasks that require remembering items that are ver-
puberty and that the magnitude of the difference bal in nature or can be verbally labeled. However,
is similar across the examined age groups (1214 women also excel on tasks requiring little or no
years) (Herlitz et al. 2013). verbal processing, such as recognition of unfamil-
Verbal ability. When it comes to verbal ability, iar odors or faces. In contrast, there is a male
the prevailing opinion has been that women advantage on episodic memory tasks requiring
outperform men. However, the picture is slightly visuospatial processing. Thus, the pattern of gen-
more complicated. A meta-analysis on the exis- der differences in episodic memory mirrors the
tence of gender differences in verbal abilities pattern seen in verbal and visuospatial tasks,
Gender Differences in Memory and Cognition 937
with the notable caveat that gender differences Gender, Age Decline, and Age
favoring women are also found in tasks requiring Differences
little or no verbal or visuospatial processing
(Lowe et al. 2003). Studies of episodic memory Are there any reasons to expect that men and
function in children have found the same patterns women decline cognitively at different rates in
as in adults, with girls having a slight overall old age? Biologically, there are some factors that
advantage compared to boys as well as girls would suggest age-related variation in the magni-
being better at verbal memory tasks and boys tude of gender differences. One such factor is
being better at visuospatial memory tasks (e.g., accelerated brain aging, or brain atrophy, with
Lowe et al. 2003). Also, the magnitude of the some reports suggesting that men show more
difference in adolescents is similar to the differ- brain atrophy than women (Raz et al. 2004).
ence found in adults, shown for example in a Such gender differences in age-related brain atro-
study examining memory in 12- to 14-year-olds phy may lead to greater gender differences with
(Herlitz et al. 2013). increasing age on tasks in which women excel, G
Mathematics. Mathematics is an umbrella term and smaller differences on tasks in which men
that includes several different cognitive abilities perform at a higher level than women. On the
concerning quantities, space, and numbers. other hand, the positive health selection of men
Performing mathematical tasks therefore involves with advanced age (i.e., the men who survive into
the recruitment of several cognitive abilities, and old age may be healthier than the average),
as a result, gender differences in mathematics together with an increased risk of women being
often vary as a function of type of task. Although affected by Alzheimers disease, may lead to a
gender differences exist in school grades in math- minimization of gender differences in which
ematics, with girls having a small advantage over women excel.
boys (d = .07) (Voyer and Voyer 2014), this edge When investigating differences related to age,
is typically not present on tasks assessing mathe- it is important to differentiate between longitudi-
matical ability. A meta-analysis taking type of nal and cross-sectional assessments of gender dif-
task into consideration showed that boys and ferences across the life span. With longitudinal
men have an advantage over girls in general studies, it is possible to examine to what extent
tasks (d = .15), with differences being larger the same individuals or groups of individuals
in cognitively more demanding mathematical deteriorate with increasing age, whereas the
tasks such as mathematical complex problem cross-sectional assessment will show to what
solving. Further, the differences are also more degree different age groups, measured at the
prominent in samples performing in the upper same time point, vary with regard to performance.
percentiles of the distribution (Hyde et al. 1990). Naturally, age groups assessed at the same time
Interestingly, boys have a larger advantage over differ not only with regard to age, but also with
girls in later school years as compared to earlier regard to the environment they have been exposed
(Hyde et al. 1990), indicating that the magnitude to. For example, later-born generations have typ-
of gender difference may increase throughout ically grown up in societies in which individuals
childhood and adolescence. have received more years of education, better
Taken together, gender differences exist in nutrition and health care, and more complex and
some cognitive tasks, with girls and women stimulating environments. However, the exposure
outperforming boys and men in some of them, to these societal improvements may also vary
whereas the reverse is true in others. With the between men and women, with women in many
possible exception of mathematical ability, these societies and age groups receiving less favorable
differences seem to be present already in child- exposure (Else-Quest and Grabe 2012).
hood and are preserved through adolescence and Longitudinal assessment. There have been sev-
young adulthood without any change in eral longitudinal studies looking at gender differ-
magnitude. ences in cognitive decline. One of these studies
investigated cognition over a 10-year period in a category uency and episodic memory tasks.
population-based sample (De Frias et al. 2006), However, although performance on all tasks
with over 600 participants (initially 3580 years declined with age, gender differences were
old). Regardless of initial age, it was shown that smaller in the older age groups for the tasks
gender differences remained stable over the exam- where men outperformed women, and larger for
ined 10-year period: women performed at a higher the tasks in which women outperformed men.
level than men on some cognitive tasks (episodic Although the underlying reasons for this pattern
memory, verbal production), whereas men are unclear, it can be speculated that it is related to
performed at a higher level on a task assessing sample differences; older women around the
visuospatial ability. In line with this, results from world who both have access to computers and
the Berlin Aging Study, with participants aged master English as a second language may have
between 70 and 100 years of age, showed that had to pass a higher cognitive threshold to acquire
men and women declined virtually in parallel, these capabilities, compared to participating men
with no evidence of any differences in decay of the same age.
over the 13-year period (Gerstorf et al. 2006). Other cross-sectional studies, however, have
Further, a recent meta-analysis, where altogether reported a different pattern of results (Weber
13 studies were included, came to the same con- et al. 2014). Data from the Survey of Health,
clusion (Ferreira et al. 2014). With very few Aging and Retirement in Europe (SHARE) were
exceptions, gender was not found to affect the used to analyze over 30,000 individuals, aged
rate of decline in the cognitive tasks assessed. 50 years and older, from 13 European countries.
As is often the case in geropsychological The participants were tested on tasks assessing
research, studies are only rarely conducted in episodic memory, numeracy, and category u-
less afuent regions. This is also the case for ency. For the data analysis, these 13 countries
studies on gender difference in cognitive decline, were merged into three geographical regions:
with most of them being conducted in Europe or Northern Europe (Denmark, Sweden), Central
in North America. Since it is possible that societal Europe (Austria, Belgium, Czech Republic,
differences could inuence men and womens rate France, Germany, The Netherlands, Poland, Swit-
of cognitive decline differently, future research is zerland), and Southern Europe (Greece, Italy,
needed to determine if the same type of patterns Spain). As expected, younger cohorts performed
are present in less afuent regions of the world at a higher level than older cohorts, regardless of
where there often also is less gender equity. gender and geographical region. Further, there
Cross-sectional assessment. An issue related to was a Northern advantage over Central and South-
the discussion above is whether the magnitude of ern regions, and gender differences varied system-
cognitive gender differences varies when different atically across age groups and regions (see Fig. 1).
age groups are compared at the same point in time. Using episodic memory as an example, women in
Indeed, cross-sectional studies have found that the Northern Europe performed at a higher level than
magnitude of gender differences may vary men across all age groups, whereas women in
depending on the age groups assessed. One such Central Europe only had an advantage in the
study (Maylor et al. 2007) gathered data on about younger age groups. In Southern Europe, there
200,000 individuals between the ages of 20 and was even less of a female advantage, with men
65. The participants, stemming from 53 countries, in the oldest age group performing at a higher
completed web-based tasks in English assessing level than women. Similar patterns were found
visuospatial ability, verbal production, and epi- for numeracy and category uency, with less or
sodic memory. As usual, men performed at a no advantage for men in Northern Europe, and
higher level than women on the visuospatial more of a male advantage in Central and Southern
tasks, whereas women outperformed men on the Europe, especially in older age groups.
Gender Differences in Memory and Cognition 939
male female
episodic memory numeracy category fluency
5
5
25
4
4
20
3
15
2
10
2
Northern Europe Northern Europe Northern Europe
1
G
5
25
4
4
20
3
15
2
10
2
Central Europe Central Europe Central Europe

1
5
5
25
4
4
20
3
15
2
10
2
Southern Europe Southern Europe Southern Europe

1
50 55 60 65 70 75 80 85 50 55 60 65 70 75 80 85 50 55 60 65 70 75 80 85
Gender Differences in Memory and Cognition, Fig. 1 Mean performances in episodic memory, numeracy, and
category uency across age by gender for Northern, Central, and Southern Europe (Adapted from Weber et al. 2014)
Why would gender differences in cognitive male conscripts who were tested on tasks
performance be larger in some age groups? As assessing general cognitive ability from the
discussed previously, there have been substantial mid-1950s to early 2000, where each yearly
and continuous increases in living condition with cohort was approximately 19 years old (Sundet
regard to, for example, health, economy, family et al. 2008). Results showed that the general cog-
size, nutrition, and education. Such improve- nitive ability increased more or less linearly and
ments, taking place over time, have been rather steeply (i.e., IQ increased from 100 to 108)
connected to improvements in cognitive perfor- from the mid-1950s to 1970, and to a lesser extent
mance, called the Flynn effect (Flynn 1987). An thereafter (i.e., IQ increased from 108 to 111).
example of this comes from a study of Norwegian These increases in cognitive ability were strongly
associated with increases in height, thereby opportunities are factors that may lead to
pointing to the importance of improvements in increased gender differences favoring women for
nutrition and health care, factors that also inu- some cognitive functions (e.g., episodic memory)
ence cognitive performance. and decreased (e.g., numeracy) or elimination
In the SHARE study mentioned above, the (e.g., category uency) of differences in other
investigators wanted to determine whether cognitive abilities. These changes seem to take
improvements in living conditions and educa- place due to a general increase in cognitive per-
tional opportunities, with women initially being formance over time, associated with societal
more disadvantaged than men (Else-Quest and improvements in living conditions and educa-
Grabe 2012), would explain why the magnitude tional opportunities, where women are more
of gender differences varied systematically across affected than men.
birth cohorts and regions (Weber et al. 2014). In
doing so, a regional development index was cre-
ated, which was specic for each country and age
group. Historical information about each nations Cross-References
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942 Genetics of Late-Life Mental, Physical, and Cognitive Function
Introduction Prior to the advent of genome-wide association

studies, family and twin studies were the primary
Molecular genetic studies have been challenging way to determine whether there is a genetic basis
to conduct and success has been slow. However, to a disorder or trait. Twin studies help us under-
the last decade has seen hundreds of positive stand the extent to which a trait is heritable by
genetic ndings associated with a myriad of com- comparing the trait in monozygotic versus dizy-
plex human diseases. This reects the dramatic gotic twins. Approximately 50% of the genome is
progress in the development and application of shared in dizygotic (DZ) twins, while the genome
newer methodologies and technologies for the is shared entirely in monozygotic (MZ) twins.
assessment and analysis of large genetic data. As Factors that are more concordant in MZ, as com-
important has been the development of the neces- pared to DZ twins, may have a stronger genetic
sary infrastructure that has enabled large-scale basis, whereas factors associated with similar
collaborations on an unprecedented scale rates of concordance in MZ and DZ twin pairs
(Lehner et al. 2015). Resulting bio- and data suggest that there are both genetic and environ-
repositories have made tens of thousands of mental factors at play. Twin and family studies
patient phenotypes and millions of genotypes suggest that approximately 2035% of longevity
available to researchers all over the globe. is due to genetic factors (Ljungquist et al. 1998;
Researchers are sharing data and biomaterials so Matteini et al. 2010; Newman and Murabito
that their use is maximized. However, with the 2013). Siblings of centenarians tend to live longer
exception of Alzheimers disease, large-scale than the general population as well, further
genome-wide association studies (GWAS) of supporting this notion (Perls et al. 2002). Indeed,
late-life disorders are fewer. The eld of late-life research on specic genes associated with longev-
cognitive and psychiatric disorders is still domi- ity has largely produced mixed ndings. A recent
nated by candidate genetic approaches. Genetic review by Shadyab and LaCroix (2015) identied
approaches to older adults have emphasized out- two genes that have consistently been associated
comes such as cognitive processes, psychiatric with longevity apolipoprotein E (APOE) and
disorders, resilience, and longevity. forkhead box O3A (FOXO3A). APOE is a plasma
protein that is implicated in transporting lipids and
is involved in the growth and recovery of nerves.
Genetic Basis of Longevity It is expressed on chromosome 19 and contains
three allelic variants (e2, e3, e4). The presence of
According to recent census estimates in the the e4 allele has been associated with Alzheimers
United States, the proportion of older adults disease (Corder et al. 1993), while both the e2 and
(>65 years and over) is expected to double by e4 alleles have been associated with cardiovascu-
2050 (Ortman et al. 2014). Among older adults, lar disease (Lahoz et al. 2001). FOXO3A lies
individuals aged 85 and over are projected to within the insulin-like growth factor 1 signaling
increase the most, by an astounding 137%. Lon- pathway. While its function is not entirely clear, it
gevity, typically dened as >85 years of age is likely associated with oxidative stress,
(Shadyab and LaCroix 2015), is the culmination maintaining insulin sensitivity, and cell-cycle pro-
of a number of factors. Lifestyle (e.g., smoking, gression (Newman and Murabito 2013). Telomere
exercise) is proposed to play a major role in lon- length has been proposed to be implicated in
gevity (Newman and Murabito 2013), and opti- longevity, as telomere length decreases with age
mal health behaviors can add many years to ones (Allsopp et al. 1992; Frenck et al. 1998). How-
life (Fraser and Shavlik 2001). However, there is ever, recent evidence suggests that telomere
evidence that individuals with longevity do not length is involved in healthy aging, not necessar-
differ in lifestyle from those without (Rajpathak ily longevity per se (Njajou et al. 2009). There is
et al. 2011), suggesting that other mechanisms, also some evidence that mitochondrial DNA
such as genetics, play a role. mutations may be associated with longevity as
well, through oxidative phosphorylation (Sevini individual effects are most relevant in
et al. 2014). explaining the genetic basis of longevity
One of the critical questions has been whether (Sebastiani et al. 2012).
genetic markers associated with longevity might
in fact subserve the medical illnesses associated
with later life. Based on published GWAS inves- Genetic Basis of Cognitive Function
tigations, Ganna et al. (2013) generated a genetic in Late Life
score from 707 common SNPs associated with
125 diseases or risk factors related with overall It is a little over two decades since the rst genetic
mortality. They then examined the association of markers began to be dened in association with
the genetic score with time-to-death and also with cognitive function. Given the age-related changes
incidence of nine major diseases, specically cor- observed in cognition, it is not surprising that the
onary heart disease, stroke, heart failure, diabetes, major focus of these investigations was older
dementia, and lung, breast, colon, and prostate adults. It began with the observation in 1993 of G
cancers, in two population-based cohorts of an association between Alzheimers disease
Dutch and Swedish individuals aged 4799 (AD) and the presence of the APOE e4 allele
years. While the genetic score was signicantly that held the promise of a denitive marker for
associated with time-to-death, the association this debilitating neurodegenerative disorder.
between the genetic score and incidence of APOE, a plasma protein involved in the transport
major diseases was stronger. and metabolism of lipids, is implicated in the
Epigenetic changes are thought to occur as a growth and regeneration of nerves following
function of age, and patterns of DNA methylation injury. It is expressed by a gene on chromosome
can change during the lifetime in response to 19 with three allelic variants (e2, e3, e4). The e4
internal and external forces (Ben-Avraham allele is associated with reduced levels of APOE,
et al. 2012; DAquila et al. 2013). Epigenetic conferring increased susceptibility and reduced
regulation includes altered methylated states of response to neuronal injury (OHara et al. 2005).
regulatory DNA sequences, modications of his- As the years passed, the accumulating evidence
tone proteins, as well as expression of regulatory suggested that the e4 allele is more a brain-
noncoding RNAs (Moskalev et al. 2014). vulnerability marker associated with impaired
MicroRNA (miRNA), specically miR-34a, has neuronal recovery from a range of physiologic
been implicated in aging, as have miRNA-339 challenges than a denitive marker for dementia
and miRNA-556 (Mehi et al. 2014). Long non- per se. Multiple sources of evidence since then
coding RNAs (lncRNAs) have also been pro- suggest that APOE e4 is associated with decreases
posed as a mechanism of aging (Moskalev in memory and cognitive function over time, but
et al. 2014). not all individuals positive for the e4 allele
It is important to acknowledge the effects of develop dementia.
demographic selection in studies of the genetic Despite the well-documented association of
basis of longevity. For example, although the APOE e4 with cognitive impairment, decline,
APOE e2 allele is more frequently observed in and dementia, comparing subjects who were cog-
populations with longevity, this may reect the nitively intact or demented, Valerio et al. (2014)
fact that carriers of the e4 allele have premature found that the association of APOE e4 with
mortality (Perls et al. 2002). Additionally, incon- dementia attenuated with advanced age. This nd-
sistent or null ndings may reect aws in study ing is highly suggestive of a survivor effect model
design. Candidate gene studies are the most com- for successful aging, consistent with ndings of
mon design used and focus exclusively on one other studies. Yet, not all age effects in genetics of
gene, which may attenuate ndings. It is likely late-life cognitive and/or psychiatric function
that polygenic and pleiotropic contributions, with reect a survivor effect. Age can profoundly
interactions of different genes rather than impact the expression of a gene, and physiological
changes with age can result in a very different It has been speculated that one of the limita-
impact of a genetic marker than occurs earlier in tions of GWAS approaches to cognitive function
the lifespan. with age is the presence of age-related medical
Over the past two decades, a wide range disorders. As pointed out by Stacey et al. 2015,
of genetic markers have been associated in multi- cognitive impairment, or decline, is not only a
ple studies with impairments in cognitive function feature of dementia but also results from normal
in older adults. These include catechol-o- aging. They suggested that genetic association
methyltransferase, which has been particularly studies focusing on polymorphisms in and around
associated with age-related changes in prefrontal inammatory genes represented a viable approach
and other cognitive functions (OHara et al. to establish whether inammatory mechanisms
2006); brain-derived neurotrophic factor might play a causal role in cognitive decline,
(BDNF), which has been associated with since cognitive function was frequently also
improved cognitive function in older adults in a assessed. This enabled the identication of spe-
range of domains (Leckie et al. 2014); and sero- cic genes potentially inuencing specic cogni-
tonin transporter polymorphism (5-HTTLPR), tive domains. Some of these studies report
which has been associated with variations in signicant cognitive domain-specic associa-
memory and cognitive control. These genetic tions, specically implicating interleukin 1b
markers have also been associated with measures (IL1b) (rs16944), tumor necrosis factor a
of brain structure, activation, and connectivity that (TNFa) (rs1800629), and C-reactive protein
are believed to subserve the decits seen in the (CRP) in a range of cognitive domains. Further,
cognitive manifestations of these markers GWAS implicated less direct and less obvious
(Waring et al. 2014; OHara et al. 2007). regulators of inammatory processes in cognitive
While candidate genetic marker investigations functioning, including PDE7A, HS3ST4, and
of cognitive dysfunction in the elderly abound, SPOCK3. The authors called for better cohesion
large GWAS investigations are few and far across studies with regard to the cognitive test
between. In one of the most comprehensive, batteries administered to participants as a means
Ibrahim-Verbaas et al. (2016) conducted a to further understand the basis of cognitive
GWAS on multiple cohorts of non-demented impairment and decline in older adults.
older adults from the Cohorts for Heart and Just as the pleiotropic effects of genes for
Aging Research in Genomic Epidemiology inammation also impacted cognitive function,
(CHARGE) Consortium, aged 45 and older, still others have begun to investigate whether
assessed with multiple measures of executive there are pleiotropic effects of genes associated
functioning and information processing speed. with psychiatric disorders that impact cognitive
They observed a signicant association in the functioning. Hill et al. (2015) examined the role of
discovery cohorts for the single-nucleotide poly- pleiotropy in explaining the link between
morphism (SNP) rs17518584 and in the joint dis- cognitive function and psychiatric disorders.
covery and replication meta-analysis after Employing two large GWAS data sets on cogni-
adjustment for age, gender, and education, in an tive function one from older age, n = 53,949,
intron of the gene cell adhesion molecule and one from childhood, n = 12,441 they found
2 (CADM2) with performance on digit symbol a genetic correlation of .711 (p = 2.26e-12)
substitution. The protein encoded by CADM2 is across the life course for general cognitive func-
involved in glutamate signaling, gamma- tion. In schizophrenia, they found a negative
aminobutyric acid (GABA) transport, and neuron genetic correlation between older age cognitive
cell-cell adhesion. Their ndings suggest that function but not in childhood. They found that
genetic variation in the CADM2 gene is associ- the pleiotropy exhibited between cognitive func-
ated with individual differences in information tion and psychiatric disorders changed across the
processing speed. life course, with an association of cognition and
psychiatric disorders dependent on the disorder of PCLO, and GRM7, for examination in their own
focus and stage of lifespan. study, since they were identied in a prior MDD
GWAS study. They rst investigated whether
these variants were associated with depressive
Genetic Basis of Late-Life Psychiatric symptoms in a population-based cohort of
Disorders 929 elderly (238 with clinical depressive symp-
toms and 691 controls) and secondly investigated
The study of genetics of psychiatric disorders has their associations with structural brain alterations.
blossomed in recent years. Genetic studies of late- A number of nominally signicant associations
life psychiatric disorders have evolved more were identied, but none reached Bonferroni-
slowly. The majority of studies examining genet- corrected signicance levels. Common SNPs in
ics within late-life psychiatric disorders are based BICC1 and PCLO were associated with a 50%
largely on specic disorders or on specic candi- and 30% decreased risk of depression, respec-
date genetic markers (OHara and Hallmayer tively. Among depressed individuals, rs9870680 G
2014). (GRM7) was associated with the volume of gray
Genetics certainly plays a role in the probabil- and white matter. Their results provide some sup-
ity of developing a psychiatric disorder, and her- port for the involvement of BICC1 and PCLO in
itability appears to vary by disorder. For example, late-life depressive disorders, and preliminary evi-
bipolar disorder and schizophrenia appear to have dence suggests that these genetic variants may
the highest heritability (85% and 81%, respec- also inuence brain structural volumes.
tively), whereas panic disorder (43%), major
depression (37%), and generalized anxiety disor-
der (28%) have lower rates of heritability Genetic Basis of Positive Traits in Older
(Bienvenu et al. 2011). A recent meta-review Adults
examined 1,519 meta-analyses and discovered
13 genetic variants that were common to two or In addition to the genetic basis of psychiatric
more psychiatric disorders. These included sero- disorders, in recent years, we have seen increased
tonergic pathways (SLC6A4 5-HTTLPR, HTR1A consideration of the genetic underpinnings of pos-
C1019G, SLC6A4 VNTR, TPH1 218 A/C), itive psychological traits in late life, as they are
dopaminergic pathways (DAT1 40-bp, DRD4 believed to confer increase resilience to environ-
48-bp, COMT Val158Met), vascular pathways mental stressors and protect against cognitive and
(APOE e4, ACE Ins/Del, MTHR C677T, MTHR psychiatric aging. Amstadter et al. (2014) exam-
A1298C), glutamatergic pathways (DAOA ined resilience to stressful life events in 7500 adult
G72/G30 rs3918342), as well as neurotrophic twins and found resilience has a genetic heritabil-
pathways (BDNF Val66Met), which suggests ity of approximately 31%. Mosing et al. (2009)
that there are common genetic variants that measured optimism and found genetic factors
increase vulnerability to psychiatric disorders explained 36% of the variation, with the rest due
across a number of diagnoses (Gatt et al. 2015). to non-shared environmental factors. Interest-
The number of genes implicated in specic disor- ingly, they found that the genetic predisposition
ders varies greatly. For example, 97 different to high optimism also predisposed to good mental
genes have been implicated in schizophrenia, health and self-rated health, suggesting a poten-
and 65 have been implicated in bipolar disorder, tially shared genetic basis among these variables.
but only 6 have been implicated in affective dis- Twin studies of subjective well-being suggest that
orders (Gatt et al. 2015). approximately 30 to 40% of its basis is genetic
Such GWAS investigations of older adults are (Rietveld et al. 2013).
very rare to date. Most recently, Ryan et al. (2016) Arguing that resilience may have a cognitive
selected variants within three genes, BICC1, basis, Mukherjee et al. (2014) dened executive
functioning resilience and conducted a GWAS complex, with no one specic gene or SNP, but
analysis which found an association between rather many loci having small effects that contrib-
RNASE13 and EF resilience (p =1.33 10 7). ute to the phenotypic variation.
They implicated genetic pathways involving
dendritic/neuron spine, presynaptic membrane,
and postsynaptic density in association with Gene by Environment Interactions
EF resilience. in Late Life
Another GWAS investigation that could be
considered to be examining positive traits was In older adults, environmental stressors can trig-
conducted by McGrath et al. (2013) who ger the onset of a psychiatric disorder just as it can
performed a GWAS of the mental and physical in younger populations. Genetic risk factors well-
components of health-related quality of life across documented to be associated with the develop-
multiple psychiatric diagnoses. After controlling ment of psychopathological response to stress
for psychiatric diagnostic category and symptom are the serotonin transporter polymorphism
severity, the strongest evidence of genetic associ- (5-HTTLPR) and the BDNF Val66Met polymor-
ation was between variants in ADAMTS16 and phism. The 5-HTTLPR short allele and the BDNF
physical functioning. Val66Met polymorphism have been shown to
Yet another candidate marker for positive traits moderate the association between stressful life
is CACNA1C, with Strohmaier et al. (2013) nd- experiences and depression across the lifespan,
ing that genetic variation in CACNA1C was in older adults, and the presence of both alleles
related to lower levels of optimism as well as also signicantly predicts depression (Kim
resilience. CACNA1C is a member of a family et al. 2007). Additionally, BDNF methylation
of genes implicated in calcium channels and con- has been shown to be associated with late-life
sidered to be key for normal function of both heart depression and suicidal ideation (Januar
and brain cells. While ndings are mixed, many et al. 2015; Kim et al. 2014), and 5-HTTLPR
recent investigations nd CACNA1C to be asso- status has been shown to predict response to anti-
ciated with a range of psychiatric disorders, depressants among older adults experiencing their
including schizophrenia, depression, and bipolar rst major depressive episode (Shiroma
disorder. This raises a critical issue pertinent to et al. 2014).
understanding the genetic basis of positive traits. However, while in a sample of 423 undergrad-
It may be that any genotype associated with a uates, Stein et al. (2009) found s allele carriers of
negative outcome, such as a specic psychiatric the 5-HTTLPR had reduced resilience to stress,
disorder, will likely have a genotype that is also this genetic marker was not found to be associated
associated with positive traits that characterize the with resilience in an older adult sample,
absence of the disorder. As such, these genetic suggesting the association of the 5-HTTLPR
markers may be nonspecic for positive traits with resilience attenuates with age (OHara
per se, but are associated with a range of positive et al. 2012). It has been however associated with
traits by virtue of not being associated with the poorer cognitive function in late life, with OHara
negative traits integral to mental health traits or et al. (2007) nding the s allele of the serotonin
symptoms. transporter polymorphism to be associated with
In one of the few investigations to specically poorer memory performance and reductions in the
investigate a range of genetic markers associated hippocampal structures that subserve memory.
with positive traits in older adults, Rana Further, in their 2012 investigation on resilience
et al. (2014) examined 426 women from the (OHara et al. 2012), the 5-HTTLPR l allele was
Womens Health Initiative study and found no not associated with resilience but was instead
signicant SNP associations with optimism and associated with better cognitive performance and
resilience. The authors concluded that positive self-rated successful aging. This raises the possi-
psychological traits are likely genetically bility that resilience may be a proxy variable for
cognition in older adults. Arguing that resilience References

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Georgia Centenarian Study 949
Rajpathak, S. N., Liu, Y., Ben-David, O., Reddy, S., Valerio, D., Raventos, H., Schmeidler, J., Beeri, M. S.,
Atzmon, G., Crandall, J., & Barzilai, N. (2011). Life- Villalobos, L. M., Bolaos-Palmieri, P. . . & Silverman,
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P. D., De Neve, J. E., Tiemeier, H . . . & Bartels, M.
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Ryan, J., Artero, S., Carrire, I., Maller, J. J., Meslin, C.,
Leonard W. Poon1, Peter Martin2 and
G
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risk variants for major depressive disorder: preliminary Mary Ann Johnson3
support for an association with late-life depressive 1
University of Georgia, Athens, GA, USA
symptoms and brain structural alterations. European 2
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Iowa State University, Ames, IA, USA
3
Sebastiani, P., Solovieff, N., Dewan, A. T., Walsh, K. M., Department of Foods and Nutrition, University
Puca, A., Hartley, S. W., Perls, T. T. (2012). Genetic of Georgia, Athens, GA, USA
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Shadyab, A. H., & LaCroix, A. Z. (2015). Genetic factors
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Ageing Research Reviews, 19, 17. Definition
Shiroma, P. R., Drews, M. S., Geske, J. R., & Mrazek,
D. A. (2014). SLC6A4 polymorphisms and age of
onset in late-life depression on treatment outcomes This entry outlines the goals, methods, procedures,
with citalopram: A Sequenced Treatment Alternatives and results of the Georgia Centenarian Study, an
to Relieve Depression (STAR*D) report. The American NIH-funded study of the oldest old 19882009.
Journal of Geriatric Psychiatry: Ofcial Journal of the
American Association for Geriatric Psychiatry, 22(11),
Phase 1 (19881992) was a cross-sectional
11401148. doi:10.1016/j.jagp.2013.02.012. study. Names of community-dwelling centenar-
Stacey, D., Ciobanu, L. G., & Baune, B. T. (2015). A sys- ians who had to be cognitively functioning were
tematic review on the association between inammatory obtained from voter registration lists. Additional
genes and cognitive decline in non-demented elderly
individuals. European Neuropsychopharmacology.
participants were recruited through media, area
Stein, M. B., Campbell-Sills, L., & Gelernter, J. (2009). agencies of aging, and church contacts. The two
Genetic variation in 5HTTLPR is associated with emo- younger groups (i.e., octogenarians and sexage-
tional resilience. American Journal of Medical Genet- narians) were recruited by random digit dialing by
ics Part B: Neuropsychiatric Genetics, 150(7),
900906.
the Survey Research Institute at the University of
Strohmaier, J., Amelang, M., Hothorn, L. A., Witt, S. H., Georgia. Altogether, we recruited 38 male and
Nieratschker, V., Gerhard, D . . . & Rietschel, M. 53 female sexagenarians, 31 male and 62 female
(2013). The psychiatric vulnerability gene CACNA1C octogenarians, and 35 male and 137 female cen-
and its sex-specic relationship with personality
traits, resilience factors and depressive symptoms in
tenarians, for a total of 321 study participants. The
the general population. Molecular Psychiatry, 18(5), majority of the participants were Caucasian
607613. (72.3%), but a sizeable number were African
950 Georgia Centenarian Study
American (27.7%). The race and gender distribu- and methodologies employed with 60-year-old
tions of the samples were representative of the participants may or may not be applicable to cen-
population in the State of Georgia. There were tenarians, even if the centenarians were cogni-
no proxies involved in Phase 1 of our study. tively intact and community dwelling. Detailed
The study was driven by two primary ques- summary of trials and tribulation of centenarian
tions. One, what is a theoretical model of aging studies can be found in Poon and Perls (2007).
that would be appropriate to describe life satisfac- Given the potential confounds between cohort
tion and functioning in extreme old age? Two, and age in a cross-sectional design, Phase
what are the strengths (and weaknesses) of cogni- 2 (19921998) was a longitudinal follow-up of
tively intact and community-dwelling centenar- the three initial age groups (i.e., sexagenarians,
ians that could contribute to their longevity, octogenarians, and centenarians) to examine var-
well-being, and life satisfaction? iations in results between cross-sectional and lon-
It can be said that gerontological research in the gitudinal ndings. Sixty-eight centenarians were
modern era had been heavy with data and signif- interviewed for a second time after 20 months,
icantly lacking in theories and models to consol- whereas sixty-three octogenarians and seventy
idate and make sense of the aging processes. sexagenarians were recontacted after 60 months.
Nevertheless, a multidisciplinary model was The primary results of Phases 1 and 2 were
needed to test hypotheses on the principal com- described in Poon et al. (1992, 2007), and the
ponents that could contribute to well-being and following are four noteworthy clusters of ndings
satisfaction in extreme old age. The solution in from the two phases. One, variability across indi-
1988 was to draw upon extant aging models that viduals is signicantly larger among the centenar-
could be adapted to isolate differences among ians compared to the younger 80s and 60s age
three cohorts the 60-year-old individuals, groups. This nding was replicated with similar
where most aging research had been conducted, measures in the Swedish Centenarian Study
and 80s, and 100s. The goal of such a model was (Hagberg et al. 2001). Contrary to the stereotype
to explore potential mechanisms that could con- of centenarians performing more poorly than
tribute to well-being and satisfaction in the oldest other age groups, some centenarians performed
old where limited research attention had been at the same or higher levels compared to their
expended to date. The resultant model was younger peers. At the same time, centenarians as
adapted from the Duke Longitudinal Study of a group showed the expected lower performance-
Aging (where Poon was trained as a postdoctoral based scores with steeper decline over time. Two,
associate) and the Bonn Longitudinal Study the study uncovered a host of compensatory
(where Martin did his doctoral study). The hypo- functions that allowed the centenarians to live
thetical model began by measuring individual independently in their communities. The primary
moderating characteristics (age, gender, marital compensatory functions were found in: (a) robust
status, number of children, etc.), followed by survival personality (i.e., higher scores on domi-
intervening abilities and resources (cognition, per- nance and suspiciousness), (b) intact crystallized
sonality, stress and coping, time used, religiosity, intelligence, (c) higher nutritional status (e.g.,
social and economic resources) that might provide body mass index), (d) social and community sup-
adaptational mechanisms, as well as nutrition, port, and (e) good overall levels of mental health.
mental, and physical health. The outcomes of the Three, an analysis was performed to ascertain
model were well-being and life satisfaction. whether the collected data could predict the num-
During the 4 years of data collection for ber of days of survival after 100 years (Poon
Phase 1, it is fair to note that the research team et al. 2000). The ve signicant predictors were
had signicant learning curves in understanding (a) being female; (b) fathers longevity, e.g., age
and adjusting the research methodologies, espe- of death; (c) higher cognition; (d) better nutri-
cially in sampling, recruitment, and testing of the tional status; and (e) better social support. The
oldest old. These issues were not trivial as design global analysis substantiated the function-specic
Georgia Centenarian Study 951
analyses in understanding survival mechanics as The majority of centenarians were female

well as substantiating and extending many public (84.9%) and Caucasian (78.7%). Likewise, more
health recommendations for healthy aging, espe- octogenarians were female (66.3%) and Cauca-
cially at extreme old age. Finally, the study found sian (82.5%).
that individuals subjective compared to objective Representative samples in Phase 3 contained a
assessments were more predictive of individuals wide spectrum of functioning of the oldest old
well-being and levels of successful aging among from those similar to Phase 1 to those who were
the oldest old (Cho et al. 2015). This nding on severely demented, institutionalized, and with
the utility of subjective assessment of well-being minimal functional capacities. Another advantage
has been supported by studies of the oldest old in of Phase 3 was the availability of data to test
other countries. interactions among gene and environment on a
Phase 3 (20012009) was a program project that variety of outcomes in mortality, morbidity, and
extended Phases 1 and 2 with population-based functioning among the oldest old.
samples of centenarians and octogenarians in Specic to geropsychology, Phase 3 was G
four projects: (a) genetics, (b) neuropathology, designed to examine cognition, neuropsychology,
(c) functional capacities (including cognition and personality, stress and coping, impact of distal and
neuropsychology, physical exams, medications, proximal events, as well as family and social
kinesiology, everyday functioning, blood chemis- resources and relationships. A description of an
try), and (d) resources and adaptation (including examination of prevalence of dementia among a
personality, social and economic resources, life representative sample of centenarians in Georgia
events, coping, and subjective well-being). is used as an illustration of cognitive study here.
The program project required the inclusion An unanswered question on the cognition of
of ve additional administrative units on centenarians is a valid estimate of dementia
(a) administration; (b) sampling; (c) cell, blood, among a representative population. In a review
and DNA; (d) data acquisition; and (e) data of literature, the reported prevalence was between
management. Two biologic archives were initiated 27% and 75% with a mean of 60%. Data from
to store and share specimen with qualied Phase 3 was used to validate the Global Deterio-
researchers: (a) centenarian blood, cell, and DNA ration Scale (GDS) (Reisberg et al. 1981) that had
at the Coriell Institute, New Jersey, and not been validated with centenarians, as well as to
(b) centenarian brains at the Alzheimers Center understand the large variation in prevalence esti-
at the University of Kentucky. While Phases mates (Poon et al. 2012). Using the Phase 3 data,
1 and 2 were conducted with collaborations from GDS was found to contain high and signicant
two universities, the added complexity of Phase correlations with MMSE and CDR, two instru-
3 included faculty researchers among nine univer- ments commonly used in global dementia assess-
sities. Description of the methodologies and ment. The GDS was also found to correlate
selected ndings can be found at Poon et al. (2007). signicantly with a battery of neuropsychological
Phase 3 provided a design that could test the tests that are used for dementia assessment
generalization of ndings obtained from (executive functioning, word uency, memory,
convenient samples of cognitively intact and abstract reasoning, and similarity). High and sig-
community-dwelling study participants in Phases nicant correlations were found with basic and
1 and 2. For this study, we recruited population- instrumental functions and mobility as well as
based samples of 244 centenarians and near cen- with neuropathologic ndings in the Braak
tenarians (98 years and older) and a comparison score, cerebral atrophy, brain weight, and
group of 80 octogenarians living in northern National Institute on Aging Reagan criteria for
Georgia. Participants were recruited from skilled dementia. Finally, there was a perfect concor-
nursing facilities and personal care homes in dance between GDS ratings and blind consensus
North Georgia. In addition, we used voter regis- diagnoses among a clinical team in 27 out of
tration lists to enroll additional participants. 39 cases (69% agreement, p < 0.0003).
952 Georgia Centenarian Study
The Phase 3 data was also used to provide biopsychosocial intervening processes in the
potential explanations on the wide range of determination of common outcomes such as mor-
reported dementia prevalence in the literature. tality, morbidity, and functional capacities. In this
One potential explanation was some studies manner, we would be able to compare and contrast
might have used convenient samples, and varia- contributing factors to health and longevity
tion in sampling criteria (convenient versus repre- around the world using the same metric.
sentative) might have biased the outcome.
Another potential explanation is that different
criteria might have been used to dene
dementia. If one uses a criterion of adequacy of Cross-References
everyday functioning (GDS stages 13), the
dementia prevalence is 52.2%. However, if one Healthy Aging
uses a strict criterion of any sign of mild confusion Psychology of Longevity
to severe dementia (GDS stage 37), then the Psychological Theories of Successful Aging
prevalence is 77.5%. Finally, we used Phase
3 data to demonstrate sample characteristics
References
(age, gender, education, and age distribution)
could also inuence the disparity of dementia Cho, J., Martin, P., & Poon, L. W. (2015). Successful aging
prevalence reported in the literature and subjective well-being among oldest-old adults. The
(Poon et al. 2012). Gerontologist, 55(1), 132143. doi:10.1093/geront/
Our 20-year exposure in research with cente- gnu074.
Hagberg, B., Alfredson, B., Poon, L. W., & Homma,
narians taught us two major lessons. First, the A. (2001). Cognitive functioning in centenarians:
study of aging at extreme old age may be equiv- A coordinated analysis of results from three
alent to cross-cultural studies in that generaliza- countries. The Journals of Gerontology. Series B, Psy-
tions of designs and methodologies employed for chological Sciences and Social Sciences, 56(3),
141151.
60-year-old persons may or may not be applicable Poon, L. W., & Perls, T. T. (2007). The trials and tribula-
to those at the end stage of life. Similar to cross- tions of studying the oldest old. Annual Review of
cultural studies, measurement invariance and Gerontology and Geriatrics, 27, 110.
large individual variability in abilities and func- Poon, L. W., Sweaney, A. L., Clayton, G. M., Merriam,
S. B., et al. (1992). The Georgia Centenarian Study.
tional capacities must be considered in measure- International Journal of Aging & Human Develop-
ment and analysis. Sampling strategies must be ment, 34(1), 118.
carefully considered. Testing time alone may be Poon, L. W., Johnson, M. A., Davey, A., Dawson, D. V.,
lengthened from twofold to vefold. Second, Siegler, I. C., & Martin, P. (2000). Psycho-social pre-
dictors of survival among centenarians. In P. Martin,
because of large individual differences in perfor- C. Rott, B. Hagberg, & K. Morgan (Eds.), Centenar-
mance outcome, main (direct) and interactive ians: Autonomy versus dependence in the oldest old
(indirect) effects among variables must be care- (pp. 7789). New York: Springer.
fully considered to understand the highly variable Poon, L. W., Jazwinski, S. M., Green, R. C., Woodard,
J. L., Martin, P., Rodgers, W. L., Johnson, M. A.,
aging processes. Hausman, D., Arnold, J., Davey, A., Batzer, M. A.,
Finally, since the beginning of the Georgia Markesbery, W. R., Siegler, I. C., & Reynolds,
Centenarian Study in 1988, there are many new S. (2007). Methodological considerations in studying
centenarian studies reported from different coun- centenarians: Lessons learned from the Georgia Cente-
narian Studies. Annual Review of Gerontology and
tries around the world. Owing to variations in Geriatrics, 27, 231264.
culture and contexts, the reliability and generaliz- Poon, L. W., Woodard, J. L., Miller, L. S., Green, R.,
ability of reported ndings are unknown at pre- Gearing, M., Davey, A., Arnold, J., Martin, P., Siegler,
sent. We believe it is utmost important to design a I. C., Nahapetyan, L., Kim, Y. S., & Markesbery,
W. (2012). Understanding dementia prevalence
metric or approach that would take into account among centenarians. Journal of Gerontology, A: Bio-
the molar environmental, sociologic, and demo- logical Sciences and Medical Sciences, 67A(4),
graphic moderating impact on individualized 358365. doi:10.1093/gerona/glr25.
Geriatric Neuropsychological Assessment 953
Poon, L. W., Martin, P., & Johnson, M. J. (2013). Longev- distinguish them from the signs that herald disease
ity lifestyle: The Georgia Centenarian Study. Interna- onset. In this regard, neuropsychological assess-
tional Innovation, 100102.
Reisberg, B., Ferris, S. H., de Leon, M. J., & Crook, ment can often provide valuable information to
T. (1981). The Global Deterioration Scale for assess- assist in early detection of cognitive impairment,
ment of primary degenerative dementia. The American differential diagnosis, and patient care.
Journal of Psychiatry, 139(9), 11361139. One of the common causes of abnormal cog-
nition in older adults is Alzheimers disease (AD),
a dementia typically characterized by impairment
Geriatric Neuropsychological in memory plus one or more other cognitive
Assessment domains of sufcient severity to interfere with
daily functioning. In the late 1990s, investigators
John A. Lucas began to recognize that characteristic patterns of
Department of Psychiatry and Psychology, Mayo cognitive inefciencies on formal neuropsycho-
Clinic, Jacksonville, FL, USA logical testing could help identify individuals at G
higher risk for developing AD and other dementia
syndromes. Different terminologies were initially
Synonyms used to describe this risk condition, including
mild cognitive impairment (MCI) (Petersen
Geriatric Neuropsychological Testing et al. 1999), questionable dementia (Devanand
et al. 1997), and cognitive impairment, no
dementia (Tuokko et al. 2001). The discovery
Definition underscored that dementia does not reveal itself
overnight but instead develops gradually and can
Geriatric neuropsychological assessment involves be detected in its early stages by psychometrically
a comprehensive evaluation of a patient that typ- sound neuropsychological techniques. Over time,
ically entails review of medical records and rele- the scientic concepts and diagnostic criteria of
vant medical test results, an interview with the mild cognitive impairment (MCI) have become
patient and collateral sources, administration and most widely accepted in clinical practice and
scoring of diagnostically valid tests measuring a research, with diagnostic criteria recently updated
wide range of cognitive domains, and communi- by a consensus group of the US National Institute
cation of results and recommendations to the of Health and Alzheimers Association (Albert
patient and referral source. et al. 2011).
Converging evidence suggests that the neuro-
pathologic process underlying AD and other
Introduction degenerative dementias most likely begins years,
if not decades, prior to the rst detectable signs of
With modern advances in science and medicine, MCI (Sperling et al. 2011). Longitudinal studies
the world population is expected to grow and age at multiple times before the onset of MCI reveal a
at exponential rates. According to the United period of gradually progressive cognitive decline
Nations (United Nations Department of Eco- up to a decade before symptoms reach the thresh-
nomic and Social Affairs, Population Division old of clinical diagnostic criteria. The observed
2015), the world population over age 59 will preclinical trajectory reects a long, slow rate of
more than double by the year 2050 to 2.1 billion. presymptomatic cognitive deterioration followed
The number of persons aged 80 and above is by accelerated decline in the years immediately
expected to more than triple, reaching 434 million preceding MCI diagnosis (Howieson et al. 2008).
over this same time period. As the population ages, Although reliable clinical prediction of disease is
it becomes increasingly important to understand still not yet possible prior to overt symptom pre-
the many changes that occur in normal aging and sentation, current research is exploring ways to
954 Geriatric Neuropsychological Assessment
combine neuropsychological data with other bio- Commonly assessed cognitive domains in
marker information to generate risk proles for geriatric assessments include: attention (e.g.,
dementia in much the same way algorithms of attention span, working memory, divided atten-
vascular risk factors are currently used to identify tion), memory (e.g., learning efciency, free
future development of heart disease. recall, recognition memory), language (e.g.,
Although effective dementia prevention thera- naming, uency, comprehension), visuospatial
pies are not yet available, it remains important to ability (e.g., perception, construction), and
identify neurodegenerative conditions early to executive functions (e.g., mental exibility, plan-
provide appropriate symptomatic relief, education ning, problem-solving). Neuropsychological test
for patients and families, and opportunities to administration follows standardized procedures,
participate in clinical trials. It is also important to with scores derived according to established
recognize that many medical conditions other guidelines and compared to normative standards
than dementia can impact cognition in later life. corrected for appropriate demographic variables.
Some cognitive impairment may be reversible, The neuropsychologist interprets the pattern of
such as that due to primary medical or psychiatric test scores and integrates them with behaviors
disorders. Rehabilitation therapies can help observed during the test session and information
patients with other conditions, such as stroke or obtained from the medical record and clinical
traumatic brain injury, recover from or compen- interview.
sate for cognitive impairments. Accurately identi- The most common referral questions for neu-
fying the nature and potential etiology of ropsychological assessment in older persons per-
cognitive disorders can help guide patient care in tain to diagnosis (e.g., early detection of disease,
meaningful ways. differential diagnosis) and/or functional status
(e.g., daily functioning, capacity to make
decisions).
Goals of Geriatric Neuropsychological
Assessment 1. Detecting cognitive impairment. Neuropsy-
chological assessment is commonly requested
Neuropsychology is the study of brain-behavior to determine whether perceived or observed
relationships through the use of specialized cog- cognitive changes are due to normal aging or
nitive assessment techniques. Neuropsychologists acquired brain dysfunction. To accomplish
use these techniques to answer questions regard- this, neuropsychologists administer tests with
ing cognitive status raised by neurologists, proven diagnostic validity. Diagnostic validity
internists, primary care physicians, hospitalists, refers to the sensitivity and specicity of a test.
mental health providers, other referral sources, Sensitivity is the probability that someone with
and patients themselves. The content and format true cognitive impairment is identied by the
of neuropsychological assessment depends on the test as being impaired (i.e., true positive)
specic referral question, clinical setting, and whereas specicity is the probability that
patient characteristics. In geriatric neuropsycho- someone without cognitive impairment is iden-
logical assessment, a comprehensive evaluation tied by the test as unimpaired (i.e., true
typically entails review of medical records and negative). Because these metrics are probabil-
relevant medical test results (e.g., laboratory stud- ities, they range in value from 0 to 1, with
ies, neuroimaging), interview with the patient and values closer to 1 being more desirable
collateral source to understand the presenting cog- (i.e., reecting higher classication accuracy).
nitive and behavioral symptoms, administration Ideal tests would have equally high sensi-
and scoring of tests measuring a wide range of tivity and specicity; however, in reality these
cognitive domains, and communication of results metrics act in opposition to one another such
and recommendations to the patient and referral that as one value increases, the other value
source. decreases. Choosing appropriate measures
depends on the question being addressed and distraction (Darowski et al. 2008), or inef-
the consequences of an incorrect decision. ciencies in learning or recall strategies (Davis
A test with high sensitivity but low specicity et al. 2013; Delis et al. 2000; Isingrini and
is useful when it is imperative to detect every- Taconnat 2008). Vocabulary and word recog-
one with impairment, even if a sizeable number nition remain stable with age; however, the
of normal individuals are misidentied as ability to come up with specic words or
impaired. For example, it may be preferable names declines (Singh-Manoux et al. 2012).
to identify someone without Ebola as being Executive functions such as novel concept for-
infected and isolate them for a brief time (i.e., mation and mental exibility also decline with
false-positive error) than to release someone age (Singh-Manoux et al. 2012; Wecker
with the virus into the general population et al. 2000). Several neurologic correlates to
(i.e., false-negative error). Conversely, choos- these age-related cognitive declines have been
ing a test with high specicity but low sensi- identied, including loss of gray and white
tivity is useful if one wants to ensure that only matter volume, damage in white matter path- G
those with true impairment are identied. For ways, and reduced neurotransmitter levels
example, clinical trial outcomes may be mis- (Harada et al. 2013). These changes, however,
leading if people without the condition of inter- are typically of insufcient magnitude to have
est are enrolled, such that a test that excludes a signicant impact on daily functioning.
some eligible candidates may be desirable if all 3. Differential diagnosis. Over the last decade,
ineligible candidates are excluded by it. studies of MCI, AD, and other dementias
It is important to note that sensitivity and have informed modern consensus diagnostic
specicity are necessary to select valid mea- criteria, most of which include evidence-
sures, but they only describe the function of based descriptions of characteristic cognitive
tests when the cognitive status of the individual changes (Albert et al. 2011; Gorno-Tempini
is known. They do not address the important et al. 2011; McKhann et al. 2011; McKeith
clinical question of whether a patient with a et al. 2005; Rascovsky et al. 2011; Roman
particular score has true impairment due to et al. 1993). Although psychometrically
disease. This information is conveyed by the sound test scores provide the clinician with
positive predictive value (PPV) of a test. important quantitative evidence of cognitive
A complete review of PPV and other clinical impairment, these data must be integrated
utility metrics is beyond the scope of this entry; with the clinical history, neurobehavioral pre-
however, it is important to know that PPV is sentation, knowledge of functional neuroanat-
disproportionately affected by test specicity, omy, and knowledge of the literature to fully
such that increasing specicity increases PPV utilize consensus diagnostic criteria.
to a greater degree than an identical increase in Impairment in the ability to learn and retain
sensitivity (Smith et al. 2008). new information (i.e., episodic memory) is the
2. Normal cognitive aging. Declines in most common neuropsychological decit in
processing speed, memory, language, and MCI patients who progress to AD (Albert
executive functions are common in normal et al. 2011). By comparison, patients with
aging (Harada et al. 2013). Older adults learn Lewy body dementia (LBD) demonstrate
less with initial exposure to new information early decits in attention and visuospatial
and require longer or repeated exposure to functions (Ferman et al. 2013; Hamilton
learn the same amount as younger adults. et al. 2012). Disturbances of behavioral regu-
They are also less efcient in retrieving learned lation and a pattern of relatively weaker exec-
information, although retention is relatively utive functions than episodic memory are seen
preserved. Age-associated memory changes in early behavioral variant frontotemporal
may be related to slow processing speed dementia (FTD) (Wittenberg et al. 2008),
(Luszcz and Bryan 1999), heightened whereas early characteristic speech and
language decits typify the progressive tend to be better predictors of ability to perform
aphasia variants of FTD and AD (Gorno- activities that place high demands on cognition
Tempini et al. 2011). Patients with vascular (e.g., managing nances) and are less robust
cognitive impairment due to strokes often in predicting ability to perform more basic or
show multifocal neuropsychological decits habitual self-care activities (Farias et al. 2003).
reecting damage to the affected neuroanat- The literature suggests that within geriatric
omy and/or disconnected brain systems. populations, performances on measures of
Patients with chronic vascular risk factors memory and executive functions are most
(e.g., diabetes, hypertension) typically demon- strongly associated with ability to perform
strate decits in processing speed, working higher order activities of daily living
memory, and mental exibility due to chronic (OBryant et al. 2011; Tomaszewski Farias
ischemic disruption of deep white matter fron- et al. 2009).
tal subcortical pathways (Sachdev et al. 2004). Neuropsychological ndings can help patients
As noted earlier, a number of conditions and families better understand and manage
may produce reversible cognitive impairment limitations in daily functioning due to cogni-
in older adults. These include depression, tive changes and identify needs for assistance
medications, hydrocephalus, nutritional de- or safeguards. A special category of geriatric
ciencies, and metabolic/endocrine conditions neuropsychological assessment is the capacity
(Tripathi and Vibha 2009). Neuropsychologi- assessment. Capacity refers to ones ability to
cal prole patterns, medical consultation, and perceive and understand information accu-
appropriate laboratory tests can often distin- rately and to act on that information in a com-
guish these disorders from static or progressive petent fashion. Capacity evaluations seek to
cognitive disorders. determine if a patient can live independently,
4. Longitudinal assessment. Neuropsychological make medical decisions, enter legal contracts,
assessments conducted at a single point in time manage nances, make or change their will,
can sometimes yield inconclusive diagnostic donate assets, name a power of attorney,
information or may identify a disease process etc. Measures of attention, comprehension,
with a potentially dynamic course. In such learning, recall, integration of information,
cases, it is often helpful to obtain prospective, planning, reasoning, and impulse control con-
longitudinal assessments to more reliably tribute valuable information to these important
establish the diagnosis, identify new patient/ decisions.
caregiver needs, or assess recovery/response to Although the ability of neuropsychological
treatment. When a progressive neurodegenera- assessment to identify cognitive impairment is
tive condition is suspected, neuropsychologists often highlighted, assessment can also identify
often will include a brief cognitive screening areas of cognitive strength that may be
measure, such as the Mini Mental State exploited to limit or compensate for the impact
(Folstein et al. 1975), Montreal Cognitive of disease on everyday functioning. Rehabili-
Assessment (Nasreddine et al. 2005), or tation models have long helped patients with
Dementia Rating Scale (Jurica et al. 2001) as traumatic brain injury and stroke adapt to cog-
part of the baseline battery. This ensures the nitive changes brought on by their condition,
ability to briey measure broad cognitive sta- and in recent years, these models have been
tus when disease has progressed beyond the modied and applied to geriatric populations
point where patients can tolerate a full neuro- with MCI and early dementia. Clinical trials
psychological assessment. demonstrate improved cognition, mood, and
5. Functional status. An older adults indepen- psychological well-being after completing
dence and other factors contributing to quality such programs (Talassi et al. 2007; Jean
of life may be altered by cognitive changes. et al. 2010); however, these interventions
Not surprisingly, neuropsychological measures only delay the time to dementia onset and do
not prevent disease progression. Nevertheless, cultures, school systems, and language back-
lengthening the timeframe during which grounds are at heightened risk of scoring low
patients remain independently functioning on neuropsychological tests for reasons other
can improve quality of life, reduce caregiver than true cognitive dysfunction, and thus being
stress, and ease nancial burdens associated mislabeled as impaired when no brain dis-
with home health costs and assisted living. ease is present. Availability of ethnic and lin-
guistic norms is growing but remains limited. It
is therefore essential that neuropsychologists
Considerations in Geriatric know when appropriate normative corrections
Neuropsychological Assessment are available, and understand the limitations of
ndings when patients do not closely match the
Regardless of the intended purpose of the neuro- demographics of the normative sample used.
psychological assessment of the older adult, clini- 2. Testing modications. Some age-related
cians must be aware of the many confounds that changes are universal (e.g., slowed processing) G
may contribute variability to test scores beyond and corrected when age-adjusted normative
that due to brain disease. Some confounds can be data are applied to test scores. Other common
addressed quantitatively by minimizing their problems of aging, however, vary considerably
inuence through normative corrections. Others from individual to individual and cannot be
must be addressed through other means, such as corrected by group normative data. Effects of
accommodation, modication of procedures, or these factors on test performance require con-
clinical judgment. sideration that may necessitate modications
to the test environment or assessment plan.
1. Normative corrections. Reducing the noise (a) Primary sensory decits. Vision impair-
in test scores due to confounds increases test ment is common in older adults due to a
specicity which, as noted earlier, improves combination of age-related changes and
the probability that a low score is due to true higher prevalence of ocular disease (e.g.,
cognitive impairment. Use of appropriate nor- cataracts, macular degeneration). Hearing
mative data serves this purpose. Since cogni- loss is also prevalent in older adults, and
tion declines with normal aging, correcting test yet, for example, less than one third of US
variance due to age is essential in geriatric elders with hearing loss use hearing aids
assessment. Most clinical assessment measures (US Department of Health and Human Ser-
provide age corrections for older adults, vices 2014). Such patients can often be
although the availability of age-adjusted accommodated with magnifying or ampli-
norms in the oldest old (age 90+ years) remains cation devices. Alternatively, the neuro-
limited. psychologist may choose tests that
In addition to age, many cognitive tests are minimize the sensory confound (e.g., giv-
sensitive to differences in education and cul- ing a hearing impaired patient a word-list
tural diversity. Corrections for years of educa- memory test where the words to be learned
tion are commonly available but considerable are presented in writing). Some patients
work remains to account for differences in test with primary sensory decits may require
performance related to cultural, ethnic, and modication of test procedures that
language variables. Research shows that these break standardization, such as using
variables often serve as proxies for other soci- enlarged stimuli, allowing extra time for
etal inuences that affect test performance, sensory-perceptual processing, or repeating
including socioeconomic status, nutrition, misperceived stimuli or instructions. Such
access to health care, health literacy, and lack modications should always be reported
of comfort/familiarity with testing (Brickman when interpreting and communicating test
et al. 2006). Individuals from different results.
(b) Sleep disorders and fatigue. Sleep quality speed (Hart et al. 2000), most likely due to
and quantity decrease with advanced age. multiple factors, including acute discom-
Healthy older adults are less able to initiate fort, distraction due to heightened somatic
and maintain sleep, and they spend less time focus, side effects of analgesic medica-
in restorative slow-wave and rapid eye tions, pain-related sleep disturbance, and
movement (REM) sleep (Espiritu 2008). pain-related mood disturbance.
Sleep may be further altered due to nocturia, Chronic pain and its related symptom-
medication effects, or changing life events atology are a source of performance vari-
such as the death of a spouse. Disorders of ance that may warrant postponing the
sleep such as obstructive sleep apnea, rest- neuropsychological assessment when
less legs syndrome, and REM sleep behav- symptoms are acute, severe, or not yet
ior disorder are also more prevalent in older fully evaluated/controlled. When testing
adults (Lee et al. 2008; Ohayon and Roth an older adult with chronic pain, the
2002; Markov et al. 2006). test environment may need to be adjusted
Chronic sleep deprivation and daytime by attending to appropriate ergonomics
somnolence impact cognitive efciency in (adjusting table height, using large diame-
characteristic ways, including slowed ter writing implements, etc.), encouraging
processing and attention deciencies patients to bring/use orthotics, and
(Waters and Bucks 2011). Higher order allowing patients to stand or change posi-
cognitive functions are affected by sleep tions as warranted to help minimize dis-
to the degree that they depend on attention traction due to pain.
and processing speed. Sleep disturbance (d) Mood. Stress, losses, and illnesses of
has a dose-dependent effect on cognitive advanced age disrupt quality of life and
impairment, with greater severity of contribute to mood changes in later life.
insomnia associated with greater cognitive Symptoms of late-life depression, how-
impairment. Sleep-related cognitive de- ever, may be subtle, atypical, or fewer in
cits typically improve, however, once nor- number than required to meet diagnostic
mal sleep patterns resume (Waters and criteria for clinical depression. The preva-
Bucks 2011). lence of major depression in community-
When assessing older patients with dwelling elders over age 64 ranges from
complaints of fatigue or somnolence, con- 1% to 5%; however, clinically signicant
sideration should be given to prioritizing/ depressive symptoms are reported by 15%
shortening the test battery and including (Fiske et al. 2009). When health concerns
higher order cognitive measures that are are present, the risk of depression increases
less dependent on sustained attention and twofold to threefold (Andreasen et al.
processing speed. The examiner 2014; Ali et al. 2006; Spijkerman et al.
should be vigilant for signs that fatigue is 2005).
confounding test performance and con- Neuropsychological studies of late-life
sider breaking up the assessment over mul- depression nd reduced information
tiple sessions if necessary. processing speed, inefcient memory,
(c) Chronic pain. Common causes of pain in and executive dysfunction (Dybedal et al.
older adults include arthritic conditions, 2013). Similar to assessment decisions in
musculoskeletal disorders, neuropathies, patients with pain or fatigue, the decision
and vertebral compression due to injury to proceed with neuropsychological testing
or osteoporosis. Neuropsychological stud- depends on the degree to which symptoms
ies suggest that chronic pain is associated are managed at the time of testing.
with decits in attention and psychomotor Depressed patients can generally sustain
sufcient effort on formal neuropsycho- Thoughtful attention to respectful interac-

logical testing to yield valid results tions is another important component of rap-
(Larrabee 2012); however, those who are port building with older patients. Oftentimes,
acutely grieving or recently presented with the patient may recognize their cognitive
an ominous diagnosis may not be able to decline and feel embarrassed by it. Those
produce valid neuropsychological proles. who formerly held positions of authority, ef-
In such cases, clinical judgment should ciency, or pride may become uncomfortable or
dictate the approach to assessment. agitated when a much younger examiner
3. Rapport. The ability to develop a working begins to ask difcult questions, judge their
relationship with patients is essential to responses, and observe task performances.
obtaining valid neuropsychological results Although test standardization may make it dif-
across all populations; however, establishing cult to avoid these threats to rapport, a skilled
rapport with older adults can present unique examiner can repair the relationship between
challenges. Attending to issues of sensory loss, tasks by expressing sincere interest in the G
pain, fatigue, and mood symptoms as patients greater life experience, recognition
described above can facilitate rapport because of their former expertise, or appreciation for
it demonstrates recognition and understanding important historical events, cultural move-
of the patients needs. The neuropsychologist ments, or values associated with the patients
should also understand that their assessment generational cohort.
may represent the rst time a patient has been
referred to a healthcare professional whose title
contains the word psychologist. Genera- Summary
tional differences in the perceived stigma of
such a referral may engender anxiety or defen- Measuring and understanding cognitive symp-
siveness in an older patient. There is also sig- toms in older adults is important in geriatric prac-
nicant potential for patients to misunderstand tice given that independent living, decision-
the process or goals of neuropsychological making capacity, and other factors affecting qual-
assessment. Referring providers may not fully ity of life may be affected when cognitive changes
explain the rationale for ordering the assess- are suspected. Clinically meaningful geriatric
ment or the exact nature of the evaluation. neuropsychological assessment therefore war-
Even when given appropriate information at rants multiple considerations. The neuropsychol-
the time of referral, patients with cognitive ogist performing the assessment must be
decits may not fully understand or remember knowledgeable about cognitive changes that
what they were told, or they may express trep- accompany normal aging, characteristic symp-
idation about being evaluated. Moreover, large toms that distinguish normal changes from early
cohorts of older persons were not afforded the disease, underlying brain systems affected by dis-
educational opportunities of subsequent gener- ease mechanisms, and current consensus diagnos-
ations and may feel intimidated by testing. tic criteria. The reason for assessment must be
These and other expectations can often be clear and the neuropsychologist must understand
identied and managed during the informed the symptom presentation and clinical history suf-
consent process at the outset of the assessment. ciently to select assessment measures with the
Careful explanation of the nature of the assess- appropriate diagnostic validity and clinical utility.
ment procedures, the type of information gath- Ongoing attention must be given to potential con-
ered, the way the information will be used to founds or threats to validity that may introduce
help the patient, and the voluntary nature of the variability to test performances, and consideration
process can help reassure otherwise reluctant must be given to the appropriate corrections or
patients. accommodations required.
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962 Gerontechnology
Wecker, N. S., Kramer, J. H., Wisniewski, A., Delis, D. C., GT and the Generation Effect
& Kaplan, E. (2000). Age effects on executive ability.
Neuropsychology, 14, 409414.
Wittenberg, D., Possin, K. L., Rascovsky, K., Rankin, The concept of technology generations, borne out
K. P., Miller, B. L., & Kramer, J. H. (2008). The early of the eld of sociology in the 1990s, describes
neuropsychological and behavioral characteristics of the idea of birth cohorts being dened by their
frontotemporal dementia. Neuropsychology Review, own particular experiences with technology (e.g.,
18(1), 91102. doi:10.1007/s11065-008-9056-z.
referring to youth of today as internet genera-
tion). Generation effects are a central issue to
many aspects of GT and are especially relevant
Gerontechnology as regards issues such as user interface design,
user acceptance, and usability across an array of
Geoffrey Lane1, Tyler Haydell2, Mersina Simanski2
technological products and applications. For
and Cassandra Stevenson3
1 instance, users who have not been exposed to a
Psychology Service, VA Palo Alto Healthcare
technology prior to a critical period of exposure
System Livermore Division, Livermore, CA,
(e.g., mid-20s) are far less likely to become uent
USA
2 users of that technology. Younger adults today
Stanford University, Stanford, CA, USA
3 who began their lives exposed to search engine
Physical Medicine and Rehabilitation Service,
technology are far more familiar with the use of
VA Northern California Healthcare System,
Boolean operators (dened as making use of
Martinez, CA, USA
words and, or, and not for the purposes of
rening search engine results for greater accu-
racy) than their older adult counterparts. In con-
Synonyms trast, older adults rely more on more familiar
system tools, such as online encyclopedias
Technogeriatrics; Technogerontology
(Rogers and Fisk 2010). More broadly, the idea
behind the technology generation effect is that
introduction of a multilayered interface to indi-
Introduction viduals socialized to single-layered user interfaces
will invariably produce an obstacle toward tech-
Gerontechnology (GT) is an applied eld of study nology adoption and usage behavior.
and is a fusion of gerontology and technology. It is An example of a single-layered interface
a relatively new eld, with the term itself design is what was found in rst-generation
apparently rst coined in the literature just prior microwave ovens with its analog controls, all
to the 1990s (Micera et al. 2008). By its very device functions were fully visible to the user
nature, the eld is dynamic, as it is predicated on (e.g., dial for cooking time, switch to toggle
the application of ever-changing technologies to high-low settings, button for power). In contrast,
the needs of an ever-changing birth cohort. It is modern microwave ovens are now equipped with
also by its nature interdisciplinary, comprised of digital controls and menu-based, hierarchical
researchers, clinicians, and academicians in elds interfaces, where software allows for various
as diverse as (but not limited to) psychology, options and functions to remain invisible until
computer science, engineering, ergonomics and selected by the user (Harrington and Harrington
human factors, geriatric medicine, and architec- 2000). The concept of technology generations has
ture. GT is concerned with the development, adop- received empirical support as an entity indepen-
tion, and use of technology for the purposes of dent of cognitive and functional decline common
maximizing the health, well-being, and functional to older adults (e.g., such as slowed processing)
independence in all domains (including social, (Bouma et al. 2007). Technology generations
occupational, vocational, and psychological) in have been grouped in different ways by various
older adults. authors, with the predominant interaction style
Gerontechnology 963
(e.g., the way the user communicates with the 1. Physiological: respiration, food, water
technology) as the principal distinguishing factor. 2. Security and safety: security of body, health,
These groups are: resources, money
3. Social: love, belonging, friendship
1. The mechanical generation, born prior to the 4. Self-esteem: love and respect of oneself and
1940s others
2. The electromechanical generation, born 5. Self-actualization: morality, creativity, peak
between the 1940s and 1960s experiences
3. The digital generation, born from the 1960s on
(Harrington and Harrington 2000) Maslows theory is extremely popular and
well-represented in GT literature. It has the benet
of suggesting concrete directions for inspiring
Gerontechnology: Theoretical technology design that goes beyond the tradi-
Perspectives tional, dependency-driven framework mentioned G
above. However, it does not have much direct
Gerontechnology is a eld relatively rich in data empirical support. The continuing popularity of
but has been historically poor in explicit theory Maslows theory in the eld of GT (and else-
development or, at least, explicit theoretical where) may be because of its broad interpretabil-
articulation which runs the risk of ageist atti- ity. By the same token, its broad interpretability
tudes and frameworks coloring how inquiry is and the complex nature of needs within Maslows
approached (Rogers and Fisk 2003). For example, hierarchy limit its usefulness as a guiding theoret-
the traditional focus on the use of surveillance ical framework for GT.
and monitoring technologies with older adults, Selection, optimization, and compensation.
such as bed and chair alarms in nursing homes, One potentially helpful way to make sense of the
may work for the laudable goal of insuring safety chaotic eld of GT, and avoid invoking a
but may end up inadvertently reinforcing the dependency-focused framework, is to refer back
role of older adults as inherently disabled and to the extremely inuential theoretical framework
dependent. laid out by Paul Baltes: that of selective optimiza-
There are a number of existing theoretical tion with compensation (SOC).
frameworks drawn from lifespan development Briey, SOC theory posits that successful
work, motivational theory, and technology usabil- aging and adaptation consists rst of selection,
ity research that may be helpful to understanding whereby an individual develops and elaborates
how to frame GT in a more positive manner. personal goals, whether due to a freely chosen
Important theoretical perspectives relating to GT reweighting of what is personally valued or as a
are drawn from motivational theory, theories of response to losses. There is optimization, i.e., the
successful aging, health psychology, and informa- active process of devoting time, energy, and
tion systems. Below is a brief selection of some of resources into developing or rening a new skill.
additional theoretical perspectives from which GT Finally, there is compensation, whereby an older
can potentially draw. adult actively makes use of a new or alternative
Maslows hierarchy of needs. Abraham behavioral repertoire or activity in order to satisfy
Maslow created his motivational theory of the personal goals, in the face of physical, functional,
hierarchy of needs in the 1950s as a counterpoint or cognitive losses. This suggests that older adults
to the prevailing behavioral and psychoanalytic will tend to focus their limited energies and
ethos of the time. He posits that all humans (older resources on activities (or technologies) they feel
and younger alike) are motivated to satisfy a series will yield the greatest benet for achieving their
of needs that go from the more basic to the more goals. For example, an older adult who, due to
existential and higher order (Oppenauer 2009), physical and functional losses, cannot travel to
namely: visit family will invest time and energy into
964 Gerontechnology
mastering the use of email and social networking SST has implications for use of technology by
applications to maintain valued social and older individuals. For example, if an older adult
family ties. views email as a benecial strategy for preserving
If these technologies do not present obvious close, intimate personal connections with friends
perceived benets to older adult users, successful and family, SST tends to predict they will gravi-
adoption will not take place, and no compensatory tate toward using it. However, if email use is seen
benets will be gained. Some issues that might primarily as a vehicle for information seeking,
degrade the perceived benet of a technology to older adults will tend not to adopt this technology.
an older adult include poor user interface Similarly to SOC theory, SST may be more nar-
(UI) design, which refers to the method by rowly interpretable and therefore of more practi-
which a computer and human interact. One well- cal use as a framework for guiding GT.
known example of UI design is the graphical user Locus of control and self-efcacy. Health
interface or GUI which the Apple Macintosh psychology also yields potentially important addi-
platform popularized in the early 1990s. tional perspectives on technology usage behavior in
UI is of paramount importance when designing older adults. As the initial development of locus of
websites, particularly for older adults. If, for control theory suggests, people tend to vary in how
example, a website makes excessive use of much they see events being determined by their
pop-up windows in their website design, it own behavior (internal locus of control) or by exter-
could be confusing for older adults and lead to nal, uncontrollable events. There is some sugges-
lower rates of use. Poor target marketing could be tion that older adult technology users are more
another factor in limiting perceived benet of a likely to feel less controlled by external circum-
given technology (e.g., new technologies are fre- stances and report greater feelings of empower-
quently marketed to consumers in their twenties ment. Likewise, self-efcacy about technology
and thirties by default). usage can be extremely powerful essentially
Unlike Maslows hierarchy of needs, SOC the- greater personal belief in technical problem-solving
ory does have the benet of being more narrowly abilities in older adult users tends to predict greater
interpretable in certain ways. The theory continues use of positive coping strategies.
to be rened in terms of its applicability to GT. While the application of these attributional
Socioemotional selectivity theory (SST). theories to GT is potentially powerful, their utility
SST is another theory that relates to successful for guiding technology design is yet to be fully
aging. It dovetails somewhat with SOC theory in realized.
that it addresses the issue of resource scarcity that Technology Acceptance Model (TAM).
is often part of aging. In SST, the issue is scarcity Unlike the above theories drawn from gerontol-
of time. ogy and psychology, TAM was borne of the study
SST broadly speaks of two goals that appear to of information systems technology and developed
motivate adults in their quest for social connec- and later rened primarily with working-age
tion, the rst being information seeking, which adults in mind.
can be relevant to professional or workplace For any given technological innovation to be
goals and is instrumental in nature. The second utilized, there needs to be a level of technology
is emotion regulation, with the goal being the acceptance. Technology acceptance is a necessary
maintenance of positive emotional states (the precursor to successful technology adoption, both
so-called positivity bias). in the straightforward individual sense (e.g.,
SST posits that as a person ages and their time whereby a novice, tentative user transitions to
becomes foreshortened, they will necessarily becoming an experienced, regular user of a
become more motivated by emotion regulation given application or device) and in the sociologi-
at the expense of information seeking. In contrast, cal sense (e.g., where a given technology attains to
younger adults tend to be motivated by both infor- critical mass of users to gain widespread,
mation seeking and emotion regulation. established use in a given population).
Gerontechnology 965
Perceived
Usefulness
(PU)
Attitude Behavioral
External Actual Usage
toward Intention to
Variables Behavior
Using (AT) Use (BI)
Perceived Ease
of Use (PEU)
Gerontechnology, Fig. 1 Technology Acceptance Model (TAM)

G
In TAM, for actual technology usage behavior factors that distinguish them somewhat from their
(UB) to occur, a user needs to rst have positive younger adult counterparts. These factors include
appraisals in terms of perceived usefulness more limited energy as well as greater constraints
(PU) and perceived ease of use (PEU). Both PU in the availability of physical and cognitive
and PEU need to reach a threshold for a positive resources. Although no one, including younger
attitude toward use (ATU) and a foregoing behav- adults, has unlimited resources and energy to
ioral intention to use to occur, which then lead to acquire and learn new technologies, older adults
successful UB. The original model is below are by denition in a phase in life where some
(Fig. 1): degree of cognitive and physical loss is expected.
TAM has been found in limited investigations Fortunately, there exist research-based guide-
to have utility in predicting older adult usage lines that take into explicit account issues of task
behavior as well. However, the applicability of difculty; age-related changes in cognitive, per-
the model has been limited somewhat by the ceptual, and processing ability; and also cultural
fact that TAM was originally developed and and cohort issues that inuence technology accep-
envisioned using working-age adults with the tance and adoption. Some examples of design
adoption of workplace technology as the target guidelines that are specic to older adults include
behavior. In other words, the perceived usefulness (Hardy and Barid 2003; Mynatt and Rogers
of a given piece of technology in older adults will 2010):
typically not be related to its perceived workplace
utility. Instead, perceived usefulness will depend Strict adherence to ergonomic design princi-
on factors such as its ability to improve the safety, ples (say, in home design) to account for the
security, and daily lives of users. higher incidence of chronic medical conditions
in older adults.
In e-learning and web design, recommend ex-
Usability and Design Issues with Older ibility in presentation (e.g., text, voice, anima-
Adults tion) to compensate for sensory limitations.
Manual and interface design should allow for a
Technology acceptance and use in older adults modest but signicant difference between
is critically dependent on usability, which is gen- average literacy levels of older and younger
erally dened by the learnability and ease of use of adults.
a given man-made physical or virtual object. Flexible design approach to accommodate
The acceptance and adoption of new technol- slower speeds of older adult users. Slowed
ogy in older adults appears to be constrained by speed of older adult operators is both a
966 Gerontechnology
consequence of normal, age-related cognitive As the population of older adults has surged,
changes and also may be related to the tech- the strain of overburdened care facilities and the
nology generation effect. negative emotional and physical effects of the loss
Introduce design features that take into account of independence and decreased quality of life
single-layered design preferences common to associated with admission to care facilities has
the electromechanical generation (e.g., one given rise to the development of technologies
control which controls one function, as that can help older individuals age in place,
opposed to a control with a multiple functions). retaining independence and living at home for as
If that is not possible, then have the most com- long as possible. Telecare, telehealth, smart
monly used functions be accessible via the home and surveillance technologies, and cogni-
topmost layer of the interface. tive orthotics all have utility in this arena. How-
Consider the use of skeuomorphic design prin- ever, given the signicant healthcare costs
ciples when designing interfaces (e.g., making associated with loss of independent functioning
software features retain features reminiscent of in older adults, it is surprising how little attention
familiar physical objects), which may help to has gone thus far toward research into technology
increase comfort and satisfaction of users. purposed (or repurposed) for use by dementia
Consider the use of voice controls, or, if avail- caregivers themselves.
able, touch screen controls to reduce the cog- GT is also of potential use for informal care-
nitive load on users. givers of older adults. An informal caregiver is an
Deliberately avoid the egocentric intuition unpaid individual (a spouse, partner, family mem-
fallacy in technology design (e.g., the ber, friend, or neighbor) involved in assisting
assumption, often tacit, by technology design others with activities of daily living, including
staff that they are representative of their end medical and social tasks. There are 43.5 million
users). This can be avoided by focusing on adults who care for a disabled or ill family mem-
basic user-centered design (UCD) ber over the age of 50. There exists a correlation
principles a process of constant feedback between caregiver well-being and health out-
between end users and technology designers comes in both the caregiver and the care recipient.
as a technological product is being developed. The outcomes for the caregiver are both physical
and mental: 4070% of family caregivers have
clinically signicant symptoms of depression
Special Populations: Dementia Care with about a quarter to half of these caregivers
Recipients and Caregivers meeting the diagnostic criteria for major depres-
sion (Zarit 2006). The caregiver population pre-
Gerontechnology for older adults with dementia sents unique challenges for technology
has been primarily devoted to developing innovators. Intervention technologies will address
surveillance technology for residential care the most prevalent caregiver needs, including:
facilities (e.g., chair alarms, bed alarms, and
WanderGuard zone alarms) and assistive medi- Coordination. Caregivers become overwhelmed
cal devices. When it comes to GTs attention to by the quantity of tasks they needs to do, as
this population, it has mostly been focused on well as the extensive time over which the care-
older adults who are receiving caregiver, residen- giver role extends. Several tools for caregivers
tial care, or both, as opposed to older adults still address this need by helping the caregiver
living and functioning independently in the com- compile and prioritize these tasks or delegate
munity (Topo 1998). It is only recently that GT the tasks between multiple family caregivers.
has begun to focus on providing for the needs of Access to resources. National health organiza-
this population in the areas of functional enhance- tions and academic journals have published
ment, leisure, comfort, satisfaction, and social extensive educational materials about best
connection. practices and disease state information
Gerontechnology 967
available to keep caregivers informed and in Surveying the Gerontechnology

control. There are also many support groups, Landscape
both in person and online, tailored to the dis-
ease or condition of the care recipient. New An emphasis on maintenance of independent
technologies should aim to deliver this infor- functioning in the demented individual for as
mation to the caregiver more effectively. Better long as possible has both implications for preser-
access to social outlets and referrals to human vation of function as well as nonspecic benets
resources should be addressed by innovators. to quality of life, well-being, and dignity for the
Decision making support. Many caregivers use individual. The gerontology canard use it or lose
support groups and other human resources to it certainly applies here. This can result in a spiral
make important decisions about their loved of low expectations, poor opportunities, and a
ones care, including when and how to transi- societally based de-skilling phenomenon
tion to formal care, medications to take, and (Fig. 2).
other facilities or services to use depending on Some reasons for this include the wide range of G
the condition of the care recipient. Technolog- variability and complexity in older adults that is
ical tools can aid the decision making process only magnied by the presence of a dementia, as
by using personalized information about the well as preexisting service delivery limitations,
caregiver and care recipient. and public perceptions.
Personal health. Caregivers are able to better Telecare, telehealth, smart home and surveil-
provide care if they continue to engage in the lance technologies, cognitive orthotics, and simi-
activities and interests that will benet their lar advances in technology all have utility in
health. Tech solutions that promote healthy breaking out of this spiral. For example, an older
behavior for the caregivers themselves will adult who, due to mild dementia, would otherwise
improve the overall caregiving experience occasionally leave a stove on in the home could
and reduce negative health outcomes. have a device that could alert him to turn off the
stove if it is left on (or turn it off remotely itself),
Because caregivers fall outside the formal or to turn off faucets, or to remind the older adult
healthcare system, special efforts must be made to take medication (e.g., combines features of
to understand the complex needs of this popula- surveillance technologies, smart technology,
tion and develop technologies that will provide and cognitive orthotics). The landscape of tech-
solutions to caregiving demands. nologies available for these purposes is quite
Gerontechnology, Low expectations by others

Fig. 2 Downward spiral of
de-skilling that can occur in
dementia (Mountain 2013)
Further deskilling
Denial of opportunity
to participate in
More denial of meaningful activities
participation in
meaningful activities
Further lowering of Deskilling

expectations
Inability to participate
968 Gerontechnology
broad and continually expanding, and can be bro- includes a variety of internet functions and appli-
ken down into categories that include the cations and includes access to health information
following. on the internet, access to health self-management
Mobility. This is a critical area for older adults, tools, and access to health records. Surveys sug-
with mobility such as a central area for the main- gest that members of the baby boom generation
tenance of independence. Sidewalks, cars, stairs, (by far the largest group of older adults in North
elevators, escalators, and elevators all require America) use e-health applications and the Inter-
attention to insure their accessibility and useful- net for health information at rates comparable to
ness for older adults. Wheelchairs are a classic their younger adult counterparts, while those of
illustration of the transition from mechanical tech- ages beyond the baby boomers (e.g., 65 and older)
nology (typied by the motorized wheelchair) to do so at somewhat lower rates. Second only to
electromechanical technology (the electric email use and search, e-health still remains by far
wheelchair or power scooter), to intelligent one of the most popular reasons for older adults to
wheelchairs, where they are equipped with spe- access the Internet.
cialized software and sensors to decrease collision However, usability and design issues specic
risk in users as well as climb stairs and curbs while to older adults are a concern. Also, older adults
keeping the user level at all times and allow the may be less able to accurately evaluate the reli-
users to retain mobility for signicantly increased ability and credibility of online health information
periods than would otherwise be feasible (due to compared to their younger adult counterparts.
sensory or cognitive decline) (Rogers and Fisk This may be due to lower average levels of edu-
2003; Kalra et al. 2009). Most recently and sig- cational attainment in older adults, lack of sophis-
nicantly, the advent of autonomous vehicle tech- tication in search strategies (an outgrowth of the
nology or self-driving cars are poised to generation effect), the high cognitive demand
transform the extent and assist the mobility of placed on older adults when sifting through such
older adults far beyond the traditional limitations enormous amounts of information on the Internet,
posed by predominantly human-controlled vehi- or a combination of these and other issues (Roy
cles. Concept vehicles promise the ability to aug- and Pineau 2007).
ment or autonomize driving capabilities by Telehealth. Telehealth technology is dened as
monitoring and utilizing context-sensitive, real- the use of electronic information and telecommu-
time data regarding the vehicle, environment, nications technologies to support long-distance
and driver. Such cars might monitor the human clinical healthcare, patient and professional health-
drivers physiological markers, such as visual related education, public health, and health admin-
attention and heart rate, and provide spatial infor- istration. Shifts in the economic landscape of the
mation regarding the vehicles location via healthcare market, shifting consumer preferences,
advanced navigation systems and monitor envi- and an ever-widening range of technological prod-
ronmental conditions and obstacles. Of course, ucts and services have all militated to make
given the new and constantly evolving nature of telehealth technology increasingly attractive for
such technologies, regulatory and liability barriers use with older adult populations. Telehealth can
will need to continue to be addressed as these include the use of systems to measurement of vital
autonomous technologies become mainstream. signs, (e.g., heart rate, blood pressure) via sensors
As of 2015, only a few American states have and remote monitoring and data collection, video-
passed legislation regarding the issues presented conferencing, and other forms of communication. It
by self-driving cars (Yang and Coughlin 2014; can be used to supplement, or in some cases,
Kalra et al. 2009). replace, medical care and physician ofce visits
E-health. E-health is a term that has been but is also viable as a supplement or replacement
coined to refer to the various ways that people for in-person mental healthcare appointments,
utilize the internet or other digital technology to including psychotherapy, and psychological assess-
access or receive health information. E-health ments, including cognitive assessments.
Gerontechnology 969
Older adults may be homebound, and chronic According to the FDA, Mobile applications
illnesses may make travel to healthcare appoint- can help people manage their own health and
ments a challenge, which militates in favor of wellness, promote healthy living, and gain access
wider deployment of healthcare technology for to useful information when and where they need
older adults. However conversely less edu- it. The ubiquitous, continuous, and data-rich
cated, more rural older adults, and those with qualities of mobile technology enable these capa-
chronic illnesses are less likely to have reliable bilities and align with the needs of the elderly
Internet access (Czaja et al. 2013). There are a population. In particular, mobile apps are well
number of other obstacles to wider use of suited to address the following areas of need for
telehealth technologies in older adults, which older adults:
include usability and related issues as well as
technology generation effects (e.g., overreliance Chronic Disease Management. Most older
on multilayered interfaces). adults have at least one chronic condition
Regarding regulatory issues, mental healthcare (80%), and half have at least two. Mobile tech- G
delivery is another area where older adults can nology is well suited to address this area, and
theoretically greatly benet from the introduction many app developers have focused their efforts
of telehealth technologies. For example, it has here. Research of existing mobile tools in this
long been recognized that older adults represent area has found evidence of efcacy in improv-
an underserved segment of the population as far as ing disease management adherence.
mental healthcare delivery is concerned. Secure Medication adherence. Because of the preva-
videoconferencing, telephone, and email commu- lence of comorbidities in the older adult popu-
nications can all be viable in this regard. However, lation, medication adherence is an especially
Medicare (which is the US Federal Government critical issue.
agency which monopolizes the health insurance Safety monitoring. With the advancements in
market for older adults) currently imposes a num- sensor technology, mobile apps are becoming
ber of limitations on how so-called tele-mental increasingly able to remotely monitor activities
healthcare delivery is offered to older adults, and items in the homes of the older individuals.
which effectively denies older adults this service Access to health information. Aside from gen-
except in rare circumstances (e.g., such as being in eral search engines like Google, specic apps
a high service need area and receiving the service exist to help connect people with information
in a facility or doctors ofce) (Eramo 2014). regarding diseases and illnesses.
Mobile applications and mobile technology. Wellness. Wellness apps constitute a signi-
There has been an explosion of interest in devel- cant proportion of all mobile health apps and
oping mobile applications or apps for older adults, have gained widespread popularity.
as well as their caregivers. There appear to be
several classes of apps out there, such as apps However, barriers relating to usability con-
designed for caregivers to help facilitate care cerns and the generation effect currently impede
coordination, formal support, wander prevention, widespread adoption of mobile tools for the older
and enhance the well-being of the caregiver. adults. Increasing smartphone penetration,
Another growing class of apps are designed to sophistication of technology, and user familiarity
facilitate reminiscence activities in the care recip- with mobile apps are eliminating previous barriers
ient as a way to calm and enhance the well-being to adoption of mobile tools in the older adult
of the caregiver. There is also the growing sector population.
of cognitive orthotic apps (Horgas and Abowd Robotics. Probably the simplest denition of a
2004), which are apps specically designed to robot is a computational device that can sense
extend and support the memory and cognitive and act in the physical world. Robots vary widely
functioning in older adults with mild cognitive in shape and size and in recent years have been
impairment or dementia of mild severity. developed to resemble more lifelike creatures
970 Gerontechnology
(humans and animals). Robots can be classied

into two basic categories: Assistive robotics and
social robotics (also known as carebots).
Assistive robotics. Robotic technology has
now become fairly commonplace and is being
used in a variety of industrial, institutional, and
home situations. Robotic assistants rst came into
widespread use in North America in the 1980s to
assist with vehicle assembly and manufacturing.
One of the rst consumer mass-market robots for
the home is the Roomba, an autonomous robot
built with sensor technology designed to vacuum
as it roams. Institutionally, assistive robots are
becoming more and more common and have Gerontechnology, Fig. 3 The Paro robot
been developed to assist with dispensing medica-
tions, performing fetch and carry tasks, and Technology in partnership with the Japanese gov-
other activities (Roy and Pineau 2007). ernment helped to develop what is currently one
Assistive robots have a variety of applications of the sole players in the social robotics eld: the
with older adults in the realm of aiding older Paro robot (Fig. 3).
adults in retaining functional capacities in the Paro is modeled on a baby harp seal and is fully
face of disability and illness. For older adults animatronic and interactive. It is a product
who have suffered strokes, exoskeletal-like robot- designed to elicit the same psychological and
ics, or wearable biomechatronic systems that fol- physiological benets as animal-assisted thera-
low the movement of the subject and provide pies and has a growing body of literature to sup-
assistance with strength and mobility, will port its effectiveness in improving quality of life
increasingly become an option (Micera indicators, as well as managing mood and behav-
et al. 2008). As was mentioned previously, robotic ior problems in dementia. There are several other
technology is increasingly being used to modify social robots that have been developed, but as of
existing mechanical technology widely used with this writing, none have been offered on a mass-
older adults, such as with wheelchairs. market basis (Kachouie et al. 2014).
Telepresence robots are now beyond the feasibil- It seems likely that this is a sector that will
ity stage with older adults, with obvious applica- grow over time, with fairly obvious utility in
tions for allowing homebound or mobility- residential care facilities for older adults, mainly
impaired older adults to attend outside functions by virtue of the fact that these kinds of devices will
and appointments and even for the purposes of free up nursing staff from providing psychosocial
facilitating leisure activities. and emotional support and allow them to focus on
Quite simply, future iterations of robotic, medical and personal care provision for their
smart assistive technology have the potential clientele.
to maintain cognitive, physical, and occupational There appear to be unique ethical concerns
independence in older adults far beyond what was posed by the carebot/social robotics sector
previously attainable. (Vallor 2011). For example, there is the concern
Social robotics or carebots. Recently, there that the use of social robots may lend itself
has been an interest in developing robots that to seeing loneliness as a technical problem to
interact with humans for the purposes of eliciting be solved rather than an expression of a
positive psychological variables such as comfort universal human condition. There are other
and relaxation and to reduce depression and anx- concerns carebots may have the effect of reduc-
iety. Japans Advanced Institute of Science and ing the dignity, quality of care, and privacy of
Gerontechnology 971
older adults and have the effect of replacing drive and necessitate new technologies to enhance
human contact. There are also concerns that health and quality of life. It is hoped that GT will
carebots are inherently deceptive, particularly as continue to be the exciting, dynamic, and rapidly-
regards older adults with dementia. So, there are changing eld it is today. Almost without a doubt,
costs to be weighed against the benets of social by it's very nature, the GT landscape of tomorrow
robotics with older adults. will likely be very different than today. We look
Smart homes. Smart home technologies forward to further renement of theoretical frame-
incorporate connected systems of data collection, works, as well as further research and develop-
data processing, and information delivery to pro- ment that will continue to yield important insights
vide the user capabilities and knowledge other- and useful products to help older adults retain
wise unavailable. Specic aims of smart home their independence, and to promote positive out-
technology include increasing understanding of a comes in all life domains.
persons health and informing appropriate person-
nel during emergencies. As advancements in sen- G
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Internet of things eld. Major companies are
developing their own platforms to enable the
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19. particularly prevalent and important in older
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In the aging literature, studies consistently nd
ogy, 15, 18. that the number of social partners shrinks with
Zarit, S. H. (2006). Assessment of family caregivers: age (Zhang et al. 2011), with research suggesting
A research perspective. In Family Caregiver Alliance this is not simply due to functional losses and
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Grandparenthood and the Changing Nature of Social Relationships 973
the number of social partners. In fact, subjective effects cannot be explained by structural factors
well-being tends to increase with age (Carstensen alone, such as cognitive abilities and perceived
et al. 1995). Two reasons may explain this phe- health symptoms (Yeung et al. 2008). Compared
nomenon. First, older adults may enjoy being with younger adults, older adults show a greater
alone more than do younger adults. For instance, preference for close social partners (i.e., people
Larson et al. (1985) found that older adults whom the individual cannot imagine life without,
reported a greater sense of control when alone. typically but not always kin and close friends)
A study by Lang and Baltes (1997) extended the (Yeung et al. 2008) over peripheral social partners
aforementioned idea by considering the effect of (i.e., people who are not as close as close partners,
context when older participants were alone. They but who are still important, such as colleagues and
found that the older old (i.e., those aged 85103 professional helpers). Although older adults have
years) felt the highest sense of autonomy with the fewer peripheral social partners than do younger
least social contacts when they were facing dif- adults, they maintain a similar percentage of close
culties in everyday life. The authors interpreted social partners in their social networks as do their G
the results as a compensation mechanism, in younger counterparts (Zhang et al. 2011). This
which being alone in daily activities may allow may make it easier for them to maintain their
older adults to maintain autonomous functioning subjective well-being or even increase their social
and still spend time with people in other daily satisfaction. Yeung et al. (2008) further examined
activities. the mechanism of the age-related decrease in
The above studies speak to the idea that alone- peripheral social partners. They found that the
ness in old age may not be as detrimental as number of peripheral social partners only
conventionally believed. This argument might be decreased among those lower (and not higher) in
particularly true for people from independent cul- interdependence. Zhang and colleagues (2011)
tural backgrounds. In independent cultures, when further found that older people with higher
people get older, they are less likely to attribute interdependence reported lower loneliness when
their loneliness to personal decits (e.g., lack of they increased their number of peripheral social
pleasant personal characteristics) than do people partners in a two-year interval, suggesting that
in interdependent cultures. A study conducted by older people higher in interdependence could ben-
Rokach and Neto (2005) found that Canadians, et from having more peripheral social partners
who were from an independent culture, adjusted (Zhang et al. 2011).
better in a lonely situation than their Portuguese Recently, Lang and colleagues argued that,
counterparts, a group who was considered to be because emotionally close partners were more
more interdependent. Researchers speculated that important for older adults than middle-aged
compared to interdependent individuals, indepen- adults, older adults might invest more effort to
dent individuals may have a less extended social maintain emotionally close partners (Lang
network, which may make it easier for them to et al. 2013). Examining this question in middle-
attribute being alone to relationship decits rather aged and older adults, Lang and colleagues (2013)
than personal decits in turn making it easier for found that perceived relationship effort was sig-
them to adjust to lonely situations (Rokach and nicantly associated with emotional closeness,
Neto 2005). Consistent with this are ndings from such that people invested more effort in people
a study conducted in Hong Kong. In the study, a who were more emotionally close. This effect was
negative correlation between the number of stronger in older adults than in middle-aged
peripheral social partners and self-reported lone- adults. The investment in emotionally close part-
liness was found among older adults who were ners may contribute to the greater emotional well-
higher in interdependence but not those who were being reported by older adults. In fact, English and
lower in interdependence (Zhang et al. 2011). Carstensen (2014) found that the social relation-
Second and more importantly, older adults may ships of older adults were associated with less
be more selective in their social partners. Such negative emotion and more positive emotion
than those of younger and middle-aged adults in a (1986), Miche and colleagues (2013) found that
longitudinal study with three waves of 5-year friendship network types in old age tend to be
intervals. classied into four categories. In the rst group,
In sum, while the number of peripheral social the discerning friendship style, individuals select
partners decreases with age, emotionally close a small number of close friends. The second
social partnerships remain stable across adult- group, independent friendship style, refers to a
hood. Older adults make greater efforts to manag- relatively larger group of friends with lower emo-
ing social relationships than do younger and tional closeness. The nal two groups, selective
middle-aged adults (Lang et al. 2013). They also acquisitive style and unconditional acquisitive
benet more from these social relationships in style, have the largest number of friends that differ
reducing perceived loneliness (Zhang et al. in emotional closeness, with selective acquisition
2011), reducing negative emotions, and increas- as being emotionally closer than unconditional
ing positive emotions (Lang and Carstensen 1994) acquisition.
than do their younger counterparts. Despite the variations in styles, older individ-
uals generally have more favorable experiences
with friends than with family members (Rook and
Types of Relationship Ituarte 1999). This nding can most likely be
explained by the structural differences between
In addition to studying social network composi- friendship and family relationships. Friendships
tion in terms of closeness, researchers have also are mostly formed and maintained on a voluntary
investigated age-related differences in the types of basis, while family relationships are more or less
relationship that older adults value (Fung predetermined. Older adults usually form friend-
et al. 2008). In German participants, Fung and ships with individuals who share their interests
colleagues (2008) found that older age was asso- and lifestyles and who have reciprocal social rela-
ciated with a smaller proportion of nuclear family tionships with them. Friendships in old age also
members and a larger proportion of acquain- provide better companionship compared to family
tances. In Hong Kong Chinese, however, older relationships. For example, Huxhold et al. (2014)
age was associated with a larger proportion of examined the relationship between social activi-
nuclear family members and a smaller proportion ties with different social partners and the changes
of acquaintances. Fung and colleagues argued in affective well-being and life satisfaction among
that, compared with Germans, Hong Kong Chi- older adults across a 6-year interval. They found
nese showed a greater family in-group bias in that social activities with friends were related to
social network composition with age. maintenance or positive changes of life satisfac-
In a study using data from the World Values tion as well as a reduction in negative affective
Survey (Li and Fung 2012), Li and Fung exam- experiences among older adults. However, social
ined age differences in trust across 38 countries. activities with family members were associated
They found that age positively correlated with with increased negative affective experiences in
general trust and also trust toward different social the sample.
groups, including family, friends, neighbors, and To summarize, despite the decrease in the num-
strangers. However, the positive association ber of social partners as people age, subjective
between age and trust toward friends and well-being is maintained or even increased.
strangers was weaker in countries that scored Research suggests that the change in social net-
lower on individualism. work size is more than a product of age-related
Friendship is another type of social relation- structural changes such as mortality and func-
ship that can be as close as that experienced by tional losses. Instead, older adults actively prune
family members but also as peripheral as acquain- their social network by keeping emotionally close
tances. Building upon the theoretical framework social partners and cutting down relationships
on friendships in old age proposed by Matthews with peripheral social partners. The pruning
appears to contribute to the maintenance and even education (King and Elder 1998) and better phys-
increase in subjective well-being of older adults. ical health (King and Elder 1998) tend to make
One particular emotionally close relationship val- more contact with grandchildren and elicit more
ued by majority of older adults is that with their role satisfaction when engaged in grandparenting
grandchildren. They discuss the relevance of behavior. Gender has been found to be another
grandparenthood in the next section. important factor in grandparenthood. The gender
differences in grandparenthood tend to be related
to gender differences in life expectancy (i.e.,
Grandparenthood women generally live longer than men), social
status (i.e., men have higher status than women),
Grandparenthood is one of the major relationships nancial resources (i.e., men have better nancial
that older adults maintain. It plays an important resources than do women), and socialization
role in the subjective well-being of older adults levels (i.e., men have more social exposure than
and is increasingly important in older age. Previ- do women) (Field and Minkler 1988). Gender G
ous research suggests that grandparenting is a roles also inuence grandparenting behaviors.
goal-directed behavior. How people view grand- Traditionally, women are responsible for interper-
parenthood is inuenced by their perceptions of sonal dynamics within families, and men are
future time. Fung et al. (2005) summarized three responsible for task-oriented involvements out-
dimensions of meaning associated with grandpar- side the family (Szinovacz 1998). In line with
enthood: (1) obligation and accomplishment (e.g., this reasoning, research has found that grandfathers
having grandchildren makes me satised and are more likely to provide instrumental supports,
complete in this life stage), (2) benecial gains such as nancial assistance, but have greater dif-
(e.g., life as a grandparent is wonderful), and culty expressing their emotions toward
(3) perceived loss in absence (e.g., I feel that my grandchildren. In contrast, grandmothers were
life would have lacked something had I have more likely to provide emotional supports (Smorti
never been a grandparent) (p. 135). Fung and et al. 2012).
colleagues found that when people perceived It also seems that grandmothers play a more
future time as more limited, they attached greater diverse role than grandfathers in the work of
importance to grandparenthood in all three dimen- grandparenting. For instance, grandmothers pro-
sions than did people who perceive future time as vide care and emotional support and participate in
less limited. This nding is consistent with the recreational activities with grandchildren. There-
line of research arguing that when one believes fore, grandmothers report greater contact with
their time is limited, they select emotionally close their grandchildren than do grandfathers. The
social partners, such as family members. In grandchildren also perceived themselves as
another study, Thiele and Whelan (Fung having more contact with, and greater closeness
et al. 2005) found that grandparents experienced with, grandmothers than grandfathers (Smorti
greater happiness from grandparenting when they et al. 2012). As a result, grandmothers are more
adopted the goal of generativity (e.g., pass along emotionally close and affectively supportive to
knowledge to future generation). These ndings grandchildren than are grandfathers. Although
suggest that grandparenting behavior is both grandmothers and grandfathers report
inuenced by the goal that older adults adopt. similar levels of positive emotion toward
their grandchildren and consider their role as
supporting and providing care, grandmothers are
Gender and Grandparenthood more satised with their role and report a higher
level of perceived inuence and intimacy.
Previous research consistently reports the inu- In addition to the gender of grandparents, the
ence of socioeconomic factors in grandparenting interaction between lineage and gender is
behavior. For instance, those with lower levels of another issue that has received much attention.
Two theories in the eld of evolutionary psychol- attention to the inuences of culture on
ogy have been proposed to explain these effects: grandparenting. In one exception, Sandel
the kin-keeper theory and the kin selection theory. et al. (2006) investigated the lay theory of grand-
The kin-keeper theory argues that women (i.e., mother role in European Americans and Taiwan-
grandmothers and mothers) place greater empha- ese Chinese through in-depth interviews. They
sis on intra-family relationships, making them found both universal and culture-specic aspects
essentially the kin-keepers in a family. Due to in grandparenting behavior. Grandmothers in both
their higher level of involvement, grandmothers cultures engaged in similar activities and considered
and mothers build closer connections with family the role of being a grandmother to be distinctive
members, including the grandchildren, than do from being a mother. However, they interpreted
grandfathers. Accordingly, the theory would pre- their roles in different ways. Specically, European
dict that grandchildren should be closer to mater- American grandmothers saw themselves as
nal grandparents than paternal grandparents. In friends and playmates of their grandchildren and
contrast, the kin selection theory is based on the dened their role of being a grandmother in
assumption of inclusive tness, which argues that companionship terms. They considered giving
one favors others who may be able to pass on advice to the parents (their children) on parenting
ones genes. Because men maintain fertility lon- to be problematic. Taiwanese Chinese grand-
ger than women and have a greater chance to mothers, however, dened themselves as temporary
produce offspring, they invest less in each off- caregivers. They disciplined misbehaving
spring, including grandchild, than do women grandchildren and advised the parents.
(Surbey 1998). In addition, because male off- Research on ethnicity has also found ethnic
spring may have a greater chance to pass on variation in grandparenting. African American
genes, people may have a closer relationship grandparents reported more contact with
with grandsons than granddaughters. grandchildren than did grandparents from White
Dubas (2001) compared and contrasted the cultures (Field and Minkler 1988). Phua and
kin-keeper theory and the kin selection theory in Kaufman (2008), using the data from US Census
grandparenting by examining the moderating role in 2000, found that Japanese grandparents were
of gender in the grandparent-grandchild relation- more likely than Asian Indian grandparents to
ship. She found evidence that partially supports take on the grandparenting responsibility.
the kin selection theory. The relation between Collecting data from in-depth interviews with
maternal grandmothers and grandchildren was 30 New Zealand women from four different cul-
not closer than the relation between paternal tural backgrounds (i.e., New Zealand European,
grandmothers and grandchildren. However, New Zealand Maori, Central European, and New
granddaughters rated their relation with grand- Zealand Chinese), both similarities and differ-
mothers closer and more important than did ences between ethnicities were found (Phua and
grandsons. Grandsons, on the other hand, rated Kaufman 2008). Armstrong (Phua and Kaufman
their relation with grandfathers closer and more 2008) summarized that women from all four
important than did granddaughters. Drawing on ethnic backgrounds considered being a grand-
these ndings, Dubas (2001) suggested that both mother to be an indicator of being old and of
matriarchal and patriarchal relationships were having a shorter future. Because their future
critical in grandparent-grandchild relationship. was limited, the interviewed women expressed
placing greater value on their relationship with
grandchildren and an increased sense of
Culture and Grandparenthood generativity. Some interviewees even mentioned
that they decided to retire early or reduce
It is well documented that culture shapes human working hours, in order to take care of their
behavior. However, few studies have paid specic grandchildren. Meanwhile, ethnic differences
were also observed. Different views of grandpar- that older adults have limitations in conducting
enthood were found, in terms of social status, activities with high physicality. Custodial grand-
seniority, social renewal, and social integration. parents spend considerable time with
For instance, the New Zealand Chinese and Maori grandchildren and expend considerable energy
interviewees associated old age and being a that can impair the physical and mental health of
grandparent with seniority and a higher level of the grandparents.
social status. Such a pattern was not found among Overall, being a grandparent is a valued and
New Zealand Europeans and Central Europeans. important role for older adults, because it connects
The sense of social renewal is particularly salient them with emotionally close social partners. An
in Central European grandmothers, because they appropriate level of grandparenting engagement
all immigrated to New Zealand after World War improves physical and mental health and in gen-
II. New Zealand European grandmothers associ- eral advances life satisfaction in older adulthood.
ated grandparenthood with an increased social Gender is an important factor, with grandmothers
support network and greater social engagement. generally building closer relationships with G
grandchildren than do grandfathers. Such a pat-
tern may be derived from the traditional gender
Positive and Negative Outcomes of role that women are responsible to foster harmo-
Grandparenthood nious relationship within families. In addition to
gender, previous studies also observe culture and
Much research has summarized the benets of ethnicity differences in grandparenting behaviors.
having grandchildren. According to Timberlake
(1981), there are eight benets of grandparent-
hood: (1) to support ones social identity as grand- Conclusion
parent, (2) to perceive ones own life has being
expanded, (3) to help, (4) to increase interpersonal Social network size shrinks as individuals age.
connectedness with others, (5) to provide positive The shrinkage of network size is associated with
emotional experiences, (6) to provide a goal in the active pruning of social partners by older
older adulthood, (7) to assert inuence on others, adults: emotionally close partners are kept in the
and (8) to obtain achievements over others. These social circle, while peripheral social partners are
benets of grandparenthood correlated positively reduced. This change in social network structure
with better physical health (Hughes et al. 2007), appears to contribute to maintenance and even
engagement in exercise (Hughes et al. 2007), improvement in the subjective well-being of
fewer depressed symptoms (Grundy et al. 2012), older adults. Among these, grandparenthood is
and a higher level of life satisfaction (Grundy an especially valued and emotionally close rela-
et al. 2012). Christiansen examined the associa- tionship for older adults that has implications for
tion between grandparenthood and mortality subjective well-being that differs as a function of
(Grundy et al. 2012). She found that among gender and culture.
women who became grandmothers after the age
of 50 years, being a grandmother was associated
with a lower mortality rate (Christensen and Cross-References
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Grief and Bereavement: Theoretical Perspectives 979
experiences, the death of a person is irrevocable

Grief and Bereavement: Theoretical and cannot be altered by the coping efforts of
Perspectives survivors. Indeed, the major coping task faced
by those who have experienced the death of a
Kathrin Boerner1, Margaret Stroebe2, Henk loved person is to reconcile themselves to a situ-
Schut2 and Camille B. Wortman3 ation that cannot be changed and nd a way to
1
Psychology of Entrepreneurial Behavior, carry on with their own lives.
Institute of Psychology, University of Kassel, The most common loss of a loved one for older
Kassel, Germany adults is the death of a spouse (Carr et al. 2006).
2
Department of Clinical and Health Psychology, Therefore, the bulk of research on late life losses
Utrecht University, Utrecht, The Netherlands has focused on this type of loss. However, older
3
Department of Psychology, SUNY Stony Brook, adults may also experience other types of losses
Stony Brook, NY, USA including the death of a child, grandchild, sibling,
or close friend. These can also be major losses and G
may each have unique implications and chal-
Synonyms lenges for the person who is faced with them.
Research insights shedding light on these experi-
Deep sorrow (caused by someones death); ences, however, are much more limited. It is thus
Mourning (expression of grief); Personal loss important to keep in mind that much of our under-
standing of and thinking about late life losses is
derived from work on spousal loss.
Definition Furthermore, it is important to dene the key
terms that will be used throughout this entry. The
The term bereavement denotes the objective situ- term bereavement is derived from the Latin word
ation of a person who has experienced the death of rumpere (to break, to carry, or tear away) and
someone signicant. Grief then refers to the emo- refers to the objective situation of a person who
tional experience of the psychological, behav- has suffered the loss of someone signicant. In
ioral, social, and physical reactions the bereaved most cases, bereavement robs survivors of love
person might experience as a result of this death. and companionship, as well as future hopes and
plans that they expected to share with the person
who died. Grief is derived from Latin gravare
Introduction (to weigh down) and refers to the emotional expe-
rience of a number of psychological, behavioral,
The loss of a loved one is a ubiquitous human social, and physical reactions to ones loss. The
experience, which is often regarded as a serious word mourning is derived from the Latin word
threat to health and well-being. This topic is rele- memoir (mindful). It refers to actions expressive
vant to the study of geropsychology for two rea- of grief which are shaped by social and cultural
sons. First, there is consensus among researchers practices and expectations. Pointing to the time-
and practitioners alike that coming to terms with less message of the original meanings of these
personal loss is a critical part of successful adult terms, Jeter (1983) commented that as the
development (Baltes and Carstensen 1996). Sec- ancients, people today surviving the death of a
ond, losses tend to accumulate in late life. This can family member do feel robbed, weighted down,
place survivors in a state of chronic stress and and are mindful of the past, knowing that life will
undermine their capacity to deal with any never be the same (p. 219). But how do individ-
particular loss. uals cope with such an experience? To address this
The death of a loved one provides an excellent question, models and approaches that seem most
arena to study basic processes of stress and inuential to current understanding of bereave-
adaptation to change. Unlike many stressful life ment and grief are examined.
980 Grief and Bereavement: Theoretical Perspectives
Classic Psychoanalytic View of normal development, individuals form instinc-

tive affectional bonds or attachments, initially
One of the most inuential approaches to loss has between child and parent and later between adults.
been the classic psychoanalytic model of bereave- He believed that the nature of the relationship
ment, which is based on Freuds seminal paper, between a child and his or her mother or caregiver
Mourning and Melancholia (1917). According has a major impact on subsequent relationships.
to Freud, the primary task of mourning is the He suggested that when affectional bonds are
gradual surrender of ones psychological attach- threatened, powerful attachment behaviors are
ment to the deceased. Freud believed that relin- activated, such as crying and angry protest. Unlike
quishment of the love object involves a painful Freud, Bowlby believed that the biological func-
internal struggle. The individual experiences tion of these behaviors is not withdrawal from the
intense yearning for the lost loved one, yet is loved one but rather reunion. However, in the case
faced with the reality of that persons absence. of a permanent loss, the biological function of
As thoughts and memories are reviewed, ties to regaining proximity with attachment gures
the loved one are gradually withdrawn. This pro- becomes dysfunctional. Consequently, the
cess, which requires considerable time and bereaved person struggles between the opposing
energy, was referred to by Freud as the work of forces of activated attachment behavior and the
mourning. At the conclusion of the mourning reality of the loved ones absence.
period, the bereaved individual is said to have Bowlby maintained that in order to deal with
worked through the loss and to have freed him- these opposing forces, the mourner goes through
self or herself from an intense attachment to the four stages of grieving: initial numbness, disbe-
unavailable person. Freud maintained that when lief, or shock; yearning or searching for the
the process has been completed, the bereaved deceased, accompanied by anger and protest;
person regains sufcient emotional energy to despair and disorganization as the bereaved
invest in new relationships and pursuits. This gives up the search, accompanied by feelings of
view of the grieving process has dominated the depression and hopelessness; and reorganization
bereavement literature over much of the past cen- or recovery as the loss is accepted and there is a
tury and only more recently has been called into gradual return to former interests. By emphasizing
question (Bonanno and Kaltman 1999; Stroebe the survival value of attachment behavior,
1992; Wortman and Silver 1989). For example, Bowlby was the rst to give a plausible explana-
it has been noted that the concept of grief work is tion for responses such as searching or anger in
overly broad and lacks clarity because it fails to grief. Bowlby was also the rst to maintain that
differentiate between such processes as rumina- there is a relationship between a persons attach-
tion, confrontative coping, and expression of ment history and how he or she will react to the
emotion (Stroebe and Schut 2001). loss of a loved one. For example, children who
endured frequent separations from their parents
may form anxious and highly dependent attach-
Attachment Theory ments as adults and may react with intense and
prolonged grief when a spouse or partner dies
Another theoretical framework that has been (see Shaver and Tancredy (2001), or Stroebe
extremely inuential is Bowlbys attachment the- et al. (2005), for a more detailed discussion).
ory (Bowlby 1969, 1973, 1980; see also Fraley Because it provides a framework for understand-
and Shaver 1999; Shaver and Tancredy 2001). In ing individual differences in response to loss,
this work, Bowlby integrated ideas from psycho- Bowlbys attachment model has continued to be
dynamic thought, from the developmental litera- inuential in the study of grief and loss (Shear
ture on young childrens reactions to separation, et al. 2007). Mikulincer and Shaver (2013) have
and from work on the mourning behavior of pri- conducted sophisticated empirical research,
mates. Bowlby maintained that during the course conrming the importance of attachment security
in the prediction of adjustment to bereavement these and other critiques and a lack of empirical
and providing ne-grained understanding of support, most researchers have come to the con-
many associated phenomena. clusion that the idea of a sequence of stages is not
particularly useful (Stroebe et al. 2001).
Getting Past Stage of Grief

Trauma Theory and Meaning Making
While several theorists have proposed that people
go through stages or phases in coming to terms An inuential stream of thought in the eld of
with loss (see, e.g., Bowlby 1980; Horowitz bereavement has come from trauma theory. Even
1986), perhaps the most well known of these though one could argue that most late life losses
models is the one proposed by Kbler-Ross in may not involve experiences of a traumatic nature,
her highly inuential book On Death and Dying for example, because the occurrence of the death
(Kbler-Ross 1969). This model, which was may be considered timely in the context of the life G
developed to explain how dying persons react to course, there could be traumatic aspects to a loss
their own impending death, posits that people go experience in late life. For example, witnessing a
through denial, anger, bargaining, depression, and prolonged period of serious illness and intense
ultimately acceptance. It is Kbler-Rosss model suffering of a loved one can have elements of
that popularized stage models of bereavement. trauma, even if the illness and death occur at an
For many years, Kbler-Rosss model has been expected life stage. Similarly, the death of an older
taught in medical, nursing, and social work person can be experienced as very sudden, if this
schools. It has also appeared in articles in news- person had been in good health and highly
papers and magazines written for bereaved per- engaged in life or even if the person died after
sons and their family members. As a result, stage years of chronic illness and decline. Therefore, it
models have strongly inuenced the common appears that conceptual thinking coming from
understanding of grief in our society. trauma theory should be considered even in the
As research began to accumulate, it became context of late life loss.
clear that there is little support for the view that The model of stress response syndromes by
there are systematic stages. Although there are Horowitz and colleagues (1986) purports that
studies that purport to support stage models traumatic experiences disrupt a persons life via
(Maciejewski et al. 2007), the weight of the evi- blockage of cognitive and emotional processing.
dence suggests that reactions to loss vary consid- Similar to the notion of grief work as a necessary
erably from person to person and that few people step toward recovery, the assumption here is that
pass through the stages in the expected fashion processing the trauma is essential if the person is
(see Archer 1999; Attig 1996, for a review). Sev- going to be able to move on and that stressful life
eral major weaknesses of stage models have been events play an important role in the etiology of
identied (Neimeyer 1998). First, they cannot various somatic and psychiatric disorders due to
account for the variability in response that follows failure of such processing. A further line of
a major loss. Second, they place grievers in a research derived from the related eld of trauma
passive role when in fact grieving requires the was that of Janoff-Bulman (1992), particularly
active involvement of the survivor. Third, such through the identication of shattered beliefs
models fail to consider the social or cultural fac- which need to be rebuilt. This has been expanded
tors that inuence the process. Fourth, stage to the study of meaning making particularly by
models focus too much attention on emotional Neimeyer and collaborators (2001, 2006).
responses to the loss and not enough on cognitions The basic idea in the perspective is that major
and behaviors. Finally, stage models tend to losses challenge a persons sense of identity and
pathologize the reactions of the majority of people narrative coherence. Narrative disorganization
who do not pass through the stages. As a result of can range from the relatively limited and transient
to more sweeping and chronic, depending on the physical and mental health consequences that
nature of the relationship and the circumstances result from the loss, are thought to depend on
surrounding the death. According to Neimeyer, a these factors.
major task of grief involves reorganizing ones life
story to restore coherence and maintain continuity
between the past and the future. However, dif- Caregiving and Bereavement
culties in establishing the role of meaning making
in adjustment remain (e.g., studies have not As most deaths in late life are preceded by chronic
always succeeded in separating the process from illnesses, family members, in particular spouses,
the outcome, beliefs from adjustment, or are often involved in prolonged periods of care-
establishing the direction of causality among giving in the years, months, or weeks before their
these factors). Others have distinguished two loved ones death. Therefore, conceptual thought
components of meaning making. Davis, Nolen- that considers the specic case of bereavement
Hoeksema, and Larson (1998) identied two dis- after caregiving is particularly relevant to the
tinct processes, making sense of the loss and nd- topic of late life loss. Three major lines of thought
ing benet, which entail distinguishable derived from stress theory have emerged in the
psychological concerns for the bereaved person, literature (for a review, see Boerner and Schulz
with, for example, the former diminishing in 2009; Schulz et al. 2008) regarding bereavement
importance in time, while the latter grows stronger in the context of caregiving. The cumulative stress
as time goes on. perspective, or wear and tear hypothesis, argues
that the combined effects of the stress of caregiv-
ing and the death deplete peoples coping
Stress and Coping Approach resources and result in greater adjustment difcul-
ties following the loss. The stress reduction per-
Over the past two decades, a theoretical orienta- spective makes the opposite prediction, arguing
tion referred to as the stress and coping approach, that the death brings relief because it puts an end
or the cognitive coping approach (Lazarus and to caregiving stressors and the suffering of the
Folkman 1984), has become highly inuential in person who is dying and so results in more posi-
the eld of bereavement. Stress and coping theo- tive bereavement outcomes than found among
rists maintain that life changes such as the death of non-caregivers. Finally, it has been suggested
a loved one become distressing if a person that caregivers more or less expect to be bereaved,
appraises the situation as taxing or exceeding his which in turn allows at least some degree of antic-
or her resources. An important feature of this ipatory processing and preparation that may ben-
model is that it highlights the role of cognitive et the person after the death.
appraisal in understanding how people react to When all three perspectives are considered, the
loss. A persons appraisal, or subjective assess- emerging picture seems to be a combination of
ment of what has been lost, is hypothesized to depletion, relief, and anticipation effects (Schulz
inuence his or her emotional reaction to the et al. 2008). For example, once the death occurs,
stressor and the coping strategies that are the caregiver may feel extremely exhausted, but at
employed. To explain why a given loss has more the same time relieved that his or her loved one no
impact on one person than another, stress and longer has to suffer and that the immense strain of
coping researchers have focused on the identica- the caregiving role has ended and also may have
tion of potential risk factors, such as a history of had a chance to think about the impending death
mental health problems, as well as protective fac- and their life afterward, possibly have a conversa-
tors, such as optimism or social support (for a tion with the loved one about these topics, and
review, see Hansson and Stroebe 2007; Pearlman take care of some pragmatic necessities related
et al. 2014; Stroebe et al. 2006, 2007). The to the death (e.g., nancial planning, funeral
appraisal of the loss, as well as the magnitude of arrangements).
The bulk of research studies to date indicate the same way to other life experiences and that we
that many caregivers experience some sort of therefore also need models specically focusing
stress relief and/or benet of anticipation rather on bereavement.
than a depletion of their resources or at least that Two theoretical models reecting this aspira-
the rst can outweigh the latter. However, tion are Bonannos four-component model
bereavement outcomes following caregiving (Bonanno and Kaltman 1999) and Stroebe and
may also depend on how the loved ones end-of- Schuts (1999, 2010) dual-process model.
life phase was experienced. For example, spouses Bonannos goal was to develop a conceptually
of patients who died while on hospice care lived sound and empirically testable framework for
longer than spouses of patients who did not use understanding individual differences in grieving.
hospice (Christakis and Iwashyna 2003). In con- He identied four primary components of the
trast, family members were found to have poorer grieving process the context in which the loss
mental and physical health outcomes when occurs (e.g., was it sudden or expected, timely or
aggressive treatments were performed at the untimely?), the subjective meanings associated G
patients end of life (Wright et al. 2008). Besides with the loss (e.g., was the bereaved person
consideration of such quality of life indicators resentful that he or she had to care for the loved
characterizing the time preceding death, there is one prior to the death?), changes in the represen-
evidence that previous notions of anticipatory tation of the lost loved one over time (e.g., does
grief have been based on largely unfounded the bereaved person maintain a continuing con-
assumptions of the benets of anticipatory griev- nection with the deceased?), and the role of cop-
ing for post-death adaptation. Rather, ndings ing and emotion regulation processes that can
have linked higher levels of pre-loss grief to mitigate or exacerbate the stress of loss.
higher levels of post-death grief (Liu and Lai Bonannos model makes the prediction that recov-
2006). This corresponds with the more general ery is most likely when negative grief-related
nding in the bereavement literature that those emotions are regulated or minimized and when
who experience high levels of distress before the positive emotions are instigated or enhanced
death are also at risk of adjustment difculties (Bonanno 2001). This hypothesis, which is dia-
post-death (Bonanno et al. 2002; Schulz metrically opposed to what would be derived from
et al. 2006). the psychodynamic approach, has generated con-
siderable interest and support in recent years.
The dual-process model of coping with
Bereavement-Specific Theories bereavement (DPM; Stroebe and Schut 1999,
2010) indicates that following a loved ones
Much of the theorizing discussed above involved death, bereaved people alternate between two dif-
conceptual models that could be applied to ferent kinds of coping: loss-oriented coping and
bereavement, but they were not developed specif- restoration-oriented coping. While engaged in
ically to account for peoples reactions to the loss-oriented coping, the bereaved person focuses
death of a loved one. For example, the stage on and attempts to process or resolve some aspect
model by Kbler-Ross was developed to describe of the loss itself. Dealing with intrusive thoughts
the experience of dying persons, Bowlbys attach- about the death is an example of loss-oriented
ment model was originally designed to explain coping. Restoration-oriented coping involves
distress resulting from mother-infant separation, attempting to adapt to or master the challenges
trauma theories addressed the case of various inherent in daily life, including life circumstances
traumatic experiences, and the stress and coping that may have changed as a result of the loss.
approach dealt with any type of stressor. While Examples of restoration-oriented coping include
coping with the death of a loved one has elements distracting oneself from the grief, doing new
of all these areas, one could argue that there may things, or mastering new skills. Stroebe and
be unique coping challenges that do not apply in Schut have proposed that bereaved individuals
alternate between loss- and restoration-oriented distressed person? Or would the lack of congru-
coping and that such oscillation is necessary for ence in the experience of individual members lead
adaptive coping. Hansson and Stroebe (2007) to a mismatch and potential interference of
applied the DPM to the experience of bereave- coping efforts? Future work addressing these
ment in late life, cataloguing specic difculties questions would make an important contribution
for older persons (such as the increased frequency because people rarely face a loss in a social vac-
and cumulative impact of multiple bereavements uum (Stroebe et al. 2013). Theoretical models that
in the loss-oriented sphere and physical impair- do not address interpersonal processes in grieving
ment, which may prevent the bereaved from car- lack this vital component of coping with loss.
rying out the tasks that the deceased had taken A related, also understudied, social context
care of, in the restoration-oriented sphere). topic is the role of cultural inuences on grief
and bereavement. Ethnicity and cultural back-
ground have been found to be related to bereave-
Outlook ment outcomes. For example, in a cross-cultural
study, Chinese participants seemed to recover
Today, the fundamental question facing bereave- more quickly from bereavement emotionally
ment theorists and researchers alike is the follow- compared to US Americans, but they also
ing: Why is it that some older adults are reported more somatic complaints (Bonanno
completely devastated by the death of a spouse, et al. 2005). Culturally shaped spiritual convic-
while others seem to emerge sometimes after a tions may also have an impact on how individuals
period of intense suffering relatively unscathed deal with loss. For example, for a person who
or even ultimately strengthened by what has hap- believes that life is suffering and death is transcen-
pened? As noted above, accumulating evidence dence, as seen in Zen Buddhism, the experience of
regarding variability in response to loss led loss may be easier to bear. There may also be
researchers to move away from traditional grief culture-specic implications of particular losses.
models and instead employ frameworks, such as For example, in many cultures, losing ones hus-
the stress and coping approach, Neimeyers focus band involves loss of respect and basic human
on meaning making, Bonanno and Kaltmanns rights, which is likely to make coping more dif-
four-component model, and the dual-process cult, in particular for cohorts of older women who
model, developed by Stroebe and Schut, each of were not in a position to develop an autonomous
which can account for divergent responses to loss. lifestyle or status. Exploring in more detail
Drawing from these models, investigators are try- whether and how the meanings associated with
ing to identify risk and protective factors that response to loss vary by culture might help us to
inuence the nature and course of grief following gain a better understanding of the inuence of
spousal loss. Below, we provide a brief summary culture-specic factors such as attitudes and
of selected new directions that we think should be expectations toward loss experiences.
pursued to rene and expand conceptual thought Biological aspects of adaptation to a major loss
in the eld of bereavement. could also be more important than expected so far
To date, most of the bereavement literature has (Curtis and Cicchetti 2003). There is some evi-
focused on adaptive processes within rather than dence for persistent alteration of stress mecha-
between individuals. An intriguing question, nisms and brain functioning from early trauma.
however, is what happens to larger social units, Early life stress apparently produces a sensitiza-
such as families, when group members experience tion of the cortical corticotropin-releasing neuro-
a shared loss in different ways (e.g., one family nal system and the hypothalamic-pituitary-
member expresses intense distress, whereas adrenal axis stress response, as well as structural
another shows less distress)? In such a case, and functional changes in the brain. Further,
would those who are more distressed be likely to recent research has identied neurophysiological
benet from the presence or availability of the less mechanisms linking stress to various negative
consequences with respect to the immune, gastro- Boerner, K., & Schulz, R. (2009). Caregiving, bereave-
intestinal, and cardiovascular systems (OConnor ment, and complicated grief. Bereavement Care,
28(3), 1013. doi:10.1080/02682620903355382.
2013). Using physiological methods and the Bonanno, G. A. (2001). Grief and emotion: A social-
means of brain research could enrich ongoing functional perspective. In M. S. Stroebe &
efforts in psychosocial research on bereavement. R. O. Hansson (Eds.), Handbook of bereavement
Finally, combining physiological and psychoso- research: Consequences, coping, and care
(pp. 493515). Washington, DC: American Psycholog-
cial factors into more complex models to predict ical Association.
reactions to loss might allow us to better under- Bonanno, G. A., & Kaltman, S. (1999). Toward an inte-
stand why some people are devastated by a loss grative perspective on bereavement. Psychological
like the death of a spouse, while others weather Bulletin, 125, 760786.
Bonanno, G. A., Wortman, C. B., Lehman, D., Tweed, R.,
this kind of life event well or even experience Haring, M., Sonnega, J., . . .Nesse, R. M. (2002). Resil-
positive development or personal growth in the ience to loss, chronic grief, and their pre-bereavement
context of major loss. predictors. Journal of Personality and Social Psychol-
Theoretical advancement through more active ogy, 83, 11501164. G
Bonanno, G. A., Papa, A., Lalande, K., Zhang, N., & Noll,
consideration of areas such as interpersonal and J. G. (2005). Grief processing and deliberate grief
physiological processes, as well as cultural inu- avoidance: A prospective comparison of bereaved
ences, has the potential to deepen our understand- spouses and parents in the United States and the Peo-
ing of grief and bereavement. This is particularly ples Republic of China. Journal of Consulting and
Clinical Psychology, 73(1), 8698. doi:10.1037/0022-
important for the case of complications in griev- 0006X.73.1.86.
ing. However, while recognizing symptoms of Bowlby, J. (1969). Attachment. (Attachment and loss, Vol.
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(Attachment and loss, Vol. 2). New York: Basic Books.
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persons response to loss may develop into a bereavement in late life. New York: Springer.
Christakis, N. A., & Iwashyna, T. J. (2003). The health
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how this development could be prevented. There- study of hospice use by decedents and mortality out-
fore, continued conceptual development in the comes in surviving, widowed spouses. Social Science
eld of bereavement is a vital effort. & Medicine, 57(3), 465475.
Curtis, J. W., & Cicchetti, D. (2003). Moving research on
resilience into the 21st century: Theoretical and meth-
odological considerations in examining the biological
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H
Health and Retirement Study, questions about health and aging. A major data
A Longitudinal Data Resource for resource that may be less well known to psycho-
Psychologists logical research scientists is the Health and Retire-
ment Study (HRS). HRS is a nationally
Amanda Sonnega and Jacqui Smith representative longitudinal study of more than
Health and Retirement Study, Survey Research 37,000 individuals aged 50 to 100+ (and
Center, Institute for Social Research, University deceased) from about 23,000 households in the
of Michigan, Ann Arbor, MI, USA USA. The survey, which has been elded every
2 years since 1992, was established at the direc-
tion of the US Congress to provide a national
Synonyms resource for data on the changing health and eco-
nomic circumstances associated with aging. HRS
Aging cohort; Health; Longitudinal; Nationally was the rst longitudinal study of older people to
representative data; Retirement collect detailed economic and health information
in the same study (Juster and Suzman 1995). The
goal was not only to build our understanding of
Definition aging but also to provide scientic data for
studying national-level social and policy changes
Psychologists are discovering opportunities to that may affect individuals. Indeed, the data are
explore complex questions using large datasets. often used to study the effects and implications of
This chapter describes and illustrates the value of different public policies. Thus, the topics
the Health and Retirement Study (HRS), a nation- covered include resources for successful aging
ally representative multidisciplinary dataset on (e.g., economic, public, familial, physical, psy-
aging in the USA featuring a rich blend of eco- chological, and cognitive), behaviors and choices
nomic, health (including genetics and bio- (e.g., work, health behaviors, residence, transfers,
markers), cognition, and psychosocial use of programs), and events and transitions
information. (e.g., health shocks, retirement, widowhood,
institutionalization).
HRS has rich longitudinal measurement of
Introduction several domains income and wealth; health
(including biomarkers and genetics), cognition,
Psychologists are increasingly using population- and use of health care services; work and retire-
based multidisciplinary survey data to examine ment; and family connections linked to various
DOI 10.1007/978-981-287-082-7
988 Health and Retirement Study, A Longitudinal Data Resource for Psychologists
external sources of mortality, pension, Social aged 5161. The Asset and Health Dynamics
Security, and medical care data. Since 2006, Among the Oldest Old (AHEAD) study was
HRS participants have also reported on personal elded the next year to include the cohort born
evaluations of their life circumstances, subjective 18901923, then aged 70 and older. The two
well-being, lifestyle, and stress. The blend of eco- studies merged in 1998, and in order to make the
nomic, health, and psychosocial information in sample fully representative of the US population
the HRS provides unprecedented potential to over age 50, two new cohorts were enrolled,
study increasingly complex questions about the Children of the Depression Age (CODA),
adult behavior and aging. In addition, HRS has born 19241930, and the War Babies, born
become the model for a network of harmonized 19421947. To keep the sample representative of
longitudinal studies of aging around the the population over age 50, HRS refreshes the
world, offering the opportunity for valuable sample every 6 years with younger cohorts not
cross-national comparisons (see Cross-Reference previously represented. In 2004, Early Baby
for examples). Boomers (EBB, born 19481953) were added,
Most of the data are public and are available at and in 2010, Mid Baby Boomers (MBB, born
no cost to all registered users. Sensitive health 19541959) were added. In 2016, the Late Baby
data (such as genetic information) and restricted Boomers (born 19601964) will be added. With
data (such as Social Security and Medicare all of these cohorts, in 2014 HRS includes a
records) require a separate application process wealth of information about the life histories of
that is detailed on the website. HRS is a large older Americans over the last 100 years.
and very complex dataset. Various resources for The HRS sample is based on a multistage area
getting started using the data are available on the probability design involving geographic strati-
website, and a free online help desk is offered for cation and clustering and oversampling of
all users: hrsquestions@umich.edu. To increase African-American and Hispanic individuals.
the accessibility of this rich data resource, Sample weights are derived and provided to
researchers at the RAND Corporation have cre- account for differential probability of selection
ated a user-friendly version of much of the HRS and differential nonresponse in each wave
public data. The RAND contribution is available (Heeringa and Connor 1995). To determine eligi-
through the HRS website and is a good starting bility for the study, interviewers conduct a brief
place for new users. Visit the HRS website household screening interview. Adults over age
(hrsonline.isr.umich.edu), especially under the 18 living in the household are listed with their age
documentation link, for more information on all and couple status. A primary respondent is ran-
of the topics addressed in this chapter. domly selected from all age-eligible household
This chapter describes the HRS study design members, and if the selected person is coupled,
and provides descriptions of content in areas of their spouse or partner is also recruited to the
particular relevance to geropsychologists includ- study, regardless of age. Household screening
ing cognition and depression, physical health and efforts have been conducted in 1992, 2004, and
limitations, anthropometric measures and physi- 2010. The core survey occurs every 2 years, mak-
cal performance, biomarkers and genetics, and ing 2014 the twelfth follow-up of the initial 1992
psychosocial functioning. It also illustrates the participants.
potential of these data for psychological research. Baseline response rates range from 81.6% to
69.9% more recently. While baseline response
rates have been somewhat lower in recent years
Study Design following national trends, follow-up response
rates have remained high, ranging from 85% to
The Sample 90%. Follow-up rates are based on the sample for
Recruited in 1992, the original HRS cohort which interviews were attempted. At each follow-
included individuals born 19311941, then up, interviewers attempt to locate the entire
Health and Retirement Study, A Longitudinal Data Resource for Psychologists 989
sample that participated at baseline. If a respon- homes after baseline are interviewed there.
dent is not interviewed in one wave, he or she is The result is that HRS now fully represents the
contacted again in the next. Complete response US nursing home population. Among other
rates and sample sizes for each cohort are detailed things, this means that research can address the
elsewhere (Sonnega et al. 2014). functioning and well-being of the oldest old.
Finally, HRS monitors vital status through its
Special Design Features own efforts to locate respondents and through
HRS has several design features that enhance linkages to the National Death Index. In addition,
potential for psychological research. First, in the event of respondent death, HRS attempts an
African-American and Hispanic households are exit interview with a surviving spouse, child, or
oversampled at about twice the rate of whites, other informant to obtain information about med-
proportional to the US population. Ofstedal and ical expenditures, family interactions, disposition
Weir (2011) show that HRS has been successful at of assets following death, and other circumstances
recruiting and retaining minority participants. In during the nal stages of life.
2010, the minority sample from the Baby Boom
cohorts was further increased by a supplemental Data Collection H
screening effort. This increases opportunities for In HRS, the baseline (initial entry) interview is
important subgroup analyses. conducted in the respondents home face to face
Second, as noted above, HRS enrolls both (FTF) every 2 years. It takes approximately 3 h to
members of coupled households. In single house- complete and constitutes the bulk of the data. The
holds, respondents answer all questions. In sample size is around 20,000 at any given wave.
coupled households, each member of the couple At the end of this core interview in every wave,
is designated as either a nancial or family there are 10 or so experimental 3-min modules
respondent. Questions about housing, income, that provide greater depth on a topic that is in the
and assets are asked of the nancial respondent, core or information on a topic that is not in the
and questions about family composition and core but may be of interest. Each module is com-
transfers are asked of the family respondent. pleted by a different random subsample of the
Individual responses are sought from both core sample. Module sample sizes are about
partners in a household about work, health, 1,500. Some psychosocial content is available in
disability, cognitive status, and well-being. modules.
Likewise, psychosocial measures are collected Prior to 2004, the primary mode for follow-up
individually for both members of the couple. interviews was telephone, except for respondents
Thus, HRS provides exceptional opportunities over the age of 80 who are always offered FTF
for dyadic analysis. follow-up interviews. Since 2006, HRS has uti-
Third, when respondents are unable or unwill- lized a mixed-mode design for follow-up inter-
ing to complete an interview by themselves, HRS views in which a random half of the sample is
interviewers seek a proxy respondent. Proxies are assigned to an in-home FTF interview that is
usually a spouse or other family member. In each enhanced with physical and biological measures
wave, about 9% percent of interviews are and a psychosocial questionnaire. The other half
conducted with a proxy respondent, about 18% of the sample completes only the core interview
for those who are 80 and older. Proxy interviews mostly by telephone (again, those over 80 are
succeed in retaining individuals who are cogni- offered FTF interviews). The half-samples alter-
tively impaired, reducing attrition bias due to cog- nate waves so longitudinal information from the
nitive impairment in a study of aging individuals enhanced FTF (EFTF) interview is available
(Weir et al. 2011). every 4 years at the individual level, and the
Fourth, HRS samples community-dwelling expanded content is available at every wave on a
individuals in the rst wave of data collection. nationally representative half-sample. Beginning
However, respondents who move to nursing in 2010, the EFTF begins with the baseline
Health and Retirement Study, A Longitudinal Data Resource for Psychologists, Table 1 Timeline for collection
of psychosocial data in HRS
Planned
Prior 2004 2006 2008 2010 2012 2014 2016
Core sample *+ + + + + + + +
EFTF sample A B A B A B
* Various sample modules, + indicators of depression, single-item life satisfaction, A rst random half sample, B second
random half sample, NB physical measures and biomarkers also follow this timeline beginning in 2006
interview and alternates waves from that (Sonnega et al. 2014). This section highlights
point on. Table 1 graphically portrays the design portions of the core survey that may be of partic-
of the EFTF. ular interest to geropsychologists, specically
Finally, to expand data collection at lower cost cognition, depression, physical health, and
and respondent burden, HRS also conducts stud- limitations. It also covers anthropometrics,
ies in the off years from the core survey. These physical performance, biomarkers, genetics, and
studies are elded in subsamples as Internet-based psychosocial information, which are all obtained
surveys, mailed paper-and-pencil questionnaires, in the EFTF interview. Where available,
or in-home assessments. Sample sizes for these associated HRS user guide/documentation reports
studies range from approximately 3,000 to 5,000 are cited for content areas discussed in this
respondents. Some studies took place only once; section.
others are biennial studies of varying duration.
Cognition and Depression
Linkages to Administrative Records From the beginning of the study, HRS researchers
HRS attempts to obtain permission from all HRS embraced a broad denition of health to include
respondents to access and link their HRS survey aspects of mental health and cognitive function-
data to their Social Security earnings and benet ing. Measures of cognitive functioning included
records and from Medicare-eligible respondents in most waves of HRS since 1992 include
to their Medicare records. Linkage consent rates ten-word immediate and delayed recall to assess
range from 78% to 84%. In addition, HRS memory; a serial sevens subtraction test of work-
attempts to obtain a wide range of pension plan ing memory; counting backward to assess atten-
information from respondents current and past tion and processing speed; object naming test to
employers. Finally, health care utilization and assess language; and recall of the date, president,
other data from the Veterans Affairs (VA) health and vice-president to assess orientation (Ofstedal
care system are linked to HRS respondents who et al. 2005). Information from these survey mea-
have self-reported prior military service and have sures is summarized as a composite score ranging
received VA health care. All of these sources of from 0 to 35 where a higher score indicates better
linked data not only provide validation of self- cognitive functioning. This composite measure
reported information but also add information has been widely used to study trajectories of cog-
not collected from respondents in the survey. nitive functioning.
These sources of linked data are made available An HRS supplemental study, the Aging,
to researchers under restricted data use Demographics, and Memory Study (ADAMS),
agreements. is an in-home neuropsychological assessment
designed to provide a diagnostic determination
Study Content of dementia or cognitive impairment without
Survey content from the 2010 wave of data dementia (Heeringa et al. 2009). The study
collection, which is generally representative aimed to estimate the prevalence of dementia as
of the core interview, is summarized elsewhere well as risk factors and outcomes. ADAMS was
conducted in a subsample of the HRS population including things like jogging a mile, walking up
age 71 and older who would be at higher risk for a ight (or several ights) of stairs, pushing a
cognitive impairment. The original sample of heavy object across the oor, and picking up a
1,770 was followed up through in 2002, 2006, coin. These series of questions also include ques-
and 2008, providing information on incident tions about respondents receipt of help from
dementia and other longitudinal cognitive other people with each of these activities and the
changes. use of assistive aids (e.g., walking stick). This
From its inception, HRS has included a short section reects the assumption that respondents
screening measure of depressive symptoms need not be asked about relatively easy tasks if
derived from the Center for Epidemiologic Stud- they reported being able to do more challenging
ies Depression Scale (Stefck 2000). Beginning tasks (Fonda and Herzog 2004).
in the third wave, a short form of the World Health
Organizations Composite International Diagnos- Anthropometric Measures and Physical
tic Interview was also administered. This scale Performance
determines a probable diagnosis of major depres- As noted above, the enhanced FTF interview
sive episode, as dened by the Diagnostic and includes physical tests and collection of biological H
Statistical Manual of Mental Disorders, third edi- specimens. HRS employs a set of standardized
tion revised. assessments of lung function (peak expiratory
ow), grip strength, balance, and walking speed.
Physical Health and Limitations Arterial blood pressure and pulse are also mea-
At each wave, HRS assesses a range of health sured, and height, weight, and waist circumfer-
conditions. The survey asks respondents if a doc- ences are obtained. Before each measure,
tor has ever (or since the last wave) told them that respondents are asked whether they understand
they have high blood pressure, diabetes, cancer, the directions for the measurement and if they
lung disease, heart disease, stroke, and arthritis. feel safe completing it. If the respondent answers
For each of these conditions, respondents also no to either question, the measure is not adminis-
report on whether they are taking any medications tered. Likewise, interviewers are instructed not to
for that condition (Fisher et al. 2005). Questions administer a measure if they do not feel it is safe to
are also included about symptoms such as pain, complete it (Crimmins et al. 2008).
swollen ankles, headaches, vision, and hearing.
The study also tracks several critical health behav- Biomarkers and Genetics
iors. Respondents report on their use of alcohol, Blood is obtained through ngerprick and is col-
history of smoking, their sleep quality, and lected in the form of dried blood spots during the
amount of exercise. Preventive health services EFTF interview. Blood samples have been
assessed include mammography screening, breast assayed for ve biomarkers: total and HDL cho-
self-exam, prostate exam, cholesterol screening, lesterol, glycosylated hemoglobin (HbA1c),
Pap smear, and u shot (Jenkins et al. 2008). C-reactive protein (CRP), and Cystatin C, for
HRS also captures information about physical which data from the 2006 and 2008 waves are
limitations by asking respondents to report on currently available for analysis (Crimmins
difculties with activities of daily living (ADLs) et al. 2013).
such as bathing, eating, dressing, walking across a Respondents saliva is obtained for DNA
room, and getting out of bed. Instrumental activ- extraction. HRS saliva samples are genotyped by
ities of daily living (IADLs) include preparing a the Centers for Inherited Disease Research
meal, shopping, using a telephone, taking medi- (CIDR) and archived with the database of Geno-
cation, and handling money. Limitations with types and Phenotypes (dbGaP) at the National
these fundamental life tasks can indicate fairly Institutes of Health (NIH). To date, HRS has
severe disability. The third set of measures, the genotyped almost 20,000 respondents from 2006
Nagi items, evaluate less fundamental tasks to 2012. The genotype data through 2008 and a
limited set of phenotype measures have been as well to other data collected as part of the EFTF
deposited in dbGaP. In addition, HRS has pre- interview, namely, anthropometrics and physical
pared candidate gene and single-nucleotide poly- functioning, biomarkers, and genetics.
morphism (SNP) les to provide access to As with the core survey, in coupled house-
carefully select subsets of the HRS genotype holds, both members of the couple complete the
data available on dbGaP. These are smaller and PLQ, and in some cases, the questionnaire is
more manageable les designed for users inter- completed by a proxy. A question at the end of
ested in a specic gene or SNP. Researchers wish- the survey asks, Were the questions in this book-
ing to use the HRS genetic data must rst apply to let answered by the person whose name is written
dbGaP for access to the genotyped data. The pro- on the front cover? Approximately 12% of psy-
cess to request access to any dbGaP study is done chosocial questionnaires are completed by proxy
via the dbGaP authorized access system. HRS respondents. A caregiver often acts as a scribe for
also measures average telomere length using very old participants, especially if the participant
quantitative PCR (qPCR). The 2008 Telomere is vision impaired or nds it difcult to hold a pen
Data release includes average telomere length due to arthritis. Because the questionnaire was left
data from samples from 5,808 HRS respondents. with respondents at the end of the EFTF interview
These data are considered sensitive health data for them to complete and mail back to study
and require permission to use. Detailed access ofces, the questionnaire came to be known as
information can be found on each products page and is referred to on the HRS website as the
on the HRS website. Leave-Behind and is listed as section LB.
This section describes the psychosocial mea-
Psychosocial Functioning sures available within each broad content area
Table 1 depicts the psychosocial content available (summarized in Table 2). Some of the scales and
in the core survey and in the Participant Lifestyle measures in the PLQ are well known and widely
Questionnaire (PLQ), a questionnaire left behind used. Others are measures that have been devel-
at the end of the EFTF interview that respondents oped by HRS researchers or other research psy-
complete and return by mail. As noted above, chologists. More detailed information about the
HRS has included measures of depressive symp- scales and measures through 2010 is provided in
toms and probable depression in the core survey the documentation report/user guide available on
since the second wave (section D in the core). As the HRS website (Smith et al. 2013). The user
of 2008, all participants in the core are also asked guide lists the actual items in the questionnaire
a single item of life satisfaction (section B in the and reports the response coding and interitem
core). Before 2004, HRS piloted several psycho- consistency (reliability) information. Variations
social measures that are available as part of exper- in variable names across waves are also noted.
imental module data. In 2004, HRS piloted the With a few exceptions, the content of the PLQ
PLQ and elded the revised questionnaire did not change substantially from 2006 to 2010;
in 2006. however, variations across waves are documented
The table also illustrates the design of the in the user guide.
EFTF, which was described previously. Begin-
ning in 2006, half of the core sample was ran- Subjective Well-being
domly selected to participate in the EFTF and Well-being is assessed with several measures. Life
receive the PLQ (A). The other half of the sample satisfaction is measured with the ve-item Diener
received that EFTF in 2008 (B). The rst longitu- Satisfaction with Life Scale, an established and
dinal data from the EFTF and thus the PLQ were reliable measure of subjective well-being that has
collected from half-sample A in 2010. Longitudi- been used extensively in international compara-
nal data was collected in 2012 from the second tive studies (Diener et al. 1985). Domain satisfac-
half-sample (B). This rotational design will con- tion is assessed with seven items that tap
tinue in future waves. Note that this table applies satisfaction in several life domains: housing, city
Health and Retirement Study, A Longitudinal Data (happy, interested, frustrated, sad, content, bored,
Resource for Psychologists, Table 2 Summary of HRS or in pain) while they were watching TV,
psychosocial content
volunteering, exercising, other health-related
Well-being Lifestyle Social activity, commuting, socializing, spending time
relationships
with spouse/partner, or running errands (Smith
Life satisfaction Activities in Spouse/child/
Domain life kin/friends et al. 2014). A standard item of nancial strain
satisfaction Neighborhood Positive (Campbell et al. 1976) was added in 2008 that
Depression evaluation support asks respondents how difcult it is to make
Positive/negative Religiosity Negative monthly bill payments. As noted, depression is
affect Discrimination support
Hedonic well- Lifetime Closeness captured in the core interview.
being traumas Loneliness
Purpose in life Early life Early parental Lifestyle and Stress
Self-acceptance experiences relationships Activities in life assess the level of social engage-
Personal growth Stressful life Friend contact
Financial strain events Child contact ment and participation across a range of 20 differ-
Ongoing stress ent activities (e.g., attending religious services,
Personality Work Self-related caring for others, work on a hobby or project, H
beliefs etc.) (Jopp and Hertzog 2010). Another set of
Extraversion Work stress Personal questions has respondents evaluate the physical
Neuroticism Work mastery
Openness discrimination Perceived
disorder (vandalism/grafti, rubbish, vacant/
Agreeableness Work constraints deserted houses, crime) as well as the social cohe-
Conscientiousness satisfaction Hopelessness sion/trust (feel part of this area, trust people, peo-
Cynical hostility Capacity to Subjective age ple are friendly, people will help you) of their
Anxiety work Perceptions of
Anger Effort-reward aging
neighborhood (Mendes de Leon et al. 2009).
balance Subjective A four-item measure of religious beliefs, mean-
Work support social status ing, and values is used (Fetzer Institute 2003).
Work/family Optimism Two dimensions of discrimination are evaluated.
priorities Pessimism
Work/life
A six-item scale measures the hassles and chronic
balance stress associated with perceived everyday dis-
crimination (Williams et al. 1997), followed by
ten potential attributions for discrimination such
or town, daily life and leisure, family life, nan- as age, race, weight etc. (Kessler et al. 1999).
cial situation, health, and overall life satisfaction Assessment of lifetime traumas asks about the
(Campbell et al. 1976). Positive and negative experience of seven major lifetime traumas from
affect is assessed with an adjective checklist an ongoing longitudinal study of the health con-
(e.g., afraid, upset, determined, enthusiastic, sequences of trauma in older adults (Krause
guilty, active, etc.) largely derived from the Posi- et al. 2004). From the same study, early life expe-
tive and Negative Affect Schedule Expanded riences assess traumatic experiences before age
Form (PANAS-X) (Watson and Clark 1994). 18 (repeating a year of school, trouble with the
Some items were obtained from other researchers police, parental physical abuse, and parental drug
work in this area of study (Carstensen et al. 2000). or alcohol abuse). Recent stressful life events (last
The Ryff Scales of Psychological Well-being 5 years) include three items related to unemploy-
(Ryff 1995) includes a seven-item subscale that ment, moving to a worse neighborhood,
measures purpose in life. The 2006 version of experiencing robbery or burglary, and being the
PLQ also included the dimensions of self- victim of fraud (Turner et al. 1995). The 2006
acceptance and personal growth. Beginning in PLQ included assessment of chronic stressors
2012, the PLQ includes a measure of hedonic that includes eight ongoing problems such as
well-being, which asks respondents to rate how nancial strain, housing problems, and work dif-
much they experienced seven different emotions culties (Troxel et al. 2003).
Quality of Social Ties multiple facets of job satisfaction and multiple

A series of questions evaluates respondents work stressors. An eight-item scale taps the expe-
social network (four questions ask respondents if rience of chronic work discrimination (Williams
they have spouses/partners, children, family, and et al. 1997). Capacity to work measures the per-
friends) and the level of closeness they feel and ceived ability to work with respect to a jobs
amount of contact they have with those contacts physical, mental, and interpersonal demands
(Turner et al. 1983). For each category of contact, (Ilmarinen and Rantanen 1999). Two dimensions
seven questions assess perceived social support or

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Nancy A.

With 148 Figures and 100 Tables

ISBN 978-981-287-081-0 ISBN 978-981-287-082-7 (eBook)

Library of Congress Control Number: 2016953014

# Springer Science+Business Media Singapore 2017

Printed on acid-free paper

This Springer imprint is published by Springer Nature

In Undaunted Courage, the late historian, Stephen Ambrose (1996) chronicled

are impressive. Together, hundreds of scholars have shared their expertise to

Abeles, N. (2015). Historical perspectives on clinical geropsychology. In

Ambrose, S. E. (1996). Undaunted courage: Meriwether Lewis, Thomas

Wahl, H., & Wettstein, M. (2016). Plasticity of aging. In N. Pachana (Ed.),

Geropsychology is a relatively young eld which spans a range of topic areas

Brisbane Australia Nancy A. Pachana

The Encyclopedia of Geropsychology has been a truly international collabo-

Dr. Nancy A. Pachana is a clinical

Christopher Hertzog School of Psychology, Georgia Institute of Technol-

Marcia G. Ory Health Promotion and Community Health Sciences, School

Deborah Attix Duke Clinical Neuropsychology Service, Department of Psy-

Bob G. Knight School of Psychology and Counseling, University of South-

scar Ribeiro Institute of Biomedical Sciences Abel Salazar of the Univer-

Mnica Yassuda Gerontology and Neurology Departments, University of

Daniela S. Jopp University of Lausanne, Institute of Psychology, Gopolis,

Hannes Zacher School of Management, Queensland University of Technol-

Catherine Haslam School of Psychology, The University of Queensland,

Helene Fung Chinese University of Hong Kong, Shatin, Hong Kong

Fiona Alpass School of Psychology, Massey University, Palmerston North,

Sherry Ann Beaudreau Psychiatry Service, Sierra Pacic Mental Illness

Matthias Kliegel Department of Psychology, University of Geneva, Geneva,

Chris Stephens School of Psychology, Massey University, Palmerston

Hans-Werner Wahl Department of Psychological Aging Research, Univer-

Colette Browning RDNS Institute, Victoria, Australia

Marja Aartsen NOVA Norwegian Social Research, Oslo and Akershus

Fiona Alpass School of Psychology, Massey University, Palmerston North,

Fiona Kate Barlow School of Applied Psychology and Menzies Health

Magdalena Bathen: deceased.

Erin D. Bigler Department of Psychology and Neuroscience Center,

Mary Breheny School of Public Health, Massey University, Palmerston

Lisa Calvano West Chester University of Pennsylvania, West Chester, PA,

Anna Chapman RDNS Institute, Melbourne, VIC, Australia

Kaitrin Conniff Palo Alto University, Palo Alto, CA, USA

Ans De Vos Antwerp Management School, Antwerp, Belgium

Mary E. Dozier San Diego State University/University of California, San

Thomas J. Farrer Department of Psychiatry and Behavioral Sciences, Duke

Ulrike Fasbender Department of Business and Management, Oxford

Joanne Feeney The Irish Longitudinal Study on Ageing, Department of

Lei Feng Department of Psychological Medicine, Yong Loo Lin School of

Qiushi Feng Department of Sociology, National University of Singapore,

Daniela Figueiredo School of Health Sciences, University of Aveiro, Aveiro,

Karen Fingerman Human Development and Family Sciences, Population

Gwenith G. Fisher Department of Psychology, Colorado State University,

Jane E. Fisher Department of Psychology/298, University of Nevada, Reno,

Amy Fiske Department of Psychology, West Virginia University, Morgan-

Emma Flanagan Norwich Medical School, University of East Anglia, Nor-

Kitty-Rose Foley Department of Developmental Disability Neuropsychiatry,

Evgenia Folts Department of Pediatrics, University of Iowa Carver College

Simon Forstmeier Faculty II Department of Education Studies and Psy-

Franco Fraccaroli Department of Psychology and Cognitive Science, Uni-

Karen Glanz Perelman School of Medicine, University of Pennsylvania,

Madison E. Hanscom Department of Psychology, College of Natural Sci-

Agneta Herlitz Division of Psychology, Department of Clinical Neurosci-

Martijn Huisman NOVA Norwegian Social Research, Oslo and Akershus

Mary Lee Hummert Communication Studies Department, University of