Journal of Aging Studies
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- J Aging Res
- v.2018; 2018
Perspectives of Older Adults on Aging Well: A Focus Group Study
1 Department of Health and Rehabilitation, Institute of Neuroscience and Physiology, University of Gothenburg, Gothenburg, Sweden
2 Department of Physiotherapy & Rehabilitation, Faculty of Health Professions, Al-Quds University, Jerusalem, State of Palestine
3 Centre for Ageing and Health, AGECAP, University of Gothenburg, Gothenburg, Sweden
Carin willén, associated data.
The data used to support the findings of this study are available from the corresponding author upon request.
With increasing number of older adults worldwide, promoting health and well-being becomes a priority for aging well. Well-being and physical and mental health are closely related, and this relation may become more vital at older ages as it may contribute to aging well. The state of well-being is a multifaceted phenomenon that refers to an individual's subjective feelings, and exploring perspectives of older adults on aging well is developing to be an important area of research. Therefore, the aim of this study was to explore perceptions on aging well among older adult Palestinians ≥60 years.
A qualitative research design in the context of focus group discussions was used; seven focus groups were conducted including fifty-six participants (aged 63–81 years). Data were analyzed using a qualitative interpretative thematic approach described by Braun and Clarke.
Three major themes were identified, “sense of well-being , ” “ having good physical health , ” and “ preserving good mental health.” The participants perceived that aging well is influenced by positive feelings such as being joyous, staying independent, having a life purpose, self-possessed contentment, and financially secured, in addition to be socially engaged and enjoying good physical and mental health.
This study contributes to get a better insight concerning older adults' perspectives on aging well. Enhancing physically active lifestyle, participation in social and leisure activities, healthy eating habits, having a purpose in life, and being intellectually engaged are all contributing factors to aging well. Vital factors are to be considered in developing strategic health and rehabilitative plans for promoting aging well among older adults.
Worldwide, the age group of sixty years old and older is growing faster than any other age group [ 1 ]. With this remarkable increase of older adults; promoting health and well-being becomes a priority for aging well [ 2 ]. Aging well is conceptualized using different contemporary theoretical frameworks in the last decades, including healthy aging, positive aging, productive aging, active aging, and successful aging [ 3 , 4 ]. These theoretical frameworks integrate both biological and social sciences, considering social participation, psychology, lifestyles, activities, finances, and other domestic and environmental factors as well [ 4 ]. The WHO defines active aging [ 1 ] as “the process of optimizing opportunities for health, participation, and security in order to enhance quality of life as people age including those who are frail, disabled, and in need of care.” As a policy framework [ 1 , 5 ], active aging allows people to realize their potential for physical, social, and mental well-being throughout the life course and to participate in society. The concept of active aging can be applied for promoting aging well in both developed and developing countries and this is consistent with our study setting in the West Bank/Palestine.
The state of well-being is a multifaceted phenomenon in the older population which generally involves happiness, self-contentment, satisfying social relationships, and autonomy [ 6 ]. The sense of well-being refers to an individual's feelings, in this case, based on how older persons perceive the concept of well-being. Thus, the term “subjective well-being” is frequently used [ 7 ]. Well-being is also subject to other persons' feelings about oneself whether that is positive or negative. According to McNulty et al. [ 8 ], well-being is determined jointly by the interplay between individual characteristics and qualities of people's social environments.
With advanced age, well-being might be adversely influenced by declining physical health and functioning due to age-related changes [ 9 , 10 ]; older adults may consequently encounter more challenges in pursuing aging well [ 7 , 11 , 12 ]. Maintaining good physical health and functioning plays an important role in facilitating mobility and enables older adults to perform more integrated functional tasks which include activities of daily living, fulfillment of social roles, and recreational activities [ 7 , 13 ]. Evidence suggests that better physical functioning is associated with physical activity, an interaction that is positively reflected on physical and functional well-being [ 14 – 16 ]. In addition, good physical functioning contributes to decrease falls' incidence [ 17 – 19 ] and prevent the negative impact of falling consequences including social isolation and activity restriction in older adults [ 20 , 21 ].
Older adults are strongly concerned about cognitive health in term s of keeping a good memory and prevent cognitive decline. Therefore, cognitive functioning was addressed as a primary contributor to aging well [ 22 , 23 ]. Good cognitive health is linked to social connectedness, independence, and life activities, and it might be preserved and enhanced by maintaining an intellectually engaged and physically active lifestyle [ 24 , 25 ]. Furthermore, having positive mental attitudes towards aging and one's capabilities may contribute to healthier mental health, higher level of satisfaction, and lower levels of anxiety and depression among older adults [ 26 ].
Well-being and physical and mental health are closely linked and the link may become more important at older ages, a connection that contributes to aging well in terms of life satisfaction, feelings of happiness, having sense of purpose, and meaning in life [ 27 – 30 ]. In the West Bank/Palestine, about one-third of adult Palestinians ≥18 years reported low levels of well-being; this was influenced by different socioeconomic factors including marital status, living standard, and community participation [ 31 ]. These contributing factors to well-being can be more prominent among older adult Palestinians, a marginalized growing population age group with a high rate of poverty, unemployment, and chronic diseases that requires further studies and research [ 32 , 33 ]. To our knowledge, this is the first qualitative study exploring perceptions of older adult Palestinians on aging well. Thus, the aim of this study was to explore perceptions about aging well among older adult Palestinians who were 60 years old and older at the time of the data collection.
2.1. Study Design
Focus group method was used to acquire data about perceptions of older adults towards aging well. Focus groups are defined as “carefully planned series of discussions designed to obtain perceptions on a defined area of interest in a permissive, nonthreatening environment” [ 34 ]. Group interaction is a fundamental part of this method, in which the vital group discussions among the participants produce the data of the studied topic [ 35 , 36 ].
A convenient sample was selected from previous related cross sectional studies [ 16 , 19 ], addressing physical activity and physical functioning among older adults ( n =176). The inclusion criteria were being community dwelling older adults (aged ≥60 years), living in the West Bank (Palestine), being able to walk with or without walking aids, and having no communication deficits that would make interviewing and discussions impossible.
In order to obtain a broader view of the participants' perceptions about aging well; heterogeneity was taken into consideration [ 34 , 35 ] through inviting older adults with different age and levels of education. Issues related to heterogeneity and homogeneity within the groups were considered during groups' formation in order to enhance an interactive discussion and to get a broad range of experience that covering a wide scope of the studied topic [ 34 , 35 ].
All participants were given verbal and written information about the aim of the study and they signed an informed consent form. The participants were ensured confidentiality and informed that participation was voluntary and that they could drop out of the study at any time. The study received ethical approval from the research Ethics Committee of Al-Quds University, Palestine (Ref No: 1/REC/13), which complies with the Declaration of Helsinki.
All focus groups were arranged by the first author as a moderator. Focus group sessions were conducted in familiar, comfortable, and accessible settings for the participants and took place in community and physiotherapy centers in the West Bank (Palestine).
The moderator started the group sessions by welcoming the participants and clarifying the purpose of the study. Subsequently, the participants were invited to introduce themselves and were given a chance to ask if they had any inquiry regarding the study.
The moderator clarified that the discussion would be carried out involving the participants themselves as knowledgeable and expert persons of the studied topic and that the moderator would not contribute to answer the questions. The moderator guided the discussion and encouraged all participants to share and ensured giving sufficient time for each participant to express his or her own view; in addition, comprehension probes were used if needed to clarify responses.
The sessions were initiated with a starting question “ How do you describe aging well ,” followed by these questions:
- What do you think about older adults' lifestyles in our community?
- How do you think aging well can be achieved? Meaning how aging well can be facilitated?
- What obstacles stand in the way of aging well?
The focus groups lasted from 90 to 120 minutes; the interviews were digitally audio-recorded. All interviews were transcribed verbatim by the first author and translated from Arabic to English by the first author in collaboration with a bilingual translator.
2.4. Data Analysis
The analyzing process was conducted using the interpretative thematic analysis described by Braun and Clarke [ 37 ]. The initial phase of the analysis “becoming familiar with the data” was initiated with reading and rereading the transcripts for several times. Repeated reading contributed to get a better understanding and enhanced researchers' familiarity with the data. Following the initial stage, “generating initial codes (coding)” from the data set that had a reoccurring pattern was performed in the second phase. Coding was carried out through systematic way of organizing and gaining meaningful characteristics of data related to the research question. The first author began the process of initial coding; all transcriptions were coded one by one. Research team meetings were held to discuss the generating initial codes; exchanges that helped create an interpretative space for testing the findings and confirming coding analyses. This process was repeated until coding consensus was reached. The software NVivo 10 [ 38 ] was used as a helpful tool for analysis. The third phase “searching for themes” focused on a broader level of analysis and involved the researchers identifying suitable themes to which codes could be attributed, initial codes pertinent to research question were integrated into themes considering how relationships were formed between codes and potential themes. To visualize and explore trends and relationships in the source data, codes, and themes, a tree mapping was formulated using NVivo wizards. Derived themes were reviewed in phase four of the analysis, through cyclical process that involves back and forth movements between phases of data analysis until consensus was reached on the final themes. Consequently, in phase five, “Defining and naming themes” was completed, through refining existing themes and subthemes that will be presented in the final analysis.
3.1. Descriptive Information
A total of 56 participants were recruited in this study, the mean age was 68.3 ± 4.72, ranged between 63 and 81 years old. The participants were assigned into different groups according to their place of residency and their preferences to participate in groups that consisted of only women, only men, or women and men together in one group. Accordingly, seven focus groups were formulated: four women groups, two men groups, and one group of women and men together. Participants in all seven groups ranged from 5 to 10 participants. The developed groups were homogenous in terms of independence level and place of residency. The majority of the participants (78%) had one or more chronic diseases, and all participants who lived alone (16%) were women. Participants' demographic and clinical characteristics are illustrated in Table 1 . The participants' names were changed to preserve the anonymity of the participants.
Demographic and clinical characteristics of the participants ( n =56).
3.2. Perceptions on Aging Well
Three major themes were identified, and twelve interrelated subthemes were derived. These themes and subthemes were elicited from the discussions for all focus groups combined within the scope to which they were supported by the qualitative data. Themes and subthemes are presented in the following sections.
3.2.1. Sense of Well-Being
Sense of well-being was highlighted through discussions in different focus groups as an important attribute to aging well. This theme was categorized into four related subthemes; feeling joyous, self-possessed contentment, satisfying social relationships, and staying independent.
(1) Feeling joyous was viewed as a catalyst to go on in life “joy extends life span,” “joy makes you energetic”; in these words, the participants expressed on the importance of being happy. They have connected happiness with living to advanced age, it was important for them to keep sweet flavor to their lives, no matter how difficult their circumstances were.
- Nelly (F, 65y) : Despite life is full with troubles and blues, I continue.
- Nadia (F, 73y) : I try to be happy, means one accepts everything, no matter bad or good.
- Nelly : Yes, we need something taking us out of our concerns and make us happy.
- Shafiq (M, 68y) : Absolutely right, being happy is very important for us in this age.
The participants found ways to add joys to their lives through different strategies such as gatherings, spending time with grandchildren, and sharing activities with others. For them, having leisure activities was of great importance in the context of aging well for older adults.
- Fatima (F, 70y) : We get together from time to time, where we joke and laugh, listening traditional songs or singing together, this encourages us and makes us happy .
- Sara (F, 64y) : For me, the sweetest thing I do is playing with grandson .
- Ibrahim (M, 67y) : Yes, grandsons are dearest of sons, they refresh my heart .
- Sara : I feel energized; I play with them as a young girl .
(2) Self-possessed contentment was apparently viewed as an important concern for older adults. Throughout the participants' discussions, feeling secured and being satisfied were frequently mentioned, self-contentment was manifested in the necessity of having access to needed resources in terms of health services and daily-life requirements. In this context, feeling financially secured contributed to the state of self-contentment and was described as a facilitating mean to manage life pressures for being able to age well:
- Zeinab (F, 65y) : When you get old and there is no income, you may be in destitution .
- Ribhieh (F, 67y) : Financial status plays a big role in our life .
- Zeinab : This brings you many worries and occupies your mind .
- Ibrahim (M, 67y) : Yes, the fact if one at ease can eat better can dress better, can live better, this reflects on the state of well-being for us as old people .
(3) Satisfying social relationships were viewed as an attribute to aging well at both familial and community levels. Among different groups' discussions, the participants talked about how important it was for them to be accepted and involved in an area of life. They reflected on how being isolated and lonely might be a serious obstacle to aging well. This subtheme was mostly prominent among women:
- Nayfeh (F, 66y) : I live alone, nobody knocks my door, that's hard .
- Mariam (F, 70y) : I live alone too, but my son lives in the first floor (same building). My daughter lives in town, and they are always around, that helps a lot, they do n 't let me alone at all .
- Huda (F, 65y) : Yes, It's hard to live alone, but I go out, I share in different occasions, social participation is a good motivator for us as we growing old .
Staying socially active was described in different phrases and was manifested about “having good neighbors and visiting friends,” “highly motivated person towards life,” and “not being dismal.” Participation in community events was described by some participants as a helpful tool for older adults to stay socially active. Additionally, being socially active was connected with community voluntary work. The participants, both men and women commented on how vital for them it was to do voluntary activities, which helped them as older adults to efficiently spend their free time by doing something sensible to serve their own community. The participants reflected on how voluntary work or being involved in charitable work may enhance their state of well-being.
(4) Staying independent was viewed as a major characteristic of aging well. Apart from the participants' living status (alone or with family), the importance of being independent was connected with the autonomous status of the older adults. A major concern that was frequently mentioned was not being or becoming a burden to others. Along the interactive discussions in all groups, the participants reflected on the necessity of staying independent in performing their daily life activities including both personal and instrumental activities.
- Seham (F. 65y) : I am taking care of myself, my health is good, I need to stay healthy and mentally oriented, so I w on 't seek anybody help .
- Hannah (F, 81y) : I live alone, I have a big house. I do everything by myself; nobody brings me even a glass of water .
3.2.2. Throughout the Second Theme “Having Good Physical Health”
Throughout the second theme “having good physical health,” the participants have considered maintaining physical health as an important component of aging well, through our analysis, having good physical health was categorized into five related subthemes; staying active, free from debilitated illness, healthy eating habits, fall prevention, and having a good physical appearance.
(1) Staying active was connected to aging well, the participants prominently commented on the importance of staying active by keep on moving. The participants viewed staying active as a key factor for good health. Frequently, the participants talked about staying active in terms of walking which was viewed as a useful tool for aging well; walking was the most prevalent mode of physical activity and has been mentioned repeatedly as a routine activity. Staying active was also connected to good physical functioning, helping older adults to maintain good physical functioning, and keeping good health.
- Hannah (F, 81y) : I like going out even I have pain in my legs, if I stay home, I will be destructed .
- Salwa (F, 66y) : Me too, I' am taking care of my health, I walk a lot .
- Zarifeh (F, 67y) : You know, I have a brother in law, he is 81 years old, he is still working and going out everywhere by feet .
Staying active was also revolved around continuing to work, which was described differently by the participants; men talked more about income generating and community work, while women talked about household and charitable work. Despite there were different perspectives on the concept of “continuing to work,” still it was considered as an important attribute for good physical health and for aging well throughout women and men expressions.
In other circumstances, staying active has been linked to gardening. The participants expressed on the importance of doing some gardening in order to stay active and energetic.
- Salem (M, 72y) : I work in my garden, and I see myself more active than my sons .
- Nelly (F, 65y) : Ohh, I love gardening a lot, I spend like two hours caring of my plants, digging around them. Always my plants look good, my whole garden is tidy, and that keeps me active and energetic .
(2) Free from debilitated illness , staying healthy in terms of absence of debilitated diseases was highlighted during group discussions as an important attribute to good physical health and consequently to aging well. The participants described how occurrences of illness may influence their physical health and their daily-life activities.
- Ribhieh (F,67y) : Illness sometimes over shadow, I try to forget it, but it is dominated .
- Fatima (F, 70y) : After rheumatism, I am not able to walk like before, that affected me a lot .
- Ribhieh : Yes, it caused me gloominess sometimes .
- Nelly (F, 65y) : Ahh, you know, I underwent two surgeries, and I've suffered a lot, but I've challenged every pain and every disease, I try to live my life .
(3) Healthy eating habits were evoked and being discussed in all groups, the participants reflected on this by focusing on the importance of taking healthy foods. Culturally, ideas regarding the Palestinian diet, which consists mainly of olives oil and lots of vegetables, were mentioned frequently. The participants related healthy diet with good physical health and longevity.
Within this subtheme, promoting healthy eating habits related to aging well were addressed. The participants talked about healthy habits to be taken as well as unhealthy eating style to be skipped. In this context, overeating or getting a full stomach was described as a source of disease, a behavior that has to be prevented in order to maintain good health. Unhealthy eating habits like skipping breakfast and excessive use of salt and sugar were viewed as aggravating factors for some disease symptoms.
(4) Falls prevention was a persistent topic that has been discussed among the participants as an important contributor to good physical health. For them, it was vital to stay active but constantly they were concerned about falling. They have viewed falling at this age as a devastating problem, thinking about fall consequences both physically and socially. The participants connected their concern of falling with the associated physical decline.
- Majida (F, 70y) : I prefer using a cane rather than falling down .
- Wardeh (F,77y) : Yah, me too, I pay attention to prevent slipping or falling .
- Majida : Before I got sick, there was no problem, I did n 't never ever catch any handrails .
- Mariam (F, 70y) : Yes I see, it is hard to fall and get fracture at this age, healing is not granted .
(5) Having a good physical appearance was viewed as an important trait to age well. The participants talked about how vital it was for them to keep in good physical appearance; this was connected with “keeping good shape,” “having good stature,” and “maintaining external appearance.” Others pointed out that older persons who are aging well “maintaining good external appearance and dressed well.”
3.2.3. Preserving Good Mental Health
The vitality of maintaining good mental health was viewed as an important attribute to aging well. This theme was categorized into three related subthemes: staying alert, having a positive attitude, and modes to keep good mental health.
(1) Staying alert : participants valued their state of mental alertness related to being independent, having control over their own affairs, and being self-governing. Being mentally alert and having a good memory was mentioned frequently as an imperative dimension of aging well.
- Salma (F, 68y) : I was living with my mother in law, she reached her nineties, and she had a clear mind, everyone respected her, and I've learned a lot from her .
- Ribhieh (F, 66y) : Yes I agree, If the brain is still good, you will be fine .
(2) Having a positive attitude emerged as an important attribute to aging well, and it was diversely characterized as follows: “my spirit is strong, I just follow my mind,” “I don't let anybody put me down,” and “I'm in any way, I want to live.” The participants commented on the importance of getting this impulse of life by staying positive. In this context, having positive attitudes towards own capabilities as older adults was reflected by fulfilling own ambitions and having a life purpose in pursuit of one's aspiration.
Being positive was also connected with spiritual merits, having faith, praying, and trust in God; these traits have been mentioned frequently through discussions in different groups. The participants commented on the importance of reaching a state of serenity and tranquility as an important attribute to aging well.
(3) Modes to keep good mental health including actions such as reading newspapers and books, watching TV and listening to the radio, eating certain foods like nuts, staying active, and playing mental games. All these statements were mentioned to describe taken activities by the participants in order to keep good mental health and to age well:
- Farida (F, 64y) : I read newspaper every day, that keeps me oriented .
- Nayfeh (F, 66y) : For me, I can't read well, watching TV and hearing radio amuses me and keeps me alert .
- Hannah (F, 81y) : I work with letters and numbers, Sudoku is good if you manage to deal with it .
- Farida : Ohh, That's good too .
Willingness to learn new skills was also considered by some participants as a way to keep a good mind; the new skills were mostly revolving around computer uses, handcrafts, and simple maintenance work.
Happiness, self-contentment, satisfying social relationships, and independence are primary characteristics of the state of well-being that contribute to aging well in the older population [ 6 ]. A study by Tamir and Ford [ 39 ] indicated that people who generally wanted to feel more happiness and less anger experienced greater well-being. Corresponding with our results, as illustrated in the first theme, the participants have considered joy and happiness an important tool to age well. Feeling joyous was viewed as a catalyst to go on in life and was connected with living to advanced age. When older adults experience well-being, they are also experiencing the sense of self-contentment which is connected to the feeling of being happy and satisfied. Self-contentment in this study was manifested in feeling financially secured and in the necessity of having access to needed resources in terms of health services and daily-life requirements. The findings are consistent with a similar study [ 40 ], where financial security appeared to be an essential contributor to aging well.
Well-being is also subject to how a person feels that other people in their surroundings perceive them, whether this is positive or negative [ 8 ]. The findings are corresponding with our results in the subtheme “satisfying social relationships,” and the participants commented on the importance of having social connections at both familial and community levels. These findings are in harmony with the concept of active aging [ 1 ], which enables older people to realize their diverse potentials for well-being. However, the well-being of a person does not only depend on the individual, rather well-being has a social component as well, and it is determined jointly by the interplay between individual characteristics and qualities of people's social environments [ 39 ].
The participants reflected on how sensible for them it was not to be ignored and isolated at this age, and they thought being isolated and lonely as a serious obstacle to aging well. This concern was mostly prominent among older women who are more likely to spend their later stage of their lives alone [ 32 ]. Related to literature, living alone and low social participation were found to be significant risk factors for later disability onset [ 41 ]. Older adults who live alone report more fatigue and more health difficulties than older adults who do not live lonely [ 42 , 43 ], issues that are negatively contributing to aging well.
Our findings revealed that autonomy and independence were viewed as primary attributes to age well. Concern of being a burden to others was very prominent throughout participants' expression. Older adults in other cultural circumstances as well placed a high value on personal independence and self-reliance, where staying independent was viewed as a major trait for aging well [ 24 , 44 ]. The participants related their level of independence to their physical and mental health; a sensible understandable relation as a higher level of physical functioning enables older adults to perform more integrated functional tasks which include activities of daily living and the fulfillment of social roles as well as recreational activities [ 7 ], issues that are essential to age well.
Throughout the second theme “having a good physical health,” the participants connected their good physical health with staying active. Often, they have talked about staying active in terms of walking. This can be explained as walking was viewed as one of the most popular forms of physical activity among older adults and can easily be adapted into daily lifestyle [ 45 ].
In this study, walking was connected to good physical functioning and has been mentioned repeatedly as a routine activity, helping older adults to maintain good physical functioning and keeping good health. Findings are consistent with similar studies indicating that walking is positively associated with physical and functional well-being in older adults [ 14 , 15 ].
Physical health was addressed according to Phelan et al. as being in good health and absence of chronic diseases [ 46 ]. In Rowe and Kahn's model, it was addressed as avoiding disease and maintaining high cognitive and physical function [ 47 ]. In this study, the majority of the participants, about 78% had one or more chronic diseases. For them, the concern about physical health in term of diseases was more prominently about being free from debilitated illness that may incapacitate their abilities and limit their daily-life activities. Results that are consistent with a related study showed that participants with higher prevalence of chronic diseases recorded lower level of physical activity [ 15 ].
Promoting healthy eating habits related to aging well was also addressed in this study. The participants related healthy diet with good physical health and consequently to aging well, a subtheme that was also found among perceptions of older Japanese adults in a study towards aging well [ 40 ].
Additionally, falls prevention was a persistent topic that has been discussed among the participants as an important contributor to good physical health. For them, especially women, it was imperative to stay active but constantly they were concerned about falling. This can be attributed to the fact that higher incidence of falls is associated with higher age, and women tend to fall more frequently than men [ 48 , 49 ]. Participants have viewed falling at this age as a big problem, thinking about fall consequences both physically and socially. A subtheme is consistent with other studies [ 17 – 19 ], which have shown that good physical health and physical functioning play an important role in decreasing falls' incidence and fear of falling and, in turn, prevent the negative impact of falling consequences including social isolation, activity restriction, and enhance state of well-being in older adults [ 20 , 21 ].
In this study, preserving good mental health and staying alert were viewed as important attributes to aging well, and good mental health was connected to staying independent and being self-governing. In a study by Laditka et al. [ 24 ], maintaining good cognitive health was linked to social connectedness, independence, and life activities that are difficult to maintain with poor cognitive health. Within the second theme, “having a positive attitude” was described as an attribute to good mental health and to age well. This can be understandable as having positive attitudes towards aging and owns capabilities may contribute to healthier mental health. More positive attitudes were associated with higher level of satisfaction and lower levels of anxiety and depression in older adults [ 26 ].
Within this theme, participants related having a positive attitude to spiritual merits, having faith, praying, and trust in God. These traits have been mentioned frequently in different groups where the participants commented on the importance of reaching a state of serenity and tranquility that can be achieved through spiritual dimension as an important attribute to aging well. A spirituality dimension of aging well was found in similar studies [ 24 , 40 ] as well under categories such as faith, religion, blessings, and internal peace.
The state of well-being is positively influenced by having a life purpose that can motivate older adults to sustain independence, social life, and make life meaningful for older adults [ 29 ]. The feeling of having a purpose in life was also contributing to aging well in our study that was manifested by fulfilling ambitious and having a life goal in pursuit of one's aspiration.
Evidence suggests that cognitive functioning may be preserved and enhanced by maintaining an intellectually engaged and physically active lifestyle. Meaningful social engagement is also an important factor of better maintenance of cognitive functioning in old age [ 25 ]. Keeping good mental health was an important concern for older adults in this study; different modes were described to maintain good mental health including being mentally engaged (reading, playing mental games), taking good foods for the brain like nuts and staying physically active.
4.1. Strengths and Limitations
The aim of this study was to explore perceptions about aging well among older adults, as the state of aging well refers to an individual's subjective feelings and is basically dependent on the older adults' views [ 7 , 50 ]. Therefore, a qualitative research design in the context of focus group discussions was used; this qualitative thematic analysis approach contributed to get better insight into older adults' perceptions and experiences that cannot be elicited through quantitative studies.
Using focus group discussion as a method of data collection has enabled the researchers to get both individual and interactive opinions by the participants. This method is effectively used in research on aging [ 51 , 52 ], and it is considered appropriate for collecting the views and experiences of a selected group through dynamic interaction and vital group discussion of a studied topic [ 35 , 36 ]. In addition, focus group method was used, because it is a friendly respectful research method and not a condescending method [ 53 ] to be used with older adult participants. To assure permissive and nonthreatening environment for conducting this study [ 34 ], participants were assigned into different groups according to their place of residency and their preferences to participate in groups that consist of only women, only men, or women and men together. This procedure contributed to a relaxed discussion atmosphere through having familiar, comfortable, and accessible settings for the participants.
The groups' size in this study was determined based on the research question, taking into consideration that small groups with less than five participants may limit the range of interactive discussions, while large groups meaning more than ten participants can be hard to be managed by the moderator and may bound the participants' opportunities to share their thoughts and experiences [ 34 , 54 ].
The relationship between the researcher (first author) and the participants has been developed progressively through several interviews. Our sample was selected conveniently from previous related cross-sectional studies [ 16 , 19 ], addressing physical activity, physical functioning, and fall-related efficacy among older adults. Familiarity of researcher with the participants gave a chance to create a comfortable interviewing atmosphere, which helped the researcher build a trusting connection with the participants and encouraged the participants to talk more freely.
This study addresses aging well in a holistic manner that includes state of well-being, physical and mental health, independence, and social participation [ 3 , 55 ]. This helped us in giving a better understanding about the interaction between different physical, social, and mental functioning dimensions regarding the state of well-being among older adults. However, further studies addressing each dimension in more depth may add additional evidence towards a better understanding of the concept of aging well.
A possible limitation of this study could be that we recruited older adults who are relatively independent and functioning and living in the community at own homes within a family or alone, and most of them rated their self-fitness between good and very good. Further studies are needed to explore perspectives on aging well among older adults living in institutions with lower level of functioning and independence.
This study gives in-depth understanding of the dynamic multidimensional physical, social, and mental functioning on the state of well-being among older adults. Findings contribute to get better insight about older adults' perspectives on aging well. Aging well is positively influenced by feeling joyous, staying independent, self-possessed contentment, and being financially secured, in addition to being socially engaged and enjoying good physical and mental health. Enhancing a physically active lifestyle, social participation, and leisure activities as well as healthy eating habits and having a purpose in life and intellectually engagement are all important factors to promote aging well. Vital factors are to be considered in developing strategic health and rehabilitative plans for promoting aging well among older adults.
This study is based on a doctoral thesis [ 56 ], which was supported by Gothenburg University and Al-Quds University. The authors would like to thank all the participants for their valuable contributions to this study.
Conflicts of interest.
The authors declare that they have no conflicts of interest.
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Age-Related Variation in Health Status after Age 60
Contributed equally to this work with: Giola Santoni, Sara Angleman, Anna-Karin Welmer, Francesca Mangialasche, Alessandra Marengoni, Laura Fratiglioni
* E-mail: [email protected]
Affiliation Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
Affiliations Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden, Stockholm Gerontology Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
Affiliations Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden, Karolinska University Hospital, Stockholm, Sweden
Affiliations Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden, Section of Gerontology and Geriatrics, Department of Medicine, University of Perugia, Perugia, Italy
Affiliation Geriatric Unit, Department Clinical and Experimental Science, University of Brescia, Brescia, Italy
- Giola Santoni,
- Sara Angleman,
- Anna-Karin Welmer,
- Francesca Mangialasche,
- Alessandra Marengoni,
- Laura Fratiglioni
- Published: March 3, 2015
- Reader Comments
3 Jun 2015: Santoni G, Angleman S, Welmer AK, Mangialasche F, Marengoni A, et al. (2015) Correction: Age-Related Variation in Health Status after Age 60. PLOS ONE 10(6): e0130024. https://doi.org/10.1371/journal.pone.0130024 View correction
Disability, functionality, and morbidity are often used to describe the health of the elderly. Although particularly important when planning health and social services, knowledge about their distribution and aggregation at different ages is limited. We aim to characterize the variation of health status in a 60+ old population using five indicators of health separately and in combination.
3080 adults 60+ living in Sweden between 2001 and 2004 and participating at the SNAC-K population-based cohort study. Health indicators: number of chronic diseases, gait speed, Mini Mental State Examination (MMSE), disability in instrumental-activities of daily living (I-ADL), and in personal-ADL (P-ADL).
Probability of multimorbidity and probability of slow gait speed were already above 60% and 20% among sexagenarians. Median MMSE and median I-ADL showed good performance range until age 84; median P-ADL was close to zero up to age 90. Thirty% of sexagenarians and 11% of septuagenarians had no morbidity and no impairment, 92% and 80% of them had no disability. Twenty-eight% of octogenarians had multimorbidity but only 27% had some I-ADL disability. Among nonagenarians, 13% had severe disability and impaired functioning while 12% had multimorbidity and slow gait speed.
Age 80-85 is a transitional period when major health changes take place. Until age 80, most people do not have functional impairment or disability, despite the presence of chronic disorders. Disability becomes common only after age 90. This implies an increasing need of medical care after age 70, whereas social care, including institutionalization, becomes a necessity only in nonagenarians.
Citation: Santoni G, Angleman S, Welmer A-K, Mangialasche F, Marengoni A, Fratiglioni L (2015) Age-Related Variation in Health Status after Age 60. PLoS ONE 10(3): e0120077. https://doi.org/10.1371/journal.pone.0120077
Academic Editor: Pasquale Abete, University of Naples Federico II, ITALY
Received: November 19, 2014; Accepted: January 19, 2015; Published: March 3, 2015
Copyright: © 2015 Santoni et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited
Data Availability: All relevant data are within the paper and its Supporting Information files.
Funding: The Swedish National study on Aging and Care, SNAC, ( www.snac.org ) is financially supported by the Ministry of Health and Social Affairs, Sweden; the participating county councils and municipalities; and the Swedish Research Council. In addition, a specific grant (LA2013-0412) was obtained from Ragnhild och Einar Lundströms Minne foundation ( http://www.lindhes.se/stiftelseforvaltning/ansokan-om-bidrag ). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
Competing interests: The authors have declared that no competing interests exist.
The older population is increasing worldwide,[ 1 ] a development that will challenge societies and their health care systems. The best way to face these challenges is to prolong the proportion of years of life lived in good health by identifying realistic preventive and care priorities.[ 2 ] An important step in this direction is to better understand the age-related changes in older adults and to detect the most prevalent patterns in the different phases of aging.
The older population consists of an extremely heterogeneous group of persons;[ 3 ] the older the age group, the greater the variation found in cognition, physical and sensory function, and social engagement, to mention just a few examples.[ 4 ] For that reasons, there is a large agreement among researchers and clinicians in using multiple health indicators to capture the complexity and variability of health status in older adults.[ 1 ] Most of the currently used indexes that objectively assess the general health status of older adults (e.g. comprehensive geriatric assessment and Multidimensional Prognostic Index[ 5 ] constructs to mention a few) include four dimensions:[ 6 ] morbidity, physical functioning, cognitive functioning, and disability (defined as dependence in Activities of Daily Living [ADL]). Although these indicators of poor health are correlated with each other and with survival,[ 7 – 10 ] knowledge about their distribution, aggregation in the general population, and occurrence at different ages is still very limited.
The aims of this study were to characterize the health status of 60+ old adults and to detect the age-related variability using 5objective health indicators. Specifically, we set out to explore the age-related differences between these indicators and to estimate the prevalence of the most frequent patterns of their aggregation.
Data were gathered from the Swedish National study of Aging and Care in Kungsholmen (SNAC-K), a community-based longitudinal study of the general population in central Stockholm.[ 11 ] Participants were randomly selected from the population of adults aged 60+ living at home or in institutions in the Kungsholmen district of Stockholm between 2001 and 2004. To reduce attrition during follow-up, the sample was selected from 11 age cohorts: 60, 66, 72, 78, 81, 84, 87, 90, 93, 96, and 99+. The two youngest and the four oldest age groups were oversampled. Of the original 5111 people invited to participate, 521 were not eligible (200 dead, 262 without contact information: 59 deaf, moved away, or not Swdesh speaker). Among the remaining 4590, 1227 declined to participate, leaving a study population of 3363 (73% participation rate). In the present analyses, data were complete for 3080 participants.
Physicians made clinical diagnoses on the basis of the general health status of participants, laboratory tests, and hospital records. Diagnostic criteria were derived from the ICD10, except for dementia (DSM-IV), and diabetes. On the basis of a literature review and a previous report on multimorbidity,[ 12 ] a disease or a condition (i.e., the residual disability after an acute disease) was defined as chronic if it met one or more of the following criteria: was of prolonged duration; left residual disability; worsened quality of life; or required a long period of care, treatment, or rehabilitation. The number of chronic diseases (CD) occurring in the same person ranged from zero to ten.
Cognitive functioning was assessed with the Mini Mental State Examination (MMSE),[ 13 ] a measure of global cognitive decline that encompasses basic cognitive domains. MMSE score range was 0 to 30. Physical functioning was measured as gait speed. Participants were asked to walk 6m or, if the participant reported walking quite slowly, 2.4m. If the participant was unable to walk or attempted unsuccessfully to walk, a value of 0 was recorded. Gait speed range was 0–2m/sec. Disability was defined as the number of instrumental-ADL (I-ADL) and personal-ADL (P-ADL) the person was unable to perform independently. I-ADL measure the ability of the participant to live independently in the community. To avoid tasks that might be very gender specific, we included only 4 tasks in our analyses: grocery shopping, managing money, using the telephone, and using public transportation. We considered people who lived in an institution to be dependent in grocery shopping. P-ADL measure the ability to perform 5 basic self-care tasks: bathing, dressing, toileting, transferring, and eating.
SNAC-K received ethical permission for baseline and follow-ups from the Ethics Committee at Karolinska Institutet and the Regional Ethics Review Board in Stockholm (Dnrs: 01–114, 04–929/3, 2007/279–31). Written informed consent was obtained from all participants.
In the statistical analyses, we accounted for the sampling design either by stratifying by or adjusting by age. In age-stratified analyses, 4 age groups were used: sexagenarian, septuagenarian, octogenarian, and nonagenarian (including centenarians). In age-adjusted analyses, age was modeled as a spline with 4 nodes.
Differences between participants and dropouts were analyzed with Fisher’s exact test. Risk ratios of non-participation were derived from generalized linear models (binomial distribution with log link) stratified by age and adjusted by sex and survival status since baseline (3 time intervals: alive after 6 years, deceased after 2 years, and deceased within 2 years).
To compute the association between age and each health indicator (number of CD, gait speed, MMSE score, I-ADL, and P-ADL) while adjusting by sex, we used logistic quantile regression[ 14 ]. For each outcome, we derived 10th percentile (p10), median, and 90th percentile (p90) curves to indicate the values below which 10%, 50%. and 90% of the population had better scores.
Logistic regression was used to derive the probability of poor health status across age, adjusted by sex. Several indicators of poor health status were considered: 1+ CD, gait speed<1.2 m/sec,[ 10 ] MMSE<27, MMSE<20, 1+ I-ADL disabilities, and 1+ P-ADL disabilities. For each indicator, we plotted the sex-adjusted probability curves as a function of age. Two cut-off points of MMSE were used to capture different levels of cognitive impairment.[ 15 ]
To explore the aggregation of different health indicators, we categorized each health measure into 2–3 groups: 3 groups for number of CD (0, 1, 2+), gait speed (<0.4, ≥0.4 and <1.2, and ≥1.2 m/sec);[ 10 , 16 ] and MMSE score (<20, 20–26, and >26); and 2 groups for both I-ADL and P-ADL (0, 1+). The cut-off of 1.2 for gait speed was the speed required for optimal community ambulation, and the cut-off of 0.4 was an indicator of severely impaired mobility.[ 10 , 16 ] Dementia was removed from the CD list because MMSE was present as a measure of cognitive status. Sixty-three different health combinations were present (“health states” in the manuscript). To estimate the prevalence of each health state, we ran a linear regression model adjusted by sex and stratified by age. We plotted the health states with prevalence >5%.
A sensitivity analysis of the effect of missing values was performed through imputations of ten new imputed datasets with multivariate imputation chained equation (MICE).[ 17 ]
Data analyzed with Stata/SE 13.0 (StataCorp LP., College Station, Texas, USA).
Of the 4590 participants alive and eligible at baseline, 1227 declined to participate. Participation rates were above 70% in all age groups and were similar among men and women ( Table 1 ).
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The proportion of people living in institution was significantly higher among participants (6%) than among non-participants (12 people, <1%) %), although it is possible the latter could be an underestimate, as there were some persons originally invited to participate who could not be contacted (N = 262). For the age cohorts 60 through 87, shorter time to death after the beginning of the study was associated with higher risk of non-participation ( Table 2 ). This association was not present among the nonagenarians.
The complete dataset used in the analyses consisted of information about 3080 people (mean age 74 years; 64% women; 16% with <9 years of education). The 283 participants excluded because of missing data were significantly older (mean age 85), more likely to be women (75%), to have <9 years of education (30%), and to live in institution (23%) than the participants for whom data were complete.
Fig. 1 shows p10, median, and p90 curves (95% CIs) as a function of age for number of CD, gait speed, MMSE score, number of I-ADL impairments, and number of P-ADL impairments. The three curves together give a graphical representation of the change of their distribution across age groups. Curves for MMSE, I-ADL, and P-ADL were all flat in the lower age range and worsened rapidly with increasing age. In contrast, both median and p90 of number of CD and of gait speed changed almost constantly with age. P90 of I-ADL started to increase in groups 72+, whereas median MMSE, I-ADL, and p90 of P-ADL started to change only in groups 81+. Additional analysis was performed by further adjusting for years of education as an indicator of socioeconomic status. The results were not different from the one presented in the paper (data not shown).
10th percentile (p10, hollow circle), median (p50, full circle) and 90th percentile (p90, hollow circle) with relative 95% confidence intervals of the five health indicators adjusted by sex.
The analyses of the prevalence of impairment in each indicator reveled similarities in the age distribution of the indicators ( Fig. 2 ). In particular, similar age-related changes were present in probability of I-ADL impairment and probability of any cognitive impairment (MMSE<27) and between probability of P-ADL impairment and probability of severe cognitive impairment (MMSE<20).
Fig. 3 illustrates the prevalence of health states with figures over 5%, by age group. The best health state was characterized by people with no chronic diseases, gait speed equal or above 1.2 m/sec, MMSE score above 26, no I-ADL, and no P-ADL impairments. the prevalence of this state decreased with age, from 29% (95% CI: 26.97, 31.93) among the sexagenarians to 3% (95% CI: 1.48, 4.27) among the octogenarians. None of the nonagenarians belonged to this group. The most prevalent health states among people younger than age 80 were combinations of CD or of CD with mild impairment in gait speed. In this study population, the eighth decade of life was a transitional age, characterized by an increasing proportion of people with one or more I-ADL impairments. This increasing proportion pushed the percentage of people with a combination of at least one I-ADL disability and at least one another indicator of poor health beyond 5% of the total study population (6% with multimorbidity, slow gait speed, and 1+ I-ADL, 95% CI: 3.62, 8.53). Among nonagenarian, health status was characterized by a combination of multimorbidity, severe cognitive and physical impairment, and ADL disabilities. Furthermore, most of the common health states also included P-ADL disabilities. When health states with a prevalence of over 5% were summed together in each age group, they accounted for 92% of the sexagenarians and 80% of the septuagenarians. However, health states with a prevalence of over 5% accounted for only 63% of the octogenarians and 49% of the nonagenarians. Thus there was greater heterogeneity in the health states of the two oldest age groups.
Only the most common (over 5%) indicators or their aggregations within each age group are reported. CD = number of chronic diseases. Gait speed (GS): slow = ≤0.4 m/sec; medium = 0.4–1.2 m/sec; fast: ≥ 1.2 m/sec. MMSE: good = ≥27; medium = 20–26; bad = <20.
Results of the analyses of the imputed data were similar to those of the analyses of the complete dataset; minor differences were present mostly among the oldest age groups.
In this large cohort, we were able to capture the complexity and heterogeneity of health status in 60+ old adults using five health indicators that can be easily implemented in clinical settings, including primary care. Until 80, most people do not have functional impairment or disability, despite the presence of morbidity or even multimorbidity. Disability is common only after age 90. The 80s are a transitional period when major health changes take place; often following the co-occurrence of more than one negative health event. These findings imply that at different ages different health indicators are better predictors of medical and social needs in older adults.
If we consider good health as the absence of chronic diseases, functional impairment, and disability, good health is still the most prevalent pattern among sexagenarians. However, even among octogenarians, the most prevalent health state is characterized by presence of chronic disorders with impairment only in gait speed. In other words, morbidity and multimorbidity start early in late adulthood, but functional dependence becomes common only for people older than age 90. Similarly, Jacobs et al.[ 18 ] showed that at age 70, health profiles were characterized by some multimorbidity with preserved cognitive and functional status that gradually deteriorated after 78. In the Newcastle 85+ study,[ 19 ] prevalence of disability was relatively low among 85-year-olds, whereas prevalence of 3+ diseases reached 90%.
Some health indicators shared similar age-related patterns. Similar tandem-slope patterns are present between any cognitive impairment and I-ADL disability and between severe cognitive impairment and P-ADL disability. Other studies have found a specific pattern of age-related increases in cognitive and physical decline that roughly parallel an increase in disability.[ 20 , 21 ] Our findings confirm that I-ADL disabilities are good indicators of initial cognitive impairment, and P-ADL disabilities are strongly related to dementia.[ 22 ] Among younger old people, gait speed seemed directly associated with morbidity, whereas older groups exhibited decreasing gait speed independently of chronic diseases. This finding is in line with reports in the literature,[ 8 , 23 ] showing the association between limitations in physical functioning and chronic diseases is less evident among the oldest old than among younger old adults. The negative relationship between age and gait speed might reflect the decrease in muscle mass that starts around age 50 and that can lead to sarcopenia.[ 24 ] In our population gait speed started to decline even before the presence of any disability confirming that gait speed cab be considered a measure of pre-frailty[ 25 ] and could be used as an early marker of health change among young older adults.
Heterogeneity in health increases with age. The number of different health states found in each age group increased from 27 among sexagenarians to 46 among nonagenarians. Greater heterogeneity in health status among older people, pointed out decades ago,[ 26 ] was confirmed recently by Lowsky 3 in the US using survey data. We found that heterogeneity is particularly evident among nonagenarians, who have survived beyond the average life expectancy of their birth cohort, suggesting that multiple genetic and contextual factors are relevant to longevity, which can be achieved through a variety of pathways.[ 27 ]
Finally, our results confirm that several indicators of health are needed to characterize both the health status and the differences in need for medical, social, and hospital care among older people. Although age-related increases in all impairments were expected, we showed the differential capability of each indicator in capturing both intra- and inter-age health variations.
This study has both strengths and limitations. The SNAC-K participation rate was high, and we had the opportunity to estimate the effect of drop-outs. The study population covered a wide age range and included people with dementia and people living in institutions. Further, all participants were examined using standard procedures and criteria. However, the data are cross-sectional, so differences observed among age groups might be due to cohort effects and not only to changes associated with aging. We considered only five indicators of health. The indicators analyzed are objective reliable measures that are correlated with many other relevant health measures (e.g. polypharmacy). The population is also a selected group that has survived beyond baseline age requirements. Another limitation is selective participation in the younger age groups, as participants in these age groups were potentially healthier than those who declined to participate. The present study may thus underestimate the prevalence of poor health and overestimate homogeneity in people younger than 90 years. Finally, the educational level of the study population is higher than that in Stockholm or in Sweden. Although higher education level is associated with better functional status[ 28 ] it is also associated with longer survival,[ 29 ] which can results in higher occurrence of poor health.
Our study provides a clear picture of heterogeneous health of older adults, which varies from good functioning, lack of disability, and no morbidity through morbidity and multimorbidity to severe disability. Most people younger than age 90 had functionally good health. We could identify two transitional periods: 1) 81–84, when prevalence of relatively good functional health decreased and prevalence of multimorbidity, lower cognitive functioning, and I-ADL disabilities increased and 2) 84–87, when higher prevalence of severe cognitive and physical impairment gradually led to disability in P-ADL. The first period seems to represent the passage from the third to the fourth age,[ 18 ] and the second, the beginning of the fourth age.[ 1 ] This means that the need for medical care increased from age 70 to 90, but the need for social assistance, including institutionalization, became prevalent only at very advanced ages.
In addition to the funding agencies, we would also like to extend our thanks to the invaluable contributions by the study participants and data collection staff.
Conceived and designed the experiments: GS SA AM LF. Analyzed the data: GS. Wrote the paper: GS SA FM AKW AM LF.
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- Published: 17 February 2022
Mental speed is high until age 60 as revealed by analysis of over a million participants
- Mischa von Krause ORCID: orcid.org/0000-0001-7424-1454 1 na1 ,
- Stefan T. Radev ORCID: orcid.org/0000-0002-6702-9559 1 na1 &
- Andreas Voss ORCID: orcid.org/0000-0002-4499-3660 1
Nature Human Behaviour volume 6 , pages 700–708 ( 2022 ) Cite this article
- Cognitive ageing
- Human behaviour
Response speeds in simple decision-making tasks begin to decline from early and middle adulthood. However, response times are not pure measures of mental speed but instead represent the sum of multiple processes. Here we apply a Bayesian diffusion model to extract interpretable cognitive components from raw response time data. We apply our model to cross-sectional data from 1.2 million participants to examine age differences in cognitive parameters. To efficiently parse this large dataset, we apply a Bayesian inference method for efficient parameter estimation using specialized neural networks. Our results indicate that response time slowing begins as early as age 20, but this slowing was attributable to increases in decision caution and to slower non-decisional processes, rather than to differences in mental speed. Slowing of mental speed was observed only after approximately age 60. Our research thus challenges widespread beliefs about the relationship between age and mental speed.
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The raw data are available on the Project Implicit OSF page ( https://osf.io/y9hiq/ ). The processed data, including the DM parameter estimates, can be found on our GitHub page ( https://github.com/stefanradev93/DataSizeMatters ).
We provide open-source code for replicating all analyses and pretrained neural networks for preprocessing and obtaining the Bayesian diffusion model parameter estimates on our GitHub page ( https://github.com/stefanradev93/DataSizeMatters ).
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This research was supported by a grant from the German Research Foundation to the Graduate School 530 SMiP (GRK 2277; Statistical Modeling in Psychology; to all authors). The funders had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. We thank Project Implicit for openly sharing their data.
These authors contributed equally: Mischa von Krause, Stefan T. Radev.
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Institute of Psychology, Heidelberg University, Heidelberg, Germany
Mischa von Krause, Stefan T. Radev & Andreas Voss
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M.v.K. conceived the research idea and studied the literature. S.T.R. conceived the simulation-based inference method. M.v.K. and S.T.R. wrote the code and scripts for all methodological steps, performed the analyses, and visualized the results. M.v.K and S.T.R. wrote and prepared the original draft. M.v.K., S.T.R. and A.V. wrote, reviewed and edited the final manuscript. All authors have read and agreed to the final version of the manuscript.
Correspondence to Mischa von Krause or Stefan T. Radev .
The authors declare no competing interests.
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von Krause, M., Radev, S.T. & Voss, A. Mental speed is high until age 60 as revealed by analysis of over a million participants. Nat Hum Behav 6 , 700–708 (2022). https://doi.org/10.1038/s41562-021-01282-7
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Did NEJM Study Determine a Person’s Most Productive Age?
The “extensive” research was said to confirm a person reaches their "most productive age" between 60 and 70., madison dapcevich, published feb 16, 2022.
About this rating
Curious about how Snopes' writers verify information and craft their stories for public consumption? We've collected some posts that help explain how we do what we do. Happy reading and let us know what else you might be interested in knowing.
In January 2022, a widely circulated Facebook post claimed that a person's "most productive years" are between the ages of 60 and 80, according to an unreferenced study published in the peer-reviewed and credible research publication New England Journal of Medicine (NEJM). As of this writing, the post had received more than 68,000 shares.
In addition to similar iterations on social media, Snopes readers also sent our newsroom screengrabs from an email chain with the subject line, “The brain of an elderly person” that claimed older people have “more brilliant brains and achieve more than younger people”:
In particular, the post claimed that the “most productive age of a person is from 60 to 70 years,” that the “second most productive human stage is the age from 70 to 80 years old,” and that the third “most productive” time is between the ages of 50 and 60. Before that, the person was said to have “not reached his peak.”
“Therefore, if you are 60, 70 or 80 years old, you are at the best level of your life,” claimed the poster.
Snopes dug through the NEJM publications available and were not able to find evidence of such a study having been conducted or published by the journal. To confirm, we reached out to the publication directly and were told that no such article has been published by NEJM.
“The NEJM does not use the numbering system cited in the Facebook post [N.Engl.J.Med. 70,389 (2018)],” NEJM editorial coordinator Grace Hansen-Dewa told Snopes.
There was neither an “issue 70” nor an “issue 389” published in 2018, she said, nor were these the page numbers of articles related to the topic.
“In 2018, the article found on page 70 is “Favism and Glucose-6-Phosphate Dehydrogenase Deficiency”, which begins on page 60. The article found on page 389 is the end of “Case 3-2018: A 5-Month-Old Boy with Hypoglycemia”, which begins on page 381.
Because the study in question never existed, we have rated this claim as “False.” However, there is scientific work that has been conducted in the past to determine when a person might be most productive.
While there is extensive literature on various life stages and their measures of productivity, each depends on a variety of factors including whether you’re looking at physical, mental, emotional, or financial parameters. Without knowing exactly what such parameters were used to make the original poster's case, it is difficult to further determine when a person may be at their peak potential.
Some research finds that the later years may be the best time in a person's life. In a 2015 TedX talk, real estate developer and primary spokesperson for Halftime Institute, Lloyd further argued that there is “compelling evidence” that the second half of a person’s life could be the “very best season” of life.
But there's also evidence arguing the contrary.
In the comments section of a 2019 NEJM Facebook post that featured the issue cited in the misleading claim, several users made mention of the viral post, some of whom shared research they had found to suggest some there may be some truth to a person’s better years occurring later in life.
“Historians of science have generally concluded that scientific output tends to rise steeply in the twenties and thirties, peak in the late thirties or early forties, and then trail off slowly through later years,” wrote one such study published in 2012 to determine how an aging demographic may hold implications for societal productivity.
A commentary published in a 2008 further argued that the “determinants of productivity vary by age” and their relative importance on measuring productivity at various stages in one’s lifetime.
“Given that experience has a reasonably strong effect on productivity, the peak productivity potential occurs in ages 35-44,” noted the study.
There were some other dubious and somewhat vague claims that we wanted to address from the Facebook post as well, the first being that the “average age of dads is 76.” It is unclear if at what stage of fatherhood the original poster meant, but a 2017 study published in the journal Human Reproduction found that the average age of a dad at their child’s birth is just under 31 years old — and about 1 in 10 fathers will be 40.
The claim in question is a great lesson in media literacy, whereby it is important to pay attention to context. For example, the original poster claimed that most Nobel Prize winners were 62, but it does not specify whether that is the age at which they received the prize or the age at which they conducted the work they were awarded for.
The average age of a Nobel Prize laureate, a proxy to study at which age scientist produce their most groundbreaking work, is at least 65 and mostly over 72, according to the BBC . (Prize winners were all also mostly men, which could say more about societal privilege than age itself.) Research conducted in 2010 looked at the age at which invention occurs and found that the average is 39.
In short, there are a wide variety of factors that may influence a person’s “productivity” and how one might set about measuring it. While there is some evidence to suggest certain gauges of productivity occur later in life, other research finds that a person may be more productive in other arenas of life at various stages, such as financial earnings, parenthood, or an individual's own measure of productivity.
You may also enjoy reading:
- Is 150 Years Really the Limit of Human Lifespan?
- Will Drinking a Young Person's Blood Provide Anti-Aging Health Benefits?
- Do Humans Age Most At 34, 60, and 78 Years Old?
- Does Adding Your Age to Your Birth Year Equal 2,018 for 'One Day Only'?
Sources Bjørk, R. “The Age at Which Noble Prize Research Is Conducted.” Scientometrics, vol. 119, no. 2, 2019, pp. 931–39. Welcome to DTU Research Database, https://doi.org/10.1007/s11192-019-03065-4. Facebook, https://www.facebook.com/login/?next=https%3A%2F%2Fwww.facebook.com%2Fphoto.php%3Ffbid%3D10209167783067040%26set%3Da.1043622826184%26type%3D3%26eid%3DARDz7Qn9NjGx4G2Y_YceudfyVI8Oa7WZSsR4u_gaUimr5-UlsIsPzMGpYFnvslIDnKhEG1U2o-zsSi-7. Accessed 16 Feb. 2022. “Nobel Prize Facts.” NobelPrize.Org, https://www.nobelprize.org/prizes/facts/nobel-prize-facts. Accessed 16 Feb. 2022. “Notable Articles of 2018.” The New England Journal of Medicine, Jan. 2019, https://cdn.nejm.org/pdf/Notable-Articles-2018.pdf. Nov 24, Mumbai Mirror /. Updated:, et al. “What Is the Right Age to Retire?” Mumbai Mirror, https://mumbaimirror.indiatimes.com/opinion/columnists/dr-altaf-patel/what-is-the-right-age-to-retire/articleshow/79375910.cms. Accessed 16 Feb. 2022. Population, Institute of Medicine (US) Committee on the Long-Run Macroeconomic Effects of the Aging U. S. Aging, Productivity, and Innovation. National Academies Press (US), 2012. www.ncbi.nlm.nih.gov, https://www.ncbi.nlm.nih.gov/books/NBK148825/. Aging, Productivity, and Innovation. National Academies Press (US), 2012. www.ncbi.nlm.nih.gov, https://www.ncbi.nlm.nih.gov/books/NBK148825/. Skirbekk, Vegard. “Age and Productivity Potential: A New Approach Based on Ability Levels and Industry-Wide Task Demand.” Population and Development Review, vol. 34, 2008, pp. 191–207. JSTOR, https://www.jstor.org/stable/25434764. “Age and Productivity Potential: A New Approach Based on Ability Levels and Industry-Wide Task Demand.” Population and Development Review, vol. 34, 2008, pp. 191–207. JSTOR, https://www.jstor.org/stable/25434764. The American Elder - The Topeka Capital-Journal, 11/30/2020. https://digital.olivesoftware.com/olive/odn/topekacapitaljournal/shared/showarticle.aspx?doc=TCJ%2F2020%2F11%2F30&entity=Ar00501&sk=E752CF74&mode=text. Accessed 16 Feb. 2022. The Average Age for New U.S. Dads Has Passed 30. https://www.science.org/content/article/average-age-new-us-dads-has-passed-30. Accessed 16 Feb. 2022. The Most Productive Years of Your Life May Surprise You | Lloyd Reeb | TEDxCountyLineRoad. www.youtube.com, https://www.youtube.com/watch?v=VfkBDRa9J1I. Accessed 16 Feb. 2022. “Why Are Nobel Prize Winners Getting Older?” BBC News, 7 Oct. 2016. www.bbc.com, https://www.bbc.com/news/science-environment-37578899.
By Madison Dapcevich
Madison Dapcevich is a former writer for Snopes.
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Original research article, age differences in age perceptions and developmental transitions.
- 1 Department of Psychology, Michigan State University, East Lansing, MI, United States
- 2 Department of Psychology, University of St. Thomas, Saint Paul, MN, United States
- 3 Department of Psychology, Stanford University, Stanford, CA, United States
Is 50 considered “old”? When do we stop being considered “young”? If individuals could choose to be any age, what would it be? In a sample of 502,548 internet respondents ranging in age from 10 to 89, we examined age differences in aging perceptions (e.g., how old do you feel?) and estimates of the timing of developmental transitions (e.g., when does someone become an older adult?). We found that older adults reported older perceptions of aging (e.g., choosing to be older, feeling older, being perceived as older), but that these perceptions were increasingly younger than their current age. The age to which individuals hope to live dramatically increased after age 40. We also found that older adults placed the age at which developmental transitions occurred later in the life course. This latter effect was stronger for transitions involving middle-age and older adulthood compared to transitions involving young adulthood. The current study constitutes the largest study to date of age differences in age perceptions and developmental timing estimates and yielded novel insights into how the aging process may affect judgments about the self and others.
“I will never be an old man. To me, old age is always 15 years older than I am.”
– Francis Bacon
Walking through a birthday card aisle offers plenty of reminders about how aging is something to avoid. Life begins at 40. Fifty is the new 30. Although these cards often represent tongue-in-cheek ways of helping the recipient feel better about aging, very little is known about how both perceptions of age and estimates of the timing of developmental transitions differ by age. Is 50 “old”? When do we stop being “young”? If individuals could choose to be any age, what age would they be? The current study examines age differences in aging perceptions (e.g., how old do you feel?) and estimates of the timing of developmental transitions (e.g., when does someone become an older adult?).
Perceptions of Aging
In the current study, we operationalize aging perceptions as evaluations individuals tie to different ages by reporting (a) the age they would like to ideally be, (b) the age they feel like, (c) the age they hope to live until, and (d) how old other people think they are. To date, most research has focused on lifespan differences in and consequences of (b), which researchers refer to as subjective age ( Kleinspehn-Ammerlahn et al., 2008 ). There is a large literature documenting the antecedents and consequences of subjective age that highlights the roles of subjective health, age-group reference effects, gendered experiences, and aging attitudes (see Montepare, 2009 ). The preponderance of research suggests that adults tend to report feeling younger than their chronological age (e.g., up to 20% younger; Rubin and Berntsen, 2006 ) and this effect increases with age. Reporting a younger subjective age is associated with a wide variety of benefits for health and well-being ( Montepare and Lachman, 1989 ; Kotter-Grühn et al., 2009 ; Mock and Eibach, 2011 ). However, feeling younger is not the only aging perception that changes across the lifespan. There are also corresponding shifts toward youth for how old people think they look, what their interests are, and the activities they like to engage in ( Kastenbaum et al., 1972 ).
Why does a shift toward affiliating with youth happen more as people age? Insights from the age-group dissociation effect provide a potential explanation ( Weiss and Lang, 2012 ). In short, people try to psychologically dissociate themselves from stigmatized groups (i.e., older adults). When stigmatized outgroups are salient, people engage in avoidance-oriented behavior. Motivations underlying the age-group dissociation effect can be identified in the evolutionary psychology literature ( North and Fiske, 2012 ). For example, inclusive fitness cues motivate individuals to prefer helping younger relative to older adults in times of need ( Burnstein et al., 1994 ). Likewise, individuals often associate older adults with weakness, resource waste, and possible exposure to infectious disease—all of which lead to higher levels of stigma ( Jensen and Oakley, 1980 ; Kurzban and Leary, 2001 ; Duncan and Schaller, 2009 ).
Previous research has identified many antecedents and consequences of the age-group dissociation effect. For example, openness to experience and less traditional gender ideologies might be protective factors for well-being among individuals undergoing difficult and uncertain age transitions ( Weiss et al., 2012 ). Further, age group dissociation can protect individuals from the deleterious effect that negative age stereotypes have for older adults' self-esteem ( Weiss et al., 2013 ). Some of the distancing techniques that older adults employ include identifying with middle aged adults and even directing their attention away from other older adults ( Weiss and Freund, 2012 ).
In sum, older adulthood is an identity that carries significant stigma ( Levy and Banaji, 2002 ), and individuals become increasingly closer to assuming this stigmatized identity as they age. When people become older adults, they could view themselves as becoming part of a group to which they have held negative attitudes toward their whole life. In general, individuals are motivated to create psychological and physical distance between themselves and stigmatized outgroups (e.g., Cesario et al., 2010 ). In this case, one way in which people can enhance this distance is to identify with younger age groups, whether that be through selectively reporting feeling younger than they are, reporting that others perceive them as being younger, or choosing a younger ideal age to be ( Blau, 1956 ; Heckhausen and Krueger, 1993 ; Weiss and Lang, 2012 ). By extension, adolescents might report a relatively older subjective age given their desire to affiliate with a more desirable group (e.g., young adults; Galambos et al., 2005 , 2009 ).
There is also a sense that an individual's reference group changes as they age. For example, younger adults who compare themselves to other younger adults are unlikely to distort their subjective age because young adults are not a stigmatized group ( Galambos et al., 2009 ). However, adolescents and older adults share a motivation to identify with more highly regarded age groups and thus distort or shift their perceptions of aging. Nevertheless, even in the context of age-group dissociation, older adults, being closer to the end of their lives, may push their ideal life expectancy to an older age from a motivation toward self-preservation ( Karni and Schmeidler, 1986 ; Brown et al., 1999 ). Indeed, multiple studies have shown that older adults increase their ideal-age-to-live-until as a way of elongating horizons in the face of mortality ( Mirowsky, 1999 ; Lang et al., 2007 ). Some researchers have also hypothesized that older adulthood might serve as a reminder of mortality—triggering protective, life-elongating defense mechanisms to mitigate the anxiety that arises from these reminders ( Maxfield et al., 2010 ; Chopik, 2017 ).
Given research on the age-group dissociation effect in which people try to psychologically distance themselves from older adults, we hypothesized that, compared to younger adults, older adults would report (a) ages that they ideally would like to be that are older, albeit ages that are increasingly younger than their chronological age, (b) older subjective ages, albeit ages that are increasingly younger than their chronological age and (c) being perceived by others as older, albeit increasingly younger than their chronological age. Younger adults will report age perceptions closer to their chronological age because younger adults are not stigmatized in the same way that older adults are. Given research on self-preservation and mortality reminders, we also hypothesized that older adults would report an older ideal age to live until.
The exact age at which older adulthood starts is hotly debated in the social and developmental psychology literature. Different fields and researchers use different indices—biological indices ( López-Otín et al., 2013 ), cognitive indices ( Hasher and Zacks, 1988 ), expected years left to live ( Sanderson et al., 2017 ), or historical standards ( Roebuck, 1979 )—for determining what makes someone old. Like aging perceptions, the perceived timing of developmental transitions depends on where individuals are in the life course. For example, older adults tend to report that older adulthood happens at a later age relative to younger adults ( Barrett and Von Rohr, 2008 ; Barrett and Toothman, 2016 ). Indeed, a recent Pew survey further replicated this effect, showing adults 18–29 believe that a person becomes old at age 60, whereas middle-aged respondents believe that a person becomes old at age 72; respondents aged 65 and older believed that a person becomes old at age 74 ( Taylor et al., 2009 ). Longitudinal studies of middle-aged adults suggest a similar effect—that individuals “elongate” the age range that one is considered a middle-aged adult as they live through this period themselves ( Kuper and Marmot, 2003 ). Like research on the protective functions of subjective age, perceiving the middle age period as longer is associated with a host of positive health outcomes, including a lower risk of hypertension, diabetes, functional limitations, heart disease, and better recovery from illnesses (see Barrett and Toothman, 2014 , 2016 ).
Unfortunately, work on normative perceptions of age transitions has several limitations. For example, most studies examine only one age group's perceptions of developmental transitions ( Barrett and Von Rohr, 2008 ) or ignore certain groups (e.g., middle-aged adults) entirely by comparing only extreme groups of younger and older adults ( Cohen, 1983 ; Freund and Isaacowitz, 2013 ). Further, research on estimates of developmental transitions have focused exclusively on instructing participants to report the perceived age of either the average middle-aged ( Kuper and Marmot, 2003 ) or older adult ( Barrett and Toothman, 2016 ). Less is known about younger developmental transitions and how perceptions of these transitions differ by age. Do transitions from childhood to young adulthood show similar age differences, such that older adults give older estimates even for transitions that are less socially stigmatized? In the current study, we address these limitations by employing a large sample of adults ( N = 250,000 +) ranging in age from 10 to 89 to examine age differences in estimates of developmental transitions (i.e., childhood to young adulthood, young adulthood to adulthood, adulthood to middle age, and middle age to older adulthood).
To date, we know little about age differences for these perceptions of younger developmental transitions. Drawing on some of the same principles from age-group dissociation effects, we hypothesized that age differences for these younger transitions would be smaller in magnitude compared to older transitions. Given that older transitions (e.g., becoming a middle-aged or older adult) are more stigmatized, the age-group dissociation effect should be large for these transitions, given that individuals try to psychologically distance themselves more from these groups. As such, middle-aged and older adults should “push” these transitions further into the future, giving increasingly older age estimates to make themselves appear to be relatively younger. At the same time, the age-group dissociation phenomenon also suggests that middle-aged and older adults should “pull” younger developmental transitions toward their current age. In distancing themselves from stigmatized groups, people are motivated to identify with groups that affirm positive aspects themselves ( Abrams and Hogg, 1988 ). Thus, we hypothesized that older adults would report higher estimates for early life transitions as well. Younger adults are will simply use their cultural knowledge to estimate these transitions. In other words, they will be unlikely to be motivated to shift their developmental timing estimates because of the distance from stigmatized age transitions that their chronological age affords them. Thus, younger developmental transitions should be observed among younger adults when compared to older adults' estimates.
The Current Study
In the current study, we examined age differences in perceptions about aging and estimates for developmental transitions. Perceptions about aging were operationalized as (a) what age participants would choose to be, (b) how old participants feel, (c) what age participants would like to live until, and (d) how old other people think participants are. We expected that older adults would report older perceptions compared to younger adults, albeit younger perceptions relative to their current age (e.g., younger subjective and ideal ages; Kleinspehn-Ammerlahn et al., 2008 ). We expected younger adults to provide estimates close to their chronological age considering that they are part of a valued age group. Older adults were expected to report an older age they would like to live until. We also expected older adults to report older age estimates for developmental transitions in an effort to identify more with younger adults, which they consider a more valued age group ( Weiss and Lang, 2012 ). Specifically, older adults will perceive both younger transitions and older transitions as happening at later ages to make themselves feel relatively younger. Finally, because older adults are a stigmatized group, we expected this shift to be particularly true of transitions into older adulthood relative to transitions into younger age groups. Younger adults were not expected to shift the timing of developmental transitions given their distance from stigmatized age groups. To test these hypotheses, we ran regression analyses predicting the raw ages that participants provided for age perceptions and developmental transitions.
Participants and Procedure
Participants were 502,548 individuals (69.1% Female) from the Project Implicit Demo Site, a website that hosts studies on the Implicit Association Test (data and materials are available at osf.io/cv7iq/). No targeted recruitment was undertaken. People interested in implicit bias navigate to the website and complete a measure of implicit bias in exchange for personalized feedback. Thus, the entire sample is one of convenience—people freely completing measures about aging with no expectation of compensation.
Data were collected from September 2006 to December 2015, the entire time window for which the questions were posted and data are available. The overall sample ranged in age from 10 to 89 ( M = 26.88 years, SD = 12.14 years); the median level of education was some college. Self-reported race/ethnicity was 69.3% Caucasian, 9.8% Hispanic, 7.7% African American, 7.2% Asian, and 6.1% Mixed/Other ethnicities. Despite the sample being relatively young, each decade of life was well represented (e.g., 10–19 years: 162,601; 20–29 years: 199,565; 30–39 years: 58,866; 40–49 years: 40,837; 50–59 years: 29,517; 60–69 years: 9,490; 70+ years: 1,672). An additional 315,394 participants were excluded from the present analyses because these participants were younger than 10, had missing data on age, or had missing data on all the primary study variables. The majority of respondents were from the United States (85.3%) and the survey was presented entirely in English. Supplementary analyses examining differences between the United States and other countries generally found similar effects. For several methodological and conceptual reasons, cultural comparisons were not part of the current report 1 . We further elaborate on this decision in the Discussion section.
Because the Project Implicit site's primary purpose is to host variants of the Implicit Association Test, we also had data on implicit and explicit age bias. The order of the IAT and one of the two blocks of self-report questions (perceptions about aging or age estimates for developmental transitions) were counterbalanced across participants. Associations between implicit/explicit bias and the variables below are consistent with predictions made from age-group dissociation effect (e.g., greater bias against older adults was associated with younger age perceptions), albeit these associations were small (|0.01| < r < |0.22|). As such, we did not include these data in the current report but felt the need to disclose that these data are available. For a review of age differences in implicit and explicit bias using this data set, please see Chopik and Giasson (2017) .
Because we analyzed an existing data source, the Michigan State Institutional Review Board considered this research exempt from ethical oversight as it did not constitute human subjects research (IRB# 17-1113).
Perceptions about Aging
A random sample of participants ( N = 251,496) received four open-ended questions asking which age they would choose to be (“If you could choose, what age would you be?”; hereafter age choice in all tables), what age they felt like (“How old do you feel?”; subjective age ), what age they hope to live until (“To what age do you hope to live?”; hope to live ), and how old other people think they are (“On average, how old do other people think you are?”; perceived age ). Participants typed in a numeric age in response to each question. Descriptive statistics for these questions can be found in Table 1 .
Table 1 . Correlations and descriptive statistics among primary study variables.
Age Estimates for Developmental Transitions
A different random sample of participants ( N = 251,052) received four open-ended questions asking the age at which four developmental transitions occurred. The four transitions were from childhood to young adulthood (“A person moves from being a child to being a young adult at what age?”), from young adulthood to adulthood (“A person moves from being a young adult to being an adult at what age?”), from adulthood to middle-age (“A person moves from being an adult to middle-aged at what age”), and from middle-age to older adulthood (“A person moves from being middle-aged to being old at what age?”). Participants typed in a numeric age in response to each question. Data on the preceding age perception questions were not collected for these individuals. Descriptive statistics for these questions can be found in Table 1 .
Because of our large sample, there was a concern that many effects would likely be statistically but not practically significant. To address this, we employed an effect size-based approach to interpret our results ( Srivastava et al., 2003 ; Chopik and Edelstein, 2014 ). As in previous research, we limited our discussion to individual effects that exceed a certain threshold deemed meaningful when using large samples (Δ R 2 ≥ 0.001 and F change ≥ 25) ( Chopik et al., 2013 ). Further, prior research suggested that the most complex age trends that can be meaningfully interpreted involve cubic patterns ( Terracciano et al., 2005 ). Thus, we tested the linear (age), quadratic (age 2 ), and cubic (age 3 ) effects of age; we did not test more complex models. Age was centered prior to computing these higher order terms in order to reduce multi-collinearity. Gender was included as a control variable in each model given research on gendered perceptions of what is considered an older adult ( Zepelin et al., 1987 ; Seccombe and Ishii-Kuntz, 1991 ; McConatha et al., 2003 ). We initially tested incremental models (i.e., predicting perceptions and age estimates from an individual age term, before adding a more complex pattern) before realizing that in nearly every case (except for two), the inclusion of age 2 and age 3 surpassed our effect size threshold. We report the full models for simplicity with individual F changes for each estimate, but the information for the sequential model testing analysis can be requested from the first author.
Descriptive statistics and intercorrelations among the study variables are given in Table 1 2 . We limit our discussion to correlations greater than 0.05. As a reminder, we hypothesized that (a) older adults would report older perceptions of aging (e.g., feeling older) and (b) older adults would report older age estimates across developmental transitions.
As an initial confirmation of our hypotheses, older adults reported choosing an older age to ideally live until, feeling older, and being perceived as older compared to younger adults. Older adults reported older age estimates for each of the transitions, also supporting our hypotheses. We more formally modeled non-linear associations in the main analyses. Responses were generally correlated within perceptions and within age estimates. Our hypotheses were largely supported, albeit the effect sizes of each were small.
Finally, women also reported being perceived as younger and perceived the adulthood-middle-age and middle age-older adulthood transitions as occurring later in life.
Age differences in perceptions of aging and age estimates of developmental transitions can be seen in Table 2 . For nearly all variables (except subjective age , the childhood to young adult transition , and the young adult to adult transition ), the quadratic effect of age was the best fitting model, based on the F change cut-off criterion. For the remaining three outcomes, the cubic model was the best fit.
Table 2 . Regression results for age perceptions and developmental estimates.
As seen in Figures 1A–D , older adults were higher in each age perception compared to younger adults, consistent with the correlational analyses reported above. Specifically, older adults reported older ideal ages, feeling older, and being perceived as older. Worth noting, in each of these cases, each of these three age evaluations were lower than participants' actual ages, particularly among older adults 3 . An interesting quadratic pattern emerged with respect to the age to which participants hoped to live, which was masked in the above correlational analyses (see Figure 1C ). After age 40, the age people hope to live to dramatically increased.
Figure 1 . Age differences in age perceptions. The transposed line in (A,B,D) represent the identify line for individual age and the age for each dependent variable. (C) did not follow the response pattern of (A,B,D) with participants reporting that they would like to live to at least 88 yrs old on average; thus, the transposed line is not provided.
As seen in Figure 2 , older adults gave older age estimates for both younger and older developmental transitions. This shift was especially apparent for older transitions, as seen in the linear effect of age being smaller for the childhood-young adult transition (β = 0.16) and larger for the middle age-older adulthood transition (β = 0.36).
Figure 2 . Age differences in developmental transitions for (A) middle-age to older adulthood, (B) adulthood to middle-age, (C) young adulthood to adulthood, and (D) childhood to young adulthood. Shaded colors represent 95% confidence intervals.
In the current study, we examined age differences in perceptions of aging and estimates for developmental transitions. Older adults reported perceiving themselves as older, but these perceptions were increasingly younger than their current age. We also found that older adults placed the age at which developmental transitions occurred later in the life course. This latter effect was stronger for transitions involving middle-age and older adulthood compared to transitions involving young adulthood. The current study constitutes the largest study to date of age differences in age perceptions and developmental timing estimates and yielded novel insights into how the aging process may affect judgments about the self and others.
The observed age differences in age perceptions and developmental estimates align well with existing research on how our attitudes toward older adults affect judgments about ourselves and others. As people age, they become increasingly closer to identifying with a stigmatized group (i.e., older adults). As a result, people engage in efforts to psychologically distance themselves from older adults. One way in which people do this is to give younger perceptions of aging—reporting that they would choose to be younger, that they feel younger, and that people think they are younger than their current age. Older participants gave older desired lifetimes compared to younger adults, which is consistent with individual's motivations toward self-preservation and defensive reactions toward mortality reminders ( Lang et al., 2007 ; Maxfield et al., 2010 ). These desired lifetime effects among older adults were reflected in other patterns as well. For example, the association between subjective age and ideal age to live until was higher for older and middle-aged adults ( r s = −0.08; see Supplementary Materials) compared to younger adults ( r = −0.04). In other words, older adults who tend to report relatively younger subjective ages also tend to report an older age they would like to live until, suggesting that the defensive processes of the age-group dissociation effect and self-preservation might work hand-in-hand in middle-age and older adulthood. However, future longitudinal research that directly measures these mechanisms can more appropriately document the time scale and process through which these perceptions of aging change across the life span. Older people also shift the timing of developmental transitions to later ages, pulling younger transitions toward their current age and pushing older transitions away from their current age, thus making themselves feel relatively younger. Altogether, our results converge with insights provided by the age-group dissociation effect that individuals avoid identification affiliation with stigmatized groups ( Weiss and Lang, 2012 ).
In the current study, we examined normative age differences in age perceptions and developmental timing. However, a great deal of research is dedicated to experimentally inducing the mechanisms that lead to many of these age differences. Is there evidence for the malleability of age perceptions? Are there ways of counteracting negative perceptions about aging? The vast majority of studies on aging perceptions feature manipulations that increase the salience of negative aging stereotypes ( Levy and Banaji, 2002 ; Levy and Myers, 2004 ; Levy and Schlesinger, 2005 ; Levy, 2009 ). The salience of negative information about aging is often used to induce the age-group dissociation effect ( Weiss and Freund, 2012 ; Weiss and Lang, 2012 ; Weiss et al., 2013 ). Few studies have examined how instructing individuals to acknowledge the positive aspects of aging might reduce stereotypes and the age-group dissociation effect. In one exception, Levy et al. (2014) developed an intervention that trained individuals to pair positive words with older adults in an effort to change their implicit associations. In a sample of 100 older adults, they found that enhancing positive associations with aging was associated with more positive age stereotypes, more positive perceptions about aging, and improved physical functioning. However, an explicit intervention in which participants were instructed to “imagine a senior citizen who is mentally and physically healthy” was ineffective for changing participants' attitudes. Unfortunately, few comprehensive and well-powered tests of the extent to which different interventions to reduce age bias and negative age perceptions currently exist ( Braithwaite, 2002 ; Christian et al., 2014 ). Parallel efforts to reduce other types of bias (e.g., race bias) using existing bias-reduction interventions suggest that the literature's current interventions have very small effects on bias, rarely change explicit behavior, and almost never persist over time ( Lai et al., 2013 , 2014 , 2016 ). Future research can more adequately test different interventions for changing age perceptions and tailors these interventions to maximize effectiveness in different age groups.
The current study used a large developmentally diverse sample and included measures of both age perceptions as well as estimates of developmental transitions. Nevertheless, there are some limitations worth acknowledging.
Most notably, the cross-sectional nature of the data limits our ability to make causal and developmental claims about how these age perceptions change across the life span. Fortunately, there is both experimental ( Weiss and Lang, 2012 ) and longitudinal work ( Kuper and Marmot, 2003 ) suggesting that the aging process and age stereotypes are the main predictors behind the differences in age perceptions and developmental estimates that we observed in the current study. Nevertheless, future work can examine these questions both experimentally and longitudinally to further strengthen a developmental interpretation. Further complicating our interpretation is that there are likely cohort differences in the link between age perceptions and many important outcomes (e.g., Barrett and Toothman, 2014 ). Attitudes and expectations about older adults and developmental timing likely change over time and across generations, as they do toward other sociodemographic groups ( Zepelin et al., 1987 ; Westgate et al., 2015 ). Future studies should adequately disentangle age, period, and cohort effects to examine how perceptions about aging change at different levels and time scales within a broader population.
Another limitation is that our sample consisted of individuals primarily from the United States. This is an important limitation as there is substantial variability in attitudes toward older adults and aging found across cultures ( Löckenhoff et al., 2009 ; North and Fiske, 2015 ). Unfortunately, several methodological restrictions prevented our ability to systematically study cultural variation in many of our effects. For example, many of the sample sizes of individual countries were very small (i.e., 60% of the geographic regions had sample sizes below 100), the data are based on convenience samples of volunteers and likely do not reflect the population under study, and the survey was administered entirely in English. Although age differences in the constructs we examined in the current paper may vary across cultures and geographic regions, it is unclear if these differences can be attributable to statistical power issues, language administration of the survey, or any number of other methodological or conceptual explanations ( van Herk et al., 2004 ; Harzing, 2006 ; Chopik et al., 2017 ). A thorough treatment and examination of these issues and cultural differences in perceptions of aging is beyond the scope of the current paper. Nevertheless, we encourage other researchers to examine how variation in aging attitudes might be accounted for by culture-level indicators identified by previous research (e.g., GDP, education, % of older adults, values, and character/personality; McCrae and Terracciano, 2005 ; Schwartz, 2006 ; Terracciano and McCrae, 2007 ; Löckenhoff et al., 2009 ; Hofstede et al., 2010 ; Norris and Inglehart, 2011 ).
Finally, our sample was comprised mostly of young adults on average ( M age = 26.88 years old). Worth noting, even the small percentage of older adults in our sample greatly dwarfed all existing studies on aging perceptions and developmental timing estimates (e.g., there were over 40,000 participants age 50 and over). However, although having such a large sample enabled us to compare people of different ages, it would be ideal to have a more age-balanced, nationally representative sample to provide more precise estimates of all our variables.
These limitations notwithstanding, the current study advances our knowledge on age differences in age perceptions and developmental timing estimates. The pattern of age differences observed in the current study aligns well with research and theory suggesting that people psychologically distance themselves from older adults by providing younger age perceptions and older developmental transitions.
WC conducted the analyses, interpreted the data, and drafted the manuscript. RB and DJ interpreted the data and provided critical revisions. DJ constructed the figures. HG provided critical revisions. All authors read and approved the final version of this manuscript.
Conflict of Interest Statement
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2018.00067/full#supplementary-material
1. ^ We find the question of how culture might attenuate the effects observed very interesting. Unfortunately, the subsamples of individual countries were too small to make meaningful comparisons. For example, respondents from China (0.3% of the total sample) and South Korea (0.2%) were too small to properly test this question. Aside from the sample size/power issues, the questions were administered entirely in English, and the sample was non-representative of the population from which it was drawn. We expand on the question of testing cultural differences in the section Discussion.
2. ^ Correlations and descriptive statistics for younger (aged 10–39), middle-aged (aged 40–64), and older adults (aged 65+) are reported in Supplementary Tables 1–3.
3. ^ There are a few different ways of modeling subjective age in the literature. In the current study, we analyzed the raw ages that participants provided in order to maintain interpretational consistency across models and outcomes. However, previous researchers have also expressed subjective age as a discrepancy score (i.e., chronological age-subjective age; e.g., Weiss and Lang, 2012 ) and a proportional discrepancy (i.e., chronological age-subjective age/chronological age; e.g., Rubin and Berntsen, 2006 ). We re-ran the models with these two metrics of subjective age; these results can be found in Supplementary Tables 4, 5 and Supplementary Figures 1, 2. Their interpretation is consistent to what is reported in the main text and in Figure 1 . Specifically, as individuals age, they report increasingly younger subjective ages relative to their chronological age. This proportional distortion grew across the lifespan, eventually peaking at just over 20%, which is consistent with previous research ( Rubin and Berntsen, 2006 ).
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Keywords: age perceptions, developmental transitions, project implicit, age differences, middle age, older adulthood
Citation: Chopik WJ, Bremner RH, Johnson DJ and Giasson HL (2018) Age Differences in Age Perceptions and Developmental Transitions. Front. Psychol . 9:67. doi: 10.3389/fpsyg.2018.00067
Received: 28 August 2017; Accepted: 16 January 2018; Published: 01 February 2018.
Copyright © 2018 Chopik, Bremner, Johnson and Giasson. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: William J. Chopik, [email protected]
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Older people’s civic participation: mapping the field, discussion and implications, acknowledgments, conflict of interest.
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Fifty-Five Years of Research Into Older People’s Civic Participation: Recent Trends, Future Directions
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Rodrigo Serrat, PhD, Thomas Scharf, PhD, Feliciano Villar, PhD, Camila Gómez, Msc, Fifty-Five Years of Research Into Older People’s Civic Participation: Recent Trends, Future Directions, The Gerontologist , Volume 60, Issue 1, February 2020, Pages e38–e51, https://doi.org/10.1093/geront/gnz021
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This study analyzes critically existing knowledge concerning older people’s civic participation, pinpoints gaps in the literature, and proposes new directions for research.
We conducted a scoping review of literature on older people’s civic participation. To conduct this review, we followed the 5-step framework developed by Arksey and O’Malley (Arksey H, O’Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Method. 2005; 8: 19–32), and expanded by Levac and colleagues (Levac D, Colquhoun H, O’Brien KK. Scoping studies: Advancing the methodology. Implement Sci. 2010; 5: 69).
Research into older people’s civic participation has grown steadily over the past 55 years. However, the increasing number of publications mainly concerns collective forms of social participation, particularly volunteering, with other types of participation being more stable over time. Contextual as well as dynamic aspects of civic participation remain underdeveloped. Diversity of older people is scarcely represented in current research.
This scoping review identifies 4 critical gaps in the literature that should be at the forefront of future research. These are classified as conceptual, contextual, processual, and diverse aspects of research into older people’s civic participation.
Older people’s civic participation has emerged as a key topic for gerontology and public policy. International organizations, including the United Nations (2002) and European Commission (2012) , have prioritized civic participation as a means to promote active and successful ways of aging. Growing scholarly interest has increased the number and diversity of publications on the theme. Existing systematic reviews have explored such aspects of older adults’ civic participation as motivations for and barriers to volunteering ( Principi, Chiatti, Lamura, & Frerichs, 2012 ) or benefits of volunteering in terms of physical and mental health ( Jenkinson et al., 2013 ). However, to date, no scoping study has reviewed overall knowledge relating to this field. Responding to this gap, this article has two aims: first, to analyze critically existing knowledge concerning older people’s civic participation, and second, to pinpoint knowledge gaps and propose new directions for research.
Civic participation is often considered the “gold” standard for active and successful aging. Over recent decades, scholars and policy-makers have contributed to the emergence of a “win-win” narrative, which emphasizes the twofold contribution of civic participation to improving older people’s health and quality of life and to strengthening and developing their communities (e.g., Gonzales, Matz-Costa, & Morrow-Howell, 2015 ). Indeed, the literature describes a range of benefits associated with civic participation, which ranges from higher levels of cognitive functioning ( Proulx, Curl, & Ermer, 2018 ) to redressing loneliness following widowhood ( Carr, Kail, Matz-Costa, & Shavit, 2018 ). However, concerns have also been raised regarding the downside effects of promoting civic participation among elders, such as imposing an ethics of forced productivity (e.g., Martinson & Minkler, 2006 ).
The concept of civic participation itself remains highly contested, mainly because of its complexity and multidimensionality. According to Berger (2009) , the term suffers from conceptual stretching. Although some scholars assume a restrictive perspective on civic participation, limiting its extension to specific activities such as volunteering (e.g., O’Neill, Morrow-Howell, & Wilson, 2011 ), others use it as a catch-all concept to refer to any activity having the potential to create social capital (e.g., Putnam, 2000 ).
What Is Civic Participation?
Referring to activities “…outside the own family and circle of close friends” ( Ekman & Amnå, 2012 , p. 291), civic participation can be described as active citizen participation “… in the life of a community in order to improve conditions for others or to help shape the community’s future” ( Adler & Goggin, 2005 , p. 241). Several authors have created typologies of civic activities based on different classification criteria (e.g., Adler & Goggin, 2005 ; Berger, 2009 ; Ekman & Amnå, 2012 ). Notwithstanding differences in the conceptual dimensions of proposed classifications, most authors agree on three basic axes of classification.
First, there is a differentiation between civic engagement (or involvement or attention) and civic participation. Although civic engagement simply denotes psychological attentiveness to social and political issues, participation conveys the idea of action and must be conceived as behavioral in nature. Second, civic participation encompasses either activities conducted individually (termed individual, private, or informal participation) or within a group or organization (termed collective, public, or formal participation). Third, civic activities may primarily aim to help others, solve a community problem, or produce common good, with no manifest political intention (referred to as social, civil, community, pre-political, or latent political participation), or may explicitly seek to influence political outcomes (termed political participation or manifest political participation).
Combining the second and third “behavioral” dimensions of classification generates a typology encompassing four kinds of civic activities (presented with selected examples in Table 1 ). Crucially, specified activities may vary in terms of intensity of participation. For instance, participation in community or political organizations may range from passive forms, such as mere membership of an organization, to more demanding forms, such as belonging to an organization’s board.
Types of Civic Activity
What Has Been Researched on Older People’s Civic Participation?
Beyond the type of civic activity considered, research on older people’s civic participation can be divided according to the process model of participation into studies focused on antecedents, experiences, or consequences of participation ( Wilson, 2012 ). Research on antecedents considers why some older people participate in civic activities whereas others do not. Factors associated with civic participation studied thus far include higher human and social capital resources (e.g., McNamara & Gonzales, 2011 ), personality variables such as higher extraversion (e.g., Mike, Jackson, & Oltmanns, 2014 ), or simultaneous engagement in other active aging pursuits, although the direction of this influence may vary according to the type of active aging activity considered ( Dury, De Donder, et al., 2016 ). Further research addresses motivations for (e.g., Principi, Schippers, Naegele, Di Rosa, & Lamura, 2016 ) or barriers to (e.g., Petriwskyj, Serrat, Warburton, Everingham, & Cuthill, 2017 ) participation in civic activities.
A second type of study concerns older people’s experiences of participation. There is growing interest in aspects such as the meanings that participants attach to participation (e.g., Lilburn, Breheny, & Pond, 2018 ) or the experiential learning processes that occur within organizations (e.g., Piercy, Cheek, & Teemant, 2011 ). Several studies also focus on factors associated with retention, that is, with longer participation of older people in programs and organizations (e.g., Devaney et al., 2015 ). An emerging line of inquiry addresses the dynamics of participation across the life-course, such variations in volunteer behavior over the life span in response to life transitions (e.g., Lancee & Radl, 2014 ).
Studies focused on consequences address the effects of civic participation on people who participate. Thus, civic participation has been associated with better physical and mental health (e.g., Lum & Lightfoot, 2005 ), higher cognitive function (e.g., Proulx et al., 2018 ), lower mortality risk (e.g., Okun, Yeung, & Brown, 2013 ), higher well-being (e.g., Kahana, Bhatta, Lovegreen, Kahana, & Midlarsky, 2013 ), increased physical activity (e.g., Varma et al., 2016 ), or decreased loneliness (e.g., Carr et al., 2018 ).
When studying this issue among older people, regardless of the stage of the participation process addressed, previous literature highlights the importance of considering both who participates and where and when civic participation occurs. First, older people’s civic participation may be understood from the perspective of diversity. As a group, older people encompass considerable diversity in terms of “… gender, ethnicity, sexuality, disability, health status, need for assistance with personal and domestic care, class, political persuasion, work and life experience” ( Barnes, 2005 , p. 257). This diversity influences who is able to participate in civic activities, as barriers for participation vary according to older people’s embodied, cultural, and socioeconomic characteristics ( Petriwskyj et al., 2017 ), in which ways they are able to participate, as gender shapes the civic roles expected for older men and women ( Nesteruk & Price, 2011 ), and what benefits accrue from participation, as these vary according to older people’s socioeconomic status ( Morrow-Howell, Hong, & Tang, 2009 ). Second, older people’s civic participation is shaped by the sociopolitical contexts in which participation occurs ( Goerres, 2009 ). Cross-national research (e.g., Haski-Leventhal, 2009 ) highlights the importance of understanding context when addressing older people’s civic participation.
We conducted a scoping review of literature on older people’s civic participation. Scoping studies aim to identify the current state of knowledge and summarize gaps in research. Our review adopted the five-step framework developed by Arksey and O’Malley (2005) , and expanded by Levac, Colquhoun, and O’Brien (2010) , with a systematic team approach characterizing each step of the review.
Step 1: Identifying the Research Question(s)
The team identified two research questions for the scoping review: (1) what is the current knowledge on older people’s civic participation?, and (2) what are the challenges that future research on older people’s civic participation should address?
Step 2: Identifying Relevant Studies
Drawing on the help of a professional librarian, we developed an iterative process of selecting search terms and databases. Final searches were conducted in four databases in April 2017 (PsycINFO, Sociological Abstracts, Web of Science, and Scopus) using the keywords: ( Ageing OR Aging OR Aged OR Old age OR older people OR older persons OR older adults OR seniors OR senior citizens OR elder* OR later life OR third age ) AND (all the combinations between civic OR civil OR citizen* OR political OR social OR community AND participation OR engagement OR involvement, AND volunteering ). It is important to note that from the list of civic activities detailed in Table 1 only volunteering was used as a keyword as the remainder did not produce additional results. Although we limited our searches to empirical, review, or conceptual papers written in English, we did not use any year of publication limit. Searches were updated in May 2018 following the same criteria to add recent papers.
Step 3: Study Selection
We scanned titles and abstracts, applying two inclusion criteria: (1) the paper’s focus was on civic participation, (2) the paper’s focus was on older people (defined as those aged ≥50 years) or on comparisons between older and younger age groups. Papers not focused on civic participation or having a broader focus, as well as papers not focused on older adults or including older adults and younger people but not analyzing results as a function of age, were therefore excluded from the review. Decisions about excluding or including papers began with a title and abstract review, followed by a full-text review when abstracts provided insufficient information to make a decision. Decisions about ambiguous papers were taken together by two or more authors.
Step 4: Charting the Data
We extracted key information from each paper included in the final sample, and charted it using a data-charting form in Microsoft Excel ( Arksey & O’Malley, 2005 ). We developed and updated the data-charting form in meetings preceding data extraction, and at the initial and middle points of the process. Besides bibliographic information, we charted the type(s) of civic activities considered in papers (according to the typology presented in Table 1 ), the type of paper (empirical, conceptual, review), and its objectives, key findings, and conclusions. We also gathered data on the methodology used in empirical papers (research design, data collection technique, and sample characteristics). To ensure consistency of approach to data extraction across the author team, on completing data extraction, two authors reviewed independently a random selection of 15% of papers included in the sample, classified them according to the earlier mentioned criteria, and compared results ( Levac et al., 2010 ). Agreement between researchers was full.
Step 5: Collating, Summarizing, and Reporting Results
The last step involved two kinds of analysis ( Arksey & O’Malley, 2005 ; Levac et al., 2010 ). First, we calculated the frequencies of each of the categories included in the data-charting form using SPSS 20 to describe general trends in research on older people’s civic participation, such as its extent, main characteristics, and distribution by type of civic activities. Second, we conducted a qualitative content analysis of the papers classified under the four types of civic activity.
The initial search identified 1,178 papers after removal of duplicates. Screening of titles and abstracts and, when necessary, full-texts resulted in exclusion of 749 papers ( Figure 1 ). Results from analysis of the remaining 429 papers included in the scoping review are presented in two sections. First, we provide a descriptive summary of the extent, characteristics, and distribution (according to type of civic participation addressed) of the reviewed papers. Second, we synthesize results from the qualitative content analysis of the papers included under each of the four types of civic activity identified in Table 1 .
Flow chart. Scoping review on older people’s civic participation.
The 429 papers included in the scoping review were published between 1963 and 2018, with a significant increase in the number of publications from the late 1990s and, notably, from 2006 ( Figure 2 ). The number of publications peaked in 2006 ( n = 31), corresponding with the publication of a special issue of the journal Generations that included 18 papers on older people’s civic participation. The increasing number of publications was mainly accounted for by collective forms of social participation, with other types of participation being more stable over time.
Number of publications on older people’s civic participation, by type of participation and year of publication. Period 1963–2017 ( N = 429). Type 1 = social participation—individual forms; Type 2 = social participation—collective forms; Type 3 = political participation—individual forms; Type 4 = political participation—collective forms.
The number of papers published by type of civic activity revealed significant differences. Although the overwhelming majority of papers (83.4%) focused on Type 2 of civic participation (social participation—collective forms), far fewer addressed Types 4 (political participation—collective forms; 13.3%), 3 (political participation—individual forms; 11.2%), and 1 (social participation—individual forms; 6.1%). Most papers included in the review were empirical (81.4%), with a smaller proportion of conceptual papers (16.6%), and only a few review papers (2.1%), almost all of which addressed Type 2 of civic activity ( Table 2 ).
Number and Types of Paper Included in the Scoping Review (in Frequencies and Percentages), by Type of Civic Activity ( N = 429)
Notes: Type 1 = social participation—individual forms; Type 2 = social participation—collective forms; Type 3 = political participation—individual forms; Type 4 = political participation—collective forms.
a The sum of n may exceed N as a same paper could address more than one type of civic activity.
Further analysis of the 348 empirical papers included in the review showed a clear dominance of studies using U. S. samples (54.7%), with samples from Australia (6.6%), the United Kingdom (4%), Canada (3.7%), The Netherlands (3.1%), and Spain (2.9%) lagging far behind. Other regions and countries of the world were underrepresented or absent altogether ( Table 3 ).
Country of Origin of the Sample (Empirical Papers; N = 349)
In terms of methodology, most empirical papers used quantitative designs (75.1%), with a small proportion of qualitative designs (21.8%), and very few mixed-methods designs (3.2%). Two thirds of papers adopted cross-sectional (66.8%) and one-third longitudinal designs (33.2%). Most papers focused on older adults (84.2%), with few comparing older with younger age groups (15.8%). Table 4 presents methodological characteristics of the papers by type of civic activity.
Empirical Papers’ Key Methodological and Conceptual Characteristics (in Frequencies and Percentages), by Type of Civic Activity ( N = 349)
b The sum of categories’ frequencies may exceed the total number of papers as a same paper could be classified in more than one category.
Concerning conceptual aspects, most papers focused on antecedents of civic participation (61.3%). This applied especially to papers classified under Types 3 (100%) and 4 (85%) of civic activity. Although slightly more than one third (37%) of papers addressed outcomes of civic participation, this proportion varied significantly across types of civic activity ( Table 4 ). Studies addressing older people’s experiences of participation were far less frequent (14.3%), with most of these considering Type 2 of civic activity.
Most empirical papers included in the review treated participation as a dichotomous variable (71.6%), with a minority considering the intensity of this participation in terms of frequency (28.4%). Dynamic aspects of civic participation were considered only by 6.9% of papers. With regard to contextual aspects, 18 papers (5.2%) addressed the influence of organizational characteristics on civic participation, such as the relationship between organizational support provided to older volunteers and the benefits they accrue from participation ( Tang, Choi, & Morrow-Howell, 2010 ), only 3 (0.9%) explored municipality and neighborhood influences, 9 (2.6%) focused on rural areas, and 16 (4.6%) considered civic participation from a cross-cultural perspective. Diversity (defined as a central focus of the study on diverse and potentially marginalized groups of older people) was scarcely addressed, with only 16.3% of papers considering the characteristics of such groups as older people with disabilities or health problems (4%), older women (2.3%), older people belonging to racial or ethnic minorities (1.7%), institutionalized elders (1.1%), or older migrants (1.1%). Fifteen papers (4.3%) considered more than one dimension of diversity.
Type 1: Social Participation—Individual Forms
Twenty-six papers addressed individual forms of social participation. Most such studies focused on helping behaviors outside the family or “informal” volunteering ( n = 18), with a smaller number addressing financial donations to charities, nongovernmental organizations and/or philanthropic foundations ( n = 5), and three papers including both types of activity. Individual forms of social participation were always discussed within the broader framework of formal volunteering activities, with only three papers addressing these activities by themselves. Two of these studies focused on charitable giving (e.g., James, 2009 ) and one on informal volunteering ( Warburton & McLaughlin, 2006 ).
Most papers in this type of civic activity addressed the antecedents of participation, including such aspects as older people’s motivations (e.g., Jones & Heley, 2016 ), human and social capital (e.g., Cramm & Nieboer, 2015 ), transition into retirement (e.g., Van den Bogaard, Henkens, & Kalmijn, 2014 ), or previous experience with the activity (e.g., Erlinghagen, 2010 ). Seven papers focused on the outcomes of participation in terms of psychological well-being (e.g., Kahana et al., 2013 ), health (e.g., Burr, Han, Lee, Tavares, & Mutchler, 2018 ), or mortality risk (e.g., Ayalon, 2008 ). Only two papers addressed older people’s experiences of participation; one explored the meanings attached by older women to this activity ( Warburton & McLaughlin, 2006 ), the other was a longitudinal study analyzing patterns of change and stability ( Choi & Chou, 2010 ).
Contextual aspects were nearly absent, with only one paper exploring this type of participation in rural settings ( Jones & Heley, 2016 ), and one cross-cultural study ( Erlinghagen & Hank, 2006 ). Diversity was also scarcely addressed. Beyond the earlier mentioned study of older women, two papers focused on the oldest old (e.g., Cramm & Nieboer, 2015 ), and one on older migrants’ participation ( Wright-St Clair & Nayar, 2017 ).
Type 2: Social Participation—Collective Forms
Three-hundred fifty-eight papers considered older people’s participation in formal volunteering. These papers addressed a broad array of volunteering organizations, including health, educational, social, religious, entrepreneurial, and community organizations. Around half of papers focused either on antecedents (55.5%) or outcomes (42.8%) of older people’s participation in this type of civic activity, with a significantly smaller proportion addressing experiences of participation (16.1%). Factors associated with volunteering studied thus far include human and social capital resources (e.g., McNamara & Gonzales, 2011 ), personality variables (e.g., Mike et al., 2014 ), or simultaneous engagement in other active aging activities (e.g., Dury, De Donder, et al., 2016 ). Papers also addressed motivations for volunteering, which have been explored using mostly Clary and colleagues’ (1998) Volunteer Functions Inventory (e.g., Principi, Schippers, et al., 2016 ), or barriers to participating in volunteering, which range from structural factors, such as financial costs, to sociocultural influences, such as age discrimination (e.g., Warburton, Paynter, & Petriwskyj, 2007 ). Four of the nine review papers included in the sample addressed antecedents of participation in this type of civic activity.
Regarding outcomes of participation, 125 studies focused on understanding the effect of volunteering in variables such as physical and mental health (e.g., Lum & Lightfoot, 2005 ), cognitive function (e.g., Proulx et al., 2018 ), mortality risk (e.g., Okun et al., 2013 ), well-being (e.g., Kahana et al., 2013 ), physical activity (e.g., Varma et al., 2016 ), health care use (e.g., Kim & Konrath, 2016 ), loneliness (e.g., Carr et al., 2018 ), or prospective engagement in lifestyle (e.g., Parisi et al., 2015 ) or productive activities (e.g., Morrow-Howell, Lee, McCrary, & McBride, 2014 ). Seven of the nine review papers on this type of civic activity focused on outcomes of participation.
Experiences of participation have been studied much less, with only 16.1% of papers focused on this issue. Most of this research addressed factors associated with retention of older people within volunteering organizations (e.g., Tang, Morrow-Howell, & Choi, 2010 ). Other papers addressed volunteers’ perception of stressors (e.g., Varma et al., 2015 ), satisfaction and enjoyment (e.g., Okun, Infurna, & Hutchinson, 2016 ), training experiences (e.g., Hainsworth & Barlow, 2003 ), or transformative learning processes (e.g., Lear, 2013 ).
Although contextual and diversity aspects featured more frequently than in the case of other types of civic activity, only 12.3% and 16.4% of papers respectively addressed these aspects explicitly. The influence of organizational aspects on participation was present in 15 papers (e.g., Greenfield, Scharlach, & Davitt, 2016 ), neighborhood and community influences in only 3 papers (e.g., Gonzales, Shen, Wang, Martinez, & Norstrand, 2016 ), and issues related to volunteering in rural environments in 7 papers (e.g., Warburton & Winterton, 2017 ). Eleven papers provided cross-cultural comparisons, mostly between European countries (e.g., Hank & Erlinghagen, 2010 ). Regarding diversity, volunteering by people with disabilities or health problems ( n = 12; e.g., Principi, Galenkamp, et al., 2016 ), older women ( n = 7; e.g., Seaman, 2012 ), elders belonging to racial or ethnic minorities ( n = 5; e.g., Johnson & Lee, 2017 ), or institutionalized older people ( n = 4; e.g., Leedahl, Sellon, & Gallopyn, 2017 ) were the more common subgroups explored.
Type 3: Political Participation—Individual Forms
Forty-eight papers addressed individual forms of political participation. Most of these focused on voting behavior ( n = 45), either by itself ( n = 24) or explored conjointly with other individual forms of participation, such as contacting representatives, writing letters, E-mails, or articles with political content, signing petitions, or donating money to political parties and organizations ( n = 21). Of the remaining papers, two addressed contacting behaviors, and one politicized forms of consumption.
All papers included under this type of civic activity focused on antecedents of participation, and explored therefore the association of this type of participation with such aspects as human and social capital variables (e.g., Nygård & Jakobsson, 2013 ), political attitudes (e.g., Kam, Cheung, Chan, & Leung, 1999 ), or public policy changes (e.g., Campbell, 2003 ). Contextual aspects were scarcely addressed, with only two papers exploring this type of participation in rural settings (e.g., Erol, 2017 ), and four cross-cultural studies (e.g., Melo & Stockemer, 2014 ). Diversity was nearly absent. Two papers addressed this form of participation in older people with disabilities or health problems (e.g., Schur, Shields, & Schriner, 2005 ), and one each in people belonging to racial or ethnic minorities ( Morrison, 2014 ), institutionalized elders ( Leedahl et al., 2017 ), and older migrants ( Rosenbaum & Button, 1989 ).
Type 4: Political Participation—Collective Forms
Fifty-seven papers focused on older people’s collective political participation. Most of these studies analyzed either participation in political organizations or forums ( n = 25) or in social movements ( n = 15). Four papers addressed older people’s volunteering for political campaigns and a further four their participation in protest activities. Nine papers considered more than one form of collective political participation. Most studies focused on antecedents of participation (85%), with smaller proportions addressing experiences (7.5%) or outcomes (12.5%) of participation.
Studies of antecedents assessed the association of participation with such aspects as human and social capital (e.g., Burr, Caro, & Moorhead, 2002 ), motivations (e.g., Serrat & Villar, 2016 ), political attitudes (e.g., Goodwin & Allen, 2000 ), political generation (e.g., Brown & Rohlinger, 2016 ), or personality variables (e.g., Serrat, Villar, Warburton, & Petriwskyj, 2017 ). Studies of experiences were less frequent, and explored issues including the meanings that older people attach to participation (for instance, as a key component of their personal identities; e.g., Fox & Quinn, 2012 ), opinions on different aspects of the process of participation (such as their perception of supporting and facilitating factors; e.g., Reed, Cook, Bolter, & Douglas, 2008 ), or experiential learnings acquired while participating (which relate to social, political, and instrumental domains; e.g., Serrat, Petriwskyj, Villar, & Warburton, 2016 ). Five studies explored outcomes of participation, analyzing the impact of participation in variables such as psychological well-being ( Serrat, Villar, Giuliani, & Zacarés, 2017 ) or individuals’ collective identity ( Fraser, Clayton, Sickler, & Taylor, 2009 ).
The influence of organizational aspects on participation was present in three papers (e.g., Serrat et al., 2016 ), and issues related to participation in rural environments in two (e.g., Erol, 2017 ). Five papers provided cross-cultural comparisons, mostly between European countries (e.g., Nygård, Nyqvist, Steenbeek, & Jakobsson, 2015 ). Diversity barely featured, with only one paper addressing each of the following groups: older people with disabilities ( Schur et al., 2005 ), older women ( Jirovec & Erich, 1995 ), migrants ( Rosenbaum & Button, 1989 ), and the oldest old ( Kruse & Schmitt, 2015 ).
This study aimed to analyze critically existing knowledge concerning older people’s civic participation and to pinpoint knowledge gaps and propose new directions for research. A first conclusion arising from our scoping review is that research into older people’s civic participation has grown steadily over the past 55 years, and particularly during the last two decades. This reflects a growing interest in academic research in promoting active and successful ways of aging, which echoes policy and practice recommendations by major international organizations (e.g., United Nations, 2002 ). However, our review also identifies four critical gaps and leading-edge research questions that should be at the forefront of future research (see Table 5 ). These can be classified as conceptual, contextual, processual, and diverse aspects of research into older people’s civic participation.
Overview of Critical Gaps and Future Leading-Edge Research Questions
Critical Gap 1: What Do We Know About Participation? Broadening the Scope of Research Into Older People’s Civic Participation
Results from this scoping review reveal that not all types of civic activity have received the same attention in research. Although collective forms of social participation, especially formal volunteering, have dominated academic discourse on older people’s civic participation, the other three types of civic participation have been largely overlooked. Regarding individual forms of social participation, authors (e.g., Nesteruk & Price, 2011 ) have consistently warned about the risks of ignoring the numerous contributions made by older people outside the sphere of formal volunteering, such as helping neighbors or friends who do not live in the same household. In a recent example of research addressing this gap, Burr and colleagues (2018) show that health benefits accruing from informal helping behaviors and formal volunteering differ by gender. However, although informal helping behaviors are the most common forms of older people’s civic participation (e.g., Kruse & Schmitt, 2015 ), our review demonstrates that they have received the least attention in research. This may be due, in part, to the fact that informal helping behaviors could be more difficult to study, as they tend to occur in a more private sphere in comparison to other civic activities, but especially because these behaviors have been barely included within the most prominent models of active and successful aging (e.g., de São José, Timonen, Amado, & Santos, 2017 ), even if they are of greater importance for older people than other activities commonly included within these models (e.g., Huijg et al., 2017 ).
There is also a striking difference between the number of papers concerned with individual and collective forms of political participation, and those addressing collective forms of social participation. This suggests that research into older people’s civic participation has favored a conception of older people as “contributors” to sustaining welfare states rather than as “political activists” who may challenge the social and political processes underlying welfare states (e.g., Martinson & Minkler, 2006 ). This implies a necessity to broaden the scope of research on older people’s civic participation and advance toward a more nuanced understanding of what it means to participate civically in later life. In particular, research may benefit from bringing politics back into studies of older people’s civic participation to consider not only ways in which older people may contribute to their communities but also ways in which they may support or contest prevailing social and political values and processes. Recent research on organizations representing seniors’ interests (e.g., Doyle, 2014 ; Serrat, Warburton, Petriwskyj, & Villar, in press ) goes clearly in this direction. Thus, we need to move beyond conceiving of older people as social actors and consider them simultaneously as political agents, as a collective whose voices and opinions must be acknowledged in decision-making processes.
Critical Gap 2: Where and When Does Participation Take Place? Addressing Contextual Aspects of Older People’s Civic Participation
As older people’s civic participation is decisively shaped by the particular contexts in which participation occurs, considering where and when participation takes place is essential to enhancing understanding of this phenomenon. However, our review shows that contextual aspects of civic participation remain underdeveloped at three levels. First, at the microcontextual level, we need more research addressing organizational dimensions of participation. An emerging body of studies suggests that organizations play an important role in such aspects as the recruitment and retention of older participants (e.g., Devaney et al., 2015 ) or the benefits individuals obtain from participation (e.g., Hong & Morrow-Howell, 2013 ). Especially valuable are studies, such as that of Hong, Morrow-Howell, Tang, and Hinterlong (2009) , which incorporate systematically an institutional perspective on civic participation into their designs.
Second, at the mesocontextual level, civic participation is better understood when considering the broader context of neighborhood and community influences. The work of Dury, Willems, and colleagues (2016) shows that older people’s perceptions of physical and social dimensions of neighborhood as well as objective municipality features are associated with participation in formal volunteering in later life. However, this mesocontextual dimension remains under-researched, emphasizing the considerable potential to develop new studies concerning neighborhood and community influences on civic participation in later life.
Third, at the macrocontextual level, most research has been conducted using U.S. samples, with other nations and world regions clearly underrepresented, if not absent. Sociopolitical contexts, which vary across countries and cultures, determine not only such aspects as possibilities and constraints for older people’s civic participation, but also understandings of what it means to be civically involved (e.g., Chen & Adamek, 2017 ). Notwithstanding recent attempts to compare patterns of civic participation across countries in different world regions ( Nygård et al., 2015 ; Serrat et al., in press ), too few studies address this macrocontextual level. Thus, there is a need for more evidence drawn from countries other than the United States, and especially for cross-cultural research comparing older people’s civic participation across diverse sociopolitical contexts.
Critical Gap 3: How Does Participation Develop? Exploring Experiences and Dynamics of Older People’s Civic Participation
Although our scoping review identifies a large literature on antecedents and outcomes of older people’s civic participation, less is known about the process of participation in two key respects. First, older people’s experiences while participating in civic activities are far less addressed than antecedents or outcomes of participation. Such experiences are important in understanding, for example, individuals’ decisions around continuing or withdrawing from participation (e.g., Tang, Morrow-Howell, & Hong, 2009 ). To date, research has covered several related issues, such as the meanings participants attach to their participation (e.g., Lilburn et al., 2018 ) or the learning process they experience while participating (e.g., Piercy et al., 2011 ). However, more studies should explore older people’s experiences of civic participation, and also the role of these experiences on individuals’ decisions to stop or continue participating.
Second, older people’s civic participation may also be considered a dynamic process, as individuals participate and withdraw from participation over the life-course. However, most previous studies focus exclusively on later life conditions and experiences to understand civic participation in old age. An exclusive reliance on this approach obscures the causes and consequences of civic participation trajectories over the life-course. Research needs to move on from identifying factors associated with civic participation among older people to examine how these factors unfold over time and influence individuals’ participation in (or withdrawal from) civic activities across the life-course. Although some researchers have addressed dynamic facets of civic participation, showing for instance the variations in volunteer behavior over the life span in response to life transitions (e.g., Lancee & Radl, 2014 ), we need more studies that encompass individuals’ biographical experiences and changes in civic participation as people age.
Critical Gap 4: Who Participates? Taking Into Account Older People’s Diversity When Studying Civic Participation
Older people’s civic participation may also be understood from the perspective of diversity ( Barnes, 2005 ). Older people, as a group, encompass considerable diversity and this influences who is able to participate in civic activities, as barriers for participation vary according to older people’s embodied, cultural, and socioeconomic characteristics (e.g., Petriwskyj et al., 2017 ), the ways in which they are able to participate, as gender shapes the civic roles expected for older men and women (e.g., Nesteruk & Price, 2011 ), and what benefits accrue from participation, as these vary according to older people’s socioeconomic status (e.g., Morrow-Howell et al., 2009 ). Although consideration of diversity in studies of older people’s civic participation has progressed considerably, there is merit in exploring challenges faced by marginalized groups of older people in achieving full inclusion in civic activities.
The small number of papers identified by this scoping review considered only one dimension of diversity, mainly having a disability or health condition, being a woman, or belonging to a racial or ethnic minority. In this respect, recent developments in intersectionality theory emphasize the importance of considering the nonadditive effects of multiple systems of inequality experienced by people with particular social locations. Age by itself represents a system of inequalities, as it has material consequences and influences life chances. Analysis of older people’s civic participation would benefit, therefore, from considering the interaction of age as a system of inequality with such other systems as gender, race, class, disability, or sexual orientation.
Limitations and Conclusions
Several limitations should be considered when interpreting this study’s results. These include its focus on literature published in English and in peer-reviewed journals, which may exclude relevant literature published in other languages and/or formats. Moreover, space limitations preclude a more detailed presentation of results from the qualitative content analysis. Notwithstanding these issues, this is, to the best of our knowledge, the first scoping review to address older people’s civic participation. In highlighting the extent, range, and characteristics of research in this burgeoning field, the review confirms the key role of civic participation as a way for older people to keep active and socially involved, and to have their voices heard and represented in political arenas. By synthesizing existing knowledge and identifying critical gaps in research, we hope that we can contribute to the further advancement of this important field of study.
This work was supported by the Spanish Ministry of Economy, Industry and Competitiveness (PSI2016-77864-R to R. Serrat and F. Villar); the University of Barcelona in collaboration with “La Caixa” Bank Foundation (postdoctoral fellowship to R. Serrat); and the European Cooperation in Science and Technology program (COST Action CA15122, grant to carry out a short-term scientific mission at Newcastle University to R. Serrat).
We want to thank Jordi Tremosa Armengol, librarian at the University of Barcelona (Mundet Campus), who provided invaluable help with the scoping review of the literature. We are also grateful to the anonymous reviewers for their helpful suggestions in revising the article.
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- Published: 14 February 2020
Loneliness and social isolation interventions for older adults: a scoping review of reviews
- Olujoke A. Fakoya ORCID: orcid.org/0000-0002-3545-7567 1 ,
- Noleen K. McCorry 1 &
- Michael Donnelly 1
BMC Public Health volume 20 , Article number: 129 ( 2020 ) Cite this article
Loneliness and social isolation are growing public health concerns in our ageing society. Whilst these experiences occur across the life span, 50% of individuals aged over 60 are at risk of social isolation and one-third will experience some degree of loneliness later in life. The aim of this scoping review was to describe the range of interventions to reduce loneliness and social isolation among older adults that have been evaluated; in terms of intervention conceptualisation, categorisation, and components.
Three electronic databases (CINAHL, Embase and Medline) were systematically searched for relevant published reviews of interventions for loneliness and social isolation. Inclusion criteria were: review of any type, published in English, a target population of older people and reported data on the categorisation of loneliness and/or social isolation interventions. Data extracted included: categories of interventions and the reasoning underpinning this categorisation. The methodology framework proposed by Arskey and O’Malley and further developed by Levac, et al. was used to guide the scoping review process.
A total of 33 reviews met the inclusion criteria, evaluating a range of interventions targeted at older people residing in the community or institutionalised settings. Authors of reviews included in this paper often used the same terms to categorise different intervention components and many did not provide a clear definition of these terms. There were inconsistent meanings attributed to intervention characteristics. Overall, interventions were commonly categorised on the basis of: 1) group or one-to-one delivery mode, 2) the goal of the intervention, and 3) the intervention type. Several authors replicated the categorisation system used in previous reviews.
Many interventions have been developed to combat loneliness and social isolation among older people. The individuality of the experience of loneliness and isolation may cause difficulty in the delivery of standardised interventions. There is no one-size-fits-all approach to addressing loneliness or social isolation, and hence the need to tailor interventions to suit the needs of individuals, specific groups or the degree of loneliness experienced. Therefore, future research should be aimed at discerning what intervention works for whom, in what particular context and how.
Peer Review reports
Loneliness and social isolation are international public health concerns that particularly affect the ageing society globally [ 1 ]. Loneliness and social isolation are distinct but interrelated concepts. According to Valtorta and Hanratty [ 2 ], one of the most widely used definitions of loneliness constitutes of social and emotional loneliness: loneliness is a subjective negative feeling associated with a perceived lack of a wider social network (social loneliness) or absence of a specific desired companion (emotional loneliness). There is much less consensus about the definition of social isolation however authors have approached it as a multidimensional concept, defining social isolation as the objective lack or paucity of social contacts and interactions with family members, friends or the wider community [ 2 ].
Loneliness and social isolation are risk factors for all-cause morbidity and mortality with outcomes comparable to other risk factors such as smoking, lack of exercise, obesity and high blood pressure [ 3 , 4 , 5 ]. In addition, loneliness has been associated with decreased resistance to infection, cognitive decline and mental health conditions such as depression and dementia [ 3 ]. Whilst every individual will experience loneliness at some point in their lives to a certain degree [ 6 ], research has highlighted that older people are particularly vulnerable to experiencing loneliness and social isolation [ 7 , 8 ]. Approximately 50% of individuals aged over 60 are at risk of social isolation and one-third will experience some degree of loneliness later in life [ 3 ]. Although loneliness and social isolation have been associated with a reduction in health status and therefore a decreased quality of life, findings suggest that both concepts may have independent impacts on health and therefore should be regarded as individual characteristics [ 9 ]. However, there is also an overlap in the factors which contribute to loneliness and social isolation and sometimes authors use the terms interchangeably [ 10 , 11 ].
Risk factors for loneliness and social isolation among older people include: family dispersal, decreased mobility and income, loss of loved ones, and poor health. It is thought that societal change including reduced inter-generational living, greater geographical mobility and less cohesive communities have also contributed to higher levels of loneliness in the older population [ 7 , 12 ]. Due to advancements in public health and medical technologies, in addition to improved sanitation, the average life expectancy of the population aged 60 years or over has increased globally, resulting in a projected 56% growth in this population from 901 million to 1.4 billion by 2030 [ 13 ]. Healthy life expectancy however still lags behind, and the increasing prevalence of loneliness contributes to this state of affairs [ 14 ].
Given the increasing burden of loneliness and its impact on health and wellbeing, it is not surprising that there has been a growing academic literature, public and policy interest worldwide in loneliness and social isolation. For example, the Campaign to End Loneliness began in 2010 in the United Kingdom (UK) and aimed to create connections among older age people [ 8 ]. In Denmark, a campaign titled ‘ Danmark spiser sammen ’ which when translated in English means ‘Denmark eats together’ was established in 2015 as a popular movement against loneliness [ 15 ]. The Australian Coalition to End Loneliness (ACEL), inspired by the Campaign to End Loneliness in the UK, was developed in Australia in 2016 and aimed to use evidence-based interventions and advocacy to increase awareness of, and address, loneliness and physical social isolation [ 16 ]. ACEL did not clarify what was meant by the term ‘physical social isolation’ and this further highlights the varied terminology used regarding loneliness and social isolation. There are also growing campaigns in the Netherlands and New Zealand to tackle loneliness [ 1 ]. ALONE, a national organisation in Ireland that offers support to older people, launched a Christmas campaign in 2018 called ‘Have a Laugh for Loneliness’ which encouraged families, friends and communities to get together during the winter in order to combat loneliness in their communities [ 17 ].
Several reports about the range and types of loneliness interventions have been published globally. Within the United Kingdom, these have included reports by organisations such as Age UK [ 18 ] and the Institute of Public Health in Ireland [ 19 ]; guidelines by the National Institute for Clinical Excellence [ 20 ]; reviews by the Social Care Institute for Excellence [ 7 , 21 ], and material collated by the Campaign to End Loneliness [ 1 ]. The Canadian Counselling and Psychotherapy Association (CCPA) have published guidelines for addressing loneliness [ 22 ]. Similarly, in the United States of America (USA), organisations such as Humana [ 23 ], have published reports and a toolkit to overcome loneliness and social isolation, and the National Institute on Aging (National Institutes of Health) [ 24 ] have published reports on improving the development of interventions to reduce loneliness and social isolation.
The report published by Age UK [ 25 ] specifically highlighted the gap between evidence of what constitutes an effective ‘loneliness intervention’ in the academic literature and the practice of those delivering interventions. Nevertheless, service providers are experiencing increasing demand to provide initiatives to tackle loneliness, even in the absence of empirical evidence to fully support their innovations.
There are several published systematic reviews of loneliness and/or social isolation interventions, e.g. Cattan and White [ 26 ], Cattan, et al. [ 10 ] and Dickens, et al. [ 9 ]. For example, Cattan and White [ 26 ] critically reviewed the evidence of effectiveness of health promotion interventions targeting social isolation and loneliness among older people. It was reported that an effective intervention to combat social isolation and loneliness among older people tended to be long-term group activity aimed at a specific target group, with an element of participant control using a multi-faceted approach [ 26 ]. Cattan, et al. [ 10 ] conducted a systematic review to determine the effectiveness of health promotion interventions that targeted social isolation and loneliness among older people, and found educational and social activity interventions that target specific groups can alleviate social isolation and loneliness among older people. However, the effectiveness of home visiting and befriending schemes remains unclear [ 10 ]. Similarly, a systematic review conducted by Dickens, et al. [ 9 ] aimed to assess the effectiveness of interventions designed to alleviate social isolation and loneliness in older people. It was reported that common characteristics of effective interventions were those developed within the context of a theoretical basis, and those offering social activity and/or support within a group format. Interventions where older people were active participants also appeared more likely to be effective [ 9 ].
Within this diverse literature, there are a range of frameworks used to categorise loneliness/social isolation interventions, often without clear definitions or rationale. Hence, there is a need to: map, organise and synthesise the large and diverse body of literature in this area; describe the range of intervention types; and to synthesise their content and characteristics.
Scoping reviews are useful for synthesising research evidence and are often used to categorise existing literature in a field. They can be used to map literature in terms of nature, features and volume; to clarify definitions and conceptual boundaries; and to identify research gaps and recommendations. They are particularly useful when a body of literature exhibits a large, complex or heterogeneous nature [ 27 ].
Scoping review objectives
The objective of this scoping review is to map the large body of literature and to describe the range of interventions to reduce loneliness and social isolation among older adults. By focusing on existing reviews of loneliness/social isolation interventions, it aims to synthesise the ways in which interventions have been conceptualised and their components described.
Scoping review questions
How have authors of the reviews that were included in this paper (hereafter referred to as ‘review authors’) grouped or categorised loneliness and social isolation interventions?
How have review authors defined the terms used to categorise interventions?
How have review authors described their reasoning for categorising interventions in the format used?
Are there any similarities or differences in the terms used to categorise interventions across the reviews?
The conduct of this scoping review was based on the framework and principles reported by Arksey and O’Malley [ 28 ] and further recommendations provided by Levac, et al. [ 29 ]. Additional guidance on reporting by Peters, et al. [ 27 ] was also used. As the primary interest was in capturing how loneliness and social isolation interventions are categorised and described in the literature, an efficient way of doing this was to focus on review papers (of any type) rather than primary literature. Appropriate adjustments were made to reflect the nature of the evidence (i.e. only secondary evidence) being reviewed. The review included the following 5 key phases [ 28 ]:
Stage 1: Identifying the research question
Stage 2: Identifying relevant studies
Stage 3: Study selection
Stage 4: Charting the data
Stage 5: Collating, summarising and reporting the results
The optional ‘consultation exercise’ recommended by Arskey and O’Malley [ 28 ] was not conducted.
Information sources and search strategy
Following several preliminary scoping searches which were intended to gain familiarity with the literature and aid with the identification of key words, three health bibliographic databases (Medline, EMBASE and Cumulative Index to Nursing and Allied Health Literature (CINAHL)) were searched for relevant literature from their inception until the date that the search was conducted (15th June 2018). Searches were devised in collaboration with an information specialist librarian and the research team. The search strategy was developed to identify reviews of loneliness/social isolation interventions for older people, but the strategy was tailored to the specific requirements of each database as seen in Additional file 1 : Table S1. Grey literature was searched using Google (including Google Scholar) and the first 30 links (sorted by relevance) were compared against the inclusion criteria. Backward citation chaining was also undertaken which involved hand-searching the reference lists of the reviews identified to find other relevant research [ 30 ]. Electronic search results were exported into an Excel spreadsheet and duplicates deleted. Additional file 1 : Table S1 details the search terms and strategy.
Whilst loneliness and social isolation are distinct concepts (as defined previously), we have included both outcomes as a focus of the review but have taken care to document the review findings in relation to these concepts. Hence, papers were included if they satisfied all of the following eligibility criteria:
A review of any type;
Available in English language;
Focus of the review on loneliness and/or social isolation interventions for older adults/elderly individuals;
Reported a categorisation of loneliness and/or social isolation interventions or grouped interventions.
Reviews of interventions in any setting or context, including older populations with existing physical or mental health problems were of interest. Since there are various definitions of the age range of ‘older’ populations, a lower age limit was not specified as an inclusion criteria. Rather, reviews were included which identified themselves as focusing on older people. There were no limiters applied in relation to date or subject, but the search was limited to reviews published in English because of limited resources for translation.
Selection of reviews
The selection of relevant reviews was undertaken in three stages: 1) Initial screening of the title and abstract which was conducted by the first author (OAF), 2) retrieval and screening of the full text which was completed independently by the first and second authors (OAF and NMC), with discrepancies resolved through discussion with all three authors, and 3) data extraction and collation. The agreement coefficient was 97%. Papers that did not meet the criteria were excluded, with the reason(s) for exclusion recorded. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) chart (Fig. 1 ) reports the phases of paper identification and selection.
PRISMA flow diagram illustrating the search strategy. This flow diagram provides the phases of article identification and selection, which resulted in the identification of 33 articles that were deemed eligible for inclusion in the review. Prepared in accordance with Tricco AC, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): Checklist and Explanation. Annals of Internal Medicine. 2018. pp. 467–473. doi: https://doi.org/10.7326/M18-0850
Data extraction and charting
Eligible papers were independently reviewed by OAF and NMC and the following data were extracted: author information (title, author and year of publication), aims and objectives of the review, type of review (e.g. systematic, literature etc.), inclusion criteria used in the review (where appropriate), number of primary studies included in the review (where appropriate), number of interventions reviewed (where appropriate), categories used by the review authors, and any explanation given by the authors in regards to the categorisation of interventions. It should be noted that the following parameters were not applicable to non-systematic type reviews such as basic literature reviews and some evidence reviews: inclusion criteria; number of primary studies; and number of interventions reviewed.
Electronic searches identified 529 citations, resulting in 485 unique citations to be screened for inclusion following removal of duplicates (see Fig. 1 ). The titles and abstracts were assessed for their relevance to the review based on the inclusion criteria (Stage 1 screening), resulting in 46 citations being retained. The full texts of all these citations were obtained and after applying the inclusion criteria (Stage 2 selection), 30 citations were excluded; 12 did not provide data relevant to categorisation of loneliness and/or social isolation intervention(s), 15 were not reviews and three did not have a primary or secondary objective of reducing loneliness and/or social isolation. An additional 17 citations were identified through backward citation chaining and these citations were also included. As such, 33 citations were included in the scoping review (see Fig. 1 ). Characteristics of the included reviews are shown as a structured table and as a narrative summary in Additional file 2 : Table S2.
Characteristics of reviews
There is increasing interest and research in the area of loneliness and social isolation among the older population. The first review appeared in 1984 and following that, there were three more reviews up until the year 2003. Subsequently, there were more frequent publications of literature on loneliness and/or social isolation and at least one review was published consecutively every year from 2010 onwards. This information is represented in a diagrammatic form in Fig. 2 .
Number of review articles on loneliness and social isolation interventions published from 1984 to 2018. The first review of loneliness and social isolation interventions appeared in 1984 and following that, there were three more reviews up until the year 2003. There were more frequent publications of reviews on loneliness and/or social isolation from 2010 onwards
Type of reviews
Review papers were published between 1984 and 2017 and of these, systematic reviews were the most common type of reviews obtained [ 9 , 10 , 26 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 ], followed by literature reviews [ 6 , 42 , 43 , 44 , 45 , 46 , 47 ], evidence reviews [ 18 , 48 , 49 , 50 ], narrative reviews [ 25 , 51 , 52 ], and other types of review including critical [ 53 ], empirical [ 54 ], rapid [ 55 ] and integrative review [ 11 ]. This information is represented in a diagrammatic form in Fig. 3 .
Type of review articles on loneliness and social isolation interventions published from 1984 to 2018. Systematic reviews were the most common type of reviews published between 1984 and 2018. Other types of reviews include literature, evidence, narrative, critical, empirical, rapid and integrative reviews
Of those reviews which employed a systematic means of selecting eligible primary research ( n = 14), ten papers included only studies published in English, two review papers included studies published in any language, one review included studies published in English and Italian [ 34 ], and 1 included studies published in English, French, Italian and Spanish [ 41 ].
Concept of loneliness and social isolation
In terms of the consideration of the concepts of loneliness and social isolation, most reviews (28/33) could be assigned to one of three categories: 1) reviews that explicitly focused on interventions to reduce social isolation ( n = 4) e.g. Chen and Schulz [ 37 ], Findlay [ 33 ], Oliver, et al. [ 47 ] and Wilson and Cordier [ 52 ]; 2) reviews that explicitly focused on interventions to alleviate loneliness ( n = 11), e.g. McWhirter [ 6 ] and Masi, et al. [ 31 ] and Cohen-Mansfield and Perach [ 53 ]; and 3) reviews that included papers with interventions for both loneliness and social isolation ( n = 13) e.g. Poscia, et al. [ 34 ] and Cattan, et al. [ 10 ]. The remaining five reviews focused on loneliness and other outcomes of interests such as anxiety and depression ( n = 3); or other related concepts such as social participation [ 56 ], and social connectedness [ 35 ]. While there is a distinction between loneliness and social isolation, there was not any obvious differences in reviews that focused on loneliness or social isolation in terms of the review type, where the research was conducted, and how the findings were reported.
Loneliness/social isolation was not always reported as the primary outcome and was sometimes reported alongside other health outcomes as seen in three reviews [ 36 , 38 , 40 ]. A review by Choi, et al. [ 40 ] examined the effectiveness of computer and internet training on reducing loneliness and depression in older adults. Elias, et al. [ 38 ] evaluated the effectiveness of group reminiscence therapy for loneliness, anxiety and depression in older adults. In a review by Franck, et al. [ 36 ], interventions were reviewed if they addressed social isolation, loneliness, or the combination of depression with social isolation or loneliness. In a systematic review by Morris, et al. [ 35 ], the effectiveness of smart technologies was examined in improving or maintaining social connectedness.
The majority of the reviews ( n = 24) focused solely on the older population [ 9 , 10 , 11 , 18 , 25 , 26 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 46 , 48 , 49 , 50 , 51 , 53 , 55 , 56 ] but the age range used to define this population varied [ 32 , 35 , 36 , 37 , 38 , 53 ], or was not specified at all [ 9 , 10 , 11 , 26 , 33 , 46 , 51 , 56 ]. For example, a systematic review by Morris, et al. [ 35 ] targeted older people who live at home and included participants that were aged ≥45 years, whereas Cohen-Mansfield and Perach [ 53 ] and Chen and Schulz [ 37 ] targeted individuals aged ≥55 years; and Chipps, et al. [ 32 ], Franck, et al. [ 36 ], and Elias, et al. [ 38 ] targeted individuals aged ≥60 years. Where age was not specified, review authors used the term ‘older people’ or its synonyms, e.g. older adults [ 40 ] and seniors [ 39 , 56 ], to describe the target population. It was stated in two of these reviews that the definition for the older person was defined by the criteria used in the studies included in the review [ 26 , 56 ].
Some reviews focused on specific subgroups of the older population which research has identified to be more prone to loneliness and social isolation. For example, six reviews focused only on older people residing within the community [ 6 , 10 , 39 , 42 , 48 , 52 ], whereas three focused only on older people living in institutionalised settings e.g. care or nursing homes [ 36 , 38 , 47 ]. The majority of reviews (21 in total) included populations of both community-dwelling individuals and those living in long-term care [ 9 , 11 , 18 , 25 , 31 , 32 , 33 , 34 , 35 , 37 , 40 , 41 , 44 , 45 , 46 , 49 , 50 , 51 , 53 , 55 , 56 ]. Residential status was not reported in three reviews [ 26 , 43 , 54 ]. This population characteristic is represented diagrammatically in Fig. 4 .
Pie-chart of residential status of populations included in eligible reviews identified. The majority of reviews ( n = 21) included populations of both community-dwelling individuals and those living in long-term care. Six reviews focused solely on older people residing within the community and three focused solely on older people living in institutionalised settings such as care or nursing homes. Three reviews did not report the residential status of the target population
Only two of the 33 reviews [ 41 , 52 ] included gender as an inclusion criteria, and these two papers focused specifically on interventions targeted at the male population only, including Men’s Sheds [ 52 ] and gendered interventions for older men [ 41 ]. Men’s Sheds are community-based organisations that provide a space for older men to participate in craftwork and engage in social interaction [ 52 ]. Review authors often reported that the gender distribution of participants in primary research involving loneliness/social isolation was heavily skewed towards the female population [ 31 , 33 , 34 , 37 , 39 ]. The subsets of the female population reported in the reviews includes: isolated older women, women at risk of suicide, senior women on the housing waiting list [ 33 ]; community-living, chronically ill women [ 31 ]; women with primary breast cancer, community-dwelling, single women [ 34 ]; and community-dwelling low-income women with low perceived social support [ 39 ].
Countries in which interventions were delivered
The countries in which interventions were delivered was not reported in some of the review papers ( n = 16). Of the papers that did report this ( n = 17), USA was the most reported ( n = 14), followed by Netherlands ( n = 13), Canada ( n = 10), UK ( n = 9), Australia ( n = 8), Sweden (n = 8), Finland ( n = 5), Taiwan (n = 5), Israel ( n = 4), Norway (n = 4), Germany (n = 4), Japan ( n = 3), China ( n = 2), Hong Kong (n-2), Denmark (n = 2), Italy (n = 2), New Zealand (n = 2), South Africa (n = 1), Austria (n = 1), Slovenia (n = 1) and Iran (n = 1).
Categorisation of interventions
There was a broad range of terms that review authors used to describe the characteristics of interventions, such as: format [ 31 ], delivery mode [ 9 , 31 , 34 ], goal [ 42 , 44 , 46 ], type [ 9 , 31 , 34 , 53 ], focus [ 53 ], and nature [ 46 ], and often the same terms had different meanings. Some authors used two or more categorisation systems as seen in the reviews by Dickens, et al. [ 9 ] and Poscia, et al. [ 34 ], where interventions were categorised by both their ‘delivery mode’ and ‘type’. Alternatively Grenade and Boldy [ 46 ] categorised interventions by their ‘nature’ and ‘goal’, and Cohen-Mansfield and Perach [ 53 ] categorised interventions based on their ‘focus’ and ‘type’. Masi, et al. [ 31 ] categorised interventions based on their ‘type, format and mode’. It was common ( n = 20) for review authors to categorise interventions on the basis of whether they were delivered via a ‘group’ or ‘one-to-one’ [ 9 , 10 , 18 , 26 , 31 , 33 , 34 , 36 , 38 , 39 , 42 , 44 , 45 , 46 , 49 , 50 , 51 , 53 , 55 , 56 ]. In a review by Raymond, et al. [ 56 ], social participation interventions were delivered in an individual or group context. Elias, et al. [ 38 ] explored the effectiveness of group reminiscence therapy in alleviating loneliness whereas the Medical Advisory Secretariat [ 39 ] evaluated in-person group-based interventions in alleviating loneliness and social isolation among community-dwelling care seniors. The term ‘mode’ was used frequently within review papers but often with inconsistent meanings. By way of illustration, Poscia, et al. [ 34 ] and Dickens, et al. [ 9 ] referred to the categorisation of interventions via group or one-to-one delivery as ‘mode’, and classified interventions as individual, group or mixed (both individual and group). In contrast, delivery ‘mode’ in Masi, et al.’s [ 31 ] review referred to ‘technology’ or ‘non-technology’ based interventions, and ‘format’ was used to describe whether the intervention was implemented on a one-to-one basis or as a group (if more than one person participated in the intervention at the same time or if the intervention involved asynchronous interactions such as internet-based chat room exchanges).
Some review authors categorised interventions by their type ( n = 4) [ 9 , 31 , 34 , 53 ], and the descriptions for this category also varied. In a review by Dickens, et al. [ 9 ], interventions categorised by their ‘type’ were described as: ‘offering activities’ (e.g. social or physical programmes), ‘support’ (discussion, counselling, therapy or education), ‘internet training’, ‘home visiting’ or ‘service provision’. In another review, intervention type was described as: 1) social skills training if it focused on improving participants’ interpersonal communication skills, 2) enhancing social support if the intervention offered regular contacts, care or companionship, 3) social access if the intervention increased opportunities for participants to engage in social interaction (e.g. online chat room or social activities), and 4) social cognitive training if the intervention focused on changing participants’ social cognition [ 31 ].
Similar to the categories used in the review by Masi, et al. [ 31 ], Poscia, et al. [ 34 ] categorised interventions by their type, further describing the category as offering: [ 1 ] social support (e.g. discussion, counselling, therapy or education), 2) social activities, in form of social programmes, 3) Physical activity (fitness programme or recreational activity), 4) technology (e.g. companion robot, telephone befriending or internet use), 5) singing sessions, and 6) horticultural therapy. By contrast, when Cohen-Mansfield and Perach [ 53 ] categorised interventions by their ‘type’ this referred to whether interventions were delivered in a ‘group’ or ‘one-to-one’.
Three reviews categorised interventions by their ‘goal’ [ 42 , 44 , 46 ]. In two of these reviews [ 42 , 44 ] the same constructs were used to define goals and these were: 1) to facilitate social bonding e.g. via cognitive behaviour therapy or social skills training, 2) to enhance coping with loneliness e.g. through support groups, and 3) to prevent loneliness from occurring e.g. through community awareness and educational programs. In the third review [ 46 ], the authors implicitly addressed these three constructs but used different terminology, i.e. to enhance people’s social networks, and promote personal efficacy and behaviour modification, and/or skills development. A similar categorisation system was used by Cacioppo, et al. [ 45 ], but these review authors labelled this category as ‘models of loneliness interventions’ rather than ‘goal’, and included interventions aimed to: 1) provide social support, 2) increase opportunities for social interaction and 3) teach lonely people to master social skills.
A total of six reviews focused on technology-based interventions to improve communication and social connection among older people [ 32 , 35 , 37 , 40 , 47 , 48 ]. An evidence review by Age UK [ 48 ] reviewed the use of modern (e.g. internet) and assistive technology (e.g. telecare or telehealth) in maintaining and establishing social contact. Chen and Schulz [ 37 ] reviewed the effects of communication programs such as telephone befriending, computer and internet, and high-technology apps such as virtual pet companions in reducing loneliness and social isolation in the elderly. The effectiveness of e-interventions which can be described as online activities e.g. computer or internet training and usage; interpersonal communication e.g. Skype; and internet-operated therapeutic software e.g. Nintendo Wii entertainment system and videogames, were synthesised and assessed for decreasing social isolation and loneliness among older people living in community/residential care [ 32 ]. One systematic review evaluated the effectiveness of smart technologies [ 35 ], which can be described as internet-based support groups and computer use and training, whereas the potential of videophone technology in improving communication between residents and family members was reviewed by Oliver, et al. [ 47 ]. In another review, computer and internet training among lonely and depressed older adults were examined [ 40 ].
The rationale for the categorisation of interventions was reported in the majority of reviews ( n = 21). It was stated in an integrative review by Gardiner, et al. [ 11 ] that interventions were categorised based on their purpose, intended outcomes and mechanisms by which they targeted loneliness and social isolation. Gardiner, et al. [ 11 ] highlighted the importance of this categorisation given the growing diversity in intervention types, and considered rigorous and transparent categorisation to be a necessary pre-requisite for identifying which elements of interventions influence their effectiveness. Their thematic synthesis identified six categories which included: social facilitation interventions, psychological therapies, health and social care provision, animal interventions, befriending interventions, and leisure/skills development. In a narrative synthesis by Jopling [ 25 ], interventions were grouped in accordance to addressing three key challenges: 1) reaching lonely individuals, 2) understanding the nature of an individual’s loneliness and developing a personalised response, and 3) supporting lonely individuals to access appropriate services.
Other reviews [ 36 , 37 , 38 , 39 , 40 , 41 , 47 , 48 , 49 , 50 , 51 , 55 ] did not report a rationale for the categorisation of interventions (as seen in Additional file 2 : Table S2). Some review authors justified their categories on the basis that they had been used in previous reviews, e.g. two reviews [ 10 , 33 ] replicated the categorisation used in a previous study by Cattan and White where intervention studies were divided into four categories based on the programme or method type, i.e. group activity; one-to-one intervention; service delivery; and whole community approach [ 26 ]. Likewise, McWhirter [ 6 ] used similar categories as Rook and Peplau [ 57 ], such as cognitive-behavioural therapy, social skills training, and the development of social support networks; Andersson [ 42 ] categorised interventions based on the typology of social network interventions by Biegel, et al. [ 58 ] (either clinical treatment, family caretaker enhancement, case management, neighbourhood helping, volunteering linking, mutual aid/self-help, and community empowerment); and Masi, et al. [ 31 ] categorised the intervention type (i.e. providing social access, social cognitive training, social skills training or social support) based on similar constructs used in the reviews by Rook [ 44 ], McWhirter [ 6 ], Cattan and White [ 26 ], Findlay [ 33 ], Cattan, et al. [ 10 ] and Perese and Wolf [ 43 ].
The objective of this scoping review was to map the large body of literature and describe the range of interventions aimed at reducing loneliness and/or social isolation among older adults. By focusing on existing reviews of loneliness/social isolation interventions, it aimed to synthesise the ways in which interventions have been conceptualised and their components described.
There are various interpretations of loneliness and social isolation in the literature. Social isolation can be defined as ‘a state in which an individual lacks a sense of belonging socially, lacks engagement with others, and has a minimal number of social contacts which are deficient in fulfilling quality relationships’ [ 59 , 60 , 61 , 62 ]. On the other hand, loneliness can be defined as a ‘subjective state based on a person’s emotional perception of the number and/or quality of social connections needed in comparison to what is being experienced at the time’ [ 63 , 64 ]. There is evidence to suggest that both concepts are distinct [ 9 , 65 , 66 , 67 ] as an individual can have a large number of social connections and still experience the subjective feeling of loneliness, or alternatively be objectively isolated but not experience loneliness [ 68 ]. For some individuals, social isolation is a risk factor for loneliness [ 18 ], and hence interventions designed to target social isolation may also alleviate loneliness. For other individuals, where the pathway to loneliness is not as a result of social isolation, such interventions are likely to have limited impact.
Although it is generally understood that loneliness and social isolation are distinct concepts, some review authors have stated that the terms are often used interchangeably [ 10 , 11 , 46 ] or are conflated into a single construct [ 68 ]. While there were fewer reviews identified that specifically focused on social isolation ( n = 4) compared to loneliness ( n = 11), there were no differences in terms of the countries where the research was conducted, the review type, or how the findings were reported. Distinguishing between the concepts of loneliness and social isolation is important when describing the goals of interventions and hence for specifying intervention characteristics that are relevant and effective in addressing each of these problems [ 4 ]. This clarity is necessary if service providers are to use the accumulated evidence to choose interventions which are appropriate and effective relative to their service context and goals, for matching individuals to appropriate interventions, and for choosing appropriate outcome measures for evaluation. Rook [ 44 ] made reference to the causes of loneliness and often linked these with the ‘goal’ of the interventions. Social inhibition or deficient social skills were linked to loneliness for some people and hence it was suggested that helping lonely individuals establish interpersonal ties might improve how they relate to others or provide new opportunities for them to have social contact. Alternatively, in circumstances where an individual was geographically isolated, an intervention which improves the social network may be more appropriate.
Review authors have used a range of terms to categorise the characteristics of interventions, such as mode of delivery, focus, nature, format, type and goal, but often with different meanings. Interventions were commonly categorised only by whether they were delivered to a group or to an individual. This is an important characteristic because group interventions are likely to be more appropriate for addressing social loneliness among individuals with insufficient social links [ 69 ] than one-to-one interventions. However, it is only one of many intervention characteristics which may be directly, or via interaction with other characteristics, associated with intervention effectiveness.
Terms and terminology are important when undertaking research in the field of loneliness [ 70 ]. Consistency in the definition of the terms and terminology increases accuracy, improves reporting, and aids in the replication of interventions across contexts [ 71 ].
In some reviews, the underlying theoretical basis or rationale for the categorisation of interventions was not provided. Lack of theoretical underpinnings or explanations as to why interventions were categorised in a certain manner could lead to difficulty when attempting to distinguish in what context a particular category of intervention is most appropriate or effective. This reduces the value of the accumulated evidence base, since we are less able to identify candidate characteristics that may contribute to the effectiveness of interventions. Hence, there is a need for the development of a comprehensive framework that encompasses, defines, and elucidates all the key constructs identified in this scoping review. Without this framework, research to identify the effective mechanisms of loneliness interventions will be undermined by lack of clarity around intervention characteristics.
Interventions to reduce loneliness and/or social isolation are complex as they have several interacting components (e.g. goals, personnel, activities, resources and delivery mode), which may interact with features of the local context in which they are applied (e.g. age profile of participants, health status, environment such as housing, and cultural characteristics) [ 72 ]. These characteristics need to be sufficiently described in order to allow use of the body of evidence to identify which characteristics (or combination of characteristics) are effective in a particular context and for which specific population.
The Template for Intervention Description and Replication (TIDieR) checklist and guide, published by Hoffmann, et al. [ 73 ] was developed as an extension of the Consolidated Standards of Reporting Trials (CONSORT) 2010 statement [ 74 ] and the Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT) 2013 statement [ 75 ]. The TIDieR checklist provides a standardised template for authors to describe key elements for reporting of non-pharmacological interventions. The development of the checklist is associated with a wider movement towards standardising research reporting, demonstrated by the growing EQUATOR (Enhancing the QUAlity and Transparency Of health Research) network [ 73 ]. The overarching purpose of the TIDieR checklist is to prompt authors to describe interventions sufficiently in order to allow their replication [ 73 ].
The benefits of using the TIDieR framework is that it can be used for better description and reporting of interventions. This may lead to a more standardised reporting of intervention characteristics particularly in the primary literature, and therefore make synthesis of the literature more consistent. Additionally, it allows for comparison of key characteristics of interventions and for synthesis of interventions that share similar characteristics. The checklist makes it easier for authors to structure the accounts of their interventions/services; for editors to assess these descriptions; and for readers to use the information [ 73 ]. However, although the TIDieR checklist may go some way towards assisting with the reporting of complex interventions, it might not be able to capture the full complexity of these interventions [ 73 ] such as the interaction between different intervention components or their combined effect, the difficulty or complexity of behaviours/skills required either by those delivering or receiving the intervention; and also variability of outcomes [ 76 ]. This is particularly relevant to loneliness/social isolation interventions which rely on more than one mechanism, therefore making it unclear which particular aspect of the intervention contributed most to its success or failure.
The heterogeneous nature of the interventions aimed at alleviating loneliness and/or social isolation among the older population; the settings where they are delivered e.g. care home or community; the group or one-to-one intervention delivery mode; and the population characteristics described in this scoping review, present a challenge for policy recommendations. The individuality of the experience of loneliness is also an important issue which has also been highlighted in the literature, as this may cause difficulty in the delivery of standardised interventions [ 3 ]. There is no one-size-fits-all approach to loneliness interventions [ 25 , 70 ], and it is recommended that the assessment of individual needs should be conducted during the early phases of intervention, with subsequent tailoring of programmes to meet the needs of individuals [ 77 ], specific groups or the degree and determinants of the individual’s loneliness. This includes sociodemographic factors i.e. age, poverty, being a carer; the social environment i.e. access to transport, driving status and place or resident; and physical or mental health [ 2 ]. It is also essential to consider the needs of less well-researched groups such as individuals with physical disabilities, or ethnic minority groups, caregivers, recent immigrants, individuals with hearing and visual impairments, those who have been isolated for a long time, and older men [ 78 ]. Several review authors have reported that the uptake of participants in the primary studies was heavily skewed towards the female population. This may be due to the reluctance of older men to engage with services and activities compared to women [ 41 ]. Moreover, women also have a longer life expectancy across nations than men, and are more likely to participate in research studies [ 37 ].
Systematic reviews are most appropriate for synthesising the findings of research that evaluates clinical treatments (simple interventions) [ 79 ] and consequently base their estimates of effectiveness on one (or more) of the intervention characteristics, e.g. group or individual delivery settings. Complex interventions have several interconnecting parts and it is recognised that the evaluation of this type of interventions should go beyond the question of effectiveness to identify ‘mechanisms’ of action which can be described as the resources offered through an intervention and the way that people respond to those resources (for example, how do resources intersect with participant’s beliefs, reasoning, attitude, ideas and opportunities?) [ 80 , 81 ]. Hence, a realist review may be a more suitable approach to research synthesis when attempting to understand the mechanisms by which complex social interventions work (or not) in particular contexts [ 62 ]. The realist review is a model of research synthesis that is designed to work with complex interventions or programmes and provides an explanatory analysis aimed at discerning what works, for whom, in what circumstances, in what respects and how [ 82 ]. This approach is more likely to result in findings that will help to identify and tailor interventions to fit the profile of the individual and their pathway to loneliness.
Strengths and limitations
A strength of this scoping review is that it is the first review of its type to examine the range of loneliness interventions for the older population and to describe how these interventions have been reported and categorised. It has highlighted the need for an appropriate framework to specify and describe the nature of loneliness and social isolation interventions, ideally a framework which defines interventions based on their mechanisms of action, and as a result helps to tailor or choose interventions which are matched to the individual’s needs and pathway to loneliness. Although this review utilised multiple databases and grey literature, searching other databases such as Cochrane Library and PsychInfo may have yielded other relevant published papers relevant to the aims of this scoping review. In addition, because the review was limited to papers published in the English language, it is possible that other potentially relevant reviews were omitted. A quality assessment of the reviews included was not undertaken, although this is not always necessary for scoping reviews (Arksey and O’Malley, 2006).
A broad range of interventions have been developed in an attempt to combat loneliness and social isolation among older people. Interventions were often categorised solely on the basis of whether they were delivered to a group or an individual. Moreover, the underlying theoretical basis or rationale for the categorisation was not provided in a third of reviews. Lack of theoretical reasoning could lead to difficulty when attempting to distinguish in what context a particular category of intervention is most appropriate or effective, and also by which mechanisms these interventions work to reduce loneliness and social isolation. Comprehensive description of these interventions, using appropriate and consistent terminology should be encouraged as this will increase the value of the accumulated evidence base for service providers and policy-makers. Not all older people experience loneliness in the same way or to the same degree and hence there is a pressing need to tailor interventions to meet individual’s requirements. It is recommended that future research differentiates the diverse group of older adults and takes an approach aimed at discerning what interventions work for specific subsets of this population; the contexts where these interventions work; and the mechanisms by which they operate in that given context. This information will be highly valuable in the planning and implementation of programmes to reduce loneliness and social isolation, and improving the wellbeing of older people.
Australian Coalition to End Loneliness
Canadian Counselling and Psychotherapy Association
Cumulative Index to nursing and allied health literature
Consolidated standards of reporting trials
Enhancing the QUAlity and Transparency Of health Research
Information communication technology
Preferred reporting items for systematic reviews and meta-analysis
Randomised controlled trial
Standard protocol items: recommendations for interventional trials
Template for intervention description and replication
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This review is part of a PhD project of the first author, OAF, supervised by NMC and MD.
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Olujoke A. Fakoya, Noleen K. McCorry & Michael Donnelly
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OAF, NMC and MD conceptualised the review. OAF took the lead in writing the review however NMC was also heavily involved in the production of the review. OAF and NMC designed the systematic search strategies. OAF conducted the searches which was overseen by NMC and MD. OAF, NMC and MD assessed citations for inclusion. OAF carried out the data extraction and analysed the data. OAF drafted the initial manuscript. OAF, NMC and MD contributed to writing the manuscript. All authors read and approved the final manuscript.
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Additional file 1: table s1..
Scoping review search strategies.
Additional file 2: Table S2.
Characteristics of reviews included in the scoping review.
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Fakoya, O.A., McCorry, N.K. & Donnelly, M. Loneliness and social isolation interventions for older adults: a scoping review of reviews. BMC Public Health 20 , 129 (2020). https://doi.org/10.1186/s12889-020-8251-6
Received : 30 January 2019
Accepted : 21 January 2020
Published : 14 February 2020
DOI : https://doi.org/10.1186/s12889-020-8251-6
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Ageing and health
- All countries face major challenges to ensure that their health and social systems are ready to make the most of this demographic shift.
- In 2050, 80% of older people will be living in low- and middle-income countries.
- The pace of population ageing is much faster than in the past.
- In 2020, the number of people aged 60 years and older outnumbered children younger than 5 years.
- Between 2015 and 2050, the proportion of the world's population over 60 years will nearly double from 12% to 22%.
People worldwide are living longer. Today most people can expect to live into their sixties and beyond. Every country in the world is experiencing growth in both the size and the proportion of older persons in the population.
By 2030, 1 in 6 people in the world will be aged 60 years or over. At this time the share of the population aged 60 years and over will increase from 1 billion in 2020 to 1.4 billion. By 2050, the world’s population of people aged 60 years and older will double (2.1 billion). The number of persons aged 80 years or older is expected to triple between 2020 and 2050 to reach 426 million.
While this shift in distribution of a country's population towards older ages – known as population ageing – started in high-income countries (for example in Japan 30% of the population is already over 60 years old), it is now low- and middle-income countries that are experiencing the greatest change. By 2050, two-thirds of the world’s population over 60 years will live in low- and middle-income countries.
At the biological level, ageing results from the impact of the accumulation of a wide variety of molecular and cellular damage over time. This leads to a gradual decrease in physical and mental capacity, a growing risk of disease and ultimately death. These changes are neither linear nor consistent, and they are only loosely associated with a person’s age in years. The diversity seen in older age is not random. Beyond biological changes, ageing is often associated with other life transitions such as retirement, relocation to more appropriate housing and the death of friends and partners.
Common health conditions associated with ageing
Common conditions in older age include hearing loss, cataracts and refractive errors, back and neck pain and osteoarthritis, chronic obstructive pulmonary disease, diabetes, depression and dementia. As people age, they are more likely to experience several conditions at the same time.
Older age is also characterized by the emergence of several complex health states commonly called geriatric syndromes. They are often the consequence of multiple underlying factors and include frailty, urinary incontinence, falls, delirium and pressure ulcers.
Factors influencing healthy ageing
A longer life brings with it opportunities, not only for older people and their families, but also for societies as a whole. Additional years provide the chance to pursue new activities such as further education, a new career or a long-neglected passion. Older people also contribute in many ways to their families and communities. Yet the extent of these opportunities and contributions depends heavily on one factor: health.
Evidence suggests that the proportion of life in good health has remained broadly constant, implying that the additional years are in poor health. If people can experience these extra years of life in good health and if they live in a supportive environment, their ability to do the things they value will be little different from that of a younger person. If these added years are dominated by declines in physical and mental capacity, the implications for older people and for society are more negative.
Although some of the variations in older people’s health are genetic, most is due to people’s physical and social environments – including their homes, neighbourhoods, and communities, as well as their personal characteristics – such as their sex, ethnicity, or socioeconomic status. The environments that people live in as children – or even as developing fetuses – combined with their personal characteristics, have long-term effects on how they age.
Physical and social environments can affect health directly or through barriers or incentives that affect opportunities, decisions and health behaviour. Maintaining healthy behaviours throughout life, particularly eating a balanced diet, engaging in regular physical activity and refraining from tobacco use, all contribute to reducing the risk of non-communicable diseases, improving physical and mental capacity and delaying care dependency.
Supportive physical and social environments also enable people to do what is important to them, despite losses in capacity. The availability of safe and accessible public buildings and transport, and places that are easy to walk around, are examples of supportive environments. In developing a public-health response to ageing, it is important not just to consider individual and environmental approaches that ameliorate the losses associated with older age, but also those that may reinforce recovery, adaptation and psychosocial growth.
Challenges in responding to population ageing
There is no typical older person. Some 80-year-olds have physical and mental capacities similar to many 30-year-olds. Other people experience significant declines in capacities at much younger ages. A comprehensive public health response must address this wide range of older people’s experiences and needs.
The diversity seen in older age is not random. A large part arises from people’s physical and social environments and the impact of these environments on their opportunities and health behaviour. The relationship we have with our environments is skewed by personal characteristics such as the family we were born into, our sex and our ethnicity, leading to inequalities in health.
Older people are often assumed to be frail or dependent and a burden to society. Public health professionals, and society as a whole, need to address these and other ageist attitudes, which can lead to discrimination, affect the way policies are developed and the opportunities older people have to experience healthy aging.
Globalization, technological developments (e.g., in transport and communication), urbanization, migration and changing gender norms are influencing the lives of older people in direct and indirect ways. A public health response must take stock of these current and projected trends and frame policies accordingly.
The United Nations (UN) General Assembly declared 2021–2030 the UN Decade of Healthy Ageing and asked WHO to lead the implementation. The UN Decade of Healthy Ageing is a global collaboration bringing together governments, civil society, international agencies, professionals, academia, the media and the private sector for 10 years of concerted, catalytic and collaborative action to foster longer and healthier lives.
The Decade builds on the WHO Global Strategy and Action Plan and the United Nations Madrid International Plan of Action on Ageing and supports the realization of the United Nations Agenda 2030 on Sustainable Development and the Sustainable Development Goals.
The UN Decade of Healthy Ageing (2021–2030) seeks to reduce health inequities and improve the lives of older people, their families and communities through collective action in four areas: changing how we think, feel and act towards age and ageism; developing communities in ways that foster the abilities of older people; delivering person-centred integrated care and primary health services responsive to older people; and providing older people who need it with access to quality long-term care.
- UN Decade of Healthy Ageing (2021-2030)
- Health topic: ageing
- WHO Ageing and Health Unit
- WHO Demographic Change and Healthy Ageing Unit
- Misconceptions on ageing and health
- Q&A - Ageism
- Age-friendly World
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By 2050, the world's population of people aged 60 years and older will double (2.1 billion). The number of persons aged 80 years or older is