it is even more complicated than that. Two other American gerontologists, Christopher Callahan and Colleen McHorney, took part in an academic retreat in Indianapolis to discuss successful ageing, and found an even wider difference in how ‘experts’ define success.15 What emerged was that, for some scientists, health was the main – if not the only – definition of successful ageing. But for others it was something quite different and quite complex.
‘To a humanist, health may be less relevant than realizing one’s ambitions or helping a fellow human being to achieve his or her ambitions – neither necessarily requires health or longevity,’ they wrote. ‘If someone fulfilled the dreams of a nation, yet died of lung disease at aged 50 years, is that successful ageing?’
The narrow definitions of successful ageing may be inadequate, they said, but ‘we may not have the tools to embrace the broader, more complex perspective’. The problem is that scientists, with their biomechanical, biomedical models, are not very good at complexity, and any discussion with older people – humanist or not – suggests that the scientific model is simply inadequate.
Callahan and McHorney say they want a new science of complexity, which they believe is just beginning to influence research on successful ageing. But their emphasis on humility is welcome. Because this is not only about complexity – though that certainly is a part of it. It is also about talking to older people and finding out from them what they think successful ageing is. Because, as sure as eggs is eggs, it is very different from the scientific, biomedical model.
One key element that Ann Bowling and Paul Dieppe cite in their article, based on a huge literature review, is that ‘active engagement with life’ is a key component in successful ageing.16 ‘Active engagement’ is pretty difficult to define too, but there are some key elements to it. Top of the list are issues to do with autonomy and perceived autonomy. For many older people, the last thing they want to do, if they can possibly avoid it, is give up their home. It isn’t that they necessarily love their own home, though many do; it is losing their autonomy that people so despair of, moving into a care home and not being allowed to take quite basic decisions for themselves.
If you have dementia, then there are relatively few alternatives if your family is unable to give you the care you need, particularly as the dementia advances. But with most kinds of physical frailty, people are determined to keep their autonomy, and will do a great deal to make sure they do so even if they do, sadly, have to go into residential or nursing care. That is why the best of the care and nursing homes do all they can to promote a sense of autonomy and give people a range of choices.
Along with the autonomy question – making decisions about when to go to bed and when to get up, when to eat, whether to go out or not, what programmes to watch or listen to – there are also questions about social engagement. The academic literature includes discussions about social, community and leisure activities, about social networks, support, participation and activity. But if you ask many older people what matters, as Stephen Moss’s interviews made clear, it is love: love of a partner, even one maybe now dead, of children and grandchildren, siblings, friends and more distant family, an interest in the world. Often success means dealing with the world after the death of someone you love, as Katherine Whitehorn describes in her wonderful autobiography:
Being a widow is not helped by also being old. It’s a relief, in a way, that my sagging curves no longer have an audience, but being on my own makes the prospect of being really ill and frail alarming. When I broke my wrist, there was Gavin to drive me to hospital and fasten my bra … Losing your husband has two separate aspects: there’s missing the actual man, your lover; his quirks, his kindness, his thinking. But marriage is also the water in which you swim, the land you live in: the habits, the assumptions you share about the future, about what’s funny or deplorable, about the way the house is run, or should be; what Anthony Burgess called a whole civilization, a culture, ‘a shared language of grunt and touch’. You don’t ‘get over’ the man, though you do after a year or two get over the death; but you have to learn to live in another country, in which you’re an unwilling refugee.17
Bowling and Dieppe cite the theoretical definitions of successful ageing as life expectancy, life satisfaction and well-being (including happiness and contentment), mental and psychological health and cognitive function, personal growth, learning new things, physical health and functioning, independent functioning, psychological characteristics and resources, including perceived autonomy, control, independence, adaptability, coping, self-esteem, positive outlook, goals, sense of self, social community, leisure activities, integration and participation, social networks, support, participation and activity. But they point out that there are a whole range of extra lay definitions, including accomplishments, enjoyment of diet, financial security, neighbourhood, physical appearance, productivity and contribution to life, sense of humour, sense of purpose and spirituality – none of which are mentioned in the ‘professional’ literature at all. When you look at the categories that lay people added, they are the things that make anyone tick at any time of life: food and drink, sense of humour, a sense of purpose and, of course – much misunderstood by professionals – a sense of spirituality.
Even without those additions to the literature, much of the research shows that many of the areas of successful ageing are interrelated. Having a large number of social interactions and activities and lots of relationships is associated strongly with greater satisfaction with life and with generally better health and functioning better. Despite considerable class differences in survival and different attitudes according to the numbers of stressful events in life – such as loss of a partner or even a child – there are ways to make it easier for people to age well on their own terms, and according to their own values. Personal values, individual experience and a nonprofessional perspective are all key to defining what successful old age is for individuals. But a large part of that is about the nature of life, relationships, love and the ability to act.
So you have to give three cheers to Ann Bowling and Paul Dieppe’s conclusion: ‘Health professionals need to respect the values and attitudes of each elderly person who asks for help, rather than imposing our medical model on to their lives.’
The tyranny of a definition
Dr Muriel Gillick, a Professor of Ambulatory Care at Harvard Medical School, wrote one of the best reflections I have ever read on the subject of centenarians:18
Centenarians have something important to teach. Often they have wisdom arising from their accumulated experiences which they enjoy sharing, and which they are able to share because they aren’t burdened by multiple maladies, each with its own demanding regimen of pills, monitoring tests, and physician visits. Their world is the antithesis of the elderly community in Florida, which has developed a culture that revolves around their health. The average elderly Floridian sees multiple specialists, often making more than one physician visit each week. Gathered around the table while eating an ‘early bird special,’ they exchange doctor stories. When one member of the group reports that he has seen a new specialist – perhaps a rheumatologist has joined the ranks of his cardiologist, urologist, and general internist – the others eagerly add the new doctor to their own list of ‘providers.’ In parts of Florida, the state with the largest elderly contingent in the United States, Medicare spends more than twice as much per capita for health care as it does anywhere else. What its citizens get in exchange for this largesse is more hospital days, more tests, more ICU admissions, and more
