Adult Development and Associated Health Risks

Abstract

Much has been learned about adult development in recent decades. Adults go through stages of development (emerging adulthood, young adulthood, middle adulthood, post-retirement, and very old age) with certain challenges at each stage. Viewing patients through a developmental lens is part of providing patient-centered care. Knowing the prominent issues, stressors, and risks at each stage of development is important in understanding patients. This knowledge can help customize medical advice to patients regarding obesity, disability, sleep, substance use, relationships, and age-related declines. This paper summarizes an updated view of adult development and discusses its relevance to health risks and patient-centered care practices at different stages.

Despite significant gains in understanding adult development over the past decades, discussion of applying this knowledge to health care practice is sparse. Human beings display obvious physical, cognitive, and emotional changes throughout their youth, but transformations during adulthood are not always as salient. Development continues and understanding typical issues adults confront at different stages can help clinicians make connections between patients’ health status and the demands they face. This knowledge can assist providers in encouraging patients to be proactive in addressing health challenges throughout adulthood.

Aging is not as predetermined as previously thought¹ with the outcome of the aging process varying widely based on interactions between biology, culture, and behavior.² Heterogeneity across people increases over time,^1,3,4 resulting in significant diversity among adults. It is particularly noteworthy that lifestyle factors and behavior account for more variance (70%) in health related and psychological outcomes than do genetics (30%).¹ While there is a range of outcomes at any stage of adult development, there are significant opportunities for augmenting health at all stages.

This topic synopsis aims to summarize an updated view of adult development and discuss its relevance to health risks and patient-centered care practices at different stages. Articles were found by reading a special issue of American Psychologist dedicated to adult development, followed by hand searches of references and Google Scholar searches to find articles addressing health issues with adults at different ages.

Stages of Adult Development

While there are many ways of conceptualizing stages of adult development, one comprehensive approach using 5 broad stages is presented below.⁵ This approach reflects the current thinking of several experts.^5–7 The cutoff in years for these stages is somewhat arbitrary as adult social roles relate to stage of development more than age.⁷ The age estimates in the later years are particularly fluid as subsets called “the young-old” (ages 60–74), “the old” (ages 75–84) and “the oldest-old” (≥85) have been discussed for years due to the heterogeneity of these ages.⁸

Although age in years may not be determinative of stage, it can be helpful in developing hypotheses about what patients may be coping with as they move through adulthood. Adults generally progress through life as follows:

• Emerging adulthood (18–29 years) is full of non-committal attitudes and exploration of different paths with frequent moves and changes in relationships and employment.^6,9 Events marking the transition into adulthood (eg, finishing education, obtaining stable work, marriage, and parenthood) now come at later ages than they did historically.

• Young and middle adulthood (30–45 years) is when marital, parenting, and career commitments take place. Young adults may have found a life partner, decided whether to have children, and become established at work.³ These years are described as intensely demanding and rewarding, and researchers have proposed a new term “career-and-care-crunch” to draw attention to the peak demands during this period.³

• Middle to late adulthood (40–65 years) is described as a pivotal time of balancing multiple roles related to work, family, and community.⁷ The stressors of caring for aging parents, parenting adolescents, and meeting work demands are most salient. This stage is affected by previous experiences and often shapes what is to come in later life. It links earlier and later periods of life.⁷

• In post-retirement (66–89 years) one is freed from work and family related tasks and can focus on personal goals related to leisure and social relationships.⁵ Relationship satisfaction generally increases with age while networks tend to shrink.¹⁰ Those in the younger category (60–74 years) often experience positive changes such as emotional stability and well-being.¹ However, retirement can have negative consequences for cognition, health, and well-being.⁶ There is great heterogeneity in this stage.

• Very old age (≥90 years) is about trying to maintain physical and cognitive functioning and independence.⁵ In a qualitative study of the shift from old age to very old age, diminishing capacities and the awareness of the irreversibility of the aging process marked the transition into this stage.¹¹ Loss of contemporaries, an inversion of family dynamics, and living in the present moment were pronounced in this stage.¹¹

Risks change over the course of adult development. Knowing the relevant risks can help clinicians anticipate problems and guide patients.

Risk of Obesity

Obesogenic environments are of particular concern as metabolic disease risk is increasing across U.S. birth cohorts,¹² particularly among emerging adults. Obesity prevalence increased from 11% to 22% in a sample of 19–26-year-olds followed over a five-year period.¹³ In addition, 26% of men and 28% of women were found to be obese by age 37, with those of Hispanic ethnicity and black women having higher rates of obesity.¹⁴

Increasing activity at a young age is important, as physical inactivity in adolescence strongly predicts obesity in young adulthood. Furthermore, obesity in emerging and young adulthood both contributes to continued inactivity and can be the result of a history of inactivity.¹⁵ Attention to adiposity in early adulthood, as well as weight gain throughout adulthood, is recommended due to research showing that men who are moderately overweight in early adulthood or who have adult weight gain are associated with high risk of major chronic diseases.¹⁶ Cancers were associated more strongly with body mass index (BMI) in early adulthood, while type 2 diabetes was associated more strongly with adult weight gain.

Risk of Disability

Disability has often been defined in studies as limitations in activities of daily living (ADL) and activities of instrumental daily living (IADL). Researchers used ADL, IADL and other measures of disability (mobility, large muscle, gross motor, and fine motor limitations) to look at U.S. disability trends. They found that the rise in prevalence of chronic disease (diabetes mellitus, psychiatric conditions, and arthritis) and increased obesity rates have been associated with an increase in disability in adults ages 53–88.¹⁷ Using ADL and IADL, data indicate significant increases in disability rates in those aged 55–65 years from 2004 to 2015.¹⁸ Estimated prevalence rates are 9.2% for men and 10.6% for women.¹⁸ Harnessing patients’ motivation to prevent or delay disability may help providers collaborate with patients in middle adulthood to bring about more years of health. Health at this stage is predictive of physical and mental health in old age as midlife social activities, health, and lifestyle predict later outcomes.⁷

Risks Related to Sleep

Both short and long sleep durations are associated with increased risks and all-cause mortality. Seven hours of sleep is associated with the least amount of risk.¹⁹ Sleeping less than seven hours per night is specifically associated with obesity, diabetes, high blood pressure, coronary heart disease (CHD), stroke, and mental distress.²⁰ Sleeping more than 10 hours is associated with CHD, stroke, and diabetes.²¹ Based on 2014 data, 62%–63% of adults aged 25–64 years get 7 hours or more of sleep per night,¹⁹ leaving approximately 38% sleeping less than 7 hours during the demanding years of combining work and family.³ Those most likely to get ≥7 hours of sleep are outside this time of balancing multiple roles, particularly 74% percent of those 65 and over and almost 68% of young adults.²⁰

Lack of sleep seems to occur at multiple ages. However, the associations of unhealthy habits differ based on age. In those aged 20–30 years, poor habits of going to bed late are associated with poor eating habits.²² In those age 50 and older, insomnia is associated with binge drinking frequency.²³ Given that 36% of those aged 50 and over report binge drinking in the previous three months,²³ an alarming number of these adults are likely to have sleep problems associated with increased risk for health issues.

Risks Related to Substance Use

Emerging adults in the 18–25 age range have the highest rates of illicit drug use and binge drinking, with approximately 39% using substances. By 26–29 years of age, this decreases to 34%.²⁴ The 25–34 age group is experiencing the highest rate of overdose from opiates, but the number of overdose deaths among those ≥55 is growing.²⁵ Of note is that the proportion of older adults (≥65 years) being admitted to treatment facilities for substance use disorders increased from 3.4% to 7.0% between 2000 and 2012 — the majority of these involving alcohol.²⁶ Alcohol-related deaths are 4 times higher among adults aged 45–74 than those aged 25–34.²⁷ Primary care providers who are sensitive and open to discussing substance use issues can play a crucial role in the health of these patients.²⁸

Risks Related to Family/Relationships

Effectively navigating the inherent changes in family relationships over time can facilitate overall health and well-being. In Western and non-Western populations, marital satisfaction has been observed to decrease with the onset of parenting and with additional children being added to the family.^29,30 This appears to be especially true for women and for parents who are highly educated.³⁰ Risk of divorce decreases with age, with 23 out of 1000 people divorcing between ages 25–34 in 2017 and 5 out of 1000 divorcing at age 65 and above.³¹ While divorce rates of older adults are lower than those at younger ages, when comparisons are made over time, the divorce rates from 1990 to 2017 increased for those 45 years and older, more than doubling for those over 55.³¹ Thus, clinicians and caregivers will encounter more older adults who are going through divorce than in previous times.

Clinicians are also encouraged to attend to widowhood as mortality after widowhood is significantly elevated for husbands and wives at all ages. All-cause mortality increases 18% for husbands and 16% for wives losing a spouse.³² It is advised that health care providers be aware of relationship risks over time and the need for social support for overall well-being.

Risks of Decline

Adult aging often results in loss of muscle and bone mass, putting adults 65 and older at increasing risk for problems with mobility and falls. Over 30% of those over 65 fall every year.³³ Resistance training and exercises have been shown to improve muscle and bone mass in adults middle age and older.³⁴ Age-related losses are not necessarily permanent as studies have shown them to be reversible.¹ Although cognitive declines typically occur with aging, marked cognitive declines usually occur later in one’s 80s¹ and can be mitigated by stimulating and complex activities.^1,2 Per Staudinger,² the idea is to “challenge it or lose it” rather than “use it or lose it” as there is evidence that learning new skills and encountering novel stimuli and challenges are protective of the brain as it ages.

Retirement can be associated with declines in physical and cognitive functioning,³⁵ and models using population health data suggest that postponing retirement is protective against cognitive decline.^35,36 Factors affecting health after retirement include being forced to retire,³⁷ physical activity, working part-time, social support and marriage,³⁵ educational attainment,³⁶ and reasons for retirement being unrelated to health.³⁸

Aging and Misconceptions

In addition to lack of knowledge, there is misinformation about adult development in our culture.⁷ For example, most mid-life adults are not at risk for a mid-life crisis, with only 35% of those above age 50 reporting this.³⁹ Most middle-aged adults are satisfied with their life throughout their mid-life years, with increases in life satisfaction from 40 to 60 years of age.⁴⁰ A second example of a misconception is that empty-nest will be a time of emotional distress and depression.⁷ Although multiple variables impact feelings during the transition to empty nest, data show that most people do not report empty nest syndrome⁴¹ but rather experience increased well-being after children leave the home.⁴²

Age stereotypes are prevalent in the United States despite evidence showing that positive views of aging are warranted.^1,43,44 Older adults are not a burden to society but make important contributions. For example, they are often involved in caregiving or volunteering.⁴⁵ Furthermore, 2020 data show that 39% of those aged 55–74 continue to work, with close to 9% of those 75 and over remaining in the labor force.⁴⁶ Negative stereotypes have a deleterious effect on health outcomes,¹ while positive self-perceptions of aging are associated with less obesity⁴⁷ and less cognitive decline over time.⁴⁸

Recommendations

Health care providers can leverage information about development to ask the right questions and motivate patients to establish healthy habits for significant future benefits. During the instability of emerging adulthood, assessing substance use is paramount. In the demanding time of early adulthood, the risk of increased obesity can prompt discussion of the need for self-care. Furthermore, relationship care is vital for maintaining intimate relationships over time. For middle to late adulthood, discussing risks of disability, sleep problems, alcohol use, and caring for others is critical for patient care. Knowing that health in mid-life sets the stage for later outcomes may help patients foster lifestyle changes. Facilitating plans for a stimulating retirement with physical and mental challenges may prevent associated declines. For post-retirement, there is increased all-cause mortality for those losing a spouse. For very old age, loss and isolation are prevalent. Social support is crucial for the patient’s well-being; thus, asking about and boosting social support are recommended.

Consider the following examples. In a 35-year-old female with newly diagnosed diabetes mellitus, it would be important to know about the demands she faces with parenting and work, as well as the support she has to help her develop a plan of self-care. Similarly, a clinician caring for a 50-year-old male patient with hypertension would want to be aware of the patient’s stress at work, responsibility with aging parents, and anxieties parenting teenagers. Patients in their 50s and 60s who divorce after decades of marriage may have a hard time finding others who can relate. Most divorces occur earlier, so their risk of feeling alone is increased.

Summary

Primary care providers have a unique opportunity to influence the healthy development of patients over the course of adulthood. It is essential to keep up with knowledge related to adult development to facilitate supportive and productive conversations about overall health. Clinicians can leverage their understanding of typical issues, stressors, and risks at each stage of development to optimize patient health using anticipatory guidance and addressing common concerns.

Patient-Friendly Recap.

• Adult development stages include emerging adulthood, young adulthood, middle adulthood, post-retirement, and very old age.

• Knowledge of upcoming developmental tasks can lead to anticipatory guidance to reduce risks and optimize health at different stages.

• Lack of knowledge and misinformation about adult development in our culture can and should be remedied to provide the best health care possible.