Applying Concepts of Successful Aging in Measuring and Promoting Whole Person Health

Abstract

Countries around the world have large aging adult populations. There is wide public health concern about the health and well-being of aging adults, and a movement to transform healthcare systems to become age-friendly. The concept of “successful aging” recognizes the importance of aging and expands the goal beyond the absence of disease to functioning and well-being. In this perspective, we discuss aging as a part of life that should be considered in whole person health and cite work with the US veteran population as an example of how successful aging and age-friendly practices can be incorporated into whole person health for adult populations. We also review studies of successful aging that may offer important ways to define and measure whole person health and discuss how it might be instructive to assess successful aging with multiple indicators across the adult life span, particularly in underserved populations at-risk of premature aging and poor health. Finally, we conclude with a discussion of the “life course perspective” that may serve as a useful model for the interplay between successful aging and whole person health.

Aging is inevitable, constant, and important to the study of health. In the 19th and early 20th centuries, Western medicine had a reductionist concept of health, defined as the absence of physical disease or illness.¹ Through that lens, aging and declining health were synonymous. However, beginning in the latter half of the 20th century, the practice and research of health began to become more wholistic as the World Health Organization redefined health as a “state of complete physical, mental, and social well-being”.² A few decades later in the 1980s, Rowe and Kahn³ described the concept of “successful aging” to counteract the narrow gerontological emphasis on disease. Instead, aging was proposed to be multidimensional; and successful aging to encompass physical and cognitive functioning, and active engagement in life as well as avoidance of disease and disability.⁴ The 21st century has led to even greater recognition of the importance of functioning, quality of life, and social factors. For example, the US Surgeon General has called the levels of loneliness experienced by adults, especially aging adults, an epidemic and public health crisis.⁵

There is good reason to study and measure successful aging. The share of the world’s population 60 years of age and older will increase from 1 billion in 2020 to 2 billion by 2030.⁶ Aging is a salient issue for population health and greatly impacting healthcare systems in many countries. In the United States, there are large growing cohorts of aging adults, and this is even more pronounced in the veteran population. According to 2020 US Census data of the general US population, 17% are 65 years of age or older⁷; and in the US veteran population, 49% are 65 years of age or older.⁸

In this perspectives article, we argue that the concept of successful aging should be incorporated into the measurement of “whole person health.” We draw upon work done in the US veteran population as an example, but the ideas apply to broader adult populations. We also recognize many healthcare systems are implementing evidence-based “age-friendly” healthcare practices. These are practices that are person-centered and seek to respond to aging adults’ needs and preferences, including challenges that come with older age such as falls, cognitive impairment, and polypharmacy. The appreciation of whole person health would not be complete without consideration of how to help people achieve successful aging. In discussing “whole person health,” we follow the definition provided by the National Center for Complementary and Integrative Health, which states whole person health is “considering multiple factors that promote health or disease. It means helping and empowering individuals, families, communities, and populations to improve their health in multiple interconnected biological, behavioral, social, and environmental areas.”⁹ To further clarify these terms and their relation with each other, we consider whole person health to be a defining philosophy about health; successful aging to be one desired outcome of whole person health, and age-friendly practices as a modality for practitioners to help clients achieve that outcome.

Although there is no consensus definition of successful aging, most definitions contain elements of physical functioning; community engagement; well-being and life satisfaction; personal resources (eg, resilience, spirituality); and extrinsic factors like finances.¹⁰ Strong definitions of successful aging seem to include both objective and subjective indicators. One comprehensive review of 28 studies that used different measures of successful aging among mostly community samples of older adults reported 35.8% were successfully aging, although there was wide variability in estimates.⁴ Part of the reason for the diversity of definitions and experiences of successful aging may be because the concept is not only multidimensional, but varies based on an individual’s background, culture, and preferences.^11,12 In addition to the biology of aging, there is also the personal experience of aging and people experience age differently, which may be influenced by societal or community perceptions. Thus, we believe it is important to incorporate elements of successful aging into understanding and measuring whole person health, which aims to be individualized and based on the person’s background, needs, and aspirations.

Let us consider work with the US veteran population to discuss how successful aging might be incorporated into whole person health. The US Department of Veterans Affairs (VA) operates the largest, integrated healthcare system in the country and has undergone a major transformation over the past decade to a Whole Health approach to care.¹³ The VA’s Whole Health approach begins with the veteran and their personal life and health goals, which is then used to form a personalized care plan. A major component of this approach is the national rollout of a Whole Health Coaching program which consists of coaches helping veterans explore their values, develop personal health plans, and make progress in achieving their health goals. These coaches draw upon evidence-based practices, like motivational interviewing, appreciative inquiry, and positive psychology, to support health behavior change.¹⁴ There are opportunities for whole health coaches to consider the frame of successful aging as a process and outcome toward behavior change as well.

Whole health coaches could ask veterans, how they see aging as part of their health, how they might define successful aging, and what parts of successful aging they would like to achieve, for instance. Studies of VA’s Whole Health Coaching program and other VA programs that serve large aging veteran populations have largely focused on traditional healthcare outcomes.^14,15 But as the VA continues to innovate and implement age-friendly healthcare practices,¹⁶ the Whole Health Coaching program could incorporate successful aging as an important outcome in of itself and set an example for other healthcare systems. Two examples of age-friendly initiatives in the VA are the Patient Priorities Care approach,¹⁷ which helps veterans identify and align their health priorities to their care; and an initiative between the Housing and Urban Development-VA Supportive Housing (HUD-VASH) and VA’s Geriatric Extended Care (GEC) programs to help veterans “age in place” through enhanced services.¹⁸ Initiatives such as these could be incorporated into resources for whole health coaches and also be referral sources for the VA’s Whole Health program.

A handful of studies have assessed successful aging among US veterans using multiple indicators/measures¹⁹ or combined multiple indicators to create a composite measure representing 1 latent factor.^20,21 One national study using a composite measure among veterans 60 years of age or older reported that 82% rated themselves as aging successfully.²⁰ But a large qualitative study found that when older veterans were asked, they collectively described more than 50 categories that were important to successful aging, including commonly researched categories like functioning and social engagement, but also less researched categories like personality, moral compass, and luck.²² Similar findings have been made in general older adult populations where aging adults have a more expanded definition of successful aging than what research has focused on.²³ Thus, it may be sensible to move beyond one normative model, which is exclusionary, and adopt greater flexibility about what constitutes successful aging.²⁴

What it means to age successfully may be age-dependent²⁵ and may be experienced differently by underserved populations. For example, there is evidence of early onset of aging-related conditions among young veterans with posttraumatic stress disorder,²⁶ and similarly, studies have found homeless veterans and other adults develop geriatric syndromes early.²⁷ These findings suggest the concept and goal of successful aging should not only be applied to older adults, but it may be instructive to assess successful aging across the adult life span and across various populations, as part of whole person health.

Much of the work with veterans may be applicable to the general adult population, but there may be limitations as veterans have unique exposures that impact their health.²⁸ One study using data from the Women’s Health Initiative found that while women veterans were more likely to die earlier and reported lower physical functioning, life satisfaction, purpose in life, quality of life, and social support than women nonveterans; women veterans did not differ from nonveterans on other metrics of successful aging, including resilience, mastery, self-control, well-being, and enjoyment of life.¹⁹ Another study using large survey data found that men and women post-9/11 veterans reported poor health status, but reported greater engagement in positive health behaviors (eg, healthy eating, exercise) and greater social well-being (eg, intimate relationships, supportive friends) than nonveterans.²⁹ These findings illustrate the ways different populations, including veterans and nonveterans, may differ on dimensions of well-being and the value of considering different elements of successful aging, and by extension, whole person health.

A useful conceptual model has been proposed by Rowe and Kahn³⁰ in the 21st century called the “life course perspective,” in which changing roles over time and opportunities to capitalize on age are considered in successful aging. This is relevant to measuring whole person health across different populations because the life experiences and aging process of individuals need to be considered if the focus is on seeing the whole person. This model may help incorporate successful aging into whole person health that appreciates the diverse ways that people can be healthy and encourages measuring multiple objective/subjective indicators over time. In conclusion, this Perspectives article points to the importance of successful aging in achieving whole person health and poses a number of considerations to help design healthcare services to be age-friendly and holistic.