Older Adults’ Perspectives on Successful Aging: Qualitative Interviews

Abstract

OBJECTIVES

Lay perceptions of “successful aging” are important for understanding this multifaceted construct and developing ways to assist older adults to age well. The purpose of this qualitative study was to obtain older adults’ individual perspectives on what constitutes successful aging, along with their views regarding activities and interventions to enhance its likelihood.

METHODS

Qualitative interviews were conducted with 22 community-dwelling adults over age 60. Participants were recruited from retirement communities, a low-income senior housing complex, and a continued learning center in San Diego County. Interview transcripts were analyzed using a “Coding Consensus, Co-occurrence, and Comparison” grounded theory framework.

RESULTS

The mean age of participants was 80 years (range: 64 to 96), with 59% being women. Two primary themes were identified as key to successful aging - i.e., self-acceptance/self-contentment (with sub-themes of realistic self-appraisal, a review of one’s life, and focusing on the present) and engagement with life/self-growth (with sub-themes of novel pursuits, giving to others, social interactions, and positive attitude). A balance between these two constructs appeared critical. A need for interventions that address support systems and personally tailored information to make informed decisions and enhance coping strategies were also emphasized.

CONCLUSIONS

Older adults viewed successful aging as a balance between self-acceptance and self-contentedness on one hand and engagement with life and self-growth in later life on the other. This perspective supports the concept of wisdom as a major contributor to successful aging. Interventions to enhance successful aging may include those that promote productive and social engagement along with effective coping strategies.

INTRODUCTION

In the past several decades, increasing effort has been placed on understanding and defining what constitutes healthy or successful aging, broadening the focus of research on aging beyond physical disease and disability (1–7). However, there remains little consensus about the definition and constituents of successful aging. A literature review of quantitative studies of successful aging found that the single most commonly employed criterion for operationalizing successful aging involved absence of physical disease/disability with only about a third of the older adults meeting this criterion (8). However, several reports assessing subjective appraisals of successful aging indicate that a majority of older people believe they are aging well (3;9–12). Understanding what constitutes successful aging for older adults themselves, may help guide future definitions of successful aging and subsequently, the development of models of care, interventions, and policy reform.

In a survey questionnaire study, Montross and colleagues (12) found that over three quarters of a community sample of older adults rated themselves as successfully aging, although only 15% reported an absence of physical illness and disability. Bowling and Iliffe (13) noted that a definition of successful aging based on lay perspectives was more predictive of quality of life than criteria based on physical functioning. In an earlier study using focus groups of seniors, we found that the main perceived contributors to successful aging included attitude/adaptation, security/stability, health/wellness, and engagement/stimulation (14). These domains appeared to be interrelated such that engagement needed a foundation of security and stability whereas positive attitude and adaptation strategies seemed to compensate for physical disability. The participants placed much greater emphasis on psychosocial factors than on longevity, genetics, and absence of disease/disability as being critical for successful aging. This conceptualization of successful aging differs from several of the operationalized biomedical definitions previously proposed (8), but is consistent with other qualitative studies of older adults’ perspectives on successful aging, which have highlighted the importance of attitudinal factors and psychological resilience (9;15;16).

A single method of study is unlikely to adequately shed light on a multi-faceted phenomenon such as successful aging. Triangulation (use of multiple data sources) is useful for developing a deeper understanding of a complex construct (17). Accordingly, we wished to complement the results of our earlier focus group study with an investigation employing individual interviews. From a qualitative methods standpoint, both approaches may reveal similar constructs, but they can provide insights into different questions – focus groups may identify consensus aspects of positive aging (i.e., the ingredients), whereas individual interviews may address the individual process and “how” older people may come to age well (i.e., the recipe). Thus, in the present study, we aimed to further examine the structure and attributes of successful aging, including the individual processes involved. We also asked study participants for their suggestions on how to age well and recommended interventions to promote healthy aging.

METHODS

Participants

Individual interviews were conducted with a purposively selected sample of 22 independent-living, community-dwelling adults over age 60, who were able to sign an informed consent. To obtain maximum variation (18) in perspectives and experience, recruitment occurred at four locations within San Diego County. Eleven subjects were recruited from the independent living segments of two continuing care retirement communities, which provide multiple levels of care to residents. An additional four participants were recruited from a low-income senior housing residence located in downtown San Diego. Another seven were enrolled from the University of California, San Diego (UCSD) Osher Institute for Continued Learning, which offers membership-driven lectures and courses to retirees. Potential participants were recruited through several means. Some individuals responded to flyers, which were posted at participating organizations and solicited participants who believed they were aging successfully. Others were recruited based on recommendations from facility staff for individuals likely to be interested in the study. Third, previous participants of related studies being conducted at UCSD were contacted, if they had expressed an interest in further study participation. About one-third of recruited individuals (32%) had participated in our previous focus group study (14). Both studies included participants from a similar age range. Participants were aware in advance that the interview would consist of a discussion of their views on successful aging. The age of participants ranged from 64 to 96 years old, with a mean of 80 (sd = 9.1). A majority (59%) were women, with most (86%) participants identifying themselves as Caucasian.

Procedures

The study was approved by the UCSD Human Research Protections Program. Each participant provided a written informed consent for the study (including audio-taping and transcription of the interviews) prior to participation.

Each interview was completed in the individual’s home or at her/his place of preference. A predetermined list of broad, research-driven questions/probes was developed for use by the interviewers, based on insights gained from a review of the existing literature and our earlier focus group study. Primary questions included: 1) How would you define successful aging?; 2) What is important to aging successfully?; 3) How have your life experiences influenced the course of your life and how you age?; and 4) What are your suggestions on how to age well and recommendations for specific interventions to promote healthy aging?

During each interview, the interviewer started with general questions, including those listed above. Additional questions were asked, when needed, to elicit further details. Participants were interviewed by either of the first two authors. Qualitative research techniques outlined by Patton (18) served as the training manual. Interviews lasted for up to two hours in length, with the content of each interview audio taped and subsequently transcribed.

Data Analysis

Transcripts were analyzed using the method of “Coding Consensus, Co-occurrence, and Comparison” outlined by Willms et al. (19). The personal interview content was initially coded independently by the project investigators at a general level in order to condense the data into analyzable units. Segments of transcripts ranging from a phrase to several paragraphs were assigned codes based on key questions from the personal interview guide or emergent categories or themes. In certain instances, it was appropriate for the same segment of text to be assigned more than one code. Each transcript was independently coded by one or two investigators. Disagreements in code description or assignment were resolved through discussions among investigators with the appropriate refinement of codes, as needed. The list of codes was finalized via group consensus, and resulted in a list of themes, issues, and opinions related to successful aging. Based on the final coding structure, nearly 10% of the overall transcript content, including a subset of 58 coded statements, was reviewed, to determine the level of agreement in the codes applied and to assess inter-rater reliability. Ninety-one percent of the segments were coded the same, indicating a high degree of concordance between raters (20).

The computer program QSR NVivo (21) was used to further organize the developed list of codes by generating a treelike structure of individual categories or factors called “nodes” and connecting transcript segments to these category groups. Through the process of constant comparison (22), the independent categories were further condensed into discrete themes.

RESULTS

The analysis of the personal interview transcripts revealed an emphasis by respondents to focus on the importance of accepting oneself, including the development of a realistic self-appraisal and a review of one’s life. In addition, participants went beyond this sense of acceptance to also focus on the importance of active engagement with life and growth, including novel, productive, and social engagement, and the value of a positive attitude. These constructs are further discussed in detail below, including the balance needed between these two elements of successful aging. Participant quotes, identified in italics, are also included as supportive illustrations.

Self-Acceptance and Self-Contentment

Overall, participants largely emphasized the importance of achieving self-acceptance and self-contentment.

“[Successful aging is] accepting what you are at this time. Not dwelling on what you could have been or forgot to do or couldn’t do or things you want to do that are no longer capable of it. Just being content. That’s not the right word either because contentment I think can lead to stagnation. But to be satisfied with where you are.”

Nearly two-thirds of all respondents (64%) specifically mentioned a comfort with self and/or self-confidence. For some, this was a newfound feeling.

“I’ve never felt more authentically me, ever, than I do right now. And it’s just so cool. It’s very cool.”

One’s spirituality, with or without a chosen religion, was also tied to some participants’ sense of comfort and self-realization.

“I’m spiritually - not religious - I’m spiritually very calm with myself. I discovered things about myself in mid to later years that have been sitting there all the time.”

Three sub-themes emerged under this main theme: realistic self-appraisal, a review of one’s life, and focusing on the present.

Realistic Self-Appraisal

Participants appeared to have developed a realistic self-appraisal. For some, this was expressed as “making the best of what you have”. Reality was not necessarily expressed from a negative perspective. Feelings of happiness and enjoyment with life were often expressed and the value of not worrying too much was also conveyed.

“[Aging] is life. You take it as it comes. And you take into consideration - you soon learn what you can and can’t do. And it takes me longer to write a letter and I’m certainly not as sharp mentally as I once was. And I see deterioration there. But you can’t worry about it because that’s life.”

“You have to know yourself a bit. But I think most people who are getting up in years kind of do. I mean if they don’t, then it’s too late. And then you have to be strong enough to persevere and kind of muddle through the difficulty to get to that point where you like to be who you are. You may have to modify. Your own image of yourself is still that of somebody in their 20’s or 30’s or 40’s. You got to realize you’re not and still actually say ‘ok, it’s all right.’ And then modify; suit your desires to what is realistic.”

“Something is how it is… If I can change it, fine; if I can’t, fine.”

A Review of One’s Life

In order to feel a sense of contentment and acceptance of oneself, participants appeared to have completed a personal review of their lives. This life review often resulted in a personal sense of inner strength and accomplishment, along with the sense of having “had a good life”.

“I am very grateful that I have reached this point, but I didn’t do it because I knew how to do it. I had to do it as I went along, step by step. Everyone has a different problem and situation and then I got to the point where I said, ‘this is it’.”

“(It is important to get people) to talk about their past accomplishments and make them feel proud of having done, instead of sad that they can’t do it anymore.”

Focusing on the Present

Nearly all the participants (95%) noted their tendency to focus on living in the present. Essentially, the current moment was often considered the only moment that truly mattered. Some expressed “living one day at a time” and not worrying about the future.

“I just keep putting one foot in front of the other and facing life as it comes to me. I don’t worry about dying. It’s coming and I just don’t want to rush it.”

“[Successful aging is] enjoying the automatic part of life as much as you can and the special moments as much as you can… It took a long time for people to realize that right now is really what life is all about. The future is unpredictable up to a point. This moment, right now, because my organs are working, is life.”

Engagement with Life and Self-Growth

Nearly all of the participants (95%) mentioned the importance of remaining engaged with life and discussed a “can do” approach to self-growth and successful aging. Four sub-themes emerged in this category: novel pursuits, giving to others, social interactions, and positive attitude.

Novel Pursuits

Participants discussed the importance of trying new things that were of personal interest and enjoyment.

“Just don’t feel because I’ve done this all my life, that’s all I can do. Try something.”

“Do things you really want to do. I mean even if it’s you’ve got the money and you love to take cruises, for God sakes, take cruises!”

As the following statements illustrate, engagement was equated with the process of growth and development:

“Every time we do something new, it’s a new adventure and you have to learn new skills and you have to be adventurous. So I have reinvented myself a dozen times and this is a new reinvention… and it suits fine.”

“For those that are active, they are growing whether they realize it or not – they’re still growing. They still enjoy going to a movie. They still enjoy sleeping with people. They enjoy good food. That’s all growing. You know they’re not sitting in their rooms… waiting for something to happen.”

The importance of seeking intellectual stimulation and continuously challenging oneself (i.e., crossword puzzles) was also mentioned, particularly in reference to maintaining one’s mental health and “keeping the mind sharp.”

“I think it really helps me to feel there’s another challenge ahead – a couple of challenges. I wish I’d live another 20 years.”

Giving to Others

A large majority (73%) of participants also focused on “giving of themselves” to others and contributing to society. They mentioned the importance of volunteering or helping others not only for the sake of generosity, but also for the positive impact on themselves, including enjoyment, fulfillment, stimulation, social interaction, and the ability to remain engaged. It was also often tied into one’s sense of purpose and provided life meaning.

“When I was busy working, I was an introvert, very quiet, just worked, paid bills. And all of that turned into what? And I came here… I’ve always wanted to help other people. I got the opportunity here… If I can do something for somebody and knowing that I’m not expecting nothing back, I’m doing it because I enjoy doing it and it makes me feel great inside.”

“I went [to volunteer] thinking that because things turned out so positively for me, I had something to offer them. It turned out the other way around. They were all – every person – had something to offer.”

Social Interactions

Participants also stressed the importance of being surrounded by people and having a “sense of connection” and “feeling that somebody cares”. They emphasized the critical need to maintain or develop social relationships and seek community and social support (e.g., retirement community living, participation in church organizations, etc.). Friends, even more so than spouse or family, were most often cited as a key source of support and appeared to be a driving force behind participants’ enjoyment and sense of well-being.

“Every social interaction that I have I feel is always a learning (process). There are so many people who have had experiences that I can glean from… I can get their knowledge and I can incorporate it into myself and that’s growing.”

The importance of friendship was often identified in the context of living in a retirement community or following the loss of a spouse. Interaction with young people was also specified by some people as being important for successful aging and “keeping you young.” This included interaction with family members (e.g., grandchildren), friends, and connections made through volunteer work. When participants discussed factors that could impede successful aging, isolation was the main barrier identified, further suggesting the importance of social connections.

“Keep your old friends, make some new ones, don’t isolate yourself.”

“I can’t sit in my room all day long watching T.V. I like to be out around my friends talking, you know, what’s going on in this place and finding out things, being involved.”

Positive Attitude

A “good attitude” with positive outlook was frequently emphasized. Most participants appeared to have reached a balance between both accepting oneself and having a personal desire to grow and remain engaged in life. They did not deny the aging process and embarked upon this time of their life with a realistic, yet positive, outlook. They had the ability to determine what they could and could not change and attended to their inner self while also connecting with the world around them. Many respondents discussed the development of coping strategies used to accept or adapt to life’s challenges, whether it be the loss of a spouse, friends and/or family, the inability to drive and/or physical setbacks. Some participants expressed the importance of resigning and accepting the past and either moving onward and forward or incorporating lessons learned into their current outlook.

Individuals discussed examples of not only their own personal approach, but also role models (or the antithesis) encountered throughout their lives.

“You just don’t sit and say ‘oh, woe is me’. ‘No, I can’t do this because I have that.’ And ‘oh, I can’t do that because I have this.’ Those words don’t exist in successful aging.”

“You can’t always do the things you did do, but there are other things you can do and look for them…”

“My uncle was a potato farmer and sometimes his crop failed and he would just get up and do it again.”

Intervention Recommendations

In addition to asking participants about their views of successful aging, participants were also asked about particular interventions they would recommend to assist others age successfully. Responses were centered around three topics: 1) acquisition of tailored information needed to make informed decisions and enhance coping strategies, particularly in relation to understanding and preparing for health challenges and life obstacles; 2) development of programs and support systems, including social and environmental support (e.g., home care services, transportation, and innovative retirement communities); and 3) development of meaningful activities. Although general support services were recommended, it was also noted that a part of the problem was a lack of awareness of existing programs.

“I found that by understanding the nature of disease and its progression, I was prepared for what would happen next. There's not as much stress. If I know it's coming, I don't go, oh, what does that mean? You're prepared…”

“I guess it applies to all patients, but primarily to an older patient, who needs the assurance…sit with the patient and say this is what the doctor has found out and this is what the program is going to be and this is how we’re going to handle it and so forth…”

“Maybe there should be some talks on that, on the quality of life. In spite of your bills and medications, what can you do to improve that, so you can keep your goals alive?”

DISCUSSION

Our qualitative study based on personal interviews was aimed at identifying older adults’ perceptions about what constituted successful aging and what could be done to promote it. Two overarching, and seemingly opposing, themes were self-acceptance and engagement/self-growth. Acceptance was described in terms of a comfort with the self and one’s past experiences, along with a realistic self-appraisal. In contrast, engagement was described in terms of personal growth and the pursuit of active engagement, including selection of activities that contributed to individual growth, personal enjoyment and fulfillment, and the improvement of others’ well being. A balance between these two themes appeared to be important to successful aging. Interventions to increase the likelihood of successful aging were described in terms of social support services, meaningful activities, and tailored health information. Relative to our and others’ previous work identifying the components of successful aging, such as with qualitative focus groups, the individual interviews conducted in this study helped to further elucidate the personal developmental context of successful aging.

Older adults’ perspectives in our study and others (4;9;10;13;16;23) emphasized psychological and behavioral adaptations to life changes and disabilities, rather than freedom from or avoidance of physical disability. Our study adds to previous work suggesting that operational definitions of successful aging often fail to capture the subjective experience of older adults (16) and some of the widely studied ‘phenotypes’ of successful aging are not consistent with the perspectives of older adults.

Our findings are also quite consistent with lifespan developmental theories in aging, particularly the selection, optimization, and compensation model of Baltes (2;24), along with the socioemotional selectivity theory of Carstensen (25;26) and its emphasis on the age-related increase in present-focused and socially-oriented goals and its alignment with well-being. To add to life course theories of normal aging and development focused on the importance of continuity (4;24;27), the older adults we interviewed also described the importance of trying new activities and life directions. There was thus a balance between stability/consistency and experimentation/growth.

The concept of successful aging presented here has striking similarities with the construct of wisdom. The “serenity prayer” asks for serenity to accept the things one cannot change, courage to change the things one can, and wisdom to know the difference between the two (28). The emphasis by our interviewees on giving to others and feeling a sense of accomplishment corresponds with Erikson’s last two stages of human development, including his emphasis on “generativity versus stagnation” and “integrity versus despair”; with the successful outcome of the latter being attainment of wisdom (29;30). The themes and subthemes of successful aging identified in our study bear notable resemblance to domains of wisdom in ancient and modern conceptualizations of wisdom such as social decision making, self-understanding, prosocial behavior, emotional homeostasis, and tolerance (31;32). Wisdom is not a natural consequence of aging, but is associated with successful aging (7).

There is substantial theoretical, clinical, and research literature on lifespan development and aging (4;33–36). Since our results closely parallel those of these earlier scientists, one may postulate that, despite major historical changes and a substantially increased longevity, basic defining characteristics of successful aging have largely remained unchanged.

Compared to our previous paper on the definition of successful aging using focus groups (14), the results with the personal interview format were similar in the attributes associated with successful aging, but different in regard to exposition about how these attributes could be attained. Areas of agreement between the two qualitative approaches include the relevance of adaptation, positive attitude, maintenance of well-being, and engagement. The focus groups highlighted the importance of the interrelationships among these attributes (e.g., the need for a secure environment in order to have a positive attitude) (14). In contrast, the findings of the individual interviews were reflected personal narratives, as individuals described the antecedents to their current experience. Overall, they provided more depth in terms of the emotional strategies involved in aging well. In particular, the emphasis by participants on the acceptance of self and a concentration on the present moment had not previously emerged in our focus groups.

Clinically, the implications of this study include the perceived need for interventions to help people identify various means of social support, especially for isolated individuals, along with opportunities for engagement in novel and meaningful activities, such as those that facilitate intergenerational interactions and a sense of ‘usefulness’ (37;38). Promoting feelings of usefulness could be especially valuable, given a report by Gruenewald et al. (39) as a part of the MacArthur study of successful aging, which found a protective effect of the feelings of usefulness on disability and mortality at a 7-year follow up. In addition, as identified by Duay and Bryan (40), the role of learning in the process of adapting to age-related changes can serve a variety of purposes such as gaining social experience, providing a coping strategy, and finding ways to have fun. Older adults’ expressed need for tailored information concerning both specific medical issues and more general concepts (e.g., quality of life) suggests that efforts are needed to ensure individuals have information tailored to their circumstances to make decisions. Tailoring health education to individual needs is an active area of research in some aspects of public health, but has not received adequate attention in geriatric psychiatry (41). A central focus by participants on the successful ability to address challenges and seek comfort with oneself, along with the apparent introspective review of their individual lives, suggests that greater effort is needed by clinical practitioners to address these issues with patients. This may be particularly valuable for individuals struggling with depression or anxiety.

There are several limitations to our study. First, the participants were recruited through non-random sampling methods, which may have resulted in the recruitment of both self-selected successful agers and a non-representative sample of the general population. Second, although basic demographic data, including age, gender, and ethnicity were collected from participants, our limited sample size, sampling methods and large age range did not adequately allow for comparisons across age/gender/race or recruitment source categories. We also did not obtain information on other clinical characteristics (e.g., medical diagnoses, complete family history). A mixed-methods approach examining demographic/clinical factors including cultural context and their influence on response variability is recommended for further study. For instance, previous research on older adults has shown that women tend to rely more on friends for social support, whereas men tend to rely more on their spouses (42). A more in-depth investigation of respondents’ personal history (e.g., previous hardships, career choice) could also provide a greater understanding of individual perspectives on successful aging (16). Furthermore, the salience of the past in relationship to current experience of successful aging was likely influenced by the interview, as one of the questions asked of participants was about their past and its impact on their aging process. However, the content of the transcripts pertaining to evidence of a life review revealed a depth that was not restricted to the immediate point in time of the interview. Past experience was not a prominent feature of the findings from our previous focus group study.

Despite the limitations, the personal interview design used in this study provided insights into older adults’ personal experiences and views on successful aging to a greater extent than that accomplished in previously collected survey questionnaire and focus group formats. Future research should seek to study the developmental process of successful aging as this could lead to improved understanding and shaping of the successful aging experience.