Encyclopedia of Aging (Two Volume Set)

THE ENCYCLOPEDIA OF AGING: A Comprehensive Resource in Gerontology and Geriatrics Fourth Edition RICHARD SCHULZ, PhD Edi...

Author: Richard Schulz | Linda Noelker | Kenneth Rockwood | Richard Sprott

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THE ENCYCLOPEDIA OF AGING: A Comprehensive Resource in Gerontology and Geriatrics Fourth Edition RICHARD SCHULZ, PhD Editor

Springer Publishing Company, Inc.

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ENCYCLOPEDIA OF AGING A Comprehensive Resource in Gerontology and Geriatrics

Fourth Edition

RICHARD SCHULZ, PhD EDITOR-IN-CHIEF

Linda S. Noelker, PhD Kenneth Rockwood, MD, FRCPC Richard L. Sprott, PhD ASSOCIATE EDITORS

NEW YORK

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THE


Fourth Edition

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c 2006 Springer Publishing Company, Inc. Copyright All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior permission of Springer Publishing Company, Inc. Springer Publishing Company, Inc. 11 West 42nd Street New York, NY 10036 Managing Editor: Sheri W. Sussman Assistant Managing Editor: Alana Stein Cover Designer: Mimi Flow Production: Chernow Editorial Services, Inc. Composition: TechBooks 06 07 08 09 10/ 5 4 3 2 1

Library of Congress Cataloging-in-Publication Data The encyclopedia of aging: a comprehensive resource in gerontology and geriatrics / Richard Schulz, editor-in-chief.—4th ed. p. cm. Includes bibliographical references and index. ISBN 0–8261–4843–3 (set) 1. Gerontology—Encyclopedias. 2. Aged—Encyclopedias. I. Schulz, Richard. II. Title. HQ1061 .E53 2001 305.26 03—dc21 00-049663 CIP Printed in the United States of America by Bang Printing.

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CONTENTS The Editors

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Foreword to the Fourth Edition

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Contributors

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List of Entries

VOLUME I Entries A – K Subject Index

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1 I-1

Contributor Index

I-61

VOLUME II Entries L – Z

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Subject Index Contributor Index

I-1 I-61

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THE EDITORS Richard Schulz, PhD, is Professor of Psychiatry, Psychology, Epidemiology, Sociology, and Health and Rehabilitation Sciences, and Director of the University Center for Social and Urban Research at the University of Pittsburgh. He is also Associate Director of the Institute on Aging at the University of Pittsburgh. He received his AB in Psychology from Dartmouth College and his PhD in Social Psychology from Duke University. He is the recipient of several honors, including the Kleemeier Award for Research on Aging from the Gerontological Society of America and the Developmental Health Award for Research on Health in Later Life from the American Psychological Association. He also served as Editor of the Journal of Gerontology: Psychological Sciences. He has spent his entire career doing research and writing on adult development and aging. Funded by numerous NIH institutes for more than two decades, his research has focused on the social-psychological aspects of aging, including the role of control as a construct for characterizing life-course development and the impact of disabling late life disease on patients and their families. This body of work is reflected in publications, which have appeared in major medical (JAMA, NEJM ), psychology (Psychological Review, Psychological Bulletin, JPSP), and aging (Journal of Gerontology, Psychology and Aging, JAGS, AJGS) journals. Linda S. Noelker, PhD, joined Benjamin Rose in 1974 as an applied aging researcher and is currently the Senior Vice President for Planning and Organizational Resources. In that capacity, she oversees the Research Institute and the Institutional Advancement and the Advocacy and Public Policy Departments. She received her MA and PhD from Case Western Reserve, where she is an Adjunct Professor of Sociology. She also is the Editor-in-Chief of The Gerontologist, the leading journal in applied aging research, practice, and policy. Dr. Noelker holds leadership positions in the American Society on Aging and the Gerontological Society of America and recently received the 2005 American Society on Aging Award for exemplary contributions to the field of aging. Throughout her career, she has conducted research on the nature and effects of family care for frail aged, patterns of service use by older adults and their family caregivers, and sources of stress and job satisfaction among the direct care workforce. She has published widely on the support networks of older adults, quality of life, the well-being of family caregivers, predictors of service use, and the nature of social relationships in nursing homes. Kenneth Rockwood, MD, FRCPC, Professor of Medicine (Geriatric Medicine & Neurology) and Kathryn Allen Weldon Professor of Alzheimer Disease Research, is the Director of the Geriatric Medicine Research Unit at Dalhousie University. He is a Canadian Institute of Health Research (CIHR) Investigator and a member of the CIHR Institute of Aging Advisory Board. He has a long-standing interest in delirium, dementia, and frailty. Professor Rockwood is author of more than 200 peer-reviewed scientific publications, and five books. He is a staff physician in the Department of Medicine at the Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada Currently, he is the principal investigator in the Video Imaging Synthesis of Treating Alzheimer’s disease (VISTA) study, an investigator-initiated national, multicenter project to identify and track novel treatment vii

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effects in patients with mild to moderate Alzheimer’s disease who are treated with galantamine, an antidementia medication. Kenneth Rockwood is a native of Newfoundland and became a Doctor of Medicine at Memorial University in 1985. He is married to an internationally recognized scientist in the Faculty of Medicine—Susan Howlett, Professor of Pharmacology, and together they have two teenage sons, Michael and James. Richard L. Sprott, PhD, Executive Director of the Ellison Medical Foundation, began his undergraduate studies at Franklin and Marshall College in Lancaster, Pennsylvania. He completed them at the University of North Carolina at Chapel Hill, earning a BA with honors in Psychology. After receiving his PhD in Experimental Psychology (Behavior Genetics) at the University of North Carolina, he went on to a postdoctoral fellowship in Behavior Genetics at the Jackson Laboratory in Bar Harbor, Maine. Following two years of teaching at Oakland University, Dr. Sprott returned to the Jackson Laboratory where he conducted a research program on single gene influences on behavior and the interaction of aging variables with those genes. After a decade in Maine, Dr. Sprott moved to the National Institute on Aging where he directed the Institute’s programs on the Biology of Aging. A major focus of his career has been the development of animal models for aging research. He developed a nationwide research program on biomarkers of aging and the effects of dietary restriction on longevity. He is the author of a large number of books and articles. He is an internationally recognized expert on animal model development and plays an active role in model development in countries around the world. He is the Past President of the International Biogerontological Resource Institute (IBRI) in Friuli, Italy. Dr. Sprott left the National Institute on Aging in 1998 to become the first Executive Director of the Ellison Medical Foundation, created to support basic biological and biomedical research on aging and recently expanded to provide similar support for basic research on infectious diseases of importance in the developed and developing worlds. The Ellison Medical Foundation is the largest private foundation source of funding for research on the biology of aging, providing about $28,000,000 per year in grant funds for aging research, and $12,000,000 for infectious disease research.

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FOREWORD TO THE FOURTH EDITION The Fourth Edition of the Encyclopedia of Aging marks the 20th anniversary of what has become the authoritative, comprehensive, and multidisciplinary introduction to gerontology and geriatrics. Originally proposed by Ursula Springer, PhD, and edited by George L. Maddox, PhD, the Encyclopedia serves as the gateway to the world of aging and the aged. The vision and hard work of these pioneers have established the Encyclopedia as a leading resource in the field. With the Fourth Edition of the Encyclopedia, we hope to continue this tradition by providing the most up-to-date and comprehensive introduction to gerontology and geriatrics currently available. Knowledge about adult development and aging is advancing at an incredibly rapid pace. This is particularly true in the medical, biological, and social sciences, where new information becomes available almost daily. Keeping abreast of new developments in multiple disciplines requires expertise that far exceeds the capabilities of any one individual. Thus, the team of associate editors assembled for this project represents cutting edge expertise in biology (Richard Sprott), medicine and health (Ken Rockwood), and sociology (Linda Noelker). Advances in psychological aspects of aging were covered by the editor-in-chief. Together we commissioned, reviewed, and edited well more than 400 entries, and while previous editions of the Encyclopedia provided a firm foundation for this one, almost every entry has been updated and many new ones have been added. As with previous editions, our goal has been to explain complex issues in plain English that can be understood by educated laypersons. The structure of the Encyclopedia remains the same. A comprehensive index is provided in both volumes, and extensive cross-referencing within the text provides readers with links among entries, enabling a comprehensive, in-depth view of topics. Sheri W. Sussman, the veteran Managing Editor of previous editions of the Encyclopedia, and her assistant, Alana Stein, provided the logistic support, guidance, and encouragement to keep this project on track. My able assistant at the University of Pittsburgh, Anna Aivaliotis, stepped in when needed to solve emerging problems and more importantly keep me on track throughout this project. Of course, the most essential ingredients to the success of this volume are the several hundred authors who contributed their expertise to write the entries for this edition. The quality of their work is outstanding. Without them, this Encyclopedia would not be possible. Richard Schulz, PhD Editor-in-Chief

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CONTRIBUTORS W. Andrew Achenbaum, PhD College of Humanities, Fine Arts, and Communication University of Houston Houston, Texas

Rebecca S. Allen, PhD Department of Psychology Center for Mental Health and Aging University of Alabama Tuscaloosa, Alabama

Robert A. Applebaum, PhD Scripps Foundation Gerontology Center Miami University Oxford, Ohio

Jonathan D. Adachi, MD McMaster University Hamilton, Ontario, Canada

Robert G. Allen, PhD Lankenau Institute for Medical Research Wynnewood, Pennsylvania

Patricia A. Areán, PhD Department of Psychiatry University of California, San Francisco San Francisco, California

Susan Allen, PhD Center for Gerontology and Health Care Research Brown University Providence, Rhode Island

Robert Arking, PhD Department of Biological Sciences Wayne State University Detroit, Michigan

Ronald H. Aday, PhD Middle Tennessee State University Murfreesboro, Tennessee George J. Agich, PhD The Cleveland Clinic Cleveland, Ohio Judd M. Aiken, BS, MS, PhD Department of Animal Health and Biomedical Sciences University of Wisconsin, Madison Madison, Wisconsin Marilyn Albert, PhD Gerontology Research Unit Harvard Medical School Charlestown, Massachusetts Steven M. Albert, PhD, MSc Department of Sociomedical Science Columbia University New York, New York

Keith A. Anderson, MSW Graduate Center in Gerontology College of Public Health The University of Kentucky Lexington, Kentucky Melissa Andrew, MD, MSc (Public Health), BSc Division of Geriatric Medicine Dalhousie University Halifax, Nova Scotia, Canada Jacqueline Angel, PhD School of Public Affairs University of Texas at Austin Austin, Texas

Wilbert S. Aronow, MD Divisions of Cardiology and Geriatrics New York Medical College Valhalla, New York Robert C. Atchley, PhD Department of Gerontology The Naropa Institute Boulder, Colorado Alejandro R. Ayala, MD Clinical Endocrinology Branch NIDDK/NIH Bethesda, Maryland

James E. Allen, PhD, MSPH School of Public Health University of North Carolina at Chapel Hill Chapel Hill, North Carolina

Joaquin A. Anguera, PhD (c) Division of Kinesiology University of Michigan Ann Arbor, Michigan

Lodovico Balducci, MD Department of Interdisciplinary Oncology University of South Florida College of Medicine Tampa, Florida

Philip A. Allen, PhD Department of Psychology University of Akron Akron, Ohio

Toni C. Antonucci, PhD Department of Psychology University of Michigan Ann Arbor, Michigan

Beverly A. Baldwin, PhD (deceased) School of Nursing University of Maryland Baltimore, Maryland

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Contributors

Arthur K. Balin, MD, PhD, FACP Medical Director The Sally Balin Medical Center Media, Pennsylvania Ashley S. Bangert, PhD (c) Department of Psychology University of Michigan Ann Arbor, Michigan John C. Barefoot, PhD Duke University Medical Center Durham, North Carolina Jane Barratt, PhD Secretary General International Federation on Ageing Montreal, Quebec, Canada Nir Barzilai, MD Albert Einstein College of Medicine Bronx, New York Scott A. Bass, PhD Dean of the Graduate School Vice Provost for Research and Planning University of Maryland Baltimore, Maryland John W. Baynes, PhD University of South Carolina Columbia, South Carolina William Bechill, MSW Former U.S. Commissioner on Aging Current Chair of the Board for the Center on Global Aging at Catholic University Washington, DC

Vern L. Bengtson, PhD Ethel Percy Andrus Gerontology Center Social and Behavioral Sciences Division University of Southern California Los Angeles, California Karen McNally Bensing, MSLS The Benjamin Rose Institute Cleveland, Ohio Edit Beregi, MD, DMSci Retired Director of the Gerontology Center Budapest, Hungary Howard Bergman, MD Department of Geriatric Medicine McGill University Montreal, Quebec, Canada David E. Biegel, PhD Mandel School of Applied Social Sciences Case Western Reserve University Cleveland, Ohio Robert H. Binstock, PhD Department of Epidemiology and Biostatistics Case Western Reserve University Cleveland, Ohio Kira S. Birditt, PhD Institute for Social Research University of Michigan Ann Arbor, Michigan Fredda Blanchard-Fields, PhD Georgia Institute of Technology Atlanta, Georgia

Nigel Beckett, MB, ChB, MRCP Imperial College Faculty of Medicine Hammersmith Campus London, UK

Dan G. Blazer, MD, PhD Department of Psychiatry Duke University Medical Center Durham, North Carolina

François Béland, PhD Co-Director, Solidage Research Group Department of Health University of Montreal Montreal, Quebec, Canada

Avrum Z. Bluming, MD, MACP Department of Medicine University of Southern California Los Angeles, California

Ann Benbow, PhD SPRY Foundation Washington, DC

Cory R. Bolkan, MS, PhD (c) Human Development and Family Sciences Oregon State University Corvallis, Oregon

Enid A. Borden, BA, MA CEO, Meals on Wheels Association of America Alexandria, Virginia Kevin Borders, PhD Kent School of Social Work University of Louisville Louisville, Kentucky Hayden B. Bosworth, PhD Senior Health Scientist Duke University Medical Center Durham, North Carolina Meg Bourbonniere, PhD, RN Yale University School of Nursing New Haven, Connecticut Susan K. Bowles, PharmD College of Pharmacy Centre for Health Care of the Elderly Capital District Health Authority Halifax, Nova Scotia, Canada Dana Burr Bradley, PhD University of North Carolina at Charlotte Charlotte, North Carolina Lawrence G. Branch, PhD College of Public Health University of South Florida Tampa, Florida Joshua R. Bringle, MS University of Massachusetts at Amherst Amherst, Massachusetts Harold Brody, MD, PhD Department of Anatomy State University of New York School of Medicine Buffalo, New York G.A. Broe, AM, BA, MBBS, FRACP Prince of Wales Medical Research Institute and University of New South Wales Randwick, NSW, Australia Susan V. Brooks, PhD The University of Michigan Ann Arbor, Michigan

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Contributors W. Ted Brown, MD, PhD Chairman, Department of Human Genetics NYS Institute for Basic Research in Developmental Disabilities Staten Island, New York Winifred Brownell, PhD College of Arts and Sciences University of Rhode Island Kingston, Rhode Island Entela Bua, MD, PhD Department of Animal Health and Biomedical Sciences University of Wisconsin, Madison Madison, Wisconsin Barbara Bucur, PhD Center for the Study of Aging and Human Development Duke University Medical Center Durham, North Carolina Elisabeth O. Burgess, PhD Department of Sociology Georgia State University Atlanta, Georgia Louis D. Burgio, PhD Department of Psychology Center for Mental Health and Aging University of Alabama Tuscaloosa, Alabama Robert N. Butler, MD President and CEO International Longevity Center USA, Ltd. New York, New York Kevin E. Cahill, PhD Tinari Economics, Inc. Livingston, New Jersey Margaret P. Calkins, PhD IDEAS Institute Kirtland, Ohio Richard T. Campbell, PhD Department of Sociology University of Illinois at Chicago Chicago, Illinois Elizabeth Capezuti, RN New York University New York, New York

Gregory D. Cartee, PhD Department of Kinesiology University of Wisconsin, Madison Madison, Wisconsin Neil Charness, PhD Department of Psychology Florida State University Tallahassee, Florida Yung-Ping Chen, PhD Gerontology Institute University of Massachusetts Boston, Massachusetts Judith G. Chipperfield, PhD Health, Leisure, and Human Performance Research Institute Winnipeg, Manitoba, Canada Victor G. Cicirelli, PhD Department of Psychological Sciences Purdue University West Lafayette, Indiana Giovanni Cizza, MD, PhD Clinical Endocrinology Branch NIDDK/NIH Bethesda, Maryland A. Mark Clarfield, MD, FRCPC Ben-Gurion University of the Negev Beersheva, Israel and Division of Geriatric Medicine McGill University Montreal, Quebec, Canada Robert L. Clark, PhD Department of Business Management North Carolina State University Raleigh, North Carolina Carl I. Cohen, MD Division of Geriatric Psychiatry State University of New York Brooklyn, New York Harvey Jay Cohen, MD Department of Medicine Duke University Medical Center Durham, North Carolina Nathan S. Consedine, PhD Department of Psychology Long Island University Brooklyn, New York

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Constance L. Coogle, PhD Virginia Center on Aging and Department of Gerontology Virginia Commonwealth University Medical Center Richmond, Virginia Fay Lomax Cook, PhD School of Education and Social Policy Northwestern University Evanston, Illinois Susan G. Cooley, PhD U.S. Department of Veterans Affairs West Palm Beach, Florida Germaine Cornélissen, PhD Halberg Chronobiology Center University of Minnesota Minneapolis, Minnesota Joseph F. Coughlin, PhD MIT Age Lab Massachusetts Institute of Technology Cambridge, Massachusetts Vincent J. Cristofalo, PhD Lankenau Institute for Medical Research Wynnewood, Pennsylvania Stephen Crystal, PhD Institute for Health, Health Care Policy, and Aging Research New Brunswick, New Jersey Ana Maria Cuervo, MD, PhD Albert Einstein College of Medicine Bronx, New York Leslie Curry, PhD, MPH University of Connecticut Health Center Farmington, Connecticut Stephen J. Cutler, PhD Departments of Sociology and Gerontology University of Vermont Burlington, Vermont Sara J. Czaja, PhD Department of Psychiatry and Behavioral Sciences University of Miami School of Medicine Miami, Florida

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Contributors

Elizabeth M. Dax, MD, PhD National Institute on Aging and The Johns Hopkins School of Medicine Baltimore, Maryland Howard B. Degenholtz, PhD Center for Bioethics and Health Law University of Pittsburgh Pittsburgh, Pennsylvania Sharon A. DeVaney, PhD Purdue University West Lafayette, Indiana

Glen H. Elder, Jr., PhD University of North Carolina at Chapel Hill Chapel Hill, North Carolina

David B. Finkelstein, PhD Director, Pathobiology Program National Institute on Aging Bethesda, Maryland

Bernard T. Engel, PhD School of Medicine Johns Hopkins University Raleigh, North Carolina

Joseph H. Flaherty, MD Geriatric Research, Education and Clinical Center St. Louis VA Medical Center Division of Geriatrics St. Louis University School of Medicine St. Louis, Missouri

Joan T. Erber, PhD Department of Psychology Florida State University Miami, Florida

Samantha Devaraju-Backhaus, MA Center for Psychological Studies Nova Southeastern University Fort Lauderdale, Florida

Carroll L. Estes, PhD Institute for Health and Aging University of California, San Francisco San Francisco, California

Roger A. Dixon, PhD Department of Psychology University of Alberta Edmonton, Alberta, Canada

J. Grimley Evans, MD Division of Clinical Gerontology University of Oxford Oxford, UK

Elizabeth B. Douglas, MA Executive Director Association for Gerontology in Higher Education Washington, DC

Lois K. Evans, DNSc, RN, FAAN School of Nursing University of Pennsylvania Philadelphia, Pennsylvania

Elizabeth Dugan, PhD Division of Geriatric Medicine University of Massachusetts Medical School Worcester, Massachusetts David Dupere, MD, FRCPC Division of Palliative Medicine Queen Elizabeth II Health Sciences Center Dalhousie University Halifax, Nova Scotia, Canada Tzvi Dwolatzky, MD, MBBCh Beersheva Mental Health Center and Ben-Gurion University of the Negev Beersheva, Israel Rita B. Effros, PhD Department of Pathology and Laboratory Medicine University of California Los Angeles, California David J. Ekerdt, PhD Gerontology Center University of Kansas Lawrence, Kansas

John A. Faulkner, PhD University of Michigan Ann Arbor, Michigan John Feightner, MD, MSc, FCFPC University of Western Ontario London, Ontario, Canada Patrick J. G. Feltmate, MD Dalhousie University Halifax, Nova Scotia, Canada Christine Ferri, PhD Center for Aging UMDNJ-School of Osteopathic Medicine Stratford, New Jersey Luigi Ferrucci, MD Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute Baltimore, Maryland Gerda G. Fillenbaum, PhD Center for the Study of Aging and Human Development Duke University Medical Center Durham, North Carolina

Jerome L. Fleg, MD Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute Baltimore, Maryland Leon Flicker, MB, BS, PhD, FRACP Geriatric Medicine Unit at Royal Perth Hospital The University of Western Australia Perth, Australia Anne Foner, PhD Department of Sociology Rutgers University New Brunswick, New Jersey Barry Fortner, PhD Rush-Presbyterian-St. Luke’s Medical Center Chicago, Illinois Susan Freter, MD, FRCPC Department of Medicine Dalhousie University Halifax, Nova Scotia, Canada Alexandra M. Freund, PhD Departments of Human Development and Social Policy and Psychology Northwestern University Evanston, Illinois Robert B. Friedland, PhD Center on an Aging Society Georgetown University Washington, DC Brant E. Fries, PhD University of Michigan and Ann Arbor VA Medical Center Ann Arbor, Michigan

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Contributors James F. Fries, MD Department of Medicine Stanford University School of Medicine Stanford, California Christine L. Fry, PhD Department of Anthropology Loyola University of Chicago Chicago, Illinois Terry T. Fulmer, RN, PhD, FAAN Division of Nursing New York University New York, New York Ari Gafni, PhD Institute of Gerontology and Biophysics Research Division University of Michigan Ann Arbor, Michigan Mary Ganguli, MD, MPH University of Pittsburgh Pittsburgh, Pennsylvania Joseph E. Gaugler, PhD Department of Behavioral Science College of Medicine University of Kentucky Lexington, Kentucky Serge Gauthier, MD, FRCPC Departments of Neurology and Neurosurgery, Psychiatry, and Medicine Director, Alzheimer Disease and Related Disorders Research Unit McGill University Montreal, Quebec, Canada Louise E. Gelwicks Gerontological Planning Association Santa Monica, California Linda K. George, PhD Department of Sociology Duke University Durham, North Carolina Scott Miyake Geron, PhD Faculty of Medicine, Dentistry and Nursing University of Manchester Manchester, UK

Lora Giangregorio, PhD Lyndhurst Centre Toronto Rehabilitation Institute Toronto, Ontario, Canada Roseann Giarrusso, PhD Andrus Gerontology Center University of Southern California Los Angeles, California Laura N. Gitlin, PhD Center for Applied Research on Aging and Health Thomas Jefferson University Philadelphia, Pennsylvania Stephen M. Golant, PhD University of Florida Gainesville, Florida Charles J. Golden, PhD Center for Psychological Studies Nova Southeastern University Fort Lauderdale, Florida Barry J. Goldlist, MD, FRCPC, FACP, AGSF Director, Division of Geriatric Medicine University of Toronto and Director, General Medicine and Geriatrics University Health Network/Mt. Sinai Hospital c/o Toronto Rehab Institute Toronto, Ontario, Canada Judith G. Gonyea, PhD School of Social Work Boston University Boston, Massachusetts Michael Gordon, MD, MSc, FRCPC, FRCP Edin Vice President, Medical Services and Head, Geriatrics and Internal Medicine Baycrest Centre for Geriatric Care University of Toronto Toronto, Ontario, Canada Elise Gould, PhD Economy Policy Institute Washington, DC David C. Grabowski, PhD Department of Health Care Policy Harvard Medical School Boston, Massachusetts

Edward M. Gramlich, PhD Board Member Board of Governors of the Federal Reserve System Washington, DC Aubrey de Grey, PhD Department of Genetics University of Cambridge Cambridge, UK Janet D. Griffith, PhD Research Triangle Institute Research Triangle Park, North Carolina Francine Grodstein, ScD Brigham and Women’s Hospital Harvard Medical School Cambridge, Massachusetts Murray Grossman, MD Department of Neurology University of Pennsylvania School of Medicine Philadelphia, Pennsylvania Gordon Gubitz, MD, FRCPC Department of Medicine Dalhousie University Halifax, Nova Scotia, Canada Juan J. Guiamet, PhD Instituto de Fisiologia Vegetal Universidad Nacional de La Plata La Plata, Argentina ZhongMao Guo, PhD Department of Physiology University of Texas Health Science Center at San Antonio San Antonio, Texas Franz Halberg, MD Director, Halfberg Chronobiology Center University of Minnesota Minneapolis, Minnesota Calvin B. Harley, PhD Chief Scientific Officer Geron Corporation Menlo Park, California Charles R. Harrington, PhD Department of Mental Health Institute of Medical Sciences University of Aberdeen Fosterhill, Aberdeen, UK

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Alan A. Hartley, PhD Department of Psychology Scripps College Claremont, California

Margaret L. Heidrick, PhD College of Medicine University of Nebraska Omaha, Nebraska

Lynn Hasher, PhD University of Toronto Toronto, Ontario, Canada

L. Carson Henderson, PhD, MPH College of Public Health Department of Health Promotion Sciences University of Oklahoma Oklahoma City, Oklahoma

Betty Havens, DLitt (deceased) University of Manitoba Brandon, Manitoba, Canada Robert J. Havighurst, PhD Department of Education University of Chicago Chicago, Illinois Catherine Hawes, PhD Department of Health Policy and Management School of Rural Public Health Texas A&M University System Health Science Center College Station, Texas Lara Hazelton, MD, FRCPC (Psychiatry) Department of Psychiatry Dalhousie University Nova Scotia Hospital Dartmouth, Nova Scotia, Canada Robert P. Heaney, MD Creighton University Omaha, Nebraska Randy S. Hebert, MD, MPH Division of General Medicine University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Jutta Heckhausen, PhD University of California, Irvine Irvine, California Franz Hefti, PhD Vice President Merck Sharp & Dohme Essex, United Kingdom Jenifer Heidorn, MA, PhD (c) Purdue University West Lafayette, Indiana

Jon G. Hendricks, PhD University Honors College Oregon State University Corvallis, Oregon John G. Hennon, EdD University of Pittsburgh Pittsburgh, Pennsylvania

Karen Hooker, PhD Director, Program on Gerontology Human Development and Family Sciences Oregon State University Corvallis, Oregon Michelle Horhota, MS Georgia Institute of Technology Atlanta, Georgia Darlene V. Howard, PhD Georgetown University Washington, DC Shafter Cristina Howard Institute for Health and Department of Psychology Rutgers University New Brunswick, New Jersey

Christopher Hertzog, PhD School of Psychology Georgia Institute of Technology Atlanta, Georgia

Susan E. Howlett, PhD Department of Pharmacology Faculty of Medicine Dalhousie University Halifax, Nova Scotia, Canada

Thomas M. Hess, PhD Department of Psychology North Carolina State University Raleigh, North Carolina

William J. Hoyer, PhD Department of Psychology Syracuse University Syracuse, New York

Nancy Hikoyeda, MPH Stanford Geriatric Education Center University of California, Los Angeles San Jose, California

Ruth Huber, PhD Kent School of Social Work University of Louisville Louisville, Kentucky

Franklin G. Hines, PhD (c) Department of Psychology Florida State University Tallahassee, Florida

Robert B. Hudson, PhD School of Social Work Boston University Boston, Massachusetts

Gregory A. Hinrichsen, PhD Director of Psychology Training The Zucker Hillside Hospital and Professor of Psychiatry Albert Einstein College of Medicine Glen Oaks, New York

Mary Elizabeth Hughes, PhD Department of Sociology Duke University Durham, North Carolina

David Hogan, MD Department of Geriatric Medicine University of Calgary Calgary, Alberta, Canada

Linnae L. Hutchison, MBA Department of Health Policy and Management School of Rural Public Health Texas A&M University System Health Science Center College Station, Texas

Heidi H. Holmes, PhD (c) Graduate Center for Gerontology University of Kentucky Lexington, Kentucky

Bradley T. Hyman, PhD Department of Neurology Research Massachusetts General Hospital Boston, Massachusetts

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Contributors Margaret B. Ingraham, BA, MA Director of Policy and Legislation Meals on Wheels Association of America Alexandria, Virginia Donald K. Ingram, PhD Gerontology Research Center National Institutes of Health Baltimore, Maryland James S. Jackson, PhD Institute for Social Research University of Michigan Ann Arbor, Michigan Susan T. Jackson, PhD, CCC-SLP Department of Hearing and Speech University of Kansas Medical Center Kansas City, Kansas Cynthia R. Jasper, PhD Department of Consumer Science University of Wisconsin, Madison Madison, Wisconsin Tiffany Jastrzembski, PhD (c) Department of Psychology Florida State University Tallahassee, Florida S. Michal Jazwinski, PhD Department of Biochemistry and Molecular Biology Louisiana State University Health Science Center New Orleans, Louisiana Nancy S. Jecker, PhD Department of Medical History and Ethics University of Washington Seattle, Washington Susan J. Jelonek, MBA Andrus Gerontology Center University of Southern California Los Angeles, California Lori Jervis, PhD University of Colorado at Denver Health Sciences Center Denver, Colorado Megan M. Johnson, PhD (c) Department of Sociology University of Vermont Burlington, Vermont

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Shanthi Johnson, PhD, PDt School of Nutrition and Dietetics Acadia University Wolfville, Nova Scotia, Canada

Cary S. Kart, PhD Scripps Gerontology Center Miami University Oxford, Ohio

Thomas E. Johnson, PhD Department of Integrative Physiology Institute for Behavioral Genetics University of Colorado Boulder, Colorado

Sathya Karunananthan, MS (c) Canadian Initiative on Frailty and Aging Solidage Research Group Lady Davis Institute Montreal, Quebec, Canada

Steven Jonas, MD, MPH, MS, FNYAS Department of Preventive Medicine Stony Brook University School of Medicine Stony Brook, New York Lyndon J. O. Joseph, PhD Division of Gerontology Baltimore VA Medical Center Baltimore, Maryland Boaz Kahana, PhD Department of Psychology Case Western Reserve University Cleveland, Ohio Eva Kahana, PhD Director, Elderly Care Research Center Department of Sociology Case Western Reserve University Cleveland, Ohio Arnold Kahn, PhD Department of Cell and Tissue Biology University of California, San Francisco San Francisco, California Rosalie A. Kane, DSW Division for Health Services, Research and Policy School of Public Health University of Minnesota Minneapolis, Minnesota Marshall B. Kapp, JD, MPH Office of Geriatric Medicine and Gerontology Wright State University School of Medicine Dayton, Ohio

Julia Kasl-Godley, PhD VA Hospice Care Center VA Palo Alto Health Care System Palo Alto, California Robert J. Kastenbaum, PhD Department of Communication Arizona State University Tempe, Arizona Sharon R. Kaufman, PhD Institute for Health and Aging University of California, San Francisco San Francisco, California Melanie E. M. Kelly, PhD Department of Pharmacology Dalhousie University Halifax, Nova Scotia, Canada Joseph W. Kemnitz, PhD Director, National Primate Research Center University of Wisconsin, Madison Madison, Wisconsin Susan J. Kemper, PhD University of Kansas Lawrence, Kansas Gary M. Kenyon, PhD Gerontology Program St. Thomas University Fredericton, New Brunswick, Canada Leslie Dubin Kerr, MD Department of Medicine and Geriatrics Mount Sinai Medical Center New York, New York Anne-Marie Kimbell, PhD Texas A&M University System Health Science Center College Station, Texas

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Douglas C. Kimmel, PhD Professor Emeritus, Department of Psychology City College, City University of New York New York, New York Thomas B. L. Kirkwood, PhD Co-Director, Institute for Ageing and Health University of Newcastle Newcastle upon Tyne, UK Paul Kleyman Aging Today, American Society on Aging San Francisco, California Donald Kline, PhD Departments of Psychology and Surgery (Ophthalmology) University of Calgary Calgary, Alberta, Canada Leon W. Klud, PhD Congressional Joint Committee on Taxation Washington, DC Thomas Kornberg, PhD Department of Biochemistry University of California, San Francisco San Francisco, California Suzanne R. Kunkel, PhD Scripps Gerontology Center Miami University Oxford, Ohio Ute Kunzmann, PhD International University of Bremen Bremen, Germany Claudia K. Y. Lai, RN, PhD School of Nursing The Hong Kong Polytechnic University Hong Kong SAR, China Kenneth M. Langa, MD, PhD Department of Internal Medicine and Institute for Social Research University of Michigan Ann Arbor, Michigan

Melinda S. Lantz, MD Director of Psychiatry The Jewish Home and Hospital New York, New York Felissa R. Lashley, RN, PhD, ACRN, FAAN, FACMG College of Nursing Rutgers University Newark, New Jersey Nicola T. Lautenschlager, MD School of Psychiatry & Clinical Neurosciences Royal Perth Hospital Perth, Australia Barry D. Lebowitz, PhD National Institute of Mental Health Bethesda, Maryland

Sue E. Levkoff, ScD, SM, MSW Brigham and Women’s Hospital Department of Psychiatry Harvard Medical School Boston, Massachusetts Phoebe S. Liebig, PhD Andrus Gerontology Center University of Southern California Los Angeles, California Robert D. Lindeman, MD University of New Mexico School of Medicine Albuquerque, New Mexico Charles F. Longino Jr., PhD Department of Sociology Wake Forest University Winston-Salem, North Carolina

Chin Chin Lee, MPH (c) Center on Aging University of Miami School of Medicine Miami, Florida

Oscar L. Lopez, MD Departments of Neurology and Psychiatry University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania

Makau Lee, MD, PhD University of Mississippi Medical Center Jackson, Mississippi

Antonello Lorenzini, PhD Lankenau Institute for Medical Research Wynnewood, Pennsylvania

Bruce Leff, MD The Johns Hopkins University School of Medicine Department of Health Policy and Management The Johns Hopkins University Bloomberg School of Public Health Baltimore, Maryland Eric J. Lenze, MD Western Psychiatric Institute and Clinic University of Pittsburgh Pittsburgh, Pennsylvania Howard Leventhal, PhD Institute for Health and Department of Psychology Rutgers University New Brunswick, New Jersey Jeff Levin, PhD Valley Falls, Kansas

Jonathan D. Lowenson, PhD Department of Chemistry and Biochemistry University of California, Los Angeles Los Angeles, California Judith A. Lucas, EdD, APN, BC Institute of Health Care Policy and Aging Research Rutgers University New Brunswick, New Jersey Cindy Lustig, PhD University of Michigan Ann Arbor, Michigan Stephen Lyle, MD, PhD Harvard Medical School Boston, Massachusetts Thomas R. Lynch, PhD Director, Cognitive Behavioral Research and Treatment Program Duke University Durham, North Carolina

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Contributors J. Beth Mabry, PhD Department of Sociology Indiana University of Pennsylvania Indiana, Pennsylvania Chris MacKnight, MD, MSc, FRCPC Department of Medicine Dalhousie University Halifax, Nova Scotia, Canada George L. Maddox, PhD Long Term Care Resources Program Duke University Center for the Study of Aging Durham, North Carolina Carol Magai, PhD Department of Psychology Long Island University Brooklyn, New York Kevin J. Mahoney, PhD Graduate School of Social Work Boston College Chestnut Hill, Massachusetts James Malone-Lee, MD, FRCP Head, Department of Medicine Archway Campus University College London London, UK P. K. Mandal, PhD Department of Psychiatry University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Ronald J. Manheimer, PhD North Carolina Center for Creative Retirement University of North Carolina at Asheville Asheville, North Carolina Spero M. Manson, PhD University of Colorado Denver Health Sciences Center Denver, Colorado Kenneth G. Manton, PhD Center for Demographic Studies Duke University Durham, North Carolina

Jennifer A. Margrett, PhD Department of Psychology West Virginia University Morgantown, West Virginia Kyriakos S. Markides, PhD Department of Psychiatry University of Texas Medical Branch Galveston, Texas Lori N. Marks, PhD University of Maryland College Park HLHP-Public & Community Health College Park, Maryland Elizabeth W. Markson, PhD Associate Director, Gerontology Center Boston University Boston, Massachusetts Sandy Markwood CEO, National Association of Area Agencies on Aging Washington, DC George M. Martin, MD Director Emeritus, Alzheimer’s Disease Research Center University of Washington Seattle, Washington Anne Martin-Matthews, PhD Scientific Director School of Social Work and Family Studies University of British Columbia Vancouver, British Columbia, Canada Lynn M. Martire, PhD Department of Psychiatry University of Pittsburgh Pittsburgh, Pennsylvania Meredith Masel, LMSW Department of Preventive Medicine and Community Health University of Texas Medical Branch Galveston, Texas Edward J. Masoro, PhD Department of Physiology University of Texas Health Science Center San Antonio, Texas

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Emad Massoud, MB, MSc, FRCSC Program Director Otolaryngology-Head & Neck Surgery Dalhousie University Halifax, Nova Scotia, Canada Roger J. M. McCarter, PhD Department of Physiology University of Texas San Antonio, Texas Gerald E. McClearn, MS, PhD Center for Developmental and Health Genetics Pennsylvania State University University Park, Pennsylvania R. J. McClure, PhD Department of Psychiatry University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Richard W. McConaghy, PhD University of Massachusetts Boston, Massachusetts Anna M. McCormick, PhD Biology of Aging Program National Institute on Aging Bethesda, Maryland Peter N. McCracken, MD, FRCPC Division of Geriatric Medicine University of Alberta Edmonton, Alberta, Canada Robert R. McCrae, PhD Gerontology Research Center National Institute on Aging Baltimore, Maryland Ian McDowell, PhD Department of Epidemiology University of Ottawa Ottawa, Ontario, Canada Debbie McKenzie, BS, PhD Department of Animal Health and Biomedical Sciences University of Wisconsin, Madison Madison, Wisconsin Mary McNally, MSc, DDS, MA Faculty of Dentistry Dalhousie University Halifax, Nova Scotia, Canada

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Contributors

Christina McNamara, RN, MN, GNC Queen Elizabeth II Health Sciences Center Dalhousie University Halifax, Nova Scotia, Canada Shelly McNeil, MD, FRCPC Dalhousie University Halifax, Nova Scotia, Canada Michelle L. Meade, PhD Beckman Institute University of Illinois at Urbana-Champaign Urbana, Illinois Kate de Medeiros, MS University of Maryland Baltimore, Maryland Zhores A. Medvedev, PhD National Institute for Medical Research London, UK Kimberly M. Meigh, PhD (c) Communication Science and Disorders University of Pittsburgh Pittsburgh, Pennsylvania Heather Menne, MGS Margaret Blenkner Research Institute The Benjamin Rose Institute Cleveland, Ohio E. Jeffrey Metter, MD Division of Epidemiology and Clinical Applications National Heart, Lung, and Blood Institute Baltimore, Maryland Mathy D. Mezey, RN, EdD, FAAN Director, The John A. Hartford Foundation Institute for Geriatric Nursing New York University New York, New York Jean-Pierre Michel, MD Geriatric Department Geneva University Geneva, Switzerland Richard B. Miller, PhD Brigham Young University Provo, Utah

Alexandra Minicozzi, PhD Department of Economics University of Texas at Austin Austin, Texas Arnold B. Mitnitski, PhD Department of Medicine and Faculty of Computer Science Dalhousie University Halifax, Nova Scotia, Canada Ethel L. Mitty, EdD, RN Steinhardt School of Education Division of Nursing New York University New York, New York Charles V. Mobbs, PhD Mount Sinai School of Medicine New York, New York Frank J. Molnar, MSc, MDCM, FRCPC CIHR CanDRIVE Research Team Elisabeth-Bruyere Research Institute Ottawa, Ontario, Canada Timothy H. Monk, DSc Clinical Neuroscience Research Center Western Psychiatric Institute and Clinic University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Harry R. Moody, PhD Brookdale Center on Aging of Hunter College The City University of New York New York, New York James T. Moore, MD Halifax Psychiatry Center Daytona Beach, Florida Vincent Mor, PhD Center for Gerontology and Health Care Brown University School of Medicine Providence, Rhode Island Pablo A. Mora, PhD Institute for Health and Department of Psychology Rutgers University New Brunswick, New Jersey

Russell E. Morgan Jr., DrPh President, SPRY Foundation Washington, DC John E. Morley, MB, MCh Department of Gerontology St. Louis University Health Sciences Center St. Louis, Missouri Roger W. Morrell, PhD The Practical Memory Institute Silver Spring, Maryland Nancy Morrow-Howell, PhD Warren Brown School of Social Work Washington University St. Louis, Missouri Penelope A. Moyers, EdD, OTR, FAOTA Department of Occupational Therapy University of Alabama at Birmingham Birmingham, Alabama Katrin Mueller-Johnson, PhD Institute of Criminology University of Cambridge Cambridge, UK Benoit H. Mulsant, MD, MS University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Joanne Mundorf Department of Communication Studies University of Rhode Island Kingston, Rhode Island Norbert Mundorf, PhD Department of Communication Studies University of Rhode Island Kingston, Rhode Island Martin D. Murphy, PhD Department of Psychology The University of Akron Akron, Ohio Ganesh C. Natarajan, MD Boston University Medical Center Boston, Massachusetts

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Contributors H. Wayne Nelson, PhD Department of Health Science Towson University Towson, Maryland F. Ellen Netting, PhD Virginia Commonwealth University School of Social Work Richmond, Virginia Nancy E. Newall, MA Health, Leisure, and Human Performance Research Institute Winnipeg, Manitoba, Canada Nancy R. Nichols, PhD Department of Physiology Monah University VIC, Australia Robert A. Niemeyer, PhD Department of Psychology University of Memphis Memphis, Tennessee Katherina A. Nikzad Graduate Center for Gerontology University of Kentucky Lexington, Kentucky Christy M. Nishita, PhD Andrus Gerontology Center University of Southern California Los Angeles, California Linda S. Noelker, PhD The Benjamin Rose Institute Cleveland, Ohio Soo Rim Noh, PhD University of Illinois at Urbana-Champaign Champaign, Illinois Larry D. Noodén, PhD Department of Biology University of Michigan Ann Arbor, Michigan Dawn D. Ogawa, BA Institute for Health and Aging University of California, San Francisco San Francisco, California Jiro Okochi, MD University of Occupational and Environmental Health Kitakyushu City, Japan

Morris A. Okun, PhD Department of Educational Psychology Arizona State University Tempe, Arizona S. Jay Olshansky, PhD School of Public Health University of Illinois at Chicago Chicago, Illinois Angela M. O’Rand, PhD Department of Sociology Duke University Durham, North Carolina Erdman B. Palmore, PhD Departments of Psychiatry and Sociology Duke University Medical Center Durham, North Carolina K. Panchalingam, PhD Department of Psychiatry University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania Alexandra Papaioannou, MD McMaster University Hamilton, Ontario, Canada Denise C. Park, PhD Department of Psychology University of Illinois at Urbana-Champaign Champaign, Illinois Scott L. Parkin Vice President, Communications The National Council on the Aging Washington, DC Christopher Patterson, MD, FRCPC McMaster University Hamilton, Ontario, Canada Nancy L. Pedersen, PhD Department of Medical Epidemiology and Biostatistics Karolinska Institute Stockholm, Sweden M. Kristen Peek, PhD Department of Preventive Medicine and Community Health University of Texas Medical Branch Galveston, Texas

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Adam T. Perzynski, PhD (c) Department of Sociology Case Western Reserve University Cleveland, Ohio Ruth Peters, BSc, MSc Imperial College Faculty of Medicine Hammersmith Campus London, UK J. W. Pettegrew, MD Departments of Psychiatry and Neurology Health Service Administration University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania John P. Phelan, PhD The Biological Laboratories Harvard University Cambridge, Massachusetts Charles D. Phillips, PhD, MPH Department of Health Policy and Management School of Rural Public Health Texas A&M University System Health Science Center College Station, Texas Amy Mehraban Pienta, MA, PhD University of Michigan Ann Arbor, Michigan Russell I. Pierce, MD, MPH Honolulu, Hawaii Robert J. Pignolo, MD, PhD Division of Geriatric Medicine University of Pennsylvania Philadelphia, Pennsylvania Karl Pillemer, PhD Department of Human Development and Cornell Institute for Translational Research on Aging Cornell University Ithaca, New York Brenda L. Plassman, PhD Department of Psychiatry Duke University Medical Center Durham, North Carolina

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Leonard W. Poon, PhD Gerontology Center University of Georgia Athens, Georgia

G. William Rebeck, PhD Neurology Service Massachusetts General Hospital Boston, Massachusetts

Peter R. Rockwood, MD Newfoundland Medical Board St. John’s, Newfoundland & Labrador, Canada

Linda Farber Post, JD, BSN, MA Bioethicist and Clinical Ethics Consultant Saddle River, New Jersey

Russel J. Reiter, PhD Department of Cellular and Structural Biology University of Texas Health Science Center San Antonio, Texas

Ekaterina Rogaeva, PhD Centre for Neurodegenerative Diseases Department of Medicine University of Toronto Toronto, Ontario, Canada

Sandra L. Reynolds, PhD School of Aging Studies University of South Florida Tampa, Florida

Darryl B. Rolfson, MD, FRCPC Division of Geriatric Medicine University of Alberta Edmonton, Alberta, Canada

Michael J. Poulin Department of Social Ecology University of California, Irvine Irvine, California Colin Powell, MB, FRCP Queen Elizabeth II Health Sciences Center Dalhousie University Halifax, Nova Scotia, Canada Pat Prinz, PhD University of Washington Seattle, Washington Jon Pynoos, PhD Andrus Gerontology Center University of Southern California Los Angeles, California Sara Honn Qualls, PhD Department of Psychology Gerontology Center University of Colorado at Colorado Springs Colorado Springs, Colorado Christine M. Quinn-Walsh, PhD (c) Neuroscience Program and Institute of Gerontology University of Michigan Ann Arbor, Michigan Paul E. Rafuse, PhD, MD, FRCSC Department of Ophthalmology Dalhousie University Halifax, Nova Scotia, Canada William L. Randall, EdD Department of Gerontology St. Thomas University Fredericton, New Brunswick, Canada Arati V. Rao, MD Department of Medicine Duke University Medical Center Durham, North Carolina

Arlan Richardson, PhD Department of Physiology Geriatric Research, Education, and Clinical Center University of Texas Health Science Center at San Antonio San Antonio, Texas Virginia Richardson, PhD College of Social Work Ohio State University Columbus, Ohio

James C. Romeis, PhD School of Public Health St. Louis University St. Louis, Missouri Sarah F. Roper-Coleman, PhD University of California, Irvine Irvine, California

Brad A. Rikke, PhD Institute for Behavioral Genetics University of Colorado Boulder, Colorado

Debra J. Rose, PhD Division of Kinesiology and Health Science Co-Director of the Center for Successful Aging California State University, Fullerton Fullerton, California

Sara E. Rix, PhD Senior Policy Advisor Public Policy Institute AARP Washington, DC

J. B. Ross, MB, BS, FRCPC D Obst RCOG Division of Dermatology Dalhousie University Halifax, Nova Scotia, Canada

Jay Roberts, PhD Department of Pharmacology Medical College of Pennsylvania Philadelphia, Pennsylvania

John Rother AARP Washington, DC

Cynthia K. Robinson, MLS Director of Library and Information Services National Primate Center University of Wisconsin, Madison Madison, Wisconsin Kenneth Rockwood, MD, FRCPC Department of Medicine Queen Elizabeth II Health Sciences Centre Dalhousie University Halifax, Nova Scotia, Canada

Graham D. Rowles, PhD Graduate Center for Gerontology University of Kentucky Lexington, Kentucky Laurence Rubenstein, MD, MPH Director, Geriatric Research, Education and Clinical Center Sepulveda, California David C. Rubin, PhD Department of Psychology Duke University Medical Center Durham, North Carolina

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Contributors Robert L. Rubinstein, PhD Department of Sociology and Anthropology University of Maryland Baltimore, Maryland Eric Rudin, MD Albert Einstein College of Medicine Bronx, New York Laura Rudkin, PhD Department of Preventive Medicine and Community Health University of Texas Medical Branch Galveston, Texas Alice S. Ryan, PhD Division of Gerontology Baltimore VA Medical Center Baltimore, Maryland Bruce Rybarczyk, PhD, ABPP (RP) Rush University Medical Center Chicago, Illinois Mark Sadler, MD, FRCP (c) Dalhousie University Halifax, Nova Scotia, Canada Judith Saxton, MD Departments of Neurology and Psychiatry University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania K. Warner Schaie, PhD, ScD (hon), Dr Phil.h.c Department of Human Development and Psychology Pennsylvania State University State College, Pennsylvania Victoria L. Scharp, MS, PhD (c) Communication Science and Disorders University of Pittsburgh Pittsburgh, Pennsylvania Susan S. Schiffman, PhD Department of Psychiatry Duke University Medical School Durham, North Carolina Kristin Grace Schneider, PhD (c) Department of Psychology Social and Health Sciences Duke University Durham, North Carolina

Lawrence Schonfeld, PhD Department of Aging and Mental Health Louise de la Parte Florida Mental Health Institute University of South Florida Tampa, Florida Richard Schulz, PhD University of Pittsburgh Pittsburgh, Pennsylvania Carol A. Schutz Executive Director, Gerontological Society of America Washington, DC Jori Sechrist, MS Purdue University West Lafayette, Indiana Daniel L. Segal, PhD Department of Psychology University of Colorado at Colorado Springs Colorado Springs, Colorado Rachael D. Seidler, PhD Department of Psychology Division of Kinesiology Neuroscience Program and Institute of Gerontology University of Michigan Ann Arbor, Michigan Julie F. Sergeant, PhD (c) University of Kansas Lawrence, Kansas Matthew C. Shake, PhD University of Illinois at Urbana-Champaign Champaign, Illinois Amy R. Shannon, Esq. Legislative Representative Federal Affairs Department AARP Washington, DC Katherine Shear, MD University of Pittsburgh Pittsburgh, Pennsylvania Tarek M. Shuman, EdD United Nations World Assembly on Aging New York, New York

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Felipe Sierra, PhD National Institute on Aging Bethesda, Maryland Merril Silverstein, PhD Andrus Gerontology Center University of Southern California Los Angeles, California Lori Simon-Rusinowitz, PhD University of Maryland, College Park HLHP-Center on Aging College Park, Maryland Eleanor M. Simonsick, PhD National Institute on Aging and The Johns Hopkins School of Medicine Baltimore, Maryland Dean Keith Simonton, PhD Department of Psychology University of California Davis, California Marilyn McKean Skaff, PhD Department of Family and Community Medicine University of California, San Francisco San Francisco, California Max J. Skidmore, PhD Department of Political Science University of Missouri Kansas City, Missouri Anderson D. Smith, PhD College of Sciences Georgia Institute of Technology Atlanta, Georgia Jacqui Smith, PhD Max Planck Institute for Human Development Berlin, Germany Matthew J. Smith, PhD Department of Physiology University of Kentucky Lexington, Kentucky Michael A. Smyer, PhD Dean, Graduate School of Arts and Sciences and Associate Vice President for Research Boston College Chestnut Hill, Massachusetts

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David L. Snyder, PhD Department of Pharmacology Medical College of Pennsylvania Philadelphia, Pennsylvania

Harvey L. Sterns, PhD Department of Psychology The University of Akron Akron, Ohio

Jay H. Sokolovsky, PhD Department of Anthropology University of South Florida St. Petersburg, Florida

Ronni S. Sterns, PhD Institute for Life-Span Development and Gerontology The University of Akron Akron, Ohio

Nina S. Sonbolian, BS Clinical Endocrinology Branch NIDDK/NIH Bethesda, Maryland William E. Sonntag, PhD Department of Physiology and Pharmacology Wake Forest University School of Medicine Winston-Salem, North Carolina Dara H. Sorkin, PhD Center for Health Policy Research University of California, Irvine Irvine, California David W. Sparrow, DSc Department of Medicine Boston University School of Medicine Brookline, Massachusetts Avron Spiro III, PhD Department of Epidemiology Boston University School of Public Health Boston, Massachusetts Sara Staats, PhD Ohio State University at Newark Newark, Ohio Bernard D. Starr, PhD Gerontology Program Marymount Manhattan College New York, New York Derek D. Stepp Director, Association for Gerontology in Higher Education Washington, DC Anthony A. Sterns, MA Creative Action, Inc. Akron, Ohio

Alan B. Stevens, PhD Director, Dementia Care Research Program Division of Gerontology and Geriatric Medicine University of Alabama Birmingham, Alabama Judy A. Stevens, PhD National Center for Injury Prevention and Control Atlanta, Georgia David G. Stevenson, PhD Department of Health Care Policy Harvard Medical School Boston, Massachusetts Peter St George-Hyslop, MD, DSc Centre for Research in Neurodegenerative Diseases Department of Medicine Division of Neurology Toronto Western Hospital Research Institute University of Toronto Toronto, Ontario, Canada Elizabeth A. L. Stine-Morrow, PhD Department of Educational Psychology University of Illinois at Urbana-Champaign Champaign, Illinois

J. Jill Suitor, PhD Purdue University West Lafayette, Indiana Robert J. Sullivan Jr., MD Department of Community and Family Medicine Duke University Medical Center Durham, North Carolina Emiko Takagi, MA, PhD (c) Andrus Gerontology Center University of Southern California Los Angeles, California Jeanette C. Takamura, MSW, PhD U.S. Department of Health and Human Services Washington, DC Alvin V. Terry Jr., PhD Director, Small Animal Behavior Core Medical College of Georgia Augusta, Georgia David R. Thomas, MD, FACP, AGSF, GSAF Division of Geriatric Medicine St. Louis University Health Sciences Center St. Louis, Missouri Vince S. Thomas, PhD Department of Community and Family Medicine Dartmouth Medical School Hanover, New Hampshire Constance Todd, MPA The National Council on the Aging Washington, DC

Leroy O. Stone, PhD University of Montreal and Statistics Canada Ottawa, Ontario, Canada

Catherine J. Tompkins, PhD Center for the Neural Basis of Cognition University of Pittsburgh Pittsburgh, Pennsylvania

Neville E. Strumpf, PhD, RN, C, FAAN Director of the Center for Gerontologic Nursing Science University of Pennsylvania School of Nursing Philadelphia, Pennsylvania

Connie A. Tompkins, PhD Communication Science and Disorders Center for the Neural Basis of Cognition University of Pittsburgh Pittsburgh, Pennsylvania

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Contributors Edgar A. Tonna, PhD, FRMS Institute for Dental Research New York University Dental Center New York, New York

Pantel S. Vokonas, MD Boston University School of Medicine Boston, Massachusetts

Maria Tresini, PhD Lankenau Institute for Medical Research Wynnewood, Pennsylvania

Heather M. Wallace University of Kentucky Lexington, Kentucky

John A. Turner AARP Washington, DC Peter Uhlenberg, PhD University of North Carolina Chapel Hill, North Carolina R. Alexander Vachon III, PhD President, Hamilton PPB Washington, DC Kimberly S. Van Haitsma, PhD Polisher Research Institute Madlyn and Leonard Abramson Center for Jewish Life North Wales, Pennsylvania James W. Vaupel, PhD Founding Director, The Max Planck Institute for Demographic Research Rostock, Germany Paul Verhaeghen, PhD Department of Psychology Syracuse University Syracuse, New York Ronald T. Verrillo, PhD Institute for Sensory Research Syracuse University Syracuse, New York Jan Vijg, PhD Basic Research Laboratory Cancer and Therapy Research Center San Antonio, Texas Michael M. Vilenchik, PhD Senior Scientist Longevity Achievement Foundation Media, Pennsylvania Dennis T. Villareal, MD, FACE, FACP Division of Geriatrics and Nutritional Science Washington University School of Medicine St. Louis, Missouri

Robert B. Wallace, MD, MSc Department of Epidemiology University of Iowa College of Public Health Iowa City, Iowa Edith Walsh, PhD RTI International Washington, DC Christi A. Walter, PhD Department of Cellular and Structural Biology University of Texas Health Science Center San Antonio, Texas Eugenia Wang, PhD Bloomfield Centre for Research in Aging Sir Mortimer B. Davis Jewish General Hospital Montreal, Quebec, Canada Huber R. Warner, PhD Biochemistry and Metabolism Branch National Institute on Aging Bethesda, Maryland Debra K. Weiner, MD Pain Medicine at Centre Commons University of Pittsburgh Medical Center Pittsburgh, Pennsylvania Carlos Weiss, MD Division of Geriatric Medicine and Gerontology The Johns Hopkins University School of Medicine Baltimore, Maryland Tracy Weitz, MPA Institute for Health and Aging University of California, San Francisco San Francisco, California

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Chris Wellin, PhD Department of Sociology and Gerontology Scripps Gerontology Center Miami University Oxford, Ohio David G. Wells, PhD Department of Molecular Cellular and Developmental Biology Yale University New Haven, Connecticut Jennie L. Wells, BSc, MSc, MD, FRCPC St. Joseph’s Health Care Parkwood Hospital and The University of Western Ontario London, Ontario, Canada Susan Krauss Whitbourne, PhD University of Massachusetts at Amherst Amherst, Massachusetts Heidi K. White, MD, MHS Department of Medicine Duke University Medical Center Durham, North Carolina Monika White, PhD President/CEO, Center for Healthy Aging Santa Monica, California J. Frank Whittington, PhD Department of Sociology Georgia State University Atlanta, Georgia Darryl Wieland, PhD, MPH Research Director, Geriatrics Services Palmetto Health Richland and Professor of Medicine University of South Carolina School of Medicine Columbia, South Carolina Joshua M. Wiener, PhD RTI International Washington, DC Kathleen H. Wilber, PhD Andrus Gerontology Center University of Southern California, University Park Los Angeles, California

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Monique M. Williams, MD Department of Medicine Washington University School of Medicine St. Louis, Missouri Sherry L. Willis, PhD Department of Human Development Pennsylvania State University University Park, Pennsylvania Arthur Wingfield, PhD Brandeis University Waltham, Massachusetts Phyllis M. Wise, PhD Department of Physiology University of Kentucky Lexington, Kentucky Christina Wolfson, PhD Department of Epidemiology and Biostatistics McGill University and Director of Centre for Clinical Epidemiology and Community Studies Jewish General Hospital Montreal, Quebec, Canada

Fredric D. Wolinsky, PhD College of Publish Health University of Iowa Iowa City, Iowa Carsten Wrosch, PhD Department of Psychology Centre for Research in Human Development Concordia University Montreal, Quebec, Canada Hans Christian Wulf, MD, DSc Department of Dermatology Bispebjerg Hospital University of Copenhagen Copenhagen, Denmark

Gwen Yeo, PhD Stanford Geriatric Education Center Stanford University School of Medicine Palo Alto, California Laurie Young Executive Director Older Women’s League Washington, DC Steven H. Zarit, PhD Department of Human Development and Family Studies Pennsylvania State University University Park, Pennsylvania

Frances M. Yang, PhD Brigham and Women’s Hospital Department of Psychiatry Harvard Medical School Boston, Massachusetts

Zachary Zimmer, PhD Population Council New York, New York

F. Eugene Yates, MD Department of Medicine/ Gerontology University of California Los Angeles, California

David Zitner, MD Director of Medical Informatics Faculty of Medicine Dalhousie University Halifax, Nova Scotia, Canada

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LIST OF ENTRIES AARP (The American Association of Retired Persons) A-B-C Model Abstract Thinking Acid-Base Balance Acquired Immune Deficiency Syndrome Activities of Daily Living Activity Theory Adaptive Capacity Adherence Adjustment ADL/IDL Adult Day Care Adult Development Adult Foster Care Homes Adult Protective Services Advanced Glycation End-Products African American Elders Age and Expertise Age Discrimination Ageism Age Stereotype Aging, Attitudes Toward Aging, Images of Aging Policy Aging Services AIDS/HIV Alcohol Use Alzheimer’s Disease: Clinical Alzheimer’s Disease: Genetic Factors Ambulatory and Outpatient Care

American Association of Homes and Services for the Aging American Federation for Aging Research American Geriatrics Society American Society on Aging Americans with Disabilities Act Anti-Aging Medicine Anxiety Aphasia APOE 4 Apoliprotein Epsilon 4 Apoptosis Architecture Arthritis Asian and Pacific Islander American Elders Assisted Living Association for Gerontology in Higher Education Attention Attention Span Autoimmunity Autonomy and Aging Baby Boom Generation Baltimore Longitudinal Study of Aging Behavior Management Bereavement Berlin Aging Study Biography Biological Aging Models Biological Models for the Study of Aging: Flies

Biological Models for the Study of Aging: Nematodes Biological Models for the Study of Aging: Rhesus Monkeys and Other Primates Biological Models for the Study of Aging: Rodents Biological Models for the Study of Aging: Transgenic Mice/Genetically Engineered Animals Biological Models for the Study of Aging: Yeast and Other Fungi Biological Theories of Aging Biology of FAT Biomarker of Aging Blood Blood Pressure Body Composition Boomers Calcium Metabolism Canadian Research on Aging Cancer Cancer Control Cancer Prevention Carbohydrate Metabolism Cardiovascular System: Heart Cardiovascular System: Overview Cardiovascular System: Vasculature Caregiver Burden Caregiving (Informal) Care Management

Italics indicate that this subject is covered under a different title.

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Case Management Cash and Counseling Cash Payments for Care Cell Aging: Relationship Between In Vitro and In Vivo Models Cell Aging In Vitro Centenarians Central and Peripheral Nervous Systems Morphology Cerebrovascular Disease: Stroke and Transient Ischemic Attack Chronobiology: Rhythms, Clocks, Chaos, Aging, and Other Trends Circulatory System Cognitive Behavioral Therapy Cognitive Dysfunction: Drug Treatment Cognitive Impairment Cognitive Processes Cognitive Therapy Communication Disorders Communication Technologies and Older Adults Community Needs Assessment Competence Complementary and Alternative Medicine Compliance Comprehensive Geriatric Assessment Compression of Morbidity Connective Tissues Consumer Education Consumer Fraud Consumer Issues Consumer Protection Continuity Theory Creativity Crime: Victims and Perpetrators Critical Theory and Critical Gerontology Cross-Cultural Research Daily Activities Death and Dying Death Anxiety Delirium

Dementia Dementia: Frontotemporal Dementia: Lewy Body Demography Dentisty, Geriatric Depression Developing Nations Developmental Psychology Developmental Tasks DHEA Diabetes Diet Restriction Disability Discrimination Disengagement Theory Disposable Soma Theory Disruptive Behaviors Divorce DNA (Deoxyribonucleic Acid): Repair Process Doctor-Patient Relationships Driving Drug Interactions Drug Reactions Drug Side Effects Duke Longitudinal Studies Early Onset Dementia Economics Economic Security Elder Abuse and Neglect Elder Law Electronic Patient Records Emotion Employee Retirement Income Security Act Employment End-of-Life Care Energy and Bioenergetics Environmental Assessment EPESE Epilepsy Episodic Memory Established Populations for Epidemiological Studies of the Elderly (EPESE) Estrogen Replacement Therapy Ethics Ethnicity Ethnographic Research

Ethnography European Academy for Medicine of Ageing (EAMA) Euthanasia Evolutionary Theory Exchange Theory Executive Function Exercise Exercise Promotion Eye: Clinical Issues Family and Medical Leave Act Family Relationships Fear of Death Fecal and Urinary Incontinence Female Reproductive System Filial Responsibility Foster Homes Frailty Friendship Frontal Lobe Dysfunction Functioning Gastrointestinal Functions and Disorders Gender Gene Expression Generalized Anxiety Disorder Generativity, Theory of Gene Therapy Genetic Heterogeneity Genetic Programming Theories Geographic Mobility Geriatric Assessment Programs Geriatric Education Centers Geriatric Medicine Geriatric Psychiatry Geriatric Research, Education, and Clinical Centers Geriatrics Gerontological Society of America Gerontology Goal Attainment Scaling Goal Setting Grandparent-Grandchild Relationships Group Therapy Growth Hormone and InsulinLike Growth Factor-1 Guardianship/Conservatorship

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Hair Health and Retirement Study Health Beliefs Health Care: Financing, Use, and Organization Health Care Policy for Older Adults, History of Health Informatics Health Information Through Telecommunication Health Insurance Health Maintenance Organizations Health-Related Quality of Life Hearing Hemispheric Asymmetries Hip Fractures Hispanic Elderly HMOs Home Equity Conversion Homelessness Home Modifications Homeostasis Homocysteine Homosexuality Hormone Replacement Therapy (HRT) Hospice Hostility Housing Human Factors Engineering Human Immunodeficiency Virus Humanities and Arts Humor Hypertension ICIDH Immune System Immunizations Implicit Memory and Learning Individual Retirement Arrangements (IRAs) Industrial Gerontology Inflation Influenza Information-Processing Theory Injury Institutionalization Instrumental Activities of Daily Living

Intelligence Interference Intergenerational Equity Intergenerational Relationships International Association of Gerontology International Classification of Functioning, Disability, and Health International Federation on Ageing International Longevity Center Internet Applications Interpersonal Psychotherapy Introversion Isomerization Job Performance Kidney and Urinary System Language Comprehension Language Production Learned Helplessness Learning Legal Services Leisure Life Course Life Events Life Expectancy Life Extension Life Review Life Satisfaction Life Span Life-Span Theory of Control Lipofuscin Lipoproteins, Serum Living Wills and Durable Powers of Attorney Locus of Control Loneliness Longevity: Societal Impact Longitudinal Data Sets Longitudinal Research Longitudinal Retirement History Survey (LRHS) Long-Lived Human Populations Long-Term Care: Ethics

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Long-Term Care Insurance, Private Long-Term Care Ombudsman Program Long-Term Care Placement Long-Term Care Policy Long-Term Care Regulation Long-Term Care Workforce Loss LRHS Macroeconomics Magnetic Resonance Spectroscopy: Brain Membrance and Energy Metabolism Marital Relationships MCI Medicaid Medicare Medication Misuse and Abuse Melatonin Membranes Memory: Autobiographical Memory: Discourse Memory: Everyday Memory: Neurochemical Correlates Memory: Remote Memory: Spatial Memory: Working Memory and Memory Theory Memory Assessment: Clinical Memory Schema Memory Training and Mnemonics Menopause: Psychological Aspects Mental Health Mental Health Services Mental Status Examination Metamemory Midlife Crisis Migration Mild Cognitive Impairment Minorities and Aging Minority Populations: Recruitment and Retention in Aging Research Mitochondrial DNA Mutations

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Mobility Modernization Theory Mood Disorders Mortality Motivation Motor Function: Central Nervous System Motor Performance Multidimensional Functional Assessment Musculoskeletal System Narrative Analysis National Association of Area Agencies on Aging National Association of Boards of Examiners for Long-Term Care Administrators National Council on Aging National Institute of Mental Health Epidemiologic Catchment Area Project National Institute on Aging National Institute on Aging: Biology of Aging Program National Long-Term Care Survey Native Alaskans Native American Elders Native Peoples Neuroendocrine Theory of Aging Neuroplasticity Neuroticism Neurotransmitters in the Aging Brain Neurotrophic Factors in Aging Normative Aging Study Nursing Home Reform Act Nursing Homes Nutrition Nutrition Programs: Meals on Wheels Obesity Older Americans Act Older Women’s League Older Workers Oral Health Organizations in Aging

Osteomalacia Osteoporosis Outpatient Care Oxidative Stress Theory Pain and Pain Management Palliative Care Parent-Child Relationships Parkinson’s Disease Pension Plans Pensions: History Pensions: Policies and Plans Personal Accounts Personal Care/Personal Assistant/Personal Attendant Services Personality Pets Pharmacodynamics Phobias Physician-Assisted Suicide Physiological Adaptation Plant Aging Policy Analysis: Issues and Practices Political Behavior Political Economy of Aging Theory Polypharmacy Population Aging Population Aging: Developing Countries Postmenopausal Hormone Therapy Poverty Prejudice Pre-Senile Dementia Pressure Ulcers Preventive Health Care Prion Diseases Prison Populations Problem Solving Problem-Solving Therapy Productive Aging Productivity Professional Nursing Progeroid Syndromes Program of All-Inclusive Care for the Elderly (PACE) Prostate Disease

Prostatic Hyperplasia Proteins: Posttranslational Modifications Proteolysis and Protein Turnover Psychiatric Diagnosis and the DSM Psychological Assessment Psychosocial Functioning Psychosocial Interventions Psychotherapy Purpose in Life Quality Improvement and Assurance in Health Care Quality of Life Racemization Racial and Ethnic Groups Reaction Time Reality Orientation Rehabilitation Religion Reminiscence Resilience Resource Utilization Groups Respiratory System Respite Care Restraints: Physical/Chemical Retailing and Older Consumers Retirement Retirement Communities Retirement Income and Pensions Retirement Planning Reverse Mortgages Rigidity Rural Elders Savings Seizures Selection, Optimization, and Compension Model Self-Assessed Health Status Self-Care Activities Self-Concept Self-Esteem Senescence and Transformation Senior Centers Senior Companion Program

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Sexuality Sibling Relationships Side Effects Skeletal Muscle Characteristics Skin Aging Sleep Sleep Disorders Social Breakdown Theory Social Capital and Social Cohesion Social Cognition and Aging Social Gerontology: Theories Social Isolation Social Learning Theory Social Problems: Aging, Poverty, and Health Social Security Social Security Income Program Social Security Reform Social Stratification Social Stress Social Support Sodium Balance and Osmolality Regulation Somatic Mutations and Genome Instability Special Care Units for Persons with Dementia

Specialized Housing/ Housing with Suppportive Services Speech Stem Cells Stress Stress and Coping Stress Theory of Aging Stroke Subjective Well-Being Substance Abuse and Addictions Successful Aging Suicide Sundown Syndrome Supplementary Security Income Program Support Groups Surveys Swedish Twin Studies Taste and Smell Tax Policy Technology Telemedicine and Telegeriatrics Telomeres and Cellular Senescence Temperature Regulation Abnormality Terminal Change

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Testosterone Replacement Therapy Thanatology Third World Thyroid Gland Touch Transportation Tuberculosis Tumor Suppression Twins Studies in Aging Research Urinary Tract: Symptoms, Assessment, and Management Vascular Cognitive Impairment Veterans and Veteran Care Vision: System, Function, and Loss Vitamins Volunteerism Wandering Wear-and-Tear Theories Widowhood Wisdom Women’s Changing Status: Health, Work, Family Word-Finding Difficulty

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A AARP (THE AMERICAN ASSOCIATION OF RETIRED PERSONS) With more than 35 million members, AARP is the leading not-for-profit, nonpartisan membership organization for people who are 50 years of age and older in the United States. It is dedicated to making life better, not only for its members, but for all Americans. The AARP vision is a society in which all can age with independence, dignity, and purpose.

rural; taking care of children, taking care of parents, or both, and empty nesters. The organization’s goals include: • Informing members and the public on issues important to older Americans and their families. • Advocating on legislative, consumer, and legal issues before Congress, the state houses of all 50 states, the courts, and regulatory bodies at every level of government. • Fostering community service and health promotion programs. • Offering a wide range of special products and personal services to members.

Mission AARP provides information and resources; engages in legislative, regulatory, and legal advocacy; assists members in serving their communities; and offers a wide range of benefits, products, and services. These include AARP The Magazine, which is published every two months and is the highest circulation magazine in the United States; the AARP Bulletin, a monthly newspaper; AARP Segunda Juventud, a quarterly newspaper in Spanish; NRTA Live & Learn, a quarterly newsletter for 50+ educators; and www.aarp.org, the award-winning Web site. AARP has staff and offices in all 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. AARP is dedicated to enhancing the quality of life as people age by leading positive social change and delivering value to members. AARP recognizes that the phrase “quality of life” means different things to different people. Some need help coping with the basics of daily living. Others want to get involved in personally rewarding volunteer activities or health promotion programs. And, some members want to make the most of their leisure time with sports and travel opportunities. The range of connections to services, activities, and products possible through AARP’s programs is so large that few are aware of all of them. AARP serves the most rapidly growing portion of the population—an increasingly diverse segment— who are working full-time, part-time, and retired; married, widowed and single; urban, suburban, and

Membership Membership in AARP is open to any person who is 50 years of age or older. Almost one-third of the U.S. population falls into this age group and more than 45% of all people over the age of 50 are AARP members. U.S. citizenship, or even U.S. residence, is not a requirement for membership. More than 40,000 members live outside the United States. People also do not have to be retired to join. In fact, 44% of AARP members work part time or full time. For this reason, AARP shortened its name in 1999 from the American Association of Retired Persons to just four letters. AARP. The “median age” of AARP members is 65, so half are younger than 65 and half are older. Slightly more than half of members are women.

History Ethel Percy Andrus, PhD, who retired as principal of a large Los Angeles high school, founded the National Retired Teachers Association (NRTA) in 1947 to promote her philosophy of active, productive aging and to respond to the need of retired teachers for health insurance. At that time, private health insurance was virtually unavailable to older Americans, for it was not until 1965 that the Congress enacted Medicare, which provides healthcare benefits to those 65 and older. 1

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Dr. Andrus approached dozens of insurance companies until she found one willing to take the risk of insuring older persons. She then developed other benefits and programs for retired teachers, including a discount mail-order pharmacy service. Over the years NRTA heard from thousands of others who wanted to know how they could obtain insurance and other NRTA benefits without being retired teachers. In 1958, Dr. Andrus realized the time had come to create a new organization open to all Americans. Today, NRTA continues as a division within AARP. In 1963, Dr. Andrus established an international presence for AARP by founding the Association of Retired Persons International (ARPI), with offices in Lausanne, Switzerland, and Washington, D.C. While ARPI disbanded as a separate organization in 1969, AARP has continued to develop networks and form coalitions abroad with its office of International Affairs (IA). IA is creating a growing presence in the worldwide aging community, promoting the well-being of older people everywhere through advocacy, education, and policy development. IA also functions as a clearinghouse for information on successful programs and possibilities for older people throughout the world, both learning from and mentoring those abroad. Dr. Andrus’s motto for AARP was “To serve, not to be served.” Since 1958, AARP has grown and changed dramatically in response to societal changes; however, AARP has remained true to its founding principle.

Advocacy Efforts For a number of years, Fortune magazine has named AARP the nation’s foremost advocacy organization (“most powerful lobbying organization”). This is an extraordinary accomplishment given that AARP is a not-for-profit, nonpartisan organization that has no Political Action Committee (PAC), does not contribute any money to candidates or political parties, and does not endorse or oppose political candidates or parties. The strength comes from members choosing to be involved in policy issues that affect them and their families. Whether the issue is Social Security, Medicare, Medicaid, pension protection and reform, age discrimination, long-term care, work and retirement, or transportation, AARP volunteers make their presence count on Capitol Hill and in state capitals throughout the country.

AARP members are not only vocal on health and income security issues, but they are active advocates on consumer issues as well. AARP volunteers are fighting consumer fraud, including telemarketing, sweepstakes, and mail fraud. Issues range from the rights of grandparents to setting utility and telephone rates to safety standards for manufactured housing. AARP has had particular success in the courts opposing predatory lending, a practice by which older Americans are encouraged to remortgage homes that are paid off or nearly paid off for egregiously high interest rates and unfavorable payoff periods. AARP backs up its advocacy efforts with quality policy research efforts. The AARP Public Policy Institute (PPI) was created in 1985 to conduct objective, relevant, and timely policy analyses to inform the development of AARP’s public policy positions, and to contribute to public debate and discussion. Research findings are typically published in the form of detailed reports such as Issue Papers, Issue Briefs, and Data Digests. PPI also publishes numerous shorter Fact Sheets, In-Briefs, and “FYIs” each year. All are available on the Web site.

Volunteer Programs AARP volunteers are the heart and soul of the Association. The members of its Board of Directors and its national officers are all unpaid volunteers, as are the state presidents and thousands of legislative and program volunteers and chapter leaders. Members can be involved in a number of innovative community service and education programs, including tax preparation assistance, driver training and re-education, grief and loss counseling, and independent living programs, if they choose. Through their involvement in national state, and local affairs, AARP volunteers are shaping the experience of aging positively for members and for society.

Special Services Dr. Andrus was a pioneer in establishing group health insurance for older Americans. She recognized then, as AARP does today, that making such services available to—and affordable for—older Americans is essential to maintain the quality of life for all people as they grow older. From the

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beginning, AARP has responded to members’ needs by making available products and services created especially for them. Through market innovation and leadership, AARP Services, Inc. (ASI), a wholly owned subsidiary of AARP created in 1999, manages the wide range of products and services offered as benefits to AARP’s members. ASI also develops new products and services that reflect the changing expectations and needs of members. Developing good products means selecting quality business partners as providers, so ASI continually monitors each service’s operation to make sure AARP’s service-provider partners are meeting the Association’s standards. Among the programs ASI manages are Medicare supplemental insurance, automobile/homeowners insurance, a prescription drug program, long-term care insurance, a motoring plan, a credit card, and life insurance. ASI also oversees the AARP Privileges Program, designed to respond to the wideranging needs of the AARP traveler by providing discounts on hotels and motels, auto rentals, airlines, cruise lines, vacation packages, entertainment products, and consumer goods. Discounted legal fees are available from state Bar Association members of the AARP Legal Services Network. Profits from any of the services offered by ASI are rolled back into the activities of the non-profit AARP organization so that dues for members can be kept as low as possible and charitable services supported.

Foundation programs are funded by grants, taxdeductible contributions from AARP members, the general public, and AARP. In 2004, the Foundation reorganized and greatly enlarged its capacity to raise additional funds from individuals, corporations, other foundations, and government agencies. The Foundation also strengthened its partnership with AARP by increasing support of AARP’s charitable programs that advance the Foundation’s mission. AARP members support the Foundation’s charitable work through volunteerism, as well as through annual and long-term financial contributions.

The Foundation

A-B-C MODEL

Through the AARP Foundation, AARP works to expand the understanding of aging with research and service. In its 30 years of grant making, the Foundation has supported more than 630 projects with grants totaling approximately $35 million. Foundation programs provide security, protection, and empowerment for older people in need. Low-income older workers receive the job training and placement they need to rejoin the workforce. Free tax preparation is provided for low- and moderate-income older individuals. The Foundation’s litigation staff protects the legal rights of older Americans in critical health, long-term care, and consumer and employment court cases. Additional programs provide information, education, and services to ensure that people older than 50 lead lives with independence, dignity, and purpose.

See Behavior Management

Conclusion AARP recognizes that aging is synonymous with living. As we progress along life’s continuum, we find that what matters most is not age but experiences along the way. AARP’s founder Dr. Ethel Percy Andrus once observed, “The stereotype of old age—increasingly costly and troublesome—is contradicted by the host of happy and productive older people participating and serving beyond the call of duty. Second only to the desire to live is the natural yearning to be wanted and needed, to feel that one’s contribution to life is essential.” John Rother See also Organizations in Aging

ABSTRACT THINKING Young children understand the relation between objects and events in a functional manner. They note that the first object is seen to go with or to operate on the second object. Complementarity criteria are integral components of their thinking. By contrast, older children and young adults tend to use similarity criteria. As one ages, however, the use of complementarity criteria increases once again (Reese & Rodeheaver, 1985). The reversal to complementarity as people age is thought to be caused by environmental factors rather than attributable to changes

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in competence. Young children as well as elderly people are rarely required to state their thoughts in a specifically prescribed way, and complementary categorization may therefore seem more natural since such categories are grouped naturally in time and space. Older adults do not necessarily lose the ability to use more abstract criteria, but they are often willing to indulge in an alternative mode that offers greater imaginary scope. Complementarity as an aspect of thinking has been found to be more prevalent in nonprofessional than in professional men or women from age 25 to 69, with neither age nor gender differences found to be significant (Denney, 1974). Luria (1976) observed the same phenomena in a study in Central Asia, where uneducated workers were more likely to engage in concrete thought, while educated collective farm members were more prone to use abstract thought. Abstract thinking and aging has also been investigated in the context of the crystallized-fluid ability model (cf. Cattell, 1963). Convergent fluid abilities that involve abstract thinking have shown an average decline somewhat earlier than was found for the more concrete information-based crystallized abilities. Paradoxically, abstract thinking may become more important as people age because many lifelong experiences must be reappraised. Even well-established everyday behaviors that previously could be performed in a routine and concrete manner may now require a modicum of abstract thought to evoke a novel response appropriate to changed circumstances (cf. Schaie & Willis, 1999; Willis & Schaie, 1993). An alternate explanation for the reduction in abstract reasoning with increasing age might be sought in the reduction of cortical volume in brain areas essential for high levels of abstract thinking (cf. Gunning-Dixon & Raz, 2003). The contention that the increased incidence of concrete thought in elderly people may be the result of experiential rather than neurological factors is further supported by positive results of training studies that involve persons who had not earlier used abstract classification principles (Denney, 1974), or who had had a lower performance rating on abstract ability measures (Schaie & Willis, 1986; Willis, 1996, 2001).

K. Warner Schaie

See also Cognitive Processes Intelligence Metamemory Problem Solving

References Cattell, R. B. (1963). Theory of fluid and crystallized intelligence: A critical experiment. Journal of Educational Psychology, 54, 1–22. Denney, N. W. (1974). Classification ability in the elderly. Journal of. Gunning-Dixon, F. M., & Raz, N. (2003). Neuroanatomical correlates of selected executive functions in middle-aged and older adults: A prospective MRI study. Neuropsychologia, 41, 1929–1941. Luria, A. R. (1976). Cognitive development: Its cultural and social foundations. Oxford, UK: Oxford University Press. Reese, H. W., & Rodeheaver, D. (1985). Problem solving and complex decision making. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (2nd ed., pp. 474–499). New York: Van Nostrand Reinhold. Schaie, K. W., & Willis, S. L. (1986). Can intellectual decline in the elderly be reversed? Developmental Psychology, 22, 223–232. Schaie, K. W., & Willis, S. L. (1999). Theories of everyday competence and aging. In V. L. Bengtson & K. W. Schaie (Eds.), Handbook of theories of aging (pp. 174– 195). New York: Springer Publishing Co. Willis, S. L. (1996). Everyday cognitive competence in elderly persons: Conceptual issues and empirical finding. Gerontologist, 36, 595–601. Willis, S. L. (2001). Methodological issues in behavioral intervention research with the elderly. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (5th ed., pp. 78–108). San Diego, CA: Academic Press. Willis, S. L., & Schaie, K. W. (1993). Everyday cognition: Taxonomic and methodological considerations. In J. M. Puckett & H.W.Reese (Eds.), Mechanisms of everyday cognition (pp. 33–54). Hillsdale, NJ: Erlbaum.

ACID-BASE BALANCE Hydrogen ion (H+ ) is a highly reactive cation. For that reason it is essential that the concentration of Fr in the body fluids be tightly regulated. In healthy people the H+ concentration of the blood plasma ranges from 36 to 43 nanomoles per liter (pH 7.457.35). H+ is produced by acids and consumed by

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bases; thus, the regulation of the H+ concentration is called acid-base balance. The body is continuously producing acids and bases. The production of carbon dioxide, which is a major end product of metabolism, is equivalent to producing carbonic acid. Although large quantities of carbon dioxide are produced each day, they are eliminated from the body by the lungs through alveolar ventilation as quickly as they are produced. The important point is that the nervous system controls alveolar ventilation so that the concentration of carbon dioxide in the blood plasma is maintained at the level needed for the maintenance of an appropriate H+ concentration in the body fluids. The body also produces fixed acids (i.e., acids not eliminated by the lungs) and produces bases. If fixed acid production is in excess of base production, the kidneys excrete the excess H+ in the urine. It is also the case that if base production is in excess of the fixed acid production, the kidneys excrete the excess base in the urine. Although the finely regulated pulmonary and renal functions can sometimes transiently fail to do the job, no immediate problem occurs because the body is rich in chemical buffers that serve to blunt rapid change in H+ concentration. Do these exquisite systems for the control of H+ concentration continue to function effectively at advanced ages? It has long been held that healthy elderly living in usual unchallenged conditions have no problem in maintaining normal acid-base balance (Lye, 1998). However, a careful meta-analysis of published data on acid-base balance and age has challenged this long-held view (Frassetto & Sebastian, 1996). This analysis indicates that a significant rise in steady-state blood I-i+ concentration occurs with increasing adult age. Moreover, assessment of the concentration of blood carbon dioxide concentration revealed a decrease with age, and this would be expected because of the increase in alveolar ventilation by the respiratory system in response to a rising blood H+ concentration. On the basis of these findings, plus the meta-analysis assessment that plasma bicarbonate concentration decreases with age, it is likely that the age-associated deterioration of kidney function is responsible for the increasing H+ concentration. Of course, to be certain of the gerontological validity of the findings of this meta-analysis requires data from a welldesigned longitudinal study. The results of such a study have yet to be reported. However, if the conclusions from this meta-analysis are valid, an age-associated

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progressive increase of this magnitude in the near steady-state H+ concentration could have negative consequences in regard to bone loss, muscle mass loss, and kidney function. In contrast to uncertainty of the effect of age on unchallenged, near steady-state acid-base balance, the evidence is clear that healthy elderly people respond less well than the young to an acidbase challenge. In an early study, young and old were challenged by a load of ammonium chloride (Adler, Lindeman, Yiengst, Beard, & Shock, 1968). The body metabolizes ammonium chloride to hydrochloric acid. In that early study, it was found that increased blood levels of H+ and decreased levels of bicarbonate ion persisted much longer in old than in young individuals. Altered kidney function appears to be the main reason for this difference between young and old. Indeed during the first 8 hours following ammonium chloride administration, a much greater percentage of the acid load is excreted in the urine by the young than by the old (Lubran, 1995). There is also evidence that the elderly cope less effectively with increased acid loads caused by exercise. This decrease in the ability of the kidney to excrete H+ predisposes the elderly to the development of and delayed recovery from metabolic acidosis (Lindeman, 1995). Whether the respiratory change in alveolar ventilation is as effective in the elderly in compensating for changes in blood H+ concentration is subject to debate; not all studies have found the response of the respiratory system to chemical stimuli to be blunted with increasing age (Rubin, Tack, & Cherniack, 1982). Of course, the elderly have many age-associated diseases that predispose them to acid-base disorders (e.g., chronic obstructive pulmonary disease and chronic renal disease). Thus, acid-base disorders are commonly encountered in geriatric medicine. Edward J. Masoro See also Kidney and Urinary System

References Adler, S., Lindeman, R. D., Yiengst, M. J., Beard, E.S., & Schock, N. W. (1968). Effect of acute acid loading on urinary acid excretion by the aging human kidney. Journal of Laboratory and Clinical Medicine, 72, 278– 289.

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Lindeman, R. D. (1995). Renal and urinary tract function. In E. J. Masoro (Ed.), Handbook of physiology: See, 11, Aging (pp. 485–503). New York: Oxford University Press. Lubran, M. M., (1995). Renal function in the elderly. Annals of Clinical and Laboratory Science, 25, 122– 133. Rubin, S., Tack, M., & Cherniack, N. S. (1982). Effect of aging on respiratory responses to CO2 and inspiratory resistance loads. Journal of Gerontology, 37, 306–312.

ACQUIRED IMMUNE DEFICIENCY SYNDROME See AIDS/HIV

ACTIVITIES OF DAILY LIVING The term activities of daily living (ADL) refers to a range of common activities whose performance is required for personal self-maintenance and to remain a participating member of society. As illustrated by the International Classification of Functioning, Disability, and Health (ICF) (WHO, 2001), ADL is a central aspect of human functioning, affected by and affecting health conditions, physiological and psychological functioning, and participation in life situations, while also interacting with environmental and personal factors (de Kleijn-de Vrankreijker, 2003). Intended for international use, ICF should provide a common language for gathering data and interdisciplinary communication. That, however, remains for the future. To date, the recoding of current disability survey questions to meet ICF criteria has proved to be difficult (Swanson et al., 2003). Nevertheless, the U.S. National Committee on Vital and Health Statistics identified ICF “as the only viable code set for consistently reporting functional status.” (Iezzoni & Greenberg, 2003). The theoretical model of ADL proposed by Katz (1983) suggests three areas: mobility (e.g., Rosow & Breslau, 1966); instrumental (I) ADL, which is concerned with complex activities needed for independent living (e.g., taking own medications, using the telephone, handling everyday finances, preparing meals, shopping, traveling, and doing housework (Lawton & Brody, 1969)); and basic personal care

tasks (BADL) (e.g., toileting, dressing, eating, transferring, grooming, and bathing (Katz et al., 1959)). More recent analyses, typically based on large representative samples of older persons, offer conflicting suggestions regarding the psychometric characteristics of IADL and BADL items. Some investigators have found that these items constitute not two, but three dimensions (Fillenbaum, 1985; Stump, Clark, Johnson & Wolinsky, 1997; Thomas, Rockwood & McDowell, 1998). Within each factor, the items have sometimes been found to constitute a hierarchical measure, but this is not invariable. In fact, a multiplicity of hierarchies have been identified for the Katz items (Lazaridis et al., 1994). While there is considerable agreement across studies in the items included in each of these groups, differences in the items present reflect the datasets from which information was drawn. Thus, the study of Thomas et al. (1998), based on data from the Canadian Study of Health and Aging, which used the Older Americans Resources and Services ADL scale (Fillenbaum, 1988), identifies toileting, dressing, eating, transferring, and grooming as Basic self-care. Intermediate self-care items include bathing, walking indoors, housework, meal preparation, shopping, and traveling alone, while Complex self-management (which is recognized as having a substantial cognitive component) includes handling money, using telephone, and handling own medicine. Alternatively, BADL and IADL items have been found to constitute a hierarchy (Spector & Fleishman, 1998; Suurmeijer et al., 1994). Spector & Fleishman (1998) used a set of items which overlap considerably with those of Thomas et al. (1998)— the only differences are the absence of grooming and the inclusion of incontinence, laundry, and the specification that housework is light—yet have come to a different conclusion regarding multidimensionality. Possibly alternative statistical techniques and different samples of elders (nationally representative vs. disabled) account for the discrepant findings. Standardized ADL assessments have increased in use, acceptance, and importance during the last 40 years, while the number of such assessments has proliferated. Current measures date back to the Katz Index of Independence in Activities of Daily Living (Katz et al., 1959) and to the Barthel Index (Mahoney & Barthel, 1965). Both were developed in rehabilitation settings to measure tasks basic to personal self-care, and include comparable items, such

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as feeding, continence, transferring, use of toilet, dressing, bathing, and for the Barthel, mobility. Use of these scales has since diverged. Modifications of the Barthel permit increasingly specific focus on the type of rehabilitative intervention required and the impact of that intervention. Experience with this and related assessments used in rehabilitation have culminated in the Functional Independence Measure (FIM™, Linacre et al., 1994), which operationalizes the Uniform Data System for Medical Rehabilitation (UDS). FIM™ is currently the basis for reimbursement in rehabilitation, where level of functioning, and not diagnosis, indicates service needs. (See Multidimensional Functional Assessment for further information on FIM™.) The level of detail required in rehabilitation is inappropriate where assessment of the general older population is concerned, because the overwhelming majority can perform basic activities. To better discriminate within the general older population, inquiry is directed to more difficult tasks, including mobility and instrumental ADL (although not all of these tasks are more difficult to perform than BADL activities). The multiplicity of measures that exist differ in several important regards. Some are intended for general use, others with a specific subgroup (e.g., persons with arthritis, cognitive impairment, dementia, multiple sclerosis, stroke, etc.; see e.g., Bowling, 2001, for measures intended for neurological and rheumatological conditions, and cardiovascular disease; Burns, Lawlor & Craig, 2004, for measures designed for psychiatric conditions, including dementia; and Spilker, 1996 for measures in multiple areas). Information may be sought from the individual, from a family member, or a service provider. Information from the three may not be equivalent (Dorevitch, Cossar, Bailey, Bisset, Lewis, Wise, & McLennon, 1992). Items may differ across measures. Inquiry may focus on whether the person can perform the task (i.e., capability) or does perform the task (actuality), with what level of difficulty, or pain, and whether problems are the result of particular health conditions. There may be inquiry into the type of help received (e.g., from an aid, a person, or both); help from a person is seen as indicating more dependence than the use of an aid. The time interval considered (current, past week, past month, past year) may vary. Possible responses may be dichotomous (e.g., can do unaided

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vs. not), trichotomous (e.g., can perform unaided, need some help, cannot perform at all), or polychotomous (e.g., FIM™ uses very clearly specified seven-point scales). Differences in wording have yielded estimates of disability prevalence differing by up to 60%, with potentially serious impact on service planning (Freedman & Martin, 2004; Wiener, Hanley, Clark, & van Nostrand, 1990). Statistical techniques are now being applied in an attempt to equate different measures (Jette, Haley & Ni, 2003). While the majority of scales require self- (or proxy-) report, performance scales have also been developed. Information from the two sources are not identical, but may be complementary, with level of performance valuable in distinguishing among persons who self-report no problems (Hoeymans, Feskens, van den Bos, & Kromhout, 1996; Myers, Holiday, Harvey, & Hutchinson, 1993; Reuben et al., 2004; Young et al., 1996). Although of extraordinary value, current ADL scales nevertheless have some drawbacks. Environmental factors that might affect performance are seldom considered (Freedman & Martin, 2004). Some activities are rarely included (e.g., sexual activities), and few measures have kept pace with technological advances (e.g., use of ATMs, microwaves, cell phones). In its initial wave the Health and Retirement Survey (Soldo, Hurd, Rodgers, & Wallace, 1997) included such items, but these were later dropped. ADL tasks may be affected by gender and culture. The manner in which various activities must be performed may vary from country to country. Tasks important in one country may not be as relevant in another. Some tasks may not be relevant at all in, say, a developing country (Fillenbaum et al., 1999), or may measure different abilities (Jitapunkul, Kamolratanakul & Ebrahim, 1998). ADL is central to any assessment of personal independent functioning. Information on ADL capacity has been used more extensively and for a greater variety of purposes than has information from any other type of assessment. It has been used to indicate individual social, mental, and physical functioning, as well as for diagnosis; to determine service requirement and impact; to guide service inception and cessation; to estimate the level of qualification needed in a provider; to assess need for structural environmental support; to justify residential location; to provide a basis for personnel employment

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decisions; to determine service change and provide arguments for reimbursement; to calculate active and disabled life expectancy; and to estimate eligibility for specific services (e.g., attendant allowances). Accurate assessment of ADL is probably one of the most valuable of measures. Excellent reviews, which provide information on psychometric characteristics, and some of which reproduce the ADL measures used in assessment of the elderly may be found in Bowling, 1997; 2001; Burns, Lawlor, & Craig, 2004; Israel, Kozarevic, & Sartorius, 1984; McDowell & Newell, 1996; Salek, 1998; and on the QOLID (Quality of Life Instruments Database) site (www.qolid.com). The latter lists 1000 quality-of-life instruments, including detailed information on more than 450 of these. Gerda G. Fillenbaum See also Disability Mobility Self-Care Activities

References Bowling, A. (1997). Measuring health: A review of quality of life measurement scales. Philadelphia. Philadelphia: Open University Press. Bowling, A. (2001). Measuring disease: A review of disease-specific quality of life measurement scales (2nd ed.) Philadelphia, Open University Press. Burns, A., Lawlor, B., & Craig, S. (2004). Assessment scales in old age psychiatry (2nd ed.). New York: Martin Dunitz, Taylor & Francis Group. de Kleijn-de Vrankreijker, M. W. (2003). The long way from the International Classification of Impairments, Disabilities and Handicaps (ICIDH) to the International Classification of Functioning, Disability and Health (ICF). Disability and Rehabilitation, 25, 561– 564. Dorevitch, M. I., Cossar, R. M., Bailey, F. J., Bisset, T., Lewis, S. J., Wise, L. A., & McLennan, W. J. (1992). The accuracy of self and informant ratings of physical functional capacity in the elderly. Journal of Clinical Epidemiology, 45, 791–798. Fillenbaum, G. G. (1985). Screening the elderly: A brief instrumental activities of daily living measure. Journal of the American Geriatrics Society, 33, 698–706. Fillenbaum, G. G. (1988). Multidimensional functional assessment of older adults: The Duke Older Ameri-

cans Resources and Services Procedures. Hillsdale, NJ: Erlbaum. Fillenbaum, G. G., Chandra, V., Ganguli, M., Pandav, R., Gilby, J. E., Seaberg, E. L., Belle, S., Baker, C., Echemont, D. A., & Nath, L. M. (1999). Development of an activities of daily living scale to screen for dementia in an illiterate rural older population in India. Age and Ageing, 28, 161–168. Freedman, V. A., & Martin, L. G. (2004). Incorporating disability into population-level models of health change at older ages. Journal of Gerontology, 59A, 602–603. Hoeymans, N., Feskens, E. J. M., van den Bos, G. A. M., & Kromhout, D. (1996). Measuring functional status: Cross-sectional and longitudinal associations between performance and self-report (Zutphen Elderly Study 1900-1993). Journal of Clinical Epidemiology, 49, 1103–1110. Iezzoni, L. I., & Greenberg, M. S. (2003). Capturing and classifying functional status information in administrative databases. Health Care Financing Review, 24(3), 61–76. Israel, L., Kozarevic, D., & Sartorius, N. (1984). Source book of geriatric assessment. Basel: Karger. Jette, A. M., Haley, S. M., & Ni, P. (2003). Comparison of functional status tools used in post-acute care. Health Care Financing Review, 24(3), 13–24. Jitapunkul, S., Kamolratanakul, P., & Ebrahim, S. (1998). The meaning of activity of daily living in a Thai elderly population: Development of a new index. Age & Ageing, 23, 97–101. Katz, S., Chinn, A. B., and the staff of the Benjamin Rose Hospital (1959). Multidisciplinary studies of illness in aged persons. Part II. New classification of functional status in activities of daily living. Journal of Chronic Diseases, 9, 55–62. Katz, S. (1983). Assessing self-maintenance: Activities of daily living, mobility and instrumental activities of daily living. Journal of the American Geriatrics Society, 31, 721–727. Lawton, M. P., & Brody, E. M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179– 186. Lazaridis, E. N., Rudberg, M. A., Furner, S. E., & Cassel, C. K. (1994). Do activities of daily living have a hierarchical structure? An analysis using the Longitudinal Study of Aging. Journal of Gerontology: Medical Sciences, 49, M47–M51. Linacre, J. M., Heinemann, A. W., Wright, B. D., Granger, C. V., & Hamilton, B. B. (1994). The structure and stability of the Functional Independence Measure. Archives of Physical Medicine and Rehabilitation, 75, 127–132.

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Activity Theory Mahoney, F. I. & Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Maryland State Medical Journal, 14, 61–65. McDowell, I., & Newell, C. (1996). Measuring health: A guide to rating scales and questionnaires (2nd ed.). New York: Oxford University Press. Myers, A., Holiday, P. J., Harvey, K. A., & Hutchinson, K. S. (1993). Functional performance measures: Are they superior to self-assessments? Journal of Gerontology: Medical Sciences, 48, M196–M206. QOLID Quality of Life Instruments Database. www.qolid.com Reuben, D. B., Seeman, T. E., Keeler, E., Hayes, R. P., Bowman, L., Sewall, A., Hirsch, S. H., Wallace, R. B., & Guralnik, J. M. (2004). The effect of self-reported and performance-based functional impairment on future hospital costs of community-dwelling older persons. Gerontologist, 44, 401–407. Rosow, I., & Breslau, N. (1966). A Guttman health scale for the aged. Journal of Gerontology, 21, 556– 559. Salek, S. (1998). Compendium of quality of life instruments. Chichester, UK: John Wiley & Sons. Soldo, B. J., Hurd, M. D., Rodgers, W. L., & Wallace, R. B. (1997). Asset and Health Dynamics among the Oldest Old: An overview of the AHEAD study. Journals of Gerontology: Social Sciences, 52B (Special Issue), 1–20. Spector, W. D., & Fleishman, J. A. (1998). Combining activities of daily living with instrumental activities of daily living to measure functional disability. Journals of Gerontology: Psychological and Social Sciences, 53B, S46–S57. Spilker, B. (Ed.). Quality of life and pharmacoeconomics in clinical trials. Philadelphia: Lippincott-Raven. Stump, T. E., Clark, D. O., Johnson, R. J., & Wolinsky, F. D. (1997). The structure of health status among Hispanic, African American, and White older adults. Journals of Gerontology: Psychological and Social Sciences, 52B, Special No., 49–60. Swanson, G., Carrothers, L., & Mulhorn, K. A. (2003). Comparing disability survey questions in five countries: a study using ICF to guide comparisons. Disability and Rehabilitation, 25, 665–675. Suurmeijer, T. P., Doeglas, D. M., Moum, T., Braincon, S., Krol, B., Sanderman, R., Guillemin, F., Bjelle, A., & van den Heuvel, W. J. (1994). The Groningen Activity Restriction Scale for measuring disability: Its utility in international comparisons. American Journal of Public Health, 84, 1270–1273. Thomas, V. S., Rockwood, K., & McDowell, I. (1998). Multidimensionality in instrumental and basic activities of daily living. Journal of Clinical Epidemiology, 51, 315–321.

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Wiener, J. M., Hanley, R. J., Clark, R., & van Nostrand, N. F. (1990). Measuring the activities of daily living: Comparisons across national surveys. Journal of Gerontology, 45(6), S229–237. World Health Organization (2001). International classification of functioning, disability and health. Geneva, WHO. www.who.int/classification/icf Young, N. L., Williams, J. I., Yoshida, K. K., Bombadier, C., & Wright, J. G. (1996). The context of measuring disability: Does it matter whether capability or performance is measured? Journal of Clinical Epidemiology, 49, 1097–1101.

ACTIVITY THEORY In the gerontology of the early 1960s, activity theory and disengagement theory became opposing grand metaphors for successful aging. In the case of activity theory, the archetype image portrayed an older person who had managed to maintain vigor and social involvement despite the vagaries of aging. For disengagement theory, the archetype image was of an older person who had voluntarily and gracefully disengaged from the hustle and bustle of midlife to a more serene and satisfying contemplation of life from a distance. These dualistic images of two very different paths of aging have been a part of Western civilization for a long time. Robert Havighurst and his colleagues at the University of Chicago (Havighurst, 1963; Havighurst, Neugarten, and Tobin, 1963) were the early spokespersons for activity theory. Havighurst laid no claim to have invented activity theory; he simply put in writing what many practitioners of the day assumed: that keeping active was the best way to enjoy satisfying senior years. According to this view, except for the inevitable changes in biology and health, older people are the same as middle-aged people, with essentially the same psychological and social needs. In this view, the decreased social involvement that characterizes old age results from the withdrawal by society from the aging person; and the decrease in interaction proceeds against the desires of most aging men and women. The older person who ages optimally is the person who stays active and who manages to resist the shrinking of his [or her] social world. [She or] he maintains the activities of middle age as long as possible, and then finds substitutes for those activities he [or she]

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In contrast to activity theory, disengagement theory (Cumming and Henry, 1961) held that successful aging involved growing older gracefully by gradually replacing the equilibrium system of social relations typical of midlife with a new equilibrium more appropriate to the interests of people approaching the end of life. This new equilibrium was presumed to involve a lower overall volume of social relations and a less psychological investment in the social affairs of the larger community. Rosow (1963) picked up this theme of equilibrium in his rendition of activity theory, but his position was that the best course of action was to maintain the equilibrium of middle age. He argued that Americans do not want to grow old and that, by inference, their “basic premise in viewing older age is that the best life is the life that changes least.” (Rosow, 1963, p. 216). He went on to argue that a “good adjustment” to older age involves maximum stability and minimum change in life pattern between late middle age and later years. Activity theory assumed that activity produced successful aging through the relationship between activity and life satisfaction or subjective wellbeing. It was presumed that activity level was the cause and life satisfaction the effect.

Major Concepts of Activity Theory Activity theory is built around four major concepts: activity, equilibrium, adaptation to role loss, and life satisfaction. Each of these very general concepts is open to a variety of interpretations, which has led to no small amount of confusion. Activity. At its simplest, activity is any form of doing. But in Havighurst’s original formulation of activity theory, activity was not just a level of doing but also a pattern of activity that formed the person’s lifestyle. Activity theory predicted that maintaining both level and pattern of activities from middle age into old age would lead to the highest level of life satisfaction in older age.

Equilibrium. Activity theory makes the functionalist assumption that activity patterns arise to meet needs and that the needs of older people are no different from the needs of middle-aged people; therefore, whatever equilibrium the person has achieved in middle age should be maintained into one’s senior years. Significant assaults to this midlife equilibrium are best resisted, and lost activities or roles should be replaced. Simply dropping out would not meet functional needs and would therefore be expected to lead to lowered life satisfaction. Adaptation to Role Loss. Role loss was assumed to be a common experience for aging individuals because of the withdrawal of society from the aging person. Activity theory predicted that the most successful way to adapt to role loss was to find a substitute role to satisfy needs. The original formulation assumed that role substitutes should be roughly equivalent to the roles lost, so retirement would lead to a search for job substitutes, for example. Later, the concept of substitution was broadened by Maddox (1963) to include alternative activities of any kind. Life Satisfaction. How do we know when a person has aged successfully? Both activity theorists and disengagement theorists agreed on one thing. Life satisfaction was the best criterion for measuring social and psychological adjustment. Havighurst and his colleagues’ (1963) concept of life satisfaction was made up of five components: zest and enthusiasm, resolution and fortitude, a feeling of accomplishment, self-esteem, and optimism. This construct addressed the level of subjective wellbeing experienced by an individual, not his or her evaluation of specific objective circumstances. The Life Satisfaction Index B (Havighurst, 1963) was constructed to measure these attributes, and it has been most often used as the dependent variable in formal tests of activity theory.

Evolution of Activity Theory In its original form, activity theory was a homeostatic, equilibrium theory of the relation between activity patterns and life satisfaction. However, the theoretical ties between activity theory and functional

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equilibrium theory were largely ignored, although they were made explicit by Rosow (1963). Lemon, Bengtson, and Peterson (1972) reformulated activity theory into an interactionist theory. By interactionist, they meant both symbolic interactionist in the form of a relation between self and role and the use of reflected appraisals to bolster the self as well as social interactionist in the form of role supports going from others to the aging individual. Thus, for Lemon and colleagues, the motivation for maintaining activity was not the meeting of functional needs but the need to maintain a socially supported self-structure that was assumed to lead to optimal life satisfaction. Lemon et al. (1972) developed a formal propositional theory that attempted to explain why high activity levels could be expected to produce high life satisfaction and declines in activity could be expected to result in lower life satisfaction. Their theory was based on a series of assumptions about the relationships among role loss, role supports (feedback from others about role performance), selfesteem, and life satisfaction. This reformulation of activity theory was essentially a domino theory in which role loss was presumed to lead to less role support and lower activity, which were presumed to lead to lower self-esteem, which in turn was presumed to cause lower life satisfaction. On the other hand, maintaining high activity levels by substituting for lost roles would maintain activity level and role support, which would maintain self-esteem, and thereby maintain life satisfaction. Further, they classified activities into informal, formal, and solitary, and they hypothesized that all three types would be associated with life satisfaction, but informal activity was expected to show the strongest association because of its greater likelihood of providing role support, followed by formal activity, and informal activity was expected to show the lowest association with life satisfaction because of its presumed lack of role support. Unfortunately, their test of the theory provided little support for this reformulation. The only significant association they found between activity and life satisfaction occurred for informal activities among married women. Longino and Kart (1982) retested Lemon, Bengtson, and Peterson’s (1972) hypotheses and reported more support for the hypothesized relationships between types of activities and life satisfaction. They also suggested several

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additional hypotheses to be included in the interactionist activity theory: • Formal activity damages self-concept and lowers morale. This hypothesis was based on the notion that service use is the most common type of formal activity in an older population and that service use results in negative role support. • Lower life satisfaction leads to increased formal activity. Here they argued that the causal direction of activity theory may be wrong. Elders with low morale tend to be targeted by formal service providers; therefore low life satisfaction causes formal activity, not the reverse. • Formal activity is a variable context and its effects on life satisfaction depend on the extent to which it offers opportunities for supportive human relationships. • Role supports may not be substitutable. If confidants are lost, they may not be replaceable. • Frequency of activity is as important as the type of activity. They found that any level of informal activity resulted in life satisfaction near the sample mean, whereas an absence of informal activity resulted in a significant deficit in life satisfaction compared to the sample mean. Part of the difficulty with the interactionist version of activity theory may have been its simplistic assumptions about the relation of self and roles. Research evidence on the relationship between self and role in later life suggests that the linkage is neither as direct nor as simple as the interactionist formulations of activity theory indicate. For example, Markus and Herzog’s (1991) review of the literature on aging and the self conceptualized the self as a dynamic, complex structure made up of past, current, and future images of the self arising from specific antecedents. Self-schema are used to organize and interpret experience, regulate affect, and motivate behavior. Life satisfaction is presumed to be one of the consequences of these self processes. In this formulation all roles are not equally important to the self, only those that are part of the set of core self-schema that persists over time. Likewise, the place of specific activities in the core self could be expected to be a significant intervening variable in the relations among activity patterns, activity change, the self, and life satisfaction.

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Research on activity has addressed some of these concerns. Larson, Zuzanek, and Mannell (1985) and Mannell (1993), for example, looked at the meaning of specific activities for the individual as a significant intervening variable in the relationship between activity and life satisfaction. Larson and colleagues reported that the retired adults in their study voluntarily spent almost half of their waking hours alone, but being alone was not a negative experience for the majority of them. When they were alone, they were engaged in activities that required concentration and challenge. Mannell probed this issue further and found that the link between specific activities and life satisfaction was the culmination of a complex string of contingencies. First, activities had to be available that had a high potential for attracting individual investment of time and energy. Second, activities had to be freely chosen, not obligatory, and accompanied by a sense of commitment. Third, activities had to produce the experience of flow, life experience transported to a higher level of quality by activities that focus attention, match challenges to capabilities, reduce self-consciousness, and increase feelings of control. If these contingent conditions were met, then we could expect activities to bolster life satisfaction.

Important Unaddressed Issues Does activity theory apply equally to men and women as they age? To what reference point in the past should patterns of activity and life satisfaction in old age be compared? When does old age begin chronologically? Does activity influence some of the components of life satisfaction more than others? Does activity influence life satisfaction, or is it the other way around? Is activity level correlated with life satisfaction consistently? Gender differences are very obvious in the findings of research on aging and activities. The number and types of activities and the frequency of participation in an array of activities have all been found to differ substantially by gender, with activity patterns of older men showing a stronger relation to life satisfaction than the activity patterns of older women. However, there has been no attempt to integrate these findings into activity theory, to explain why activities are more important to the life satisfaction of older men than to older women.

Activity theory might be further refined by looking at specific components of subjective well-being. It is likely that self-esteem is not the only mental construct that is influenced by the experiences gained from a person’s activities. Lawton (1983) mapped a number of dimensions of subjective wellbeing that could profitably be used in research on activity theory. Finally, activity level is not always correlated with life satisfaction. Indeed, in a meta-analysis of 10 predictors of subjective well-being among elders, Okun et al. (1984) found that activity level was only modestly related to life satisfaction when the effect of health was controlled. Health was by far the strongest predictor of life satisfaction. Research on activity theory should be sure to control the effects of health and life stage before coming to conclusions about the influence of activity level on life satisfaction.

Directions for Activity Theory Current research using activity theory falls into two categories: research aimed at comparing activity theory with other theories as descriptions of typical patterns related to aging and research aimed at testing and extending the social psychological components of activity theory to better specify the causal relationships between activity and life satisfaction. Researchers who focus primarily on activities tend to describe activity patterns and then compare their descriptions to the ideal descriptions presented in the homeostatic, functional version of activity theory. Because there is usually a good bit of change in the frequency of specific activities over time in later adulthood, the equilibrium hypothesis of activity theory is usually rejected. However, researchers who focus primarily on life satisfaction are increasingly looking at the social psychological relation between specific activities and life satisfaction. These researchers have met with increasing success in identifying specific conditions under which activity is strongly related to life satisfaction. But as the list of specifications grows, the power of activity theory as a general theory of aging is diminished. Despite the many difficulties with activity theory, its ties to the cultural conception of successful aging have made gerontologists reluctant to abandon

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it. Some of each new generation of gerontologists have been attracted to the basic ideas contained in activity theory. Instead of rejecting the theory out of hand, it is used as an ideal standard against which to compare actual activity patterns. For those more interested in activity theory as theory, the focus has shifted to understanding the conditions under which the kernel of truth contained in the cultural conception could be expected occur in its more obvious forms. As a result, activity theory has seldom been tested in recent research but instead is more often used as one element of a more complex theoretical argument.

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Activity and aging (pp. 125–145). Newbury Park, CA: Sage. Markus, H. R., & Herzog, A. R. (1991). The role of the self-concept in aging. Annual Review of Gerontology and Geriatrics, 11, 110–143. Okun, M. A., Stock, W. A., Haring, M. J., & Witter, R. A. (1984). Health and subjective well-being: A metaanalysis. International Journal of Aging and Human Development, 19, 111–132. Rosow, I. (1963). Adjustment of the normal aged. In R. H. Williams, C. Tibbitts, & W. Donohue (Eds.), Processes of aging: Social and psychological perspectives (Vol. 2, pp. 195–233). New York: Atherton.

Robert C. Atchley See also Continuity Theory Disengagement Theory Social Gerontology: Theories

References Cumming, E., & Henry, W. E. (1961). Growing old: The process of disengagement. New York: Basic Books. Havighurst, R. J. (1963). Successful aging. In R. H. Williams, C. Tibbitts, & W. Donohue (Eds.), Processes of aging: Social and psychological perspectives, (Vol. 1, pp. 299–320). New York: Atherton. Havighurst, R. J., Neugarten, B. L., & Tobin, S. S. (1963). Disengagement, personality and life satisfaction in the later years. In P. F. Hansen (Ed.), Age with a future (pp. 419–425). Copenhagen: Munksgaard. Larson, R., Zuzanek, J., & Mannell, R. (1985). Being alone versus being with people: disengagement in the daily experience of older adults. Journal of Gerontology, 40, 375–381. Lawton, M. P. (1983). Environment and other determinants of well-being in older people. The Gerontologist, 23, 349–357. Lemon, B. W., Bengtson, V. L., & Peterson, J. A. (1972). An exploration of the activity theory of aging: Activity types and life satisfaction among in-movers to a retirement community. Journal of Gerontology, 27, 511–523. Longino, C. F., Jr., & Kart, C. S. (1982). Explicating activity theory: A formal replication. Journal of Gerontology, 37, 713–722. Maddox, G. L. (1963). Activity and morale: A longitudinal study of selected elderly subjects. Social Forces, 42, 195–204. Mannell, R. C. (1993). High-investment activity and life satisfaction among older adults. In J. R. Kelly (Ed.),

ADAPTIVE CAPACITY A major characteristic of living things is the ability to adapt to environmental changes. For example, upon perceiving a threat mammals will incur an immediate activation of the sympathetic nervous system that will stimulate heart and breathing rate in preparation for the increased metabolic demands of fighting or fleeing. If the metabolic demand is actually activated (for example, by running), heart and breathing rate will be further activated as long as the metabolic demand from the muscles continues. Similarly, exposure to a novel antigen will produce a robust activation of the immune system, including the proliferation of immune cells that produce antibodies against the novel antigen, a process that is essential to survive infections. At the cellular level, many toxic insults produce a characteristic profile of molecular responses, called the heat shock response, that is highly protective. However, there are limits to the extent to which organisms can adapt. For example, each individual can only sustain a maximum metabolic demand even at peak performance (such as during a sprint). In humans the maximum sustainable metabolic demand, constrained by a number of factors but especially by cardiovascular capacity, is often measured by the rate of oxygen consumed at maximum short-term effort on a treadmill (a parameter called VO2max ). Thus VO2max constitutes a major indicator of the capacity of the cardiovascular system to adapt to short-term metabolic stress; thus VO2max may be considered to reflect short-term adaptive capacity for metabolic demand. It is has been amply demonstrated that in healthy humans VO2max decreases steadily during

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aging, approximately 9% per decade (Rosen et al., 1998). Similarly, immune responses to novel antigens (McGlauchlen, 2003) and the heat shock response (Shamovsky, 2004) are increasingly attenuated with age. On the other hand, short-term adaptive capacity can be modified by chronic stimulation, a phenomenon which may be termed long-term adaptive capacity. For example, repetitive aerobic exercise (for example, endurance training at 70% VO2max for 30 minutes 3 times per week for 12 weeks) enhances VO2max , apparently by inducing remodeling of the cardiovascular system. The enhancement of VO2max by chronic training appears to occur about as well in healthy elderly men as in younger men, and older master athletes exhibit higher VO2max than healthy older nontrained humans. Nevertheless, VO2max decreases about as fast in athletes who are in training as in age-matched controls (although trained athletes continue to exhibit higher VO2max than nontrained healthy controls as they age). Furthermore, since the effect of age on VO2max is substantially greater than the training effect on VO2max , even though training can enhance VO2max about as well in older as in younger individuals, this effect of training cannot completely reverse or prevent the reduction in VO2max during aging (Trappe et al., 1996). Short-term and long-term adaptive capacity occur in response to many perturbations, including changes in temperature, altitude, diet, and many other environmental factors. In general, short-term adaptive capacity decreases with age. For example, a cold environment causes many physiological responses, including shivering and enhanced heat production, which allow maintainance of normal body temperature; these adaptations to cold are enhanced after chronic exposure to low temperature. As with VO2max (and possibly related to this parameter), the ability to adapt to a cold environment is impaired with age (Anderson et al., 1996). However, chronic exposure to cold enhances adaptation to cold about as well in older as in younger individuals. Nevertheless, as with VO2max , because the effect of age on cold tolerance is greater than the effect of chronic exposure to cold, chronic exposure to cold cannot fully reverse the effects of age on cold tolerance. This pattern of greater impairments of short-term than long-term adaptive capacity is common for many responses to environmental perturbations. An important but largely unresolved question is the physiological significance of adaptive capacity

during aging under circumstances in which environmental fluctuations are minimal, as in the case of most human populations. The fact that the elderly are more likely to die of hyperthermia or hypothermia clearly indicates that in extreme circumstances impairments in short-term adaptive capacity can have profound effects. On the other hand, the vast majority of deaths during aging, either in human populations or in the laboratory, occur without major fluctuations in the environment. Nevertheless, VO2max is closely related to cardiovascular health, suggesting that long-term adaptive capacity, which is less impaired during aging than short-term adaptive capacity, could play an important role in mediating effects of lifestyle on health and mortality during aging (Bortz and Bortz, 1996). Since long-term adaptive capacity is relatively intact during aging, and especially since short-term adaptive capacity seems to be intrinsically reduced during aging, training and other lifestyle changes may be at least as valuable in the elderly as in the young. Consistent with this principle, elderly individuals who maintain a lifelong engagement with intellectual stimulation exhibit fewer cognitive impairments than nonengaged controls. While a training effect on age-related cognitive deficits has not yet been rigorously demonstrated, this question obviously is of great practical interest. Adaptive capacity may reflect a fundamental process of aging. For example, long-lived lines of fruitflies and nematodes not only live longer, but even when young are more resistant to the effects of numerous environmental stresses than shorter-lived strains (Lin et al., 1998). Thus genetic influences on longevity also influence short-term adaptive capacity, suggesting that adaptive capacity may play an important role in age-related mortality even in benign environments. Charles V. Mobbs See also Stress Theory of Aging Successful Aging

References Anderson, G. S., Meneilly, G. S., & Mekjavic, I. B. (1996). Passive temperature lability in the elderly. European Journal of Applied Physiology, 73, 278–286.

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Adherence Bortz, W. M., IV, & Bortz, W. M., II. (1996). How fast do we age? Exercise performance over time as a biomarker. Journal of Gerontology: A Biological and Medical Science, 51, M223–225. Fitzgerald, M. D., Tanaka, H., Tran, Z. V., & Seals, D.R. (1997). Age-related declines in maximal aerobic capacity in regularly exercising vs. sedentary women: a meta-analysis. Journal of Applied Physiology, 83, 160–165. Lin, Y. J., Seroude, L., & Benzer, S. (1998). Extended lifespan and stress resistance in the Drosophila mutant methuselah. Science 282, 943–946. Rosen, M. J., Sorkin, J. D., Goldberg, A. P., Hagberg, J. M., & Katzel, L. I. (1998). Predictors of ageassociated decline in maximal aerobic capacity: a comparison of four statistical models. Journal of Applied Physiology, 84, 2163–2170. Trappe, S. W., Costill, D.L., Vukovich, M. D., Jones, J., & Melham, T. (1996). Aging among elite distance runners: A 22-yr longitudinal study. Journal of Applied Physiology, 80, 285–290.

ADHERENCE When a physician prescribes a medication for a patient, an implied contract is made between the two— one requiring specific behaviors by both doctor and patient. The doctor must prescribe the correct drug in the proper dose, provide the patient with adequate instructions for its use and warnings about possible adverse effects, and monitor the patient’s use of the drug to ensure a therapeutic outcome. The patient is expected to purchase the medication, take it as directed, and report to the physician any untoward side effects—in other words, to adhere to the doctor’s instructions. For elderly patients, adherence may be particularly difficult, given their greater risk of adverse effects from medication.

Types of Nonadherence Nonadherence (or noncompliance, as it is still sometimes called) can be classified as overuse, underuse, erratic use, and contraindicated (or inappropriate) use. Patients who overuse drugs either take more types of drugs than necessary, take more than the prescribed amount of one drug, or take a “pm” (i.e., take as needed) drug when it is not actually needed. Underuse includes the failure to have the prescription filled (“initial noncompliance”), the premature

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discontinuation of the drug, and the consistent failure to take as much of the drug as the doctor ordered. Erratic use means that the patient generally fails to follow instructions. This type includes missed doses (underuse), double doses (overuse), and drug confusion, which is taking the wrong drug by mistake or taking doses at the wrong time, by the wrong route of administration, or with the wrong liquid. Contraindicated drug use occurs when the patient takes a drug that is inappropriate either because it is unnecessary or potentially harmful. This can occur when the older patient selfmedicates incorrectly or when the physician prescribes the wrong drug—one that is ineffective, produces a harmful or unwanted side effect, or interacts negatively with other medications being taken, food, or alcohol. Obviously, these four types of nonadherence are not mutually exclusive, and the older patient may engage in more than one at a time. Most researchers agree that the failure to take medications (underuse) is by far the most common type of nonadherence, generally comprising over half of all reported instances (e.g., Gurwitz, Glynn, Monane, Everitt, Gilden, Smith, et al., 1993). Although underuse can have serious consequences for a person for whom the medication is necessary for control of a dangerous condition, it is probably the safest form of misuse for those who take psychotropic medications and many of those on multiple drug regimens. This behavior has been termed intelligent noncompliance. Shimp and Ascione (1988) have differentiated between unintentional nonadherence, when the patient merely forgets a dose or gets confused about how or when to take it, and intentional nonadherence, which occurs when the patient deliberately alters the dose or the timing or chooses not take it at all. Evidence suggests that intentional nonadherence may be more common with up to 30% of prescriptions never even filled by the patient. A majority of older patients state that they would discontinue taking a drug that they felt was not working and self-medicators will stop using a drug or, use less because they do not like the drug, the dosage, the side effects, or the cost; or they get better results by taking it their way.

Extent of Nonadherence It is extremely difficult to estimate how often physicians do not live up to their responsibilities under

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the doctor-patient contract; the consensus is that the failure rate is quite high (Simonson, 1994). We have somewhat better data on the patient’s side of the bargain. Nonadherence is, of course, a problem in patients of all ages. Early researchers suggested that nonadherence is particularly likely among elderly persons, because it is known to correlate highly with several factors common to old age, including chronic illness, multiple prescription drugs, social isolation, and mental confusion. Later reviews of adherence studies, however (e.g., Simonson, 1984), concluded that no clear evidence exists of any relationship between age and adherence. Simonson (1984) reports that researchers have estimated that nonadherence by the elderly ranges from 2% to 95%. Most studies place the proportion of older people who admit some nonadherence in taking prescription drugs at around 40%–60% (Botelho & Dudrak, 1992), although many instances probably are not therapeutically significant. Nevertheless, Ascione (1994) argues that nonadherence in an older person is likely to have much more serious consequences than in a younger individual because of the elder’s greater likelihood of serious illness and comorbidity. The results of nonadherence in older persons include failure to recover, aggravation of the condition, hospitalization, and the addition of medications to treat the supposed intractable symptoms. So far, few investigators have attended to sex or race differences in adherence, though some findings suggest that they may exist (Bazargan, Barbre, & Hamm, 1993; Kail, 1992).

Causes of Nonadherence Many factors can contribute to nonadherence among older persons. Simonson (1984) has organized them into three main groups: those related to the patient, to therapy, and to the health professional. Patientrelated causes include failure to understand the importance of therapy; misunderstanding the doctor’s instructions; self-medication; not feeling well; physical disabilities, including sensory losses; and lack of supervision. Factors associated with the therapy itself include the number of drugs prescribed, the frequency of doses, difficult dosage forms, adverse drug reactions, and the expense of medications. Health professionals, including physicians, nurses, and pharmacists, also can precipitate nonad-

herence in their elderly patients by failing to establish a good relationship with the patient, expressing doubt about the drug’s efficacy, and being unwilling to spend time educating patients. Using a different organization scheme, Ascione (1994) lists the contributing factors as: (1) complexity of the drug regimen; (2) the patient’s poor drug knowledge; (3) the patient’s physical limitations (especially sensory losses); (4) poor communication between professional and patient; and (5) psychosocial characteristics of the patient, such as health beliefs and social isolation. Some researchers (e.g., Morrell, Park, Kidder, & Martin, 1997) have suggested poor cognitive function, especially memory problems and the inability to understand complex medical instructions, as a possible cause of nonadherence in older people. Research so far seems to show that both memory and visual perception can affect adherence, at least among the oldest-old, and that various memory aids can improve adherence (Morrow, Hier, Menard, & Leirer, 1998). On the other hand, nonadherence is patient-initiated and represents a majority of older people’s attempts to control their own therapy. Thus, it seems likely that cognitive deficits are a significant cause of nonadherence for older persons who suffer such losses but may have little or no effect on the vast majority of elders. Older people are at risk of nonadherence due to many factors outside their control, including their own health status, the number and types of drugs they are prescribed, the failure of therapeutic instructions, health care organization costs, and social isolation. In fact, nonadherence can create significant problems for elderly persons (Ascione, 1994), but many writers (e.g., Simonson, 1994) agree that, “compared with the inability of health care professionals to prescribe and administer drugs properly and to monitor their use by older patients, nonadherence is relatively less troublesome.”

Reducing Noncompliance Ascione (1994) aptly summarizes what little is known about reducing nonadherence among older persons: “What appears most successful is a comprehensive approach that assesses the individual needs of the patient, uses multiple strategies and incorporates a medication monitoring system to give

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continual feedback to the patient.” He groups the strategies developed so far as dissemination of drug information, simplification of the administration process, and teaching medication management skills. Frank J. Whittington See also Doctor-Patient Relationships

References Ascione F. (1994). Medication compliance in the elderly. Generations, 18, 28–33. Bazargan, M., Barbre, A. M., & Hamm, V., Failure to have prescriptions filled among Black elderly. Journal of Aging and Health, 5, 264 –282. Botelho M. B., & Dudrak R. (1992). Home assessment of adherence to long-term medication in the elderly. Journal of Family Practice, 35, 61–65. Gurwitz, J. H., Glynn, R. J., Monane, M., Everitt, D. E., Gilden, D., Smith, N., & Avorn, J. (1993). Treatment for glaucoma: Adherence by the elderly. American Journal of Public Health, 83, 711–716. Kail, B. L. (Ed.). (1992). Special problems on noncompliance among elderly women of color. Lewiston, NY: Academic Press. Morrell, R. W., Park, D. C., Kidder, D. P., & Martin, M. (1997). Adherence to antihypertensive medications across the life span. The Gerontologist, 37, 609–619. Morrow, D. G., Hier, C. M., Menard, W. E., & Leirer, V. O. (1998). Icons improve older and younger adults’ comprehension of medication information. Journal of Gerontology: Psychological Sciences, 53B, P240– P254. Shimp, L. A.., & Ascione, F. J. (1988). Causes of medication misuse and error. Generations, 12, 17–21. Simonson, W. (1984). Medications and the elderly: A guide for promoting proper use. Rockville, MD: Aspen Systems Corporation. Simonson, W. (1994). Geriatric drug therapy: Who are the stakeholders? Generations, 18, 7–12.

ADJUSTMENT See Adaptive Capacity

ADL/IDL See Activities of Daily Living

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ADULT DAY CARE Adult Day Care Services Adult day services (ADS) are “community-based group programs designed to meet the needs of functionally and/or cognitively impaired adults through an individual plan of care” (National Adult Day Services Association [NADSA], 2002). These programs provide a variety of health, social, and personal services in a protective setting. Most programs provide activities, meals, social services, personal assistance, and health services; others include nursing and medical services, rehabilitation therapies, counseling, and transportation. ADS vary greatly depending on whether they follow a medical, social, or combination model; whether they are dedicated to special populations (e.g., aged, disabled, Alzheimer’s care, and developmentally disabled); or whether they are for persons of all ages. For example, dementia-care programs may provide cognitive stimulation, family counseling, and music therapy (Jarrott, Zarit, Berg, & Johansson, 1998). ADS goals include improving participant functioning and independence; delaying or preventing placement in residential care; and alleviating caregiver burden. ADS regulations vary widely across states and funding sources. Some states require licensure or certification; some have voluntary standards; still others require nothing. The Commission on Accreditation of Rehabilitation Facilities (CARF) voluntarily accredits ADS programs as a way to maintain standards through an agreement with NADSA. No federal policy governs adult day health services (ADHS) apart from the Program of All Inclusive Care for the Elderly (PACE), a model of acute and chronic care for elderly persons that is based on day health care and funded by Medicare and Medicaid. Medicaid also funds ADHS under 1915c HCBS waivers. Forty-five states report having waivers that include ADHS for persons meeting nursing home level-of-care criteria (http://www.cms.hhs.gov/medicaid/waivers). Federal funding of ADS comes through the Social Security Act including Medicaid (Title XIX), Social Services Block Grants-Title XX (SSBG), and the Older Americans Act (Title III). Other funding sources vary and include private pay, philanthropic support, other state programs, and private longterm care insurance. State programs vary widely for

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eligibility, program goals and standards, services, staffing, reimbursement, and monitoring (HowellWhite, Scotto Rosato, & Lucas, 2003; Lucas, Scotto Rosato, Lee, & Howell-White, 2001). Adult day health care is not a Medicare reimbursable service, although Medicare reimburses for rehabilitative services (i.e., physical, occupational, and speech therapy) delivered in some adult day health settings. The recent Medicare Modernization Act of 2003 allows for a demonstration of ADHS as a substitute for Medicare reimbursable home health care. A recent national survey of ADS conducted by Partners in Caregiving (Cox, 2003) reported that 3407 adult day centers are operating in the United States, which represents a 25% growth rate between 1997 and 2002. For-profit programs represented the greatest growth sector in new programs (44%). Characteristics of centers reported in this survey include the facts that 78% are not-for-profit; most (74%) are affiliated with a larger organization; most operate 5 days a week for an 8 to 10 hour day; 21% are based on the medical model, 37% are social, and 42% are combination programs; the average number of enrollees is 43, with an average daily attendance of 26; average cost is $56 per day. Participant average age is 72, 66% are women, and more than 50% have some cognitive impairment. Most participants attend 2 to 3 days a week for 5 to 6 hours, with participants enrolled for an average of 2 years. NADSA is the national association for ADS providers. It serves as an important resource for ADS programs, providing “national program standards and guidelines,” technical assistance, training, national conferences, newsletter, Web site, and advocacy with policymakers (NADSA, The National Adult Day Services Association, Inc. 772 Grant Street, Suite L, Herndon, VA 20170. www.nadsa.org). Partners in Caregiving is another resource. This program is funded by RWJF and located at Wake Forest University. This program provides technical assistance to improve financial viability and quality with, teaching centers, a newsletter and Web site. Its work demonstrates that ADS can effectively serve people with chronic conditions (see http://www.rwjf.org/reports/npreports/ partnerse.htm). (Partners in Caregiving, Wake Forest University School of Medicine, Medical Center Boulevard, Winston-Salem NC, 27157.)

Research in ADS The seminal work by Weissert (1976; 1977) surveyed 10 adult day programs. Analysis resulted in conceptualizing the programs into the “medical” model (provides rehabilitative therapies) and “social” model (stresses social activities, client function, nutrition, and recreation). Using data from the National Adult Day Care Survey (Weissert et al., 1989) these prevailing models were expanded by Conrad and associates (1993) to include “special purpose” centers (i.e., serve single type of clientele). The Dementia Care Respite Services Program (Cox and Reifler, 1994; Reifler, Henry, Sherrill, Asbury, & Bodford, 1992) described dementia-specific adult day care. Their national survey of 240 centers found: 17% were social; 25% were medical; and the remaining were a combination medical-social model.

Program Effectiveness Research Gaugler and Zarit (2001) provide a recent systematic review of ADS program effectiveness research. Their schema organizes program effectiveness research according to the ADS goals of client functioning, caregiver outcomes, and impact on institutionalization. A notable study by Weissert and colleagues (1980) used an experimental design to evaluate four programs (including On Lok) but found negligible effect on ADL functioning. Satisfaction was very high for 82.2% of clients (Weissert et al., 1990). This was followed by an evaluation of 24 California programs by Capitman (1982) which found 90% of enrollees maintained or improved ADL function. A large-scale study by Hedrick and associates (1993) determined the effect of adult day health care compared to usual care on health and psychosocial status at eight Veterans Affairs (VA) medical centers over one year. There were no differences in psychosocial, ADL functioning or health, but costs were significantly higher than for clients assigned to usual care. While large, their sample was 96% male and the effectiveness of social programs was not addressed. Gaugler (1999) in a quasiexperimental study of adult day services for dementia caregivers, did not find significant differences in frequency of behavior problems or ADL dependencies. Evaluations of ADS as part of integrated

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demonstration programs have also been conducted. Eng and colleagues (1997) found PACE clients had lower mortality rates when compared to nursing home residents. Studies of impact on family caregivers have reported that ADS can be quite effective in providing caregivers with emotional and psychological relief from the daily demands of care with sustained and regular utilization. A noteworthy example is the Adult Day Care Collaborative Study (ADCCS) (Zarit et al., 1998) that found utilization of ADS for at least 8 hours per week over at least 3 months resulted in significantly lower feelings of role overload, worry, depression, and anger. Replicating these results in a large-scale study was attempted in the Medicare Alzheimer’s Disease Demonstration Evaluation (MADDE) by Newcomer and colleagues (1998). Caregivers in the treatment group reported significantly less depression and burden, but effect sizes were small. Using longitudinal data from the ADCCS, Jarrott and colleagues (1999) found caregiver satisfaction to be high with ADS staff, program availability, and activities. Experts have also been interested in whether ADS act as a substitute for or delay institutionalization. Weissert and colleagues’ study (1980) found participation in ADS lowered nursing home use. California’s evaluation, Capitman (1982) focused on nursing-home eligible clients and found ADS delayed placement about 15 to 22 months. For caregivers, Kosloski and Montgomery (1995) reported high respite use lowered probability of institutional care; however, Gaugler (1999) found that dementia clients using ADS were more likely to be placed in nursing homes. The large scale VA and MADDE studies (Hedrick et al., 1993; Newcomer et al., 1998) did not show significant effects on institutionalization. However, Weissert and associates (1997) in evaluating Arizona’s Long-Term Care System (ALTCS) comprised of many HCBS, found nursing home days were reduced when eligibility was “targeted” to those who were screened most likely to need long-term nursing home care. In 2004, Dabelko explored ADHS length of stay and reported that those older, at higher nutritional risk, nonwhite, and receiving public funding, disenrolled at higher rates. Lack of social support, cultural issues, and higher disability levels for later enrolled publicly funded clients were seen as important to earlier disenrollment. ADS stays were both

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for short-term and long-term care, indicating ADS may provide multiple roles in the continuum of care for older adults. Other recent ADS studies have focused on changing client characteristics (Cefalu, Ettinger, & Espeland, 1996; Travis, Steele, & Long, 2001), funding streams, and policy issues. For example, Bradsher, Estes, & Stuart (1995) identified program growth, rising demand, and higher levels and chronicity of disability among ADS clients and noted the barriers to access for persons with dementia or behavior problems. Dabelko and Balaswamy (2000) compared users of ADS and home health care (HHC) users. ADS users were younger, had greater cognitive impairment, needed more supervised assistance with ADLs, and had more social contacts than HHC users—suggesting the need for integrated models (physical, mental, and social services) for both settings. The research so far implies that ADS does not affect functional outcomes consistently, but appears to exert positive effects on subjective aspects of wellbeing, such as satisfaction. Work with PACE suggests that ADHS programs may serve as an important setting that can provide the coordinating link in a continuum of long-term care services, when enhanced with case management and access to acute care and chronic care services. The models that integrate ADS with adult day care with a variety of services and case management, such as PACE and ALTCS, appear effective in delaying nursing home use. Judith A. Lucas See also Program of All-Inclusive Care for the Elderly (PACE)

References Bradsher, J. E., Estes, C. L., & Stuart, M. H. (1995). Adult day care: A fragmented system of policy and funding streams. Journal of Aging & Social Policy, 7(1), 17– 38. Capitman, J. A. (1982). Evaluation of adult day health care programs in California pursuant to Assembly Bill 1611, Chapter 1066, Statutes of 1977. Sacramento: Office of Long-term Care and Aging, Department of Health Services.

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Cefalu, C., Ettinger, W., & Espeland, M. (1996). A study of the characteristics of the dementia patients and caregivers in dementia-nonspecific adult day care programs. The Journal of the American Geriatrics Society, 44(6), 654–659. Conrad, K. J., Hughes, S. L., Hanrahan, P., & Wang, S. (1993). Classification of adult day care: A cluster analysis of services and activities. Journal of Gerontology: Social Sciences, 48(3), S112–122. Cox, N. J. (2003). National Study of Adult Day Services 2001–2002. Partners in Caregiving: The Adult Day Services Program, Winston-Salem, NC: Wake Forest University School of Medicine. Cox, N. J., & Reifler, B. V. (1994). Dementia Care and Respite Services Program. Alzheimer’s Disease and Associated Disorders, 8(3), 113–121. Dabelko, H. I. (2004). Individual and environmental factors that influence length of stay in adult day care programs. Journal of Gerontological Social Work, 43(1), 83–105. Dabelko, H. I. & Balaswamy, S. (2000). Use of adult day services and home health care services by older adults: A comparative analysis. Home Health Care Services Quarterly, 18(3), 65–79. Eng, C., Padulla, J. Eleazer, G. P., McCann, R., & Fox, N. (1997). Program of All-Inclusive Care for the Elderly (PACE): An innovative model of integrated geriatric care and financing. Journal of American Geriatrics Society, 45, 223–232. Gaugler, J. E. & Zarit, S. H. (2001). The effectiveness of adult day services for disabled older people. Journal of Aging & Social Policy, 12(2), 23–47. Gaugler, J. E. (1999). Evaluating community-based care for people with dementia: The cost-effectiveness of adult day services. Unpublished PhD dissertation, The Pennsylvania State University, University Park. Hedrick, S. C., Rothman, M. L., Chapko, M., Ehreth, J. Diehr, P. Inui, T. S., et al., (1993). Summary and discussion of methods and results of the Adult Day Health Care Evaluation Study. Medical Care, 31, SS94– 103. Howell-White, S., Scotto Rosato, N., & Lucas, J. A. (Nov., 2003). Adult Day Health Services Across States: Results from a 50 State Survey of State Health Policies. Slide Presentation available at http://[email protected]/presentations. Accessed 10/06/04. Jarrott, S. E., Zarit, S. H., Berg, S., & Johansson, L. (1998). Adult day care for dementia: A comparison of programs in Sweden and the Unites States. Journal of Cross-Cultural Gerontology, 13, 99–108. Jarrott, S. E., Zarit, S.H., Stephens, M.A., Townsend, A. & Greene, R. (1999). Caregiver satisfaction with

adult day service programs. American Journal of Alzheimer’s Disease, 14(4), 233–244. Kosloski, K., & Montgomery, R. J. (1995). The impact of respite care use on nursing home placement. The Gerontologist, 35, 67–74. Lucas, J.A., Scotto Rosato, N., Lee, J.A. & HowellWhite, S. (Dec 10, 2001). Adult Day Health Services: A Review of the Literature. Report for the N. J. Department of Health and Senior Services, Rutgers University: Center for State Health Policy. Available at http://[email protected]/papers. Accessed 10/06/04. National Adult Day Care Services Association (2002). Mission statement. Available at http://www.nadsa.org. Accessed 10/06/04. Newcomer, R., Fox, P., Yordi, C., Wilkinson, A., Arnsberger, P., Donatonni, G., et al. (1998). Medicare Alzheimer’s Disease Demonstration Evaluation: Final Report. San Francisco: Institute for Health and Aging, University of California. Reifler, B. V., Henry, R. S., Sherrill, K. A., Asbury, C. H., & Bodford, J. S. (1992). A national demonstration program on dementia day centers and respite services: An interim report. Behavioral Health & Aging, 2, 199–205. Travis, S., Steele, L., & Long, A. (2001). Adult day services in a frontier state. Nursing Economics, 19(2), 62–67. Weissert, W. G. (1976). Two models of geriatric day care. The Gerontologist, 16(5) 420–427. Weissert, W. G. (1977). Adult day care programs in the United States: Current research projects and a survey of 10 centers. Public Health Reports, 92(1), 49–56. Weissert, W.G., Wan, T., Livieratos, B., & Katz, B. (1980). Effects and costs of day-care services for the chronically ill. Medical Care, 18, 567–584. Weissert, W.G., Elston, J.M., Bolda, E.J., Cready, C.M., Zelman, W.N., Sloane, P.D., Kalsbeek, W.D., et al. (1989). Models of adult day care: Findings from a national survey. The Gerontologist, 29, 640–649. Weissert, W.G., Elston, J.M., Bolda, E.J., Zelman, W.N., Mutran, E. & Mangum, A.B. (1990). Adult day care: Findings from a national survey. Baltimore, MD: John Hopkins University Press. Weissert, W.G., Lesnick, T., Musliner, M., & Foley, K.A. (1997). Cost savings from home and communitybased services: Cost savings from Arizona’s Medicaid long-term care program. Journal of Health Politics, Policy, & Law, 22(6), 1329–1357. Zarit, S. H., Stephens, M.A. Townsend, A., & Greene, R. (1998). Stress reduction for family caregivers: Effects of adult day care use. Journal of Gerontology, 5, S267– 278.

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ADULT DEVELOPMENT Adult development refers to normative and nonnormative changes in the physical, cognitive, and psychosocial domains, which occur between age 20 and 65 years. These physical, cognitive, and psychosocial developmental changes in adulthood are highly variable depending on which stage in adult development is being examined. For instance, while early adulthood is characterized by growth and vitality, midlife is a stage where some developmental domains reach their full potential and other domains have developmental declines that become more common and noticeable. In contrast, later adulthood is characterized by the challenges of physical and cognitive decline, as well as psychosocial loss. However, many of these changes are not universal, so any discussion of adult development must be conditioned upon significant, interindividual variability. Traditionally, developmental research has largely ignored adulthood in favor of childhood and adolescence. With the rise of the life-span prospective (review in Baltes, Staudinger, & Lindenberger, 1999) there has been an increased attention to old age and more recently to midlife (Lachman, 2004; Ryff, Singer, & Seltzer, 2002) and young adulthood; however, the focus on adult development still does not reach the degree of focus on childhood and adolescence. The age boundaries of each stage of adult development are somewhat vague and arbitrary, but most would agree that young adulthood encompasses between ages 20 and 40; midlife at least the years between 40 and 55, and at most from 35 to 65 years (Staudinger & Bluck, 2001); and late adulthood begins at age 65. Three pioneers in life-span developmental psychology have focused on development in adulthood and should be mentioned: Erikson, Loevinger, and Levinson. Erikson’s (1985) stage theory of psychosocial development posits that as individuals move through life, they experience distinct crisis regarding a developmental issue important to the current phase of their life. According to Erikson, the normative crisis of early adulthood concerns “intimacy versus isolation,” in which the individual seeks to make a commitment to another individual. The normative crisis of midlife concerns the topic of “generativity versus stagnation,” which challenges

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the individual in the area of assisting and mentoring young people and thus guiding the next generation. In later life the individual is concerned with acceptance of their life and impending death. This stage is referred to as “ego integrity versus despair.” If an individual does not successfully master each of these goals, he or she experiences psychological distress related to the developmental topic. A second theory of adult development builds on the work by Erikson and focuses on ego development (Loevinger, 1997). According to Loevinger, adult ego development moves through stages pertaining to conformity, conscientiousness, individualism, autonomy, and finally, in late adulthood, integration. A third conceptual approach addressing development in adulthood is Levinson’s “seasons” of adulthood (1986). The main goal of the season in early adulthood concerns the establishment of a family. During the midlife season, Levinson suggests that although biological capacities are decreasing, individuals are still able to maintain active and energetic lives. In addition, he also suggests that during this time of development, individuals are responsible for the current generation’s development. Finally, the late adulthood season is characterized as a period of reflection of one’s life and acceptance of impending death.

Physical, Sensory, and Cognitive Development in Adulthood Adulthood is a time of life characterized mostly by growth and stability, but over the adult life span loss and decline begins (Heckhausen, 2001). Levels of stability or decline differ greatly in different areas of physical, sensory, and cognitive functioning. Although there is great interindividual variability, some of the most noticeable signs of aging across the life span include the loss of pigmentation leading to the graying of hair, thinning of hair caused by hair germination center destruction, rigidity of the skin’s dermal layer leading to wrinkling, and changes in the strength and tone of voice (Whitbourne, 2001). Less noticeable signs of aging, which may affect many individuals in adulthood, include decrease in bone density, decline in muscle mass, visual and auditory deterioration, changes in cardiovascular fitness and respiratory functioning, and changes in

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body regulation (e.g. decreased basal metabolism rates, endocrine and immune function, and sexual changes) (Masoro & Austad, 2001). In general, cognitive changes in adulthood are much more subtle than physical changes. Young adulthood is characterized as a time when cognitive abilities reach their peak levels (Lehman, 1945; Ericsson, 2000). Losses in midlife are primarily at the level of peak performances in that only at times when performance is pushed to its limits by optimizing training and performance conditions do declines in developmental reserve capacity become apparent (Lindenberger, Marsiske, & Baltes, 2000). A prominent theoretical perspective for interpreting cognitive developmental change is the distinction between fluid and crystallized intelligence (Horn & Cattell, 1966), or as in a more recent conceptualization between the pragmatics and mechanics of intelligence (Baltes, 1987). Crystallized intelligence refers to general knowledge developed through a lifetime of experiences (accumulated knowledge) (Sternberg, Grigorenko, & Oh, 2001). In contrast, fluid intelligence refers to “creative and flexible thinking” required to solve novel problems (e.g. anagrams, memory tests). In general, research examining age-related changes in fluid and crystallized intelligence has found that fluid intelligence declines with age, but crystallized intelligence remains stable or even increases (e.g. professional specialization) across the life span (Kaufman & Horn, 1996). However, in a more detailed examination of cognitive decline in fluid intelligence, it is important to distinguish between fluid intelligence pertaining to the solving of more practical problems and that pertaining to more traditional (academic) problem-solving tasks. Performance on traditional problem-solving tasks begins to decline around age 20 years and continues to decline throughout adulthood, whereas performance on practical problem-solving tasks peaks in midlife, suggesting that it is at this time that individuals are best at practical problem-solving (Sternberg, Grigorenko, & Oh, 2001). In their related dual-processing model, Baltes and colleagues (1999) distinguish between the mechanics of intelligence that generally refer to processing abilities (information-processing strategies and problem-solving functions) independent of specific content, and the pragmatics of intelligence that typically refers to knowledge about facts and procedures, including practical thinking, expertise, wis-

dom, and knowledge accumulated across the life span. While the pragmatics of intelligence are expected to grow into adulthood and then remain stable into old age, there is abundant evidence of age-related decline in the mechanics of intelligence (Salthouse, 2003). The declines in mechanics of intelligence compromise individual capacities beginning in midlife only under conditions of multitasking and time pressure (Lindenberger, Marsiske, & Baltes, 2000). Thus, implications of these declines for everyday functioning in midlife are constrained to time-sensitive multitasking in everyday behavior (e.g., talking on the phone while merging into freeway traffic) and select professions (e.g., air traffic controllers). Strategies that are part of the pragmatics of intelligence (e.g., sequence activities to avoid multitask overload) in midlife can compensate for the weaknesses in the mechanics of intelligence (Baltes, 1993). However, such strategies may become increasingly insufficient as cognitive decline progresses in advanced old age.

Psychosocial Influences on Development in Adulthood Adaptation to growth and resilience in managing losses are 2 key focuses in adult development (Heckhausen, 1999). Several developmental tasks and transitions represent important challenges for adaptation and resilience. First, adulthood is a period of continued growth but also of emerging decline and loss. In comparison to early adulthood, midlife into late adulthood (the 40s, 50s, 60s, and beyond) is marked by a dramatic increase in developmental changes that are loss-related. However, many developmental processes continue to advance in midlife (e.g., expertise) and even into old age (e.g. improved emotional balance). Thus, individuals have to cope with the co-occurrence of growth and decline (Heckhausen, 1999), perhaps more so during midlife than during any other phase of the life span. The individual needs to orchestrate the allocation of resources so that areas of functioning involving growth are optimized and other areas of impeding loss are protected. Second, during adulthood the pronounced perspective on life shifts toward an increasing awareness of the “finitude of life.” While in early adulthood the future is open and many paths seem viable,

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in midlife there is a focus shift from time lived from birth to time left before death. An aspect of Erikson’s (1963) developmental theory concerns the acceptance that the time left until death is limited and it is only through acceptance that ego integrity can be achieved. Because of this change in perspective, individuals may begin to view goals as unattainable, which then may lead to goal disengagement. The passing of these “developmental deadlines” can result in strong needs for emotion regulation and goal readjustments (Heckhausen, Wrosch, & Fleeson, 2001). Goals that are now “off time” are sacrificed for goals that can still be obtained. For goals that must be abandoned (e.g. due to the “biological clock” for procreation running out) individuals may need to cope with the loss of the goal through emotion regulation. Losses in old age often require further disengagement and selective optimization (Baltes & Baltes, 1990) of most cherished and/or essential areas of functioning (Schulz & Heckhausen, 1996). Regret of the lost goals may lead to depression and rumination and an increased need to cope with the loss. Finally, developmental challenges in adulthood can vary with regard to whether they are age normative and nonnormative. Changes in physical (e.g. menopause) and cognitive (e.g. decreases in fluid intelligence) functioning are considered to be age normative and as such may be easier to cope with because the individual can prepare for the change and disengage in the goals associated with the decline. In contrast, nonnormative challenges cannot be predicted, so the adaptation to the developmental change can be more challenging and as such, there may be higher regulatory demands. For example, a cancer diagnosis is unpredictable and as such it will be more challenging and require more resources to adapt to the change. Because of the many age-specific burdens and challenges in various stages of adulthood, the conclusion might be reached that these challenges overwhelm individuals. Indeed, the notion of a midlife crisis suggests that developmental losses, rising awareness of the finitude of life, and opportunities lost result in depression and problem behavior in a majority of midlife adults (Whitbourne, 1986; Hunter & Sundel, 1989). Although Jacques (1965) suggested that the midlife crisis is a normative developmental milestone generally accepted by the greater public, there is little empirical ev-

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idence to suggest that the midlife crisis is either normative or widespread (Hunter & Sundel, 1989). In fact, most research on midlife development has found that midlife is a period with “continuous development, maintained well-being, adaptivity, and resilience” (Heckhausen, 2001). For many of the challenges encountered during adulthood, individuals have appropriate strategies for mastering them or at least avoiding the socioemotionally debilitating consequences. Specifically there are 3 types of regulatory resources available to deal with stressful situations: social support and social relations, general psychological resources, and specific control strategies for managing the stress of the loss. First, social support involves instrumental and emotional support from others in one’s social network. Second, general psychological resources comprise such personality characteristics as ego resiliency (Block & Block, 1980) or generalized self-efficacy beliefs (Bandura, 1977). Finally, strategies for managing the challenges of midlife include control striving, experience and knowledge about adult development, and the existence of multiple roles and identities. Control strategies of developmental regulation help individuals to match their goal selections (e.g., whether to focus on career goals or have a child) to the opportunities available at the particular age and its developmental ecology. Thus, for example, an impeding deadline related to declining fertility might prompt a woman and/or her partner in early midlife to give priority to founding a family over pushing for advances in their career, whereas later in midlife other priorities take precedence (Heckhausen, Wrosch, & Fleeson, 2001). Sets of control strategies orchestrated for goal engagement or, for goal disengagement, can help the individual to address the transitions from better to worse opportunities in an organized and efficient manner. Thus, during adulthood, each of its phases has its own set of challenges, opportunities, and risks for development. Many of these challenges involve the potential for disillusionment, decline, and loss. Growth and loss co-occur and confront the individual with converse regulatory challenges. It is most impressive to see how most individuals fare well across these transitions. Sarah F. Roper-Coleman Jutta Heckhausen

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See also Life Course Life-Span Theory of Control Personality Selection, Optimization, and Compensation Model Successful Aging

References Baltes, P. B. (1987). Theoretical propositions of life-span developmental psychology: On the dynamics between growth and decline. Developmental Psychology, 23, 611–626. Baltes, P. B. (1993). The aging mind: Potential and limits. Gerontologist, 33, 580–594. Baltes, P. B., & Baltes, M. M. (1990). Psychological perspectives on successful aging: The model of selective optimization with compensation. In P. B. Baltes & M. M. Baltes (Eds.), Successful aging: Perspectives from the behavioral sciences (pp. 1–34). New York: Cambridge University Press. Baltes, P. B., Staudinger, U. M., & Lindenberger, U. (1999). Lifespan psychology: Theory and application to intellectual functioning. Annual Review of Psychology, 50, 471–507. Bandura, A. (1977). Toward a unifying theory of behavioral change. Psychological Review, 84(2), 191–215. Block, J. H., & Block, J. (1980). The role of ego-control and ego-resiliency in the organization of behavior. In W. A. Collins (Ed.), Development of cognition, affect, and social relations (pp. 39–101). Hillsdale, NJ: Erlbaum. Ericsson, K. A. (2000). How experts attain and maintain superior performance: Implications for the enhancement of skilled performance in older individuals. Journal of Aging and Physical Activity, 8(4), 366–372. Erikson, E. H. (1985). The life cycle completed. New York: Norton. Heckhausen, J. (1999). Developmental regulation in adulthood: Age-normative and sociostructural constraints as adaptive challenges. New York: Cambridge University Press. Heckhausen, J. (2001). Adaptation and resilience in midlife. In M. E. Lachman (Ed.), Handbook of midlife development (pp. 345–394). New York: John Wiley. Heckhausen, J., Wrosch, C., & Fleeson, W. (2001). Developmental regulation before and after a developmental deadline: The sample case of “biological clock” for child-bearing. Psychology and Aging, 16, 400–413. Horn, J. L., & Cattell, R. B. (1966). Refinement and test of the theory of fluid and crystallized intelligence. Journal of Educational Psychology, 57, 253–270.

Hunter, S., & Sundel, M. (1989). Introduction: An examination of key issues concerning midlife. In S. Hunter & M. Sundel (Eds.), Midlife myths: Issues, findings, and practice implications (pp. 8–28). Newbury Park, CA: Sage Publications. Jacques, E. (1965). Death and the midlife crisis. International Journal of Psychoanalysis, 46, 502–514. Kaufman, A. S., & Horn, J. L. (1996). Age changes on tests of fluid and crystallized ability for women and men on the Kaufman Adolescent and Adult Intelligence Test (KAIT) at ages 17–94 years. Archives of Clinical Neuropsychology, 11(2), 97–121. Lachman, M. E. (2004). Development in midlife. Annual Review of Psychology, 55, 305–331. Lehman, H. C. (1945). “Intellectual” vs. “physical peak” performance. Scientific Monthly, 61, 127–137. Levinson, D. (1986). A conception of adult development. American Psychologist, 41, 3–13. Lindenberger, U., Marsiske, M., & Baltes, P. B. (2000). Memorizing while walking: Increase in dual-task costs from young adulthood to old age. Psychology and Aging, 15, 417–436. Loevinger, J. (1997). Stages of personality development. In R. Hogan & J. A. Johnson, et al. (Eds.), Handbook of personality psychology. St. Louis: Washing University, Department of Psychology. Masoro, E. J., & Austad, S. N. (2001). The handbook of the biology of aging. San Diego: Academic Press. Ryff, C. D., Singer, B. H., & Seltzer, M. M. (2002). Pathways through challenges: Implications for well-being and health. In L. Pulkkinen & A. Caspi (Eds.), Pathways to successful development: Personality in the life course (pp. 302–328). New York: Cambridge University Press. Salthouse, T. A. (2003). Interrelations of aging, knowledge, and cognitive performance. In U. M. Staudinger & U. Lindenberger (Eds.), Understanding human development: Dialogues with lifespan psychology (pp. 265–287). Dordrecht, Netherlands: Kluwer Academic Publishers. Schulz, R., & Heckhausen, J. (1996). A life-span model of successful aging. American Psychologist, 51, 702– 714. Staudinger, U. M., & Bluck, S. (2001). A view on midlife development from life-span theory. In M. E. Lachman (Ed.), Handbook of midlife development (pp. 345–394). New York: John Wiley. Sternberg, R. J., Grigorenko, E. L., & Oh, S. (2001). The development of intelligence at midlife. In M. E. Lachman (Ed.), Handbook of midlife development (pp. 217–247). New York: John Wiley. Whitbourne, S. K. (1986). The me I know: A study of adult identity. New York: Springer Publishing.

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Adult Foster Care Homes Whitbourne, S. K. (2001). The physical aging process in midlife: Interactions with psychological and sociocultural factors. In M. E. Lachman (Ed.), Handbook of midlife development (pp. 109–155). New York: John Wiley.

ADULT FOSTER CARE HOMES Adult foster care (AFC) typically involves minimal assistance and around-the-clock supervision for several adults residing in a private community-based dwelling. Proprietors of such homes supply material and emotional support typical of “informal” caregiving. There are approximately 34,000 community residential facilities, including AFC homes, across the United States (Wildfire, Hawes, More, Lux, & Brown, 1998). More often than not, residents of AFC homes are unrelated and require some assistance with activities of daily living, such as housekeeping, personal care, and meal planning and preparation. The amount of assistance can vary greatly among AFC homes and among residents within an AFC home. Assistance provided is generally more than is received in a board-and-care home but less than is found in assisted living or continuing care retirement communities where transportation, assistance with medication administration, supportive services, and onsite professional medical staff are often provided. Stark and colleagues (1995) described AFC homes as a cottage industry in which there are limited profits from the provision of care. Often care is provided by family members of the foster care provider with occasional paid helpers for peak hours. AFC homes are highly effective for older adults with early- to mid-stage Alzheimer’s disease or other forms of dementia (Golant, 2003). Residents with complex medical conditions or who require extensive assistance are better suited to facilities equipped to provide higher levels of care, such as nursing homes. AFC homes are likely to increase in popularity in the coming years for several reasons: (1) fewer family members are available to care for older adults due to changes in family structure (Cantor, 1991); (2) people are living to older ages with chronic illnesses that necessitate assistance but not skilled care (Morgan, Eckert, & Lyon, 1995); and (3) the Olmstead Act encourages states to make available community-based housing options

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to all persons who are capable of living with minimum support (Pease, 2002; Centers for Medicaid and Medicare Services, 2005). Oregon has made AFC homes one of the most viable support options for older adults by covering the cost of residence under home and communitybased Medicaid waivers. As a testament to the appeal and affordability of AFC, 70% of AFC residents in Oregon are able to afford their own care. At present, Oregon has over 12,000 beds compared to fewer than 1,500 in Florida (Polivka, 2004). If Florida had the same proportion of AFC beds in comparison with nursing home beds, there would be over 60,000 AFC beds currently available. Kane (2001) has shown that residents of AFC homes fare better socially and psychologically than residents of other long-term care settings. Other studies have found higher levels of interpersonal and environmental satisfaction among residents of AFC (Curtis, Sales, Sullivan, Gray, & Hedrick, 2005). History and Trends. The concept of adult foster care can be traced to Gheel, Belgium, in the year 600 A.D. when ill wanderers were taken into the homes of kind strangers and provided with care (Sherman & Newman, 1988). Although adult foster care for older adults in the United States is a fairly recent trend, board-and-care homes providing similar care can be traced to Colonial times (Reinardy & Kane, 1999; Sherman & Newman, 1979). English poor laws in the colonies provided reimbursement from public funds to unrelated families who provided food, shelter, and care to the elderly and the poor. Public foster family programs and boarding houses for mentally ill adults were also developed in the late 19th century. Boarding homes for older adults were established in the 1930s, and proprietary rest homes were common during the Depression. Typically, AFC homes serve from 1 to 6 residents. The majority are older adults, often in an early or moderate stage of Alzheimer’s disease or in frail or declining health. One-third have diagnoses of mental illness and/or developmental disabilities (Melcher, 2000). While designed to provide assistance, these homes were originally designed for the support of older adults in declining health, not adults with significant mental health problems striving for independent living. Thus, adult foster care homes are not entirely appropriate for those with mental illness or developmental disabilities. The National

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Alliance for the Mentally Ill (NAMI) is working to find other similar resources for these populations. Residents in AFC homes with more personal control over their lives and surroundings are more satisfied with their living arrangements (Polivka & Salmon, 2001; Reinardy & Kane, 1999). Compared with residents in nursing homes and assisted living facilities, AFC residents express a preference for their current placement, but report less satisfaction with their quality of life and personal control than do assisted living residents. Management and Oversight. Proposed changes to long-term care policy in the United States through the 1970s and 1980s focused on alternatives to nursing home placement for older adults (Nyman, Finch, Kane, Kane, & Illston, 1997). Some states, such as Oregon, offer Medicaid coverage for AFC homes, while others are private pay only. AFC homes are not regulated by comparable standards or laws across the United States or abroad, a point of contention with the nursing home industry. Nursing homes are required to follow strict rules with heavy penalties for noncompliance, whereas in most states AFC homes are not subject to such oversight. With the advent of assisted living, the issue of governmental regulation for other types of congregate care, including AFC, is emerging as a significant public policy issue. Many states are developing recommendations, guidelines, and preliminary governance standards for the full range of congregate care settings between independent living and skilled nursing. Kentucky for example, with 265 AFC homes, requires state licensing and allows a maximum of 3 nonrelated residents per household (Pease, 2002). At issue with regulation and oversight are unannounced inspections of AFC homes, with the majority of residents in support of such measures to ensure quality of care and resident protection (Cummins, 2002). Adult foster care homes, called by various titles but fitting the same description, are reported in 26 of the 50 states in the United States. Regulations and support services for such homes vary across the states (Hawes, Wildfire, & Lux, 1993; Folkemer, Jensen, Lipson, Stauffer, & Fox-Grage, 1996). Much of the oversight is at the state level, although federal regulations for board-and-care homes were established with an amendment to the Social Secu-

rity Act in 1976 (Pease, 2002). The Keys Amendment required states to develop minimum standards for homes with 3 or more residents that receive federal monies. In 1981, the Rinaldo Amendment to the Older Americans Act required states to have ombudsman representation for each AFC or board-andcare home. At present, the states are still negotiating the types and levels of governmental regulation and oversight. Oregon, Minnesota, Ohio, and Washington, states with substantial numbers of AFC homes, are pioneers in developing standards of care and regulation. Providers and Training. The majority of AFC homes are family-owned and managed, with little or no profits for providers. Many of the providers have previous health care experience and the majority are aged 50 and older. Pay for care and services can be from private sources, Medicaid, or other government vouchers, Social Security or through the Veterans Administration. Oregon and Minnesota are reporting an increase in homes run by not-for-profit and for-profit organizations (Pease, 2002; Kane, Baker, Salmon, & Veazie, 1998). Currently, very little training is provided to the proprietors and personnel of AFC homes. Needed educational programs for providers include training on legal issues, budgeting and management strategies, home and fire safety, accident prevention, medical emergency procedures, nutrition counseling, medication, exercise, personal hygiene, and use of and/or linkages to local community resources. Advantages and Disadvantages. Perhaps the greatest advantage of adult foster care homes is the potential for close familial relationships to be fostered among residents and providers. Care is provided in a comfortable home-like setting within a community where social and formal service networks are stable and familiar. Skruch & Sherman (1995) found that family relationships were reported more between resident and provider than among residents. Such relationships are beneficial not only to residents but also to providers who might otherwise be living alone and in social isolation. Residents of AFC homes who have more control over their lives and surroundings appear to fare better physically and psychosocially than residents of other more medically focused congregate settings such

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as nursing homes (Kane, 2001; Polivka & Salmon, 2001; Reinardy & Kane, 1999). Part of this may be attributed to the increased sense of privacy as compared to more institutionalized facility living, ability to retain significant personal possessions, freedom to structure ones physical and social environment, and compatibility among residents and staff (Kane, Baker, Salmon, & Veazie, 1998). Provision of care within a community setting is beneficial to the community as well. The cost of AFC homes is much less than the provision of nursing home care and with increasing governmental funds covering the cost of adult foster care placements direct costs to individuals and their families are reduced. Residents of care homes are more likely to be involved in community organization activities and contribute to use of community resources. This type of symbiotic relationship is particularly valuable in small, rural communities and cities in which naturally occurring retirement communities are prevalent. Additionally, AFC community dwellings are also generally more architecturally attractive and able to blend into neighborhood environments than larger structures designed for congregate living. Adult foster care also provides a bridge between independent living and fully supportive skilled care. Depending on the resident, community-based service offerings, and facility-based assistance, the possibility of aging-in-place or remaining in care until death is enhanced. The comfortable, homelike surroundings can be structured to challenge those who are more independent while supporting those in declining health. A one-size-fits-all approach, typical of the highly structured medical model of residential care, is not the standard. Indeed, AFC homes epitomize flexibility of care provision and client-focused care. As with all situations involving care of the frail or cognitively impaired, the risk of victimization, neglect, and abuse is also present. The same characteristics that make the AFC homes so appealing are also the features that potentially contribute to the failure of this option. With limited oversight from a regulating body, there is limited assurance of quality care. Residents who are, or perceive themselves to be, neglected or abused may be fearful of retribution. They may not have access to authorities to which reports may be made. Lack of a central location, an

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invisible dispersion of AFC homes throughout communities, and the absence of centralized reporting mechanisms make it difficult for states to effectively monitor such facilities. Conclusions. Variations of AFC have been demonstrated to be effective in providing care for the ill and frail for many centuries. Such options are especially beneficial in delaying or avoiding entry into skilled nursing care and allowing residents to have more control over their daily lives, feel part of the larger community, and retain a modicum of privacy and independence. AFC is cost-effective and affords both social and physical health benefits compared to other congregate care settings. Heidi H. Holmes Graham D. Rowles See also Long Term Care: Ethics Long Term Care Ombudsman Program

References Centers for Medicaid and Medicare Services. (2005). Americans with Disabilities Act: The Olmstead Decision. Available: http://www.cms.hhs.gov/olmstead/ default.asp Cantor, M. H. (1991). Family and community: Changing roles in an aging society. Gerontologist, 31(3), 337– 346. Cummins, R. (2002). Hawaii care homes: An AARP survey. Washington, DC: AARP. Curtis, M. P., Sales, A. E. B., Sullivan, J. H., Gray, S. L., & Hedrick, S. C. (2005). Satisfaction with care among community residential care residents. Journal of Aging and Health, 17(1), 3–27. Folkemer, D., Jensen, A., Lipson, L., Stauffer, M., & FoxGrage, W. (1996). Adult foster care for the elderly: A review of state regulatory and funding strategies (Vols. 1 and 2). Washington, DC: AARP Public Policy Institute. Golant, S. M. (2003). The ability of U.S. assisted living facilities to accommodate impaired older persons with health care needs: A meta-analysis. Gainesville, FL: University of Florida, Department of Geography and Institute on Aging. Hawes, C., Wildfire, J. B., & Lux, L. J. (1993). The regulation of board and care homes: Results of a survey in the

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50 states and the District of Columbia. Washington, DC: AARP Public Policy Institute. Kane, R. A. (2001). Long-term care and a good quality of life: Bringing them closer together. Gerontologist, 41(3), 293–304. Kane, R. A., Baker, M. O., Salmon, J., & Veazie, W. (1998). Consumer perspectives on private versus shared accommodations in assisted living settings. Washington, DC: AARP, Public Policy Institute. Melcher, B. (2000). Presentation to the Mental Health Study Commission, NAMI, North Carolina. Available: http://www.naminc.org/presentationmhsc3.htm Morgan, L. A., Eckert, J. K., & Lyon, S. M. (1995). Small board-and-care homes: Residential care in transition. Baltimore, MD: John Hopkins University Press. Nyman, J. A., Finch, M., Kane, R. A., Kane, R. L., & Illston, L. H. (1997). The substitutability of adult foster care for nursing home care in Oregon. Medical Care, 35(8), 801–813. Pease, R. M. (2002). The marginalization of family care homes in Kentucky. Unpublished doctoral dissertation. Lexington, KY: University of Kentucky. Polivka, L. (2004). Community residential care for the frail elderly: What do we know, what should we do? Available: http://www.nga.org/center/divisions/ 1,1188,C ISSUE BRIEF∧ D 7176,00.html Polivka, L., & Salmon, J. (2001). Consumer-directed care: An ethical, empirical, and practical guide for state policymakers. Tampa, FL: Florida Policy Exchange Center on Aging. Reinardy, J., & Kane, R. A. (1999). Choosing an adult foster home or a nursing home: Residents’ perceptions about decision making and control. Social Work, 44(6), 571–585. Sherman, S. R., & Newman, E. S. (1979). Foster family care for the elderly: Surrogate family or mini institution? International Journal of Aging and Human Development, 10, 165–176. Sherman, S. R., & Newman, E. S. (1988). Foster families for adults: A community alternative in long-term care. New York: Columbia University Press. Skruch, M. K., & Sherman, S. R. (1995). Assessing the interpersonal environment in small residential care homes: A comparison of findings on family-likeness in New York and Maryland. Adult Residential Care Journal, 9(2), 67–79. Stark, A., Kane, R. L., Kane, R. A., & Finch, M. (1995). Effect of physical functioning of care in adult foster homes and nursing homes. Gerontologist, 35(5), 648– 655. Wildfire, J. B., Hawes, V. L., More, L., Lux, L., & Brown, F. (1998). The effect of regulation on the quality of care in board and care homes. Generations, 21(4), 325– 329.

ADULT PROTECTIVE SERVICES Adult Protective Services (APS) protects vulnerable adults by investigating allegations of elder abuse, including abuse, neglect, abandonment, and financial exploitation. Based on the outcome of an investigation, APS may offer legal and/or social services. Adults who need APS tend to have physical or mental impairments that put them at risk for harming themselves (self-neglect) or being harmed by others. Elder abuse or mistreatment is discussed in detail elsewhere in this encyclopedia, but indications are that factors placing older adults at risk for mistreatment include the presence of a brittle support system, loneliness, family conflict, alcohol abuse, psychiatric problems, social awkwardness, and short-term memory problems (Shugarman, Fries, Wolf, & Morris, 2003). In cases where elder abuse occurs in institutional settings, there are mechanisms set in place, flawed though they may be, to identify such abuse and manage the consequences. Such resources include institutional review processes and the State Ombudsman program adopted after the passage of the Omnibus Budget Reconciliation Act of 1987. When elder abuse occurs in the community, recourse is available through Adult Protective Services programs in each state.

Historical and Legislative Background The need for APS has been acknowledged as a social problem since the early 1950s, but it was not until the 1960s that it was studied formally and incorporated into our public policies by passage of the 1962 amendments to the Social Security Act (Otto, 2000). By the end of the 1960s, there were only twenty community protective services programs in the country (Mixson, 1995). After the passage of the Title XX amendment to the Social Security Act (1974), federal funding was provided to the states through Social Security Block Grants (SSBG) that allowed states the flexibility to provide protective services to adults. SSBG funding reached a peak of $83.3 million spent on APS in 1980; since that time, funding has been reduced to just under $40 million (Otto, 2000). In 1978, the Select Committee on Aging conducted the first intensive investigation on elder abuse

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and recommended that states enact laws to address this problem (U. S. Congress, 1981). Since that time, all 50 states have established APS programs that provide a system of preventative, supportive, and surrogate services to community-dwelling older adults to enable them to remain in their homes without fear of abuse or exploitation (Greenberg, McKibben, & Raymond, 1999). Most states include elder mistreatment provisions in their existing APS legislation, while many use domestic violence statutes and/or elder abuse laws to protect the older adults from abuse. California has a special criminal statute that pertains to elder abuse. In addition, 42 states have mandatory reporting laws (Capezuti, Bush & Lawson, 1997) that require various health care professionals, paraprofessionals, and laypersons (including various privately employed health care providers and caregivers) to report known or suspected mistreatment to their state agency. Eleven states address selfneglect as a type of neglect that may warrant protection, and either designate it as a separate category of elder mistreatment or include it within their general abuse definitions (Velick, 1995). For information on state agencies charged with responsibility for APS, the National Center on Elder Abuse provides a list of weblinks that can be accessed at http://www.elderabusecenter.org/default.cfm?p= apsstate.cfm (NCEA, accessed 10-28-04). In addition, information on state statutes can be found at http://web2.westlaw.com (cited in Jogerst, Daly, Brinig, Dawson et al., 2003).

Service Philosophy and Delivery APS workers are frequently called on to make critical, life changing decisions in complex situations. Statutes typically require APS investigations to be initiated within 24 hours of receiving a report with the appropriate actions taken as quickly as possible to ensure the safety of the victim. Many cases involve life and death medical problems, difficult issues surrounding the older adult’s mental capacity to consent to or refuse services, undue influence, guardianship, powers of attorney, and the rights of victims to self-determination versus the state’s parens patriae duty to protect helpless citizens (National Association of Adult Protective Services Administrators [NAAPSA], 2003).

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Although many have criticized APS for being modeled inappropriately on the Child Protective Services paradigm, some basic tenets of service exist that are unique to older adults. These tenets include the client’s right to self-determination, use of the least restrictive alternative, maintenance of the family unit whenever possible, use of communitybased services rather than institutions, avoidance of ascription of blame, and the presumption that inadequate or inappropriate services are worse than none (Otto, 2000). To protect and serve older adults subject to alleged abuse, APS receives reports, conducts investigations, evaluates risks to clients, assesses clients’ ability to give consent, develops and implements case plans, counsels clients, arranges for a variety of services and benefits, and monitors ongoing service delivery (Otto, 2000). Services most likely to be recommended by APS for abused older adults include medical and social services, guardianship, psychological and/or family counseling, legal counsel, and institutional placement when necessary.

Prevalence of Abuse Pillemer & Finkelhor (1989) conducted the first random sample survey of abuse, relying on interviews with 2,020 community-dwelling elderly persons in the Boston area. They reported that the overall rate of mistreatment was 32 persons per thousand. Using population estimates of 1987 and assuming that their results could be replicated nationwide, this would imply over 950,000 older adults mistreated. Because it was believed that most cases of elder mistreatment go unreported, in 1996 the National Center on Elder Abuse (NCEA) conducted the National Elder Abuse Incidence Study (NEAIS) to estimate the number of older adults mistreated in the United States over a 12 month period within 20 representative counties, relying on two sources of data: APS investigations and reports from 1,150 trained “sentinels,” that is, individuals employed by agencies that regularly provided services to elders (National Center on Elder Abuse [NCEA], 1998). Using probabilistic methods, the NEAIS investigators estimated that 551,011 older adults (or 16 in every 1000) were victims of abuse, neglect, exploitation, and/or self-neglect in 1996, with a range of the estimate being between 314,995 and 787,027.

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Most cases of mistreatment (79%) were identified through the trained sentinels, while only 21% were substantiated reports through APS. However, in a more recent study, Jogerst et al. (2003) found abuse rates that ranged from 4.5 per 1000 in New Hampshire to 14.6 per 1000 in California, for a national range of between 160,000 and 520,000 victims of abuse. Estimates of the need for APS, thus, vary widely although all indicate a significant number of potentially abused older adults in our society.

APS Referrals According to the National Elder Abuse Incidence Study, most substantiated reports to APS were from family members hospitals, law enforcement, inhome service providers, friend/neighbors, the victims themselves, and physicians, nurses, or medical clinics (NCEA, 1998). In a recent study of APS in Florida in the 1990s, Reynolds and Schonfeld (in press) found the most prevalent reasons for referrals to be medical neglect, conditions hazardous to health, inadequate supervision when a caregiver is present, inadequate food, bruises and/or welts, inadequate supervision when a caregiver is absent, and complaints of harassment, belittlement, or ridicule. In the NEAIS (NCEA, 1998), researchers found that victims of abuse and neglect were women (57.6%), white (84%), and had low annual income (most had less than $14,000). The eldest victims, age 80 and older, were abused and neglected at the highest rate, two to three times their proportion of the older adult population. Elder self-neglect is a different category than those who are victims of acts perpetrated by others. Of those older adults who self-neglect, most were white (77.4% versus 20.9% black), female (65%), and age 75 or older (65%). Almost all (93.4%) have some difficulty caring for themselves, and have some form of confusion/disorientation (45.4% sometimes confused, 29.9% very confused). In the same study, males were more often the perpetrators of mistreatment for abandonment (83.4%), physical abuse (62.6%), emotional/psychological abuse (60.1%), and exploitation (59.0%), while females were more likely to neglect an older adult (52.4%). More than three quarters of perpetrators (77.4%) were white, and most (66%) were under age 60. With respect to relationship

with the victim, adult children were the most frequent perpetrators of all categories of abuse for abandonment (79.5%), exploitation (60.4%), emotional/psychological abuse (53.9%), physical abuse (48.6%), and neglect (48.6%—NCEA, 1998).

Ongoing Issues for APS While it is commendable that all 50 states now address the need for Adult Protective Services in some formal manner, all APS programs are subject to a number of ongoing issues that threaten their ability to accomplish their missions. As noted in a survey of state APS administrators (n = 42 respondents), first and foremost are the issues of underfunding and understaffing, a problem that is rampant. Other problems include lack of emergency or alternative placements for victims, lack of public awareness, and insufficient community resources (NAAPSA, 2003). Another issue is the outcome of APS referral for older adults and their families. In a recent study, Lachs, Williams, O’Brien, and Pillemer (2002) used the EPESE to examine older adults referred to APS in Connecticut, finding that referral to APS resulted in a five-time greater risk of nursing home placement compared to those not referred to APS. In spite of the stated desire to preserve the family unit and apply the least restrictive alternative interventions, Lachs and colleagues’ findings (2002) indicate that these efforts are of questionable effect.

The Future of APS To ensure the maintenance and enhancement of programs to assist older adults suspected of being victims of abuse, several improvements should be made. First, APS programs need increased federal funding, improvements in training, access to examples of best practice models, and a national public awareness campaign (National Association of Adult Protective Services Administrators, 2003). Second, we need to continue advocacy for the rights of elders, and push for greater involvement of the medical community (Kohn, 2003). In one study, Marshall, Benton, and Brazier (2000) found that physician referrals accounted for only 2% of cases of abuse. The implication is that physicians

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are either unable or unwilling to identify and report potential abuse. Recent efforts to devise expedient methods for physicians to screen older adults for further diagnostic assessment for abuse have been encouraging (Fulmer, Guadagno, Bitondo Dyer, & Connolly, 2004), but much more needs to be done. APS provides a much needed service to older adults living in the community. Communities, large and small, must be encouraged to recognize the potential threat of elder abuse and the importance of APS in protecting potential victims of abuse. This will take a commitment of time, money, and advocacy to ensure that APS remains a viable source of comfort to abused older adults. Sandra L. Reynolds Lawrence Schonfeld See also Elder Abuse and Neglect Elder Law Guardianship/Conservatorship

References Capezuti, E., Brush, B. L., & Lawson, W. T. (1997). Reporting elder mistreatment. Journal of Gerontological Nursing, 23, 24–32. Fulmer, T., Guadagno, L., Bitondo Dyer, C., & Connolly, M. T. (2004). Progress in elder abuse screening and assessment instruments. Journal of the American Geriatrics Society, 52, 297–304. Greenberg, J., McKibben, M., & Raymond, J. (1990). Dependent adult children and elder abuse. Journal of Elder Abuse and Neglect, 2, 73–86. Jogerst, G. J., Daly, J. M., Brinig, M. F., Dawson, J. D., et al. (2003). Domestic elder abuse and the law. American Journal of Public Health, 93, 2131–2136. Kohn, N. (2003). Second childhood: What child protection systems can teach elder protection systems. Stanford Law & Policy Review, 14, 175. Lachs, M. S., Williams, C. S., O’Brien, S., & Pillemer, K. A. (2002). Adult Protective Service use and nursing home placement. The Gerontologist, 42, 734–739. Marshall, C. E., Benton, D., & Brazier, J. M. (2000). Elder abuse. Using clinical tools to identify clues of mistreatment. Geriatrics, 55, 47–50, 53. Mixson, P. M. (1995). An Adult Protective Services perspective. Journal of Elder Abuse & Neglect, 7(2/3). National Association of Adult Protective Services Administrators, (2003). Problems Facing State Adult Protec-

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tive Services Programs and the Resources Needed to Resolve Them. Washington, DC: NAAPSA. National Center on Elder Abuse (1998). The National Elder Abuse Incidence study. Final report. Washington, DC: National Center on Elder Abuse. Otto, J. M. (2000). The role of Adult Protective Services in addressing abuse. Generations, Summer 2000, 33–38. Pillemer, K., & Finkelhor, D. (1988). The prevalence of elder abuse: A random sample survey. The Gerontologist. 28, 51–57. Reynolds, S. L., & Schonfeld, L. (in press). Using Florida’s Adult Protective Services data in research: Opportunities and challenges. Journal of Elder Abuse & Neglect, forthcoming. Shugarman, L. R., Fries, B. E., Wolf, R. S., & Morris, J. N. (2003). Identifying older people at risk of abuse during routine screening practices. Journal of the American Geriatrics Society, 51, 24–31. U. S. Congress, (1981). Elder Abuse, an Examination of a Hidden Problem. Report by the Senate Subcommittee on Aging. Washington, DC: 97th Congress. Com. Pub. 97–277. Velick, M.M.R.S. (1995). A necessary yet underutilized response to elder abuse. Elder Law Journal, 3, 165.

ADVANCED GLYCATION END-PRODUCTS As we age, the long-lived proteins in our body become gradually browner, more fluorescent, more highly crosslinked and less soluble. These changes are most apparent in the lens of the eye, which becomes visibly yellow and brown with age, interfering with the transparency of the lens and color vision. Similar changes occur in collagen, the major structural protein of the body, found in skin and tendons and in the basement membranes of the kidneys, arteries and other tissues. The gradual browning and crosslinking of arterial collagen is associated with the age-dependent decrease in elasticity and compliance of the arterial wall. These age-related changes in tissue proteins are thought to result, in part, from nonenzymatic reactions between proteins and reducing sugars in extracellular fluids. In 1984 Anthony Cerami introduced the term, advanced glycation end-product (AGE), to describe the class of compounds formed as a result of chemical reactions between sugars and proteins. The term AGE is a play on words—AGEs are involved in the chemical aging of tissue proteins and contribute to the

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(CH2)4 O

C

(CH2)4 NH2

NH CH

(CH2)4

Lysine

NH

+

CH2

H

C

O

H C OH (CHOH)3

NH

C

C O (CHOH)3 CH2OH

CH2 COOH

[O2]

Carboxymethyllysine

[O2]

Lysine

Arginine

N+

HN

Fructoselysine

CH2OH Glucose

N

HN Arginine

Pentosidine

FIGURE 1 Reaction of lysine with glucose to form the Amadori compound, fructoselysine, the primary glucose adduct on glycated proteins. Fructoselysine is oxidized to form AGEs, e.g. by oxidative cleavage to form carboxymethyllysine, or by oxidative reaction with arginine to form pentosidine. (CML)

age-dependent increase in chemical modification and crosslinking of tissue proteins. The chemistry of “AGEing” reactions in vivo is similar to that of Maillard or browning reactions that occur during the cooking and caramelization of foods and enhance food color, taste, and aroma. One of the first steps in this reaction is the condensation of a reducing sugar with an amino group in protein, yielding a Schiff base (imine) adduct, which then undergoes an Amadori rearrangement to form a relatively stable ketoamine adduct to the protein (Figure 1). This process of addition of a sugar to a protein is known as nonenzymatic glycosylation, or glycation, of protein. The Amadori product is not brown or fluorescent, nor is it a protein crosslink. It is a reversible modification of protein, but is a precursor to AGEs, which are irreversible chemical modifications and crosslinks in protein. The Maillard reaction first attracted the interest of biomedical scientists in the mid-1970s when a modified form of hemoglobin, isolated from normal human blood, was shown to contain glucose as an Amadori adduct. During the 120 day lifespan of the red cell, less than 10% of human hemoglobin is converted to this glycated form, now known as glycated hemoglobin or HbA1c . However, the concentration of glycated hemoglobin increases in the

blood of diabetic patients and correlates strongly with mean blood glucose concentration during the previous one-month period. Measurements of glycated hemoglobin are widely used for monitoring long-term blood glucose control in diabetes. Glycation is now recognized as a common chemical modification of body proteins, occurring mostly at the ε-amino group of lysine residues. The glycation of proteins in vivo suggested that the later, browning stages of the Maillard reaction also take place in the body, leading to the formation of AGEs. Indeed, more than a dozen structurally characterized AGEs are now known to accumulate with age in long-lived proteins, such as lens crystallins and tissue collagens—these same compounds are found in cooked foods, pretzels, and toasted bread. They include lysine modifications such as Nε -carboxymethyllysine (CML), Nε -carboxyethyllysine (CEL) and pyrraline; fluorescent and nonfluorescent crosslinks, such as pentosidine, crosslines, vesperlysines, and glucosepane; and imidazoles and imidazolones derived from glyoxal and methylglyoxal. Most of these AGEs increase in lens proteins with age, and, because of chronic hyperglycemia, are found at higher concentrations in collagen and other longlived proteins (e.g., myelin and actomyosin from

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patients with diabetes). Increased age-adjusted levels of AGEs in tissue collagens are associated with the development of retinal, renal, neurological, and vascular complications of diabetes. AGEs are also detectable at high concentration in protein deposits in the brains of patients with Alzheimer’s disease, in atherosclerotic plaque, in amyloid plaque of patients with hemodialysis-associated amyloidosis, and in articular collagen in arthritis. In these diseases, AGEs may have a role in recruitment of macrophages, enhancing inflammation, and tissue damage. AGEs may also chelate transition metal ions (iron and copper) in redox-active form, catalyzing oxidative stress, and may react with soluble proteins, contributing to deposition of plasma protein in the vascular wall and glomerular basement membrane in diabetes. AGE-proteins are recognized by scavenger receptors on macrophages and by AGE-specific receptors, including RAGE (Receptor for AGE) on macrophages. AGE receptors and RAGE are also found on endothelial and neural cells, myocytes, and lymphocytes. The uptake of AGE-proteins by macrophages and endothelial cells is associated with generation of oxygen radicals and release of cytokines that promote collagen turnover and biosynthesis, cell proliferation, and tissue remodeling, suggesting that receptor-mediated binding of AGEs may trigger the rejuvenation of tissues. The meaning of the term, AGE, has evolved over time. It is now used to refer to a broad range of carbohydrate-derived products formed during advanced stages of the Maillard reaction in vivo. Not all AGEs accumulate in tissue proteins with age, and some AGEs react with and form crosslinks with other proteins, so that they are not necessarily “end-products.” AGEs may also be formed from a variety of carbohydrates other than blood sugar (glucose), including ascorbate, fructose, sugar phosphates, and even simpler molecules, such as methylglyoxal. Ascorbate is present at high concentrations in the lens and may be a major precursor of AGEs in lens proteins. There is increasing evidence that some circulation AGEs may also be derived from the diet, especially cooked foods, and that the dietary AGEs, known as glycotoxins, may affect renal and vascular function. Analogs of AGEs have also been detected in phospholipids and in DNA, and products similar to, and in some case identical to AGEs, known as advanced lipoxidation end-products (ALEs), are

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formed during peroxidation of lipids in plasma and membranes. More than 25 AGE/ALEs have been structurally characterized and have been measured in tissue proteins throughout the body by chemical analysis and immunological methods. Oxygen and catalysts of oxidation reactions, such as copper and iron ions, accelerate the Maillard reaction. Oxygen and oxidative reactions are considered fixatives of the chemical modification of proteins by carbohydrates, and glycoxidation products are a subclass of AGEs formed by both glycation and oxidation reactions. All ALEs require oxygen and peroxidation reactions for their formation from lipids. Antioxidants and AGE/ALE inhibitors, such as aminoguanidine and pyridoxamine, which trap reactive sugars and dicarbonyl intermediates in formation of AGE/ALEs, are effective in preventing or retarding the development of complications in animal models of diabetes and are being tested in clinical trials. Other drugs used for treatment of diabetes and cardiovascular disease, such as angiotensin converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs) and hypolipidemic agents, also inhibit the accumulation of AGE/ALEs in collagen in experimental animals, suggesting that their beneficial effects may be attributed, in part, to inhibition of AGE/ALE formation. Although the relationship between AGE/ALEs and aging is still associative, caloric restriction, which extends the lifespan of rodents, also inhibits the accumulation of AGE/ALEs in tissue collagens, possibly through a combined effect on blood glucose and lipids and oxidative stress. Future research will continue to focus on the structure and mechanism of formation of AGE/ALEs, but especially on the AGE/ALE inhibitors for treatment of aging and chronic disease. John W. Baynes See also Carbohydrate Metabolism Diabetes

References Baynes, J. W. (2003). Chemical modification of proteins by lipids in diabetes. Clinical Chemical and Laboratory Medicine, 41, 1159–1165. Monnier, V. M. (2003). Intervention against the Maillard reaction in vivo. Archives of Biochemistry and Biophysics, 419, 1–15.

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Peppa, M., Uribarri, J., Vlassara, H. (2004). The role of advanced glycation end products in the development of atherosclerosis. Current Diabetes Reports, 4, 31– 36. Reddy, V. P., Obrenovich, M. E., Atwood, C. S., Perry, G., Smith, M. A. (2002). Involvement of Maillard reactions in Alzheimer disease. Neurotoxin Research, 4, 191–209. Thorpe, S. R., Baynes, J. W. (2003). Maillard reaction products in tissue proteins: new products and new perspectives. Amino Acids, 25, 275–281. Yan, S. F., Ramasamy, R., Naka, Y., Schmidt, A. M. (2003). Glycation, inflammation, and RAGE: a scaffold for the macrovascular complications of diabetes and beyond. Circulation Research, 93, 1159–1169.

Web Sites http://www.chemsoc.org/exemplarchem/entries/2001/ caphane/maillard.html http://teachhealthk-12.uthscsa.edu/pa/pa10/pa10pdf/ 10overview.pdf http://food.oregonstate.edu/color/maillard/ http://maillard.sc.edu

AFRICAN AMERICAN ELDERS In recent years, substantial progress continues to be made in social and psychological research on black older adults, and the research and scholarly literature is expanding (Curry & Jackson, 2003; Whitfield, 2004; Beech & Goodman, 2004). The title of this entry reflects the heterogeneity of the black population in the United States: with the increased growth of both the black Caribbean and African immigrant populations in the United States, the term “African American,” denoting a native black heritage traced to slavery, is no longer as viable as in prior decades (Jackson, 2003; Jackson & Williams, 2003). Recent research continues to feature “racial” comparisons; however, more studies and analyses are being done, permitting greater attention to the heterogeneity among other racial and ethnic groups (Whitfield, 2004). Larger concerns with health disparities (Anderson, Bulatao, & Cohen, 2004; Beech & Goodman, 2004) are propelling greater focus on broader, more inclusive, and more heterogeneous concerns of both race and ethnicity among all groups, placing the previously strict comparison

of black-white differences in a larger national and international context (Anderson, et al., 2004; Jackson, 2003). While progress in research has been and can continue to be made with a focus within a race or ethnic group (Jackson, 1985; Whitfield, 2004), observed health morbidity and mortality differences among racial and ethnic groups have propelled research in a more strictly comparative framework. There is a need for more systematic, empirical research on aging within the black population, especially with a life-course focus (Brown, Jackson, & Faison, 2005). Continued improvement in the quality of data among race and ethnic groups, especially national survey data (for example, the Health and Retirement Survey, Jackson, Lockery, & Juster, 1996; and the National Survey of American Life, Jackson & Williams, 2003) is leading to greater use of more representative samples and the application of methodologically sophisticated data collection and analytic methods (Skinner, Teresi, Holmes, Stahl, & Stewart, 2001). There is still not a great deal of support for a coherent field of ethnogerontology (Jackson, 1985). On the other hand, a growing emphasis on population aging worldwide (United Nations, 2002) is leading to greater concern with international issues and the immigration of older individuals (Jackson, 2003). The areas of socioeconomic status, health status, family and social support, psychological well being, and work and retirement are used below to sample progress over the last 5 years.

Socioeconomic Status Older black Americans continue to lag behind older whites in all indicators of social and economic statuses (Anderson, et al., 2004; Federal Interagency Forum on Aging-Related Statistics, 2004; Friedland & Summer, 2005). Indicators of income, education, and poverty statuses reveal the continued poor position of older blacks relative to older whites. Belying a cohort replacement perspective, the continuing poor relative position of blacks suggests that entering new cohorts of children and adults are not faring appreciably better than prior ones (Brown, et al., 2005); unfortunately, recent data on the statuses of middle-aged and younger blacks, relative to whites, in housing, income, occupation, health,

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and education indicates only small expected gains as new cohorts enter older ages (Anderson, et al., 2004; Muhammad, Davis, Leondar-Wright, & Lui, 2004). Again it is important to note that some improvements in socioeconomic status indicators have occurred. For example, in 2001 approximately 34% of the black elderly lived below the poverty level. Today approximately 24% (compared to 8% of whites) live at or below this level, though women (27.4%) far outstrip men (18.1%) in this regard. Some of this gender difference is accounted for by sex differences in mortality rates and living arrangements between black men and women. But it is true that older blacks are better fed, better housed, and in better health than in earlier eras, though the relative differences between racial groups persist (Anderson, et al., 2004). According to the author, most of this improvement is attributable to government assistance programs (Williams & Jackson, 2005), which are still the prime support of black Americans in older (and to some extent younger) age groups. A larger relative proportion of blacks, as compared to whites, because of histories of poor occupational opportunities, lack of wealth, and private retirement funds, are heavily dependent upon these government programs (Jackson, et al., 1996; Brown & Jackson, 2005; Williams & Jackson, 2005). The figures on net worth or wealth perhaps best illustrate the nature of the problem. Since 1984, the net worth of households headed by older whites has improved 81% to $205,000. Reflecting the continuing gap, the net worth of households headed by blacks rose 61% from $25,600 to $41,000: the gap was larger in 2004 than in 1984 (Federal Interagency on Aging Related Statistics, 2004). Continuing attacks on state programs, a stagnant national economy, especially in the northeast, slow job creation, particularly those that provide sustainable incomes at low education levels, and simultaneous growth in low-paying service positions (e.g., fast food restaurants) that do not provide sustainable incomes, leave little room for black youth and young adults, or for their middle-aged cohorts, whose educational attainments and job preparation capital still lags significantly behind that of whites (Muhammad, et al., 2004; Williams & Jackson, 2005). It continues to be uncertain that future cohorts of older blacks will be generally as well off as their white counterparts, although the author foresees growing heterogeneity

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among older black cohorts themselves in social and economic well-being as a function of the growing status differences among younger aged black cohorts (Jackson & Williams, 2003). Thus, it is likely that a growing, but still small, group of older blacks will take adequate pensions and financial resources into older age; this proportion, though larger than in prior years, will still be relatively small in comparison to the proportion of older whites who enjoy these statuses (Friedland & Summer, 2005).

Health, Morbidity, and Mortality Recent papers clearly document that at nearly every point across the life course black Americans have poorer morbidity and mortality than whites (Hayward & Heron, 1999; Whitfield & Hayward, 2003; Williams & Jackson, 2005). At age 65, whites can expect to live on average 2 years longer than blacks. As earlier publications have pointed out, this is because black death rates are higher in adulthood in the below-65 age groups (Gibson, 1994; Gibson, & Jackson, 1992). It is also well documented that there is increased longevity over that of whites among blacks who live to approximately the age of 85 or so (Federal Interagency Forum on Aging-Related Statistics, 2004). Many have suggested possible selection biases resulting in the survival of particularly robust and hardy individuals (e.g., Hayward & Heron, 2002; Whitfield & Hayward, 2003). Others have claimed that this supposed crossover is only an artifact of faulty reporting and exaggerated age claims. The effect has been firmly established (Preston, Elo, Rosenwaike, & Hille, 1996), although there continues to be no widely accepted explanations (Hummer, Benjamins & Rogers, 2004; Jackson, 1985). The racial mortality crossover appears to be a real phenomenon (Preston, et al., 1996), one that involves some type of “survival of the fit.” More important than the work on the race crossover phenomenon, however, is the recent research on active life expectancy. Crimmins and colleagues (2004) have shown large race and ethnic differences in active life expectancy and complex relationships between longevity and health. For example, Asian Americans may live longer in relatively good health as compared to Native Americans and black Americans (Hayward & Heron, 1999).

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Research on older blacks has long documented heterogeneity in social and psychological health indicators (Anderson, et al., 2004). Clark and colleagues (1993) have shown evidence for greater functional health, in comparison to whites, among older blacks. Recent work (Hayward & Heron, 1999) points to the need for more focused and detailed studies on the relationships among race/ethnicity, mortality, and morbidity. The nature of differences in the structure of health, the processes of health, and the influence of service use on experienced health problems remain open questions (Gibson, 1994; Williams & Jackson, 2005). The growing heterogeneity among the American black population, especially due to immigration, is a phenomenon that will have important implications for health and mortality, but also for understandings of well-being more generally (Jackson, Antonucci & Brown, 2004; Jackson, 2003).

Psychological Well-Being Research on well-being has shown an increasing sophistication over the last few years (Brown, et al., 2005; Federal Interagency Forum on Aging-Related Statistics, 2004). Structural factors, like income and education, tend to show small but positive relationships to well-being (Brown, et al., 2005). Some recent evidence also suggests that younger cohorts of blacks may be less satisfied than older cohorts at comparable periods in the life span (Brown, et al., 2005; Chatters & Jackson, 1989). This is in sharp contrast to whites, who have shown the opposite pattern. This lowered satisfaction and happiness in younger blacks may be related to rising expectations and structural constraints that are likely to persist into older age, portending future cohorts of older blacks with lowered levels of subjective well-being (Brown, et al., 2005).

Work and Retirement Family and Social Support Two myths have characterized research on the black family and social support networks (Antonucci & Jackson, 2004; Mendes de Leon & Glass, 2004; Taylor, Jackson, & Chatters, 1997). The first is a view of older blacks cared for by loving and extended family members and kin. The other is a view of the impoverished lonely older black abandoned by a disorganized and incompetent family system. National and other large social surveys indicate a reality somewhere in between (Taylor, et al., 1997; Taylor, Chatters, & Levin, 2004; Chatter, Taylor, Lincoln, & Schroepfer, 2002). These recent research findings document the existence of extended families but also demonstrate that much of the assistance is reciprocal, that the black aged often provide help to younger family members and neighbors (Chatters, et al., 2002; Antonucci & Cantor, 1994). The importance of community institutions like the church as sources of physical and emotional support to older blacks has also been well documented (Taylor, et al., 1997; Taylor, Chatters, & Levin, 2004). Some recent data indicates possible changes in the structure of American families and more dispersed living patterns that may result in lowered possibilities of support in older ages (Jackson, Brown, & Antonucci, 2005).

Little empirical research had been devoted to the study of work and retirement in the black aged (Jackson, et al., 1996). Some earlier work had speculated that the entire retirement process, viewed within a life-span context, may be very different for blacks. Since blacks often have long histories of dead-end jobs with poor benefits and bleak expectations, the advantages of retirement are lessened (Brown, et al., 2005). Thus, inadequate income, poor housing, and uncertain futures face many older blacks at retirement age (Brown, et al., 2005). Faced with limited retirement resources, many blacks may continue working past customary retirement ages out of desperation (Brown, et al., 2005). Some recent research indicates that these individuals are physically, psychologically, and socially worse off than their retired black counterparts (Brown, et al., 2005). As suggested earlier, even the relatively poor but stable government retirement support blacks may receive (if they are fortunate enough to qualify) may, in contrast, be better than sporadic and poor jobs in the regular labor market (Jackson, 2001). Thus, retirement may provide a small but secure government income, leading to increased psychological and social well-being (Brown, et al., 2005). In contrast to 5 years ago, more research on the social gerontology of the black aged is being included

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within the general investigation of ethnicity and cultural factors in aging (Antonucci & Jackson, 2004; Jackson, et al., 2004, 2005; Brown, et al., 2005). The existence of new national datasets and more powerful analytical techniques is increasing the quality and quantity of research on African American aging in all areas (Whitfield, 2004). New national data collection efforts, like the Health and Retirement Survey and the new National Survey of American Life (Jackson, et al., 2004) are improving the available data on the aging experience of African Americans (Curry & Jackson, 2004; Whitfield & Hayward, 2003). While better data is always needed, especially longitudinal and panel studies, the improvement in a relatively few short years has been impressive. Similarly, the approach to research on the black elderly is continuing to include a greater recognition of the heterogeneity among elderly blacks, as well as other race and ethnic groups (Anderson, et al., 2004; Brown, et al., 2005). Research is more focused on the role of the life course, culture, socioeconomic status, and gender as important structures and processes related to potential process differences within and among older groups of color (Anderson, et al., 2004; Jackson, et al., 2004; Whitfield, 2004). The field of ethnogerontology as an organizing theoretical framework in the study of the black aged seems to be a growing reality over the last few years, though it is not characterized as such (Jackson, 1985). Recent research continues to reverse past trends of poor data and impoverished theory; generalizable, high-quality findings are beginning to emerge concerning health, socioeconomic status, social support, family patterns, well-being, work, and retirement among black older populations (Anderson, et al., 2004; Brown, et al., 2005). Interestingly enough, research emphases on differences within race and ethnic groups is being reversed of late, especially in health-related research (Anderson, et al., 2004; Williams & Jackson, 2005). This is due in part to the acceleration of work on health inequalities and disparities, bringing a greater focus to cross-ethnic group comparisons (Anderson, et al., 2004; Whitfield & Hayward, 2003). While of vital importance in addressing real disparities in physical and psychological health, one perverse outcome of this theoretical and research attention may be to impede further development of theory and empirical research that focuses on differences in social, psychological, and health statuses

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and processes within race and ethnic groups (Brown, et al., 2005). As noted in the earlier volume, work on population genetics may hold some promise for focusing greater attention on intra-group, individual factors and processes related to observed population level disparities (Whitfield, 2004). James S. Jackson See also Ethnicity Minority Populations: Recruitment and Retention in Aging Research

References Anderson, N. P., Rodolfo, R. A., & Cohen, B. (Eds.). (2004). Critical perspectives on racial and ethnic differences in health in late life. Panel on Race, Ethnicity, and Health in Later Life. Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. Antonucci, T. C., & Jackson, J. S. (2004). Ethnic and cultural differences in intergenerational social support. In V. L. Bengtson & A. Lowenstein (Eds.), International perspectives on families, aging, and social support. Aldine de Gruyter Publishing Co. Beech, B. M., & Goodman, M. (2004). Race and research: Perspectives on minority participation in health studies. Washington, DC: America Public Health Association. Brown, E., Jackson, J. S., & Faison, N. (in press, 2005). The work and retirement experiences of aging black Americans. In J. James & P. Wink (Eds.), The crown of life: Dynamics of the early post-retirement period. Chatters, L. M., & Jackson, J. S. (1989). Quality of life and subjective well-being among black adults. In R. Jones (Ed.), Black adult development and aging, (pp. 191–214). Berkeley, CA: Cobb & Henry. Chatters, L. M., Taylor, R. J., Lincoln, K. D., & Schroepfer, T. (2002). Patterns of informal social support from family and church members among African Americans. Journal of Black Studies, 33(1), 66–85. Clark, D. O., Maddox, G. L., & Steinhauser, K. (1993). Race, aging, and functional health. Journal of Aging and Health, 5, 536–553. Crimmins, E. M., Hayward, M. D., & Seeman, T. E. (2004). Race/ethnicity, socioeconomic status, and health. In N. P. Anderson, R. A. Rodolfo, & B. Cohen (Eds.), Critical perspectives on racial and ethnic differences in health in late life. Panel on race,

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ethnicity, and health in later life. (pp. 310–352). Panel on Race, Ethnicity, and Health in Later Life. Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. Curry, L., & Jackson, J. S. (2003). The science of inclusion: Recruiting and retaining racial and ethnic elders in health research. Washington, D.C.: Gerontological Society of America. Federal Interagency Forum on Aging-Related Statistics (2004).: Older Americans 2004: Key indicators on well being. Washington, DC: U.S. Government Printing Office. Friedland, R. B., & Summer, L. (2005). Demography is not destiny, revisited. Washington, DC: Center on an Aging Society, Georgetown University. Gibson, R. C. (1994). The age-by-race gap in health and mortality in the older population: A social science research agenda. Gerontologist, 34, 454–462. Gibson, R. C., & Jackson, J. S. (1992). The black oldest old: Health, functioning, and informal support. In R. M. Suzman, D. P. Willis, & K. G. Manton (Eds.), The oldest old (pp. 321–340). New York: Oxford University Press. Hayward, M. D., & Heron, M. (1999). Racial inequality in active life among adult Americans. Demography, 36(1), 77–91. Hummer, R. A., Benjamins, M. R., & Rogers, R. G. (2004). Racial and ethnic disparities in health and mortality among the U.S. elderly population. In N. P. Anderson, R. A. Rodolfo, & B. Cohen (Eds.), Critical perspectives on racial and ethnic differences in health in late life. Panel on race, ethnicity, and health in later life. ((pp. 53–94). Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. Jackson, J. J. (1985). Race, national origin, ethnicity, and aging. In R. H. Binstock & E. Shanas (Eds.), Handbook of aging and the social sciences (pp. 264–303). New York: Van Nostrand Reinhold. Jackson, J. S. (2001). Changes over the life-course in productive activities: Black and white comparisons. In N. Morrow-Howell, J. Hinterlong, & M. Sherraden (Eds.), Productive aging: Perspectives and research directions (pp. 214–241). Baltimore: Johns Hopkins University Press. Jackson, J. S. (2003). Conceptual and methodological linkages in cross-cultural groups and cross-national aging research. Journal of Social Issues, 58(4), 825– 835. Jackson, J. S., & Williams, D. R. (2003). Surveying the Black American Population. In, J. S. House, F. T. Juster, R. L. Kahn, H. Schuman, & E. Singer (Eds.),

Telescope on society: Survey research and social science at the University of Michigan and beyond. Ann Arbor: University of Michigan Press. Jackson, J. S., Chatters, L. M., & Taylor, R. J. (1993). Status and functioning of future cohorts of AfricanAmerican elderly: Conclusions and speculations. In J. S. Jackson, L. M. Chatters, & R. J. Taylor, Aging in black America (pp. 301–318). Newbury Park, CA: Sage Publications. Jackson, J. S., Lockery, S. M., & Juster, F. T. (1996). Introduction: Health and retirement among ethnic and racial minority groups. Gerontologist, 36(3), 282–284. Jackson, J. S., Antonucci, T. C., & Brown, E. (2004). A cultural lens on biopsychosocial models of aging. In P. T. Costa Jr., & I. C. Siegler, (Eds.), Recent advances in psychology and aging. Amsterdam: Elsevier B. V. Jackson, J. S., Brown, E., & Antonucci, T. C. (in press, 2005). Ethnic diversity in aging, multicultural societies. In M. Johnson, V. L. Bengtson, P. Coleman, & T. Kirkwood (Eds.), The Cambridge Handbook of Age and Ageing. Cambridge, UK: Cambridge University Press. Jackson, Torres, Caldwell, Neighbors, Nesse, Taylor, Trierweiler, & Williams. (2004). The national survey of American life: A study of racial, ethnic, and cultural influences on mental disorders and mental health. International Journal of Methods in Psychiatric Research 13(4), 196–207. Mendes de Leon, C. F., & Glass, T. A. (2004). The role of social and personal resources in ethnic disparities in late-life health. In N. P. Anderson, R. A. Rodolfo, & B. Cohen (Eds.), Critical perspectives on racial and ethnic differences in health in late life. Panel on race, ethnicity, and health in later life. (pp. 353–405). Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. Muhammad, D., Davis, A., Lui, M. & Leondar-Wright, B. (2004). The state of the dream 2004: Enduring disparities in black and white. Boston: United for a Fair Economy. Myers, H. F., & Hwang, W. (2004). Cumulative risks and resilience: A conceptual perspective on ethnic health disparities in late life. In N. P. Anderson, R. A. Rodolfo, & B. Cohen (Eds.), Critical perspectives on racial and ethnic differences in health in late life. Panel on race, ethnicity, and health in later life. (pp. 492–539). Committee on Population, Division of Behavioral and Social Sciences and Education. Washington, DC: National Academies Press. Preston, S. H., Elo, I. T., Rosenwaike, I., & Hill, M. (1996). African American mortality at older ages: Results from a matching study. Demography, 33, 193– 209.

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Age and Expertise Skinner, J. H., Teresi, J. A., Holmes, D., Stahl, S. M., & Stewart, A.L. (2001). Measurement in older ethnically diverse populations. Journal of Mental Health and Aging, 7(1), 5–200. Taylor, R. J., Chatters, L. M., & Levin, J. (2004). Religion in the lives of African Americans: Social, psychological, and health perspectives. Thousands Oaks, CA: Sage Publications. Taylor, J. T., Jackson, J. S., & Chatters, L. M. (Eds.). (1997). Family life in black America. Thousand Oaks, CA: Sage Publications. United Nations. (2002). World population ageing: 19502050. New York: United Nations. Whitfield, K. E. (2004a). Closing the gap: Improving the health of minority elders in the new millennium. Washington, DC: Gerontological Society of America. Whitfield, K. E. (2004b). Sources of individual differences in indices of health disparities among older African Americans. Phylon, 50(1-2), 145–159. Whitfield, K. E., & Hayward, M. (2003). The landscape of health disparities among older adults. Public Policy and Aging Report, 13(3), 1–7. Williams, D. R., & Jackson, P. B. (2005). Social sources of racial disparities in health. Health Affairs, 24(2), 325–334.

AGE AND EXPERTISE Two primary questions drive research on age and expertise. At what age do people typically reach peak performance levels? Do the same mechanisms support expert performance in early and late adulthood? Both lead to an intriguing issue: Can people develop and maintain expertise in later life? Experts are usually defined as those who demonstrate consistently superior performance on representative tasks from a domain (Ericsson & Lehmann, 1996). It typically takes about 10 years (1000 hr–10,000 hr) of intense devotion to selfimprovement activities, deliberate practice, to become a world-class expert.

Age and Peak Performance Quetelet (1842/1969) and Lehman (1953) were among the first to identify the classic curvilinear function between age and performance, which showed a sharp rise in performance in young adulthood, a peak in the decade of the thirties, and gradual decline thereafter. Peak performance tends to occur

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in the mid-30s in intellectual domains, such as chess (Elo, 1965; Charness, Krampe, & Mayr, 1996) and in the 20s or early 30s in athletics (Schulz & Curnow, 1988; Schulz, Musa, Staszewski & Siegler, 1994; Stones & Kozma, 1995). According to Simonton (1997), the ability of aging elite artists and scientists to sustain exceptional performance is less the result of consistent success than consistent productivity. In both science and sports, individuals apparently past their prime have occasionally broken world records or won world championships, but not without several previous attempts. Also, a better predictor of the developmental trajectory is professional age, rather than chronological age. Several mechanisms have been proposed to account for such high-level performance in the face of expected age-related decline.

Mechanisms Supporting Expertise General or specific abilities are usually assumed to underlie expert performance. By this logic, musicians who must memorize musical scores should have better memory for music notation than nonmusicians. Further, if aging degrades memory abilities, then older musicians ought to perform worse than younger ones in professional activities. The former assumption has proven accurate (e.g., Meinz & Salthouse, 1998) though the latter has not. Studies consistently fail to show much of a relationship between age and productivity in the work place (Salthouse & Maurer, 1996). One explanation for the failure to find a link between age and job performance is that older experts may not rely on the same abilities as younger ones to perform the same task. They may compensate for a decline in one ability (e.g., speed of response) by honing another (e.g., working memory). Salthouse (1984) showed that older high-speed typists are slower at tapping tasks than their younger counterparts, but compensate by buffering more text (greater eye-hand span) to give them additional time to create efficient overlapping keystroke patterns. It also appears that experts can partially circumvent general age-related declines in physical and psychological capacities by deliberately engaging in counteractive measures. Krampe and Ericsson (1996) found minimal age-related declines in speeded music-related performance (tapping task) among older expert pianists who maintained

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rigorous maintenance practice schedules, despite finding declines in general psychomotor speed. Relative to the older experts, older amateur pianists exhibited significantly slower performance in both tasks. Both cumulative and current practice levels were positively related to performance. Similarly, Tsang and Shaner (1998) reported that age-related declines among pilots in flight simulator tasks appear to be somewhat attenuated by experience. When older active pilots were asked to perform two aviation-relevant tasks at the same time, their performance was comparable to middle-aged and younger pilots. However, when the same individuals were asked to perform two general tasks, older active pilots performed substantially worse than their younger colleagues, suggesting that the positive effects of maintenance practice were restricted to the domain of expertise. Older pilots’ memory for air traffic control messages is normally inferior to that of younger pilots (Morrow et al., 2001). However, it becomes comparable to that of younger pilots when sufficient environmental support, in the form of note taking, is allowed (Morrow et al., 2003). Thus, storing information in the environment can be a useful compensatory strategy for older adults when task demands exceed working memory capabilities. Computer simulations hint at how acquired knowledge may compensate for waning abilities. Neural network models with greater knowledge of opening chess positions were better protected against simulated age-related declines, such as degrading the signal-to-noise ratio in the nervous system, on a recall task (Mireles & Charness, 2002). This is consistent with the finding that extensive knowledge of rare words is strongly predictive of crossword puzzle solving proficiency, even in the case of older puzzlers who exhibit age-related declines in reasoning and problem solving ability (Hambrick, Salthouse, & Meinz, 1999). These results imply that acquired knowledge can mitigate declines in age-sensitive fluid intelligence abilities to allow for exceptional performance even at the far end of the age spectrum.

Conclusions Recent studies of expert performance reveal mixed findings. Although there is a strong tendency for ba-

sic abilities and for some aspects of domain-specific performance to decline with age, critical skills in some domains may be sustained through practice and the accumulation of structured knowledge. Experts may compensate for, or adapt to changing abilities. However, the nature and potency of these compensatory mechanisms are not thoroughly understood and will continue to spur future investigations. A question that remains to be explored is whether expert levels of performance in a new domain can be attained at a later stage of life. Older adults may have additional monetary resources and time at their disposal to engage in skill acquisition, though research indicates that they take about twice as long as younger counterparts to learn a new skill, such as word processing (Charness et al., 2001). Further, deliberate practice requires strong motivation and it remains to be seen under what circumstances older adults choose to forego more enjoyable activities for those needed to build expertise. Neil Charness Tiffany Jastrzembski Franklin G. Hines This work was supported by a grant from the National Institute on Aging (1 PO1 AG17211-05, CREATE) to the first author.

References Charness, N., Kelley, C. L., Bosman, E. A., & Mottram, M. (2001). Word processing training and retraining: Effects of adult age, experience, and interface. Psychology and Aging, 16, 110–127. Charness, N., Krampe, R. Th., & Mayr, U. (1996). The role of practice and coaching in entrepreneurial skill domains: An international comparison of lifespan chess skill acquisition. In K. A. Ericsson (Ed.), The Road to Excellence (pp. 51–80). Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Elo, A. E. (1965). Age changes in master chess performances. Journal of Gerontology, 20, 289–299. Ericsson, K. A., & Lehmann, A. C. (1996). Expert and exceptional performance: Evidence of adaptation to task constraints. Annual Review of Psychology, 47, 273– 305. Hambrick, D. Z., Salthouse, T. A., & Meinz, E. J. (1999). Predictors of crossword puzzle proficiency and moderators of age-cognition relations. Journal of Experimental Psychology: General, 128, 131–164.

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Ageism Krampe, R. Th., & Ericsson, K. A. (1996). Maintaining excellence: Deliberate practice and elite performance in young and older pianists. Journal of Experimental Psychology: General, 125, 331–359. Lehman, H. C. (1953). Age and achievement. Princeton, NJ: Princeton University Press. Meinz, E. J. & Salthouse, T. A. (1998). The effects of age and experience on memory for visually presented music. Journal of Gerontology: Psychological Science, 53B, P60–P69. Mireles, D. E., & Charness, N. (2002). Computational explorations of the influence of structured knowledge on age-related cognitive decline. Psychology and Aging, 17, 245–259. Morrow, D., Menard, W. E., Stine-Morrow, E. A. L., Teller, T., & Bryant, D. (2001). The influence of expertise and task factors on age differences in pilot communication. Psychology and Aging, 16, 31–46. Morrow, D. G., Ridolfo, H. E., Menard, W. E., Sanborn, A., Stine-Morrow, E. A. L., Magnor, C., Herman, K. L., Teller, T., & Bryant, D. (2003). Environmental support promotes expertise-based mitigation of age differences on pilot communication tasks. Psychology and Aging, 18, 268–284. Quetelet, L. A. J. (1969). A treatise on man and the development of his faculties. Gainesville, Fl.: Scholars’ Facsimiles and Reprints. (Original work published 1842). Salthouse, T. A., & Maurer, J. J. (1996). Aging, job performance, and career development. In J. E. Birren & K. W. Schaie (Eds.). Handbook of the psychology of aging (4th ed., pp. 353–364). New York: Academic Press. Salthouse, T. A. (1984). Effects of age and skill in typing. Journal of Experimental Psychology: General, 13, 345–371. Schulz, R., & Curnow, C. (1988). Peak performance and age among superathletes: Track and field, swimming, baseball, tennis, and golf. Journal of Gerontology: Psychological Sciences, 43, P113–120. Schulz, R., Musa, D., Staszewski, J., & Siegler, R. S. (1994). The relationship between age and major league baseball performance: Implications for development. Psychology and Aging, 9, 274–286. Simonton, D. K. (1997). Creative productivity: A predictive and explanatory model of career trajectories and landmarks. Psychological Review, 104, 66–89. Stones, M. J., & Kozma, A. (1995). Compensation in athletic sport. In R. A. Dixon & L. Bäckman (Eds.), Compensating for psychological deficits and declines (pp. 297–316). Mahwah, NJ: Lawrence Erlbaum Associates, Inc. Tsang, P. S., & Shaner, T. L. (1998). Age, attention, expertise, and time-sharing performance. Psychology and Aging, 13, 323–347.

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AGE DISCRIMINATION See Ageism Age Stereotype Aging, Images of

AGEISM Ageism is defined as a process of systematic stereotyping and discrimination against people because they are old, just as racism and sexism accomplish this for skin color and gender. It is deeply engrained in society, categorizing old people as senile, rigid in thought and manner, and old fashioned in morality and skills. In medicine, terms like “crock” and “vegetable” are common (Shem, 1978). Ageism allows the younger generation to see older people as different from themselves; thus, they suddenly cease to identify with persons who grow old as human beings. This behavior serves to reduce their own sense of fear and dread of aging. Stereotyping and myths surrounding old age are explained in part by a lack of knowledge and insufficient contact with a wide variety of older people. But another factor comes into play—a deep and profound dread of growing old. Ageism is a broader concept than gerontophobia, which refers to a rarer, “unreasonable fear and/or irrational hatred of older people, whereas ageism is a much more comprehensive and useful concept” (Palmore, 1972). This concept and term was introduced in 1968 (Butler, 1969). Age prejudice is a human rights violation that is exhibited in health care, employment, the media. Discrimination exists in the very definition of who is considered poor in the United States, in that people age 65 and older must be poorer than younger adults in order to be counted as poor (Muller, 2001). Some of the myths of age include a lack of productivity, disengagement, inflexibility, senility, and loss of sexuality (Stone & Stone, 1997; Bytheway, 1995). There have been some advances in, and more attention to, the productive capabilities of older people, and a better understanding that older persons have desires, capabilities, and satisfaction with regard to sexual activities. The “write-off ” of older persons as “senile” because of memory problems, for example, is being replaced by an understanding of the profound and most common forms of what is popularly

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referred to as “senility,” namely, Alzheimer’s disease. Senility is no longer seen as inevitable with age. Rather, it is understood to be a disease or group of diseases. When means of effectively treating dementia are available, ageism will also decline. The underlying psychological mechanism of ageism makes it possible for individuals to avoid dealing with the reality of aging, at least for a time. It also becomes possible to ignore the social and economic plight of some older persons. Ageism is manifested in a wide range of phenomena (on both individual and institutional levels), stereotypes and myths, outright disdain and dislike, or simply subtle avoidance of contact; discriminatory practices in housing, employment, and services of all kinds; epithets, cartoons, and jokes. At times, ageism becomes an expedient method by which society promotes viewpoints about the aged in order to relieve itself from the responsibility toward them, and at other times ageism serves a highly personal objective, protecting younger (usually middle-aged individuals, often at high emotional cost), from thinking about things they fear (aging, illness, and death). Ageism, like all prejudices, influences the behavior of its victims (Hausdorff and Levy, 1999). Older people tend to adopt negative definitions about themselves and to perpetuate the various stereotypes directed against them, thereby reinforcing societal beliefs. They may in a sense “collaborate” with the enemy, with stereotypes. Ageism can apply to stages of life other than old age. Older persons have many prejudices against the young and the attractiveness and vigor of youth. Angry and ambivalent feelings may flow, too, between older and middle-aged people. Middle-aged people often bear many of the pressures of both young and older people, and they experience anger toward both groups. Some older people refuse to identify with their peers and may dress and behave inappropriately in frantic attempts to appear young. Others may underestimate or deny their age. Since the introduction of the concept of ageism, there have been some gains on the part of older adults. The Age Discrimination and Employment Act of 1967, amended in 1978, ended mandatory retirement in the federal government and advanced it to age 70 in the private sector. Mandatory retirement at all ages was abolished in the United States in 1986 (with a few exceptions, such as police officers and fire fighters), and the European Commission has

mandated that members of the European Union have laws making age discrimination illegal in place by 2006. Although the underlying dread, fear and distaste for older persons remains, several trends may help reduce ageism in the future: (1) With the aging of baby boomers old age is in the process of being redefined as a more robust and contributory stage of life. (2) Increasing interest in aging in the general public, mass media, government, and academia will support increasing knowledge and fewer misconceptions about older persons. (3) Increasing scientific research on aging has reduced and will continue to reduce ageism by providing a realistic picture of older people and aging and by improving the health of older persons. (4) By 2000 persons over the age of 65 and younger adults had nearly attained the same education level, challenging the stereotype that older men and women were illiterate or poorly educated. (5) As people become more aware of racism and sexism they tend to become more aware of discrimination in general, and will be less likely to approve or practice ageism (Palmore, 2004). Reminiscence or life review has helped focus attention on what can be learned from listening to the lives of the old. Indeed, the memoir has become, in the minds of some, the signature genre of our age. Robert N. Butler See also Age Stereotype Aging, Images of

References Butler, R. N. (1969). Ageism: Another form of bigotry. The Gerontologist, 9, 243–246. Bytheway, B. (1995). Ageism: Rethinking ageing series. Buckingham, UK: Open University Press. Hausdorff, J., Levey, B., & Wei, J. (1999). The power of ageism on physical function of older persons: Reversibility of age-related gait changes. Journal of the American Geriatrics Society, 47, 1346–1349. Muller, Charlotte, Nyberg James, & Estrine, Judith. (2001). Old and poor in America. International Longevity Center-USA. Palmore, Leonard B. (2004). The future of ageism. International Longevity Center-USA. Shem, S. (1978). The house of God. New York: Dell. Stone, M., & Stone, L. (1997). Ageism: The quiet epidemic. Canadian Journal of Public Health, 88, 293–294.

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AGE STEREOTYPE An age stereotype is a simplified, undifferentiated portrayal of an age group that is often erroneous, unrepresentative of reality, and resistant to modification. Although the word stereotype was first used in the technology of duplicate printing, where a metal plate (i.e., the stereotype) was first cast into a mold, the American journalist Walter Lippmann introduced its usage for both scholarly and popular audiences in his 1922 book Public Opinion. Lippman argues that seeing things freshly and in detail is exhausting and so people see a trait that marks a type and “fill in the rest of the picture by means of the stereotypes we carry about in our heads” (p. 89). Age stereotypes have to do with people “filling in the picture” of a person or group of people after knowing only one characteristic—age. In this way, age stereotypes are similar to other overgeneralized and oversimplified portrayals of groups sharing a social characteristic; gender and race are persistent bases for stereotyping. Age stereotypes can be positive and negative. Hummert and colleagues (1994) used a checklist of positive and negative adjectives to identify traits commonly attributed to people of different age groups. By combing these traits, the researchers identified several stereotypes of older people. The negative stereotypes included “shrew/curmudgeon” and “despondent”; positive stereotypes included “perfect grandparent,” “small-town neighbor,” and “golden ager.” Political scientist Robert Binstock (1983, 1994) makes a frequently cited argument that, since the 1960s and 1970s Americans have reversed their “compassionate stereotype” of the elderly as poor, frail, and dependent to a new stereotype of the elderly as prosperous, active, and politically powerful. Neither image is accurate. Is a positive stereotype better than a negative stereotype? Both are examples of overstated homogeneity and implicit creation of “other” or “outgroup.” By stereotyping people, we assume that everyone in the other group (not our own group) is like each other and that they are not like us. The fact that our assumptions about the “outgroup” are often negative compounds the problems that arise from stereotyping. One of the problems with stereotyping is that we sometimes act on these oversimplified assump-

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tions; this leads to age discrimination. Older workers have been discriminated against on the basis of the stereotypes that they are unable to learn new things, less productive than younger workers, more likely to miss work because of sickness, and set in their ways. Even though all of these stereotypes have been disproven by research, they still persist. The extent of age discrimination in the work place that ensues from these stereotypes has been the impetus for continual changes to the Age Discrimination in Employment Act. A recent Supreme Court decision made it easier for older workers to sue their employer for age discrimination, allowing plaintiffs to use the same kind of evidence as is used in gender and race discrimination cases, and making it harder for employers to defend their actions on the basis that the age discrimination was not intentional (New York Times, April 1, 2005). Recent research has examined additional consequences of stereotyping. Levy discusses a new line of research showing that older people internalize negative stereotypes and that these aging selfstereotypes can influence cognitive and physical health. Hess, Hinson, and Statham (2004) studied the ways in which positive and negative stereotypes influence the older adults’ performance on a memory task. Participants who were exposed to negative stereotypes performed more poorly than those who were primed with positive stereotypes. The idea of “stereotype threat” is used to help explain the impact of stereotypes on memory, cognition, and health. This concept suggests that when individuals are afraid that their behavior will reinforce a negative stereotype about a group to which they belong, their performance is affected. Age stereotypes are communicated in numerous ways. Television programs, advertisements in all media, the jokes we tell, and birthday cards are often full of age stereotypes. Stereotypes stem from our need to simplify our social world through the creation of categories and they are related to age norms which suggest that certain roles and behavior are appropriate at certain ages and not at other ages. From these benign or neutral starting points, age stereotypes can lead to age discrimination, aging self-stereotypes, and can thus affect both psychological and social quality of life for older people. Further research on the origins, perpetuation, and impact of age stereotypes will help us understand a

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complex array of factors that influence the experiences of aging in our society. Fay Lomax Cook Updated by Suzanne R. Kunkel See also Ageism Aging, Images of

References Binstock, R. H. (1983). The aged as scapegoat. The Gerontologist, 23, 136–143. Binstock, R. H. (1994). Changing criteria in old-age programs: The introduction of economic status and need for services. The Gerontologist, 34, 726–730. Hummert, M. L., Garstka, T. A., Shaner, J. L., & Strahm, S. (1994). Stereotypes of the elderly held by young, middle-aged, and elderly adults. Journal of Gerontology: Psychological Sciences, 49, P240–P249.

AGING, ATTITUDES TOWARD See Ageism Age Stereotype Aging, Images of

AGING, IMAGES OF Since the early 1970s, social scientists have been investigating the power of the media to influence attitudes about aging in the United States. The majority of research in assessing images of aging has been done in the realm of television. However, that may begin to change in the next decade as the pervasive influence of the Internet is explored with respect to images of aging.

Internet and Print Internet and Aging. Using the Google search engine on the Internet in 2004, one can locate 9,220,000 links to Web sites that include reference to the aged, 8,520,000 to aging, 6,500,000 to elderly, and 985,000 just to images of aging. Many more sites are of interest to older adults, includ-

ing those that provide information, products, and services, which may not have explicit references to aging or images of aging. The Internet features materials designed specifically for the Web as well as ready access to images first published through print and broadcast media. Due to its interactive and highly segmented nature, it is difficult to generalize the portrayal of older adults on the Internet. However, due to the vast number of Web sites, those catering to the elderly are far more prevalent compared to television networks and programs. A recent study by Hilt and colleagues (2004) provide some insights on elderly Internet use patterns that may permit some inferences about Internet content related to older demographics. Email is one of the most common activities for older adults, and might aid in conveying a modern, upbeat image of older users. Web surfing tends to be targeted to sites that are useful (weather, health, travel, education) or entertaining (jokes, games, culture). Older adults often use Google.com and Yahoo.com to find these sites. The authors contend that currently local radio and television Web sites have limited usefulness to older viewers. But they recommend redesigning them to help older users navigate the Web and locate information and entertainment easily. Cody and colleagues (1999) found that training older adult learners in Internet use had a positive impact on their attitudes toward learning and perceived social support. As far as the content that is distributed via the Internet, Gerbner, and colleagues (2002) contend that the distortions found in the traditional media may be multiplied through additional channels, such as multichannel cable and satellite and Internet-delivered video. This is particularly significant, since levels of concentration in media ownership continue to increase. Even the most popular Internet search engine, Google, has recently become the object of criticism because of ageist hiring practices. Recently, a 54-year-old director of operations was dismissed because he did not fit into the youthful culture of the company. The average age of Google’s male workers is 29.7 years old, and 28.4 for women (Liedtke, 2004). Print Media. Despite widespread access to information via the Internet, television still wields great power to influence millions of people and, therefore, commands considerable attention. In the

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print medium, some magazines promote the image of an active and healthy older consumer. Older people are pictured in association with products such as medications, including those used to address incontinence and impotence, dental and digestive aids, cosmetics to reduce the signs of aging, and assorted health products. In contrast, upscale business publications might present affluent seniors, advertising elegant automobiles, life insurance companies, upscale travel, and financial institutions. De Luce (2001) examined images of aging in publications and reported that Forbes, Fortune, and Prevention offered the most images of mature models and marketing aimed at readers older than age 50, clearly targeting the segment of older adults who have considerable discretionary income. Hilt and Lipschultz (2004) point out that Americans aged 50 and older control half the country’s discretionary income and 75% of all personal assets. Newspaper articles featuring older people tend to focus on extremes: either the severely disadvantaged or those who are interesting because they accomplish feats contrary to age stereotypes, such as hang gliding or skydiving. One vivid recent example featured former President George Bush skydiving to celebrate his 80th birthday, a story that still appears on 6,690 Web sites to date.

the needs of older adults. Powell and Williamson’s (1985) review of the mass media revealed stereotypic ageist biases and a trend toward learned helplessness. Robinson and Skill (1995) report that only 2.8% in their study of the 1,228 adult speaking characters in primetime television were determined to be 65 years and older. Of those older characters, only 8.8% were in lead roles, a figure that is lower than studies reported in the 1970s. In a study of primetime network programs broadcast between 1993 and 2002, Signiorelli (2004) reports that “less than 3% of the characters, both male and female, white and minority, in major and supporting roles, are characterized as elderly.” She also found that women aged 50 to 64 years are more often classified as elderly, while men in that age group are portrayed as middle-aged. Negative images of older adults are not limited to fictional programs. In general, the television industry and advertisers have been obsessed with young viewers (Larson & Elkin, 1999). Numerous older anchors have become victims of the pressure to reach younger demographics. Reuven (2002) points to the average age of corporate (28 years) and advertising account representatives (31 years) as one of the factors that may play a role in the decline of older news personalities.

Television and the Aging

Gender and Aging on Television

The most pervasive mediated images of aging are projected by television. Often unrealistic expectations about life are encouraged when the world of television is confused with the real world. A major concern is not only what is shown, but also what is not shown, and what this lack of content teaches viewers. Older people are not seen on television in proportion to their numbers in real life (Signiorelli, 2004). Moreover, they appear to be marginalized and represented in negative stereotypes. In a review of 28 studies, Vasil and Wass (1993) found that older persons were underrepresented in both electronic and print media in terms of their presence in the United States population. Although older adults are the group with the greatest exposure time to television (Hilt & Lipschultz, 2004), most research describes unfavorable portrayals of them on television. Studies of television programs and surveys of older viewers have demonstrated that television caters poorly to

Research since the 1970s has documented that women are less likely to be seen in television programs as they age than are men (Gerbner et al., 2002). Davis and Davis (1985) report that women appear on screen about one-third as often as do men. Men are more likely to be found populating dramas when they are in the 30 to 49 age bracket. Women are more likely to be in their 20s and early 30s. Women on television tend to be younger than men, and minority women tend to be younger than white women (Signiorelli, 2004). On television, for those older than age 50 men by far outnumber women. This picture is beginning to change, however. Robinson and Skill (1995) reported that the proportion of female characters on primetime aged 50 to 64 years has increased since 1975. They suggest that “this may be one of the reasons the public believes TV portrayals of older Americans has improved in recent years.” Nevertheless, Signiorelli (2004) contends that men in the 50 to 64 age group tend to be portrayed as

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middle-aged, while women are more likely to appear elderly. Although the predominant image of older women on television has been as a nurturer, followed by nags or adoring attendants, that pattern is beginning to change. Thanks to the expansion of cable, shows featuring older women in prominent roles are available in syndication as repeats long after episodes ceased production. In the 1980s, Golden Girls presented older women as attractive and sexually active; repeats of the series remain in syndication in 2004. With repeat episodes still broadcast via syndication, Jessica Fletcher, a murder mystery writer and amateur detective on Murder She Wrote appears as an attractive older woman who is intelligent, perceptive, courageous, and effective in her investigative skills. In science fiction series, characters that would be considered much older in human years are portrayed as middle aged in various alien species. The popular Web site Seniornet.org recently requested reader input under the heading “What’s worth watching?” and the mostly female respondents tended to focus on soap operas (Days of Our Lives, As the World Turns, and Passion), music programs, and a number of PBS programs targeted to older viewers, such as Maggie Growl and Sweet Old Song, but also the cable channel Court TV. Among popular programs West Wing attracted considerable attention. In general, younger characters are portrayed in more prestigious positions. An interesting gender interaction was found for the 50 to 64 age group: white men in this age group are still shown in prestigious positions, while professional prestige for women and minorities has already declined. After age 65, white men are also cast in less prestigious job categories (Signiorelli, 2004). One exception to the negative portrayal of the elderly on TV is advertising. In ads older persons are typically portrayed as vigorous and healthy. However, their gender distribution is contrary to demographic trends. While only 40% of adults older than 65 are male, in advertising between 62% and 70% of characters in this age group are males (Harris, 2004). Hajjar (1997) found similar effects in her content analysis of television commercials. Older than age 60 characterizations (8% of the total) were 70% male and 84% white. Positive characterizations tend to be clustered in the categories of food/beverage and financial/insurance, while negative ones focus on medical/pharmaceutical products.

Health and Older Adults on Television The medical show remains a television staple, and ER, the most watched example in 2004, portrays older adults as patients, concerned family members, and health practitioners. The patients have suffered from various conditions ranging from acute illness and accidents to terminal illness and chronic problems associated with aging. Some have died, just as younger adults and children have on the same show. Older people tend to have “multiple comorbid conditions and complicated prevention and treatment regiments” (Dishman et al., 2004). Poor health provides more drama than good health. It would be easy to assume that older people are going to be the ill people in the world of television drama. Characters in soap operas do not generally have diseases that viewers are likely to have. Often their health problems are so exotic that they are not threatening to the average viewer. In many continuing dramas, the ill get well. Death befalls only those who must be written out of the story. Thus, older people are not usually victims of illness on television.

Consequences of Age Stereotyping The images of age presented on television tend to promote stereotypes. Stereotyping and simplistic portrayals are convenient shorthand for support characters in television programming. Older individuals are more likely to play supporting than central roles. As television educates viewers to see aging as a negative and undesirable experience, it perpetuates a self-fulfilling prophecy. Gerbner and colleagues (2002) point out that the kinds of distortions discussed above can have considerable impact in shaping perceptions and attitudes, especially among heavy television viewers. Viewers older than age 65 are among the heaviest group of viewers. Grajczyk and Zöllner (1998) point out that it can be a lifeline and a window to the outside world, “a substitute for primary interpersonal communication, a tool for structuring time patterns and keeping up the rhythms of long-established every-day rituals.” Hofstetter and Schultze (1993) found that negative perceptions of aging appear to be related to “contextual aging” (i.e. social interaction, health, living alone, economic status) rather than chronological age.

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Expectations for the Future Television viewing by adults increases with age (Mundorf & Brownell, 1990). The aging American populace and the increasing proportion of disposable income among those older than 50 years have lead advertisers and television producers to gradually discover the gray market. In the early 1980s, networks began to change their programming strategies in response to these demographic and economic shifts in the population. Presently, extensive programming on cable channels offers viewers contemporary images of older adults. This contrasts to stereotypical images of rebroadcast shows from the 1950s and silent era films. In a study of viewing preferences, older adults made little reference to cable programming (Mundorf & Brownell, 1990). The potential of cable TV appears to be increasing as more access and programming options are provided. With the expansion of cable and the increase in programming opportunities, we should expect more targeting of market niches that feature an increased number of older adults and especially more in lead characters. Television is slowly mirroring the changes occurring among American men and women. As adults are living higher quality lives at older ages, what is portrayed as “old” keeps changing. Women in their 50s and 60s are seen as attractive and sexually active. But the changes are not happening fast enough for many older adults. Chafetz and colleagues (1998) report that many older adults expressed serious reservations about the attitudes displayed toward the elderly as implied in negative or insufficient news coverage. Movies made for television frequently use older performers as central characters. Age-related issues are often confronted in an era where social problems are seen as legitimate subjects for comedy as well as drama. Each season showcases at least 1 significant film about aging and being old (“What’s worth watching,” 2004). Series programs have not ignored the story potential of being old in American society. Confronting old age is no longer taboo. In addition, images of aging on the Internet may soon gain comparable influence to those on television as more adults who possess computer expertise reach their 60s. Winifred Brownell Norbert Mundorf Joanne Mundorf

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See also Age Stereotype Ageism

References Chafetz, P. K., Holmes, H., Lande, K., Childress, E., & Glazer, H. R. (1998). Older adults and the news media: Utilization, opinions and preferred reference. Gerontologist, 38, 481–489. Cody, M. J., Dunn, D., Hoppin, S., & Wendt, P. (1999). Silver surfers: Training and evaluating Internet use among older adult learners. Communication Education, 48, 269–286. Davis, R. H., & Davis, J. A. (1985). TV’s image of the elderly. Lexington, MA: Lexington Books. Dishman, E., Matthews, J., & Dunbar-Jacob, J. (2004). Everyday Health: Technology for Adaptive Aging. In Pew and Van Hemel (Eds.), Technology For Adaptive Aging. Washington, D.C.: National Academy of Sciences Press. Gerbner, G., Gross, L., Morgan, M., Signiorelli, N., & Shanahan, J. (2002). Growing up with television: Cultivation processes. In J. Bryant & D. Zillmann, Media effects (pp. 43–68). Mahwah, NJ: L. Erlbaum Associates. Grajczyk, A., & Zöllner, O. (1998). How older people watch television. Gerontology, 44, 176–181. Hajjar, W. (1997). The image of aging in television commercials: An update for the 1990s. In N. Al-Deen, Cross-cultural communication and aging in the United States (pp. 231–244). Hillsdale, NJ: Erlbaum. Hofstetter, C. R., & Schultze, W. A. (1993). The elderly’s perception of TV ageist stereotyping: TV or contextual aging? Communication Reports, 6, 92–100. Harris, R. J. (2004). A cognitive psychology of mass communication. Mahwah, NJ: Erlbaum. Hilt, M. L., & Lipschultz, J. H. (2004). Elderly Americans and the Internet: E-mail, TV news, information and entertainment Websites. Educational Gerontology, 30, 57–72. Larson, C., & Elkin, T. (1999). Special report—upfront markets. Media Week, 44–48. Liedtke, M. (2004). Google accused of elderly discrimination. Available: Sitepoint.com. de Luce, J. (2001). Silence at the newsstands. Generations, 25, 39–43. Mundorf, N., & Brownell, W. (1990). Media preferences of older and younger adults. Gerontologist, 30, 685– 691. Powell, L. A., & Williamson, J. B. (1985). The mass media and the aged. In H. Fox (Ed.), Aging. Guilford, CT: Dushkin Publishing Group. Reuven, F. (2002). Eliminating the elderly. New Leader, 85(3), 47–49.

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Robinson, J. D., & Skill, T. (1995). The invisible generation: Portrayals of the elderly on primetime television. Communication Reports, 8, 111–119. Signiorelli, N. (2004). Aging on television: Messages relating to gender, race, and occupation in primetime. Journal of Broadcasting and Electronic Media, 48, 279–301. Vasil, L., & Wass, H. (1993). Portrayal of the elderly in the media: A literature review and implications for educational gerontologists. Educational Gerontology, 19, 71–85. “What’s worth watching.” (2004). Available: Seniornet. org.

Web Sites aarpmagazine.org aoa.gov aging.today.org asaging.org generationsjournal.org gerontologist.gerontologyjournals.org helptheaged.org icaa.cc isapa.org ncoa.org seniornet.org

AGING POLICY See Policy Analysis: Issues and Practices

AGING SERVICES See Adult Protective Services Senior Centers Senior Companion Program

AIDS/HIV By the end of 2003, approximately 38 million people were living with HIV/AIDS, and 20 million had died since the recognition of the epidemic (Joint United Nations Program on HIV/AIDS, 2004). Infection with human immunodeficiency virus (HIV) eventually progresses to HIV disease and acquired

immunodeficiency syndrome (AIDS). AIDS can be thought of as one end of a spectrum of HIV-related conditions that may include acute infection, an asymptomatic period, and eventually certain opportunistic infections, neoplasias, and other conditions. The Centers for Disease Control and Prevention (CDC) has a still-current detailed surveillance definition and classification system for AIDS based on documentation of HIV infection, degrees of laboratory evidence of immunosuppression using CD4+ lymphocyte counts, and specified symptoms and AIDS indicator conditions (Centers for Disease Control and Prevention, 1992). The major result of HIV infection is both quantitative and qualitative immune impairment that largely affects the T-helper lymphocytes (T4, CD4+ cells), but macrophages, monocytes, glial cells, fibroblasts, and antigenpresenting dendritic cells also can become infected. This results in increased susceptibility to opportunistic infections and neoplasms. Major conditions resulting from opportunistic infections in the HIV-infected person include Pneumocystis jiroveci (formerly carinii) pneumonia (PCP); encephalitis due to Toxoplasma gondii, severe diarrhea and gastrointestinal problems due to Cryptosporidium spp., Isospora belli, and others; meningitis from Cryptococcus neoformans; candidiasis of the oral cavity, esophagus, and in women, the vagina; tuberculosis; herpes simplex virus lesions; retinitis due to cytomegalovirus; and disseminated infections due to cytomegalovirus, Mycobacterium avium complex, and others. Major neoplasms include Kaposi sarcoma and non-Hodgkin lymphomas. HIV also affects certain cells and tissues directly, particularly in the central nervous system. The nervous system may be affected, even asymptomatically, in persons with HIV; effects such as AIDS dementia complex (ADC), vacuolar myopathy, and peripheral neuropathy are common (Peiperl, Coffey, & Volberding, 2004; Wormser, 2004). Medical treatment has been directed: (1) against HIV itself through the use of combinations of antiretroviral drugs, of which highly active antiretroviral therapy has been a mainstay, (2) toward immune system enhancement, and (3) toward the prevention and treatment of specific opportunistic infections and conditions. The latter includes nonpharmacological measures and the use of pharmacological and biological agents, including vaccines. Monitoring viral load and CD4+ cell counts as well as clinical

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status is integral to the treatment. Treatment in the older adult parallels that of other adult age groups, with the necessary adaptations in dosage and/or regimens to account for the physiological and psychosocial consequences of aging, the presence of non-HIV–related coexisting chronic illness, possible interactions with drugs used to treat these other conditions, and the increased adverse drug effects in older persons due to these issues.

Transmission of HIV The major documented transmission modes for HIV are those in which persons are exposed to HIVcontaining blood or body fluids: (1) through intimate homosexual or heterosexual contact, (2) through parenteral or blood-borne exposure via transfusions, needlesticks, injection drug use, or similar means, or (3) vertically from an infected mother to her infant in the prenatal, perinatal, or immediate postnatal period. Several factors influence the likelihood of HIV acquisition, including risky behaviors such as unprotected sexual encounters, sex with highrisk partners, engaging in receptive anal intercourse, and sharing apparatus to inject drugs. The modes of HIV transmission (except perinatal) apply to all age groups including the elderly. Currently, sexual transmission is the leading mode of HIV acquisition in older adults.

Exposure Categories The CDC classifies U.S. AIDS cases by the major exposure categories in a hierarchical manner. These categories for all adults and their percentages are as follows: male-to-male sexual contact (48%); injection drug use (27.5%); male-to-male sexual contact and injection drug use (7%); heterosexual contact (15%); and other, including hemophilia, blood transfusion, perinatal, and risk not reported or identified (2.5%) (Centers for Disease Control and Prevention, 2003). In the past, blood transfusion and/or tissue transplantation was an important mode of HIV acquisition in those older than 55 years, at one time even accounting for the majority of cases in those aged 65 years and older (Ship, Wolff, & Selik, 1991). Because of the protective mechanisms now in place to screen the blood supply, this acquisition mode has decreased significantly.

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On the other hand, AIDS cases due to heterosexual transmission have increased in those 65 years and older.

AIDS Cases in Older Adults The term “invisible” has been used to describe many groups affected by the AIDS epidemic, including the elderly. Relatively little attention has been paid to both the present and future aspects of HIV in the older adult. Although the mean age of a first diagnosis of HIV/AIDS is rising, many aspects of HIV/AIDS in older adults, such as response to therapy, drug interactions, and updated epidemiological and clinical data have not been studied in controlled trials in older adults (Manfredi, 2004). In its standard statistical reporting of AIDS cases, the CDC gives data by 10-year intervals until age 65, after which it lumps together cases among those aged 65 years and older. Through 2002, approximately 6% of cumulatively reported U.S. adult AIDS cases occurred in those aged 55 years and older, and about 1.5% occurred in those aged 65 years and older (Centers for Disease Control and Prevention, 2003). The statistics described above report the age at the time of AIDS diagnosis. It is expected that an increased absolute number of cases of both HIV infection and AIDS will eventually be seen in the older population, as well as a greater relative proportion of cases due to a decrease in perinatal transmission. Reasons for the increased number include: (1) HIV-infected persons may progress to symptomatic states and AIDS over a longer period of time, in part due to early and increasingly effective therapy such as highly active retroviral therapy, and thus persons who were infected in the middleaged group will move into the elderly age category; (2) persons in older age groups may continue to receive blood transfusions and tissue/organ transplantation at higher rates than younger persons, so a certain number of cases (although relatively few, and a decreasing number) will continue to arise from this source; (3) the ready availability of drugs such as Viagra (sildenafil citrate) to treat erectile dysfunction has led to increased sexual activity in older males; (4) older persons may engage in risky sexual behaviors such as not using condoms for sexual encounters, for reasons including lack of concern about birth control, lack of awareness about HIV

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risks, and difficulty manipulating protective devices due to conditions such as arthritis, and thus they become more vulnerable to infection with HIV and/or other sexually transmitted diseases; (5) the life expectancy for persons in the United States continues to increase, and older people enjoy better health and mobility, allowing them to pursue risky behaviors and activities; and (6) age-related changes in the body’s immune function and protective barriers, such as the drying of vaginal mucosa in women, make older people more susceptible to the acquisition of HIV when they are exposed.

Sex, Drugs, and the Elderly Since the majority of cases of HIV transmission involve unprotected sexual contact and/or drug abuse, these areas have been the focus of general HIV prevention, assessment, and educational efforts. Society still subscribes to many false beliefs and negative views of sexuality in the older adult. Often, older people are seen as relatively asexual or as secure in a monogamous relationship. Even with the advent of drugs to treat erectile dysfunction, little has been described in the literature about sexual practices of the elderly population, including risky behavior, multiple and/or same-sex sexual partners, and so on. Health care workers may not ask about sexual activity as part of an older person’s health history. Most studies of sexuality among the elderly have concentrated on sexual dysfunction as opposed to sexual activity. Older persons may also believe they should hide their sexual activity, whether heterosexual, homosexual, or both, and they may not readily volunteer or discuss risk factors or exposures fearing the reaction of friends or family if they acknowledge sexual relationships, especially if those relationships are outside their usual partnership or marriage. Decades ago, sex-related activities were not openly discussed or displayed. “Gray” and “gay” were seen as antithetical terms, and men who had sex with other men were accustomed to being closeted to avoid discrimination. However, it is estimated that at least 1 million male homosexuals are older than 65 years (Ship, Wolff, & Selik, 1991). This may be an underestimate and may not consider cultural definitions of sexuality or occasional same-sex experiences. Frequently sexual transmission of HIV occurs proportionately in the older population. More than

50% of all reported AIDS cases in those aged 55 years and older are classified in some exposure category pertaining to sexual transmission (Centers for Disease Control and Prevention, 2003). Probable heterosexual transmission of HIV was reported in a woman of 89 years (Rosenzweig & Fillit, 1992). Sexual relationships outside monogamous ones may be becoming increasingly common in the elderly. Examples include: (1) older men whose long-term partners have died may now have sexual contact with several other partners who may be younger, increasing the risk of exposure to HIV; (2) elderly women may seek sexual fulfillment with younger men in a non-monogamous relationship; and (3) elderly men (married or not) may pay for sexual relationships with prostitutes (male or female) or seek available sexual companionship, which, particularly in longterm care settings, may be with a male. All of these individuals may now be at risk for HIV infection but be reluctant to disclose this behavior unless the health care provider asks specific questions regarding sexual behavior. Primary care providers may not discuss topics related to HIV risk as frequently with older patients as with younger ones, and many fail to recommend HIV testing or consider HIV in the differential diagnosis. A sentinel study examined risk factors and behaviors in a large national sample of adults older than 50 years. The prevalence of a known risk factor for HIV infection, such as being a transfusion recipient, having multiple sexual partners, or having a partner with a known risk for HIV infection, was 10%. Few of these respondents used condoms during sex or had HIV testing, particularly in comparison with a younger sample (Stall & Catania, 1994). In another study, few persons older than 50 years (11%) had discussed AIDS with their physician (Gerbert, Maguire, & Coates, 1990). In addition to sexuality, drug abuse in the older adult is another topic that is often avoided in discussion. Few studies have addressed injection drug use for nonprescribed or nonmedical purposes in the elderly. Yet medical conditions that cause pain and discomfort might cause older adults to seek drugs, as might social conditions or other reasons. Furthermore, those who began using drugs at a younger age may continue this habit into old age. Thus, health care workers also need to consider drug use when assessing risk for HIV exposure in the older person, although currently AIDS attributed to this exposure category is infrequent in the elderly.

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Clinical Aspects of HIV/AIDS and Survival in the Elderly AIDS may mimic other conditions in the elderly, and it can be difficult to recognize HIV infection in this group. It can present with vague and nonspecific signs and symptoms, such as weight loss and wasting, aches and pains, fever, cough, or cognitive impairment and confusion. Symptoms in the elderly may present against a background of multiple actual or potential illnesses and medication side effects and interactions. Cases of HIV infection in the elderly have been described in which ADC was the presenting and/or sole feature. The symptoms of ADC can include forgetfulness, slow thought processes, personality changes, depression, loss of concentration, and apathy, among other features. Many of these are similar to problems seen in the elderly from other causes, including the dementia seen in Alzheimer’s disease and in extrapyramidal disorders, as well as delirium. Because HIV infection can persist for years, with few manifestations, some persons acquiring it later in life may live their life span without showing major recognizable symptoms. Thus, clinicians must be ready to consider a differential diagnosis of HIV disease in the older adult regardless of gender. In general, when compared to younger counterparts, older adults with HIV tend to have a shorter and more severe course, shorter AIDS-free intervals, a greater number of opportunistic infections which tend to be more severe, earlier development of neoplasms, and a shorter survival period (Stoff, Khalsa, Monjan, & Portegies, 2004). Other debilitating conditions of aging may complicate those due to HIV infection, compounding and/or accelerating disease progression and decreasing functional capabilities. For example, cognitive impairment may adversely affect adherence to therapy (Hinkin, et al., 2004). Alzheimer’s disease is commonly associated with aging, and it has been suggested that there is interaction between the pathologies induced by Alzheimer’s disease and HIV-associated disorders (Stoff, Khalsa, Monjan, & Portegies, 2004). Becker, Lopez, Dew, and Aizenstein (2004) noted that HIV-positive persons older than 50 years had a greater prevalence of cognitive disorder than younger persons, and dementia was a more common classification. Those with a higher HIV viral load were at greater risk to develop cognitive impairment.

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Changed social networks and other conditions make the indirect consequences of AIDS significant for the older person. Although some persons are still living who have been known to be HIV-infected for 20 years or more and who seem to have nonprogressive disease, the ultimate outcome of HIV infection is considered to be death. Yearly overall mortality rates remain high, although newer treatment regimens with highly active antiretroviral therapy have increased life spans. Since the advent of highly active antiretroviral therapy, it is questionable whether HIV progresses more rapidly in older people than in younger ones, but increased age was still found to be a factor shortening survival in older persons already HIV-infected (Porter et al., 2003). Felissa R. Lashley See also Immune System

References Becker, J. T., Lopez, O. L., Dew, M. A., & Aizenstein, H. J. (2004). Prevalence of cognitive disorders differs as a function of age in HIV virus infection. AIDS, 18(suppl 1), S11–S18. Centers for Disease Control and Prevention. (2003). HIV/AIDS Surveillance Report 2002, 14, 1–47. Centers for Disease Control and Prevention. (1992). 1993 revised classification system for HIV infection and expanded surveillance case definition for AIDS among adolescents and adults. Morbidity and Mortality Weekly Report, 41(RR-17), 1–19. Gerbert, B., Maguire, B. T., & Coates, T. J. (1990). Are patients talking to their physicians about AIDS? American Journal of Public Health, 80, 467–468. Hinkin, C. H., Hardy, D. J., Mason, K. I., Castellon, S. A., Durvasula, R. S., Lam, M. N., & Stefaniak, M. (2004). Medication adherence in HIV-infected adults: Effect of patient age, cognitive status, and substance abuse. AIDS, 18(suppl 1), S19–S25. Joint United Nations Program on HIV/AIDS. (2004). 2004 report on the global AIDS epidemic. Geneva: World Health Organization. Manfredi, R. (2004). HIV infection and advanced age: Emerging epidemiological, clinical, and management issues. Ageing Research Reviews, 3, 31–54. Peiperl, L., Coffey, S., & Volberding, P. (Eds). (2004). HIV InSite Knowledge Base. San Francisco: University of California San Francisco. Available: http://hivinsite.ucsf.edu/InSite

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Porter, K., Babiker, A., Bhaskaran, K., Darbyshire, J., Pezzotti, P., Porter, K., Walker, A. S., & CASCADE Collaboration. (2003). Lancet, 362, 1267–1274. Rosenzweig, R., & Fillit, H. (1992). Probable heterosexual transmission of AIDS in an aged woman. Journal of the American Geriatric Society, 40, 1261–1264. Ship, J. A., Wolff, A., & Selik, R. M. (1991). Epidemiology of acquired immune deficiency syndrome in persons aged 50 years or older. Journal of the Acquired Immune Deficiency Syndrome, 4, 84–88. Stall, R., & Catania, J. (1994). AIDS risk behaviors among late middle-aged and elderly Americans. The National AIDS Behavioral Surveys. Archives of Internal Medicine, 154, 57–63. Stoff, D. M., Khalsa, J. H., Monjan, A., & Portegies, P. (2004). Introduction: HIV/AIDS and aging. AIDS, 18(suppl 1), S1–S2. Wormser, G. (Ed). (2004). AIDS and other manifestations of HIV infection. 4th ed. San Diego, CA: Elsevier Academic Press.

ALCOHOL USE Beverage alcohol (ethanol) has complex physiological and psychological effects on those who drink it, as well as a complex social history. Its use is ancient and almost universal, particularly in the development of Western civilization. Ancients often described alcohol as “the water of life”; they attributed magical significance to its effects in religious and social ceremonies and marked life-course transitions from birth to death with drinking behavior. Consuming alcohol in religious communion services and in convivial social toasts, such as “to your health,” are well-known cultural celebrations. Alcohol as a beverage appears in a remarkable variety of tastes, smells, and colors. It is consumed in a variety of settings, often with elaborate attention to the aesthetics of presentation. In sum, beverage alcohol in Western societies has a long history and has become a domesticated drug whose addictive potential tends to be understated (Roueche, 1960). Beverage alcohol has a darker side. It can be misused as well as used to produce intoxication, and for a persistently and significantly large minority of drinkers it results in addictive behavior, clinically recognized as alcoholism. The ambivalence toward beverage alcohol is dramatically illustrated by national prohibition of beverage alcohol in the United States (1917–1933), a country in which a large majority of adults historically have drunk alcohol and

in which an estimated 5% of adult drinkers persistently exhibit serious problems associated with their drinking. Interest in how drinking and abuse of alcohol relate to aging is relatively recent. Scholars who know the relevant scientific literature note that in the first 2 decades of the major journal in the field, The Quarterly Journal of Studies on Alcohol (1940–1960), only 1 article referred to aging, old age, or gerontology. In this journal’s third decade (1960–1969), 13 articles referenced aging; only after 1970 did references to age and aging become common. By 1980 a comprehensive bibliography on aging and alcohol use listed 1,200 articles, over half of which had been published in the previous decade (Barnes, Abel, & Ernst, 1980). Also in that year, a monograph on alcohol and old age was published (Mishra & Kastenbaum, 1980). Increased interest in the drinking behavior of older adults in the 1980s, particularly abuse of alcohol, appeared to have 2 sources. One was the assumption that loss of status through retirement and the stresses of growing older would, particularly among men, increase the risk of abusive use of alcohol as an expression of frustration. A second source appears to have been the concern of social welfare agencies and administrators of longterm care facilities; they reported that the everyday problems of some older adults were in fact sometimes exacerbated by intoxication and apparent alcoholism. Adequate evidence for characterizing the relationship between drinking behavior and aging, however, has continued to be somewhat sparse. Systematic comparisons of drinking behavior and alcohol abuse between societies are not available. But here, in general, is what the growing body of evidence indicates about drinking among older adults in the United States (Maddox, Robins, & Rosenberg, 1985; Midanik & Clark, 1994; Mishra & Kastenbaum, 1980):

1. A substantial majority of adults in the United States are not abstinent. At any point a minority of males (perhaps 20%) are abstinent or are ex-drinkers, and a larger minority of females are abstinent. A minority of males who drink and a smaller minority of females exhibit significant personal and social problems with their drinking. The usual estimate of alcoholism or serious problems with drinking among adults is 5%.

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2. Among adults who drink, both the frequency and the quantity of alcohol consumed tend to decrease with age. Available cross-sectional evidence tends to be flawed as the basis for concluding that there is an age-related decrease in consumption; the same outcome could be explained by the different drinking patterns of earlier and later cohorts of adults. However, changing patterns of sociability with age, age-related health problems, and the complicated interaction of alcohol with prescribed medication appear to have a moderating effect on drinking behavior in later life. Earlier assumptions that abusive drinking in adulthood ensured an early death appear to be wrong. Adults with a lifetime history of abusive drinking are observed in long-term care institutions. The assumption that “late-onset alcoholism” (i.e., an adult with no history of abuse who develops problems late in life) is common is not supported by evidence. Problems with drinking in later life appear typically to be a continuation of drinking patterns established in the adult years. 3. When abusive drinking or alcoholism is observed in later life, therapeutic intervention is at least as effective with older adults as with adults generally. Trend analysis of drug use (Johnson, 1996) and research on alcohol use among communitydwelling older adults (LaKhani, 1997) continue to reinforce these conclusions. Although recognition of possible cohort differences requires one to be cautious in making broad generalizations about future patterns of drinking behavior among older adults, no current evidence has established an increased risk of abusive drinking in later life. Evidence continues to suggest that social factors associated with aging tend to moderate drinking behavior. George L. Maddox See also Substance Abuse and Addictions

References Barnes, G., Abel, E., & Ernst, C. (1980). Alcohol and the elderly. Westport, CT: Greenwood Press. Johnson, R. A. (1996). Trends in the incidence of drug use

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in the U.S., 1919-1992. Washington, DC: U.S. Department of Health and Human Services. LaKhani, N. (1997). Alcohol use amongst communitydwelling elderly people: A review of the literature. Journal of Advanced Nursing, 25, 1227–1232. Maddox, G., Robins, L., & Rosenberg, N. (Eds.). (1985). Nature and extent of alcohol problems among the elderly. New York: Springer Publishing. Midanik, L., & Clark, W. B. (1994). The demographic distribution of U.S. drinking patterns in 1990: Description and trends from 1984. American Journal of Public Health, 84(8), 218–222. Mishra, B., & Kastenbaum, R. (1980). Alcohol and old age. New York: Grune and Stratton. Roueche, B. (1960). Alcohol. New York: Grove Press.

ALZHEIMER’S DISEASE: CLINICAL Alzheimer’s disease (AD) is a neurodegenerative condition of late adulthood with a characteristic pattern of progression that allows for an accurate clinical diagnosis during life (85% correlation with autopsy findings of neuritic plaques and neurofibrillary tangles). Early symptoms include decline in the memory of recent events, in executive abilities, and in word-finding. In AD’s moderate stage, judgment is impaired in financial affairs, supervision is required for most instrumental day-to-day tasks, and hallucinations and false beliefs can emerge, although they are more common in moderated later stages. The moderate stage is defined by impairment in instrumental activities of daily living and requiring prompting to complete personal ADLs, which otherwise are largely done without assistance. In the late stage, the patient needs help for basic activities, such as dressing, eating, and using the toilet; agitation, especially after dark, and aggressivity may occur, imposing an additional burden on caregivers often leading to the patient’s placement in a nursing home. The final stage is one of muscle rigidity leading to aspiration pneumonia. The life span of persons with AD is shorter than that for age-matched populations. A diagnosis of dementia due to AD is made on the basis of a decline in two or more cognitive domains that interferes with a patient’s social or occupational life, and which has no other neurological psychiatric or systemic cause. A new trend is to diagnose AD in its early, purely amnestic stage, labeled “amnestic mild cognitive impairment” (aMCI); sophisticated

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psychometric testing is required at this stage, and additional genetic and brain imaging testing may be needed. A pre-symptomatic stage of AD can be diagnosed in first-degree relatives of patients carrying presenilin or amyloid precursor protein mutations, using serial psychometric testing and brain imaging. Diagnosing AD in its pre-symptomatic or aMCI stages will be clinically meaningful once diseasemodifying treatments become available. A vascular component to dementia is frequently found in people aged 75 years and older, especially in those with a history of transient ischemic attacks (stroke-like symptoms lasting less than 24 hours), vascular risk factors (diabetes, high blood pressure, atrial fibrillation, high blood lipid levels), and evidence of strokes on brain imaging; the combination of AD and vascular components is referred to as “mixed dementia.” Vascular risk factors (VRF) are so frequent in patients with late-onset AD that they likely play a role in the emergence of symptoms and are certainly worth treating at all stages of AD. Along with an active and socially integrated lifestyle, treating VRF is currently one of the best ways to prevent dementia in the population at large. Management of AD includes accurate diagnosis, education of both patients and caregivers about the disease, referral to community resources and lay associations, and drug treatments for depression and other psychiatric symptoms, cognitive and functional decline, and associated VRF. Within 5 years, it is expected that there will be treatments to target the primary pathophysiology of AD, acting on brain amyloid metabolism, synaptic plasticity, or inflammatory responses. Pharmacogenetic profiles of individuals at risk or in early stages of AD will help select the best long-term therapy. Until then, cholinesteraseinhibitors (donepezil, rivastigmine, galantamine) and the NMDA receptor antagonist memantine are used to treat symptoms through the mild to moderately severe stages of AD. Cognitive training alone for aMCI, or as value added to pharmacotherapy in mild AD, is being studied. Structured caregiver education and support in mild to moderate AD may delay the need for the patient’s placement in a nursing home. For updates, consult: www.alz.co.uk/adi/publications.html#gp www.cnsforum.com Serge Gauthier

See also Dementia Dementia: Frontotemporal Dementia: Lewy Body

ALZHEIMER’S DISEASE: GENETIC FACTORS The majority of Alzheimer’s Disease (AD) cases are sporadic (∼95%), with onset after 65 years of age. Multiple studies suggest a complex etiology of AD, with both environmental and genetic factors influencing the pathogenesis of the disease. Twin studies found the concordance rate for AD among monozygotic twins to be 78% versus 39% among dizygotic twin pairs, indicating a strong genetic influence (Bergem, Engedal and Kringlen, 1997). The earliest sign of AD brain pathology is the deposition of extracellular amyloid plaques, consisting mainly of Aβ 40/42 peptides generated by cleavage of the β-amyloid precursor protein (APP). The longer and more neurotoxic isoform (Aβ 42 ) appears to be elevated in the brains of individuals affected with either sporadic or familial AD, implying that they have a shared pathogenetic mechanism. The combination of genetic and biochemical data led to the formulation of the amyloid cascade hypothesis which suggested that Aβ deposition was the primary event in disease pathogenesis (Glenner and Wong, 1984; Selkoe, 1991; Hardy and Higgins, 1992). To date four genes responsible for AD have been identified (Figure 1). The common pathological effect imparted by all four AD-linked genes is to alter APP processing and promote Aβ deposition. Approximately 5% of cases are associated with early onset AD. The disease in these families is often transmitted as a pure genetic, autosomal dominant trait. Genetic analyses of such pedigrees have found three causal genes: APP (Goate, ChartierHarlin, Mullan, Brown, Crawford, et al., 1991); presenilin 1 (PS1) (Sherrington, Rogaev, Liang, Rogaeva, Levesque, et al., 1995); and presenilin 2 (PS2) (Rogaev, Sherrington, Rogaeva, Levesque, Ikeda, et al., 1995; Levy-Lahad, Wasco, Poorkaj, Romano, Oshima, et al. 1995). Another genetic locus for inherited susceptibility to AD was resolved to the Apolipoprotein E (APOE) gene that acts as a risk factor and age at onset modifier for the late

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AD Genetics

Age at Onset Frequency

PS1

βAPP

PS2

APOE ε4 allele

New loci

Chr14

Chr21

Chr1

Chr19

Chr 10,

16-65 18-5O%

30-65

40-85

>65

Chr 12,

p(Y|Xabsent ) TX < TY 0 < p(X) < 1 there are no plausible alternative interpretations of the rxy

The first requirement establishes that X and Y are correlated (|rxy | > 0) and that a comparison group (counterfactual) must exist. The second specifies that the timing of the cause must precede that of the effect, and the third requires that the cause cannot be a constant (it must have variance; the first requirement implies this for the effect). The last requires that there can be no viable competing explanations of the observed empirical relationship between X and Y. The most straightforward and convincing method for meeting all of the requirements for establishing probabilistic cause is to conduct a randomized controlled trial (RCT). In the basic, 2-group, pre-

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post test RCT, subjects are first randomized to the treatment and control groups, both groups are observed before the treatment condition (X) is introduced in the experimental group (but not in the control group), and both groups are observed afterwards. Thus, differences in the pre-post test score deltas between the 2 groups can only be attributed to the manipulation of the treatment (X), and there are no potential confounders because the random assignment of the treatment (X) ensures that it is uncorrelated with the error term (“e” in the regression equation of Y = ayx + byx X + e), where any potential confounder resides. Most of the issues under study in gerontology and geriatrics, however, are not well (if at all) suited to such experimental manipulation. As a result, the field relies primarily on observational studies, of which surveys are the dominant form. Surveys generate information by selecting subjects (people) to whom questions will be asked, either over the phone or in person (Fowler, 2001). In quantitative surveys, the interviews are structured and standardized so that each subject is asked the same questions in the same way, and is given the same set of response options. This produces a “rectangular” data set which facilitates direct comparison and contrast between (i.e., statistical analysis of) the responses of individuals and designated groups. In qualitative surveys (or ethnographic interviews), there is a guiding list of questions, but these are open-ended and designed to stimulate responses in the subject’s own “voice,” and thus the interview process flows more naturally (i.e., it is only semi-structured). For brevity, this text only discusses quantitative surveys. At the most elementary level, there are 3 keys issues in surveys: identifying the sample, deciding between cross-sectional and longitudinal designs, and generating the questions. Each issue, of course, has many component parts and a complete discussion of them is beyond the scope of this chapter. For a more thorough consideration of those issues, 2 sources are recommended that are geared toward non-methodologists: a very readable (and bundled) set of brief paperback books that takes one through all of the stages in the survey process (Fink, 2002), and an electronic textbook that does the same thing using state-of-the-art technology (www.socialresearchmethods.net/), providing a thumbnail sketch of these issues, and an electronic

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resource that archives over 8,000 surveys that may be accessed to address issues in gerontology and geriatrics. In terms of selecting the sample, the fundamental question involves sampling error, and whether you want to be able to measure it. Sampling error derives from the fact that every time a sample from a population is asked questions, as opposed to asking the questions of everyone in the population, some error occurs. If probability-based (e.g., random) sampling is conducted, sampling errors can first be calculated, and then confidence intervals (often expressed in political or public opinion polls, for example, as “plus or minus X percent”) can be determined. When convenience samples (such as marketing surveys conducted among mall shoppers) are drawn, however, neither sampling errors nor confidence intervals can be determined. Thus, probability-based sampling is required if one wishes to generalize back to the population (sampling frame) from which one randomly selected the subjects for the interviews. Sampling error is primarily affected by sample size, such that the larger the sample, the smaller the sampling error. Most nationally representative samples require 1,000 to 1,500 subjects to have acceptable confidence intervals, depending on whether simple random sampling (the most powerful but least efficient procedure) or multistage cluster sampling (a more efficient but less powerful approach) is used. An important concept inversely related to sampling error is statistical power, which reflects the ability of a survey to test the hypotheses under consideration. The second key issue in surveys is whether to use a cross-sectional or a longitudinal design. By way of analogy, cross-sectional surveys are like taking still photographs, whereas longitudinal surveys are like taking moving pictures. Perhaps the most typical cross-sectional studies are voter preference surveys conducted during election campaigns. In these studies, a sample of potential voters is identified at a particular point in time, often through random digit dialing procedures. Subjects are then asked about their views concerning the candidates, and whom they would vote for if the election were held that day. With cross-sectional survey data, one can then look at age differences in preferences and vote intentions, which represent inter-individual (i.e., agegraded) differences at a single point in time. To address intra-individual (i.e., aging) differences, however, longitudinal designs are necessary. Longitudinal surveys track the same sample (i.e.,

persons) over time. There are 2 critical issues in longitudinal designs: how often and how long to followup (re-interview) the same sample of subjects, and the length of time between those follow-up interviews. The answer depends on the theory underlying the hypotheses being testing. Subjects have to be followed-up long enough for the aging effects to have manifested themselves, and often enough to be able to identify when the effects occurred. The most frequently used intervals between follow-up interviews range between 6 months and 2 years. The most well-known longitudinal study is the Framingham Heart Study (http://framingham.com/heart/), which began over 50 years ago when 5,209 healthy residents of that Massachusetts town were enrolled as the initial cohort, were interviewed at baseline, and were re-interviewed every 2 to 4 years thereafter. Most of what the world knows about the risks for and prevention of heart disease stem from this study. Although clearly the most powerful design for studying intra-individual (i.e., aging) effects, longitudinal studies do have limits. As with the Framingham Heart Study, these surveys typically involve following just 1 birth cohort (in this case, residents between 30 to 60 years old in the 1950s), and because no 2 birth cohorts are alike (they do not experience the same life course stages during the same historical periods), it is not necessarily the case that similar findings would emerge from studying other birth cohorts. The Greatest Generation (Brokaw, 1998) is an excellent example of a birth cohort whose lives were shaped by a remarkably unique set of experiences. The third key issue in surveys involves generating the questions to be asked. There are 2 main approaches to generating survey questions. In the first simply takes things “off-the-shelf,” and uses questions or sets of questions (i.e., scales) developed by others. The second approach relies on “homegrown” measures created specifically for the survey at hand. DeVellis (2003) provides a thorough yet readable guideline for the general process involved in either approach. Krause (2002) has recently demonstrated the benefits of using the “homegrown” approach to developing closed-ended questions for use in surveying older adults on the sensitive and difficult-to-measure topic of religion. He identifies 9 major steps in the process: focus groups, in-depth interviews, input from extant quantitative surveys, developing preliminary questions, review of those questions by an expert panel, cognitive interviews, fielding a pilot study, conducting the

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Swedish Twin Studies

national survey, and extensive psychometric testing. In Krause’s study, the focus groups of older adults provided new ways of thinking about the role of religion in their lives, the in-depth interviews provided insight about the practices that older adults engaged in, input from prior quantitative studies identified what was commonly accepted by researchers, the development of preliminary new questions provided an opportunity to clarify previous issues and cover those not previous tapped, the expert panel provided contextual and construct validity, the cognitive interviews clarified what subjects were thinking about when they answered the questions, the pilot study demonstrated the feasibility of asking older adults the items, the national survey provided a large representative sample, and the extensive psychometric testing confirmed that reliability and validity of the questions. The end result was a major contribution to a very difficult set of measurement issues. Many surveys have been conducted, and the data from thousands of them are now available for public use. Among the larger, more widely used (for aging studies) and longitudinal of these are the General Social Survey (GSS), the third National Health and Nutritional Examination Study (NHANES III), the Longitudinal Studies on Aging (LSOA I and II), the Australian (Adelaide) Longitudinal Study of Aging, the Established Populations for the Epidemiologic Study of the Elderly (EPESE), the Hispanic EPESE, the National Long-Term Care Survey (NLTCS), and the Health and Retirement Study (HRS). All but the HRS can be accessed from the site of the National Archive for Computerized Data on Aging (www.icpsr.umich.edu/nacda/). Accessing the HRS requires going directly to the HRS world-Web site (hrsonline.isr.umich.edu/). Both Web sites are remarkably easy to navigate, and nearly all materials pertinent to these surveys may be downloaded electronically. Fredric D. Wolinsky See also Longitudinal Research Longitudinal Data Sets

References Brokaw, T. (1998). The greatest generation. New York: Random House. DeVellis, R. F. (2003). Scale development: Theory and

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applications (2nd ed.). Newbury Park, CA: Sage Publications. Fink, A. (2002). The survey kit (2nd ed.). Newbury Park, CA: Sage Publications. Fowler, F. J., Jr. (2001). Survey research methods (3rd ed.). Newbury Park, CA: Sage Publications. Krause, N. (2002). A comprehensive strategy for developing close-ended survey items for use in studies of older adults. Journal of Gerontology: Social Sciences, 57B, S263–S274. Shadish, W. R., Cook, T. D., & Campbell, D. T. (2002). Experimental and quasi-experimental designs for generalized causal inference. New York: Houghton Mifflin.

SWEDISH TWIN STUDIES One of the most frequently noted observations among both scientists and lay people is that there is considerable variability in how people age. Why is it that some individuals survive to their 70s, 80s or 90s, relatively free from chronic illness, with good vigor and intact cognitive abilities, while others experience considerable physical and cognitive impairment with a reduction in activities of daily living? Is it because these individuals are genetically different, or because they have accumulated different experiences throughout life? Clearly, both genes and environment are important for aging. However, what is not as well delineated is whether the influence of genetic effects is the same throughout the last half of the lifespan. Twins represent an opportune natural “experiment” for studying these questions. Identical twins share all of their genes, and thus any differences between members of a pair must be due to environmental differences. Fraternal twins, like other siblings, have half of their genes in common. Thus, the similarity of identical and fraternal twin pairs can be compared to estimate how important genetic effects might be. If genetic effects are of importance, then identical twins should be twice as similar as fraternal twins. The extent to which identical twins are different provides an estimate of the importance of what is known as non-shared environments—those individual-specific environmental factors that cause differences among family members. There have been relatively few twin studies of aging. The first was that by Kallmann and colleagues, known as the New York State Psychiatric Institute Study of Aging. This pioneering effort focused mostly on cognitive abilities, mental health,

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and longevity. There are currently 7 twin studies of aging, 4 of which use twin registries. All represent broad multidisciplinary efforts based on populationbased samples of twins.

The Swedish Adoption/Twin Study of Aging The Swedish Adoption/Twin Study of Aging (SATSA) is a longitudinal study of all twin pairs in the Swedish Twin Registry who indicated that they had been separated before age 10 and reared apart, and a control sample of twins reared together (Pedersen, McClearn, Plomin, Nesselroade, Berg, & de Faire, 1991; Finkel & Pedersen, 2004). Both members of 351 pairs of twins reared apart and 407 matched control pairs of twins reared together, aged 26 to 87, responded to a questionnaire in 1984. Participants have thus far been assessed by 4 questionnaires at 3-year intervals between 1984 and 1993, and a follow-questionnaire in 2004, 20 years after the first. A subsample of pairs aged 50 years and older has been examined through 5 waves of inperson testing and health examinations for cognitive and functional capabilities, personality, social support, life events, health and health-related behaviors, and exposure to potential risk factors for dementia.

OCTO-Twin The focus of OCTO-Twin was all intact (i.e., both living) pairs of twins in Sweden aged 80 years or older (McClearn, Johansson, Berg, Pedersen, Ahern, Petrill, et al., 1997). During the first wave of OCTO-Twin, in 1993, 351 pairs of like-sexed twins were tested in their homes. All the domains of assessment included in SATSA are covered in OCTO-Twin, as well as additional measures sensitive to cognitive decline in the oldest-old. The OCTO-Twin sample was assessed a total of 5 times at rolling 2-year intervals.

Aging in Women and Men (“Gender Study”) Both SATSA and OCTO-Twin are based on likesexed twin pairs. To study gender differences in the importance of genetic influences, it is necessary to include unlike-sexed pairs of twins (Gold, Malmberg, McClearn, Pedersen, & Berg, 2002). In

the Gender Study, 605 unlike-sexed pairs of twins aged 69 to 89 responded to a questionnaire much the same as that sent to the SATSA twins. A subsample of 249 pairs aged 70 to 80 years (in 1995) have also participated in 3 waves of in-person assessment at 4-year intervals.

Findings These studies combined have produced approximately 225 publications in international journals. Most of the analyses have focused on the relative importance of genetic and environmental influences for a variety of behavioral and health-related measures. Perhaps the single most important conclusion is that the importance of genetic influences on these characteristics among older adults is dependent not only on what trait is being studied, but also on the individual’s gender, birth cohort, and age. For example, early results from SATSA (Pedersen, Plomin, Nesselroade, & McClearn, 1992) demonstrate that the heritability of general cognitive abilities is substantial (0.80) in twins aged 50 years and older, while OCTO-Twin reports that although genetic influences are still important in the oldestold, the heritability estimate is somewhat lower (0.60) than in midlife (McClearn, Johansson, Berg, Pedersen, Ahern, Petrill, et al., 1997). Furthermore, when evaluated longitudinally, genetic variance decreases for measures of fluid and speeded abilities (Reynolds, Finkel, McArdle, Gatz, Berg, & Pedersen, 2005). The relative importance of genetic effects for personality is generally lower than that for cognitive abilities (heritabilities on average are .35), underscoring the trait-specific nature of the importance of these influences. Genetic influences vary even within a domain: the longitudinal trajectories of genetic variation is different for measures of fluid and crystallized abilities (Reynolds, Finkel, McArdle, Gatz, Berg, & Pedersen, 2005). Furthermore, genetic influences for perceptual speed are an important component of age-related decline in other cognitive measures (Finkel & Pedersen, 2004). Perhaps one of the most pertinent characteristics for the gerontologist is self-rated health, as this measure reflects individuals’ own opinions of their status and is a predictor of survival. Both the range and degree of individual differences in self-rated

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health is greater in older persons compared with younger or middle-aged adults. Both genes and environment contribute to self-rated health longitudinally, and both age and cohort effects are seen. Age-related changes in self-rated health can be attributed to illness. Cohort differences are most likely attributable to socially mediated and individual specific environmental factors (Svedberg, Lichtenstein, Gatz, Sandin, & Pedersen, in press). Another domain included in these 3 studies is functional ability (such as grip strength and motor functioning). There are genetic influences on both level and slope (decline) in performance for motor functioning, mean arterial pressure, and forced expiratory volume (Finkel, Pedersen, Reynolds, Berg, deFaire, & Svartengren, 2003). These results have considerable practical implications, as these measures reflect areas of function that may lead to disability and the need for assistance. Nancy L. Pedersen See also Twin Studies in Aging Research

References Finkel, D., & Pedersen, N. L. (2004). Processing speed and longitudinal trajectories of change for cognitive abilities: The Swedish Adoption/Twin Study of Ag-

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ing. Aging, Neuropsychology, and Cognition, 11(2–3), 325–345. Finkel, D., Pedersen, N. L., Reynolds, C. A., Berg, S., deFaire, U., & Svartengren, M. (2003). Genetic and environmental influences on decline in biobehavioral markers of aging. Behavior Genetics, 33(2), 107–123. Gold, C. H., Malmberg, B., McClearn, G. E., Pedersen, N. L., & Berg, S. (2002). Gender and health: A study of older unlike-sex twins. Journal of Gerontology: Social Sciences, 57B(3), S168–S176. McClearn, G. E., Johansson, B., Berg, S., Pedersen, N. L., Ahern, F., Petrill, S. A., et al. (1997). Substantial genetic influence on cognitive abilities in twins 80 or more years old. Science, 276, 1560–1563. Pedersen, N. L., McClearn, G. E., Plomin, R., Nesselroade, J. R., Berg, S., & de Faire, U. (1991). The Swedish Adoption Twin Study of Aging: An update. Acta Geneticae Medicae et Gemellologiae (Roma), 40, 7–20. Pedersen, N. L., Plomin, R., Nesselroade, J. R., & McClearn, G. E. (1992). A quantitative genetic analysis of cognitive abilities during the second half of the life span. Psychological Science, 3(6), 346–353. Reynolds, C. A., Finkel, D., McArdle, J. J., Gatz, M., Berg, S., & Pedersen, N. L. (2005). Quantitative genetic analysis of latent growth curve models of cognitive abilities in adulthood. Developmental Psychology, 41(1), 3–16. Svedberg, P., Lichtenstein, P., Gatz, M., Sandin, S., & Pedersen, N. L. (in press). Self-rated health in a longitudinal perspective: A 9-year follow-up twin study. Journal of Gerontology: Social Sciences, 60, S331– S340.

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T TASTE AND SMELL Taste and smell are sensory systems that play a fundamental role in nutrition and food selection, in the sensory and hedonic experience of food, in the generation of secretions necessary for the digestion of food, and, in general, for the maintenance of a good quality of life (Schiffman, 1997). An overview of studies of taste and smell perception in older adults indicates that there are significant losses in these chemical senses over the lifespan. Both longitudinal and cross-sectional data suggest that the loss in taste and smell perception is gradual for most people. Many individuals begin to experience chemosensory decrements (especially smell perception) by age 60, with more significant losses after age 70 (Doty, Shaman, Applebaum, Giberson, Siksorski, & Rosenberg, 1984). The taste system is more robust, until medication use increases. The medical terms to classify the chemosensory changes in sense of taste include ageusia (no taste sensation), hypogeusia (decreased taste sensation, that is, elevated taste thresholds and/or diminished suprathreshold taste perception), and dysgeusia (distorted taste sensation); for the sense of smell, they are anosmia (no sensation of smell), hyposmia (decreased sensation of smell, that is, elevated odor thresholds and/or diminished suprathreshold smell perception), and dysosmia (distorted smell sensation). The majority of controlled studies of chemosensory perception in older individuals have found: (1) elevated thresholds for taste and smell (i.e., stimuli must be more concentrated before a sensation occurs), (2) reduced intensity of suprathreshold stimuli, (3) diminished ability to discriminate among suprathreshold stimuli, (4) distortions of taste and smell, and/or (5) deficits in the ability to identify tastes and odors. These sensory alterations result from normal aging, medications, medical and dental conditions, and environmental factors. Cognitive deficits in information retrieval are also associated with impaired ability to recognize and identify tastes and odors (Murphy, 1999). There is heterogeneity among older individuals in the degree of loss in taste and smell perception. Decrements in the perception of prototypical tastes 1168

such as NaCl (salty), sucrose (sweet), citric acid (sour), and quinine HCl (bitter) in older persons who suffer from no diseases and take no medications are modest; for example, thresholds are typically 2 or 3 times higher for healthy, unmedicated elderly than for younger individuals. However, far greater losses in taste sensitivity at threshold levels occur in older individuals who take even a moderate number of medications (Schiffman, 1997). Compared with a young cohort, the average detection thresholds for elderly individuals taking an average of 3.4 medications were 11.6 times higher for sodium salts, 4.3 times higher for acids, 7.0 times higher for bitter compounds, 2.5 times higher for amino acids, 5.0 times higher for glutamate salts, and 2.7 times higher for sweeteners. Losses in suprathreshold taste intensity also occur with the degree of loss related to the chemical structure of the tastant, as well as medical status, medication use, and cognitive status. Clinical studies of wasting elderly patients have found that taste losses at the threshold and suprathreshold levels are even more severe. The cause of the taste changes in normal aging but in the absence of disease and medications is not well understood. Current opinion is that taste losses from normal aging are probably due to changes in taste cell membranes (e.g., altered functioning of ion channels and receptors) rather than losses in the number of taste buds. Although some studies have found anatomical losses in the number of taste buds with age, others have found no change. Taste sensations are produced by the interaction of chemicals in foods and beverages with polarized neuroepithelial cells that are clustered into buds scattered on the dorsal surface of the tongue, tongue cheek margin, base of the tongue near the ducts of the sublingual glands, and the soft palate, pharynx, larynx, epiglottis, uvula, and first third of the esophagus. Taste cells constantly reproduce themselves, with a lifespan of approximately 10 days. The continuous turnover of cells in the renewing taste epithelium involves 2 death factors: Bax (a death factor in the Bcl-2 family of survival/death factors) and p53 (a tumor-suppressor protein linked to apoptosis and Bax transcription). Old taste receptor cells employ

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p53 and Bax as part of their apoptotic death pathway (Zeng & Oakley, 1999). This process of continuous renewal can be impaired by protein malnutrition that affects the reproduction of taste cells and reduces taste sensitivity. Three cranial nerves (the 7th, 9th, and 10th nerves) transmit taste signals from taste receptor cells to the nucleus of the solitary tract in the medulla of the brain stem and ultimately to the ventral posteromedial nucleus of the thalamus and the primary gustatory cortex. It is not known if agerelated losses in these neural pathways that transmit messages from taste buds to the brain are impaired by the aging process. Medications and medical conditions play a major role in taste losses and distortions in both healthy and frail older patients (Schiffman, 1997; Drewnowski & Warren-Mears, 2000). Clinical and laboratory studies have implicated over 250 drugs in altered taste sensations. Community-dwelling older persons aged 65 and older typically take from 2.9 to 3.7 medications, and this number increases significantly for elderly living in retirement and nursing homes. Medications can alter taste perception at several levels including peripheral receptors, chemosensory neural pathways, and/or the brain. Drugs secreted into the saliva induce adverse taste effects either by producing an unpleasant taste of their own or by modifying taste transduction mechanisms. Drugs can also interact with peripheral receptors by diffusing from the blood to stimulate the basolateral side of taste receptor cells. Olfactory losses result from normal aging, certain disease states (especially Alzheimer’s and Parkinson diseases), viral insult, head trauma, medications, surgical interventions, and environmental exposure (such as cumulated exposure to certain pollutants). The prevalence of olfactory impairment is quite high (24.5% overall among persons aged 65 and older), and impairment increased with advancing age in both men and women (Murphy, Schubert, Cruickshanks, Klein, Klein, & Nondahl, 2002). The sense of smell is generally more impaired than the sense of taste for elderly persons who take few medications. Olfactory losses occur at both threshold and suprathreshold concentrations. Detection and recognition thresholds for a broad range of food odors and volatile compounds are 2 to 15 times higher than for a young cohort. Elderly individuals have reduced capacity to discriminate the degree of difference between odors of dif-

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ferent qualities as well as to identify odors. More than three-quarters of persons older than age 80 have major difficulty perceiving and identifying odors. Studies of patients with neurodegenerative diseases such as Alzheimer’s and Parkinson have found that suprathreshold and sometimes threshold measures of odors are severely affected by cognitive status (Murphy, 1999). Perceptual losses in odor perception during aging result in part from anatomic and physiological changes in the structure of the upper respiratory tract (especially the nose), the olfactory epithelium (tissue at the top of the nasal cavity that contains olfactory receptors to which odorants bind), olfactory bulb and nerves, and certain brain structures, including hippocampus, amygdaloid complex, and hypothalamus. The changes include reductions in cell number, damage to cells, and diminished levels of neurotransmitters. As the neurons degenerate and disappear, the olfactory bulb takes on a moth-eaten appearance. These changes occur in normal aging; however, in certain disease states such as Alzheimer’s disease and Parkinson disease, the losses can be profound. Like taste cells, olfactory cells in the olfactory epithelium undergo constant renewal, although the average turnover time is 3 times longer (approximately 30 days). The turnover of olfactory neurons appears to involve apoptotic pathways similar to those in other neurons. Chemosensory losses in older adults can interfere with nutritional and immune status. This is because the chemical senses are indicators of a food’s nutritional value, due to learned association of a food’s taste and smell sensations with its post-ingestive effects. Thus, the elderly can have difficulty adjusting intake when flavor-calorie cues are inadequate. Chemosensory losses have been shown to impair appetite (de Jong, Mulder, de Graf, & van Staveren, 1999) and in some cases reduce the motivation to eat to such a degree that involuntary weight loss (wasting) occurs (Schiffman, 1997). There are no medical treatments currently available to reverse taste and smell losses that have occurred during the aging process. However, hyposmia (but not anosmia) can be “treated” by adding simulated food flavors to meats, vegetables, and other nutritious foods to amplify the odor intensity. Simulated flavors are noncaloric mixtures of odorants (odorous molecules) that are extracted from natural products or are synthesized after chemical analysis

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of the target food. They are comparable to frozen concentrated orange juice (if it were noncaloric) or extract of vanilla but have the aroma of foods such as bacon, cheese, or butter. Evidence is now emerging that flavor-enhanced food can compensate for chemosensory losses, improve palatability and/or intake, increase salivary flow and immunity, reduce chemosensory complaints in both healthy and sick elderly, and lessen the need for table salt. Improvements in immunity (increased T and B cell counts and increase in salivary IgA) with use of flavor-enhanced foods occur even when macro- and micro-nutrient intakes are not changed (Schiffman, 1997; Schiffman & Graham, 2000; Schiffman & Warwick, 1993). The improvement in immunity from flavor enhancement may involve direct neuralimmune connections known to exist between those parts of the brain that subserve olfaction and the immune system. Susan S. Schiffman

References de Jong, N., Mulder, I., de Graaf, C., & van Staveren, W. A. (1999). Impaired sensory functioning in elders: The relation with its potential determinants and nutritional intake. Journals of Gerontology. Series A. Biological Sciences and Medical Sciences, 54, B324– B331. Doty, P. (1997). Internal briefing paper addressing possible fraud and abuse issues in the cash option. Unpublished report. Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. Murphy, C. (1999). Loss of olfactory function in dementing disease. Physiology and Behavior, 66, 177–182. Murphy, C. L., Schubert, M. S., Cruickshanks, K. J., Klein, B. E., Klein, R., & Nondahl, D. M. (2002). Prevalence of olfactory impairment in older adults. Journal of the American Medical Association, 288, 2307–2312. Schiffman, S. S., & Graham, B. G. (2000). Taste and smell perception affect appetite and immunity in the elderly. European Journal of Clinical Nutrition, 54(Suppl. 3), S54–S63. Schiffman, S. S. (1997). Taste and smell losses in normal aging and disease. Journal of the American Medical Association, 278, 1357–1362. Schiffman, S. S., & Warwick, Z. S. (1993). Effect of flavor enhancement of foods for the elderly on nutritional status: Food intake, biochemical indices and anthropo-

metric measures. Physiology and Behavior, 53, 395– 402. Zeng, Q., & Oakley, B. (1999). p53 and Bax: Putative death factors in taste cell turnover. Journal of Comparative Neurology, 413, 168–180.

TAX POLICY Taxation is an increasingly important but often overlooked aspect of federal, state, and local policies for older adults. The tendency has been to focus on budget outlays or direct expenditures, such as Social Security and Medicare, and less on tax expenditures (tax credits, deductions, and exemptions). However, federal tax expenditures deserve greater attention, if only because they are equal to about 75% of federal budget outlays (Howard, 1995). Federal tax policies, rather than state and local policies, also have commanded center stage. Over the past 30 years, however, greater scrutiny has gradually been accorded to the impacts of tax policies at all governmental levels on older adults and on the larger society. In the mid-20th century, rationales for special tax treatment of the elderly included higher rates of poverty, being categorized as “deserving poor,” and “payback” for their contributions to society. Consequently, an additional exemption was enacted for persons aged 65 and older; Social Security benefits, and often other retirement income, were exempted from federal and state income taxes. Older adults also benefited from tax policies available to other age groups, such as deductions for itemized medical expenses above a certain proportion of income. Often these policies have been especially important for the elderly, given their personal expenditure patterns.

Federal Tax Policy In the 1980s, the special tax status of older persons began to erode due to concerns about the viability of Social Security, debates about “greedy geezers” and “intergenerational equity,” and the $18 billion in lost revenue of the additional age-based exemption and exclusion of Social Security benefits from taxation. The 1983 Social Security reforms established taxation of benefits, with differential (but unindexed) thresholds for singles and couples; tax revenues were earmarked for the Old Age, Survivors and Disability Insurance trust fund. The Tax Reform

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Act of 1986 eliminated the age-based exemption, but doubled the personal exemption and boosted the standard deduction for all taxpayers. In the 1990s, both the percentage and thresholds of Social Security benefits subject to income tax were increased. The earlier calls for means-testing Social Security benefits gradually subsided as proposals for privatization escalated. Also reflecting shifts from age-based preferential treatment were changes in the one-time exclusion on capital gains from the sale of the primary residence of those aged 55 and older. This policy was changed to cover all homeowners, with capital gains exclusions of $250,000 for singles and $500,000 for couples. Recent changes in the tax laws also lowered the capital gains rate on the sale of homes and dividend income to 15%. This provision has enabled older homeowners to sell their homes and retain more of the proceeds for other expenses, such as longterm care. However, other recent tax code changes may be less beneficial for older Americans because many do not itemize deductions or even have income tax liability (Gist, 2002). Among taxpayers aged 50 and older, dividend income is heavily concentrated among those with incomes above $100,000 (Gist, 2003). Other policies of potential benefit for the elderly and non-elderly alike have included raising the threshold for estate taxes, first to $600,000 and gradually to $1 million; and providing dependent care tax assistance for employed taxpayers caring for elderly spouses, parents, and children. More recently, the upper limits for estates were changed; by the year 2009, the amount excluded will be $3.5 million. Additionally, the tax rate dropped by 10%. However, due to a “sunset” provision, these changes will revert to the smaller threshold and higher tax rate in 2010, unless they are made permanent. This ambiguity makes estate planning problematic for individuals and also affects those states whose inheritance laws conform with the federal estate tax policies. Tax relief for long-term care expenses also has been increased by allowing the costs of long-term care insurance premiums and of home care to be itemized and deducted by either a family caregiver or the care recipient, under the extraordinary medical expenditures provision. This approach has been seen as more politically viable than directly providing a federal long-term care benefit, as was proposed during the Clinton administration. However,

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tax credits in place of tax deductions might induce more middle-income individuals to purchase longterm care insurance. A major tax expenditure for pensions (employer, self-employed, and individual plans such as Keoghs and Individual Retirement Accounts [IRAs]) permits contributions to be deducted from present tax obligations by employers and by the future elderly population. The 1986 tax law restricted the levels of both employer and employee pension contributions, as well as the amount of tax-deferred contributions to IRAs for higher-income individuals enrolled in an employer plan. Married couples were subsequently allowed to contribute more to IRAs. A major revamping of the tax code in 2001 substantially increased the annual maximum contributions to IRAs and employer-sponsored retirement plans, such as 401(k)s, with special “catch-up” incentives for employees aged 50 and older to contribute to save more for their retirement. These pension-related tax expenditures, costing $123 billion in lost revenues in 2003 and adding to the national deficit, have engendered discussions about which income groups and types of employees (public or private) benefit most from these exclusions. The exclusion of benefit contributions from employee taxation appears to benefit middleincome earners and public sector workers, especially federal employees. Proposals to tax the value of pensions, all or in part, as well as taxing the value of employer-provided health benefits, have been put forth primarily as a way of ensuring greater equity (Salisbury, 1993; Penner, 2000).

State and Local Tax Policies State and local governments have enacted a wide array of tax policies that affect the income of the elderly. Older adults receive more subnational tax preferences than the general population (Mackey & Carter, 1994; Penner, 2000). The low visibility of these policies has thus far forestalled any calls for repeals of these preferences (Mackey, 1995; Mackey & Carter, 1994). As would be expected, great variations exist among the states, especially in income tax policy; 7 states have no personal income tax, while 2 tax only interest and dividend income. Forty-one states and the District of Columbia exclude some amount of pension income; 26 provide full exclusion of Social

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Security benefits, and none tax Railroad Retirement income. Nearly all states with a personal income tax exclude some pension benefits of retired public employees; two-fifths exempt a portion of all pension income. Besides this special treatment, estate and inheritance taxes have been cut, often an attempt by states to become retirement havens (National Conference of State Legislatures, 2003). Most conform to the national capital gains tax on dividend income and sale of the principal residence. In addition, slightly more than half of the states provide family care incentives to taxpayers, modeled after the federal Dependent Care Assistance Program. A handful of states also have enacted deductions or exemptions for taxpayers caring for an older or disabled person. California has enacted a $500 tax credit for caregiving, which is of particular benefit to lower-income households. Furthermore, 34 states have legislated long-term care tax incentives, with 7 offering tax credits. Michigan offers both tax deductions and tax credits. The property tax is usually viewed as the most onerous for older adults in comparison with younger households (Reschovsky, 1994). In retirement, the ratio of property wealth tends to rise as income falls, increasing the property tax burden. This burden, often perceived as the least fair among common taxes and which led to the “tax revolt” in 24 states, has been exacerbated by rapid increases in residential property values for much of the past 3 decades. This tax generates 75% of county and half of municipal tax revenues. Most visible in its financing of public education, it is often the only significant tax paid by middle-class older adults to support state and local services (Mackey & Carter, 1994). Every state except Wyoming has either a homestead exemption or “circuit breaker” program of tax relief. Forty states and the District of Columbia have enacted homestead exemptions and credits that reduce the amount of assessed value subject to taxation (Baer, 2003). Twenty-four favor seniors by limiting participation to that age group or providing them with greater benefits than are available to the general population. Four states leave this up to the discretion of their localities; 16 require elderly households to meet income criteria. “Circuit breakers” in 35 states and the District of Columbia prevent property taxes from placing an overload on taxpayers (Baer, 2003). Unlike the

homestead programs, this tax relief is carefully targeted to low- and moderate-income taxpayers and can benefit both homeowners and renters. Nearly half of the states limit eligibility to the elderly and, in some cases, disabled homeowners to defer tax payments. If income guidelines are met, part or all of those taxes can be postponed until the owner’s death or the sale of the property. California allows older adults who sell their home to transfer their existing, and generally lower, property tax rates to a new in-state location in 8 counties having reciprocity. Additionally, a handful of states have enacted property tax freezes and abatements for home repairs, usually restricted to the aged. Older adults’ knowledge of these programs is considerably less than their familiarity with the homestead program (Baer, 1998). A final category of state and local taxes is the sales tax, a major source of revenue for nearly all states, counties, and cities. In 2000, 21 states cut this tax, generally benefiting low-income households. A very few states provide a credit or rebate to older adults for part of the sales tax paid. Perhaps the greatest sales tax boon for older adults is the exemption for food and especially prescription drugs, because they purchase more prescriptions than younger persons do. Because older adults characteristically spend a higher proportion of their income on such nontaxable items, their sales tax burden is lowered (Mackey & Carter, 1994). In 2002, 34 states and the District of Columbia initiated the Streamlined Sales and Use Tax Agreement, designed to make sales taxes more uniform across the states. This voluntary pact is designed to create standardized definitions of drugs, food, clothing, and durable medical equipment, among other proposals (Tubering, 2003). Because these are important expenditures for the elderly, enactment of these provisions by state legislatures would be beneficial for older adults who live in more than one state or who migrate to other states during their later years.

Basic Issues Arising from Tax Preferences for Older Adults Basic issues are raised by the use of tax expenditures, not the least of which is that the actual costs of an aging society are hard to calculate. The

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extent of forgone tax revenues is not well documented, especially at the subnational level. Most state legislature have not yet analyzed how tax benefits for the elderly now affect or will impact their revenue systems in the future (Mackey, 1995). Another issue is intergenerational and intragenerational equity. Younger households with the same level of income as older households can end up paying more taxes due to various exclusions benefiting the elderly (Penner, 2000). Many tax policies, particularly because deductions rather than tax credits are used most frequently, are more beneficial to upperincome elderly than to lower-income older persons. The more extensive taxation of Social Security benefits enacted in the 1980s and 1990s has tended to right that imbalance, but tax-preferred pensions still are less likely to benefit low-income families, who are more likely to work for employers not providing such benefits (Salisbury, 1993). Furthermore, state property tax relief programs generally favor homeowners over renters, the segment of the older population who are most likely to pay excessive costs for housing and therefore need greater assistance (Liebig, 1998). Other issues spring from the relative efficiency of tax laws in promoting the welfare of those older adults who need help the most. These include questions of whether an increase in direct spending on low-income older adults or using tax credits would be more effective, or whether age is an appropriate factor on which to base tax relief. In addition, little is known about the effectiveness of many of these provisions in increasing the well-being of older adults. For example, we do not know if property tax breaks help older persons keep their homes and age in place or cause them to maintain their homes at considerable financial and personal health risk, or if federal and state dependent care tax assistance helps older adults maintain relative independence and enhanced quality of life and avoid nursing home placement. Tax policies can be an important mechanism for achieving important policy objectives, such as homeownership and ensuring access to health care. Major questions, however, need to be addressed regarding the impact of tax expenditures on the general welfare of older adults, on different subgroups of the aged, and on society. As the baby boomers enter their retirement years, these issues will become increasingly crucial, meriting the at-

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tention of citizens and policy makers at all levels of government. Phoebe S. Liebig

References Baer, D. (1998). Awareness and popularity of property tax relief programs. Washington, DC: AARP Public Policy Institute. Baer, D. (2003). State programs and practices for reducing residential property taxes. Washington, DC: AARP Public Policy Institute. Gist, J. (2002). Profile of older taxpayers. PPI Data Digest, 76, 1–4. Washington, DC: AARP Public Policy Institute. Gist, J. (2003). Repealing the tax on dividends: Benefits and costs. PPI Data Digest, 84, 1–6. Washington, DC: AARP Public Policy Institute. Howard, D. (1995). Testing the tools approach: Tax expenditures versus direct expenditures. Public Administration Review, 55(5), 439–447. Liebig, P. S. (1998). Housing and supportive services for the elderly: Intragenerational perspectives and options. In J. S. Steckenrider, & T. M. Parrott (Eds.), New directions in old-age policies. Albany, NY: SUNY Press. Mackey, S. (1995, May). Time to talk about senior tax breaks? State legislatures, 12–13. Mackey, S., & Carter, K. (1994). State tax policy and senior citizens (2nd ed.). Denver: National Conference of State Legislatures. National Conference of State Legislatures, Fiscal Affairs Program (2003). State personal income taxes on pensions and retirement income: Tax year 2003. Penner, R. B. (2000). Tax benefits for the elderly (Occasional paper). Washington, DC: Urban Institute. Reschovsky, A. (1994). Do the elderly face high property tax burdens? Washington, DC: AARP Public Policy Institute. Salisbury, D. (1993). Pension tax expenditures: Are they worth the cost? (Issue brief No. 134). Washington, DC: Employee Benefit Research Institute. Tubering, C. (2003, February). A blueprint for streamlining sales taxes. State legislatures, 12–16.

TECHNOLOGY Longevity is perhaps the single greatest achievement of humankind in the past 100 years. In 1900 the average life expectancy was less than 50 years. Today, most adults have more than half of their adult

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life still ahead of them when they reach the age of 50. Technology and its relationship to older people has generally been associated with new medicines, treatments, and improved health care and its delivery. These technological advances have contributed greatly to adding nearly three more decades to life expectancy. Increased longevity now presents a new challenge. How might technology facilitate a quality of life that meets the needs and expectations of older adults who wish to remain as active and independent as possible in their advanced years? Although technology will continue to be critical to advancing medical science and practice, an increasing focus will be on how advances in electronics, materials, communications, and computation can contribute to a physical environment that facilitates healthy aging and caregiving. Healthy aging is the ability of individuals to live at the limits of their own capacity, not at die limits of the environment in which they live. Consequently, an increasing focus of engineering, design, human factors, and marketing research will be on applications that extend the capacity of older adults where they live, work, play, learn, and drive. Moreover, as the number of older adults who need support from spouses and adult children or service agencies increases, these caregivers will seek technologies that will enable them to provide care while managing limited resources, time, and stress (Coughlin, 1999).

Evolving Approaches to Technology and Aging Using technology to improve the condition of older adults is not new. Since the first adaptation of a stick to assist with walking, people have sought ways to extend the capacity of people to perform to their fullest. Demographic trends, legal imperatives, and advances in technology have accelerated the development of applications for older adults. There are at least three dominant approaches to technology and aging-assistive technology, universal design, and more recently, gerontechnology. Assistive Technology. Beginning with developments in rehabilitative engineering to help returning veterans from World War II, research in prosthetics

and orthotics placed an increased emphasis on technology to assist people with disabilities. Assistive technology evolved from these postwar beginnings to address the development of devices to help the individual manage physical, sensory, and cognitive challenges. Many applications, including improved wheelchairs, walkers, and vision and hearing devices, have often been referred to as assistive technology. Considerable research and engineering has been conducted to identify systems that can help disabled people of all ages. For example, these include modifications to telephones to help people who are vision-impaired to operate the touch pad and enhanced hearing aids or braille or print devices to assist the hearing-impaired. Generally, assistive technology approaches attempt to incrementally improve existing products or to modify living environments to assist people with disabilities regardless of age. Unfortunately, many of these changes are viewed as less attractive, clumsy, and sometimes expensive, making them unattractive to the user and the general public. Universal Design. Public policy trends over the past 35 years have generally advocated mainstreaming people with different abilities. Increasing public awareness and acceptance of this idea have resulted in a series of laws beginning in the late 1960s and, more recently, legislation such as the Americans with Disabilities Act of 1990, which requires equal access to facilities, and the Telecommunications Act of 1996, which calls for communications providers to offer all people the means to use the nation’s telecommunications system. These legal imperatives and research, plus the desire to develop devices that might be attractive to a larger population, have resulted in a second approach to technology—universal design. Unlike assistive technology, universal design attempts to integrate and apply a series of design principles to improve products and environments for people of all abilities and ages without modification or extra cost. Universal design has been gaining wider acceptance and adoption. It has become increasingly acceptable to product manufacturers as a strategy to meet the demands of a growing market of older people and people with disabilities and to comply with the law. Universal design is now being integrated into a range of products and environments,

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including household appliances, automobiles, and kitchens. Gerontechnology. Although universal design has great promise for meeting the needs of older adults, the unique impact of the natural aging process has caused many to argue that a special field of study that addresses the specific needs of older adults and technology be developed. This field, gerontechnology, is “the study of technology and aging for the improvement of the daily functioning of the elderly” (Graafmans & Taipale, 1998, p. 3). Gerontechnology was developed in Europe in the 1980s and takes a broad approach to the study of technology and aging, seeking to understand multiple dimensions, including research, design, manufacture, and marketing. The First International Congress on Gerontechnology was held at the Eindhoven University of Technology in 1991, integrating multiple disciplines and the application of technology in mobility, housing, medical systems, and information technology. Where previous approaches to aging and technology have largely been applications developed for people with disabilities, gerontechnology attempts to address the uncertainties of what it means to age, and to enjoy a longer life span and what unique challenges the natural aging process poses for technology—and technology for the older adult.

Next-Generation Technology for Older Adults In addition to the growing number of older adults worldwide, rapid advances in key technologies are resulting in a convergence of application development and market demand. Information technology and advanced materials, in particular, offer great near-term promise in improving the lives of older adults and caregivers. However, technology alone will not produce truly innovative nor desirable products for older adults. Additional research is needed to identify what older adults find to be an acceptable application of technology, how selected technologies will be made affordable to all income groups, and how the elderly and their caregivers will come to use and trust technology for increasingly sensitive and critical services. It will be the combination of these new technologies with increased research on the

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preferences and needs of older adults and their caregivers that will result in a wide range of new applications. For example, the revolution in the availability and growing affordability of information and computation technologies is enabling improvement in existing devices and the development of new systems designed particularly for older adults. These include next-generation wireless personal emergency response systems, remote health monitoring and caregiving, speech recognition systems to manage the home or assist in driving the car, warning and instructional systems for cooking, and the development of virtual communities. Advanced materials will facilitate a new generation of devices to help with personal mobility, such as ultra-light wheelchairs and walkers. Integration of advanced materials; sensors, and communications technologies will produce affordable and attractive wearable computers to assist with daily activities, from shopping to visiting a friend; wireless communications will coordinate trip making and rides for those who may no longer drive; and specialized clothing will address individual health needs (Charness, Parks, & Sabel, 2000).

Emergence of Two Technologies: Enabling and Caregiving Clearly, the growing number of older adults and the additional attention they will receive from researchers and industry will result in a wide range of technologies and related services. These are likely to include at least two types of technologies—enabling and caregiving. Enabling technologies and related services will facilitate continued health, well-being, and an active lifestyle that many older adults will pursue— particularly among the young-old. For example, these technologies will include new warning systems and designs that will facilitate driving longer safely. Smart appliances may help with preparing meals and observing diet restrictions. As many older adults become more sensitive to preventive care, rather than simply treating illness as it occurs, new information-based health-related systems will be developed for consumer use in the home—to monitor, to educate, and to coordinate wellness management. Service providers will build on Internet

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access to customize available medical data to individual medical needs, providing the older adult with the knowledge of how to maintain personal levels of peak performance. Caregiving technologies and related services will serve the needs of spouses, adult children, and formal caregivers caring for an older adult—typically, the oldest old. These systems may include the use of wireless personal emergency response systems in, around, and beyond the home. Information services hubs to coordinate nutrition, physical therapy, transportation, and related supports to the home will be developed. Health monitoring, warning, and service delivery technologies to ensure pharmaceutical compliance and care for chronically ill patients at home will be an increasingly viable means to manage patient health, educate caregivers, and reduce health care costs. The speed of technological innovation and the growth of an aging population offer a new frontier in applying technology to improve the lives of older adults and their caregivers. However, the excitement of what technology can do must be tempered with what will be acceptable to the individual and available to all; it may fundamentally change how we live and care tomorrow. Joseph F. Coughlin See also Communication Technologies and Older Adults Health Information Through Telecommunication Internet Applications Rehabilitation Telemedicine and Telegeriatrics

References Charness, N., Parks, D. C., & Sabel, B. A. (Eds.). (2000). Communication, technology and aging: Opportunities and challenges for the future. New York: Springer Publishing. Coughlin, J. F. (1999). Technology needs of aging boomers. In K. Finneran (Editor-in-Chief), Issues in science and technology (pp. 53–60). Washington, DC: National Academy of Science and National Academy of Engineering. Graafmans, J., & Taipale, V. (1998). Gerontechnology: A sustainable investment in the future. In J. Graafmans, V. Taipale, & N. Charness (Eds.), Gerontechnology (p. 3). Washington, DC: IOS Press.

TELEMEDICINE AND TELEGERIATRICS Globally, one of the great challenges of the modern world has been to make high-quality health care universally available. A traditional difficulty in achieving equitable access to suitable care has been that the provider and the recipient must be physically present in the same place at the same time. Recent advances in information and communication technology have increased the number of ways that health care can be delivered. As the gap has widened between adequately trained front-line care providers and an expanding older population with chronic health care needs, the integration of new information technology has provided new opportunities for access to expertise in small urban and rural communities. Hitherto, health care providers in these locales have been disadvantaged by their physical isolation. Furthermore, the explosion of available education and communication technology within the past decade have positioned telemedicine and telehealth to narrow this regional gap in health care delivery in an unprecedented manner.

Definition Telemedicine is best summarized as the “use of communications and information technology to deliver health and health care services and information over large and small distances” (Industry Canada, 1998). The common thread for all telemedicine applications is that a client of some kind, whether a patient, health care worker, or family physician, obtains an opinion from someone else with expertise in the relevant field. Fearing that this is too technical, many practicing physicians have avoided using telemedicine; sensible, practical presentations by those with experience with its use will be mandatory to convert their thinking. Much work remains to be done to establish its place in health care delivery. Much of the progress of telemedicine in the past decade has been attributable to advances in fiber optics, integrated service digital networks (ISDN), and video compression. Typically, telehealth is divided into 4 major applications: clinical (video consultations), educational (tele-learning), and administrative.

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Like a well-tuned engine, telemedicine will run smoothly when firing on all cylinders. The key components of a successful telehealth system include: 1. People: telehealth users and providers of health services 2. Telehealth application technology: hardware, software, and peripheral devices 3. Telecommunications and network links: telephone lines, Internet, and satellite Clinical telemedicine is further enhanced when there are clear clinical processes that are mutually acceptable to clients and consultant. A professional working relationship is crucial, and pains must be taken to build trust, usually in person, between the consulting and recipient partners to develop an enduring relationship. Realistically, the hardware employed is a compromise between what is desired and what is affordable. Bandwidth is the capacity to carry a quantity of data within a set time, and dictates the complexity of the information that can be sent. While bandwidths ranging from 128 kilobytes per second (kbps) to 1,540 kbps are possible, video image quality is lost at the lowest capacity. Compression prior to transmission helps to reduce the size, but this may also compromise picture quality. Enthusiasts for telemedicine must bear in mind that this approach does not equate to the gold standard of a physician seeing a patient in person. Still, according to the Institute of Medicine, telemedicine “has the potential to re-shape radically healthcare in both positive and negative ways and to alter fundamentally the personal face-to-face relationship that has been the model for medical care for generations” (Field, Institute of Medicine, Committee on Evaluating Clinical Applications of Telemedicine, 1996).

Clinical Applications A comprehensive review of the existing literature by the Cochrane collaboration compares the effectiveness of telemedicine-based care to traditional faceto-face care in various health care populations. The review included all studies that used at least 2 interactive telecommunications, had patients present, and employed objective measures. Of the 200 articles available in 2001, only 7 met their criteria,

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with 5 being telephone-based home support and the remaining 2 videoconferencing with hospitalbased specialists. The evidence supported an improvement in medication adherence and a reduction in hypoglycemic events in diabetics. The quality of care was viewed as equally acceptable by patients, physicians, and nurses. The evidence did not address differences in economic consequences, differences in professional practice during care delivery, or the transfer of skills. Geriatric evaluation and management (GEM) is effective in identifying and managing the health of the frail older adults and leads to improved mortality, cognition, and functional independence. This is most likely when there is targeting and control over implementation of recommendations (Wieland, 2003; Stuck, Siu, Wieland, Adams, & Rubenstein, 1993). However, there is only preliminary evidence that the value of GEM is preserved over the telehealth medium. GEM is the interdisciplinary evaluation of the physical, psychological, and social factors affecting the health of older patients. It is enhanced through the use of bedside screening interviews and assessment protocols. Importantly, GEM has traditionally been a “hands-on” assessment with a complete physical examination, including functional performance measures. Face-to-face discussion is viewed as advantageous to overcoming interview barriers such as cognitive, hearing, and visual impairment, or simply to observe the communication of accompanying family members. It might be predicted that the essence of GEM would be lost through the telehealth medium. Other factors favoring face-to face consultation include paranoia and patient acceptability (Gorman, MacKnight, & Rockwood, 2004). Williams, in his innovative viewpoint back in 1995, anticipated the sharing of electronic case management information across multiple sites, thus bridging the critical gaps in care delivery mechanisms (Williams, Ricketts, & Thompson, 1995). The only comprehensive review on this question thus far (Jones, 2001) shows that valid geriatric assessment is possible through telehealth including via telephone, computer-based interactions, and videoconferencing. Telephone and computerbased interactions appear to be valid in administering some of the common interviews and protocols used to screen for cognitive impairment, delirium, and dementia (Mahoney, Tarlow, & Sandaire, 1998;

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Harvey, Roques, Fox, & Rosser, 1998; Ball & McLaren, 1997). Video-based telegeriatric consultations appear to be most valid and acceptable when there is involvement of a primary care physician (Mahoney, Tarlow, & Sandaire, 1998). In 2 cohort studies using low bandwidth, Jones and colleagues demonstrated agreement between telehealth and face-to-face assessments, although the accuracy of diagnosis was questioned in assessments that require visual observation for motor symptoms (Jones, Johnston, Reboussin, McCall, 2001). Grob (2001) randomly assigned 27 nursing home residents to have either 2 in-person interviews or 1 in-person and 1 telemedicine based interview. The groups were identical on their scores on measures of cognition, depression, and neuropsychiatric symptoms of dementia. Most of the components of the neurologic exam itself appear to be reliable via telehealth with the exception of assessments for dysarthria, ataxia, and facial palsy (Shafqat, Kvedar, Guanci, Chang, & Schwamm, 1999), and the determination of coordination and eye movements (Craig, McConville, Patterson, & Wootton, 1999).

Educational Applications By now, many divisions of Continuing Medical Education within medical schools have developed learning centers to promote continued learning and professional development. Videoconferencing provides a means of sharing information and providing interactive audio, video, and computer technologies. These form an ideal application for distance learning, interactive small groups, a problem-based approach, and clinical skills training (Allen, Sargeant, Mann, Fleming, & Premi, 2003) including in rural regions (Davis, & McCracken, 2002). As a testimony to their effectiveness, a high percentage of participants reported an intention to change practice based on these videoconference sessions (Wakefield, Herbert, Maclure, Dormuth, Wright, Legare, & Brett-MacLean, 2003). Previous literature has supported that intention to change practice is indeed reflective of this occurrence (Allen, Sargeant, MacDougall, 2002). There is a paucity of literature evaluating the educational advantages of telegeriatrics, except for 1 study which found that video broadcasts of weekly Geriatric Medical Grand

Rounds did meet the demands of physicians and allied health professionals for education in geriatric medicine (Sclater, Alagiakrishnan, & Sclater, 2004). Telemedicine and telehealth are still emerging as mainstream practice in the delivery of high-quality health care to frail older adults as well as up-todate knowledge and mentorship to their front-line caregivers. The realization of this vision will depend on the degree that clinicians choose to adopt it into their practice, the development of strong working relationships between users, and support by health care decision makers and educators. Because of the potential of advanced communication technology to improve human interactions within the care of the frail elderly, in the future there is every reason to anticipate greater equity in health care distribution. Peter N. McCracken Darryl B. Rolfson See also Technology

References Allen, M., Sargeant, J., & MacDougall, E. (2002). Videoconferenced continuing medical education in Nova Scotia. Journal of Telemedicine and Telecare, 8(Suppl. 3), 2–4, Allen, M., Sargeant, J., Mann, K., Fleming, M., & Premi, J. (2003). Videoconferencing for practice-based small group continuing medical education: Feasibility, acceptability, effectiveness and cost. Journal of Continuing Education in the Health Professions, 23, 38–47. Ball, C., & McLaren, P. (1997). The tele-assessment of cognitive state: A review. Journal of Telemedicine and Telecare, 3, 126–131. Cochrane Database of Systematic Reviews. Updated 29 Aug 2001. Craig, J. J., McConville, J. P., Patterson, V. H., & Wootton R. (1999). Neurological examination is possible using telemedicine. Journal of Telemedicine and Telecare, 5, 177–181. Davis, P., & McCracken, P. N. (2002). Restructuring rural continuing medical education through videoconferencing. Journal of Telemedicine and Telecare, 8(Suppl. 2), 108–109. Field, M. J., Institute of Medicine (IOM), Committee on Evaluating Clinical Applications of Telemedicine. (1996). Telemedicine: A guide to assessing telecommunication in healthcare. Washington, DC: National Academy Press.

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Telomeres and Cellular Senescence Gorman, M., MacKnight, C., & Rockwood, K. (2004). Feasibility of telemedicine for specialized geriatric care at a regional referral hospital. Journal of the Canadian Geriatrics Society, 93–97. Harker, F., Kavanagh, S., Yellowlees, P., & Kalucy, R. S. (1998). Telepsychiatry in south Australia. Journal of Telemedicine and Telecare, 4, 187–194. Harvey, R., Roques, P. K., Fox, N. C., & Rosser, M. N. (1998). CANDID—Counseling and Diagnosis in Dementia: A national telemedicine service supporting the care of younger patients with dementia. International Journal of Geriatric Psychiatry, 13, 381–388. Industry Canada. (1998). Sector competitiveness framework of the telehealth industry. Jones, B. N. (2001). Telepsychiatry and geriatric care. Current Psychiatry Reports, 3, 29–36. Jones, B. N. III, Johnston, D., Reboussin, B., McCall, W. V. (2001). Reliability of telepsychiatry assessments: subjective versus observational ratings. Journal of Geriatric Psychiatry and Neurology, 14(2), 66–71. Mahoney, D. F., Tarlow, B., & Sandaire, J. (1998). A computer-mediated intervention for Alzheimer’s caregivers. Computational Nursing, 16, 208–216. Psychiatric assessment of a nursing home population using audio-visual telecommunication. (2001). Journal of Geriatric Psychiatry and Neurology, 14(2), 63–65. Sclater, K., Alagiakrishnan, K., & Sclater, A. (2004). Investigation of videoconferenced geriatric medical grand rounds in Alberta. Journal of Telemedicine and Telecare, 10(2), 104–107. Shafqat, S., Kvedar, J. C., Guanci, M. M., Chang, Y., Schwamm, L. II. (1999). Rolfe for telemedicine in acute stroke. Feasibility and reliability of remote administration of the NIH stroke scale. Stroke, 30, 2141– 2145. Stuck, A. E., Siu, A. L., Wieland, G. D., Adams, J., & Rubenstein, L. Z. (1993). Comprehensive geriatric assessment: A meta-analysis of controlled trials. Lancet, 342(8878), 1032–1036. Wakefield, J., Herbert, C. P., Maclure, M., Dormuth, C., Wright, J. M., Legare, J., & Brett-MacLean, P. (2003). Commitment to change statements can predict actual change in practice. Journal of Continuing Education in the Health Professions, 23, 81–93. Wieland, D. (2003). The effectiveness and costs of comprehensive geriatric evaluation and management. Critical Reviews in Oncology-Hematology, 48(2), 227– 237. Williams, M. E., Ricketts, T. C., & Thompson, B. G. (1995). Telemedicine and geriatrics: Back to the future. Journal of the American Geriatrics Society, 43, 1047–1051.

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TELOMERES AND CELLULAR SENESCENCE Telomeres Telomeres are essential genetic elements that define the physical ends of linear chromosomes. In humans, telomeres consist of tandem repeats of the DNA sequence TTAGGG (CCCTAA on the complementary strand) and associated telomere binding proteins (Griffith, Comeau, Rosenfield, Stansel, Bi-anchi, Moss, et al., 1999). The telomere is contiguous with bulk nuclear DNA, but forms a unique structure that serves to distinguish the natural chromosome end from ends generated by chromosome breaks. The telomere functions to prevent abnormal recombination or degradation at chromosome ends but is also implicated in overall chromosome positioning within the nucleus and in homologous chromosome pairing during meiosis.

Telomerase The ends of linear chromosomes cannot be fully copied by the conventional DNA replication machinery because of what is known as the endreplication problem. Without a special mechanism to compensate for the inability of DNA polymerase to copy to the terminal nucleotides of a DNA duplex, a small amount of telomeric DNA is lost on each cell division. Most eukaryotic organisms have overcome the end-replication problem through the action of a specialized telomere-synthesizing reverse transcriptase called telomerase (Blackburn, 1991). Human telomerase is a ribonucleoprotein complex that contains two essential components: hTR (human telomerase RNA) and hTERT (human telomerase reverse transcriptase) (Figure 1). hTERT is the catalytic protein component that polymerizes nucleotides onto the ends of chromosomes, using a portion of hTR as the template to direct the specific addition of TTAGGG repeats (Figure 1). The action of telomerase in human cells is to maintain or lengthen telomeres, thus compensating for the end-replication problem or other causes of telomere degradation. Although human germline, or reproductive cells, and cancer cells express telomerase activity and have stable telomeres, essentially

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FIGURE 1

Schematic of telomeres and telomerase.

all normal somatic human cells have liltle or no Le-lomerase activity and gradually lose telomeric DNA with growth both in vitro and in vivo (Harley, Futcher, & Greider, 1990). This led to the suggestion that telomere loss in the absence of telomerase activity accounts for the replicative mortality of dividing human cells.

Telomere Loss: The Cause of Replicative Senescence The observation by Hayflick and Moorhead (1961) that normal human dividing cells have a finite proliferative capacity led to numerous questions about how this form of cellular senescence could be involved in age-related diseases and what the underlying “mitotic clock” might be. Although many hypotheses for the cause of replicative senescence had been proposed, none was proved correct until the late 1990s, when scientists demonstrated that normal human cells, unlike cancer and reproductive cells, lack telomerase activity due to low or no hTERT gene expression and that, on introduction of an active hTERT gene into normal cells, a greatly extended, if not immortal, cellular life span

was achieved, without signs of malignant or cancerous changes (Bodnar, Ouellette, Frolkis, Holt, Chiu, Morin, et al., 1998). The fact that activation of a single gene with a very specific activity was capable of immortalizing normal cells in culture without inducing genomic instability or a transformed phenotype was a dramatic confirmation of the telomere hypothesis of replicative senescence and suggested that other factors that could be involved in cellular aging, such as oxidative damage or mitochondrial or nuclear mutations, were not playing a significant role in this process, at least not in the laboratory setting.

Implications for Aging and Cancer The role of telomere loss and replicative senescence in human aging and age-related diseases in vivo remains controversial, as there have been relatively few direct tests of the hypothesis. However, the escape from, replicative senescence is a. hallmark of cancer cells, and there is good evidence that the abnormal activation of telomerase plays a critical role in permitting cancer cells to progress through multiple rounds of mutational events leading to

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FIGURE 2

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Telomere length as a Sanction of cell division in reproductive, normal, and cancer cells.

lethal tumors. Thus, inhibition of telomerase activity is an attractive new approach to the treatment of cancer and one that is receiving great attention within the biotechnology and pharmaceutical industries. Recently, there has been significant support for the role of telomere loss in age-related chronic conditions and diseases through analysis of the telomerase knock-out (KO) mouse. Telomerase KO mice were generated by inactivating both maternal and paternal copies of the gene for the RNA component of murine telomerase (mTR). Because mice normally have relatively long telomeres, there was no immediate abnormal phenotype in the mTR KO mouse. However, after several generations of breeding mTR KO mice, telomeres became shortened to a length similar to that seen in aging humans, and a number of physiological deficits begin to manifest themselves as the mice aged. In particular, skin lesions were apparent in areas of chronic stress, wound healing was impaired, liver and he-matopoietic systems did not respond well to physical, chemical, or genetic insults, and the animals died earlier than their wild type counterparts (Rudolph, Chang, Lee, Blasco, Goettlieb, Greider, et al., 1999). Thus, later-generation mTR KO mice provide a model system to test the potential of “telomerase therapy” in preventing or reversing agerelated conditions or diseases in which replicative senescence is implicated.

The relationship between telomere dynamics, telomerase activity, and cell mortality and immortality is summarized schematically in Figure 2. The major diagnostic and therapeutic opportunities arising from this field of research lie in (a) monitoring telomere length and/or activating telomerase in diseases or conditions in which replicative senescence is implicated, and (b) monitoring telomerase activity and/or inhibiting telomerase in cancer. Candidates for telomerase activation are tissues and cells and the TABLE 1 Telomerase Modulation for Treatment of Disease Tissue (Cells) Skin (keratinocytes, fibroblasts) Liver (hepatocytes) Blood (lymphocytes) Vasculature (endothelium) Retina (RPE) All types (tumor cells)

Condition or Disease

Therapeutic Approach

Wound healing, wrinkling

Telomerase activation

Cirrhosis

Telomerase activation Telomerase activation Telomerase activation Telomerase activation Telomerase inhibition

Infections Atherosclerosis Macular degeneration Cancer

RPE, retinal pigmented epithelial cells.

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associated conditions or diseases in which telomeres are known to shorten with time. (All human cancer types studied to date show telomerase activity in the majority to tumor biopsies andhence are potential targets for telomerase inhibition.) Some of the disease areas currently under investigation are listed in Table 1, but it is clear that there are very broad applications of this work that warrant further study. It will be of great interest to scientists and clinicians alike to further elucidate the role of telomeres in cellular aging and human disease. Calvin B. Harley See also Cell Aging In Vitro

References Blackburn, E. H. (1991). Structure and function of telomeres. Nature, 350, 569–573. Bodnar, A. G., Ouellette, M., Frolkis, M., Holt, S. E., Chiu, C.-P., Morin, G. B., Harley, C. B., Shay, J. W., Lichtsteiner, S., & Wright, W. E. (1998). Extension of life-span by introduction of telomerase into human cells. Science, 279, 349–352. Griffith, J. D., Comeau, L., Rosenfield, S., Stansel, R. M., Bianchi, A., Moss, H., & de Lange, T. (1999). Mammalian telomeres end in a large duplex loop. Cell, 97, 503–514. Harley, C. B., Futcher, A. B., & Greider, C. W. (1990). Telomeres shorten during ageing of human fibroblasts. Nature, 345, 458–460. Hayflick, L., & Moorhead, P. S. (1961). The serial cultivation of human diploid cell strains. Experimental Cell Research, 25, 585–621. Rudolph, K. L., Chang, S., Lee, H. W., Blasco, M., Gottlieb, G. L, Greider, C. W., & DePinho, R. A. (1999). Longevity, stress response, and cancer in aging telomerase-deficient mice. Cell, 96, 701–712.

TEMPERATURE REGULATION ABNORMALITY One of the cardinal manifestations of human aging in almost any system is the loss of functional reserve. The thermoregulatory system is no exception to this rule. Much of the regulation of body tempera-

ture occurs via sympathetic control of the skin vasculature. Under normal conditions, the blood vessels in the skin dilate in response to an increase in core temperature, or to a local increase in external skin temperature. A decrease in either core temperature or ambient skin temperature provokes a vasoconstrictor effect. Many studies have demonstrated differences in these functions with aging, whether the temperature stress is provoked by altering ambient room temperature, or by intravenous infusion of fluid below body temperature. The results consistently reveal that older persons have decreased sympathetic responsiveness to temperature stress, thus making adaptation to changes in temperature less effective than in younger adults. As well, there is evidence that blood vessel responsiveness to sympathetic stimulation is lessened with advancing age. An additional challenge in the elderly is the presence of many diseases that further impair thermal regulation. For example, in type 2 diabetes mellitus the blood vessels in the skin have impaired ability to dilate, making older persons with diabetes particularly prone to hyperthermia. Congestive heart failure often results in diminished cardiac output, thus impairing the body’s ability to respond to thermal stress. As well, congestive heart failure is associated with particular impairment of exercise ability in the cold. There is also some evidence that undernutrition, a common occurrence in the frail elderly, is associated with impaired thermal regulation. Numerous neurological disorders, most of which are more common in the elderly, also impair thermal regulation.

Hypothermia Hypothermia is defined as a core temperature of less than 35◦ C. Hypothermia can occur because of accidental outdoor exposure (e.g. immersion in frigid water, or being lost outdoors) or via cool indoor temperatures. Not surprisingly, the following are the characteristics of patients with hypothermia acquired indoors: older, more associated medical conditions, and greater mortality for any comparable degree of hypothermia compared to those with outdoor-acquired hypothermia. The diagnosis of hypothermia requires a low reading thermometer. These should be routinely

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employed during colder months. For indoor hypothermia, a history of significant exposure is usually not obtained, as only modestly cool indoor temperatures can provoke hypothermia in susceptible elderly. The early signs of hypothermia occur between 32◦ and 35◦ C and include fatigue, weakness, slurred speech, confusion, cool skin, and slowness of gait. As hypothermia progresses, consciousness decreases, reflexes are slowed, pupils react slowly, muscles become rigid, and volume contraction occurs. Hypopnoea and cyanosis occur, along with bradycardia. At temperatures below 28◦ C, the skin becomes very cold, and individuals become unresponsive, with fixed, dilated pupils, rigidity, and absent reflexes. The most serious early complications are arrhythmias and cardiopulmonary arrest. Pancreatitis, gastrointestinal tract bleeding, and renal failure can also occur. Electrocardiogram abnormalities are common, and include bradycardia and prolongation of the P-R interval, QRS complex, and QT segment. Atrial fibrillation or ventricular fibrillation can occur. The most specific abnormality, however, is the presence of an Osborne wave following the QRS interval. The most common disease associated with hypothermia in the elderly is hypothyroidism, but this is a challenge to diagnose in the acute setting. Treatment involves removal from the cold environment (and removal of any wet clothing), and attention to general supportive measures as well as rewarming. General supportive treatment includes gentle movement (to avoid provoking cardiac arrhythmias), cardiac monitoring, treatment of associated medical disorders, and treatment of coldinduced organ dysfunction. Unfortunately, when serious arrhythmias occur, the cold heart is often resistant to drugs and electrical cardioversion. The 3 types of rewarming are passive, active external, and core rewarming. Passive rewarming is the most common modality employed in the elderly. This involves placing the person in a warm environment and covering them with blankets. This allows a gradual return to normothermia. Intravenous fluids are usually required, and should be warmed prior to infusion and monitored closely. There is evidence that active external rewarming in the elderly is associated with significant morbidity and mortality, so it is not commonly used. Core rewarming techniques are either quite invasive (e.g. mediastinal lavage, extra corporeal circulation) or relatively inefficient (inhalation

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rewarming) so they are not commonly used in older persons, particularly those with indoor-acquired hypothermia.

Hyperthermia Hyperthermia in older adults is usually associated with heat waves rather than the intense exertion one sees in athletes or military personnel. Recent heat waves in the United States (Chicago in 1995, 1999) and France (2003) have emphasized that even in the era of air conditioning, death by heat stroke is not a rare event. As in most age-related syndromes, the causation is multifactorial. Age-related impairment of thermal regulation, social isolation, relative poverty (no available air conditioning), medications (e.g. diuretics), and underlying diseases (especially cardiac disease) all play a role. In fact, death certificates listing heat stroke as the cause of death grossly underestimate heat-related deaths. Probably half the excess mortality during heat waves is recorded as stroke, heart failure, or myocardial infarction. Evaluation of heat waves in the United States reveals that a large proportion of those who develop heatstroke (approximately two-thirds) are elderly, and that the case fatality ratio increases with advancing age. Women seem to be particularly susceptible to heat-related illness. In North America, the previously large toll heat waves had on nursing home populations is no longer apparent. This is likely because of the introduction of air conditioning, but the 1988 heat wave in Ontario, Canada, revealed that simple measures such as encouraging intake of extra fluids, withholding diuretics and medications that impair thermal regulation, and careful monitoring of fluid status can prevent serious problems. Symptoms of profound heatstroke include severe central nervous system dysfunction such as coma, delirium, or psychosis and anhidrosis (hot, dry skin). For less severe cases, the symptoms are quite non-specific: dizziness, weakness, nausea, anorexia, headache, and shortness of breath. Fortunately, the awareness of a heat wave in the area provides the important clue to consider heat-related illness. Treatment requires removal of the person to a cool (usually air conditioned) environment, and cooling by removing clothing, ensuring air circulation, and bathing with tepid water. More severe cases can

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require ice packs. Most patients are significantly volume contracted and require fluid replacement. Fluid status must be monitored closely, as it is quite easy to provoke pulmonary oedema in these circumstances. The real key to management is prevention. Public health programs that use local media to promulgate advice on how to manage during heat waves are very effective. Some of the tips that can be distributed in this way to older adults (and their families) include: • Seek air-conditioned sites during periods of greatest heat (stores, shopping centers) • Check on people you know who might be at risk • Reduce or eliminate any strenuous activities • Drink water or other nonalcoholic beverages regularly • Shower regularly • Wear light-weight and light-colored clothes • Avoid direct sunlight • Avoid using heat producing appliances (stoves)

Fever Unlike younger adults, in whom most causes of fever are relatively benign infections, most fevers in older adults are caused by serious infections. Currently, most temperature recordings are obtained by oral or tympanic membrane thermometry. However, evidence suggests that rectal temperature is still the most reliable guide, and if infection is suspected with a normal oral or tympanic membrane temperature, measurement of rectal temperature may be helpful. Evaluation of fever and infection in nursing home residents is particularly challenging, and practice guidelines are available. Prolonged fever in older persons (or fever of unknown origin) often has treatable causes, and should be thoroughly investigated. Barry J. Goldlist

References Bentley, D. W., Bradley, S., et al. (2001). Practice guidelines for evaluation of fever and infection in long-term care facilities. Journal of the American Geriatrics Society, 49, 210–222. Bouchma, A., Knochel, J. P. (2002). Heat stroke. New England Journal of Medicine, 346, 1978–1988.

Charkoudian, N. (2003). Skin blood flow in adult human thermoregulation: How it works, when it does not, and why. Mayo Clinic Proceedings, 78, 603–612. Grassi, G., Seravalle, G. et al. (2003). Impairment of thermoregulatory control of skin sympathetic nerve traffic in the elderly. Circulation, 78, 729–735. Keatings, W. R., Donaldson, G. C., et al. (2000). Heat related mortality in warm and cold regions of Europe: Observational study. British Medical Journal, 321, 670–673. Mégarbane, B., Axler, O., et al. (2000). Hypothermia with indoor occurrence is associated with a worse outcome. Intensive Care Medicine, 26, 1843–1849. Naughton, M. P., Henderson, A., et al. (2002). Heat related mortality during a 1999 heat wave in Chicago. American Journal of Preventive Medicine, 22(4), 221–227. Norman, D. C. (2000). Fever in the elderly. Clinical Infectious Diseases, 31, 148–151.

TERMINAL CHANGE Kleemeier (1962) first described the relationship between decline in cognitive function and mortality, and Riegel and Riegel (1972) first proposed the terminal drop hypothesis, which states that a decline in cognitive function occurs approximately 5 years prior to death. The hypothesis has been difficult to investigate, because it requires multiple observations of cognitive function over a several-year period, among persons with a wide spectrum of cognitive ability who did and did not die during the observation period. This text provides an update to Bosworth’s review (Bosworth, 2001; Bosworth & Siegler, 2002) of the terminal change literature. While it is now relatively clear that low levels of cognitive function predict mortality, less is known about change in cognitive function and mortality. Thus, reviewed studies had to examine change in at least 2 or more measures of at least 1 cognitive measure and specifically test for the hypothesis of terminal change; 6 articles (4 separate studies) met this inclusion criteria and were reviewed. Anstey and colleagues (2001) examined change in memory, verbal ability, processing speed, health, sensory function, and grip strength across 2 years (1992–1994) in a sample of 1,500 persons aged 70 years and older from the Australian Longitudinal Study of Ageing. The investigators observed that after adjusting for health and demographic factors,

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only significant decline in similarity, a measure of verbal reasoning, and a composite measure of cognitive ability were predictive of mortality over 4 years. Changes in cognitive variables not related to mortality included picture naming, NART (a measure of verbal knowledge), processing speed, symbol recall, and picture recall. Hassing and colleagues (2002) examined the relationship between changes in cognition (inductive reasoning, perceptual speed, spatial abilities, and memory) and mortality in the OCTO-Twin Study. No differences in rates in change in cognitive functioning either across 2-year or 4-year preceding death were observed. In a sub-sample of the OCTO-Twin Study, Johansson and colleagues (2004) demonstrated that proximity to death was predictive decline on indicators of crystallized knowledge and verbal abilities, with some evidence of an association with working memory (i.e., digit span backward). Another study (Hassing, Small, von Strauss, 2002) examined longitudinal changes in episodic memory performance related to mortality in very old adults from the Kungsholmen Project. Longitudinal analyses comparing the 33 persons who survived compared to 10 who did not demonstrated a significant 3-year decline for both face recognition and object recall, but no evidence of differential decline as a function of mortality group. The longitudinal changes in memory preceding death were not as pronounced as the cross-sectional differences in this sample. The sample sizes were small, attrition rate was high, and there was likely a survival effect given all participants were at least 90 years old. Using the same dataset as Hassing and colleagues (2002), Small and colleagues (2003) observed accelerated decline among the decedents on tests of MMSE, episodic memory (word recall), primary memory (backward digital span), verbal fluency (category fluency), and visuospatial ability (clock drawing and clock reading, Poppelreuter’s figures). No one type of cognitive ability was more likely than another to be related to mortality. Wilson and colleagues (2003) tested the terminal change hypothesis in 763 older Roman Catholic nuns and priests without dementia at baseline and who were examined annually for up to 9 years. Using an overall global cognition measure, the investigators observed the rate of cognitive accelerated about 43 months prior to death. Terminal decline as

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observed for all domains and the rate of acceleration ranged from 33 months (for perceptual speed) to 72 months (for visuospatial ability) before death. Besides the length of annual follow-up, a novel feature of this study is that the socioeconomic status of participants was relatively homogenous throughout adulthood and old age. Since the last review, 6 studies have tested the theory of terminal change across multiple cognitive abilities and have included screening for dementia and mortality-related comorbidities. Consistency of evidence of terminal change was more apparent in these recent studies, and terminal change was reflected in most cognitive abilities. The length of the follow-up intervals were all approximately 2 years, which may be more likely to detect a significant relationship between cognitive decline and mortality. Hayden B. Bosworth

References Anstey, K., Luszcz, M. A., Giles, L. C., & Andrews, G. R. (2001). Demographic, health, cognitive, and sensory variables as predictors of mortality in very old adults. Psychology and Aging, 16(1), 3–11. Bosworth, H. B. (2001). Terminal drop. In C. A. G. Maddox, J. G. Evans, R. B. Hudson, R. A. Kane, E. J. Masoro, M. D. Mezey, L. W. Poon, & I. C. Siegler (Eds.), Encyclopedia of Aging (3rd ed.). New York: Springer Publishing. Bosworth, H. B., & Siegler, I. C. (2002). Terminal change in cognitive function: An updated review of longitudinal studies. Experimental Aging Research, 28(3), 299– 315. Fried, L. P., Kronmal R., Newman A., Bild D. E., Mittelmark M. B., Polak J. F., Robbins, J. A., & Gardin J. M. (1998). Risk factors for 5-year mortality in older adults: The Cardiovascular Health Study. Journal of the American Medical Association, 279, 585–592. Hassing, L. B., Johansson, B., Berg, S., Nilsson, S. E., Pedersen, N. L., Hofer, S. M., & McClearn, G. (2002). Terminal decline and markers of cerebro- and cardiovascular disease: Findings from a longitudinal study of the oldest old. Journal of Gerontology B: Psychological Science and Social Science, 57(3), P268–P276. Hassing, L. B., Small, B. J., von Strauss, E., et al. (2002). Mortality-related differences and change in episodic memory among the oldest old: Evidence from a population-based sample of nonagenarians. Aging Neuropsychology and Cognition, 9, 11–20.

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Johansson, B., Hofer, S. M., Allaire, J. C., MaldonadoMolina, M. M., Piccinin, A. M., Berg, S., Pedersen, N. L., & McClearn, G. E. (2004). Change in cognitive capabilities in the oldest old: The effects of proximity to death in genetically related individuals over a 6-year period. Psychology and Aging, 19(1), 145–156. Kleemeier, R. (1962). Intellectual changes in the senium. Washington, DC: American Statistical Association. Riegel, K. F. R., & Riegel, R. M. (1972). Development, drop, and death. Developmental Psychology, 6(2), 306–319.

TESTOSTERONE REPLACEMENT THERAPY See Hormone Replacement Therapy (HRT)

THANATOLOGY If biology were considered the study of life, thanatology would be the study of death. These complementary definitions have the advantage of brevity, but fall short of revealing the complexities involved. A prime motivation for the life scientists—and to the sorcerers and alchemists who preceded them— has been the desire to hold aging and death at bay (Gruman, 2003). Regarded most often as an enemy or failure, death became a marginalized theme as those in the life sciences pursued their daunting work. Meanwhile, the dynamic ascendance of science has limited thanatology largely to the realm of theology and philosophical speculation. In Western thought, the split between empirical studies of life processes and reflections on the meaning of death in human experience has tended to obscure the intimate connections between life and death. Today, however, thanatology has emerged as a multidisciplinary field of inquiry that encompasses the perspectives and methods of biomedical and social sciences and the humanities.

Historical Perspective Concern with death resonated throughout the earliest known reflections on human experience. The Sumerian Epic of Gilgamesh (Heidel, 1946), al-

ready circulating in the 2nd century B. C. E., and the 10th century Book of the Thousand and One Nights (Mathers, 1974) confronted us with the unavoidable end of our lives and works. Egyptian and Tibetan (so-called) books of the dead offered traveler’s guides for the after-death journey. It was Greek mythology that provided Metchnikoff (1903) with a name for a new science that he considered essential: Thanatos (death) was the twin brother of Hypnos (sleep). Pasteur’s distinguished successor was convinced that the study of life also required the study of death, but contributions to thanatology remained sparse for another half century. Several heuristic works did appear, such as Durkheim’s (1879/1951) analysis of suicide, Pearl’s (1922) exploration of The Biology of Death, and Frazer’s compendious if often-criticized The Fear of the Dead in Primitive Religion. By the midpoint of the 20th century, however, one could still find no textbooks, journals, or courses devoted to the study of death, and meager death content throughout the curriculum. Professionals as well as academics completed their degrees without significant exposure to the study of dying, death, grief, and related topics. In consequence, it was almost unheard of for researchers, educators, and practitioners to focus on the reduction of pain and other symptoms for terminally ill patients. It was not difficult to notice the parallel pattern of limited attention to aging and the aged. The devastation wrought by World War II impressed itself deeply on many minds, as evidenced by the newfound popularity of existential philosophy and a new willingness to break through the prevailing taboos on talking or even thinking about death. Landmark books included Shneidman and Farberow’s (1957) Clues to Suicide, Feifel’s (1959) The Meaning of Death, Choron’s (1959) Death and Western Thought, and Sudnow’s (1967) Passing On. Empirical studies started to appear with increasing frequency and Omega (1970), the first of several peer-reviewed journals, lent its support to the growing field. The Psychology of Death (Kastenbaum & Aisenberg, 1972, revised 1992 & 2000) defined a new sector of study, and The First Year of Bereavement (Glick, Weiss, & Parkes, 1974) ushered in a new era of systematic research into grief reactions. Aries (1981) contributed an illuminating historical perspective with his focus on The Hour of Our Death.

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As the 21st century started its run, thanatology had well established organizations such as the American Association of Suicidology, International association for Suicide Prevention, Association for Death Education and Practice, Befrienders International, and Last Acts, a hospice/palliative care movement with global influence, numerous peer support groups, and death education offerings in various contexts and at various levels.

Thanatologists, like gerontologists, have developed expertise in 1 or more traditional fields of scholarship and/or practice: the thanatologist who studies only death would be a curiosity. There is a terminology differential that perhaps does separate the related multidisciplinary fields of gerontology and thanatology. The useful term, “geriatrics,” denotes the application of knowledge to practice (generally in the biomedical area). By contrast, it is doubtful that many grief counselors or hospice staff would answer to the appellation “thanatrician.”

Thanatology Today Ameliorating the distress of terminally ill people and offering effective support for grieving families continues to be the central concern of thanatology. Progress has been made in palliation of pain and other symptoms associated with the dying process (Mazanec & Bertel, 2003), and the nature and function of grief is now being reconsidered on the basis of new findings and revised conceptions (Neimeyer, 2001). The concept of a “good death” is also the subject of converging cross-cultural, historical, and clinical perspectives (Kastenbaum, 2004). Researchers have also started to explore the implications of computer-mediated communications for individual and societal responses to grief (Roberts, 2003). Death anxiety remains a high priority issue for thanatologists of psychological, philosophical, and theological inclination. A salutary development here has been the articulation of theoretical positions that can be evaluated through empirical research (Tomer, 2003). Three additional emphases have also been emerging: identifying the myriad ways in which experiences and decisions in everyday life can influence the response to death-related situations (Kastenbaum, 2004); the pervasive and complex effect of sociocultural forces on every facet of death, including for example the information provided on death certificates (Peck, 2003); and the larger picture of megadeath, as threatened by war, genocide, corruption, failure of social policies, or the extinction of whole species (Rosenberg & Peck, 2003). Although directing much attention to the dying process and to the increasing mortality with age that is associated with increased longevity, thanatology cannot be defined by any one sector of its concern. Thanatology is a field of inquiry that is as broad as life itself.

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References Aries, P. (1981). The hour of our death. New York: Alfred A. Knopf. Choron, J. (1959). Death and Western thought. New York: McGraw-Hill. Durkheim, E. (1879/1951). Suicide. New York: Free Press. Feifel, H. (Ed.) (1959). The meaning of death. New York: McGraw-Hill. Frazer, J. G. (1933/1977). The fear of the dead in primitive societies. New York: Arno. Glick, I. O., Weiss, R. S., & Parkes, C. M. (1974). The first year of bereavement. New York: Wiley-Interscience. Gruman, G. J. (2003). A history of ideas about the prolongation of life. New York: Springer Publishing. Heidel, A. (1946). The Gilgamesh Epic and Old Testament parallels. Chicago: University of Chicago Press. Kastenbaum, R. (2004). On our way. The final passage through life and death. Berkeley: University of California Press. Kastenbaum, R., & Aisenberg, R. B. (1972/2000). The psychology of death. New York: Springer Publishing. Mathers, P. (Trans.) (1974). The book of the thousand and one nights. New York: St. Martins. Mazanec, P., & Bartel, J. Symptoms and symptom management. In R. Kastenbaum (Ed.), Macmillan encyclopedia of death and dying (vol. 2, pp. 864–869). New York: Macmillan Reference USA. Metchnikoff, M. E. (2003). The nature of man. New York: Putnam. Neimeyer, R. (Ed.) (2001). Meaning reconstruction and the experience of loss. Washington DC: American Psychological Association. Pearl, R. (1922). The biology of death. Philadelphia: Lippincott. Peck, D. L. (2003). The death certificate. In C. D. Bryant (Ed.), Handbook of death and dying (vol. 1, pp. 899– 908). Thousand Oaks: Sage Publishing.

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Roberts, P. (2003). Memorialization, virtual. In R. Kastenbaum (Ed.), Macmillan encyclopedia of death and dying (vol. 1, pp. 569–574). New York: Macmillan Reference USA. Rosenberg, J., & Peck, D. L. (2003). Megadeaths: Individual reactions and social Responses to massive loss of life. In C. D. Bryant (Ed.), Handbook of death and dying (vol. 1, pp. 223–235). Shneidman, E. S., & Farberow, N. L. (1957). Clues to suicide. New York: McGraw-Hill. Sudnow, D. (1967). Passing on. Englewood Cliffs, NJ: Prentice-Hall. Tomer, A. (2003). Terror management theory. In R. Kastenbaum (Ed.), Macmillan encyclopedia of death and dying (vol. 2, pp. 885–887). New York: Macmillan Reference USA.

THIRD WORLD See Population Aging: Developing Countries

THYROID GLAND Anatomy and Physiology The thyroid gland is situated in the lower anterior neck and plays a major role in regulating metabolic activity by controlling the rate of metabolism. The thyroid has an approximate weight of 20 grams and can substantially increase in size in pathologic conditions. It consists of 2 lobes joined by a thin horizontal layer of tissue called the isthmus. The thyroid gland is organized in follicles that contain a material called colloid, where thyroid hormones are synthesized. The main cellular effects of thyroid hormones are on metabolism, energy expenditure, and development. The effects of thyroid hormones include, but are not limited to, the metabolic regulation of the heart and liver, as well as bone growth and differentiation. This regulation is accomplished through the secretion of 2 main thyroid hormones, T4 (thyroxin) and T3 (triiodothyronine). Both are rich in iodine and have a similar chemical structure characterized by 2 rings. Thyroid hormones circulate in plasma, with a large portion attached to binding proteins, and a smaller portion in a free form. The lesser free hormone fraction is metabolically active. Thy-

roid hormones bind to specific receptors located in various tissues (target tissues), including the heart, skeletal muscle, and liver, where they exert their actions. Approximately 80% of T3 is produced at the level of peripheral tissues by the enzymatic conversion of T4 into T3. T3 is metabolically more potent and active than T4, which is considered by some mainly a precursor of T3. In addition, another hormone, calcitonin, is produced by the C-cells of the thyroid, which are nested among the follicles of the thyroid gland. Calcitonin plays an important role in regulating adequate blood calcium levels during growth and development and in regulating bone formation. The production and secretion of thyroid hormones is regulated by thyroid stimulating hormone (TSH), a glycoprotein. The pituitary, a gland located at the basis of the skull, and perhaps the single most important endocrine gland, synthesizes TSH. TSH production, in turn, is regulated by thyrotropinreleasing hormone (TRH), a tripeptide synthesized in the hypothalamus, a brain subregion located above the pituitary. T4 and T3 exert a negative feedback at the levels of the pituitary, the hypothalamus, and possibly higher nervous structures. Therefore, when thyroid hormone levels fall below a certain limit (set point), a compensatory surge of plasma TSH occurs, in an attempt to stimulate the thyroid gland and restore blood thyroid hormone levels. Conversely, when thyroid hormone levels increase above a certain point, TSH secretion is inhibited. In addition, various brain chemicals and neurotransmitters, such as norepinephrine and serotonin, regulate both TRH and TSH.

Aging-Associated Changes In subjects without thyroid disorders, there is an increasing prevalence of high levels of TSH with age, particularly in postmenopausal women (Schindler, 2003). In addition, normal aging is associated with slight decreases in total and free plasma T3, presently believed to be mostly the consequence of reduced conversion of T4 to T3—histopathological evidence of thyroid atrophy. A resetting to a higher level of the pituitary threshold for feedback suppression also develops in older individuals, together with an alteration of the TSH nocturnal secretion. These findings are suggestive of some degree of TRH

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hypothalamic deficiency in healthy, older individuals. Similarly, decreased levels of TRH in the paraventricular nucleus of the hypothalamus are observed in the aged male 344 Fischer rat, but not in the aged female, suggesting a gender specificity of this aging-related phenomenon (Cizza et al., 1992; Cizza et al., 1995; Cizza et al., 1996). Although human aging is also often associated with and increased prevalence of thyroid autoantibodies, very elderly individuals (healthy centenarians) do not have an increased prevalence of these antibodies, suggesting that the increase may not be the consequence of the aging process itself, but may rather be related to age-associated disease. More recently, a novel role for the hypothalamic-pituitary-thyroid (HPT) axis in maintaining homeostasis during stress has emerged. Acute immobilization stress results in an inhibition of the HPT axis, which is in part mediated at the level of the hypothalamic TRH. Such stress-induced inhibition of the HPT axis is attenuated in both aged male and female rats. However, the significance of these findings and their relevance to human physiology is unclear (Mariotti, Franceschi, Cossarizza, & Pinchera, 1995).

Pathology All thyroid diseases, including cancers, are encountered in older adults, but their prevalence and clinical expression differ from those observed in younger persons. The clinical interpretation of thyroid function tests is also more difficult in older individuals, because of aging-associated changes in thyroid function, frequent alterations secondary to non-thyroidal illnesses, and concomitant use of medications. The thyroid gland may cause pathology by producing inadequate or excessive levels of thyroid hormones, hypothyroidism or hyperthyroidism, respectively, and are the 2 major causes of thyroid disorders. In both conditions, symptoms are largely independent of the underlying cause. TSH is a growth factor for the thyroid gland, which explains why in certain pathological conditions this gland can dramatically increase its size to the point when it may cause compression to the surrounding structures. As iodine is essential to the formation of thyroid hormones, severe iodine deficiency can result in massive thyroid enlargement (goiter) and hy-

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pothyroidism. Finally, although the thyroid is an uncommon site of cancers, cancer may arise from the thyroid tissue and tend to have a more aggressive clinical course in older individuals.

Clinical Manifestations The thyroid gland manifests a wide range of action of thyroid hormones and plays an important role between the endocrine system and aging. In all age groups, there is a significant degree of overlap between the nonspecific symptoms caused by thyroid dysfunction and those attributed to common conditions (i.e. depression, fatigue, or insomnia). This overlap is far more common in older individuals in whom these manifestations can be subtle, atypical, and often hidden by other conditions. Therefore, the diagnosis of thyroid dysfunction requires a high degree of clinical differentiation. It is of importance that even mild thyroid failure can have a number of clinical effects such as depression, memory loss, cognitive impairment, and a variety of neuromuscular complaints. A recent study (the Maastricht Aging Study) of an association between TSH levels and cognitive performance in a healthy aging population demonstrated the existence of an association between TSH levels and verbal memory in a healthy population of older men and women (Van Boxtel, Menheere, Bekers, Hogervorst, & Jolles, 2004).

Diagnosis Under most circumstances, an abnormal plasma TSH is a reliable indicator of thyroid disease because T4 and T3 secretion is tightly regulated by the pituitary gland. TSH is readily measured in the blood and constitutes the best screening test for thyroid pathology in conjunction with measurements of thyroid hormones free fraction. Low plasma levels of T3 and/or T4 and high plasma levels of TSH characterize the most common form of hypothyroidism, caused by a hypofunction of the thyroid gland, or primary hypothyroidism. Conversely, elevated levels of the free and total fractions of T3 and T4, and decreased “suppressed” TSH levels, characterized primary hyperthyroidism. The most prevalent cause of hypothyroidism in developed countries is chronic autoimmune thyroiditis. In this disorder, autoantibodies against the thyroid are responsible for injury

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to the gland, resulting in hypothyroidism. Autoimmune thyroiditis is more frequent in older individuals, particularly women. Autoantibodies stimulating the thyroid may also cause hyperthyroidism, a condition known as Flajani-Basedow-Graves disease. There is a close relation between Graves disease and autoimmune thyroiditis; both are seen as the opposite ends of the spectrum of a single dysfunction of the autoimmune response. In Graves disease, other autoantibodies may induce protrusion of the ocular globes (exophthalmos), as well a rare skin condition called pretibial myxedema. Hyperthyroidism may also be difficult to recognize, particularly in the older population, for reasons referred to as “apathetic” hyperthyroidism. Finally, osteoporosis, mood disorders, insomnia, or unexplained weight loss may also be among the presenting symptoms. Thyroid nodules are commonly found in the elderly during a clinical routine examination and are frequently asymptomatic. Although most thyroid nodules are benign, approximately 5% to 10% can be malignant. Malignant nodules can be readily diagnosed with fine needle biopsy, a safe and reliable procedure that should be performed whenever there is a clinical suspicion of thyroid malignancy. Papillary carcinoma tends to be more aggressive in the elderly, particularly in men over age 60. Other thyroid cancers include follicular thyroid cancer, medullary, and anaplastic carcinoma. Iodine deficiency disorders are one of the most common causes of thyroid enlargement (goiter) and hypothyroidism in underdeveloped countries. Iodine prophylaxis has virtually eradicated such disorders in any age range, including the elderly, in those countries in which iodine deficiency is prevented by iodination of salt, water, or other forms of iodine supplementation.

Current Treatments The treatment of thyroid disease in older patients often deserves special attention due to the increased risk of complications. Once properly recognized, hypothyroidism is treated by oral administration of a synthetic thyroid hormone. Antithyroidal drugs, radioactive iodine, or surgery can cure hyperthyroidism. Malignant thyroid cancers are treated by thyroidectomy, followed by oral administration of ablative doses of radioactive iodine.

The adverse effects of depression, memory loss, cognitive impairment, and a variety of neuromuscular complaints can be improved or corrected by L-thyroxine replacement therapy, and such treatment has been found to be cost-effective. However with time, overt hypothyroidism can develop. Therefore, routine screening of thyroid function in the climacteric period to determine subclinical thyroid disease is recommended. Since aging in healthy people seems to be associated with a mild decrease in thyroid function, this poses the question whether healthy older people may benefit from the administration of thyroid hormone. Such benefits, however, should be carefully weighted against the potential toxicity of thyroid hormones at the level of heart, bone, and other organs. In the future, selective analogs of thyroid hormones carrying beneficial clinical effects, that lack undesirable cardiovascular, bone-related, or other toxicities, may be developed. In addition, further understanding of the autoimmune phenomena may guide the development of novel pharmacological agents capable of modulating the immune system and limiting the insurgence of thyroidal, as well as non-thyroidal, autoimmune diseases.

Conclusions In summary, the aging thyroid is associated with morphological and functional changes at various levels of the HPT axis, but the extent to which these changes are dependent on the aging process or on age-associated thyroidal or non-thyroidal diseases is up for debate. Thyroid diseases in older persons may frequently have a subtle clinical presentation, go frequently unrecognized, and/or be mislabeled as part of the “normal” aging process. A high degree of clinical suspicion in older individuals may facilitate an early diagnosis. Finally, the degree to which the benefits of hormone replacement therapy to older individuals, or whether prolonged variability in thyroid function can reliably be associated with cognitive change overtime, should be investigated through longitudinal studies on large cohorts of older individuals. Nina S. Sonbolian Alejandro R. Ayala Giovanni Cizza

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References Braverman, L. E., & Utiger, R. D. (1991). Werner and Ingbar’s: The thyroid (6th ed.). Cizza, G., Brady, L. S., Bagdy, G., Calogero, A. E., Lynn, A. B., Kling, M. A., Blackman, M. R., Chrousos, G. P., & Gold, P. W. (1992). Central hypothyroidism is associated with advancing age in male fischer 344/N rats: In vivo and in vitro studies. Endocrinology, 131, 2672–2680. Cizza, G., Brady, L. S., Esclapes, M., Blackman, M. R., Gold, P. W., & Chrousos, G. P. (1996). Age and gender influence basal and stress-modulated hypothalamicpituitary-thyroid function in Fischer 344/N rats. Neuroendocrinology, 64, 440–447. Cizza, G., Kvetnansky, R., Brady, L. S., Fukuhara, K., Bergamini, E., Blackman, M. R., Chrousos, G. P., & Gold, P. W. (1995). The stress-induced inhibition of the hypothalamic-pituitary-thyroid axis is attenuated in the aged fisher 344N male rate. Neuroendocrinology, 62, 506–513. Mariotti, S., Franceschi, C., Cossarizza, A., & Pinchera, A. (1995). The aging thyroid. Endocrine Reviews, 6, 686–715. Schindler, A. E. (2003). Thyroid function and postmenopause. Gynecological Endocrinology, 17, 79–85. Van Boxtel, M. P., Menheere, P. P., Bekers, O., Hogervorst, E., & Jolles, J. (2004). Thyroid function, depressed mood, and cognitive performance in older individuals: The Maastricht Aging Study. Psychoneuroendocrinology, 29, 891–898.

TOUCH All of the sensory systems suffer deficits to one degree or another as an accompaniment to advancing years, and the sense of touch is no exception. As people grow older, there is a gradual loss of the capacity to feel a mechanical stimulation imposed upon the surface of the skin. This loss does not have the dramatic quality associated with the loss of sight or hearing, resulting in blindness or deafness. As a consequence, the funding and research efforts invested in the study of somatosensation pales in comparison to that of visual and auditory research. Recently, however, there has been a resurgence of interest in the sense of touch, partly because of the serious attempts to use the skin as a substitute channel of communication in place of sight and hearing. Another factor that has contributed to the renewed interest in tactile research is simply the fact that people are

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living longer. As the percentage of the population in this older group increases, the financial burden of sensory loss upon the individual and upon society becomes more acute. In addition the impact of these deficits upon the quality of life of the elderly cannot be ignored. Many of the early studies of the sense of touch reported a decline in tactile sensation with aging. Although the methods used in these investigations are considered crude by today’s standards, their results were consistent (Verrillo & Verrillo, 1985). With few exceptions both clinical and laboratory observations reported a decline in the ability to feel a mechanical distortion of the skins surface. The more quantitative methodologies of the modern laboratory have yielded a more precise and detailed picture. Plumb and Meigs (1961), who were first study to use modern techniques to study the effects of aging upon tactile sensitivity, reported a gradual loss of the ability to feel vibrations at the fingertip between the ages of 20 and 70 years. Goff and colleagues (1965) obtained a similar result but found that the loss in women started in the early 20s whereas in men the decline commenced in the late 40s. Between 1965 and 1977 a scattering of publications reported a loss of sensation with age, but in most of these the methods were so lacking and the documentation so poor that the validity of the results may be questioned. In a study that used stateof-the-art instrumentation and adequate laboratory controls, Verrillo (1977) reported a loss of sensitivity on the hand at frequencies between 40 and 600 Hz at the rather early ages of between 10 and 20 years. This finding was subsequently verified by Frisina and Gescheider (1977). However, at 25 Hz there was no loss of sensitivity, which would indicate that it is primarily the tactile channel mediated by Pacinian corpuscles that is affected by aging. The tactile systems activated optimally by lowfrequency vibrations (below 40 Hz) are observed by non-Pacinian receptors that appear not to be affected by aging (see Bolanowski, Gescheider, Verrillo, & Checkosky, 1988, for a detailed analysis and discussion). In later experiments Verrillo (1979, 1980) found a progressive loss of sensitivity on the hand between ages 10 to 65 years, again with no loss at frequencies. A study reported by Muijser (1990) corroborated these results. All of the studies were performed on groups of subjects, usually matched within groups for age, gender, and the like. Verrillo

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in 1980 had the unique opportunity to examine the same individuals twice, once at age 10 and again at age 23 years. In this longitudinal study the loss of sensitivity was sustained at higher frequencies, with no loss at the lower frequencies. There was no difference between males and females in these studies. All of the systematic and carefully controlled experiments of threshold tactile sensitivity to date have provided a uniformity of evidence that advancing age does have a negative effect upon that sensitivity at stimulus frequencies that optimally activate the Pacinian end organs, but not in the frequency region (low) where non-Pacinian receptors are activated (Gescheider, Beils, Bolanowski, Checkosky, & Verrillo, 1994a; Gescheider, Bolanowski, Hall, Hoffman, & Verrillo, 1994b; Gescheider, Valetutti, Padula, & Verrillo, 1992; Gescheider, Edwards, Lackner, Bolanowski, & Verrillo, 1996; Verrillo, 1977a, 1977b; 1979, 1980, 1982, 1993). The reason that the Pacinian system shows negative changes with age is not known. An educated guess is that the end organs themselves undergo morphological changes and a reduction in their total neurons with age (Cauna, 1965). So far all of the results pertain to the detection thresholds of vibrotaction. Since we live in a suprathreshold world, it becomes necessary to examine the changes that may occur when the stimulation is delivered at above threshold levels. Verrillo and colleagues (2002) compared a younger (age 23 years) with an older (age 68) group of subjects in their performance in estimating the subjective magnitude of vibrations. Using the method of Absolute Magnitude Estimation (Hellman & Zwislocki, 1961; Zwislocki & Goodman, 1980) it was shown that the older subjects experienced the sensation as less intense (indicating a deficit) than the younger subjects at every level of the physical intensity of the stimulus. Consistent with the detection-threshold results, the data revealed that this effect appeared only at stimulus frequencies that activated primarily the Pacinian receptor system; the non-Pacinian systems appeared not to be affected. It may be concluded on the basis of the experimental evidence that the aging process has a negative effect on the sense of touch. To what might we attribute to this? Bolanowski and Verrillo (1982) examined the possible link between skin temperature and tactile sensitivity. This factor was studied

because of a British population survey that found significantly lower skin surface and core body temperature in persons over age 65 (Fox, Woodward, Exton-Smith, Green, Donnison, & Wicks, 1973). Bolanowski and Verrillo found that lowered temperature of the skin’s surface did indeed lower the sensitivity to vibration, but only in the Pacinian receptor system. It may be implied that skin surface and or core body temperature may be a factor in the decreased tactile sensitivity of older people. But what of other variables? Is the observed decline of sensitivity with age due to changes in the receptor end organs, to the nerve fibers carrying impulses to the central nervous system, to the blood supply at the periphery or at more central sites, or perhaps to changes in the chemical environment of the entire nervous system? simply do not know which of one or combination of these possibilities is the answer, because changes related to the process of aging have been reported for all of these factors. Ronald T. Verrillo

References Bolanowski, S. J., & Verrillo, R. T. (1982). Temperature and criterion effects in the somatosensory system: A neurophysiological and psychophysical study. Journal of Neurophysiology, 48, 837–856. Bolanowski, S. J., Gescheider, G. A., Verrillo, R. T., & Checkosky, C. M. (1988). Four channels mediate the mechanical aspects of touch. Journal of the Acoustical Society of America, 84, 1680–1694. Cauna, N. (1965). The effects of aging on the receptor organs of the human dermis. In W. Montagna (Ed.), Advances in biology of skin: Aging (vol. 6, pp. 63– 96). New York: Pergamon. Fox, R. H., Woodward, P. M., Exton-Smith, A. N., Green, M. F., Donnison, D. V., & Wicks, M. H. (1973). Body temperature in the elderly: A national study of physiological, social, and environmental conditions. British Medical Journal, 1, 200–206. Frisina, R. D., & Gescheider, G. A. (1977). Comparison of child and adult vibrotactile thresholds as a function of frequency and duration. Perception and Psychophysics, 22, 100–108. Gescheider, G. A., Beils, E. J., Bolanowski, S. J., Checkosky, C. M., & Verrillo, R. T. (1994a). Effects of aging on information-processing channels in the sense of touch: II. Temporal summation in the P channel. Somatosensory and Motor Research, 11, 359–365.

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Transportation Gescheider, G. A., Bolanowski, S. J., Hall, K. L., Hoffman, K. E., & Verrillo, R. T. (1994b). Effects of aging on the information-processing channels in the sense of touch: I. Absolute sensitivity. Somatosensory and Motor Research, 11, 345–357. Gescheider, G. A., Edwards, R. R., Lackner, E. A., Bolanowski, S. J., & Verrillo, R. T. (1996). The effects of aging in the information-processing channels in the sense of touch: III. Differential sensitivity to changes in stimulus intensity. Somatosensory and Motor Research, 13, 73–80. Gescheider, G. A., Valetutti, A. A., Jr., Padula, M., & Verrillo, R. T. (1992). Vibrotactile forward masking as a function of age. Journal of the Acoustical Society of America, 91, 1690–1696. Goff, G. D., Rosner, B. S., Detre, T., & Kennard, D. (1965). Vibration perception in normal man and medical patients. Journal of Neurology, Neurosurgery, Psychiatry, 18, 503–509. Hellman, R. P., & Zwislocki, J. J. (1961). Some factors in the estimation of loudness. Journal of the Acoustical Society of America, 33, 687–694. Plumb, C. S., & Meigs, J. W. (1961). Human vibration perception: Part I. Vibration perception at different ages. Archives of General Psychiatry, 4, 611–614. Verrillo, R. T. (1977). Comparison of child and adult vibrotactile thresholds. Bulletin of Psychonomic Society, 9, 197–200. Verrillo, R. T. (1979a). Change in vibrotactile thresholds as a function of age. Sensory Processing, 3, 49–59. Verrillo R. T. (1979b). Changes in vibrotactile threshold and suprathreshold responses in men and woman. Perception and Psychophysics, 26: 20–24. Verrillo, R. T. (1980). Age-related changes in the sensitivity to vibration. Journal of Gerontology, 35, 185–193. Verrillo, R. T. (1982). Effects of aging in the suprathreshold responses to vibration. Perception and Psychophysics, 3, 61–68. Verrillo, R. T. (1993). The effects of aging on the sense of touch. In R. T. Verrillo (Ed.), Sensory research: Multimodal perspectives (pp. 260–275). Hillsdale, NJ: Lawrence Erlbaum. Verrillo, R. T., Bolanowski, S. J., & Gescheider, G. A. (2002). Effects of aging on the subjective magnitude of vibration. Somatosensory and Motor Research, 19, 238–244. Verrillo, R. T., & Verrillo, V. (1985). Sensory and perceptual performances. In N. Charness (Ed.), Aging and human performance (pp. 1–46). New York: John Wiley. Zwislocki, J. J., & Goodman, D. A. (1980). Absolute scaling of sensory magnitude. Perception and Psychophysics, 28, 28–30.

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TRANSPORTATION The private automobile continues to be the main source of transportation in the United States. It is the primary way people gain access to services and maintain social relationships, and continuing to drive is a major factor in avoiding social isolation and maintaining full participation in community life (Sterns, Burkhardt, & Eberhard, 2003). Higher levels of mobility are being experienced by the increasing numbers of older adults. In 1997, nearly 92% of all men and 70% of women over age 60 years had a driver’s license. Over the next 15 years in the United States, almost all adults aged 65 years and older will have a license; by 2012, almost every man and 9 out of 10 women will be licensed drivers (Rosenbloom, 2004). While over three-fourths of older adults maintain their levels of driving until age 75, by ages 80 to 84, the percentage drops to 57%; by ages 85 to 90 years it is 37%. At age 90 and older, only 27% of older adults continue to drive. Thus, many older adults outlive their ability to drive. For the elderly who do not drive, a major issue is how to keep persons involved in their desired activities through alternative forms of transportation that allow them to get where they want to go, when they want to go. The means of transportation used by older adults can be characterized along a continuum from personal independence and choice to dependence. Private transportation modes include walking and automobile trips. Public transportation includes fixed-route and door-to-door services. In addition, taxi companies and social service agencies provide transportation services. Many communities provide formal older adult or special adult transportation with private and/or public funds for specific services, based on the premise that door-to-door transportation service is the cornerstone of the elderly person’s access to community medical and social services (Sterns & Sterns, 2000). Public transportation options for older adults have been recently addressed by the Transportation Cooperative Research Program Report 82 (Burkhardt et al., 2003), Improving Transit Options for Older Persons. Trips out of home by older adults are increasing dramatically, and most trips are in private autos. Today’s older adults use public transit for about 3% of their trips. Fewer than 12% of

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all older adults have used public transportation in the past 12 months. There is no public transportation system for 34.3% of older adults in the United States.

Travel Trends Over 24 million licensed drivers are aged 65 and older, and this number is expected to double by the year 2030. The number of drivers aged 85 and older, numbering close to 1 million, will be 4 to 5 times greater in 2030. There has been substantial increase in travel by older adults. Recent comparisons of driving activity between 1983 and 1995 show that older adults are increasing their travel activity; in 1995, older adults made 77% more vehicle trips, spent almost 40% more time driving, and drove 99.6% more miles compared to older adult drivers in 1983 (Rosenbloom, 2004). In 2003, 5,309 people aged 70 years and older died in motor vehicle crashes. This is a 41% increase over 1975; however, this is 10% less than in 1997. Drivers aged 70 years and older were 10% of the people holding licenses and were involved in 10% of passenger vehicle fatal crashes. By 2030, it is estimated that older adults aged 70 years and older will represent 18% of the licensed age population, and 19% of the drivers of passenger vehicles involved in fatal crashes. At ages 70 to 74 years, motor vehicle deaths begin to rise and continue to rise steeply throughout the rest of the lifespan; female death rates rise at a slower rate from ages 70 to 84. Based on data collected in 2001 to 2002, drivers aged 80 years and older had higher rates of passenger vehicle fatal crash per mile driven than all other age groups except teenagers. Drivers aged 85 years and older had the highest rates, according to the Insurance Institute for Highway Safety.

Types of Transportation Services Health care and social service agencies, transportation service providers, and the government services are searching for ways to develop or refine local transportation for older people. In this period of constrained resources, transportation services will depend on coordinated resources and

cooperation at the local and regional level. Programs and procedures for delivering transportation services will need to use traditional as well as innovative approaches. The Beverly Foundation has developed the five A’s of senior-friendly transportation: availability (transportation exists when needed), accessibility (transportation can be reached and used), acceptability (transportation is clean and user friendly), affordability (transportation is affordable), and adaptability (transportation can be modified or adjusted to meet special needs) (Kerschner, 2003). Fixed-Route Services. Most public transportation systems provide fixed-route services, using buses, trains, or trolleys to travel along predetermined routes with preset vehicle stops at predetermined locations. Passengers who use fixed-route services, compared to those who use special services, tend to display the higher levels of functional ability and independence that this form of travel requires. The percentage of people in a service area estimated to use fixed-route services range from 5% in small- to medium-size cities, to 53% of the population in New York City and 36% In Washington, D.C. (Stems, Nelson, Sterns, Fleming, Brigati, McLary, et al., 1997). Public transportation trips made by older adults has increased about 22% from 1990– 1995 (Nationwide Personal Transportation Survey, 1995). Special Transportation Services. Federal Transit Administration (FTA)-funded services. Transportation providers receiving federal funding are required to make “special efforts” for people with disabilities, such as frail elderly. Offerings include paratransit (door-to-door, demand-responsive) services and fares, equipping all buses with lifts for wheelchair accessibility, and providing Americans with Disabilities Act (ADA) special services, which complement fixed-route services. 1. Historically, many public transit systems have developed special services for older adults and people with disabilities rather than purchase accessible buses for fixed-route service. Special transportation services are demand-responsive. Whereas fixed-route services travel in a predetermined manner, special transport service is individually tailored to each rider and provides

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curb-to-curb or door-to-door service. Riders are able to request service at times that are convenient to them, rather than at times predetermined by the transportation provider. An estimated 10% to 20% of eligible older adults—or about 5% to 10% of all older adults—use such special services. 2. Department of Health and Human Services (HHS)-funded services. Social service agencies funded by the Older Americans Act or by other agencies at the state, regional, and local levels using funding from the Department of Health and Human Services may also provide special transportation services. Generally, use of such services is limited to agency clients. 3. Complementary paratransit. With the passage of the ADA in 1990, about 530 public transportation systems were mandated to provide complementary special services by January 1997. ADA regulations require individuals to meet specific criteria, based on disability, to be eligible for complementary paratransit services. Age itself is not among the criteria. 4. The majority of pre-ADA special transportation users have been older adults who, transit operators believe, will be considered ineligible by new ADA screening and certification procedures. With special transportation funding limited, transit operators believe current older adult riders will be displaced by the influx of many new riders with disabilities who will meet the eligibility criteria.

Service Routes. Service routes represent an alternative service between fixed-route and special service in a range of transportation services. Service routes circulate in neighborhoods, taking people from conveniently located bus stops close to their homes to relatively close-by and conveniently located neighborhood shopping centers and medical facilities. Positioned between pre-established fixedroute inflexibility and individually tailored door-todoor service, service routes provide passengers with greater travel choices and convenience than fixed routes and more independence and autonomy than special services. Less expensive to run than special service, these routes can provide cost savings to transportation operators (Stems, Nelson, Sterns, Fleming, Brigati, McLary, et al., 1997).

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Barriers to Transportation Use Age-related changes in physical performance and functioning create difficulties that affect older adults’ use of different transportation modes. For many older adults, changes in vision, range of movement, and cognition may pose significant barriers to and risks in driving their own vehicles, walking, and/or using fixed-route transportation services. The ability of drivers aged 55 and older to read traffic signs, see clearly at night, turn their heads while backing, reach safety belts, read instrument panels, and merge into high-speed traffic declines compared to that of drivers aged 35 to 45. Drivers aged 55 to 65 years are the safest on the road, but after age 75 collision rates increase. Those aged 75 and older are the second most likely (after those aged 15–19) to be involved in fatal crashes. In 1993 pedestrians aged 70 and older accounted for 18% of all pedestrian fatalities, a rate twice that of all ages. More than 1 of 6 pedestrian deaths and injuries among older adults occur when they are crossing or entering an intersection. Fixed-route transportation services pose disadvantages to older adults due to the infrequency, inflexibility, and complexity of service; the physical design and operating characteristics of the system; the difficulty in reading and understanding schedules, maps, and details of system operation; and the cost of service. New approaches have been developed to help transportation providers improve service delivery to meet the needs of older adults. Examples include local coordination of community transportation services for flexibility in service provision, mobility training to assist older adults in learning how to use the transportation system, and the use of low-floor buses without steps for ease in getting on and off transportation vehicles. Harvey L. Sterns Ronni S. Sterns See also Driving

References Insurance Institute for Highway Safety. Fatality Facts 2003: Older People. Centers for Disease Control and Prevention. (1994). National Health Interview Survey. Washington, DC: U.S. Government Printing Office.

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Kerschner, H. (1995). A low-cost, low-maintenance approach: The Pasadena PassRide Pilot. Nationwide Personal Transportation Survey. Washington, DC: U.S. Government Printing Office. Sterns, H. L., Burkhardt, J. E., & Eberhard (2003). Moving along the mobility continuum: Past, present and future. In J. Finn & H. L. Sterns (Eds.), The mobile elder: Getting around in later life. Generations: Journal of the American Society on Aging, pp 8–13. Sterns, R., Antenucci, V., Nelson, C., & Glasgow, N. (2003a) Public transportation: Options to maintain mobility for life. Sterns, R., Antenucci, V., Nelson, C., & Glasgow, N. (2003b). Public transportation service models. Sterns, H. L. & Sterns, R. (2000). Commentary: Social Structures and processes in public and private transportation. In K. W. Schaie, & M. Pietrucha (Eds.), Mobility and transportation in the elderly. New York: Springer Publishing. Sterns, R., Nelson, C., Sterns, H. L., Fleming, J. C., Brigati, P., McLary, J., & Stahl, A. (1997). Public transportation in an aging society: The potential role of service routes. Washington, DC. AARP.

TUBERCULOSIS Tuberculosis (TB) is an ancient disease but one that, throughout history, has exacted a toll in terms of both morbidity and mortality. TB is a communicable, chronic bacterial disease caused by tubercle bacilli, most commonly Mycobacterium tuberculosis. In the United States in 1986, the number of reported TB cases per year showed an increase for the first time since record keeping began in 1953. This upward trend was visible until 1992, when an overall decline was seen to occur in the United States, a trend that has continued through 2004, when the most recent statistics available. However, the declines from 2002 to 2003, and from 2003 to 2004, were the smallest annual decreases in the past 10 years (Centers for Disease Control and Prevention, 2004b; 2005). Globally, the picture is somewhat different. In 1993 the World Health Organization declared TB a global emergency, and has focused various target goals that include halving the prevalence and death rates of TB, detecting 70% of new infectious TB cases, and curing 85% of those detected by 2005 (World Health Organization, 2004). Worldwide, about 8 million to 9 million new TB cases occur annually, about half of which are

reported (Frieden, Sterling, Munsiff, Watt, & Dye, 2003; World Health Organization, 2004). Increases have occurred in sub-Saharan Africa and parts of Asia such as India, China, Indonesia, Bangladesh, and Pakistan, as well as countries of the former Soviet Union (Frieden, Sterling, Munsiff, Watt, & Dye, 2003; World Health Organization, 2004). The latter have a high proportion of multidrugresistant TB (MDR-TB) (Schluger, 2002). There are a variety of factors associated with high rates of TB, the importance of which vary in developed versus undeveloped countries, including: high rates of HIV infection (since co-infection is relatively common);overcrowding; poor nutrition; the high cost of drugs used to treat TB; difficulties in maintaining adherence to TB treatment plans; erratic treatment; lack of access to knowledgeable practitioners and supplies; and inadequate funding for TB control programs, resulting in inadequate surveillance, contact tracing, and follow-up of patients. Older adults have been said to constitute the biggest reservoir for TB in the United States (Stead, 1998). Early in the 20th century, TB prevalence was high, and most of today’s elderly Americans had been infected by age 30 years. The majority of TB cases in older adults are therefore the result of endogenous reactivation of a previous latent infection, but some are due to acquisition of new infection (Zevallos & Justman, 2003). Some of the factors believed to increase the risk for developing TB in older adults include: the decline in immunity related to old age; inadequate nutrition; the presence of chronic illnesses such as diabetes mellitus, chronic renal failure, and malignancies; use of immunosuppressive medications such as corticosteroids; and emotional stress. The TB case rate among older persons in nursing homes is estimated to be at least twice as high as in comparable communitydwelling persons (Strausbaugh, Sukumar & Joseph, 2003; Zevallos & Justman, 2003). Reasons for this include that persons in nursing homes tend to be older and not in as good health as their counterparts who live at home, and nursing homes and long-term care facilities represent relatively closed environments with conditions that facilitate the spread of diseases such as TB. Persons aged 65 years or older have a disproportionately high share of TB-related mortality (Zevallos & Justman, 2003).

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Epidemiology and Older Adults In 2003, the overall TB case rate per 100,000 population for all ages and races regardless of sex was 5.1, which was a decrease from the previous year but exceeded the national goal of 3.5 per 100,000 for the year 2000. For all races regardless of sex, in those aged 65 years and older, the TB case rate was 8.4 per 100,000. Those aged 65 years and older account for about 13% of the population of the United States (Zevallos & Justman, 2003); in 2003, about 20% of all TB cases occurred in this group, thus proving disproportionately high (Centers for Disease Control and Prevention, 2004b; Zevallos & Justman, 2003). The median age of persons with TB has been decreasing since 1992 for many reasons, including HIV co-infection and immigration of persons born in countries where HIV is endemic. However, as the younger cohort of those who now have TB age, a second emergency may again be seen in the future when they are older (Davies, 1999).

Transmission and Infection The major route of TB transmission is from person to person through inhalation of airborne droplet particles containing M. tuberculosis. Pulmonary TB is the most common type seen in the Unites States. Transmission through ingestion of contaminated food or drink or direct inoculation are rare in the United States. Many factors determine whether tuberculous infection is acquired by the exposed person, including: those relating to the host, such as genetic susceptibility; those relating to the organism, such as virulence; and those relating to the environment, such as the length of time and proximity of contact between the susceptible person and the person with active TB. Those who “share air,” for example in congregate living facilities such as nursing homes, particularly in an enclosed space, with a person who has active TB over a long period have a greater risk of acquisition. The sequence of events that occurs after M. tuberculosis enters the body is complicated, not completely understood, and dependent on adequate immune function to sequester the tubercle bacilli. If tuberculous infection occurs, it usually (90% of the time) does not progress to tuberculosis but remains dormant in a latent form. In the other 10% of cases, infection may progress to

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clinical disease within a year or 2 (5%), or this progression may occur years later (5%). Various factors influence whether infection is contained and controlled (Frieden, Sterling, Munsiff, Watt, & Dye, 2003; Luna, 2004). It is important to understand the difference between latent TB infection (LTBI), and TB, the disease. Persons who have living tubercle bacilli present without clinically active disease are said to have latent TB infection. These individuals: (1) have tubercle bacilli in their body; (2) are usually infected for life; (3) usually have a positive reaction to the tuberculin skin test; (4) are not infectious to others; (5) usually have a negative chest radiograph; (6) do not usually have clinical symptoms of tuberculosis; (7) usually have negative sputum smears and cultures for tubercle bacilli; (8) may be at risk for contracting tuberculosis, particularly if their immune system is compromised; and (9) may be candidates for preventive therapy. Persons who have active pulmonary tuberculosis: (1) are infected with M. tuberculosis, (2) usually have a positive reaction to the tuberculin skin test, (3) usually have clinical symptoms, (4) usually have positive sputum smears and/or cultures for tubercle bacilli before therapy has begun, and (5) may be infectious to others before treatment is effective (Centers for Disease Control and Prevention, 2004a).

Symptoms, Detection, Diagnosis, and Treatment The major symptoms of pulmonary TB can be nonspecific, and the most common presentation is insidious, with the gradual development of vague symptoms, but presentation may be acute. Common signs and symptoms for active disease that are variable in severity and may or may not be present can include: cough, usually productive, that has lasted more than 2 weeks; fatigue or malaise; anorexia; weight loss; fever, either low grade or intermittent; sweating and/ or chills at night; and chest tightness. In extrapulmonary TB, symptoms are related to the organ system affected (Schluger, 2002). The usual method for detecting latent TB infection is through targeted tuberculin skin testing using purifed protein derivative (PPD) although a newer ELISA-based blood assay has become available but not widely used (Zevallos & Justman, 2003). Guidelines for interpreting the

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test rely on what is known about the person’s medical condition and risk (American Thoracic Society, 2000). Because the tuberculin skin test depends on delayed-type hypersensitivity, which may wane over time, false negative tests due to anergy (an inability to mount an immune response) may influence testing, so that a negative reaction does not rule out LTBI or TB disease. Anergy is more common in older adults, and a two-step tuberculin skin test may be used (Zevallos & Justman, 2003). Sputum smears and culture for acid-fast and tubercle bacilli are part of the diagnostic work-up for pulmonary TB and are important in monitoring the response to therapy in those with clinical disease. The chest radiograph is one of the important diagnostic tools, but older persons may often show atypical findings (Zevallos & Justman, 2003; Luna, 2004). If LBTI is identified in an HIV-negative person, then a course of therapy to prevent active TB disease is recommended, and various options are available. One option is for isoniazid (INH) therapy, and another is for rifampin and pyrazinamide for a shorter period of time (American Thoracic Society, 2000). For those with drug-susceptible disease who are HIV-negative, there are 4 options of recommended initial treatment, most including isoniazid, rifampin, pyrazinamide, and ethambutol (Centers for Disease Control and Prevention, 2003). Detailed current treatment recommendations for pulmonary and extrapulmonary TB under various conditions such as co-infection with HIV, and liver disease as well as infection with resistant strains may be found in the reference by Centers for Disease Control and Prevention (2003). To assure adherence, directly observed therapy has found favor, and devices such as medication monitors have been used, but such devices can prove challenging to the elderly.

Clinical Manifestations in Older Adults The diagnosis of TB in the older person is often delayed or missed. In the elderly, clinical symptoms of TB may be missed because they may also be explained by other medical problems that are common in the older person, the person may be relatively asymptomatic, or symptoms may be atypical or nonclassical (Strausbaugh, Sukumar, & Joseph, 2003). For example, Norman (2000) notes that fever may be absent or blunted in 20% to 30% of the time in the elderly. “Failure to thrive” in the elderly might

actually result from unrecognized TB (Zevallos & Justman, 2003). Other illnesses mimicked by TB include pneumonia, malignancies, or congestive heart failure with pleural effusion. Sometimes it is difficult to elicit a clear history or problem description from elderly persons, especially if there are communication difficulties from medications or for other reasons. In extrapulmonary TB, where diagnosis may be difficult anyway, it can be even more problematic in the older person. For example, in meningeal TB, the headache, confusion, and dizziness can go unrecognized or be mistaken for other conditions or medication effects. Difficulty in recognition can result in continued transmission.

Treatment in Older Adults Treatment in older adults should be as simple as possible while maintaining adequacy according to current recommended standards. Elderly persons may not receive adequate treatment for a variety of reasons, such as the problems in accessing health care due to limited finances, and mobility and functional problems that make travel and transportation difficult, especially if they live in rural areas. The treatment plan should consider the older person’s vision, memory, and mental clarity as important in being able to adhere to the treatment. Directly observed therapy by a clinician or family member or other person may have to be arranged. In choosing medication, it is also important to think about the potential of adverse drug reactions, as well as interactions with other medications and with any other disease process. Side effects and adverse medication effects should be looked for carefully. Of particular concern is the potential for effects of drugs on the liver. The use of complicated devices for medication may actually have a negative effect on older persons who have a decline in physical function or in memory. Felissa R. Lashley

References American Thoracic Society. (2000). Targeted tuberculin testing and treatment of latent tuberculosis infection. American Journal of Respiratory and Critical Care Medicine, 161, S221–S247. Centers for Disease Control and Prevention. (2005). Trends in tuberculosis—United States, 2004. Morbidity and Mortality Weekly Report, 54, 245–249. Centers for Disease Control and Prevention. (2004a).

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Tumor Suppression Questions and answers about tuberculosis. Atlanta: Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. (2004b.). Tuberculosis in the United States. National surveillance system highlights from 2003. Atlanta: Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. (2003). Treatment of tuberculosis. American Thoracic Society, CDC, and Infectious Diseases Society of America. Morbidity and Mortality Weekly Report, 52(RR-11), 1–77. Davies, P. D. (1999). The effects of poverty and ageing on the increase in tuberculosis. Monaldi Archives of Chest Disease, 54, 168–171. Frieden, T. R., Sterling, T. R., Munsiff, S. S., Watt, C. J., & Dye, C. (2003). Tuberculosis. Lancet, 362, 887–899. Luna, J. A. C. (2004). A tuberculosis guide for specialist physicians. Paris: International Union Against Tuberculosis and Lung Disease. Schluger, N. W. (2002). Multidrug-resistant tuberculosis. In F. R. Lashley, & J. D. Durham (Eds.), Emerging infectious diseases: Trends and issues (pp. 203–213). New York: Springer Publishing. Stead, W. W. (1998). Tuberculosis among elderly persons, as observed among nursing home residents. International Journal of Tuberculosis and Lung Disease, 2(Suppl 1), S64–S70. Strausbaugh, L. J., Sukumar, S. R., & Joseph, C. L. (2003). Infectious disease outbreaks in nursing homes: An unappreciated hazard for frail elderly persons. Clinical Infectious Diseases, 36, 870–876. World Health Organization. (2004). 8th annual report on global tuberculosis control. Geneva: World Health Organization. World Health Organization. (2004, March). Tuberculosis. Fact Sheet No. 104. Geneva: World Health Organization. Yoshikawa, T. T. (2002). Antimicrobial resistance and aging: Beginning of the end of the antibiotic era? Journal of the American Geriatric Society, 50, S206–S209.

TUMOR SUPPRESSION In all living organisms, tissue damage occurs as a result of a variety of insults, including free radicals and other noxious environmental and endogenous agents. Therefore, longevity requires the development of mechanisms to eliminate and replace damaged cells. This comes at a price, however, since the capacity for cell renewal contains an inherent risk of uncontrolled proliferation, thus leading to the possibility of developing both benign hyperplasias and cancer. For that reason, all long-lived

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organisms have developed strong tumor suppression mechanisms that protect them from developing fatal cancers at young ages. However, evolution does not select for protection of the soma past the reproductive period, and as a result these mechanisms risk losing efficiency as organisms age (Kirkwood, Kapahi, & Shanley, 2000). Furthermore, it appears that in some cases, the very mechanisms developed to control tumor progression in young individuals can turn into tumor promoters in aged ones, thus representing a case of what evolutionary biologists have termed antagonistic pleiotropy (Kirkwood, Kapahi, & Shanley, 2000). At the cellular level, there are 2 independent but intertwined mechanisms that provide for tumor suppression: apoptosis and senescence (Lowe, Cepero, & Evan, 2004). Both are activated in response to cellular damage, and they act as potent tumor suppressors because they result in the functional removal of damaged cells from the pool of potentially proliferating cells. The role of apoptosis in aging is presently ill-defined, but we do know considerably more about cell senescence. Classically, cell senescence has been defined as the irreversible loss of proliferative capacity attained by cells after serial culture. The mechanism involves activation of a p53/p21dependent DNA damage response as a result of critical shortening of telomeres (Cristofalo, Lorenzini, Allen, Torres, & Tresini, 2004). While it has been argued that replicative senescence is unlikely to be reached by large numbers of cells in living organisms, many tissues indeed contain senescent cells (as defined by the presence of a marker, senescentassociated β-galactosidase, or SA-βGal), and the number of such cells increases with age (Dimri, Lee, Basile, Acosta, Scott, Roskelley, et al., 1995). Furthermore, most tissues from aged organisms display shortened telomeres (Aviv, 2002), and telomere length correlates with the physiological age of the individual (Epel, Blackburn, Lin, Dhabhar, Adler, Morrow, et al., 2004). A variety of adverse culture conditions, including damage by free radicals or incoherent activation of certain oncogenes, leads to the appearance of a phenotypically indistinguishable “premature senescence” state (Wright & Shay, 2002). In these cases, senescence often appears to be triggered by activation of a different pathway, the p16/pRB pathway, which leads to the formation of a stable, distinct type of inactive chromatin, termed senescence associated heterochromatic foci (SAHFs, Narita & Lowe, 2004). Thus, in both

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cases, activation of the senescence pathway requires the activation of tumor suppressor pathways, again suggesting that cell senescence may be an important mechanism of tumor suppression in vivo. It is generally believed that apoptosis might have evolved as a developmentally required mechanism. In contrast, senescence might have evolved with the specific aim of suppressing tumor formation in organisms containing large numbers of proliferatively competent cells. However, while senescence might be an effective mechanism of tumor suppression in young individuals, the presence of senescent cells might represent an increased risk for tumor promotion in aged individuals. The reason for this discrepancy lies in the phenotypic effects of senescence. Indeed, the senescent phenotype is not limited to irreversible inhibition of cell proliferation. Rather, compared to younger counterparts, senescent cells display marked changes in gene expression (Krtolica & Campisi, 2002). Several of these changes lead to a dramatic modification of the immediate milieu surrounding the senescent cells. Fibroblasts, the most studied cells in terms of senescence, secrete a large number of bioactive molecules, including extracellular matrix components as well as modifiers of this same matrix (proteases and their inhibitors). They also secrete a variety of signaling molecules, including growth factors, cytokines, chemokines, and both angiogenic and anti-angiogenic factors. The secretory pattern of senescent fibroblasts is quite different from that displayed by cells at earlier passages (Krtolica & Campisi, 2002), and together these changes suggest that senescent fibroblasts can induce a markedly changed microenvironment, in which neighboring cells will be affected by the presence of even minute numbers of senescent cells. In fact, both in vitro and in vivo experiments have shown that senescent, but not pre-senescent, fibroblasts can induce both proliferation (in vitro) and tumor formation (in vivo) in pre-malignant epithelial cells (Krtolica, Parrinello, Lockett, Desprez, & Campisi, 2001). Interestingly, senescent cells had no effect on normal epithelial cells, suggesting that the effect of their modified secretory pattern only affects initiated cells, and not normal epithelium. Cancer progression requires both DNA mutations that lead to the production of initiated cells, and a favorable milieu for them to strive. Thus, in young organisms, cancer might be rare because mutations have not accumulated to a significant extent, and neither have senescent cells. In contrast, aging results

in both an accumulation of mutated (initiated) cells and changes in the milieu induced by the presence of senescent cells, and this combination might be the reason why cancer incidence increases so dramatically in the last portion of an organism’s lifespan. In summary, while cell senescence appears to have evolved as a tumor suppression mechanism, it only does so effectively in young organisms, and it can even work as a tumor promoter in older individuals. It has thus been suggested that removal of senescent cells could contribute to cancer suppression. At the molecular level, the most potent tumor suppression mechanisms involve the proteins p53 and pRB, which act as checkpoints to control cell cycle progression. Mutations of p53 and/or pRB are the most common mutations found in a variety of carcinomas. It has long been argued that this is because these tumor suppressors work by inhibiting cell cycle progression. However, we now know that mutations in these genes can also abrogate the senescence response, which represents a cell cycle-independent mechanism of tumor suppression. Thus, it is not unreasonable to think that while mutations in p53 or pRB might contribute to cancer development through their well-known role in the control of cell cycle progression, they might also do so by inhibiting the cell senescence pathway. Since p53 activation can induce the senescent phenotype, it follows that if cell senescence is involved in organismal aging, then inactivation of p53 should lead to increased longevity. Unfortunately, this is a difficult hypothesis to prove, since inactivation of p53 (even partially, as in heterozygous mice) leads to significantly increased tumor production, resulting in a shortened lifespan, but without being informative about the effect of the manipulation on the rate of aging per se (Donehower, Harvey, Slagle, McArthur, Montgomery, Butel, et al., 1992). On the contrary, hyperactivation of p53 should lead to protection against tumors but with decreased longevity, because of induction of cell senescence. While mice overexpressing wild type p53 (super p53 mice, in which p53 expression and activity are under the control of normal mechanisms) age normally (GarciaCao, Garcia-Cao, Martin-Caballero, Criado, Klatt, et al., 2002), 2 mouse models displaying constitutive activation of wild type p53 show significant protection against tumor formation, but accompanied by a shortened lifespan (Tyner, Venkatachalam, Choi, Jones, Ghebranious, Igelmann, et al., 2002; Maier, Gluba, Bernier, Turner, Mohammad, Guise, et al.,

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2004). In both cases, activation of p53 was the result of expression of hypermorphic variants of the protein lacking the amino terminus (either p44, or a shorter, serendipitous variant simply called m). These mice display reduced tumor frequencies, but an accelerated appearance of a subset of age-related diseases and phenotypes, suggesting that they might represent models of segmental progeria. Furthermore, at least in the one case in which the issue was addressed, the mice displayed a tenfold increase in SA-βGal+ cells (Dumble, Gatza, Tyner, Venkatachalam, & Donehower, 2004). Thus, apart from its well-known function as a tumor suppressor via cell cycle arrest, activation of p53 induces premature aging, probably by activation of the senescence program. It has been proposed that the major cell type involved in the induction of a senescent phenotype in this model might be stem cells, but this issue is still unresolved at this point. Reduced longevity was not observed in the super p53 mice, probably because in this case activation of the gene was not constitutive, and thus, rather than being under the continuous presence of a stress response, cells were unaffected under normal circumstances, but were able to produce a more vigorous response when challenged (de Stanchina & Lowe, 2002). These observations have led some authors to propose that aging might not be the result of damage as usually assumed, but rather the result of an inappropriate response to such damage. In summary, longevous organisms have developed strong tumor suppression mechanisms, namely apoptosis and cell senescence. However, these mechanisms lose efficiency as the organism reaches very old ages, leading to the observed increase in cancer incidence with age. In the last few years there has been a dramatic advance in our understanding of the molecular mechanisms responsible for these intertwined phenomena. Felipe Sierra See also Swedish Twin Studies

References Aviv, A. (2002). Chronology versus biology: Telomeres, essential hypertension, and vascular aging. Hypertension, 40, 229–232.

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Cristofalo, V. J., Lorenzini, A., Allen, R. G., Torres, C., & Tresini, M. (2004). Replicative senescence: A critical review. Mechanisms of Ageing and Development, 125, 827–848. De Stanchina, E., & Lowe, S. (2002). Tumour suppression: Something for nothing? Nature Cell Biology, 4, E275–E276. Dimri, G. P., Lee, X., Basile, G., Acosta, M., Scott, G., Roskelley, C., Medrano, E. E., Linskens, M., Rubelj, I., Pereira-Smith, O. M., Peacocke, M., & Campisi, J. (1995). A novel biomarker identifies senescent human cells in culture and in aging skin in vivo. Proceedings of the National Academy of Sciences U.S.A., 92, 9363– 9367. Donehower, L. A., Harvey, M., Slagle, B. L., McArthur, M. J., Montgomery, C. A. Jr, Butel, J. S., & Bradley, A. (1992). Mice deficient for p53 are developmentally normal but susceptible to spontaneous tumours. Nature, 356, 215–221. Dumble, M., Gatza, C., Tyner, S., Venkatachalam, S., & Donehower, L. A. (2004). Insights into aging obtained from p53 mutant mouse models. Annals of the New York Academy of Science, 1019, 171–177. Epel, E. S., Blackburn, E. H., Lin, J., Dhabhar, F. S., Adler, N. E., Morrow, J. D., & Cawthon, R. M. (2004). Accelerated telomere shortening in response to life stress. Proceedings of the National Academy of Sciences U.S.A., 101, 17312–17315. Garcia-Cao, I., Garcia-Cao, M., Martin-Caballero, J., Criado, L. M., Klatt, P., Flores, J. M., Weill, J. C., Blasco, M. A., & Serrano, M. (2002). “Super p53” mice exhibit enhanced DNA damage response, are tumor resistant and age normally. EMBO Journal, 21, 6225– 6235. Kirkwood, T. L., Kapahi, P., & Shanley, D. P. (2000). Evolution, stress, and longevity. Journal of Anatomy, 197, 587–590. Krtolica, A., Parrinello, S., Lockett, S., Desprez, P. Y., & Campisi, J. (2001). Senescent fibroblasts promote epithelial cell growth and tumorigenesis: A link between cancer and aging. Proceedings of the National Academy of Sciences U.S.A., 98, 12072–12077. Krtolica, A., & Campisi, J. (2002). Cancer and aging: A model for the cancer promoting effects of the aging stroma. International Journal of Biochemistry and Cell Biology, 34, 1401–1414. Lowe, S. W., Cepero, E., & Evan, G. (2004). Intrinsic tumour suppression. Nature, 432, 307–315. Maier, B., Gluba, W., Bernier, B., Turner, T., Mohammad, K., Guise, T., Sutherland, A., Thorner, M., & Scrable, H. (2004). Modulation of mammalian life span by the short isoform of p53. Genes and Development, 18, 306–319. Narita, M., & Lowe, S. W. (2004). Executing cell senescence. Cell Cycle, 3, 244–246.

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Tyner, S. D., Venkatachalam, S., Choi, J., Jones, S., Ghebranious, N., Igelmann, H., Lu, X., Soron, G., Cooper, B., Brayton, C., Hee Park, S., Thompson, T., Karsenty, G., Bradley, A., & Donehower, L. A. (2002). p53 mutant mice that display early ageing associated phenotypes. Nature, 415, 45–53. Wright, W. E., & Shay, J. W. (2002). Historical claims and current interpretations of replicative aging. Nature Biotechnology, 20, 682–688.

TWINS STUDIES IN AGING RESEARCH Twins studies continue to be valuable in understanding the genetic influence on age-related traits and conditions, even in this era of rapid progress in molecular genetics. Continued advances in quantitative methods for twins analyses have addressed some of the analytical challenges inherent to the age-related conditions under study. The traditional twin studies design compares the phenotypic concordance of a disease or trait within monozygotic (identical) and dizygotic (fraternal) twin pairs. If one accepts the premises that monozygotic twins share 100% of their genes, dizygotic twins on average share 50% of their genes, and the environment shared by twins is roughly the same for monozygotic and dizygotic pairs, then any greater similarities in monozygotic compared to dizygotic pairs must reflect the action of genes. The proportion of disease liability that is attributable to genes, i.e., heritability, can be estimated from such comparisons of monozygotic and dizygotic pairs. Recent advances using structural equation modeling allow for the assessment of not only the influence of genes, but also the influence of both shared and nonshared environmental factors. Shared environment is familial environment, or factors to which both twins would have been exposed such as parental treatment in early life. Nonshared environment is defined as factors that are unique to one twin, such as exposures in adulthood. One area of aging research in which twin studies have advantages is in the examination of the change in genetic influences over time. Age-related conditions are often influenced by multiple, as yet unidentified, genetic factors. Many of these individual genes or gene families may switch on and off over the life cycle. Similarly, the strength of envi-

ronmental influences may change over time. The estimate of heritability in twin studies is a proportion, and it need not necessarily be constant over time. A prime example of this change in heritability over time is general cognitive ability. Studies across the lifespan have shown that heritability of general cognitive ability increases from infancy (about 20%) to childhood (40%) to adolescence (50%) to adulthood (60%). This pattern suggests that the genetic contribution to this trait may continue to increase in the very old. A recent study exploring this question in the very old found that heritability of general cognitive ability was 62%, thus it does not appear to continue to increase after age 80 (McClearn, Johansson, Berg, Pedersen, Ahern, Petrill, et al., 1997). Others have proposed dynamic biometric models to estimate the heritability of changes associated with aging. These methods have initially been applied to changes in cognition over time (McArdle & Hamagami, 2003), but could be applied to other measures of abilities also. Non-random non-response is a common problem to all longitudinal studies, and in aging studies attrition is often due to mortality. When considering change in heritability over time, this must be taken into consideration. Studies that require that both twins be alive over multiple time points of data collection may be less likely to find changes in heritability over time (Pedersen, Ripatti, Berg, Reynolds, Hofer, & Finkel, 2003). Another area of aging research well suited for twin studies is the study of diseases of complex etiology that have onset in late life, such as Alzheimer’s disease. In such diseases, multiple genetic and nongenetic (environmental) factors determine disease outcome. For many of these diseases, few if any of the relevant genes and environmental factors are known. Even so, structural modeling techniques that are widely used in twins analyses can estimate the relative influence of these genetic and environmental factors and can assess whether each of these factors add significantly to a given model. For example, among population-based studies of prevalent Alzheimer’s disease, the estimate of heritability was about 35% in twins who had an average age of onset of 71 years (Plassman, Steffens, Burke, WelshBohmer, Helms, & Breitner, in press), but this estimate increased to between 65% to 75% in twin pairs in whom the average age of onset was between age 75 to 80 years (Bergem, Engedal, & Kringlen, 1997; Gatz, Pedersen, Berg, Johansson, Johansson,

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Mortimer, et al., 1997). In a recent population-based study of incident Alzheimer’s disease, it was estimated that genetic variation accounts for about 48% of the variation in liability to Alzheimer’s disease (Pedersen, Gatz, Berg, & Johansson, 2004). Given that the average difference in age of onset of Alzheimer’s disease between 2 members of a twin pair who are concordant for the disease is about 5 years (Plassman, Steffens, Burke, WelshBohmer, Helms, & Breitner, In press) one possible explanation for the discrepancy in estimates of heritability between prevalent and incident studies is the relatively shorter period of follow-up in incident studies. The study of disease states can be expanded to not only assess the heritability of the presence of the condition, but also to consider the heritability of specific traits within the phenotype. Twin studies of depression can be used to illustrate this point. Generally twins studies have found that a history of depression is modestly to moderately heritable, but a recent study assessing depression symptoms over multiple time points reported that the level of symptomatology over time was highly heritable (McGue & Christensen, 2003). Other researchers have used this analytical approach to examine the genetic contribution to wellness in late life, as defined by the absence of certain medical conditions. Heritability of wellness was estimated at over 50% in a group of elderly male twins (Reed & Dick, 2003). This approach is not limited to the study of dichotomous variables (presence or absence of disease). It can also be applied to polychotomous or continuous variables, resulting in increased analytical power. This approach can also be applied to other physiological correlates of aging, such as white matter hyperintensities in the brain. A recent study (Carmelli, DeCarli, Swan, Jack, Reed, Wolf, et al., 1998) reported that genetic influences account for about 73% of the variability in volume of white matter hyperintensities within elderly male twin pairs. Comorbidity of age-related illnesses is quite common and often complicates the search for the etiology of a complex disorder. There are now methods to assess whether the comorbidity is due to a common underlying etiology. The above-noted structural modeling techniques can include bivariate analytical techniques designed to assess whether the co-occurrence of 2 (or more) conditions is due to genes that influence vulnerability to 1 disorder also influencing vulnerability to the other. Alter-

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natively, familial environmental factors may predispose to both disorders, or unique environmental factors may increase risk for multiple disorders. For example, Kendler and colleagues (1992) have shown that the genetic correlation between major depression and generalized anxiety disorder in female twins does not differ from one, while the genetic correlation between major depression and phobias is much smaller. Others have used this approach to assess the role of genes and environment on 3 factors associated with functional aging (Finkel, Whitfield, & McGue, 1995). The 3 empirically derived factors were physiological measures, cognitive abilities, and processing speed. These researchers reported that the genetic and shared environmental influences were common to all 3 factors, but that the non-shared environmental influences were specific to each component. This means that a single genetic component was sufficient to describe the genetic influences on the 3 components of functional aging. Likewise, a single shared environmental influence appears to account for the shared environmental component of functional aging. In the twin models described above, genetic and environmental factors are treated as latent “black box” variables. Their existence is inferred from the observed pattern of correlations within twin pairs. But demonstrating that a disorder is substantially heritable, or that a pair of disorders overlap genetically, is just the initial step in twin studies. The next step is to assess the role of specific genetic and environmental factors. This can be done in a number of ways. First, to assess environmental influences, one can use a variation of the case control method called the cotwin control method. This approach compares environmental exposures within twin pairs who are discordant for disease (or trait) or for age of onset of disease. For monozygotic twin pairs, any differences in age of onset within monozygotic twin pairs must be attributable to nonshared environmental factors, and the objective of the cotwin control method is to identify these factors. Secondly, once specific risk genes for a disease have been identified, the amount of variance attributable to individual genes can be determined and the residual genetic influence attributable to the other, yet unidentified genes, can be estimated (Nance & Neale, 1989). Many of the genetic factors associated with disorders of aging are not rare mutations, but rather are universal genetic polymorphisms with 2 or more

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common alleles, of which 1 allele carries increased or decreased risk of disease. An example of a polymorphic genetic risk factor is the apolipoprotein E (APOE) gene responsible for lipid transport. The allele of this gene is associated with increased risk of cardiovascular disease and Alzheimer’s disease. Using partitioned twin analyses, the effect of a candidate gene such as APOE on these diseases can be estimated. Thirdly, information on specific risk genes can be used to explore gene-environment interactions. For example, it is not clear why some individuals with the APOE allele develop Alzheimer’s disease, and some do not. One likely explanation is that an environmental factor(s) interacts with the allele to modify risk of the disease. Using the cotwin control method and stratifying by the particular risk genotype, one can assess whether the presence of a particular genotype alters the risk associated with a specific environmental factor. A fairly new area of exploration for twin studies is the investigation of epigenetic differences in monozygotic twins. Given that the genetic sequence in monozygotic pairs is identical, this approach may offer a way to explore molecular mechanisms underlying phenotypic discordance in monozygotic twins (Petronis, Gottesman, Kan, Kennedy, Basile, & Popendikyte, 2003). This may be particularly useful in studies of aging, given the difficulty of collecting an accurate history of a lifetime of environmental exposures and thus limiting the extent to which environmental factors can be quantified. To summarize, until all genes associated with the many complex disorders and traits of aging are identified, twins studies hold the unique potential of helping to study the effect of “anonymous” genetic influences and the environmental factors that modify them. Within twin pair comparisons provide automatic matching on identified and unidentified genes and many environmental factors that cannot reasonably be matched in non-twin samples. Brenda L. Plassman

References Bergem, A. L. M., Engedal, K., & Kringlen, E. (1997). The role of heredity in late-onset Alzheimer disease and vascular dementia. Archives of General Psychiatry, 54, 264–270.

Carmelli, D., DeCarli, C., Swan, G. E., Jack, L. M., Reed, T., Wolf, P. A., & Miller, B. L. (1998). Evidence for genetic variance in white matter hyperintensity volume in normal elderly male twins. Stroke, 29, 1177–1181. Finkel, D., Whitfield, K., & McGue, M. (1995). Genetic and environmental influences on functional age: A twin study. Journal of Gerontology: Psychological Sciences, 50B(2), 104–113. Gatz, M., Pedersen, N. L., Berg, S., Johansson, B., Johansson, K., Mortimer, J. A., Posner, S. F., Viitanen, M., Winblad, B., & Ahlbom, A. (1997). Heritability for Alzheimer’s disease: The study of dementia in Swedish twins. Journal of Gerontology, 52A(2), M117–M125. Kendler, K. S., Neale, M. C., Kesler, R. C., Heath, A. C., & Eaves, L. J. (1992). Major depression and generalized anxiety disorder: Same genes, (partly) different environments? Archives of General Psychiatry, 49, 716–722. McArdle, J. J., & Hamagami, F. (2003). Structural equation models for evaluating dynamic concepts within longitudinal twin analyses. Behavior Genetics, 33, 137–159. McClearn, G. E., Johansson, B., Berg, S., Pedersen, N. L., Ahern, F., Petrill, S. A., & Plomin, R. (1997). Substantial genetic influence on cognitive abilities in twins 80 or more years old. Science, 276, 1560–1563. McGue, M., & Christensen, K. (2003). The heritability of depression symptoms in elderly Danish twins: Occasion-specific versus general effects. Behavior Genetics, 33, 83–93. Nance, W. E., & Neale, M. C. (1989). Partitioned twin analysis: A power study. Behavior Genetics, 19, 143–150. Pedersen, N. L., Gatz, M., Berg, S., & Johansson, B. (2004). How heritable is Alzheimer’s disease late in life? Findings from Swedish twins. Annals of Neurology, 55, 180–185. Pedersen, N. L., Ripatti, S., Berg, S., Reynolds, C. A., Hofer, S. C., Finkel, D., Gatz, M., & Palmgren, J. (2003). The influence of mortality on twin models of change: Addressing missingness through multiple imputation. Behavior Genetics, 33, 161–169. Petronis, A., Gottesman, I. I., Kan, P., Kennedy, J. L., Basile, V. S. P., & Popendikyte, V. (2003). Monozygotic twins exhibit numerous epigenetic differences: Clues to twin discordance? Schizophrenia Bulletin, 29, 1690178. Plassman, B. L., Steffens, D. C., Burke, J. R., WelshBohmer, K. A., Helms, M. J., & Breitner, J. C. S. (In press). Alzheimer’s disease in the NAS-NRC twin registry of WWII veterans. Neurobiology of Aging. Reed, T., & Dick, D. M. (2003). Heritability and validity of healthy physical aging (wellness) in elderly male twins. Twin Research, 6, 227–234.

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U URINARY TRACT: SYMPTOMS, ASSESSMENT, AND MANAGEMENT Symptoms and Terminology The following presents the common lower urinary tract symptoms that affect older adults. They are defined in the Standardization of Terminology of the International Continence Society (Abrams, Cardozo, Fall, Griffiths, Rosier, Ulmsten, et al., 2003). Increased daytime frequency is the complaint by the patient who considers that he/she voids too often by day. Nocturia refers to the complaint that the individual has to wake at night one or more times to void. Urgency is the complaint of a sudden compelling desire to pass urine that is difficult to defer. Urinary incontinence is the complaint of any involuntary leakage of urine. Stress urinary incontinence is the complaint of involuntary leakage on effort or exertion, or on sneezing or coughing. Urge urinary incontinence is the complaint of involuntary leakage accompanied by or immediately preceded by urgency. Mixed urinary incontinence is the complaint of involuntary leakage associated with urgency and also with exertion, effort, sneezing, or coughing. Slow stream is reported as the individual’s perception of reduced urine flow, usually compared to previous performance or in comparison to others. Intermittent stream (Intermittency) is the term used when the individual describes urine flow that stops and starts, on one or more occasions, during micturition. Hesitancy is the term used when an individual describes difficulty in initiating micturition, resulting in a delay in the onset of voiding after the individual is ready to pass urine. Straining to void describes the muscular effort used to initiate, maintain, or improve the urinary stream. Terminal dribble is the term used when an individual describes a prolonged final part of micturition, when the flow has slowed to a trickle/dribble.

Feeling of incomplete emptying is a selfexplanatory term for a feeling experienced by the individual after passing urine. Postmicturition dribble is the term used when an individual describes the involuntary loss of urine immediately after he or she has finished passing urine, usually after leaving the toilet in men, or after rising from the toilet in women. Urgency, with or without urge incontinence, usually with frequency and nocturia, can be described as the overactive bladder syndrome, urge syndrome, or urgency-frequency syndrome. These symptom combinations are suggestive of urodynamically demonstrable detrusor overactivity but can be due to other forms of urethro-vesical dysfunction. These terms can be used if there is no proven infection or other obvious pathology.

Assessment The key message is that symptoms are not very helpful in making a diagnosis, so examination is important. Urodynamic studies, however, are not essential (Malone-Lee, Henshaw, & Cummings, 2003). Urinalysis. The diagnosis of urinary tract infection (UTI) from culture of a mid-stream urinary specimen (MSU) has relied on the detection of 105 colony forming units per ml (cfu/ml). It has been known for some time that in symptomatic women, a more appropriate threshold should be 100 cfu/ml (Stamm & Hooton, 1993). Few laboratories report this, so that MSU culture misses up to 50% of genuine infections. A positive leucocyte esterase test has a reported sensitivity of 75% to 90% in detecting pyuria associated with a UTI. However, the most reliable technique is the detection of pyuria by microscopy in fresh, unspun urine. Optimum results are achieved by counting the pus cells on a haemocytometer using the threshold of 8 wbc mm− (Stamm & Hooton, 1993). This is considered to be the gold standard and when applied to older individuals unearths many more infections than might be expected 1205

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(Stamm & Hooton, 1997; Jackson, Boyko, Scholes, Abraham, Gupta, & Fihn, 2004). The overactive bladder involves symptoms that feature in urinary infection. It is known that significant urinary infection may be painless (Stamm & Hooton, 1997). Some overactive bladder symptoms could therefore reflect genuine urinary infection, undetected by traditional analysis that does not use microscopy. The recommended definition of microscopic hematuria is 3 or more red blood cells per highpower field on microscopic evaluation of 2 of 3 properly collected specimens. Since dipsticks are so sensitive to blood, positive results must be checked by microscopy. False positives are very common. If the hematuria is associated with proteinuria, dysmorphic red cells, red cell casts with or without granular casts, or abnormal creatinine, a nephrological assessment is required. Otherwise, hematuria should be investigated by urine cytology, renal tract ultrasound, and flexible cystoscopy (Grossfeld, Litwin, Wolf, Hricak, Shuler, Agerter, et al., 2001). The significance of proteinuria can be checked by measuring the protein/creatinine ratio in a single voided urine sample (Ginsberg, Chang, Matarese, & Garella, 1983). Measurement of the Postmicturition Residual Urine Volume. Age older than 55 years, prior incontinence surgery, a history of multiple sclerosis, and vaginal prolapse stage two or greater are independent predictors of elevated postmicturition residual urine volume. This must be measured using ultrasound.

Management The symptoms, urinalysis, and postvoid residual give sufficient data to initiate management. Overactive bladder syndrome should be treated with a combination of antimuscarinic agents and bladder retraining (Szonyi, Collas, Ding, & Malone-Lee, 1995). The principle antimuscarinic agents available for this are tolterodine, oxybutynin, solifenacin, and trospium. The subject has been extremely well reviewed by Ouslander recently (2004). It is notable that the risks of causing urinary retention with these drugs are remarkably small. Stress urinary incontinence is commonly managed initially by pelvic floor exercises, although

specific efficacy data applicable to older adults is lacking. The most important breakthrough is the development of tension-free vaginal tape, which has brought the option of successful surgery to so many older women with stress incontinence (Gordon, Gold, Pauzner, Lessing, & Groutz, 2005). Oestrogen replacement therapy has a role in the management of post-menopausal symptoms and recurrent urinary infection but no efficacy for treating incontinence (Zinner, Koke, & Viktrup, 2004).

The Prostate Many older men describe symptoms of prostatism. As they grow older the risks of prostatic carcinoma increase. The American Association of Urologists has issued guidance, stating that “both prostate specific antigen (PSA) and digital rectal examination (DRE) should be offered annually, beginning at age 50 years, to men who have a life expectancy of at least 10 years. Men at high risk should begin testing at age 45. High-risk groups include men of African descent (specifically, sub-Saharan African descent) and men with a first-degree relative diagnosed at a young age. Risk increases with the number of firstdegree relatives affected by prostate cancer. If PSA is 2.5 ng/dl or greater, further evaluation with biopsy should be considered” (American Urological Association, 2000). Patients with symptoms of benign prostatic hypertrophy (BPH) who wish to avoid surgery in the form of transurethral resection of the prostate (TURP) should be offered an alpha blocker (Lowe, 2004). The inhibition of the 5-alpha-reductase enzyme by drugs like finasteride may prove more relevant to prostate cancer. James Malone-Lee See also Fecal and Urinary Incontinence Kidney and Urinary System

References Abrams, P., Cardozo, L., Fall, M., Griffiths, D., Rosier, P., Ulmsten, U. et al. (2003). The standardization of terminology in lower urinary tract function: Report from

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Urinary Tract the standardization sub-committee of the International Continence Society. Urology, 61, 37–49. American Urological Association. (2000). Prostatespecific antigen (PSA) best practice policy. Oncology (Williston Park), 14, 267–268, 280. Ginsberg, J. M., Chang, B. S., Matarese, R. A., & Garella, S. (1983). Use of single voided urine samples to estimate quantitative proteinuria. New England Journal of Medicine, 309, 1543–1546. Gordon, D., Gold, R., Pauzner, D., Lessing, J. B., & Groutz, A. (2005). Tension-free vaginal tape in the elderly: Is it a safe procedure? Urology, 65, 479– 482. Grossfeld, G. D., Litwin, M. S., Wolf, J. S., Hricak, H., Shuler, C. L., Agerter, D. C., et al. (2001). Evaluation of asymptomatic microscopic hematuria in adults: the American Urological Association best practice policy—part I: definition, detection, prevalence, and etiology. Urology, 57, 599–603. Hooton, T. M., & Stamm, W. E. (1997). Diagnosis and treatment of uncomplicated urinary tract infection. Infectious Disease Clinics of North America, 11, 551– 581. Jackson, S. L., Boyko, E. J., Scholes, D., Abraham, L.,

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Gupta, K., & Fihn, S. D. (2004). Predictors of urinary tract infection after menopause: a prospective study. American Journal of Medicine, 117, 903–911. Lowe, F. C. (2004). Role of the newer alpha, -adrenergicreceptor antagonists in the treatment of benign prostatic hyperplasia-related lower urinary tract symptoms. Clinical Therapeutics, 26, 1701–1713. Malone-Lee, J., Henshaw, D. J., & Cummings, K. (2003). Urodynamic verification of an overactive bladder is not a prerequisite for antimuscarinic treatment response. British Journal of Urology International, 92, 415– 417. Ouslander, J. G. (2004). Management of overactive bladder. New England Journal of Medicine, 350, 786–799. Stamm, W. E., & Hooton, T. M. (1993). Management of urinary tract infections in adults. New England Journal of Medicine, 329, 1328–1334. Szonyi, G., Collas, D. M., Ding, Y. Y., & Malone-Lee, J. G. (1995). Oxybutynin with bladder retraining for detrusor instability in elderly people: A randomized controlled trial. Age and Ageing, 24, 287–291. Zinner, N. R., Koke, S. C., & Viktrup, L. (2004). Pharmacotherapy for stress urinary incontinence: Present and future options. Drugs, 64, 1503–1516.

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V VASCULAR COGNITIVE IMPAIRMENT In the previous edition, this entry was listed as multiinfarct dementia. Both terms refer to the central idea that cerebrovascular disease can give rise to cognitive impairment, and even dementia, as a consequence of impaired blood supply to the brain. The concepts of multi-infarct dementia and vascular cognitive impairment (VCI) differ in ways that illustrate the history of thinking about how blood flow affects brain function. (O’Brien, Erkinjuntti, Reisberg, et al., 2003). Both terms have been initiated and popularized by the same person, Professor Hachinski of the University of Western Ontario in Canada. His initial insight was that, in neurodegenerative dementias, decreased blood flow occurred as a consequence of dementia, and not as a cause of it. That is because the cerebral demand for blood flow diminishes as brain function decreases. There are circumstances, however, in which it is the opposite, and the prototype of that occurs in patents who have had strokes; in such cases, the occluded blood vessels result in cerebral ischemia and then cell death, so that diminished brain activity is the consequence of impaired blood supply (Hachinski, Iliff, Zilhka, et al., 1975). While this occurs, it is a comparatively uncommon form of dementia; indeed, it is not even the most common cause of VCI. More commonly persons with VCI suffer ischemic damage to the white matter of the brain. The white matter can be thought of as the “wiring” that allows the various parts of the brain to communicate with each other. This widely diffused communication in neural circuits (networks of interconnected cells throughout the brain) is how higher order brain functions, such as language, initiative, thinking and long-term memory storage) occur. The metaphor of a widely distributed neural circuit is in contrast to the metaphor of a vertically organized and highly localized system, which is more akin to how the brain is organized for basic functions, such as movement. Thus the cognitive impairments (e.g. problems with memory or language) seen in patients with VCI do not occur because a discrete part of the brain has had a classical stroke; 1208

rather stroke—or even ischemia—affects either specific brain areas or the ways in which the areas interact with each other. This rather banal conclusion nevertheless underlies much of the considerable controversy regarding how to think about cognitive impairment in relation to cerebrovascular disease. It is only with considerable difficulty that many classically trained localizationists can accept that the apparent localizing value of neuroimaged lesions in VCI is less than that often seen in other neurological disorders. Still, some forms of cognitive impairment are held to be characteristic, such as the syndrome of executive dysfunction (poor judgment, loss of initiative, irritability) seen in patients with subcortical ischemia. More often, however, VCI refers to a broad syndrome of cognitive dysfunction seen in relation to cerebrovascular disease (Erkinjuntti, Inzitari, Pantoni, Wallin, Scheltens, Rockwood, et al., 2000). Because the general syndrome is so broad, subtyping is essential. How best to subtype is not clear, but one proposal is that 3 groups can be identified clinically and by neuroimaging (Rockwood, Howard, MacKnight, & Darvesh, 1999). The first group are those patients whose dementia fits a multi-infarct model (i.e. focal signs, multiple strokes, and focal cognitive deficits). Many such patients are seen in the setting of an obvious clinical stroke, where dementia can affect about one-quarter of patents. Interestingly, more than 12 months after a stroke, many patients will progress to dementia, even without a clinically evident subsequent stroke (Sachdev, Brodaty, Valenzuela, et al., 2004). A second group consists of patients in whom clinical and/or neuroimaging features suggest both vascular dementia and a neurodegenerative disorder, such as Alzheimer’s disease (these patients are said to have “mixed dementia”). Mixed dementia is particularly common after age 85 years. (Neuropathology Group, 2001) The third group are patients whose cognitive impairment does not meet the traditional criteria for dementia (e.g., those in whom a dysexecutive syndrome predominates, without significant memory impairment)—such patients often have white matter ischemia too, but then, so do many patients with VCI. This last group is described as vascular cognitive impairment, no dementia (VCI-ND).

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Vascular Cognitive Impairment

Societal Burden of VCI Taken together, the 3 subtypes of VCI are about as common as Alzheimer’s disease, affecting about 5% of people aged 65 and older (Rockwood, Wentzell, Hachinski, et al., 2000). The societal cost of VCI is likewise considerable, also approaching that of Alzheimer’s disease (Rockwood, Brown, Merry, et al., 2002). In contrast to Alzheimer’s, however, there are more costs associated earlier in the course of the disease, likely reflecting the impact of stroke on motor function—people with paralysis in addition to cognitive impairment are commonly institutionalized. In addition, the particular burden of impaired executive function also likely contributes to institutionalization earlier in the course of dementia than is usually seen in Alzheimer’s disease. VCI has an important impact on prognosis, and the survival of patients with vascular dementia is less than that of patents with Alzheimer’s disease: the median survival time (i.e. the point at which 50% have died) can be less than 3 years (Wolfson, Wolfson, Asgharian, et al., 2001).

Causes, Prevention, and Treatment of VCI As it is a syndrome, VCI has many causes. The least controversial is stroke, and its causes, such as atherosclerosis or embolism, or an inherited disorder, known as CADASIL (Kalaria, Viitanen, Kalimo, et al., 2004 ). Of some considerable interest, given the history of the area, is the idea that chronic cerebral hypoperfusion can also cause VCI without giving rise to frank infarction (Sarti, Pantoni, Bartolini, & Inzitari, 2002). This possibility remains real, but controversial. Against this background, it is not surprising that the prevention of VCI arises from the prevention of cerebrovascular disease. Still, the overlap is not just on prevention; some drugs that can be used to treat hypertension, such as nimodipine, can also be used to treat vascular dementia (Pantoni, del Ser, Soglian, et al., 2005). Importantly, too, the cholinesterase inhibitors, which are drugs used to treat Alzheimer’s disease, can also be used to treat patients with vascular dementia, many of whom have a cholinergic deficit without any Alzheimer’s disease, due to infarction of the cholinergic projection pathways

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that run with the deep white matter (Erkinjuntti, Roman, Gauthier, et al., 2004). The advent of more targeted treatments offers hope that VCI can be a better-understood and less burdensome illness than in the past. Kenneth Rockwood See also Alzheimer’s Disease: Clinical Dementia

References Erkinjuntti, T., Inzitari, D., Pantoni, L., Wallin, A., Scheltens, P., Rockwood, K. et al. (2000). Research criteria for subcortical vascular dementia in clinical trials. Journal of Neural Transmission, 59(Suppl. 1), 23–30. Erkinjuntti, T., Roman, G., Gauthier, S., et al. (2004). Emerging therapies for vascular dementia and vascular cognitive impairment. Stroke, 35, 1010–1017. Hachinski, V. C., Iliff, L. D., Zilhka, E., et al. (1975). Cerebral blood flow in dementia. Archives of Neurology, 32, 632–637. Kalaria, R. N., Viitanen, M., Kalimo, H., et al. (2004). The pathogenesis of CADASIL: An update. Journal of the Neurological Sciences, 226, 35–39. Neuropathology Group. Medical Research Council Cognitive Function and Aging Study. (2001). Pathological correlates of late-onset dementia in a multicentre, community-based population in England and Wales. Neuropathology Group of the Medical Research Council Cognitive Function and Ageing Study (MRCCFAS). Lancet, 357, 169–175. O’Brien, J. T., Erkinjuntti, T., Reisberg, B., et al. (2003). Vascular cognitive impairment. Lancet Neurology, 2, 89–98. Pantoni, L., del Ser, T., Soglian, A. G., et al. (2005). Efficacy and safety of nimodipine in subcortical vascular dementia: A randomized placebo-controlled trial. Stroke, 36, 619–624. Rockwood, K., Howard, K., MacKnight, C., & Darvesh, S. (1999). Spectrum of disease in vascular cognitive impairment. Neuroepidemiology, 18, 248–254. Rockwood, K., Wentzell, C., Hachinski, V., et al. (2000). Prevalence and outcomes of vascular cognitive impairment. Neurology, 54, 447–451. Rockwood, K., Brown, M., Merry, H., et al. (2002). Societal costs of vascular cognitive impairment in older adults. Stroke, 33, 1605–1609. Sachdev, P. S., Brodaty, H., Valenzuela, M. J., et al. (2004). Progression of cognitive impairment in stroke patients. Neurology, 63, 1618–1623.

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Veterans and Veteran Care

Sarti, C., Pantoni, L., Bartolini, L., & Inzitari, D. (2002). Cognitive impairment and chronic cerebral hypoperfusion: What can be learned from experimental models. Journal of Neurological Science, 203–204, 263–266. Wolfson, C., Wolfson, D. B., Asgharian, M. et al. (2001). A reevaluation of the duration of survival after the onset of dementia. New England Journal of Medicine, 344, 1111–1116.

VETERANS AND VETERAN CARE The mission of the U.S. Department of Veterans Affairs (VA) is to serve America’s veterans (individuals who have been honorably discharged from U.S. military service) and their families. The VA’s responsibilities include: health care, which is coordinated by the Veterans Health Administration (VHA); socioeconomic support and assistance, coordinated by the Veterans Benefits Administration; and burial services, coordinated by the National Cemetery Administration. The VA is the second largest department in the U.S. government, with over 235,000 employees and an annual budget of over $63 billion (U.S. Department of Veterans Affairs, 2004). VHA is the largest integrated health care system in the United States, with an annual medical care budget of over $28 billion. In 2003, VHA provided care to 4.8 million unique patients, including 49.8 million outpatient visits. It provides a comprehensive continuum of medical care through its163 medical centers, 137 nursing homes, and 43 residential rehabilitation treatment programs, as well as more than 75 home-care programs, 800 outpatient clinics, and 200 readjustment counseling centers. VA facilities are located in every state, Washington, DC, the Commonwealth of Puerto Rico, the American Virgin Islands, and Guam. VHA purchases some health care for veterans in other government or private facilities, and in certain circumstances also finances care for dependents and survivors of veterans. In addition to providing health care, VHA’s mission also includes providing training for health care professionals, conducting medical research, serving as backup to the U.S. Department of Defense medical services, and during national emergencies, supporting the National Disaster Medical System. In 2003, the estimated total veteran population was more than 25 million. Vietnam veterans

(8.2 million veterans, representing 33% of total veterans) are now the single largest period-of-service component of the veteran population, followed by World War II veterans (4.4 million, 17% of the total), Korean conflict participants (3.6 million, 14%), and Gulf War veterans (3.8 million, 15%). Approximately 6.4 million veterans (25%) served only during peacetime. The number of World War I veterans is now too small to estimate. The veteran population is projected to decline to 15.0 million by 2030 (U.S. Department of Veterans Affairs, 2002), under currently expected armed forces strength. The population of veterans aged 65 or older peaked at 10.0 million in 2000. It will decline to 8.9 million in 2010, but rise again to about 9.2 million in 2013 as the Vietnam era cohort ages. The number of veterans aged 85 or older is expected to nearly double, from 764,000 to a peak of 1.4 million between 2003 and 2012. Although a small proportion of the total veteran population, the number of veterans aged 100 years or more is also increasing. An over eight-fold increase is expected, from 1,400 veterans in 2003 (0.01% of the total veteran population) to a peak of almost 12,000 in 2024 (0.07% of the total). The VA has faced the challenge of a rapidly aging veteran population since the 1970s (Cooley, Goodwin-Beck, & Salerno, 1998). Although the overall size of the veteran population is declining, the proportion of older veterans has increased dramatically. To meet this challenge, the VA has developed a broad continuum of geriatrics and extended care health care services. In addition, it supports a diverse portfolio of aging-related research and provides aging-related education and training for staff and students from a wide range of medical and associated health disciplines. In the new millenium, the VA’s efforts to meet the needs of older veterans remain a high priority. In 2003, the median age of veterans was nearly 59 years, compared with only 36 years for the general population (U.S. Census Bureau, 2004). Over 38% of the veteran population (9.6 million of the total 25.2 million veterans) was aged 65 or older, compared to 12% of the total U.S. population. By 2030, 45% of all veterans (an estimated 6.8 million of the projected total 15.0 million veterans) will be aged 65 years or older. Currently, 7% (1.7 million) of all veterans are female, including 3.5% (337,000) of veterans aged 65 or older. By 2030, female veterans will account for 14.6% (2.2 million) of all

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veterans and 6.9% (671,000) of veterans aged 65 or older. As in the general U.S. population, those aged 85 or older (the “old-old”) are the fastest-growing segment of the veteran population, representing 3.0% of current veterans (764,000 of the total 25.2 million veterans in 2003). By 2030, 15% of older veterans will be aged 85 or older (1.0 million). Thus, VA will encounter a large cohort of potentially frail elderly veterans in the next 25 years. To meet the challenge of an expanding aging veteran population, VHA has developed an extensive continuum of health care services targeting the needs of this group. This includes an increasing focus on home and community-based programs, as well as coordinated use of hospital and nursing home programs. Together these programs provide preventive, acute, rehabilitative, and extended care on an outpatient and/or inpatient basis. Examples of VHA geriatrics and extended care programs include home-based primary care, homemaker/home health aide services, respite, adult day health care, domiciliary, geriatric primary care, specialty geriatric evaluation and management, specialized Alzheimer’s and related dementia care, nursing home care, and hospice. In addition to its own direct provision of care, VHA also contracts for certain services (e.g., community nursing home care) and participates in others through a grant program to State Veterans Homes (nursing home, domiciliary, and adult day health care). For more than 25 years, the VA has also provided leadership in research, training and education in geriatrics and long-term care (Kizer, 1996). VHA funds a wide range of aging-related research on basic biomedical, applied clinical, rehabilitation, and health services topics, as well as cooperative (multisite) studies. In 1975, the VA established centers of excellence in geriatrics called Geriatric Research, Education and Clinical Centers (GRECCs), whose mission is to improve the health and care of older veterans through research, education, and training, and the development and evaluation of innovative models of care. GRECCs are widely recognized as having provided leadership in geriatrics and gerontology, both within the VA and throughout the nation (Goodwin & Morley, 1994). Currently, there are 21 GRECCs across the VA system, each with a specific programmatic focus, which include among others: neuroscience, including dementia; endocrinology, especially diabetes; rehabilitation of stroke and other disorders; osteoporosis; falls and

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gait disorders; exercise; immunology; cardiovascular diseases; and palliative care. GRECCs as well as selected other VA medical centers provide physician fellowship training in geriatric medicine, constituting the largest source of trained geriatricians in the nation. In addition, VHA pioneered the concept and practice of interdisciplinary team training in geriatrics and has developed advanced training programs in geriatrics for psychiatrists, neurologists, dentists, nurses, and psychologists. Students from multiple other health care disciplines (e.g., social work, pharmacy, optometry) gain geriatrics experience during their training rotations in VA clinical settings. VHA also provides aging-related continuing education for professional staff from the VA and the community on a regular basis. Current VHA aging initiatives include the integration of geriatrics with primary care and mental health care. A variety of research and education activities are underway to identify best practice models of integrated care and to disseminate this information to health care providers in outpatient and inpatient clinical settings. Through its efforts on behalf of America’s veterans, the VA paved the path in the development of health care for all older Americans. Now in the 21st century it is well positioned to continue its leadership role in meeting the challenge of fulfilling the health care needs and improving the quality of life for the future’s cohort of aging veterans, as well as all older Americans. For additional information on the VA and its programs and services for older veterans, visit the following Web sites: VA at www.va.gov; the Veterans Benefits Administration at www.vba.va.gov; My Health e Vet at www.myhealthevet.va.gov; and VHA Geriatrics and Extended Care Strategic Health Care Group at www.va.gov/geriatricsshg. Susan G. Cooley Statements and opinions are not necessarily those of the U.S. Department of Veterans Affairs.

References Cooley, S. G., Goodwin-Beck, M. E., & Salerno, J. A. (1998). United States Department of Veterans Affairs health care for aging veterans. In B. Vellas, J. P. Michel, & L. Z. Rubenstein (Eds.), Geriatric programs

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Vision: System, Function, and Loss

and departments around the world. Paris and New York: Serdi Publishers and Springer Publishing. Goodwin, M., & Morley, J. E. (1994). Geriatric research, education and clinical centers: Their impact in the development of American geriatrics. Journal of the American Geriatrics Society, 42, 1012–1019. Kizer, K. W. (1996). Geriatrics in the VA: Providing experience for the Nation. Journal of the American Medical Association, 275(17), 1303. U.S. Census Bureau. (2004, June 14). Table 1: Annual estimates of the population by sex and five-year age groups for the United States: April 1, 2000 to July 1, 2003 (NC-EST2003-01. Available: http://eire.census. gov/popest/data/national/tables/NC-EST2003-01.pdf. U.S. Department of Veterans Affairs. (2002). VetPop2001 adjusted to census 2000. Available: www.va.gov/ vetdata/demographics/index.htm. U.S. Department of Veterans Affairs. (2004, May). Organizational briefing book. Available: www.va.gov/ ofcadmin.orgbrfbook.pdf.

VISION: SYSTEM, FUNCTION, AND LOSS Aging is associated with progressive changes in the visual system (Fozard & Gordon-Salant, 2001; Schieber, in press), and a marked increase in the prevalence of disabling visual disorders (Eye Diseases Prevalence Research Group, 2004). Even normal age-related changes can affect performance on everyday tasks (Kline, Kline, Fozard, Kosnik, Schieber, & Sekuler, 1992). Some of the changes that affect the optic media of the eye are evident as early as age 35 to 45; others are due to alterations in the sensorineural components of the retina and brain and are unlikely to be noticeable until age 45 to 55 or later.

The Visual System Optic Media. The cornea’s curvature steepens after 50, particularly in the horizontal meridian, contributing to an increased prevalence of “againstthe-rule” astigmatism. Due to its opacification and yellowing, the older lens transmits less light to the retina, especially the short wavelengths (blues). As a result of lens hardening (sclerosis), and possibly changes in the controlling ciliary muscle, the ability of the lens to adjust focus (accommodation)

declines progressively, leading to a recession of the near-point of focus (i.e., presbyopia). There is also a decline in the pupil’s resting size (senile miosis), especially in low light, as well as in the speed of its response. Changes in the lens and pupil reduce the light reaching the retina as well as the eye’s ability to transfer light differences (i.e., contrast) to the retina. The smaller pupil does compensate for some of the aberrations in the cornea and lens. Retina and Optic Nerve. Aging is accompanied by a marked loss of rods, the photoreceptor responsible for sensitivity in low light. Cones, the photoreceptor responsible for color vision and acuity, are much less affected. There also appears to be a reduction in the retinal ganglion cell counts, whose axons form the optic nerve. Lateral Geniculate Nucleus (LGN) and Cortex. Although healthy aging seems to have little effect on the density or size of neurons in the LGN (the visual relay station for the brain) or primary visual cortex (V1), functional deficits are observed. Visual transmission is slowed and old cortical cells appear less able to track flashing lights at high frequencies (Mendelson & Wells, 2002). Subtle alterations in the neurochemical characteristics, synaptic organization, and/or demyelinization of the functional pathways have been hypothesized to account for these deficits. Schmolesky and colleagues (2000) have shown a significant degradation of orientation and direction selectivity in the cortical cells of senescent monkeys, a result that they attributed to a degradation of intracortical inhibition. In a study with exciting therapeutic implications, after administering GABA, an inhibitory transmitter to V1 cells of old monkeys, Leventhal and colleagues (2003) found that many cells displayed responses characteristic of young cells. Imaging research reveals a tendency toward reduced efficiency and less specialization in the extrastriate cortical areas responsible for higherlevel visual processing (Park, Polk, Park, Minear, Savage & Smith, 2004). Eye Movements. There is little or no age-related reduction in smooth pursuit eye movement gain for target velocities slower than 5 to 10 degrees/sec, but a marked decline as velocity is increased beyond this level. Although saccadic (ballistic) movements show less change with advancing age, small

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increases in saccadic onset and some slowing in peak velocity occur. Older adults appear capable of accurate and stable fixation for task durations of at least 10 seconds.

Visual Function Sensitivity to Light and Color. Aging is associated with a loss of sensitivity to light as well as a marked slowing in the rate at which the eye increases its sensitivity in the dark. The rate of the decline on light sensitivity across age is about twice as high for scotopic (rod-mediated) as for photopic (i.e., cone-mediated) vision, a result attributable to neural and optical factors (Jackson, Owsley & Curcio, 2002). Older persons report increased difficultly carrying out a wide range of everyday tasks in dim light, including driving (Klein, Klein, Lee & Cruickshanks, 1999). Color vision testing shows a linear increase in discrimination errors from age 30 to age 80 years. Because these tend to occur along the tritan (blue-yellow) axis, older observers may have difficulty discriminating colored surfaces that differ by trace levels of blue or yellow. Much of the loss of color discrimination is related to the optic media, but changes in cones or post-receptoral processes may also play a role. Spatial Vision. Static visual acuity is a measure of the ability to resolve fine spatial stationary details. Best-corrected acuity changes only modestly through the 60s, with an accelerated decline thereafter. This deficit is exacerbated by low stimulus contrast and/or low luminance (HaegerstromPortnoy, Schneck, & Brabyn, 1999). The magnitude of the age deficit on dynamic visual acuity, a measure of the ability to resolve fine detail in moving targets, increases with target velocity. This appears to reflect the decline in smooth pursuit eye movements and reduced retinal illuminance. By measuring the minimum luminance differences needed to detect bar gratings of widely varied size (i.e., spatial frequency), the contrast sensitivity function (CSF) provides a more comprehensive measure of spatial vision than does acuity. Although some studies have reported small age-related losses on the CSF at low spatial frequencies, age deficits are robust at intermediate and higher spatial frequencies. Contrast sensitivity is usually a better predictor than acuity

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of older observers’ difficulties on everyday visual tasks. Sensitivity to Change and Movement. One of the most fundamental and consistently observed changes in the senescent visual system is a loss of ability to track rapid temporal change. Older observers’ sensitivity levels are reduced on the temporal contrast sensitivity function, a measure of the minimum contrast needed to detect a light source flickered at widely varied rates. Coherence thresholds, the minimum proportion of elements moving in a common direction to elicit the perception of motion, increase with age. Old observers also need larger positional displacements than the young to detect motion, and the ability to discriminate differences in motion direction or speed is reduced.

Age-Related Visual Disorders and Low Vision Aging is associated with an exponential increase in the prevalence of disabling visual disorders that cause low vision or legal blindness (Eye Diseases Prevalence Research Group, 2004). Low vision refers to an uncorrectable loss of sight that interferes with the ability to carry out everyday tasks. The Eye Diseases Prevalence Research Group has estimated that 2.4 million American adults had low vision (defined as corrected acuity worse than 20/40 but better than 20/200), and approximately 937,000 Americans over age 40 in 2000 were legally blind (corrected acuity of 20/200 or worse in the better eye, and/or a visual field smaller than 20 deg). Such losses of sight may result from a primary eye disease, or occur as sequelae of another illness (e.g., diabetes) or a neurodegenerative disorder such as Parkinson or Alzheimer’s disease (Jackson & Owsley, 2003). Four disorders account for most of the conditions that threaten sight in old age: cataract, age-related maculopathy (ARM), diabetic retinopathy, and glaucoma. Cataract. Cataract, a disabling opacification of the lens, is the leading cause of visual impairment among older adults. About 50% of adults manifest early cataract by age 75, and by age 80 close to 70% of adults in the U.S. exhibit clinically significant cataracts. Risk factors for cataract beyond

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aging include sunlight, steroid use, and smoking. Cataracts reduce acuity, color discrimination, and contrast sensitivity, and increase susceptibility to disability glare. Fortunately, cataracts are readily treated by the replacement of the natural lens with a synthetic intraocular lens. Age-Related Maculopathy. ARM, the leading cause of irreversible age-related visual blindness in developed countries, causes a loss of central (i.e., macular) vision. The “dry” or early form of the disease causes some impairment of acuity; the late form of ARM causes severe acuity loss. When late ARM is accompanied by a proliferation of fragile new retinal blood vessels (neovascularization), it is referred to as the exudative or “wet” form of the disease. While photodynamic and/or antioxidant therapy may slow the progression of neovascularization, no current treatments can reverse the vision loss. The severe loss of acuity, color perception, and contrast sensitivity with ARM can impair the patient’s ability to carry out even basic activities of daily life. Glaucoma. Glaucoma, a progressive loss of peripheral vision due to damage to sensory neurons where they converge to form the optic nerve, usually occurs in association with elevated intraocular pressure. It is the leading cause of blindness among Afro-Americans. In addition to “tunnel vision,” glaucoma can result in losses of contrast sensitivity, night vision, motion perception, and color vision. The patient may be unaware its presence until late in its progression. Blind spots (scotoma) can accumulate and eventually result in complete blindness. Daily activities that demand good peripheral vision such as walking, obstacle avoidance, and driving can be impaired early in the disease (Coeckelbergh, Cornelissen, Brouwer, & Kooijman, 2002; Turano, Rubin, & Quigley, 1999). Moderate glaucoma often responds well to drugs that reduce aqueous production. Diabetic Retinopathy (DR). DR is the fourth leading cause of legal blindness in adults over age 65 in the United States. It is caused by diabetesinduced changes in the retinal vasculature, an effect that is more likely for those who need to take insulin. Frequently, swelling and slight leakage from the retinal capillaries will cause some impairment of vision. For a minority, rapid neovascularization can

produce bleeding into the vitreous humour, retinal scarring, and even retinal detachment. The loss of acuity, color, and contrast sensitivity, scotoma, and reduced visual fields that can result from DR can make everyday tasks difficult. In addition to management of the underlying diabetes, lasers can be targeted to anneal leaking blood vessels, and panretinal photocoagulation used to reduce the metabolic demands of the retina that induce neovascularization.

Low Vision Intervention Older adults with low vision have greater difficulty carrying out the instrumental activities of daily living (IADLs), such as handling money, shopping, or taking medication, than performing basic activities of daily living (ADLs) such as bathing, feeding, or dressing. Since these problems stem from 2 sources, functional vision loss and adaptation to vision loss, it is critical that solutions address both (Travis, Boerner, Renhardt, & Horowitz, 2004). Examples of the former include low-vision optical aids, good lighting, large print materials, simplifying floor plans, and marking the edges of steps with high contrast strips; the latter emphasizes the need for effective peer and family support as well as psychosocial and rehabilitation services interventions to reduce social isolation and enhance overall quality of life. Donald Kline

References Coeckelbergh, T. R. M., Cornelissen, F. W., Brouwer, W. H., & Kooijman, A. C. (2002). The effect of visual field defects on eye movements and practical fitness to drive. Vision Research, 42, 669–677. Eye Diseases Prevalence Research Group (2004). Causes and prevalence of visual impairment among adults in the United States. Archives of Ophthalmology, 122, 477–485. Fozard, J. L., & Gordon-Salant, S. (2001). Changes in vision and hearing with aging. In J. E. Birren & K. W. Schaie (Eds), Handbook of the psychology of aging (5th ed., pp. 241–266). San Diego: Academic Press. Haegerstrom-Portnoy, G., Schneck, M. E., & Brabyn, J. A. (1999). Seeing into old age: Vision function

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Vitamins beyond acuity. Optometry and Vision Science, 76, 141– 158. Jackson, G. R., Owsley, C., & Curcio, C. A. (2002). Photoreceptor degeneration and dysfunction in aging and age-related maculopathy. Ageing Research Reviews, 1, 381–396. Jackson, G. R., & Owsley, C. (2003). Visual dysfunction, neurodegenerative diseases, and aging. Neurologic Clinics, 21, 709–728. Klein, B. E., Klein, R., Lee, K. E., & Cruickshanks, K. J. (1999). Associations of performance-based and selfreported measures of visual function. The Beaver Dam Eye Study. Ophthalmic Epidemiology, 6, 49–60. Kline, D. W., Kline, T. J. B., Fozard, J. L., Kosnik, W., Schieber, F., & Sekuler, R. (1992). Vision, aging and driving: The problems of older drivers. Journal of Gerontology: Psychological Sciences, 47, P27–P34. Leventhal, A. G., Wang, Y., Pu, M., Zhou, Y., & Ma, Y. (2003). GABA and its agonists improved visual cortical function in senescent monkeys. Science, 300, 812–815. Mendelson, J. R., & Wells, E. F. (2002). Age-related changes in the visual cortex. Vision Research, 42, 695– 703. Park, D. C., Polk, T. A., Park, R., Minear, M., Savage, A., & Smith, M. R. (2004). Aging reduces neural specialization in ventral visual cortex. Proceedings of the National Academy of Sciences U.S.A., 101, 13091– 13095. Schieber, F. (in press). Vision and aging. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (6th ed.). New York: Elsevier. Schmolesky, M. T., Wang, Y., Pu, M., & Leventhal, A. G. (2000). Degradation of stimulus selectivity of visual cortical cells in senescent rhesus monkeys. Nature Neuroscience, 3(4), 384–390. Travis, L. A., Boerner, K., Reinhardt, J. P., & Horowitz, A. (2004). Exploring functional disability in older adults with low vision. Journal of Visual Impairment and Blindness, 98, 534–545. Turano, K. A., Rubin, G. S. & Quigley, H. A. (1999). Mobility performance in glaucoma. Investigative Ophthalmology and Visual Science, 40, 2803–2809.

VITAMINS Vitamins are essential components of the diet that are not chemically members of any of the major categories of foodstuffs (fats, carbohydrates, proteins), which the human body is incapable of making in quantities sufficient for its normal requirements. Many populations in the world are subject to

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diets deficient in one or more of the vitamins. In Western societies gross vitamin deficiencies are rare, but older people make up one of the population groups in which they can occur. Deficiencies also have to be considered as possibilities in patients with severe bowel disease that prevents normal nutrition or absorption of nutrients. Vitamins are divided into the fat-soluble vitamins (A, D, E, and K), the water-soluble vitamins of the B complex, and vitamin C. Vitamin A precursors occur in leaves and vegetables. On a worldwide basis, vitamin A deficiency is common. It is involved in the integrity of epithelial tissues, is an important cause of blindness in children, and predisposes to cancer, particularly of the esophagus. Vitamin A deficiency is rare in Western populations but can be a cause of night blindness as it is involved in the synthesis of the visual pigments in the eye. Excess of vitamin A is poisonous and produces a characteristic syndrome of headache, flushing, hypertension, and flaking of the skin. This is sometimes seen in people who unwisely eat polar bear or shark liver, which contain vitamin A in high concentrations. Humans obtain vitamin D from two sources. One form is present in the diet, particularly in oily fish, but most is synthesized in the skin when ultraviolet light from the sun converts 7-dehydrocholesterol into cholecalciferol, vitamin D3. Vitamin D formed in the skin or absorbed from the diet is transported to the liver, where it is converted into 25-hydroxyvitamin D; then a second transformation in the kidney produces 1,25-hydroxyvitamin D, which is the most active form of the vitamin. Vitamin D deficiency can arise through lack of exposure to the sun and dietary deficiency. Some drugs (such as some antiepileptics) induce enzymes in the liver that break down the 25-hydroxyvitamin D, and damage to the kidney can prevent the formation of the most active form of the vitamin. All these factors can be relevant to older people. Gross vitamin D deficiency in old age produces the syndrome of osteomalacia, which is characterized by failure of bone to calcify properly; by weakness of the muscles, particularly the proximal muscles of the legs; generalized aches and pains; and psychiatric changes, particularly depression. Osteomalacia is rare, but it has been postulated that lesser degrees of vitamin D deficiency occur during the winter, when sunlight is at its weakest, and contribute to the problem of osteoporosis. When

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vitamin D levels fall, the parathyroid gland mobilizes calcium from the bones (calcium being essential for nerve and muscle function), and this can lead to negative balance of calcium and progressive erosion of bone. Vitamin D supplementation during the winter months is being increasingly recommended for older people. Care is needed, as vitamin D is toxic in large quantities, and some foodstuffs are fortified with vitamin D. Extra supplements should be taken only after medical advice. Vitamin E is found in plant oils and green leaves. Dietary deficiency sufficient to cause identifiable disease is extremely rare. The main function of the vitamin in the body is thought to be an antioxidant protective action on cell membranes, but so far there is no convincing evidence of benefits from vitamin E in retarding aging or preventing vascular disease (Heart Outcomes Prevention Evaluation Study Investigators, 2000). A study suggesting that vitamin E might retard the progress of Alzheimer’s disease ran into methodological problems, and further work is needed (Sano, Ernesto, Thomas, Klauber, Schafer, Grundman, et al., 1997). Vitamin K occurs in plants and is essential for the liver to generate the various factors involved in blood clotting. Deficiency in adult life is rare, as the vitamin can be synthesized by bacteria in the gut. Deficiency in the newborn leads to ahemor-rhagic disorder. Vitamin K also may be involved in the maintenance of healthy bone. Among the B vitamins, vitamin Bj (thiamine) is an essential co-enzyme in the metabolism of carbohydrates. It is present in wheat germ and other cereals, and pork is also a rich dietary source. Chronic deficiency may be a cause of heart failure (beriberi), and acute deficiency may produce a characteristic pattern of sudden brain damage known as Wernicke’s encephalopathy. This syndrome, which includes confusion and paralysis of eye muscles, may lead to Korsakov’s psychosis, a memory defect in which the victim loses all capacity to register new information. The need for thiamine is increased by a high-carbohydrate diet, which explains why beriberi and Wemicke’s encephalopathy are commonest in alcoholics. Their diet is often deficient in the vitamin, and alcohol is a carbohydrate. Vitamin B12 (cobalamin) is essential for the genesis of the blood and for maintaining the health of nervous tissue. Deficiency leads to a characteristic form of anemia (pernicious anemia) and to subacute

combined degeneration of the spinal cord associated with peripheral neuropathy. Vitamin B12 is found in animal foods, and a true dietary deficiency has been recorded only in vegans. The main cause of vitamin B, deficiency in older people is a chronic inflammation of the stomach, leading to failure of secretion of a protein called intrinsic factor, which binds to vitamin B12 and promotes its absorption. Because of this difficulty in absorption, pernicious anemia is usually treated with lifelong injections of vitamin Bj2 . The metabolism of vitamin B12 is closely linked with that of another vitamin, folate, which is found in vegetables and in some animal foods such as liver. Low intakes are not uncommon in older populations. Folic acid is an artificial form of folate that is stable and well absorbed and so used for fortifying foods and for dietary supplements. Severe deficiency of folate causes an anemia similar to that of vitamin Bu deficiency. It is important, however, not to treat vitamin B12 deficiency with folic acid alone, as this will not prevent the nerve damage of vitamin B2 , deficiency. Low folate intakes by women at the time of conception are associated with the risk of neural tube defects (especially spina bifida) in the fetus. Women who might become pregnant are therefore encouraged to take folic acid supplements, but because so many pregnancies arc unplanned, fortification of food with folic acid has been introduced in the United States to improve intake of the vitamin. Recent studies have shown that high intake of folate will reduce the average levels of homocysteine in the blood. A high level of homocysteine in the blood is a risk factor for vascular disease, including heart attacks, stroke, and venous thrombosis. Levels of folate intake sufficient to reduce homocysteine levels to a minimum are difficult to obtain without supplements or fortification of food. Because of the interactions between folate and vitamin B2 , older people considering taking folic acid supplements should check with their doctor to make sure that they do not have unrecognized vitamin B12 deficiency. Nicotinic acid (vitamin B3 , also known as niacin) is widely distributed in plant and animal foods. It can also be synthesized by bacteria in the gut from tryptophan, an amino acid derived from protein in the diet. Deficiency of nicotinic acid may occur in populations where the main form of food is maize, which is deficient in the vitamin and provides little protein.

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The deficiency disease is pellagra, a syndrome of mental changes, diarrhea and a light-sensitive dermatitis. It is now rarely seen in Western nations, usually only in impoverished alcoholics. Other members of the vitamin B group include riboflavin (vitamin B2 ), pyridoxine, biotin, andpantothenic acid. Riboflavin occurs in milk and egg white. Deficiency of riboflavin causes soreness of the tongue and of the angles of the mouth but rarely occurs as an isolated deficiency. Significant deficiencies of pyridoxine andpantothenic acid are rare. Vitamin C (ascorbic acid) is present in fresh citrus fruits and vegetables. It is an important anti-oxidant and is also involved in the synthesis of collagen. Deficiency leads to scurvy, the first features of which tend to be psychiatric, particularly depression, followed by hemorrhage. Small hemorrhages appear round the hair follicles on the legs, followed by sheet hemorrhages in the skin, again most commonly of the legs. The gums become swollen and bleeding, and teeth may be lost. The outcome may be sudden death, sometimes due to internal hemorrhage. Mild cases of scurvy are occasionally seen among elderly people. Characteristically, it is seen in elderly men living alone, with no fresh fruit or vegetables in their diet, but elderly women are similarly at risk. Vitamin C supplements are sometimes given to encourage collagen synthesis and wound healing in patients whose diet has been suboptimal—for example, debilitated older people with pressure ulcers. There is no good evidence to support the suggestion that very high doses of vitamin C will prevent colds. J. Grimley Evans See also Nutrition

References Heart Outcomes Prevention Evaluation Study Investigators (2000). Vitamin E supplementation and cardiovascular events in high-risk patients. New England Journal of Medicine, 342, 154–160. Sano, M., Ernesto, C., Thomas, R. G., Klauber, M. R., Schafer, K., Grundman, M., Woodbury, P., Growdon, J., Cotman, C. W., Pfeiffer, E., Schneider, L. S., Thai, L. J., for the Members of the Alzheimer’s Dis-

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ease Cooperative Study (1997). A controlled trial of selegeline, alpha tocopherol, or both as treatment for Alzheimer’s disease. New England Journal of Medicine, 336, 1216–1222.

VOLUNTEERISM Over the last 2 decades, gerontologists have put forward more positive perspectives on aging, and terms like successful aging and productive aging are widely discussed by academics and gerontology advocates alike. Volunteerism has been an important part of these discussions as volunteering represents a form of social involvement usually prominent in visions of later life. Historically, volunteering had been one of the few formal roles available to older adults after exit from career jobs. Yet current demographics bring renewed interest in the topic, because the burgeoning older population could be marshaled into volunteer roles to strengthen civil society. There are many definitions of volunteering and volunteerism in the literature. Cnaan and colleagues (1996) identify 4 dimensions that are common in these various definitions: volunteering occurs in the context of an organization; volunteers receive no or minimal compensation; volunteering is an act of free will; and volunteering is other-oriented. The literature contains many estimates of the percentage of people who volunteer, and these rates vary from survey to survey, based on definitions of older age and volunteering as well as the sampling techniques. The most recent estimates from the Current Population Survey (Bureau of Labor Statistics, 2004) indicate that 24.6% of those aged 65 and older volunteer. Cohort analyses indicate that more adults under age 65 volunteer. For example, the Current Population Survey (2004) indicated that 32.8% of 45 to 54 year olds volunteer, and 30.1% of 55 to 64 year olds volunteer. Thus, older age is related to lower rates of volunteering, and this is likely because younger adults take on volunteer work related to their children’s activities and work settings. Older adults generally have weaker relationships to institutions of work and education, and for adults over age 75, health and disability issues become the primary obstacles (AARP, 2003). Additionally, younger adults are more likely than older adults to be asked to volunteer; but if asked, older adults are more likely to agree (Independent Sector, 2000). Once in volunteer roles,

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older adults devote more time, with a median of 96 hours per year recorded by the Bureau of Labor Statistics in 2004. In 2000, the Independent Sector valued the contribution to society of older volunteers at $70.5 billion. Thus, the contribution made by older volunteers is substantial, and there are indications that rates of volunteering in later life are on the rise. Although older age is related to lower rates of volunteering, the amount of time committed and number of organizations increases with age, until age 75 years (Hendricks & Cutler, 2004). Many studies have documented factors associated with volunteering in later years, and the factor most consistently related to volunteering is education. Accordingly, various measures of socioeconomic status are associated with volunteering. Better health and more social connections have been fairly consistently related to volunteering. Although there is inconsistency in the findings, it is often documented that females, whites, and married older adults are more likely to volunteer. In sum, older people with more resources (financial, health, and social) appear to volunteer more. From these findings, scholars have expressed concern about the elitist nature of volunteering. Disadvantaged populations continue to be disadvantaged in later life if exclusion from volunteer activity is negatively related to well-being (Estes & Mahakian, 2000). Older volunteers are most likely to volunteer for religious and community service organizations, while younger adults are more likely to volunteer for youth and educational organizations, such as schools (Bureau of Labor Statistics, 2004). The type of organizations that attract older and younger volunteers may reflect, among other things, varying motivations for volunteering. There is some empirical support for the idea that older adults have more altruistic motivations to help others or give back to a community, while younger volunteers are seeking to gain employment/educational skills and social relationships (Omoto, Synder, & Martino, 2000). There is a growing body of literature that supports a reciprocal relationship between health and volunteering in later life (Musick, Herzog, & House, 1999; Van Willigen, 2000; Morrow-Howell, Hinterlong, Rozario, & Tang, 2003; Thoits & Hewitt, 2001). That is, healthier older adults volunteer, and volunteers experience health benefits from their involvement. Longitudinal surveys as well as quasi-

experimental and experimental studies have shown a positive relationship between volunteering and self-rated health, morbidity, functional ability, mental health, and life satisfaction. The causal mechanisms have not been established, but explanations given in the literature over the last 20 years include: feeling useful, increased self-esteem, increased social connectedness, activity that structures time, role replacement, and role enhancement. Fried and colleagues (2004) postulate that health outcomes are achieved through increased physical activity, social engagement, and cognitive stimulation. Although the magnitude of these effects is yet to be clarified, full cost-benefit analyses of later life volunteering must also consider the outcomes achieved through the volunteer activities, like improvement in reading levels of children in tutoring programs. Given the multiple benefits associated with volunteering in later life, it makes sense from a public health perspective to maximize involvement of the aging population in volunteer activities. There are few social policies that support volunteerism. Although volunteers can take a tax deduction for uncompensated expenses related to volunteering, federal initiatives primarily support volunteering through the creation of programs, like AmeriCorps, Peace Corps, Learn and Serve American. Yet these programs are biased toward youth. For example, only 3% of AmeriCorps volunteers are over age 60 (Freedman, 2002). There have been calls to modify program structures to accommodate the aging population. The Foster Grandparent Program and the Senior Companion Program are large national programs that enable older adults to volunteer. These programs provide small stipends to offset costs, and these volunteers must, in general, be lowincome and average 20 hours per week of service. Again, advocates call for modification to increase the number of older adults who could contribute to their communities through these programs. There is an increasing body of literature on innovative programs that solicit older adults for their time and talent, and target some of society’s most pressing issues: failing schools, environmental degradation, and child health. Most financial support comes from foundations and private/corporate contributions, with some partnerships with federal, state, or local governments (Morrow-Howell, Hinterlong, Sherraden, Tang, Thirupathy, & Nagchoudhuri, 2003). For example, Experience Corps is an

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innovative program where older adults are recruited to spend 5 to 15 hours a week in urban public schools. The program now operates in 13 cities, and 275,000 hours of tutoring/mentoring was provided to 20,000 students in the 2003–2004 school year. Financial support comes from private and public sources (www.experiencecorps.org). There has been considerable attention devoted to the baby boomers, given the tremendous amount of volunteer resources that they represent in their retirement years. Some survey researchers speculate that future generations are more likely to come forward to serve in larger numbers (Peter D. Hart Research Associates, 2002), given the desire for ongoing meaningful involvement. It has been estimated that 50% of baby boomers will remain involved in the community through work and community service. However, it is not known to what extent caregiving responsibilities will affect longer engagement in work and volunteer roles. Yet there is evidence that baby boomers may be motivated differently than today’s older adults; they may be more interested in social interaction and less likely to volunteer out of religious commitment. It is recommended that because baby boomers are more likely to be currently volunteering, the best way to increase volunteer capacity in future years is to ensure their ongoing involvement (Prisuta, 2004). Thus, we need to continue to develop innovative and inclusive program and policy initiatives to maximize the engagement of older adults in volunteer roles now and in the future. Nancy Morrow-Howell

References AARP. (2003). A synthesis of member volunteer experience. Washington, DC: AARP. Bureau of Labor Statistics. (2004). Volunteering in the United States, 2004. Cnaan, R. A., Handy, F., & Wadsworth, M. (1996). Defining who is a volunteer: Conceptual and empirical considerations. Nonprofit and Voluntary Quarterly, 25(3), 364–383.

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Estes, C. L. & Mahakian, J. (2001). The political economy of productive aging. In N. Morrow-Howell, J. E. Hinterlong, & M. N. Sherraden (Eds.), Productive aging: Concepts and challenges. Baltimore: Johns Hopkins University Press. Freedman, M. (2002). Making policy for an aging century: Expanding the contribution of older Americans through national and community service. Warrenton, VA: Coming of Age Conference 2002. Fried, L., Carlson, M., Freedman, M., Frick, K., Glass, T., Hill, J., McGill, S., Rebok, G., Seeman, T., Tielsch, J., Wasik, B., & Zeger, S. (2004). A social model for health promotion for an aging population: Initial evidence on the Experience Corps Model. Journal of Urban Health, 81, 64–78. Hendricks, J., & Cutler, S. (2004). Volunteerism and socioemotional selectivity in later life. Journal of Gerontology: Social Sciences, 59B(5), S251–S257. Independent Sector. (2000). American senior volunteers 2000. Morrow-Howell, N., Hinterlong, J., Rozario, P., & Tang, F. (2003). The effects of volunteering on the well-being of older adults. Journal of Gerontology, 53B(3), S137– S145. Morrow-Howell, N., Hinterlong, J., Sherraden, M., Tang, F., Thirupathy, P., & Nagchoudhuri, M. (2003). Institutional capacity for elder service. Social Development Issues, 25, 189–204. Musick, M. A., Herzog, A. R., House, J. S. (1999). Volunteering and mortality among older adults: Findings from a national sample. Journal of Gerontology: Social Science, 54B(3), S173–S180. Omoto, A. M., Snyder, M., & Martino, S. C. (2000). Volunteerism and the life course: Investigating age-related agendas for action. Basic and Applied Social Psychology, 22(3), 181–197. Peter D. Hart Research Associates. (2002). The new face of retirement: An ongoing survey on Americans attitudes on aging. New York: Peter D. Hart Research Associates. Prisuta, R. (2004). Enhancing volunteerism among baby boomers. In Reinventing Aging: Baby boomers and civic engagement. Boston, MA: Harvard School of Public Health, Center for Health Communication. Thoits, P. A., & Hewitt, L. N. (2001). Volunteer work and well-being. Journal of Health and Social Behavior, 42, 115–131. Van Willigen, M. (2000). Differential benefits of volunteers across the life course. Journal of Gerontology, 55B(5), S308–S318.

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W WANDERING In gerontology, the behavior of wandering is associated with cognitive impairment. Wandering has been used to describe diverse patterns of behavior or movement including pacing, seeking exits, entering other people’s rooms, attempting to leave a premise, getting lost, or simply purposeless ambulation. Understanding the behavior is complicated by the fact that different types of wandering behavior can co-occur in the same individual. Many definitions of wandering have been put forward by clinicians and scholars over the years. They include those focusing on locomotion patterns (e.g., pacing versus exit seeking), on geographical patterns (e.g., random versus lapping), or on the apparent reasons for wandering (e.g., anxiety versus the psychological need to either seek or avoid social interaction). Wandering has also been classified as aimless physical movement through space (i.e., a wheelchair user can also exhibit wandering behavior). The process of defining wandering has been likened to an intuitive process, whereby one would be able to identify the behavior when one saw it (Thomas, 1995). Among such multiple definitions, 2 common attributes that generate few disputes are repetitive ambulation and cognitive impairment (Algase & Struble, 1992).

Prevalence The phenomenon of wandering has not drawn much attention from researchers over the years. The few studies that have examined rates of prevalence found 17% to 63% for subjects residing in the community (Allan, 1994; Klein, Steinberg, Galik, Steele, Sheppard, Warren, et al., 1999; Hope, Tilling, Gedling, Keene, Cooper, & Fairburn, 1994) and 11% to 50% for long-term care residents (Hiatt, 1985; Hoffman, Platt, & Barry, 1987; Teri, Larson, & Reifler, 1988). Algase, who has studied wandering for nearly 2 decades, has suggested that all ambulatory nursing home residents who are 1220

cognitively impaired engage in wandering behavior to some extent (Algase, Kupferschmid, BeelBates, & Beattie, 1997). Although there is no consensus about prevalence rates, researchers seem to agree that people with Alzheimer’s disease are more likely to exhibit wandering behavior than those suffering from vascular dementia (Cooper & Mungas, 1993; Thomas, 1997). Any examination of rates of prevalence needs to consider that the prevalence of the problem is related to how wandering is defined and the particular pattern of wandering being examined. McShane and colleagues (1998) followed up 104 subjects for 5 years and found the annual prevalence rate of “getting lost” decreased over time, while the rate of “attempts to leave home” remained relatively stable as the subjects’ dementia progressed. Several postulations could explain such an observation—the families could have put the subjects under closer surveillance, more restrictions might have been placed on the subjects’ freedom of movement, or the subjects’ physical ability to ambulate independently had diminished. Consequently, those who wandered would have fewer chances to become lost.

Profiling the Wanderers As in many other fields, the findings concerning the attributes of a wanderer have been equivocal at best. Correlates between age, gender, sleep disturbances, specific cognitive deficits (such as language competence), psychiatric symptoms (such as delusion), or the use of psychotropic drugs and wandering had been found to be positive in some studies but not in others. A few studies have proposed that wanderers have a tendency to engage in motor behavior when stressed. Other preliminary results have shown that wanderers tended to have had a more active pre-morbid lifestyle or a particular personality than non-wanderers. Although scientists disagree on many issues, they tend to agree that wandering correlates with

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the severity of cognitive impairment. Wanderers with a higher frequency to engage in wandering behavior show significantly more impairment in cognition and day-to-day functioning (Logsdon, Teri, McCurry, Gibbons, Kukull, & Larson, 1998; Yang, Hwang, Tsai, & Liu, 1999). Wandering has been found to peak for residents up to age 74 years, and then begin to decline (Schreiner, Yamamoto, & Shiotani, 2000). Scientists have also noted that the wanderers were more agitated than non-wanderers (Colombo, Vitali, Cairati, PerelliCippo, Bessi, Gioia, et al., 2001). Interestingly, Hope and colleagues (2001) found that wandering typically starts when a person’s Mini-Mental State Examination score is about 13, and lasts for a period of several years. A retrospective study studying a large cohort (N = 8982) by Kiely and colleagues (2000) found that the characteristics of residents associated with the occurrence of wandering include the male gender, cognitive impairment, discomfort or unsettled states, the use of medication, pain, and the ability to wander. Their sample included nursing home residents who were not wanderers at baseline; therefore, their approach provided stronger support for a possible causal association between the characteristics of subjects at baseline and the development of wandering.

Etiology The etiology of wandering remains puzzling to researchers. From a biomedical perspective, wandering has been conceptualized as a right parietal lobe dysfunction, an impaired neural circuit, or an increased drive to walk as a result of brain damage. It has also been discussed as a dysfunctional motor response resulting from a failure to self-monitor, an impaired topographical memory, or spatial disorientation. Scientists taking a psychosocial perspective interpret wandering as an expression of human needs, believing that the person may be hungry, anxious, seeking company, or looking for some place safe and familiar. Interactionists hypothesize that wandering results from the interactions between the person and his or her environment. For instance, one study has associated wandering with low levels of noise and adequate lighting (Cohen-Mansfield, Werner, Marx, & Freedman, 1991).

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Assessment It is a challenging task to assess wandering behavior. Only 3 assessment scales can be found in the literature so far. Of them, only the Algase Wandering Scale (AWS) (Algase, Beattie, & Therrien, 2001), which has both a community and a long-term care version, has been vigorously tested as a research instrument. From the clinical point of view, assessments of wandering need to take the following into consideration prior to the formulation of an intervention plan (Lai & Arthur, 2003b): • Basic data—whether the person is safe, baseline information about the pattern and triggers of wandering, any changes in the pattern and amount of wandering • Physiological or disease-related information— whether the person is hungry or in pain, any presence of psychotic or neurological symptoms, and so on • Psychological factors—the life history, lifestyle, and previous stress-coping patterns of the person, whether the person looks bored, etc. • Environmental factors—whether the environment is comprehensible and has adequate signage, any evidence of too much or too little stimulation Regardless of whether a person wanders constantly or at times, the assessment needs to consider whether the behavior may endanger the person’s safety and well-being, and whether the behavior causes concern to the caregivers. Constant wandering can lead to an excessive expenditure of energy, fatigue, and an increased risk of falls. Wandering away from home may cause a person to get lost or sustain injuries. In long-term care facilities, the transgression of boundaries may lead to altercations among the residents. Increasingly, staff working in long-term care are concerned about the potential for litigation should residents go missing. Across different cultures, humans are conditioned to associate pacing and wandering with agitation, anxiety, and distress. In fact, some researchers (Cohen-Mansfield & Werner, 1998) have suggested another perspective in looking at the matter. Wandering can be considered a form of exercise that stimulates circulation and oxygenation. Only an individual with relatively good health has the

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capabilities to engage in wandering. Hope and colleagues (1994) found no relationship between wandering and getting lost. Wandering, therefore, does not always need to be stopped. What needs to be prevented and monitored is elopement—a term now used in gerontology literature to refer to incidents in which an older person gets away from his or her residence and is found missing. Stopping the wanderer by chemical or physical restraints could be detrimental to the person’s health. Enforced rest or bed rest can quickly lead to a cascade of events rendering the wanderer no longer capable of walking, not to mention the infringement of his or her autonomy and dignity. The goal of managing wandering behavior should be to provide a safe level of ambulation without putting the person at risk of injury (Taft, Delaney, Seman, & Stansell, 1993), rather than stopping the wandering behavior. The inability to distinguish between the various types of wandering behavior, a failure to investigate its underlying reasons, and a lack of understanding by formal caregivers regarding the needs of the elderly with cognitive impairment may lead to inappropriate management.

Therapeutic Modalities The few studies that have conducted on the control of wandering using pharmaceutical agents have not found medications to be effective (Lai & Arthur, 2003a). Sedatives and anxiolytics lowered the wanderers’ general level of physical activity and might increase their chances of sustaining a fall. Behavioral modification is one of the approaches used to manage wandering behavior. Reports on the efficacy of this approach, however, have mainly been anecdotal and are therefore inconclusive. The approach of enhancing the environment, on the other hand, has been somewhat better studied. Researchers (Cohen-Mansfield & Werner, 1998) have modified features in the immediate physical environment in an attempt to maintain the connections of the nursing home residents with what used to be familiar to them (for instance, by providing the scent of flowers and sounds of birds singing), and to reduce institutional attributes (such as by decorating the surroundings like a place in a park). The underlying assumption was that residents would be less agitated in a familiar and pleasant surrounding. The

sizes of the samples in these studies were small. Despite some favorable outcomes, further studies are required before the merits of these strategies can be substantiated. Programming activities is one of the more popular approaches to managing wandering in longterm care. Reports have suggested that individualized programming that caters to the needs of the wanderer could lower their level of agitation and decrease wandering behavior. An example would be to organize an interest group or a walking-talking partner for the wanderers. These studies reported certain benefits for the wanderers, but their findings have been clouded by their study design—there has been inadequate control of the intervening variables. In a recent clinical trial, Landi and colleagues (2004) reported that exercise training could be helpful for patients with moderate to severe cognitive impairment. Patients in the treatment group showed a statistically significant reduction in behavioral problems such as wandering, with a concomitant decrease in the use of hypnotics and antipsychotics. In summary, there are no simple answers to the successful management of intriguing behavior such as wandering. Older persons exhibiting wandering behavior need to be appraised and managed on an individual basis.

Management of Elopement Within long-term care settings, the use of visual barriers has been the most studied strategy for preventing elopement. Various designs and decoys have been used, including laying masking tape on the floor toward exit doors (Hewawasam, 1996; Hussian & Brown, 1987), placing full-length mirrors in front of the door (Mayer & Darby, 1991), using a cloth panel to conceal doorknobs (Namazi, Rosner, & Calkins, 1989), and so on. Despite reports of success in these studies, a Cochrane systematic review (Price, Hermans, & Grimley Evans, 2001) has found that none of the studies offered strong evidence to substantiate their claims. This does not necessarily mean that these strategies are ineffective, but rather that more rigorous research is required. When an older person with cognitive impairment wanders away from home or from the nursing home, it is imperative to find him or her as quickly as

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possible, in view of the dangers of accidents from road traffic and exposure. Although the use of armbands to electronically monitor residents with Alzheimer’s disease is not a new invention, there have yet to be major advances on the development and use of tracking devices. The public is concerned that being tracked in such a manner is degrading and dehumanizing. Others have argued that tracking devices will give both family members and professional caregivers ease of mind, and consequently lead to greater freedom for the older persons who wander. Most tracking or location devices use the Global Positioning System, which may not be suitable for locating people in a metropolis full of high-rises, like New York or Tokyo, but may be appropriate for less dense cities or for suburbs. Pulsed codes transmitted through radio frequencies, ultrasonic beacons, and modern technologies in telecommunications such as a cellular phone system are also used to locate a person. Many obstacles have to be overcome before location devices become widely acceptable. Would the person with cognitive impairment wear the device all the time? How long can the battery last? How big or how heavy is the device to be carried? And is it affordable for most people? These are just some of the practical questions. Rowe and Glover (2001) report that fortunately the majority of those who have gone missing were found even before the caregivers felt they needed to report to the police. Close to 50% of those reported in incidents to the Alzheimer’s Association were found by law enforcement officers, and 82% were found in under 12 hours (Rowe & Glover, 2001).

Resources There are products in the market that help caregivers locate people who wander. Electronic tagging is one such means. In 1993, the Alzheimer’s Association of the United States started to administer a program called Safe Return (Alzheimer’s Association, 2005). Its purpose is to help those with cognitive impairment who become lost in the community return safely to their home or care setting. Family caregivers can contact their local chapter and register their relatives in the program. To date, the program has had a success rate of close to 100%, and more than 7,000 cognitively impaired persons received

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help in returning home. Currently, over 90,000 individuals are registered. Canada has a similar program called Safely Home, and in Australia, a Safe Return Home program for people with Alzheimer’s was launched in early 2004. Claudia K. Y. Lai

References Algase, D. L., Beattie, E. R. A., & Therrien, B. (2001). Impact of cognitive impairment on wandering behavior. Western Journal of Nursing Research, 23, 283–295. Algase, D. L., Kupferschmid, B., Beel-Bates, C., & Beattie, E. R. A. (1997). Estimates of stability of daily wandering behavior among cognitively impaired longterm care residents. Nursing Research, 46, 172–178. Algase, D. L., & Struble, L. (1992). Wandering: What, why and how? In K. Buckwalter (Ed.), Geriatric mental health nursing: Current and future challenges (pp. 61–74). NJ: Slack. Allan, K. (1994). Dementia in acute units: Wandering. Nursing Standard, 9(8), 32–34. Alzheimer Association. (2005). Alzheimer’s association safe return. Available: http://www.alz.org/Services/ SafeReturn.asp Cohen-Mansfield, J., & Werner, P. (1998). The effects of an enhanced environment on nursing home residents who pace. Gerontologist, 38, 199–208. Cohen-Mansfield, J., Werner, P., Marx, M. S. & Freedman, L. (1991). Two studies of pacing in the nursing home. Journal of Gerontology, 46, M77–M83. Colombo, M., Vitali, S., Cairati, M., Perelli-Cippo, R., Bessi, O., Gioia, P., et al. (2001). Wanderers: Features, findings, issues. Archives of Gerontology and Geriatrics, 33(Suppl. 1), 99–106. Cooper, J. K., & Mungas, D. (1993). Risk factor and behavioral differences between vascular and Alzheimer’s dementias: The pathway to end-stage disease. Journal of Geriatric Psychiatry and Neurology, 6, 29–33. Hewawasam, L. C. (1996). The use of two-dimensional grid patterns to limit hazardous ambulation in elderly patients with Alzheimer’s disease. NT research, 1(3), 217–227. Hiatt, L. G. (1985). Interventions and people who wander—contradictions in practice. Gerontologist, 25, 253. Hoffman, S. B., Platt, C. A., & Barry, K. E. (1987). Managing the difficult dementia patient: The impact on untrained nursing home staff. American Journal of Alzheimer’s Care and Related Disorders Research, 2(4), 26–31.

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Hope, T., Keene, J., McShane, R. H., Fairburn, C. G., Gedling, K., & Jacoby, R. (2001). Wandering in dementia: A longitudinal study. International Psychogeriatrics, 13(2), 137–147. Hope. T., Tilling, K. M., Gedling, K., Keene, J. M., Cooper, S. D., & Fairburn, C. G. (1994). The structure of wandering in dementia. International Journal of Geriatric Psychiatry, 9, 149–155. Hussian, R. A., & Brown, D. C. (1987). Use of twodimensional grid patterns to limit hazardous ambulation in demented patients. Journal of Gerontology, 42, 558–560. Kiely, D. K., Morris, J. N., & Algase, D. L. (2000). Resident characteristics associated with wandering in nursing homes. International Journal of Geriatric Psychiatry, 15, 1013–1020. Klein, D. A., Steinberg, M., Galik, E., Steele, C., Sheppard, J., Warren, A., et al. (1999). Wandering behaviour in community-residing persons with dementia. International Journal of Geriatric Psychiatry, 14, 272–279. Lai, C. K. Y., & Arthur, D. G. (2003a). Wandering behaviour in people with dementia: A critical review of the literature. Journal of Advanced Nursing, 44(2), 173–182. Lai, C. K. Y., & Arthur, D. (2003b). Wandering: Can it be cured? In R. Hudson (Ed.), Clinical approaches to dementia care (pp. 70–82). Melbourne: Ausmed. Landi, F., Russo, A., & Bernabei, R. (2004). Physical activity and behavior in the elderly: A pilot study. Archives of Gerontology and Geriatrics, 38(Suppl. 1), 235–241. Logsdon, R. G., Teri, L., McCurry, S. M., Gibbons, L. E., Kukull, W. A., & Larson, E. B. (1998). Wandering: A significant problem among community-residing individuals with Alzheimer’s disease. Journal of Gerontology: Psychological Sciences, 53B, 294–299. Mayer, R., & Darby, S. T. (1991). Does a mirror deter wandering in demented older people? International Journal of Geriatric Psychiatry, 6, 607–609. McShane, R., Gedling, K., Keene, J., Fairburn, C., Jacoby, R., & Hope, T. (1998). Getting lost in dementia: A longitudinal study of a behavioral symptom. International Psychogeriatrics, 10(3), 253–260. Namazi, K. H., Rosner, T. T., Calkins, M. P. (1989). Visual barriers to prevent ambulatory Alzheimer’s patients from exiting through an emergency door. Gerontologist, 29(5), 699–702. Price, J. D., Hermans, D. G., & Grimley Evans, J. (2001). Subjective barriers to prevent wandering of cognitively impaired people. Cochrane Library, 4. Rowe, M. A., & Glover, J. C. (2001). Antecedents, descriptions and consequences of wandering in cognitively-impaired adults and the Safe Return (SR)

program. American Journal of Alzheimer Disease and Other Dementias, 16(6), 344–352. Schreiner, A. S., Yamamoto, E., & Shiotani, H. (2000). Agitated behavior in elderly nursing home residents with dementia in Japan. Journal of Gerontology: Psychological Sciences, 55b, 180–186. Taft, L. B., Delaney, K., Seman, D., & Stansell, J. (1993). Dementia care: Creating a therapeutic milieu. Journal of Gerontological Nursing, 19(10), 30–39. Teri, L., Larson, E. B., & Reifler, B. V. (1988). Behavioral disturbance in dementia of the Alzheimer’s type. Journal of the American Geriatrics Society, 36, 1–6. Thomas, D. W. (1995). Wandering: A proposed definition. Journal of Gerontological Nursing, 21(9), 35–41. Thomas, D. W. (1997). Understanding the wandering patient: A continuity of personality perspective. Journal of Gerontological Nursing, 23(1), 16–24. Yang, C. H., Hwang, J. P., Tsai, S. J., & Liu, C. M. (1999). Wandering and associated factors in psychiatric inpatients with dementia of Alzheimer’s type in Taiwan: Clinical implications for management. Journal of Nervous and Mental Disease, 187, 695–697.

WEAR-AND-TEAR THEORIES The “wear-and-tear” theory of aging, or so-called Abnutzungstheorie, was a side product of a theory by A. Weismann (1882), who was the first to make a distinction between the immortal germ plasm and its transitory and mortal vehicle, the soma. The mechanism of aging was not clear during that period, and it was natural to consider it as a kind of wearand-tear process normal for every complex system that is not able to repair all the damages and lesions of its essential parts. The central concept of the Weismann theory was the postulation of the potential immortality of the germ plasm. Aging was considered as an inherent property of somatic tissues, particularly those that do not show the ability for regeneration or cellular proliferation. Aging occurs simply because a worn-out tissue cannot renew itself forever. The survival potential of individuals should decrease, therefore, with increasing age. The “wear-and-tear” idea was not originally suggested as a theory of aging, or as something that explains the nature of aging processes. It was simply a comparison of aging with something known conventionally. Only later, when it became possible to

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give reviews of different theories of aging, were the Weismann explanations about immortal germ plasm and mortal and disposable soma normally included as one of the first in the list of different theories. It was also considered as the basis of the more specific “rate of living” theory (Rubner, 1908), which tried to find a correlation between the length of life and the total energy expenditure per gram of tissue during adult life. It could also be considered as a kind of pretheory for any modern physiological, biochemical, or molecular theory of aging that considers that the replacement of damaged or worn parts, cells, or cellular structures and molecules is not perfect enough or does not occur at a rate sufficient to compensate for the deleterious effects of time and of other external or internal factors. The accumulation of somatic mutations, errors of protein biosynthesis, unrepaired changes of DNA, and similar processes considered by modern theories of aging also belong in a more general sense to current versions of wear-and-tear theories. Because wear-and-tear processes are so commonly observed in human practice and in everyday language, the description of aging as the wear-and-tear process was perpetuated in popular literature. To be sure, certain specific processes of cellular aging could fit perfectly into a simple model of wear-and-tear. The aging of anucleated red blood cells in the circulation is essentially a wear-and-tear process because these cells do not have systems that can synthesize nucleic acids and proteins and, therefore, have no repair capabilities. The wear of teeth in many mammals is probably the most common example of this theory at the tissue level. Weismann’s theory did not have a serious impact on the subsequent attempts to study the character of age changes in different tissues. However, Weismann’s ideas about the potentially immortal germ plasm and mortal soma did have a significant influence on the study of the evolution of aging processes and on the understanding of the relation between aging and reproduction. If aging of soma does not depend on the aging of germ plasm, and somatic aging influences the reproductive system, the individuals can be “worn-out” and unable to reproduce, but they are still viable and can compete with their immature or active new generations. This situation can create evolutionary disadvantages and make it necessary to introduce in evolution some kind of life-termination mechanisms that make possible op-

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timal relationships between somatic survival and reproductive processes. This part of the original theory proved to be fruitful and stimulated ideas about programmed aging and some attempts to find the correlation between the duration of the reproductive periods and life span and generated more discussions on the evolution of aging in different species. It was also reflected in a modern “disposable soma theory” (Kirkwood & Holliday, 1979), which postulates that a higher organism that reproduces repeatedly invests more energy into the creation of the fidelity of repair of germ cells and a smaller proportion of energy into somatic maintenance. This makes impossible the high-quality repair of somatic cells and does not allow soma to last indefinitely. The disposable soma theory, like the original wear-and-tear theory, predicts the accumulation of unrepaired somatic damage through life, senile degeneration and, ultimately, death. Sacher (1966) considers that the Abnutzungstheorie “has already attained its objective by validating a fundamental hypothesis about the evolution of longevity and senescence and thereby providing a proven basis and direction for research on life prolongation.” Many critics view the “wear-and-tear” theory as simplistic, mechanistic, and too general, but they normally ignore the fact that this theory was suggested more than a century ago and was not designed to explain the total complexity of the aging process. Zhores A. Medvedev See also Oxidative Stress Theory

References Kirkwood, T., & Holliday, R. (1979). The evolution of aging and longevity. Proceedings of the Royal Society of London, B, 205, 531–536. Rubner, M. (1908). Das problem der lebensdauer und seine beziehungen tu wachstum und ernährung. München: Oldenbourg. Sacher, G. A. (1966). Abnutzungstheorie. In N. W. Shock (Ed.), Perspectives in experimental gerontology. Springfield, IL: Charles C Thomas. Weismann, A. (1892). Aufsätze u¨ ber vererbung und verwandte biologische fragen. Jena: Gustav Fischer.

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WIDOWHOOD Widowhood is a stage in the life cycle defined by the loss of one’s spouse, but it typically leads to wide-ranging changes in roles, identities, social supports, finances, and living facilities, especially when this transition occurs after many years of marriage. All married persons will experience widowhood unless they divorce, separate, or die before their spouses. Widowhood is now primarily a late-life phenomenon, as death has become more common among older persons than among young adults. It is also primarily an older woman’s issue; in almost all developed countries, older women, and particularly widowed women, outnumber their male counterparts, especially among the oldest old (Gist & Vilkoff, 1997; Ofstedal, Reidy, & Knodel, 2004). Nearly one-third of all persons over age 65 are widowed in the United States—about 14% of men, and more than 45% of women. Approximately twothirds of Americans over age 85 are widowed—80% of women and 34% of men (U.S. Census Bureau, 2003). The rates are even higher in Japan and South Korea, where more than 90% of women and 41% of men over age 85 are widowed (U.S. Census Bureau, 2004). In most countries of the world, older men are more likely to be married, and older women are more likely to be widowed (Kinsella & Velkoff, 2001). These gender differences in marital status result from several factors, including sex differences in longevity, women’s tendency to marry older men, and widowers’ higher remarriage rates. These trends will change, and the ratio of widows to widowers will decrease in the next century as men live longer and marry women closer in age (Kinsella & Velkoff, 2001). Holmes and Rahe (1967) identify the loss of a spouse and subsequent bereavement as the most stressful event that anyone experiences, although it is generally easier later in life than when it occurs “off-time” during young adulthood or middle age (Moss, Moss, & Hansson, 2001). A large body of research has established that even older bereaved spouses have higher rates of mortality and morbidity, weaker immune systems, more depressive symptoms, more chronic conditions and functional disabilities, a higher number of physician visits and days spent in nursing homes, greater overall health care costs, and higher rates of hospitalization than their married peers (Laditka & Laditka, 2003).

Contemporary studies of widowhood have challenged many traditional assumptions, including the existence of grief stages, the need for bereaved persons to detach from the deceased and “work through” their grief, and an increase in depression and loneliness during widowhood. More sophisticated research designs have been used with large samples to control for potentially confounding influences in past research. Longitudinal studies, such as the Changing Lives of Older Couples (CLOC), have yielded innovative findings about how people adjust to widowhood. New theoretical frameworks about widowhood have also motivated researchers to ask different questions and examine different outcome measures. Role theory, until recently the most common conceptual framework used to study widowhood, was especially useful in comparative analyses across societies and cultures where variations in gender roles illuminated global variations in widowhood (Lopata, 1996). More recently, scholars have applied other conceptual approaches to bereavement and widowhood. Folkman (2001) uses a stress paradigm to examine the adaptive tasks of coping with loss. Stroebe and Schut propose a Dual Process Model of Bereavement in which bereaved spouses alternate (or “oscillate”) between managing emotional or lossoriented tasks, and practical or restoration-oriented activities. Neimeyer (2001) describes an emerging “new wave” of grief theory that recognizes the complexity and cultural diversity of adjustments to bereavement and widowhood. Some experts (Stroebe, Schut, & Stroebe, in press; Parkes, 2002) have suggested that widowed person’s reactions to loss differ according to their attachment styles. Recent studies indicate that the majority of widows and widowers are resilient (Bonnano, Wortman, Lehman, Twee, Haring, Sonnega, et al, 2002). Almost everyone experiences an initial increase in grief symptoms, but for most people these symptoms subside by 18 months after the loss. Resilient widows and widowers generally are more accepting of death, more extraverted, more emotionally stable, and less dependent on spouses than their non-resilient peers. Resilient grievers also are more likely to have strong social supports from friends, relatives, and children, and to believe that they could rely on friends and family members for help with housework, home maintenance, finances, and caretaking if they became ill.

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Those who grieve chronically have higher levels of interpersonal dependence and dependency on spouses. Widowed persons who are chronically depressed typically have poor coping capacities, low extraversion, poor emotional stability, high interpersonal dependence, and strong feelings about the uncontrollability of life events. In addition, they often have inadequate instrumental supports (Bonnano, Wortman, Lehman, Twee, Haring, Sonnega, et al., 2002). Depending on the sample and the assessment procedure used, researchers report that about 40% to 70% of widowed persons experience dysphoria, a period of 2 or more weeks marked by feelings of sadness, immediately after the loss. From 15% to 30% of survivors experience clinically significant depression in the year following their spouse’s death (Zisook & Shuchter, 1991). Another consistent finding in recent studies is the tremendous variability in people’s widowhood experiences. Among the many factors that influence widowhood are income, gender, ethnic and cultural differences, social supports, and the circumstances of death, specifically timing, cause, place, extent of caregiving, extent of suffering, and communications about death. Economic resources are especially important for widows, who often abruptly lose significant income after the death of a spouse. Financial strain is a primary factor affecting widowed women (Umberson, Wortman, & Kessler, 1992; Utz, in press). This corroborates data showing that poverty among older widowed women is consistently 3 to 4 times higher than for their married peers (McGarry & Schoeni, 2003). In addition, older widows face many more economic disadvantages than older widowers; this is a global trend, although some widows improve their financial condition by living in multigenerational households (United Nations, 2002; Ofstedal, Reidy, & Knodel, 2004). Gender differences also influence widowhood. Investigators (Schut, Stroebe, van den Bout, & de Keijser, 1997) report that widows and widowers cope differently with the loss of a spouse, although significant differences exist within these groups (Richardson & Balaswamy, 2001; Richardson, in press). Carr (2004) found that widowed women who had the highest emotional dependence on their spouses had the worst self-esteem while married, but the highest self-esteem and psychological

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growth during widowhood. Older men, on the other hand, had higher self-esteem while married than in widowhood. Bereaved spouses must cope with feelings of loss for a lifelong companion, but they must also address concrete matters such as obtaining survivor benefits and maintaining a home. They must perform their former practical chores and those that their deceased spouses once performed. Utz (2004) found that older bereaved adults are often overwhelmed when initially confronted with these additional tasks, although widows were more troubled by home maintenance chores, and widowers struggled more with household tasks. Studies of later cohorts in which married couples maintain more flexible and less traditional gender roles may demonstrate different trends. Ethnic background and cultural differences affect how widowed persons grieve and how others treat them. Hsu and Kahn (2003) found that the adjustments of Taiwanese widows to the loss of a spouse were shaped by the cultural views of a “good death” and “death without suffering” that were based largely on others’ interpretations. These widows coped by finding meaning and reconstructing their identities within the Taiwanese cultural context of marriage, death, and bereavement. Numerous studies (Dimond, Lund, & Caserta, 1987) demonstrate the importance of social resources for well-being during widowhood. Many widowed persons describe their increased social participation as an active method of coping with the loss of their spouses (Utz, Carr, Nesse, & Wortman, 2002). Richardson (in press) found that widows and widowers who interacted more frequently with friends demonstrated more positive well-being throughout widowhood; involvement with confidantes was especially important for widows. Utz and colleagues (2002) found that friends and family members usually assist bereaved persons with instrumental tasks during the early stages of bereavement, and widows tend to receive more support than widowers. Although these results indicate that strong social supports improve people’s well-being during widowhood, they rarely substitute for the emotional attachments that many married persons experience with their spouses (Stroebe, Schut, & Stroebe, in press). Death circumstances influence people’s bereavement reactions in several ways. Carr and colleagues

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(2001) found that sudden deaths were associated with elevated levels of intrusive thoughts (unwelcome memories of the deceased or of the events surrounding the death that affected sleeping and concentration) during at least the early months of bereavement. In contrast, prolonged forewarning prior to death (i.e., more than 6 months) increased bereaved persons’ anxiety levels after the loss. Sudden violent deaths may be particularly distressing (Kaltman & Bonanno, 2003). Caring for a spouse often affects bereaved persons’ adjustments to widowhood, especially if it continues for many months (Schulz, Beach, Lind, Martire, Zdaniuk, Hirsch, Jackson, et al., 2001). The surviving spouse may feel relief when freed from that difficult role. On the other hand, older widowers who lose contact with friends and family members as a result of caregiving often experience more difficult adjustments to widowhood than those who successfully maintained those relationships (Carr, House, Wortman, Nesse, & Kessler, 2001). The location of a spouse’s death and their communications about death also influence survivors’ initial adjustments to widowhood. When loved ones die in nursing homes, the survivors have already struggled with losses associated with placing their spouses in these institutions; nevertheless, home deaths apparently offer bereaved persons more comfort than when spouses die in hospitals (Richardson & Balaswamy, 2001). Survivors may adjust better when the death occurs at home, because a familiar and comfortable setting promotes better communication between spouses. When spouses suffer, however, survivors often experience more negative grief reactions (Carr, 2003; Richardson & Balaswamy, 2001). These recent findings underscore the wide variability in people’s widowhood experiences and the importance of assessments that allow practitioners to tailor interventions in accordance with death circumstances and to widowed persons’ lifestyle differences, such as gender, economic, and ethnic variations. Widowed persons also vary in what they find most helpful. Some simply appreciate knowing that help is available, whether or not they use it. Others are glad to learn that their feelings are normal and that the acute pain of grief will eventually subside. Most widowed persons indicate that they achieved the most personal growth after the intense grieving period subsided, when they

felt ready to reinvest in life through new activities and relationships. Few national policies focus directly on bereavement, although some federal statutory programs include important provisions for older widowed persons. The Older Americans Act offers a network of services for older bereaved adults. Medicare finances health care and hospice benefits for people over age 65, and the Social Security Act provides economic benefits to retirees, widows, and their dependents. Many communities offer widows and widowers mutual support groups, individual counseling, and programs that assist them with instrumental needs, such as homemaker services, chore services, telephone reassurance programs, friendly visitors, repairs, and money management. Some local area agencies on aging also offer health promotion services, including screening for depression, mental health information, and referrals to psychiatric and psychological services. Most scholars concur that grief interventions work best for those who are at risk for complicated reactions and for those who seek help, but they can be ineffective and create adverse effects when they interfere with normal grieving (Schut, Stroebe, van den Bout, & Terheggen, 2001; Jordan & Neimeyer, 2003). There is also evidence that treatment is more likely to be successful if is provided after a delay, preferably between 6 to 18 months after the death (Jordan & Neimeyer, 2003). There is still very little research identifying the specific interventions that work best for different clients under different circumstances. In addition, experts have inadequately evaluated the impact of community interventions, such as support services for widows who need assistance with yard work, financial matters, or other instrumental tasks. The efficacy of interventions for widows and widowers increases when clinicians tailor interventions based on clients’ gender, ethnic background, and other personal differences. Virginia E. Richardson See also Bereavement

References Bonnano, G., Wortman, C., Lehman, D., Twee, R., Haring, M., Sonnega, J., Carr, D., & Nesse, R. (2002).

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Widowhood Resilience to loss and chronic grief: A prospective study from preloss to 18-months postloss. Journal of Personality and Social Psychology, 83, 1150–1164. Carr, D., House, J., Wortman, C., Nesse, R., & Kessler, R. (2001). Psychological adjustment to sudden and anticipated spousal loss among older widowed persons. Journal of Gerontology: Social Sciences, 56B, S237– S248. Carr, D. (2003). A good death for whom? Quality of spouse’s death and psychological distress among older widowed persons. Journal of Health and Social Behavior. Dimond, M., Lund, D. A., & Caserta, M. S. (1987). The role of social support in the first two years of bereavement in an elderly sample. Gerontologist, 27, 599– 604. Gist, Y., & Velkoff, V. (1997). Gender and aging: Demographic dimensions. U.S. Census Bureau, International Programs Center, International Brief (IB/98-2). Holmes, J. H., & Rahe, R. H. (1967). The social readjustment scale. Journal of Psychosomatic Research, 11, 213–228. Hsu, M., & Kahn, D. (2003). Adaptation as meaning construction: A cultural analysis of spousal death in Taiwanese women. Omega: Journal of Death and Dying, 47, 169–186. Jordan, J. R., & Neimeyer, R. A. (2003). Does grief counseling work? Death Studies, 27, 765–786, Kaltman, S., & Bonanno, G. A. (2003). Trauma and bereavement: Examining the impact of sudden and violent deaths. Journal of Anxiety Disorders, 17, 131– 147. Kinsella, K., & Velkoff, V. A. (2001). An aging world. U.S. Census Bureau, Series P95/01-1. U.S. Government Printing Office. Laditka, J. N., & Laditka, S. B. (2003). Increased hospitalization risk for recently widowed older women and protective effects of social contacts. Journal of Women and Aging, 15, 7–28. Lopata, H. (1996). Current widowhood: Myths and realities. Thousand Oaks: Sage Publications. Neimeyer, R. (2001). Meaning reconstruction and loss. In R. Neimeyer (Ed.), Meaning reconstruction and the experience of loss (pp. 1–9). Washington, DC: American Psychological Association. Ofstedal, B. B., Reidy, E., & Knodel, J. (2004). Gender differences in economic support and well-being of older Asians. Journal of Cross-Cultural Gerontology, 19, 165–201. McGarry, K., & Schoeni, R. F. (2003). Medicare gaps and widow poverty. Working Paper 2003-065. Ann Arbor: University of Michigan Retirement Research Center. Moss, M. S., Moss, S. Z., & Hansson, R. O. (2001). Bereavement and old age. In M. Stroebe, R. O. Hansson, W. Stroebe, & H. Schut (Eds.), Handbook of be-

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reavement research: Consequences, coping, and care (pp. 241–260). Washington, DC: American Psychological Association. Parkes, C. M. (2002). Grief lessons from the past, visions for the future, Death Studies, 26, 367–385. Richardson, V. E. (in press). A dual process model of grief counseling: Findings from the changing lives of older couples (CLOC). Journal of Gerontological Social Work. Richardson, V. E., & Balaswamy, S. (2001). Coping with bereavement among elderly widowers. Omega: Journal of Death and Dying, 43, 129–144. Schulz, R., Beach, S., Lind, B., Martire, L., Zdaniuk, B., Hirsch, C., Jackson, S. & Burton, L. (2001). Involvement in caregiving and adjustment to death of a spouse: Findings from the caregiver health effects study. Journal of the American Medical Association, 285, 3123– 3129. Schut, H. A., Stroebe, M. S., van den Bout, J., & de Keijser, J. (1997). Intervention for the bereaved: Gender differences in the efficacy of two counseling programs. British Journal of Clinical Psychology, 36, 63–72. Schut, H., Stroebe, M., van den Bout, J., & Terheggen, M. (2001). The efficacy of bereavement interventions: Determining who benefits. In M. Stroebe, R. Hansson, W. Stroebe, W. & H. Schut (Eds.), Handbook of bereavement research: Consequences, coping, and care (pp. 705–737). Washington, DC: American Psychological Association. Stroebe, M. & Schut, H. (1999). The dual process model of coping with bereavement: Rationale and description. Death Studies, 23, 197–224. Stroebe, M., Schut, H., & Stroebe, W. (in press). Who benefits from disclosure? Exploration of attachment style differences in the effects of expressing emotions. Clinical Psychology Review. Stroebe, M. S., Stroebe, W., Schut, H., Zech, E., van den Bout, J. (2002). Does disclosure of emotions facilitate recovery from bereavement? Evidence from two prospective studies. Journal of Consulting and Clinical Psychology, 70, 169–178. Stroebe, W., Zech, E., Stroebe, M., & Abakoumkin, G. (in press). Does social support help in bereavement? Journal of Social and Clinical Psychology. Umberson, D., Wortman, C., & Kessler, R. (1992). Widowhood and depression: Explaining long-term gender differences in vulnerability. Journal of Health and Social Behavior, 33, 10–24. United Nations. (2002). Report of the second world assembly on ageing. Madrid, 8–12 April 2002. Publication A/CONF.197/9. New York: United Nations. U.S. Census Bureau. (2003). Statistical abstract of the United States: 2003. Washington, DC: U.S. Government Printing Office.

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U.S. Census Bureau. (2004). International data base. Washington, DC. Population Division, International Programs Center. Available: http://www.census. gov/cgi-bin/ipc/idbsprd Utz, R. L. (in press). The economic and practical adjustments to loss. In D. Carr, R. Nesse, & C. Wortman (Eds.), Widowhood in late life. New York: Springer. Utz, R. L., Reidy, E. B., Carr, D., Nesse, R., & Wortman, C. (2004). The daily consequences of widowhood: The role of gender and intergenerational transfers on subsequent housework performance. Journal of Family Issues, 25, 638–712. Utz, R., Carr, D., Nesse, R., & Wortman, C. (2002). The effect of widowhood on older adults’ social participation: An evaluation of activity, disengagement, and continuity theories. Gerontologist, 42, 522–533. Utz, R. (in press). The economic consequences of widowhood: How do economic resources affect psychological well-being? Zisook, S., & Shuchter, S. R. (1993). Major depression associated with widowhood. American Journal of Geriatric Psychiatry, 1, 316–326.

WISDOM Many aging researchers value the investigation of individual characteristics and processes that have the potential for growth during adulthood and old age, including emotional intelligence, social competence, or self-regulation (e.g., Carstensen & TurkCharles, 1998; Freund & Baltes, 1998; Kunzmann, 2004). This entry considers one human strength that has been thought to be an ideal endpoint of human development, namely, wisdom (Baltes & Smith, 1990; Erikson, 1959; Staudinger, 1999). At the core of this concept is the notion of a perfect, perhaps utopian, integration of knowledge and character, mind and virtue (Baltes & Kunzmann, 2003; Baltes & Staudinger, 2000). Although the psychology of wisdom is a relatively new field, several promising theoretical and operational definitions of wisdom have been developed during recent years (Baltes & Staudinger, 2000; Kramer, 2000; Kunzmann & Baltes, in press; Sternberg, 1990, 1998). In these models, wisdom is thought to be different from other human strengths in that it facilitates an integrative and holistic approach toward life’s challenges and problems—an approach that embraces past, present, and future

dimensions of phenomena, values different points of views, considers contextual variations, and acknowledges the uncertainties inherent in any sensemaking of the past, present, and future. A second important feature of wisdom is that it is inherently an intra- and interpersonal concept. In this sense, wisdom has been said to refer to time-tested knowledge that guides our behavior in ways that optimize productivity on the level of individuals, groups, and even society (Kramer, 2000; Sternberg, 1998). Finally, although wisdom has been linked to a good life at all times, its acquisition during ontogenesis may be incompatible with a hedonic life orientation and a predominantly pleasurable, passive, and sheltered life. Given their interest in maximizing a common good, for example, wiser people are likely to partake in behaviors that contribute, rather than consume, resources (Kunzmann & Baltes, 2003a, 2003b; Sternberg, 1998). Also, an interest in understanding the significance and deeper meaning of phenomena, including the blending of developmental gains and losses, most likely is linked to emotional complexity (Labouvie-Vief, 1990) and to what has been called “constructivistic” melancholy (Baltes, 1997).

Conceptualizing Wisdom in Psychological Research While there appears to be considerable agreement on several important ideas about the definition, development, and functions of wisdom, all existing psychological wisdom models encompass their own unique features. On an abstract level of description, there are 2 ways of studying wisdom (Baltes & Kunzmann, 2004). The first is to focus on the nature of wise persons, that is, their intellectual, motivational, and emotional characteristics. This work is grounded in research on social and personality psychology (Ardelt, 2004; Erikson, 1959; Wink & Helson, 1997). A second approach has been to define wisdom as a body of highly developed knowledge on the basis of relevant psychological and culturalhistorical wisdom work (Baltes, 2004). This approach proceeds from the idea that a comprehensive definition of wisdom requires going beyond the individual and her characteristics, simply because wisdom is an ideal, rather than a state of being.

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Personality-Based Approaches. In this tradition, wisdom has been conceptualized as a mature part of the individual’s personality (Erikson, 1959). One promising example for this approach is work conducted by Helson and colleagues (Helson & Srivastava, 2002; Wink & Helson, 1997). Consistent with Achenbaum and Orwoll (1991), the authors have distinguished 2 components of a wise personality, namely, practical and transcendent wisdom. According to Helson, both practical and transcendent wisdom reflect interpersonal development (empathy, understanding, maturity in relationships). In addition, practical but not transcendent wisdom is thought to reflect intrapersonal development (mature affective responses, self-knowledge, integrity), whereas transcendent but not practical wisdom reflects interest and skill in the transpersonal domain (self-transcendence, recognition of the limits of knowledge, philosophical/spiritual commitments). To assess practical wisdom, the authors created an 18-item scale consisting of adjectives from the Adjective Checklist (Gough & Heilbrun, 1983). The adjectives were chosen by judges to be indicative (i.e., clear-thinking, fair-minded, insightful, intelligent, interest-wide, mature, realistic, reasonable, reflective, thoughtful, tolerant, understanding, wise) and contra-indicative (i.e., immature, intolerant, reckless, shallow) of a wise person. This scale has been employed as a self-report and an observerreport measure. Transcendent wisdom has been assessed with an open-ended question, namely, “Would you give an example of wisdom you have acquired and how you came by it?” Four judges rate self-descriptive statements in response to this question on a 5-point scale. A statement receives a high score if it is abstract, insightful, and reflects philosophical or spiritual depth, an integration of thought and affect, as well as an awareness of the complexity and limits of knowledge. Both measures of wisdom, practical and transcendent, have been shown to demonstrate satisfactory psychometric characteristics (Wink & Helson, 1997; Helson & Srivastava, 2002). Another approach to defining the wise personality has been proposed by Ardelt (2003, 2004). Based on Clayton & Birren (1980), Ardelt defined wisdom as an integration of reflective, cognitive, and affective characteristics. Ardelt views the reflective dimension as a prerequisite for the acquisition of the cognitive and emotional elements. Reflection pri-

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marily refers to a person’s willingness and ability to overcome subjectivity and projections by looking at phenomena and events from different perspectives. The cognitive element is defined as a person’s ability to understand life, that is, to comprehend the significance and deeper meaning of phenomena. The affective dimension of wisdom is reflected in the presence of positive emotions toward others (e.g., sympathy, compassion) and the absence of indifferent or negative emotions. To assess the 3 dimensions of her wisdom model in a sample of older adults, Ardelt (2003) developed a self-report questionnaire on the basis of existing personality inventories. She has provided initial evidence that her questionnaire demonstrates satisfactory psychometric characteristics, at least in a sample of older adults. In sum, research in the tradition of personality research has made valuable contributions to our understanding of the wise personality. As reviewed previously, however, different approaches have focused on different components of the wise personality, making it difficult to reach firm conclusions about the exact nature and structure of wisdom. Furthermore, given the lack of a generally accepted theoretical model of the development and functions of the wise personality, it remains unclear whether certain personality traits (e.g., affect sensitivity) represent an antecedent, constituent, or consequence of wisdom. Clarifying the structure and content of the wise personality based on rigorous and systematic questionnaire development and multi-trait, multimethod factor analytic work is an important direction for future research (see Kunzmann & Stange, in press). Wisdom as a Highly Developed Body of Knowledge. In this tradition, wisdom has been conceptualized in the context of psychometric models of intelligence (Baltes & Smith, 1990; Baltes & Staudinger, 2000; Sternberg, 1998). Sternberg’s wisdom model represents one example. Proceeding from his triarchic theory of intelligence, Sternberg (1998) considers tacit knowledge, a component of practical intelligence, as a core feature of wisdom. According to Sternberg (1998), tacit knowledge is action-oriented, it helps individuals to achieve goals they personally value, and it can be acquired only through learning from one’s own experiences, not “vicariously” through reading books or through others’ instructions. Sternberg (1998) states that

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wisdom is not tacit knowledge per se, but rather is involved when people apply their tacit knowledge to maximize a balance of various self-interests (intrapersonal) with other people’s interests (interpersonal) and aspects of the context in which they live (extrapersonal). Therefore, what sets wisdom apart from practical intelligence is its orientation toward the maximization of a common good, rather than individual well-being. Sternberg and his colleagues are currently developing open-ended tasks and coding schemes to operationalize their theoretical definition of wisdom. The tasks are complex conflict-resolution problems involving the formation of judgments, given multiple competing interests and no clear resolution of how these interests could be reconciled. Wisdom, assessed by these tasks, refers to a person’s ability to identify whose interests are at stake and what the contextual factors are under which one is operating (Sternberg, 1998). It will be interesting to see how this newly developed measure relates to personality-based wisdom questionnaires and other performancebased wisdom tests.

The Berlin Wisdom Paradigm The Berlin Wisdom Model, which has been proposed by Baltes and colleagues, is another example of work that conceptualized wisdom as a highly valued form of pragmatic intelligence (DittmannKohli & Baltes, 1990; Baltes & Smith, 1990; Dixon & Baltes, 1986; Baltes & Kunzmann, 2003; Baltes & Staudinger, 2000). This model, developed during the last 2 decades, has resulted in the most systematic research program on wisdom to date. Theoretical Definition and Assessment of Wisdom. Integrating work on the aging mind and personality, lifespan developmental theory, and cultural-historical work on wisdom, in the Berlin paradigm wisdom has been defined as a highly valued and outstanding expert knowledge about dealing with fundamental—that is, existential— problems related to the meaning and conduct of life (Baltes & Kunzmann, 2003; Baltes & Smith, 1990; Baltes & Staudinger, 2000). These problems are typically complex and poorly defined, and have multiple yet unknown solutions. Deciding on a particular career path, accepting the death of a loved one,

dealing with personal mortality, or solving longlasting conflicts among family members exemplify the type of problem that calls for wisdom-related expertise. In contrast, more circumscribed everyday problems can be effectively handled using more limited abilities. To solve a math problem, for example, wisdom-related expertise usually is not particularly helpful. Five criteria were developed to describe this body of knowledge in more detail. Expert knowledge about the meaning and conduct of life is thought to approach wisdom if it meets all 5 criteria. Two criteria are labeled basic because they are characteristic of all types of expertise: (1) rich factual knowledge about human nature and the life course, and (2) rich procedural knowledge about ways of dealing with life problems; the 3 other criteria are labeled meta-criteria because they are thought to be unique to wisdom and, in addition, carry the notion of being universal: (3) lifespan contextualism, that is, an awareness and understanding of the many contexts of life, how they relate to each other and change over the lifespan; (4) value relativism and tolerance, that is, an acknowledgment of individual, social, and cultural differences in values and life priorities; and (5) knowledge about handling uncertainty, including the limits of one’s own knowledge. To test for wisdom, participants are instructed to think aloud about hypothetical life problems. One might be: “Imagine that someone gets a call from a good friend who says that he or she cannot go on anymore and wants to commit suicide.” Another problem reads: “A 15-year-old girl wants to get married right away. What could one consider and do?” Trained raters evaluate responses to those problems using the 5 specified criteria. The assessment of wisdom-related knowledge on the basis of these criteria exhibits satisfactory reliability and validity. For example, middle-aged and older public figures from Berlin nominated as life experienced or wise by a panel of journalists–independently of the Berlin definition of wisdom–were among the top performers in laboratory wisdom tasks and outperformed same-aged adults that were not nominated (Baltes, Staudinger, Maerker, & Smith, 1995). Past Empirical Evidence. The Berlin research program on wisdom has addressed a broad range of questions concerning the development of wisdom,

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including individual and social factors that facilitate or hinder its acquisition and refinement (e.g., professional specialization, life experience, academic intelligence, or personality profile). The program also includes laboratory experiments studying ways of activating and improving adults’ wisdom-related performance in a given situation. As described in more detail elsewhere (Baltes & Staudinger, 2000; Kunzmann & Baltes, in press), some of the major findings are described. First, and consistent with the idea that wisdom is an ideal rather than a state of being, high levels of wisdom-related knowledge are rare. Many adults are on the way to wisdom, but few people approach a high level of wisdom-related knowledge as measured by the Berlin wisdom tasks. Second, wisdom-related knowledge seems to begin developing during the age period of late adolescence to young adulthood. Investigating a sample of 14- to 20 year-olds, Pasupathi and colleagues (2001) reported that wisdom-related knowledge considerably increased in this life period. Studying older adults, however, did not evince marked further changes for the average case. Specifically, in 4 studies with a total sample size of 533 individuals ranging in age from 20 to 89 years, the relationship between wisdom-related knowledge and chronological age was virtually zero and nonsignificant (Smith & Baltes, 1990; Staudinger, 1999). Within the limitations of cross-sectional data, this evidence suggests that on a group-level of analysis, wisdom-related knowledge remains stable over the adult years into the 60s and 70s. Although age-comparative studies on wisdom have been limited to what has been called to third age (i.e., young-old adults), evidence suggests that, given the absence of pathology such as dementia, some older adults will continue to perform well on wisdom tasks beyond their 70s. Third, for wisdom-related knowledge and judgment to develop during the second half of life, other factors than age become critical. The evidence suggests that it takes a complex coalition of expertise-enhancing factors from different domains, ranging from a person’s social-cognitive style (e.g., social intelligence, openness to experience) over this person’s immediate social context (e.g., presence of role models) to societal and cultural conditions (e.g., exposure to societal transitions). Past prediction studies of wisdom suggest

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that neither academic intelligence nor basic personality traits play a major role in the development of wisdom-related knowledge during adulthood. General life experiences, professional training and practice, certain motivational preferences such as an interest in understanding and helping others, and social-emotional competencies such as empathic concern seem to be more important (Kunzmann & Baltes, 2003b; Kunzmann, 2004; Staudinger, Lopez, & Baltes, 1997; Smith, Staudinger, & Baltes, 1994; Staudinger, Smith, & Baltes, 1992). If such a coalition of facilitating factors is present, some individuals may continue a developmental trajectory toward higher levels of wisdom-related knowledge. Therefore, simply getting older is not a sufficient condition for the development of higher levels of wisdom-related knowledge, and yet older adults are among the top performers in wisdom-related tasks. Fourth, the expression of wisdom-related performance, as measured by the Berlin tasks, can be enhanced by relative simple social and cognitive interventions. Boehmig-Krumhaar and colleagues (2002) demonstrated how a memory strategy— namely, a version of the method of loci—in which participants were instructed to travel on a cloud around the world can be used to focus people’s attention on cultural relativism and tolerance. Staudinger and Baltes (1996) conducted an experiment in which participants were asked to think aloud about a wisdom problem under several experimental conditions involving imagined and actual social interactions. For example, before responding individually, some participants had the opportunity to discuss the problem with a person they brought into the laboratory and with whom they usually discuss difficult life problems. This and similar experimental conditions increased performance levels by almost one standard deviation. One important implication of these 2 studies is that many adults have the latent potential to perform better on wisdom tasks than they actually do.

Conclusions Wisdom is a topic that holds much promise as aging researchers turn their attention to the positive aspects and potential gains of aging and old age. As reviewed above, the evidence suggests that wisdom may be spared from the losses that often accompany

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age. The majority of adults experience stability in wisdom-related knowledge, at least up to the 60s and 70s. Moreover, there is evidence that most adults have the potential to activate formerly deactivated and hidden bodies of wisdom-related knowledge by applying relatively simple strategies and scripts (e.g., a script about how to imagine a conversation with a person whom one considers close to wisdom). Perhaps even more important, given certain individual resources and favorable life circumstances, some adults manage to experience long-term growth in wisdom well into very old age. Importantly, most of these facilitative resources and conditions are not beyond an individual’s control, but are related to a person’s life style and preferences (e.g., interest in other people’s well-being, pursuit of personal growth values, or a cooperative interpersonal style). Although the way toward wisdom may be cumbersome at times, striving for wisdom is valuable not only for the individual but also for his or her environment. Considering the intricate problems of our lives in a society that is often driven by individualistic and materialistic motives, wisdom points to another set of avenues for satisfaction and happiness. Its very foundation lies in the orchestration of mind and virtue toward a common good. Ute Kunzmann See also Creativity Intelligence

References Achenbaum, W. A., & Orwoll, L. (1991). Becoming wise: A psycho-gerontological interpretation of the Book of Job. International Journal of Aging and Human Development, 32, 21–39. Ardelt, M. (2004). Wisdom as expert knowledge system: A critical review of a contemporary operationalization of an ancient concept. Human Development, 47, 257– 285. Ardelt, M. (2003). Empirical assessment of a threedimensional wisdom scale. Research on Aging, 25, 275–324. Baltes, P. B. (in press). Wisdom: The orchestration of mind and virtue. Available: http//www.mpib-berlin. mpg.de/dok/full/baltes/orchestr/index.htm. ¨ Baltes, P. B. (1997). Wolfgang Edelstein: Uber ein Wissenschaftlerleben in konstruktivistischer Melancholie [Wolfgang Edelstein: A scientific life in constructivis-

tic melancholy]. Reden zur Emeritierung von Wolfgang Edelstein. Berlin, Germany: Max Planck Institute for Human Development. Baltes, P. B., & Kunzmann, U. (2004). Two faces of wisdom: Wisdom as a general theory of knowledge and judgment about excellence in mind and virtue vs. wisdom as everyday realization in people and products. Human Development, 47, 290–299. Baltes, P. B., & Kunzmann, U. (2003). Wisdom: The peak of human excellence in the orchestration of mind and virtue. Psychologist, 16, 131–133. Baltes, P. B., & Smith, J. (1990). The psychology of wisdom and its ontogenesis. In R. J. Sternberg (Ed.), Wisdom: Its nature, origins, and development (pp. 87– 120). New York: Cambridge University Press. Baltes, P. B., & Staudinger, U. M. (2000). Wisdom: A metaheuristic (pragmatic) to orchestrate mind and virtue toward excellence. American Psychologist, 55, 122–136. Baltes, P. B., Staudinger, U. M., Maerker, A., & Smith, J. (1995). People nominated as wise: A comparative study of wisdom-related knowledge. Psychology and Aging, 10, 155–166. Boehmig-Krumhaar, S. A., Staudinger, U. M., & Baltes, P. B. (2002). Mehr Toleranz tut Not: lässt sich wert-relativierendes Wissen und Urteilen mit Hilfe einer wissensaktivierenden Gedächtnisstrategie verbessern? Zeitschrift für Entwicklungspsychologie und Pädagogische Psychologie. 34, 30–43. Carstensen, L. L., & Turk-Charles, S. (1998). Emotion in the second half of life. Current Directions in Psychological Science, 7, 144–149. Clayton, V. P., & Birren, J. E. (1980). The development of wisdom across the life span: A reexamination of an ancient topic. In P. B. Baltes & O. G. Brim, Jr. (Eds.), Life-span development and behavior (vol. 3, pp. 103– 135). New York: Academic Press. Dittmann-Kohli, F., & Baltes, P. B. (1990). Toward a neofunctionalist conception of adult intellectual development: Wisdom as a prototypical case of intellectual growth. In Higher stages of human development (pp. 54–78). New York: Oxford University. Dixon, R. A., & Baltes, P. B. (1986). Toward life-span research on the functions and pragmatics of intelligence. In R. J. Sternberg & R. K. Wagner (Eds.), Practical intelligence: Nature and origins of competence in the everyday world (pp. 203–235). Cambridge: Cambridge University Press. Erikson, E. H. (1959). Identity and the life cycle. New York: International University Press. Freund, A. M., & Baltes, P. B. (1998). Selection, optimization, and compensation as strategies of life-management: Correlations with subjective indicators of successful aging. Psychology and Aging, 13, 531–543.

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Women’s Changing Status: Health, Work, Family Gough, H. G. & Heilbrun, A. B. (1983). The adjective checklist manual. Palo Alto, CA: Consulting Psychologist’s Press. Helson, R., & Srivastava, S. (2002). Creative and wise people: Similarities, differences, and how they develop. Personality and Social Psychology Bulletin, 28, 1430–1440. Kramer, D. A. (2000). Wisdom as a classical source of human strength: Conceptualizing and empirical inquiry. Journal of Social and Clinical Psychology, 19, 83– 101. Kunzmann, U. (2004). Approaches to a good life: The emotional-motivational side to wisdom. In P. A. Linley, & S. Joseph (Eds.), Positive psychology in practice (pp. 504–517). Hoboken, NJ: John Wiley and Sons. Kunzmann, U., & Baltes, P. B. (in press). The psychology of wisdom: Theoretical and empirical challenges. In R. J. Sternberg, & J. Jordan (Eds.), Handbook of wisdom. Cambridge University Press. Kunzmann, U., & Baltes, P. B. (2003a). Wisdom-related knowledge: Affective, motivational, and interpersonal correlates. Personality and Social Psychology Bulletin, 29, 1104–1119. Kunzmann, U., & Baltes, P. B. (2003b). Beyond the traditional scope of intelligence: Wisdom in action. In R. J. Sternberg, J. Lautry, & T. I. Lubart (Eds.), Models of intelligence for the next millennium (pp. 329– 343). Washington DC: American Psychological Association. Kunzmann, U., & Stange, J. (in press). Wisdom as a classical human strength: Psychological conceptualizations and empirical inquiry. In A. D. Ong, & M. Van Dulmen (Eds.), Varieties of positive experience: Structure, variability, and change. New York: Oxford University Press. Labouvie-Vief, G. (1990). Wisdom as integrated thought: Historical and developmental perspectives. In R. J. Sternberg (Ed.), Wisdom: Its nature, origins, and development (pp. 52–83). Cambridge, MA: Cambridge University Press. Pasupathi, M., Staudinger, U. M., & Baltes, P. B. (2001). Seeds of wisdom: adolescents’ knowledge and judgment about difficult life problems. Developmental Psychology, 37, 351–361. Smith, J., Staudinger, U. M., & Baltes, P. B. (1994). Occupational settings facilitating wisdom-related knowledge: The sample case of clinical psychologists. Journal of Consulting and Clinical Psychology, 62, 989–999. Staudinger, U. M. (1999). Older and wiser? Integrating results on the relationship between age and wisdomrelated performance. International Journal of Behavioral Development, 23, 641–664.

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Staudinger, U. M., & Baltes, P. B. (1996). Interactive minds: A facilitative setting for wisdom-related performance? Journal of Personality and Social Psychology, 71, 746–762. Staudinger, U. M., Lopez, D. F., & Baltes, P. B. (1997). The psychometric location of wisdom-related performance: Intelligence, personality, and more? Personality and Social Psychology Bulletin, 23, 1200–1214. Staudinger, U. M., Smith, J., & Baltes, P. B. (1992). Wisdom-related knowledge in a life review task: Age differences and the role of professional specialization. Psychology and Aging. 7, 271–281. Sternberg, R. J. (Ed.). (1990). Wisdom: Its nature, origins, and development. New York: Cambridge University Press. Sternberg, R. J. (1998). A balance theory of wisdom. Review of General Psychology, 2, 347–365. Wink, P., & Helson, R. (1997). Practical and transcendent wisdom: Their nature and some longitudinal findings. Journal of Adult Development, 4, 1–15.

WOMEN’S CHANGING STATUS: HEALTH, WORK, FAMILY Women make up 58% of the population aged 65 and older, and 69% of the population aged 85 and older. Older women are less likely than older men to be currently married, and twice as likely to live alone (Fields, 2003). This entry will note the changing status of women in 3 areas: health, labor force participation, and the family.

Health Health status is determined by individual biology and the larger context of a person’s social, cultural, economic, and physical environment. The impact of these interacting factors may be felt immediately and last across the lifespan. Differences in health and illness are influenced by individual genetic and physiological constitutions, as well as by an individual’s interaction with environmental and experiential factors. In the past, research on women’s health tended to focus on diseases that impact fertility and reproduction. However, the research agenda continues to broaden and includes topics such as stress, violence, poverty, discrimination, abuse, AIDS, heart disease, cancer, incontinence, caregiving, and osteoporosis (Office of Women’s Health, 2002).

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Studies collectively named the Women’s Health Initiative (WHI) enrolled 164,500 postmenopausal women in several overlapping clinical trials and a long-term observational study. Women were recruited into the WHI study at 40 clinical centers in the United States between September 1993 and December 1998. The landmark study, funded by the National Institutes of Health and National Heart, Lung, and Blood Institute, was designed to investigate the leading causes of morbidity and mortality in postmenopausal women and to evaluate the efficacy of practical interventions in preventing the major causes of morbidity and mortality in older women (Matthews, Shumaker, Bowen, Langer, Hunt, Kaplan, 1997). Findings from the WHI called into question the safety and efficacy of long-term hormone replacement therapy for cardiovascular benefit in postmenopausal women (Anderson, Limacher, Assaf, Bassford, Beresford, Black, et al., 2004). Similarly, an ancillary study to WHI, the Women’s Health Initiative Memory Study, found no benefit in global cognitive function or incidence of mild cognitive impairment or dementia (Espeland, Rapp, Shumaker, Brunner, Manson, Sherwin, et al., 2004; Shumaker, Legault, Kuller, Rapp, Thal, Lane, et al., 2004). A positive change has been the increasing percentage of older women who obtain preventive health services. The percentage of women aged 65 and older who reported having a mammogram in the past 2 years increased from 22.8% in 1987 to 68% in 2000. The age-adjusted percentage of female Medicare enrollees aged 65 and older who are chronically disabled decreased from 27.9% in 1984 to 23.4% in 1999. During the same period, the percentage of older women Medicare enrollees living in institutions declined from 7.4% to 6%.

Work Data from the Current Population Survey (U.S. Department of Labor, 2002) show a significantly greater proportion of women now participate in the labor force compared to just 3 decades ago. In 1970 only about 43% of women aged 16 and older participated in the labor force, but by 2002 this number had risen to 60%. The number of women employed as managers, administrators, or executives has practically doubled during this time. Thirty-four percent of women worked in a managerial or professional

specialty occupation in 2002, compared with 22% in 1983. The movement of women into the labor force and into higher-paying occupations has happened as a direct result of their pursuit of higher education. However, both men and women have increased their educational attainment levels during the past 30 years. Those with college degrees earned about 76% more than those with only a high school diploma in 2002. Since 1975, the labor force participation of mothers with children under age 18 has grown from 47% to 72%. The biggest increase in labor force participation among mothers was for women with children under age 3. More than 60% of this group was employed in 2002, in stark contrast to the 34% employed in 1977. White women (35%) were more likely than black (26%) or Hispanic (19%) women to work in managerial or professional specialty occupations. Regardless of race and ethnicity, nearly 40% of all employed women work in technical, sales, and administrative support occupations. In 2002, women’s average earnings were 78% of men’s. Black and Hispanic women have more earnings parity with black and Hispanic men, respectively, than do white women with white men. White women earned 78% of white men’s earnings, black women earned 91% of black men’s earnings, and Hispanic women earned 88% of Hispanic men’s earnings. The disparity in earnings is due in part to the concentration of women in lower paying occupations, such as nursing and teaching. Both the population and the labor force are projected to continue growing steadily. By 2012, the number of people working or looking for work is expected to reach 162 million. As the population ages, the number of people in the labor force aged 55 to 64 is expected to have the most growth. The number of people in the labor force aged 65 and older is expected to increase more than 3 times as fast as the total labor force.

Family The family is often the main sources of support for individuals. The U.S. Census defines a family household as one that has at least 2 members related by birth, marriage, or adoption, 1 of whom is the householder. Family households are maintained

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by married couples or by a man or woman living with other relatives—children may or may not be present. Historically, in the United States, family households have predominated—81% in 1970—but that proportion dropped to 68% by 2003. This reflects the decrease in average household size, from 3.14 to 2.57. Households with 5 or more people decreased from 21% to 10% of all households (1970– 2003). Concurrently, an increase from 46% to 60% was observed in the proportion of households with only 1 or 2 people (Fields, 2003). In 2003, 57 million married-couple households resided in the United States, representing 76% of all family households. Men and women are delaying marriage, as reflected in the increasing average age of first marriage. In addition, married-couple households tend to be older than those in other family households. Thirty-three percent of marriedcouple households were aged 55 or older, compared to 21% of other family households. The proportion of single-mother family groups grew from 12% to 26%, and single-father groups grew from1% to 6% from 1970 to 2003. Ten million 1-parent family groups were headed by women. Women-headed households were more likely than the 2 million single-father households both to include more than 1 child (45%, compared to 37%) and to have family income below the poverty level (32%, compared to 16%). Overall, the never-married and divorced men and women composed a larger share of the population in 2003 than they did in 1970, while the proportion currently married declined. Among the population aged 75 years and older, 67% of men where living with their spouse in 2003, compared with 29% of women, and 50% of women were living alone. Elizabeth Dugan

References Anderson, G. L., Limacher, M., Assaf, A. R., Bassford, T., Beresford, S. A., Black, H., Bonds, D., Brunner, R., Brzyski, R., Caan, B., Chlebowski, R., Curb, D., Gass, M., Hays, J., Heiss, G., Hendrix, S., Howard, B. V., Hsia, J., Hubbell, A., Jackson, R., Johnson, K. C., Judd, H., Kotchen, J. M., Kuller, L., LaCroix, A. Z., Lane, D., Langer, R. D., Lasser, N., Lewis, C. E., Manson, J., Margolis, K., Ockene, J., O’Sullivan, M. J., Phillips, L., Prentice, R. L., Ritenbaugh, C., Rob-

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bins, J., Rossouw, J. E., Sarto, G., Stefanick, M. L., Van Horn, L., Wactawski-Wende, J., Wallace, R., Wassertheil-Smoller, S.; Women’s Health Initiative Steering Committee. (2004). Effects of conjugated equine estrogen in postmenopausal women with hysterectomy: The Women’s Health Initiative randomized controlled trial. Journal of the American Medical Association, 291(14), 1701–1712. Espeland, M. A., Rapp, S. R., Shumaker, S. A., Brunner, R., Manson, J. E., Sherwin, B. B., Hsia, J., Margolis, K. L., Hogan, P. E., Wallace, R., Dailey, M., Freeman, R., Hays, J.; Women’s Health Initiative Memory Study. (2004). Conjugated equine estrogens and global cognitive function in postmenopausal women: Women’s Health Initiative Memory Study. Journal of the American Medical Association, 291(24), 2959– 2968. Fields, J. (2003). America’s families and living arrangements: 2003. Current population reports, P20-553. Washington, DC: U.S. Department of Commerce; Economics and Statistics Administration; U.S. Census Bureau. Institute on Medicine. (1998). Gender differences in susceptibility to environmental factors: A priority assessment. Washington, DC: Institute of Medicine of the National Academies. Available: http://www.iom. edu/reports.asp?id=5672. Institute of Medicine. (2001). Exploring the biological contributions to human health: Does sex matter? Available: http://www.iom.edu/reports.asp?id=5437. Washington, DC: Institute of Medicine of the National Academies. Labor force. (2005). Occupational Outlook Quarterly, Winter 2003–2004. Matthews, K. A., Shumaker, S. A., Bowen, D. J., Langer, R. D., Hunt, J. R., Kaplan, R. M., Klesges, R. C., & Ritenbaugh, C. (1997). Women’s health initiative. Why now? What is it? What’s new? American Psychologist, 52(2), 101–116. Office of Women’s Health. (2002). A century of women’s health: 1900–2000. U.S. Department of Health and Human Services. Shumaker, S. A., Legault, C., Kuller, L., Rapp, S. R., Thal, L., Lane, D. S., Fillit, H., Stefanick, M. L., Hendrix, S. L., Lewis, C. E., Masaki, K., Coker, L. H.; Women’s Health Initiative Memory Study. (2004). Conjugated equine estrogens and incidence of probable dementia and mild cognitive impairment in postmenopausal women: Women’s Health Initiative Memory Study. Journal of the American Medical Association, 291(24), 2947–2958. U.S. Department of Labor. (2004). Women in the labor force: A databook. [Report 973.] Washington, DC: U.S. Department of Labor, Bureau of Labor Statistics.

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GRBT104-SecW-01-05

1238

QC: IML/FFX

T1: IML


January 31, 2006

15:40

Word-Finding Difficulty

WORD-FINDING DIFFICULTY The range of word usage or vocabulary as well as performance on unspeeded word fluency measures generally improves with aging. Further, older adults generally have no trouble understanding and accessing the meanings of words and language. However, with aging there is increased difficulty in the production or “finding” of target words, and older adults are slower and make more errors than younger adults in object naming and in retrieving appropriate words when speaking (Feyereisen, 1997; Kemper, Thompson, & Marquis, 2001). It has also been reported that the tip-of-tongue (TOT) experience—the inability to produce a known word on demand—is more frequent for older adults than for younger adults (James & Burke, 2000). The person’s feeling of knowing and the fact that the inaccessible word is in the person’s lexical repertoire is confirmed when the person spontaneously produces the word at a later time. Investigations of age-related difficulties in word finding can have theoretical as well as practical importance. Current theories of word production suggest that the process of searching for a particular word triggers the activation of a network of word meanings, and that the spoken production of this word requires the activation of the appropriate word sounds (Burke & Shafto, 2004; James & Burke, 2000). For example, TOTs occur when the meaning of a particular word is sufficiently activated, but the activation of the phonological information associated with that word is insufficient for word production. Such models do not conflict with the well-established findings of preserved verbal and semantic abilities in aging, because the age-related

difficulties in word production are attributed to delayed or diminished access to the sounds of particular words, and not to semantic processes. Of course, age-related slowing of general memory search and retrieval processes also contributes to word finding difficulties and delays in lexical access (Cerella, 1990). William J. Hoyer See also Memory and Memory Theory

References Burke, D. M., & Shafto, M. A. (2004). Aging and language production. Current Directions in Psychological Science, 13, 21–24. Cerella, J. (1990). Aging and information-processing rate. In J. E. Birren & K. W. Schaie (Eds.), Handbook of the psychology of aging (3rd ed., pp. 201–221). New York: Academic Press. Feyereisen, P. (1997). A meta-analytic procedure shows an age-related decline in picture naming: Comments on Goulet, Ska, and Kahn. Journal of Speech and Hearing Research, 40, 1328–1333. James, L. E., & Burke, D. M. (2000). Phonological priming effects on word retrieval and tip-of-the-tongue experiences in young and older adults. Journal of Experimental Psychology: Learning, Memory, and Cognition, 26, 1378–1391. Kemper, S., Thompson, M., & Marquis, J. (2001). Longitudinal change in language production: Effects of aging and dementia on grammatical complexity and propositional content. Psychology and Aging, 16, 600– 614.

P1: OSO GRBT104-Index


February 7, 2006

13:2

INDEXES



February 7, 2006

13:2



February 7, 2006

13:2

SUBJECT INDEX Note: Boldface page numbers indicates pages on which articles appear. AARP (The American Association of Retired Persons), 1–3 development of, 1–2 products/services/programs, 2–3 Abdominal fat fat, biology of, 135–136 increase and aging, 143–144 and lipoprotein levels, 664, 665 metabolic syndrome of aging, 135–136, 313 Abnutzungstheorie (wear-and-tear theory), 1224–1225 Absorption, drug interactions, 337 Abstract thinking, 3–4 Abuse of elderly. See Elder abuse and neglect Acarbose, diabetes treatment, 315 Access to Benefits Coalition (ABC), 814 Ace inhibitors, blood pressure control, 315, 561–562 Acetaminophen, for pain management, 893 Acetyl-l-carnitne, cognitive impairment treatment, 218 Acetylcholine drug modulation of, 216–217, 747 functions of, 833 and memory, 747, 833 receptors, 833 Acetylcholinesterase, and Alzheimer’s disease, 214 Acetylcholinesterase inhibitors, cognitive impairment treatment, 215, 293 Achalasia, 430 Achievement motivation, 795 Acid-base balance, 4–5 Activities of daily living, 6–8 autonomy and aging, 97–99 basic personal care tasks, 6

competence, 250–251 driving, 334–336 instrumental tasks, 6, 182 measurement limitations, 7 measures of, 6–7 mobility, 791–792 nutrition-related, 857 personal assistant services, 182–183, 911–913 self-care activities, 1051–1053 Activity theory, 9–13 basic concepts, 10 development of, 10–12 future directions, 12–13 gender differences, 12 Acupuncture, 254–255 Acute care, delivery methods, 486 Acute renal failure, 631 Ad libitum feeding, diet restriction, 316–317, 652 Adalimumab, for rheumatoid arthritis, 81 Adaptation Study (Duke), 346 Adaptive capacity, 13–14, 267 and older workers, 870 Addictions gambling, 1151 See also Substance abuse and addictions Adherence, 15–17 causes/scope of, 15–16 and memory deficits, 746 nonadherence, types of, 15 prevention, 16–17 Adiponectin, 136 Adipose tissue, and blood glucose regulation, 159–160 Adjective Checklist, 1231 I-1


I-2


February 7, 2006

13:2

Subject Index

Adoptosis, 76–77, 653 Adrenal gland, DHEA production, 310–311 Beta-adrenoceptor drugs, pharmacodynamics, 922 Adult children caregiving, 170–175 coresidence with, 902–903, 939 filial responsibility, 421–422 parent-child relationships, 901–903 parental divorce, effects of, 328–329 See also Family relationships Adult day care, 17–19 caregivers, benefits to, 19, 488 effectiveness research, 18–19 funding, 17–18 Program of All-Inclusive Care for the Elderly (PACE), 17, 973–975 services, 17 state regulation, 17 Adult development, 21–23 cognitive changes. See Cognitive processes; Intelligence continuity theory, 266–268 developmental deadlines, 658 developmental tasks, 22–23, 308–310 family relationships, 415–417 generativity, theory of, 435–437 goal-setting, 267 life course, 643–646 life-span theory of control, 657–659 midlife crisis, 776–777 multidirectionality, 307 personality theories, 914–918 psychosocial stages, 21, 435–437 seasons of adulthood theory, 21 successful aging, 1154–1155 wisdom, 1230–1234 Adult foster care homes, 25–27 history of, 25 management, 26 pros/cons of, 26–27 providers, 26 resident characteristics, 25026 Adult protective services, 28–31 elder abuse, 28–31, 353 future view, 30 historical/legal view, 28–29 referrals, 30 Adult stem cells, 1139 Advance directives

copies of, 670 living wills/durable powers of attorney, 393, 668–671 and mental competency, 383, 686 prevalence of use, 669 Advanced glycation end-products, 31–33 aging/disease related to, 32–33 biomarkers of aging, 138 inhibitors, 33 process, 31–33, 977–978 Advanced lipoxidation end-products (ALEs), 33 Adventures in Learning, 555 Adverse drug reactions. See Drug reactions Advocacy of AARP, 2 of SAGE, 537 Aerobic exercise cardiovascular remodeling, 14 and lipid level improvement, 666 African American elders, 34–37 calcium requirement, 147 caregivers of, 173, 785 and communication disorders, 234 double-jeopardy situation, 387, 783–784, 1117 family relationships, 36, 903 hypertension, 147 living arrangements, 547 morbidity/mortality, 35–36 psychological well-being, 36 research study difficulties, 784 retirment, 36 social support, 36 socioeconomic status, 34–35, 785, 947 Age Boom Academy, 619 Age Discrimination and Employment Act (1967), 42, 43, 366, 580, 1035 Age-graded influences, 307–308 Age management clinics, 68 Age pyramid, 301 Age-related macular degeneration, 408–409, 1214 Age-segregated housing, 547 Age stereotypes, 43–44 ageism, 41–42 aging, images of, 44–47 and discrimination, 43 in humor about aging, 557–558 impact on performance, 1096–1097 mass media, 43–46 and menopause, 765–766 midlife crisis, 23, 309, 776–777



February 7, 2006

13:2

Subject Index

and neuroticism, 832 older workers, 580 patronizing speech, 636 positive and negative, 43 versus productive aging, 965–966 and schemas, 762 and self-fulfilling prophesy, 46 self-stereotypes, 43 sexuality-related, 1067 social, 1096–1097 Ageism, 41–42 age-related myths of, 41–42 barrier to cancer control, 157–158 defined, 41 legal protections, 42, 580 social stratification, 1115–1118 AgePage, 500 Aggression crime, 270–272 hostility, 545 See also Agitation Aging and Environments project, 79 Aging, images of, 44–47 age stereotypes, 43–44 impact of, 46–47 mass media portrayals, 43–47 neuroticism, 831–832 rural elders, 1045–1046 Aging in Manitoba Longitudinal Study, 150 Aging-in-place, and telemedicine, 244 Aging Network, 867 Aging research and AARP, 3 adult day care effectiveness, 18–19 African American elders, 36–37 American Federation for Aging Research (AFAR), 62 on assisted living, 89 Baltimore Longitudinal Study of Aging, 101–104 Berlin Aging Study, 110–112 Canadian aging, 6, 148–151, 424 cross-cultural, 274–278 cross-sectional, 102 cross-sequential, 230, 460 driving and elderly, 335–336 Duke Longitudinal Studies of Aging, 346–347 on elder abuse, 29–30, 353

I-3

established populations for epidemiological studies of the elderly, 378–382 ethnographic, 388–389 experimental, 460–461 on frailty, 424 on guardianship/conservatorship, 473 Health and Retirement Study (HRS), 478–480 on health beliefs, 480–481 on hypertension management, 560–562 living laboratories, 62 longitudinal, 679–682 longitudinal data sets, 677–679 minorities, recruitment/rentention for, 786–788 and National Institute on Aging, 817–820 on Native American elders, 825 Normative Aging Study (NAS), 838–839 on sexuality, 1068 surveys, 1163–1165 Swedish twin studies, 1165–1167 twin studies, 1202–1204 on widowhood, 1226 Aging theories. See Animal models of aging; Biological aging models; Social gerontology theories Agitation behavior management, 105–106 delirium, 285–288 disruptive behaviors, 324–326 physical restraints, 1027–1029 sundown syndrome, 1156–1158 Agriculture, older workers, 365 AIDS/HIV, 48–51 at-risk groups, 49 differential diagnosis, 51 drug treatment, 48–49 and older adults, 49–50 pathological spectrum of, 48–49 survival and elderly, 51 transmission of, 49 and tuberculosis risk, 1198 Air-fluidization, 951 Alchemy, 69 Alcohol use, 52–53 alcoholism myth, 53 older adults, drinking behavior, 52–53 prevalence of, 1149 Aldehydes, 740 Alendronate, 885


I-4


February 7, 2006

13:2

Subject Index

Algase Wandering Scale (AWS), 1221 Alleles allele frequency, 75 antagonistic pleitropy, 394–395, 445 Alliance for Health and the Future, 619 Allotopic expression, 441 Allupurinol, for gout/pseudogout, 81 Alopecia, 477 Alpha 2 agonists, glaucoma treatment, 410 Alternative medicine. See Complementary and alternative medicine Aluminum exposure, and Alzheimer’s disease, 220 Alzheimer, Alois, 455 Alzheimer’s disease, 53–54 adult foster care homes, 25–27 and advanced glycation end-products, 33 amnestic stage diagnosis, 53–54 amyloidosis, 33, 54, 214, 626–627 and apolipoprotein E (APOE), 54–55, 75–76 and apolipoprotein epsilon 4, 75–76 cerebraospinal fluid drainage, 216 clinical memory assessment, 759–760 drug treatments, 54, 214–220, 747–748 genetic factors, 54–57, 444 and homocysteine, 535 immune factors, 568 language disorders, 635 magnetic resonance spectroscopy, 712–716 melatonin deficit, 737 neurotransmitter changes, 214, 833, 836 pathophysiology, 33, 54, 75–76, 214 remote memory deficit, 751 sleep disruption, 1084 as social problem, 1107 special care units, 1131–1132 stages, 53–54 symptoms, 53 Alzhemed, 214 Amadori rearrangement, 32, 260 Amantadine drug reactions, 343 influenza treatment, 586–587 Ambulatory and outpatient care, 59–60 alternative models, 60 palliative care, 60 rehabilitation, 1014 trends related to, 60 Amenity migration, 447 American Association for Geriatric Psychiatry (AAGP), 456

American Association of Home and Services for the Aging (AAHSA), 61–62 American Association of Retired Persons, The. See AARP (The American Association of Retired Persons) American Federation for Aging Research (AFAR), 62, 878 American Geriatrics Society, 63, 876 American Indians. See Native American elders American Society on Aging, 63–65 Americans for Generational Equity (AGE), 608, 878–879 Americans with Disabilities Act (1990), 65–68 development of, 65–66 disability rights as basis, 65–66 information resources on, 67–68 special transportation, 1194–1195 Titles I-IV provisions, 66–67 Amnesia amnestic mild cognitive impairment, 53–54, 781 childhood, 741 Korsakoff syndrome, 741, 751, 1216 Amygdaloid nucleus, 200 Beta-amyloid precursor protein (APP) Alzheimer’s disease, 54–56, 568, 626–627 drug modulation of, 214–215 Lewy Body disease, 297 Amyloidosis Alzheimer’s disease, 33, 54, 214 amyloid cascade hypothesis, 54 heart muscle, 166 prion diseases, 955 Anagen loss, 477 Andropause, 311 Andrus, Ethel Percy, 1–3 Anemia aplastic, 142 of chronic disease, 141 hemolytic, 141, 147 iron deficiency, 141 Aneurysms, causes, 164 Angina pectoris, 164, 165 Angiography, 207 Angiotensin-converting enzyme inhibitors, drug interactions, 339 Angiotensin II, and memory decline, 748 Angiotensin II receptor blockers, blood pressure control, 561–562 Angiotensinogen, 136 Animal models of aging



February 7, 2006

13:2

Subject Index

diet restriction, 317, 652, 820 evolutionary theory, 395–396 flies, 114–118, 395–396 growth hormone and insulin-like growth factor-1, 470–471 nematodes, 119–122 rhesus monkeys, 123–125 rodents, 125–129 transgenic mice, 129–131 Animals pets, 919–921 prion diseases of, 954 Aniracetam, cognitive impairment treatment, 218 Anomia, 71 Anorectal disorders, 431 Anosognosia, 238 Antagonistic pleitropy and aging, 394–395, 445 and cancer, 152 and growth hormone/insulin-like growth factor-1, 471 Anthropometric measures, 856–857 Anthropometry, 102 Anti-aging medicine, 68–69 DHEA, 310–312 false claims, 68–69 future view, 69 historical view, 69 types of, 68 See also Life extension Antibiotics, drug interactions with, 337, 339 Antibodies, 566 Anticholinergic drugs and delirium, 340 drug interactions, 339 drug reactions, 343 Anticoagulation, 167 Antidepressants anxiety treatment, 70 for depression, 304, 906 drug reactions, 923 for frontotemporal dementia, 293 SSRIs, 304, 343–344 Antiepileptic drugs, 377 Antigen receptor, 565 Antigenic peptides, 565 Antiretroviral drugs, 48 Antiviral drugs, influenza treatment, 586–587 Anxiety, 69–70 caregivers, 172

cognitive therapy, 233 components of, 70 death anxiety, 283–284 drug treatment, 70 and menopause, 765 and sleep disorders, 1087 unique aspects in elderly, 70 Aortic atherosclerosis, and homocysteine, 535 Apastic anemia, 142 Aphasia, 71–74, 237 forms of, 72–73, 292 and frontotemporal dementia, 292, 635 prevalence of, 71 rehabilitation, 73 research needs, 73–74 symptom-syndrome-lesion theory, 72 symptoms of, 71–72 tests, 72 theories of, 72–73 word-finding difficulty, 72, 73, 1238 Apitherapy, 255 Apolipoprotein E (APOE) and Alzheimer’s disease, 54–55, 75–76 apolipoprotein epsilon 4, 75–76 Apoptosis cancer, 153 tumor suppression, 1199–1201 Appendicitis, 431 Appraisal support, 1122 Apraxia of speech, 236, 635 Arachidonic acid, 217 Architectural Barriers Act (1968), 65–66 Architecture for older adults, 78–80 home modifications, 528–530 housing for elderly field, 78–79 pioneers in field, 79 publications, 79 Arcus senilis, 406 Area Agency on Aging, 770 Arecoline, cognitive impairment treatment, 217 Armed forces, Veterans/veteran care, 1210–1211 Aromatase inhibitors, cancer inhibitor, 156 Arrhythmia atrial fibrillation, 166 causes, 166 Arteries aging and changes, 168–170 function of, 163

I-5


I-6


February 7, 2006

13:2

Subject Index

Arthritis, 80–81 gout/pseudogout, 81 osteoarthritis, 80–81 rheumatoid arthritis, 81 treatment, 80–81 Artificial intelligence, 497, 498 Arts creativity, 269–270 humanities and arts, 552–556 Asian and Pacific Islander American elders, 82–86 Asian Indian American elders, 84–85 Chinese American elders, 82–83 Filipino American elders, 84 health immigrant effect, 74 Japanese American elders, 84 Korean American elders, 84 Native Hawaiian and Pacific Islander American elders, 85–86 parent-child relationship, 84, 903 Southeast Asian American elders, 85 Asian Indian American elders, 84–85 common illnesses of, 85 familism, 85 Asparagine-modifying reactions, 978 Aspirin, stroke management, 207–208 Assessment programs. See Geriatric assessment Assets and Health Dynamics of the Oldest Old (AHEAD), 678 Assistance migration, 447 Assisted living, 87–90 admission/retention, 89–90 defined, 88, 548 growth of settings, 87–88, 851 organizations, 88 payment methods, 90, 548 research related to, 89 services, 87, 89, 548, 1038 specialized housing with supportive services, 1133–1136 Assisted Living Conversion Program (ALCP), 1136 Assistive technologies communication aids, 238, 239 evolution of, 1174 listening devices, 511 Association for Gerontology in Higher Education, 91–92, 459, 878 Astrocyte-derived cytokines inhibitors, cognitive impairment treatment, 215 Astrocytes, 202

Atenolol, blood pressure control, 562 Atherosclerosis as autoimmune disease, 96 causes, 164 disorders caused by, 164 and homocysteine, 533–534 and insulin resistance, 159 Atrial fibrillation, 166 Atrial remodeling, 168 Atrophic gastritis, 430 Attention, 92–95 dual task situations, 94, 604 inhibition of return of, 94 interference, 602–605 older adults, theories of, 94–95 reallocation of, 93–94 Attitudes political, 932 rigidity, 1044 and social cognitions, 1095 Attributions locus of control, 671–673 social cognition and aging, 1094–1097 Audiological testing, 239 Aura, seizures, 377 Autoantibodies, 566 Autobiographical memory, 740–741 emotional factors, 750–751 life review, 42, 654–655 Autobiography. See Biography; Narrative analysis Autoimmune disease atherosclerosis as, 96 autoimmune hemolytic anemia, 141 rheumatoid arthritis as, 81 types of, 96 Autoimmunity, 95–96 and aging, 96 cellular activity, 95–96 Automatic thoughts, 232 Autonomic nervous system, stress response, 204–205 Autonomy and aging, 97–99 actual autonomy perspective, 98 assessment of, 97–98 bioethical issues, 383–384, 392–393 and health care, 98–99 nursing homes, 844 Autoregressive models, longitudinal research, 681 Average indexed monthly earnings (AIME), 1109 Avoidant-type coping, 109



February 7, 2006

13:2

Subject Index

Ayurvedic medicine, 254 Azathioprine, for rheumatoid arthritis, 81 B-lymphocytes, 565–567 B vitamins deficiency diseases, 1216–1217 nicotinic acid, 1216–1217 requirements for older adults, 855 sources of, 1216 vitamin B 12 and homocysteine reduction, 534, 536 Vitamin B 12 insufficiency, 141 Baby boom generation, 100–101 age and retirement, 364 age range of, 100, 299 and ageism reduction, 42 heterogeneity among, 100 and intergenerational equity, 607–609 population aging, 100–101, 299–302, 937–939 socioeconomic status, 100 Bacon, Roger, 69 Bacterial endocarditis, 165 Bacteriophage phiC31, 441 Balance aging and changes, 800 training, 551 Balloon angioplasty, 165 Baltimore Longitudinal Study of Aging, 101–104, 818 areas of study, 102–103 findings, 103–104 Barthel Index, 6–7, 1014 Bartlett, E. L., 65–66 Basal ganglia, functions of, 199 Bases, acid-base balance, 4–5 Basic personal care tasks, activities of daily living, 6 Bathrooms, modifications, 528 Bee venom injections, 255 Behavior management, 105–106 cognitions, altering, 106 cognitive therapy, 232–234 contingency management, 105–106 settings for, 105–106 Behavioral problems frontal lobe dysfunction, 427–429 See also Agitation Behavioral Risk Factors Surveillance System, 1001 Beliefs about Memory Instrument, 774

Bend points, 1109 Beneficence, 685, 926 BenefitsCheckup, 814–815 Benign prostatic hypertrophy, prostatic hyperplasia, 975–976, 1206 Benzodiazepines delirium treatment, 287 depression treatment, 304 drug interactions, 339 drug reactions, 342, 923 withdrawal syndrome, 344 Bereavement, 107–109 and culture, 108–109, 1227 and death circumstances, 1227–1228 gender differences, 709, 1227 and health problems, 107–108, 1226 siblings, 1074 and social loss, 708 widows, 107–109, 708–709, 1226–1228 Berkman-Syme Social Network Index, 1122 Berlin Aging Study, 110–112 cross-sectional sample, 111 longitudinal samples, 111–112 research questions, 110 Berlin Wisdom Model, 1232–1233 Beta-blockers blood pressure control, 561–562 glaucoma treatment, 410 Bethanechol, Alzheimer’s disease treatment, 217 Bifocals, 407 Biguanides, diabetes treatment, 315 Bile acid sequestrants, lipoprotein benefits, 667 Biliary tract, disorders of, 431 Bioenergetics, 370–371 metabolic rate modulators, 371–372 Bioethics, 383–384 biotechnology issues, 687 on care of dying, 281 on self-determinism/autonomy, 383–384 Biogerontology, 69 Biography, 112–114 dementia stories, 113 guided autobiography groups, 556 as intervention method, 113 meanings of, 112 narrative analysis, 811–812 positive aspects of, 113 Bioinformatics, 498

I-7


I-8


February 7, 2006

13:2

Subject Index

Biological aging models and adaptive capacity, 13–15 adoptosis, 76–77 advanced glycation end-products, 31–33 biomarker of aging as measure, 137–139 cell aging, 186–191 cell aging in vitro, 191–195 disposable soma theory, 322–324 DNA repair theory, 329–331 evolutionary theory, 394–396 flies, 114–118 free radical damage, 738 genetic programming theories, 445–446 growth hormone and insulin-like growth factor-1, 468–471 hemodynamic losses, 532–533 lipofuscin, 660–661 membrane hypothesis, 739–740 nematodes, 119–122 neuroendocrine theory, 826–828 neurotrophic factors, 837–838 oxidative stress theory, 887–889 plant aging, 927–929 proteins, posttranslational modifications, 977–978 proteolysis/protein turnover, 979–983 rhesus monkeys, 123–125 rodents, 125–129 senescence and transformation, 1057–1060 stress theory of aging, 1142–1144 telomeres and cellular senescence, 188, 1179–1182 transgenic mice, 129–131 wear-and-tear theories, 1224–1225 yeast/fungi, 132–135 Biological rhythms chronobiology, 209–213 and melatonin, 737–738 Biologics, for rheumatoid arthritis, 81 Biology of Aging Program, 819–820 Biomarker of aging, 137–139 advanced glycation end-products, 31–33 biomarkers in vitro/in vivo, 189 DHEA as, 310–312 protein degradation, 982–983 validating, criteria for, 138 Biomedical signal processing, 497, 498 Biopsychosocial model depression, 303–304 mental health, 768–769

Birth rate, decline and population aging, 301, 937, 941 Bisexual persons, stigmatization/stereotyping, impact of, 537–538 Bisphosphonates, 885 Bladder infections, 632 overactive, 1206 See also Urinary tract Blepharitis, 406 Blepharoplasty, 406 Blindness age-related macular degeneration, 408–409, 1214 diabetic retinopathy, 409, 1214 glaucoma, 407, 409, 1214 Blood, 139–142 aging and changes, 140, 559 changes and disease, 140–142 components of, 139 functions of, 140 lipids. See Lipoproteins, serum Blood chemistry acid-base balance, 4–5 sodium balance/osmolaity regulation, 1126–1127 Blood glucose. See Glucose regulation Blood loss, and shock, 166–167 Blood pressure aging heart, effects of, 161–162, 164, 167, 169–170 desirable pressure, 167 hypertension, 559–562 orthostasis, 166 syncope, 166 Blood transfusion, AIDS/HIV exposure, 49 Blue Cross/Blue Shield, history of, 491, 504 Body composition, 142–144 and DHEA, 311 exercise benefits, 402–403 fat, biology of, 135–136 fat-free mass, 143 fat mass, 143–144 height/weight, 143 and lipoprotein levels, 664–665 2-compartment model, 142 Body mass index (BMI) calculation of, 856–857 healthy weight, 864



February 7, 2006

13:2

Subject Index

Body temperature and circulation, 163 temperature regulation abnormality, 1182–1184 Body weight and aging, 143 BMI healthy weight, 864 cardiovascular disease reduction, 167 diet restriction, 316–318 fat, biology of, 135–136 and lipoprotein levels, 664 obesity, 864–865 visceral adiposity. See Abdominal fat Bone calcium functions, 145 disorders. See Musculoskeletal disorders musculoskeletal system, 808–810 Bone-anchored hearing aid (BAHA), 511 Bone mineral density (BMD) measure, 883–884 Bone resorption, 883 Boomers. See Baby boom generations Boren Amendment, 850 Boston Diagnostic Aphasia Examination, 72 Botox, 406 Braden Scale, 950 Brain, 198–201 aging and changes, 200–205, 799 and attention reduction, 94–95 auditory pathways, 510 brain stem, 199, 203 cerebellum, 199 cerebral hemisphere, 199–200 and cognitive processes, 427–428 diencephalon, 199 hemispheric asymmetries, 200, 512–514 language production, 71, 73 magnetic resonance spectroscopy, 712–716 neuroplasticity, 829–831 neurotransmitters and aging, 799, 832–836 neurotrophic factors in aging, 837–838 stress theory of aging, 1142–1144 ventricular system, 201 weight, 200–201 Brain-derived neurotrophic factor (BDNF), 837 Breast cancer and Hispanic Americans, 522 hormone replacement therapy risk, 541, 944–945 reducing risk, 155–156 Breathing, respiratory system, 1023–1025 Bridge jobs, 349, 365

I-9

Brief Abuse Screen for the Elderly, 352 Brinley plot, 1006–1008 British Journal of Medicine online, 498 Broca’s area, 200 Butler, Robert N., 618 C-reactive protein, and Alzheimer’s disease, 215 CADASIL, 1209 Calcitonin, 145, 885 Calcitriol, 145, 146, 882 Calcium channel blockers cognitive impairment treatment, 218 drug interactions, 338 drug reactions, 922 Calcium deposition, aging heart, 160–161, 164 Calcium metabolism, 145–147 calcium-channel activity, 145 calcium control system, 145 calcium-related disease, 145–147 race and calcium requirement, 147 Calcium supplementation osteoporosis, 146, 520 requirements for older adults, 855 Calment, Jeanne Louise, 197, 651, 656 Caloric restriction. See Diet restriction Calories, energy needs and aging, 854 Cambodian American elders, 85 Canadian aging research, 148–151 Canadian Initiative on Frailty and Aging, 424 Canadian Longitudinal Study of Aging, 150 Canadian Study of Health and Aging, 6, 149–150 Canadian Home Income Plan (CHIP), 525 Cancer, 152–154 age as risk factor, 155, 567–568 antagonistic pleitropy, 152 apoptosis, 153 breast, 155–156, 541, 944–945 cerivcal, 157 colorectal, 152–153 environmental risks, 155 esophagus, 431 kidney/urinary, 632 liver, 431 lung, 155, 157 oral, 876 ovarian, 945 pancreas, 431


I-10


February 7, 2006

13:2

Subject Index

Cancer (continued) prevention. See Cancer control prostate, 156, 157, 1206 and stem cell changes, 154, 1139 stomach, 431 telomere dysfunction, 153, 1180–1182 thyroid, 1190 uterine, 540, 765 See also specific disorders Cancer control, 155–158 barriers to, 157–158 caloric restriction, 152–153 chemoprevention, 156 early detection, 156 primary prevention, 155–156 secondary prevention, 156–157 Candesartan, blood pressure control, 561 CANDRIVE, 335–336 Capillaries, function of, 163 Capital gains tax rate, 1171 Capitation system, 507 Carbamazepine drug interactions, 338 neuropathic pain management, 894 seizure management, 378 Carbohydrate metabolism, 158–160 advanced glycation end-products, 31–33 diabetes, 158–159, 312–316 lifestyle factors, 159–160 pathophysiology and aging, 159 Carbonic anhydrase inhibitors, glaucoma treatment, 410 Carcinogenesis and aging, 155 See also Cancer Cardiac angiogram, 167 Cardiac catheterization, 167 Cardiovascular disease, 164–167 aneurysms, 164 angina pectoris, 164, 165 arrhythmia, 166 atherosclerosis, 164 cholesterol level risk factor, 662–667 congestive heart failure, 166 diagnosis, 167 heart murmurs, 164 and homocysteine, 533–536 and hormone replacement therapy, 945 hypertension, 167, 170, 559–562 immune factors, 568

myocardial infarction, 165–166 orthostasis, 166 prevention, 167–168 valve damage, 165 venous disorders, 164–165 Cardiovascular system, 163–168 components of, 163 exercise benefits, 167, 401, 666 heart, 160–162 normal aging, 163–164 vasculature, 168–170 Care management. See Case management Care of self. See Self-care activities Care plans, 179 Care programs adult day care, 17–19 adult foster care homes, 25–27 assisted living, 87–90 case management, 178–182 home-hospital care, 60 institutionalization, 595–598 Long-Term Care Ombudsman Program (LTCOP), 692–694 nursing homes, 842–853 Program of All-Inclusive Care for the Elderly (PACE), 973–975 rehabilitation, 1012–1015 senior centers, 1062–1064 senior companion program, 1064–1067 Caregiving, 170–175 activities/dynamics of, 171–172 adult day care, benefits to, 19, 488 elder abuse and neglect, 352–354 and elder abuse/neglect, 353 ethics, 383–385 ethnic/minority families, 173–174, 387 Family and Medical Leave Act (FMLA), 412–415 family relationships, 415–417 filial responsibility, 421–422 informal, prevalence of, 171 respite care, 1025–1027 rewards of, 173 siblings, 1073–1074 stress, 172–173, 304, 903 supportive interventions for cargivers, 174–175 tax benefits, 1172 technology, use/benefits of, 619–620, 1176 widow and adjustment, 1228 and women, 170–173



February 7, 2006

13:2

Subject Index

Carotid artery disease, and homocysteine, 535 Case management, 178–181 development of, 178–179 goals/features of, 178 issues/challenges, 180–181 process of, 179–180 program models, 180 Case-mix measurement, resource utilization groups, 1022–1023 Cash-balance plans, 349, 1040 Cash payments for care, 182–185 cash and counseling concept, 183–184 demonstration states, 183–184 personal assistance services (PAS), 182–183, 911–913 Cataracts, 407, 799, 1004, 1213–1214 Catecholamine agonists, cognitive impairment treatment, 217 Catecholamines dopamine, 833–834 heart and exercise, 162 norepinephrine, 834 serotonin, 834–835 Causality, locus of control, 671–673 Cavanaugh, Gloria, 64 Celiac sprue, 431 Cell aging, 186–191 genetic basis, 188–189, 194–195 interactive elements of, 186 lipofuscin, 660–661 progeroid syndromes, 188–189 Cell aging in vitro, 191–195 adoptosis, 76–77 biomarkers, 189 cell culture models, 186 cell death, 192 cell morphology, changes, 191–192 macromolecule synthesis rate, 192 proliferative decline, 186, 191–192 replicative senescence, 186–187, 191–193 telomeres and cellular senescence, 188, 193–194, 1179–1182 Cell-based therapies, stem cells, 1138–1140 Cell-culture mixing studies, 444 Cell-cycle regulators, 193 Cell death, 192, 201, 204, 661 Cell hybridization studies, 444

I-11

Cell therapy, 439 Centarians, 196–198, 656 geographic clusters of, 197, 651, 684 health profile, 197 personality traits, 197 and study of aging, 197–198, 684 supercentarians, 196–197, 656 Center for Aging Services Technology (CAST), 62 Center for Healthy Aging (CHA), 814 Center on Aging (NIMH), 458 Central nervous system (CNS), 198–203 brain, 198–201 cells of, 202–203 motor function, 798–801 peripheral nerves, 203–204 sensory system changes, 799–800 spinal cord, 201 Cephalomedullary nails, 519 Cerami, Anthony, 31 Cerebellar strokes, 208 Cerebellum, functions of, 199 Cerebral hemisphere, 199–200 hemispheric asymmetries, 512–514 lobes of, 200 Cerebral metabolic enhancers, memory improvement, 747–748 Cerebraospinal fluid drainage, Alzheimer’s disease, 216 Cerebrovascular disease, 206–208 stroke, 206–208 transient ischemic attack, 206–208 Certificate-of-need, 703 Cervical cancer, reducing risk, 157 Chelation Alzheimer’s disease treatment, 220 atherosclerosis, 255 Chemical aging, advanced glycation end-products, 31–33 Chinese American elders, 82–83 bereavement practices, 108–109 common illnesses, 82–83 menopause, view of, 765 socioeconomic status, 82–83, 785 Chinese medicine, 83 Chiropractic, 255 Chlorthalidone, blood pressure control, 562 Cholangitis, 431 Cholecystitis, 431


I-12


February 7, 2006

13:2

Subject Index

Cholesterol -lowering drugs, 666–667 control, cardiovascular disease reduction, 167 and hormone replacement therapy, 945 lipoproteins, serum, 662–667 and membrane changes, 739–740 Cholestyramine, drug interactions, 337 Choline acetylcholinesterase and Alzheimer’s disease, 214 memory improvement, 747 Cholinergic neurons and acetylcholine, 833 and Alzheimer’s disease, 214 and memory function, 747–748 Cholinesterase inhibitors Alzheimer’s disease treatment, 54, 747 Lewy Body disease, 296 memory improvement, 747 vascular cognitive impairment treatment, 1209 Chondroitin, arthritis treatment, 80–81 Chronic granulocytic leukemia, 141 Chronic lymphocytic leukemia, 142 Chronic renal failure, 631 Chronic stress, 1120, 1142 Chronobiology, 209–213 aging and chronomes, 212–213 chronomes, 210–211 rhythms, types of, 210–212 Cialis, 1071 Cigarette smoking and cognitive impairment, 1150 and lung cancer, 155, 157 prevalence and elderly, 1149 and skin, 1079 Ciliary neurtropic factor (CNTF), 837 Circadian rhythms, 211–212 and melatonin, 737 and sleep, 1082, 1087 Circuit breaker tax programs, 1172 Circulatory system blood movement mechanisms, 163 function of, 163 vasculature, 168–170 Cirrhosis, 431 Citicoline, cognitive impairment treatment, 217 Cluster analysis, longitudinal research, 681 Coagulation disorders hypercoagulable state, 207 and phlebitis, 165

Cochlear implants, 512 Cochrane Database, 1014 Cockayne syndrome, premature aging, 444, 972 Cognitive-affective processing system (CAPS), 916 Cognitive impairment and adult day care, 17–19 Alzheimer’s disease, 53–54 and anxiety, 70 aphasia, 71–74 and atherosclerosis, 164 and autobiographical memory deficit, 741 and behavior management, 105–106 and cigarette smoking, 1150 delirium, 285–288 dementia, 289–298 and disruptive behaviors, 324–326 drug treatments. See Cognitive impairment drug treatment frontal lobe dysfunction, 427–429 and language disorders, 237–238 Lewy body disease, 295–298 mental status evaluation, 771–772 mild cognitive impairment, 780–782 and pain, 892 and Parkinson’s disease, 906 psychometric testing, 428–429 terminal change, 1184–1185 and thyroid disease, 1189–1190 vascular cognitive impairment, 1208–1209 wandering, 1220–1223 Cognitive impairment drug treatments, 214–220 antiinflammatory drugs, 215 categories of, 214 cathecholamine agonists, 217 citicoline/CPD-choline, 217 estrogens, 215–216 herbal, 219–220, 254 nerve growth factors, 216 neuroprotective agents, 219 neurotransmitter modulation, 216–217 nootropic agents, 219 oxidative stress modulation, 217–219 for structural modifications, 214–215 Cognitive processes, 229–231 abstract thinking, 3–4 age and expertise, 39–40 attention, 92–95 and brain, 427–428



February 7, 2006

13:2

Subject Index

and cognitive plasticity, 764 and competence, 250–251 and computer use, 501–502 contextual approach, 229–321 creativity, 269–270 defined, 229 and emotions, 357–358 and hemispheric asymmetries, 513–514 information-processing theory, 229, 230, 588–591 intelligence, 600–602 interference, 602–605 language comprehension, 633–634 language production, 634–636 learning, 638–639 life-span view, 22 memory/memory theory, 755–758 Normative Aging Study, 838 problem-solving, 960–961 and psychological assessment, 987–988 psychometric approach, 229, 230 social cognition and aging, 1094–1097 and social cognition and aging, 1096–1097 stimulation, importance of, 14 wisdom, 1230–1234 Cognitive stimulation, reality orientation, 1009–1011 Cognitive therapy, 232–234 behavior management, 105–106 benefits and elderly, 233 cognitive-behavioral therapy, 233–234, 993–994 cognitive training, Alzheimer’s disease, 54 disorders treated, 233 effectiveness, 233, 993–994 forms of, 232–234, 993 Cohorts, in survey research, 1164 Colchicine cognitive impairment treatment, 215 for gout/pseudogout, 81 Colitis, 431 Collagen advanced glycation end-products, 31–33 aging and changes, 260, 1078–1079 heart and aging, 161, 162, 168–169 Colonoscopy, cancer risk reduction, 157 Color vision, 1213 Colorectal cancer and caloric restriction, 152–153 cellular progression of, 152–153 and high-calcium diets, 146

I-13

and hormone replacement therapy, 945 reducing risk, 156, 157 Commission on Accreditation of Rehabilitation Facilities (CARF), 17 Common illnesses of, 84 Communication aids, 238, 239 Communication disorders, 234–239 and African Americans, 234 aphasia, 71–74 hearing disorders, 238–239 information resources on, 235 language disorders, 237–238 voice/speech/swallowing disorders, 235–236 Communication technologies and older adults, 242–247 Internet applications, 619–621 Internet health information, 499–503 mobile computing, 244 resistance to use, 243 smart house, 243–244 technology gap, aspects of, 245–247 telecommunciations relay services (TRS), 67 Telecommunications Act provisions, 67 telemedicine, 244 wireless, 246 Communicative ethics, 686 Community-acquired pneumonia, 571, 586 Community-based care, Medicaid coverage, 487 Community needs assessment, 247–249 community resource profiles, 249 issues related to, 248–249 Community resource profiles, 249 Comparative research. See Cross-cultural research Competence, 250–251 adult protective services, 28–31 competence, forms of, 250 guardianship/conservatorship, 472–474 Complementarity criteria, thinking, 3–4 Complementary and alternative medicine, 253–255 acupuncture, 254–255 anti-aging medicine, 68–69 apitherapy, 255 chelation, 220, 255 Chinese medicine, 83 chiropractic, 255 for cognitive impairment, 219–220 herbal therapies, 219–220, 254 life extension, 651–654 massage, 254 menopause remedies, 1069


I-14


February 7, 2006

13:2

Subject Index

Complementary and alternative medicine (continued) pain management, 894 spirituality, 255 tai-chi, 255 Complexity hypothesis, 589 Complicated grief, 107–108, 1227, 1228 Comprehensive Assessment and Referral Evaluation (CARE), 805–806, 988 Comprehensive geriatric assessment (CGA), 60, 448–451, 453, 806 effectiveness, 450–451 history of, 448–449 in-home, 450 process, 449–450 and rehabilitation, 1012–1013 Compression of morbidity, 257–259 Computational biology, 498 Computed tomography angiography, 207 Computer use and cognitive processes, 501–502 See also Communication technologies and older adults; Internet; Technology and older adults Conflict Tactics Scale, 352 Confocal scanning laser opthalmoscope, 661 Confusion reducing, reality orientation, 1009–1011 See also Agitation Confusion Assessment Method (CAM), 285–286 Congestive heart failure causes, 166 treatment, 166 Congregate housing, government-funded, 547, 1135–1136 Conjugate pneumonia vaccines, 571 Connective tissues, 259–262 collagen, 260 elastin, 260–261 ground substance, 261 matrix metalloproteinases, 261–262 Consciousness level, mental status assessment, 772 Constipation and aging, 431 and fecal incontinence, 418 Consumer issues, 263–265 aging community as consumers, 182 mature market segments, 264–265 mature market spending habits, 263–264 retailing/older consumer, 265, 1030–1032 shopping behaviors, 265

Consumer Price Index (CPI), 582, 947 Contextual approach, cognitive processes, 229–321 Continuing care retirement community (CCRC), 1038–1039 fees/payments, 487–488, 1134–1135 types of, 1038 Continuity theory, 266–268 constructs in, 266–267 outcomes in, 267 testing of, 267–268 Continuous positive airway pressure (CPAP), 1084 Control learned helplessness, 636–638 life-span theory of, 638, 657–659 locus of control, 671–673 self-efficacy, 23, 231 Controlled Oral Word Association Test, 429 Convergent thinking, 4 Cook-Medley scale, 545 Coordination, motor performance, 801–803 Coping. See Stress and coping Corkscrew esophagus, 430 Cornea aging and changes, 406, 1212 corneal transplant, 406 Coronary artery bypass surgery, 165 Coronary artery disease and homocysteine, 533–536 See also Atherosclerosis Corticosteroids drug reactions, 343 pain management, 892–893 Cosmetic surgery, oculoplastic, 406 Cost-of-living adjustments, Social Security, 582 Cost-sharing, 729 Couching, 407 Counterstream migration, 446 COX1/COX2 inhibitors cognitive impairment treatment, 215 colon cancer inhibitors, 156 Craniectomy, for infarcts, 208 Cre/loxP system, 441 Creativity, 269–270 and divergent thinking, 269 and expertise, 39–40 humanistic inquiry, 554 production and aging, 269–270 Creutzfeldt-Jakob disease, 954–956 Crime, 270–272 by elderly, 272



February 7, 2006

13:2

Subject Index

elderly prison populations, 272, 957–959 elderly victimization rates, 270–271 fear of, 271–272 impact on elderly, 271 Critical theory, 272–274 and gerontological issues, 273–274 history of, 273, 553–554 Crohn disease, 431 Cross-cultural research, 274–278 aging research topics, 276–278 primary data collection, 275 secondary data analysis, 275–276 Cross-sectional research on aging, 102 longitudinal research, 680 surveys, 1164 Cross-sequential research cognitive decline, 230 process of, 460 Crystallized intelligence, 4, 22, 230 Cues, and attention, 93 Cultural differences. See Ethnicity; Minorities and aging Cultural investigation. See Ethnographic research D-cycloserine, cognitive impairment treatment, 218 Cynicism, 545 Cystoscope, 632, 1206 Cytokines, 565, 568, 569 Cytomegalovirus, 566, 568 Cytosol, 145 Cytotoxic T cells, 566 Daily stressors, 1120–1121 Dance troupes, 555 Data mining, 497, 498, 499 Day care. See Adult day care; Senior centers De Leon, Ponce, 69 Deamidation, 978 Death and dying, 280–283 bereavement of survivors, 107–109 cultural influences, 282 death anxiety, 283–284 end-of-life care, 368–370 hospice, 282, 542–544 medicalization of, 280–282 palliative care, 899–901 terminal change, 1184–1185 thanatology, 1186–1187

I-15

Death and loss bereavement, 107–109 loss, 707–709 widowhood, 1226–1228 Death hormone, 445 Debt, spousal responsibility, 422 Declarative memory, 756 Deconditioning, heart and aging, 167 Deep venous thrombosis, 165 Defined benefit plans ERISA coverage, 910 features of, 910, 1039, 1042, 1048 Defined contribution plans ERISA coverage, 910 features of, 910, 1039–1040, 1042, 1048 types of plans, 910 Deletion mutations, 790 Delirium, 285–288 assessment method, 285 differential diagnosis, 285–286 medication-related, 340, 343 post-operative, 287 prevalence of, 285 prevention/management, 287–288 risk factors, 286–287 sensorium level, 772 Delusions, features of, 772 Dementia, 289–291 adult foster care homes, 25–27 AIDS dementia complex, 48, 51 Alzehimer’s disease, 53–57, 214, 289 apolipoprotein epsilon 4, 75–76 clinical memory assessment, 759–760 cognitive impairment drug treatments, 214–220 and delirium, 286 external causes, 289 frontal lobe dysfunction, 427–429 frontotemporal, 289, 292–293 Health and Retirement Study (HRS), 478 historical view, 289–290 and homocysteine, 535 Lewy body disease, 289, 295–298 and mild cognitive impairment, 780–782 mixed, 54 Parkinson’s disease with, 289, 296 pre-dementia syndromes, 290–291, 782 prion diseases, 954–956 reality orientation intervention, 1009–1011 risk factors, 290 special care units, 1131–1132


I-16


February 7, 2006

13:2

Subject Index

Dementia (continued) sundown syndrome, 1156–1158 vascular cognitive impairment, 54, 214, 289, 1208–1209 Dementia Rating Scale-2, 988 Dementia stories, 113 Demographic bonus, 939 Demography, 299–302 baby boom generation, 100–101 demographic transition, 937 geographic mobility, 446–447 migration, 777–780, 937 population aging, 299–302, 936–940 rural elders, 1045–1046 Denial, elders of abuse, 352 Dental care, oral health, 873–876 Dental caries, 874–875 Dependency ratios, old-age, 350 Dependency theory. See Modernization theory Dependent Care Assistance Program, 1172 Depression, 303–305 aging and symptoms, 303 bereavement-related, 108 biopsychosocial model, 303–304 caregivers, 172, 304 cognitive theory of, 232 cognitive therapy, 233 diagnosis, 304 and divorce, 328 drug therapy, 304, 906 group therapy, 466–468 and health status, 481 interpersonal psychotherapy, 622–623 and memory loss, 303 and menopause, 765 and Parkinson’s disease, 906 problem-solving therapy, 962–964 short-term psychotherapy, 304, 994 and sleep disorders, 303, 304, 1084, 1087 stages of treatment, 622 and suicide, 1155–1156 symptoms checklists, 988 Dermotochalasis, 406 Desferrioxamine, Alzehimer’s disease treatment, 220 Desmosine, 260 DETERMINE checklist, 857 Developing countries adult-child coresidence, 939 elderly population increase, 942

fertility rates, 941 and filial obligation, 447 population aging, 939, 940–943 poverty, 939, 949 technology, use of, 245–246 tuberculosis risk, 1196 Development adult. See Adult development defined, 306 and plasticity, 307 Developmental psychology, 306–308 development, influences on, 307–308 theories of, 306–307 Developmental tasks, 22–23, 308–310 of adulthood/old age, 309–310 of childhood/adolescence, 309 Dexamethasone challenge, depression, 304 DHEA (dehydroepiandrosterone), 310–312 age and decline, 311 production of, 310–311 therapeutic use, 311 Diabetes, 312–316 complications of, 158–159, 313–314 diabetic retinopathy, 409, 1214 diagnosis, 313–314 gestational, 313 Health and Retirement Study (HRS), 479 and insulin resistance, 159 management, 314–316 medication-induced, 313 and metabolic syndrome, 313 self-monitoring, 314–315 type 1, 313 type 2, 158–159, 313 Diagnosis-related groups (DRG), 484 Diagnostic and Statistical Manual of Mental Disorders (DSM), diagnostic system, 983–986 Diagnostic Interview Schedule (DIS), 816 Dialectical behavior therapy, 995 Dialysis, 631 Diastolic function, aging heart, 161–162, 164, 167 Didrocal, 520 Diencephalon, 199 Diet and health. See Nutrition Diet restriction, 316–318 ad libitum feeding, 316–317, 652 animal models, 317, 652, 820 Biology of Aging Program research, 819–820 biomarker of aging research, 138



February 7, 2006

13:2

Subject Index

and cancer prevention, 152–153 DNA damage, repair of, 331 gastrointestinal benefits, 432 and insulin resistance improvement, 159–160 malnutrition risk, 317 and melatonin production, 737 as metabolic regulator, 372 methods, 316 in nonhuman aging models, 116 and oxidative stress, 888 Diffusion-weighted MRI, 206 Digital mammography, 157 Digital rectal examination, 1206 Digoxin drug interactions, 338 drug reactions, 343, 923 Dihydroepiandosterone, 138 Diphtheria, immunization, 571–572 Disability, 319–320 Americans with Disabilities Act, 65–68 and anxiety, 70 compression of morbidity, 257–259 definitional issues, 319–320 disability rights movement, 65–66 and frailty, 423–425 home modifications, 528–530 International Classification of Functioning, Disability, and Health (IFC), 615–617 Rehabilitation Act , Title V, 66 relationship to frailty, 423–424 Supplementary Security Income Program (SSI), 1158–1160 Telecommunications Act provision, 67 Discourse memory, 741–744 age differences, affecting factors, 742–743 deficits, theories of, 743–744 Discourse processing, 741–742 Discovery Through the Humanities, 554–555 Discrimination age stereotypes, 43–44 ageism, 41–42 aging, images of, 44–47 Disease modifying antirheumatic drugs (DMARDs), 81 Disengagement theory, 10, 321–322 goal disengagement, 23 Disposable soma theory, 322–324, 1225 Disruptive behaviors, 324–326 behavior management, 105–106 and cognitive impairment, 324–325

defined, 324 and delirium, 285–288 drug treatment correlation to, 325 physical restraints, 1027–1029 types of, 325 Diuretics blood pressure control, 167, 315, 561 congestive heart failure treatment, 166 drug interactions, 339 Divergent thinking, and creativity, 269 Diverticulosis, 431 Divorce, 327–329 economic effects of, 328 emotional effects, 328 and family relationships, 328–329 of grandparents, 329 predictors of, 327–328 Dizziness and brain, 199 syncope, 166 DNA (deoxyribonucleic acid) and cell aging, 193–195 damage/lesions, 1128 diet restriction, effects of, 331 DNA chips, 434 gene expression, 433–434 mitochondrial DNA mutations, 789–790 mutations and cancer, 152, 154 plant aging, 927 repair process, 329–331, 1128 somatic mutations and genome instability, 1127–1130 telomeres and cellular senescence, 188, 193–194, 1179–1182 transgenic mice, production of, 129–131 DNA-RNA hybrids, 441 Do-not-hospitalize order, 848 Do-not-resuscitate orders, 281 Doctor-patient relationships, 332–334 and adherence, 15–17 and Internet, 333 problems/solutions, 332 Donahue, Wilma, 79 Donepezil Alzheimer’s disease treatment, 54, 216–217 Lewy Body disease, 296 L-dopa therapy, Parkinson’s disease, 905 Dopamine age and decline, 513, 799, 834 functions of, 833–834

I-17


I-18


February 7, 2006

13:2

Subject Index

Dopamine (continued) Lewy Body disease, 297 and memory decline, 748 production of, 833–834 Doppler sonography, 165 Double-jeopardy hypothesis, minorities and aging, 117, 387, 783–784, 1117 Double tetracycline labeling, 881 Down syndrome, premature aging, 189, 971 Doxazosin, blood pressure control, 562 Drama groups, 555 Drive theory, motivation, 794–795 Driving, 334–336 age and accident risk, 334, 591, 1194 determining fitness for, 334–335 difficult tasks for older persons, 550 human-factors engineering, 550 research areas, 335 Drosophilia, biological aging model, 114–118 Drug interactions, 336–340 of absorption, 337 age-related dynamics of, 922 common interactions, 339, 922–923 drug binding interactions, 337–338 elimination interaction, 338, 340 illegal drugs, 732 pharmacodynamics, 340, 922–923 and polypharmacy, 337 protein-binding interactions, 338 Drug reactions, 342–344 failure of therapy, 344 gender differences, 923 mechanisms for, 342–343 pharmacodynamics and aging, 922–923 and polypharmacy, 342 prescribing cascade, 344 and psychological assessment, 987 risk factors, 342 withdrawal reactions, 343–344 Drug treatments. See specific disorders Dry eye, 406 Dual photon x-ray absorptiometry (DEXA), 102 Dual-processing model, intelligence, 22 Dual task situations, 94, 604, 634–635 Duke Health Profile, 806 Duke Longitudinal Studies of Aging, 346–347, 677 First/Second/Third, 346 goals of, 346 themes, 346–347

Duke University Medical Center, geriatric psychiatry program, 455 Duplex carotid ultrasonography, 207 Durable power of attorney. See Living wills/durable powers of attorney Dusteride, cancer inhibitor, 156 Dysarthrias, 236, 635 Dyslipidemia exercise benefits, 402 genetic factors, 664 treatment, 315 Dysphagia, 236, 905 Dystolic function, aging heart, 161–162, 164, 167, 169–170 E-mail, elderly use of, 44 Ear aging and changes, 509–510 anatomical divisions of, 509 disorders. See Hearing disorders hearing, 508–512 Ecdysone, 117 Echocardiogram, 167 Economic Status of Older Persons (ESOP) database, 619 Economics of aging, 348–351 African American elders, 34–35 and baby boomers, 100 cross-cultural research questions, 277 and divorce, 328 Employee Retirement Income Security Act (ERISA), 361–362 employment, 349, 362–367 home equity conversion, 523–525 income, sources of, 348–349 individual retirement arrangements (IRAs), 576–579 inflation, 582–585 intergenerational equity, 385, 583, 607–609 macroeconomic impact, population aging, 350–351 median income, 348 pensions, 349, 907–910, 1039–1040 retirement planning, 1041–1043 savings, 1048–1049 Social Security, 348–349, 1107–1115 Supplementary Security Income Program (SSI), 1158–1160 tax policy, 1170–1173



February 7, 2006

13:2

Subject Index

Eden Alternative, 852 Edentulousness, 875 Education arts/humanities and older persons, 555–556 Internet use, 500–502, 621 on-line programs, 620 training/retraining older workers, 581 Ego development, adults, 21 Ego integrity versus despair, 21, 23, 284 Ehlers-Danlos syndrome, 444 Elastic support stockings, 164–165 Elastin aging and changes, 261 heart and aging, 161, 162, 163–164, 167, 169 Elder abuse and neglect, 352–354 actions to take, 30, 353–354 adult protective services, 28–31, 353 at-risk elders, 353 and filial responsibility, 422 information resources on, 354 nursing homes, 353 prevalence of, 29–30, 353 research studies, 29–30, 353 screening instruments, 352 signs of, 353 Elder Assessment Instrument, 352 Elder law, 639–640 ethics and aging, 383–385 journals on, 640 legal issues, types of, 640 living wills/durable powers of attorney, 668–671 practitioners, finding, 640 Eldercare Locator, 354, 813 Elderhostel, 555, 1031 Elderly Nutrition Program (ENP), Meals on Wheels, 858–859, 861–863 Elders Share the Arts (ESTA), 555 ElderWeb, 246 Electoral bluff, 934 Electrocardiogram, 165, 167 Electroconvulsive therapy (ECT), for depression, 304 Electroencephalography (EEG) seizure diagnosis, 377 sleep measure, 1082–1083 Electrolyte imbalance, and delirium, 288 Electronic patient records (EPR), 497–498

Embolism and atherosclerosis, 164 and hormone replacement therapy, 945 pulmonary, 165 Embryonic stem cells, 1138–1139 Emotional abuse, 30 Emotional support, features of, 1122 Emotions, 355–359 affect, mental status assessment, 772 aging and changes, 355–356, 795 and bereavement, 107–109 and cognitive processes, 357–358 expression and elderly, 356–357 and loss, 23, 707–709 and neuroticism, 831–832 physiological factors, 357 regulation of, 355, 358 and remote memory, 750–751 and self-management beliefs, 480–481 and social cognitions, 1095–1096 and subjective well-being, 1146 Empathy, doctor-patient relationships, 333 Employee Retirement Income Security Act (ERISA), 361–362, 367 IRAs, 576 provisions of, 361–362, 909–910 Employment, 362–367 age discrimination, 42, 43, 44, 366 Americans with Disabilities Act, 65–68 and generativity concept, 437 labor force projections, 363–364, 581 NCOA programs, 815 older workers, 362–363, 580–581, 870–871 pensions, 907–910, 1039–1040 private-sector policies, 367 productive aging, 965–966 retirement decisions, 364 retirement planning, 1041–1043 See also Older workers End-of-life care communication with dying, 369, 900 components of, 368–369 euthanasia, 369–370, 392–393, 924–926 and family members, 369 home death, 900–901 hospice, 368, 542–544, 900 palliative care, 368, 899–901 prison population, 958–959 Endarterectomy, 208 Endocrine tissue, fat as, 135–136

I-19


I-20


February 7, 2006

13:2

Subject Index

Endothelial dysfunction, and aging, 169 Endothelial nitric oxide synthase (eNOS), 169 Endothelium-dependent relaxation, 169 Endurance training, metabolic benefits, 402 Energy and bioenergetics, 370–371 Energy metabolism, magnetic resonance spectroscopy, 712–716 Energy production, mitochondria, 731–732, 789 Environmental assessment, 374–375 and home modifications, 528–530 methods/measures, 374–375 theoretical basis, 374 Environmental changes, adaptive capacity, 13–14 Environmental toxins, elimination and cancer control, 155 Epastigmine, Alzheimer’s disease treatment, 217 Epidemiological studies, established populations for epidemiological studies of the elderly, 378–382 Epilepsy, 376–378 causes, 376 diagnosis, 377 management/prognosis, 377–378 seizures, features of, 377 Episodic memory, 755–756 elements of, 756 improvement method, 749 Epstein-Barr virus, 566 Ergocalciferol, 882 Ergonomics, workplace, 551, 870–871 Erikson’s theory. See Psychosocial theory Errorless learning, 238 Erythrocyte sedimentation rate, 140 Esophagus, disorders of, 430 Established populations for epidemiological studies of the elderly, 378–382, 818 methods, 379–380 questionnaire items, 380 results of, 381–382 sample populations, 379 Estate taxes, 1171 Estrogen, menopause and decline, 420–421, 764 Estrogen replacement cognitive impairment treatment, 215–216 hormone replacement therapy, 539–541 Estrus, 539 Etanercept, for rheumatoid arthritis, 81 Ethics of aging, 383–385 and advance directives, 383, 686 beneficence, 685, 926

communicative ethics, 686 diversity, respect for, 687 euthanasia, 392–393, 925–926 institutional committees, 384 justice, 686 long-term care, 685–687 paternalism, 383, 685–686 privacy rights, 687 social ethics, 384–385 See also Bioethics Ethnicity, 386–387 and death anxiety, 283–284 defined, 386 double-jeopardy situation, 387, 783–784, 1117 and dying process, 282–283 ethnic compensation concept, 387 healthy immigrant effect, 784 immigration patterns, 386 and personality characteristics, 918 situational, 386 and widowhood, 1227 See also Minorities and aging; specific ethnic-minority groups Ethnogerontology. See Ethnicity; Minorities and aging Ethnographic research, 275, 388–389 cross-cultural aging study, 389 process of, 388 Ethosuximide, 828 European Academy for Medicine of Ageing (EAMA), 390–391 EuroQOL, 1001 Euthanasia, 392–393 categories of, 925 ethical perspectives, 392–393, 925–926 legal perspective, 393 Oregon Death with Dignity Act, 369–370, 393, 926 physician-assisted suicide, 369–370, 392, 924–926 EverCare, 488–489, 849 Everyday Cognition Battery, 960 Everyday memory, 744–747 aging and decline, 745–746 contextual aspects, 746 decline, psychological impact, 745 and medication nonadherence, 746 Everyday Problem Solving Inventory, 960 Everyday Problems Test, 960 Evolutionary theory, 394–396



February 7, 2006

13:2

Subject Index

antagonistic pleitropy, 394–395, 445 disposable soma theory, 322–324 empirical support, 395–396 mutation-accumulation mechanism, 394–395 Exchange theory, 396–399 intergenerational relationships, 611 Exercise, 401–405 aerobic, 14, 666 body composition improvement, 402–403 cardiovascular benefits, 167, 401, 666 cardiovascular response, 401 defined, 401 diabetes management, 314 disability levels, 258 exercise promotion, 403–405 gains, rate of decline, 14 and growth hormone increase, 470 heart and aging, 162 injuries, 404 insulin resistance improvement, 159–160 and lipid levels, 667 mature market spending on, 264 metabolic syndrome, benefits, 402 and musculoskeletal health, 809 program, steps in, 403–405 and psychological well-being, 403 regularity, importance of, 404 rehabilitation, 1012–1015, 1014 respiratory response, 1024–1025 strength training, 314, 402–403, 885 training intensity, 401, 404 weight-loss, time-per-session, 401 Exercise stress test, 167, 404 Exfoliation syndrome, 410 Experimental research, gerontology, 460–461 Expert systems, 497 Expertise and age, 22, 39–40 experts, defined, 39 motor performance, 803 supporting theories, 39–40 Explicit memory, 573–574, 742, 756 Explicit motivation, 795 Extended families, 611, 785 Extracapsular hip fractures, 518–519 Extraversion, 623 Extrinsic motivation, 796–797 Eye, 405–410 age-related macular degeneration, 408–409, 1214 aging and changes, 406–409, 799, 1212–1213

I-21

cataracts, 407, 799, 1004, 1213–1214 cornea, 406 diabetic retinopathy, 409, 1214 glaucoma, 409–410, 1214 lens, 407 lids/lashes/lacrimals, 406 macula, 408–409 optic nerve, 409 retina, 407–408 vision, 1212–1214 Fabry diseases, 439 Failure of therapy, 344 Falls, 592–593 balance training, 551, 593 hip fractures, 515–520 nursing home residents, 592–593 physical restraints, 1027–1029 prevention and home modifications, 528–530, 550–551, 593, 885 risk factors, 593 False claims, anti-aging medicine, 68–69 False memory, 758 Familial combined hyperlipidemia, 664–665 Familism, 85 Family and Medical Leave Act (FMLA), 412–415 reform proposals, 414 restrained use of, 413 Family relationships, 415–417 African American elders, 36, 785 caregiving, 170–175 cross-cultural research questions, 277 and divorce, 328–329 elder abuse and neglect, 352–354 and end-of-life care, 369 extended families, 611, 785 familism, 85 filial piety, 84, 903 filial responsibility, 421–422 and generativity concept, 437 grandparent-grandchild, 464–465 impact of, 415–417 intergenerational, 609–613 Internet and communication, 242–243 marital relationships, 716–719 minorities and aging, 36, 84, 903 multigenerational families, 170–171 parent-child relationships, 901–903 sibling relationships, 1072–1074


I-22


February 7, 2006

13:2

Subject Index

Family relationships (continued) support aspects, 611 widowhood, 1226–1228 See also Caregiving Fannie Mae, reverse mortgages, 524 Fasting lipoprotein profile, 662–663 Fasting plasma glucose screening, 313–314 Fat biology of, 135–136 and blood glucose regulation, 159–160 fat as endocrine tissue, 135–136 fat mass and aging, 143–144 See also Abdominal fat Fat, dietary and lipoprotein levels, 662, 665–667 requirments and aging, 855 Fatal familial insomnia, 954–955 Favism, 147 Fecal incontinence, 417–419, 431 causes, 418 defined, 417 progression of, 418 Fecal occult blood exam, cancer risk reduction, 157 Federal taxes, 1170–1171 Fee-for-service plans defined, 506 Medicare FFS, 507 Felodipine, drug interactions, 338 Female reproductive system hormonal modulation of, 420 hormone replacement therapy, 539–541, 944–945 menopause, 419–421 Feminist theory, on gender differences, 432–433 Feminization of aging, 940 Fever, 1184 Feverfew, 254 Fibric acids, lipoprotein benefits, 667 Fibromyalgia, 890 Filial piety, 84, 903 Filial responsibility, 421–422 Filipino American elders, common illnesses of, 84 Financial aspects of aging. See Economics of aging Finsteride, 156 FirstGov for Seniors, 621 Fiscal management services, 184 Flashes and floaters, 407–408 Flies, biological aging model, 114–118, 394–395 Fluid intelligence, 4, 22, 40, 230 Fluids

requirements and aging, 855 sodium balance/osmolaity regulation, 1126–1127 Fluorescein angiogram, 409 Fluoxetine, withdrawal syndrome, 343–344 Focal argon laser, 408–409 Folic acid deficiency, 141, 1216 hazard and Vitamin B12, 536 homocysteine, lowering, 534, 536, 1216 Food banks, 859 Food restriction. See Diet restriction Fosamax, 520 Foster care. See Adult foster care homes Fountain of youth, 69 401K plans, 349 features of, 910 Fractures and falls, 592–593 hip, 515–520 and osteoporosis, 883–884 Frailty, 423–425 assisted living, 87–90 comprehensive geriatric assessment (CGA), 448–451 and delirium, 286–287 goal-setting, 462–463 institutionalization, 595–598 interventions, 424–425 and mobility, 791–792 rehabilitation, 1012–1015 risk factors, 424 as syndrome, 423–424 Frank Starling mechanism, 162, 402 Fraud, cash payments for care, 184–185 Free radical scavengers melatonin, 738 Vitamin E, 218 Free radicals and aging, 738, 1143–1144 oxidative stress theory, 887–889 Friendship, 426–427 and aging process, 426 benefits of, 427 Frontal lobe, 200 Frontal lobe dysfunction, 427–429 assessment of, 428–429 and attention reduction, 94–95 behaviors related to, 428 and language disorders, 635–636



February 7, 2006

13:2

Subject Index

Frontotemporal dementia, 289, 292–293 biomarkers of, 292–293 features of, 292 progression of, 293 treatment, 293 Fuchs endothelial dystrophy, 406 Function Independence Measure (FIM), 7, 806, 1014 Functional adaptation skills training (FAST), 467 Functional assessment, multidimensional, 804–807 Functional Assessment Inventory, 805 Functional Impairment Measure or Timed Up and Go, 791 Functional Status Quesionnaire (FSQ), 806 Fungi, biological aging model, 132–135 Gabapentine, seizure management, 378 Galanin, and memory decline, 748 Galantamine Alzheimer’s disease treatment, 54, 217 Lewy Body disease, 296 Galen, 69 Gallagher, Hugh, 65–66 Gallbladder, disorders of, 431 Gallstones, 431 Gambling addiction, 1151 Gamma-aminobulyric acid (GABA) aging and changes, 835 functions of, 835 and memory decline, 748 production of, 835 Gardening, mature market spending on, 264 Gargoylism, 444 Garlic, 254 Gas exchanges, respiratory system, 1024 Gastric hypochlorhydria, 430 Gastric metaplasia, 431 Gastroesophageal reflux, 430 Gastrointestinal functions/disorders, 430–432 and anxiety, 70 diet restriction, effects of, 432 disorders, 430–432 gastrointestinal organs, 430–431 Gate control theory, 890–891 Gatekeeper programs, 1103 Gatekeepers, 506

Gaucher disease, 439 Gay men. See Homosexuality Gender, 432–433 defined, 432 and power relations, 433 Gender differences activity theory, 12 aging research participation, 101 cardiovascular disease, 164 death anxiety, 283 drug reactions, 923 elder neglect/abuse, 30 feminist theory on, 432–433 hearing, 510 hip fractures, 515 in humor about aging, 558 sexuality, 1068–1069 social support, 1124 suicide, 1155 supercentarians, 197 widowhood, rates of, 107, 1226 Gender roles, defined, 432 Gene expression, 433–434 Gene therapy, 439–442 cell therapy, 439 DNA delivery methods in Situ, 440 exogenous DNA, intracellular destinations, 440–441 germline gene therapy, 440 lysosomal enhancement, 441–442 for lysosomal storage diseases, 439 mtDNA, allotopic expression, 441 somatic gene therapy, 440 stem cells, 1138–1140 whole-body interdiction of lengthening telomeres, 442 General Social Survey (GSS), 1165 Generalized seizures, 377 Generativity, 435–437 empirical measures of, 436 generativity versus stagnation, 21, 435 types of, 435–436 Genetic disorders gene therapy, 439–442 progeroid syndromes, 188–189, 971–973 Genetic factors (predisposition) adoptosis, 76–77 Alzheimer’s disease, 54–57, 444 centarian long-life, 197–198 DNA repair process, 329–331

I-23


I-24


February 7, 2006

13:2

Subject Index

Genetic factors (predisposition) (continued) genetic heterogeneity, 443–444 lipoprotein levels, 664–665 longevity, 652–653 neuroendocrine activity, 828 twin studies, 1165–1167, 1202–1204 Genetic heterogeneity, 443–444 demonstrating in humans, 444 Genetic mutations. See Mutations Genetic programming theories, 445–446 Genomics data, 498 Geographic mobility, 446–447 migration, 777–780 Geographical memory, 749–750 Geotranscendence, 321 Geriatric assessment comprehensive geriatric assessment (CGA), 60, 448–451, 453 geriatric assessment units, 1013 geriatric evaluation and management (GEM), 60, 453, 1177–1178 memory, 759–760 mental status, 771–772 multidimensional functional assessment, 804–807 psychological, 986–989 Geriatric Depression Scale, 986, 988 Geriatric education Association for Gerontology in Higher Education, 91–92 European Academy for Medicine of Ageing (EAMA), 390–391 geriatric education centers, 451–452 Gerontology Society of America projects, 459 Geriatric evaluation and management (GEM), 60, 453 comprehensive geriatric assessment (CGA), 449 features of, 1177 video-based, 1178 Geriatric failure to thrive (GFTT), 858 Geriatric Hopelessness Scale, 988 Geriatric medicine, 452–454 ambulatory and outpatient care, 59–60 comprehensive geriatric assessment (CGA), 60, 448–451, 453 development of, 453 future view, 454 geriatric education centers, 451–452 geriatric nursing, 705, 968–970 geriatric psychiatry, 455–456

geriatric research, education, and clinical centers (GRECCs), 456–457, 1211 rehabilitation, 1012–1015 supporting organizations. See Organizations in aging telemedicine/telegeriatrics, 1176–1178 Geriatric psychiatry, 455–456 history of, 455 mental health services, 770–771 National Institute of Mental Health Epidemiologic Catchment Area Project, 815–817 organizations/journals, 456 training programs, 455 Geriatric research. See Aging research Geriatric research, education, and clinical centers (GRECCs), 456–457 comprehensive geriatric assessment (CGA), 449 development of, 456 effectiveness of, 457 Geriatric Resource Information Project, 452 Germline gene therapy, 440 Gerontogenes, 119 Gerontology, 460–461 critical theory, 272–274, 553–554 defined, 460 ethics, 383–385 industrial, 580–581 Gerontology Research Center, intramural research, 818 Gerontology Society of America, 64, 91, 458–460 history of, 458 journals of, 458 projects of, 458–459 Gerontophobia, ageism, 41–42 Geropsychology, 771 Gerstmann-Straussler-Scheinker disease, 954–955 Gestational diabetes, 313 Gingivitis, 875 Gingko biloba, cognitive impairment treatment, 219–220, 254 Glaucoma, 409–410 and minority groups, 409 sudden vision loss, 407 treatment, 410 visual losses, 1214 Glial cell-derived neurotrophic factor (GDNF), 837 Gliclazide diabetes treatment, 315 drug reactions, 923



February 7, 2006

13:2

Subject Index

Glimepiride, diabetes treatment, 315 Global aphasia, 72 Glomerulonephritis, 631 Glucocorticoid hormones functions of, 827 increase and aging, 827 stress and aging, 1142–1143 Glucometers, 314–315 Glucosamine, arthritis treatment, 80 Glucose regulation advanced glycation end-products, 31–33 carbohydrate metabolism and aging, 158–160 diabetes, 312–316 Alpha-glucosidase inhibitors, diabetes treatment, 315 Glutamate aging and changes, 835 functions of, 835 and memory decline, 748 production of, 835 Gluthatione, 218 Glycation of proteins, advanced glycation end-products, 31–33, 977–978 Glycogen synthetase kinase 3 inhibitors, 214 Glycoxidation of proteins, 978 Goal Attainment Scaling (GAS), 462–463, 1014 Goal-setting, 462–463 developmental, influences on, 267 goal engagement/disengagement, 23, 657–658, 796 intrinsic/extrinsic goals, 796–797 monitoring scale, 462–463 and motivation, 796–797 process, 463 selection, optimization, and compensation model, 1049–1050 Gorham’s Proverbs Test, 428 Gout, 81 Grab bars, 528, 551 Grandparent-grandchild relationships, 464–465, 610 grandparent divorce, effects on, 329 grandparents parenting grandchildren, 465 Grandparents’ Rights, 464–465 intergenerational solidarity, forms of, 464–465, 610 maternal grandparents and closeness, 464 parental divorce, effects on, 464–465

I-25

Graves disease, 1190 Gray Panthers, 878 Green House movement, 852 Grief bereavement, 107–109 complicated grief, 107–108, 1227, 1228 loss, 707–709 measurement of, 108 psychological interventions, 108 widowhood, 1226–1228 Ground substance, 261 Group model HMOs, 506 Group therapy, 466–468 cognitive therapy, 995 depression, 466–467 functional adaptation skills training (FAST), 467 reminiscence, 994 See also Support groups Growth-curve mixture models, longitudinal research, 681 Growth hormone and insulin-like growth factor-1, 468–471 aging and decline, 469, 827 animal models, 470–471 and brain aging, 470 exercise effects, 470 GH secretion and distribution, 468 GH supplementation, 469–470 Guardianship/conservatorship, 472–474 competence, 250–251 increase and population aging, 473 powers/authority, 472–473 public guardianship, 472 purpose of, 472 research studies, 473 Guided autobiography, 113, 655 Guillain-Barré syndrome, 586 Guttata, 406 Hair, 476–477 aging and changes, 21, 476 hormones, response to, 476, 477 loss, 476–477 nutition, effects on, 476 Haloperidol, for delirium, 288 Halstead-Reitan Battery, 428 HAROLD hypothesis, hemispheric reduction, 513–514


I-26


February 7, 2006

13:2

Subject Index

Hawaiian American elders, 85–86 common illnesses of, 86 Hayflick limit, 153, 653 Head lice, 477 Health and Retirement Study (HRS), 478–480, 1165 questionnaire subjects, 478 results, 479–480 supplemental studies, 478–479 Health beliefs, 480–482 commonsense model of self-regulation, 481 and locus of control, 673 self-assessments of health, factors in, 480–481 Health care, 483–496 ambulatory and outpatient care, 59–60 and patient autonomy, 98–99 preventive, 952–954 Program of All-Inclusive Care for the Elderly (PACE), 488, 973–975 quality improvement/quality assurance, 998–999 Health care financing health insurance, 503–506 illness as social problem, 1106 and inflation, 583–584 long-term care, 487–489 Medicaid, 720–726 Medicare, 483–486, 727–731 out-of-pocket payments, rate of, 483, 584 social/health maintenance organization (S/HMO), 488–489 source of funds (1960–2002)(table), 505 Health care policies, 490–496 future view, 494–495 historical view, 490–494, 504–505 Health care proxy, 668, 670 Health informatics, 496–499 bioinformatics, 498 computational biology, 498 electronic patient records (EPR), 497–498 history of, 497 information retrieval, 498–499 intelligent data analysis, 499 Internet, 499 picture archiving/retrieval, 498 risk predictions, 498–499 Health information, online. See Internet Health insurance, 503–506 employee-sponsored, 505 enrollment trends, 505–506

future view, 508 health maintenance organizations (HMOs), 506–508 history of, 504–505 managed care, types of plans, 506 terms/definitions, 504 Health Insurance Portability and Accountability Act (HIPAA), 362, 493, 687, 690 Health Locus of Control Scale, 672 Health maintenance organizations (HMOs), 506–508 future view, 508 history of, 506 issues related to older persons, 507–508 Medicare HMOs, 484, 507, 729–730 models, 507–508 quality of care, 507 social/health maintenance organization (S/HMO), 488–489 Health promotion benefits of, 954 and Internet, 244–245 Health Utilities Index, 1001 Healthy immigrant effect, 784 Heamarthrosis, 518 Hearing, 508–512 aging and changes, 509–510 pure tone sensitivity, 510 speech discrimination, 510 speech sensitivity, 510 stimulus for, 509 temporal discrimination/summation, 510–511 Hearing aids, 511 Hearing disorders, 238–239 assistive devices, 511 cochlear implants, 512 diagnosis, 239 electronic amplification systems, 512 otosclerosis, 509–510 presbycusis, 238–239, 510 prevalence of, 508 telecommunciations relay services (TRS), 67 Heart, 160–162 aging, structural changes, 160–161 deconditioning, 167 diastolic function and aging, 161–162, 164, 167 disease. See Cardiovascular disease response to exercise, 162 Heart attack. See Myocardial infarction Heart murmurs, 164



February 7, 2006

13:2

Subject Index

Heart rate decline and aging, 162, 164, 401 and emotional arousal, 357 exercise and aging, 162, 401 Heat shock factor, 121 Height, and aging, 143 Helicobacter pylori, 430–431 Helper T cells, 566 Hematopoietic stem cells, 565 Hemispheric asymmetries, 200, 512–514 aging and changes, 513–514 anatomical, 513 and cognitive processes, 513–514 HAROLD hypothesis, 513–514 theories of dominance, 512–513 Hemolytic anemia, 141, 147 Hemophilia, 444 Herbal therapy ayurvedic, 254 for cognitive impairment, 219–220 common herbal treatments, 254 drug interactions, 734 Hiatus hernia, 430 Hierarchical Assessment of Balance and Mobility, 791–792 High-density lipoprotein (HDL), 662–666 levels and risk, 663 levels and women, 663–664 subclasses, 663 Hip fractures, 515–520 complications of, 516, 518 diagnosis, 515 extracapsular, 518–519 and homocysteine, 535 intracapsular, 516–517 medical management, 515–516 and osteoporosis, 520, 883 pathologic, 516 and pressure ulcers, 950 prevention, 520 surgical management, 518–519 Hip protectors, 885 Hippocampus, 200, 513, 827, 831 stress and aging, 1142–1143 Hippocratic oath, 392, 685 Hispanic elderly, 520–522 caregivers of, 173, 785 common disorders of, 521–522 health care financing issues, 521 increase of, 520

I-27

parent-child coresidence, 903 socioeconomic status, 521, 947 Histocompatibility antigens, 96 History-graded influences, 308 Hmong American elders, 85 Holistic approach case management, 178–181 complementary and alternative medicine, 253–255 Holocultural research, 276 Home care hospice, 544 Medicare coverage, 484–487, 728 personal assistance services (PAS), 911–913 rehabilitative, 1014 Home death, 900–901 Home Environmental Assessment Protocol, 375 Home equity conversion, 523–525 Home Equity Conversion Mortgage (HECM), 523–524 international programs, 525 reverse mortgage, 523 Home Equity Conversion Mortgage (HECM), 523–524 Home furnishings, mature market spending on, 263–264 Home-hospital care, 60 Home Keeper, 524 Home modifications, 528–530 barriers to, 529 future view, 530 human factors engineering, 550–551 for injury prevention, 529, 593 tasks in, 528 work environments, 551 Home of the Holy Ghost, 542 Home Safety Assessment scale, 375 Homelessness, 525–527 interventions for, 527 risk factors, 525–526, 948–949 Homeostasis, 531–533 aging and losses, 532–533 history of concept, 531 as stability theory, 532 Homocysteine, 533–536 and aortic atherosclerosis, 535 and carotid artery disease, 535 and coronary artery disease, 533–534 and deep vein thrombosis, 535 and dementia, 535


I-28


February 7, 2006

13:2

Subject Index

Homocysteine (continued) and hip fractures, 535 lowering, treatments for, 534, 536, 1216 optimal level, 534 and peripheral artery disease, 535 and stroke, 534–535 Homologous recombination, 131 Homosexuality, 537–538 aging, issues of, 537 AIDs/HIV, 50 later-life risks, 538 stigmatization/stereotyping, impact of, 537–538 support networks, 64, 537–538 Homotaurine, 214 Honolulu-Asia Aging Study, 818–819 Hormesis, 1144 Hormone replacement therapy, 539–541, 944–945 benefits of, 540 breast cancer risk, 541, 944–945 and cardiovascular disease, 945 DHEA, 310–312 estrogens, 215–216, 311, 944 osteoporosis benefits, 885, 944 progestins in, 540, 944 uterine cancer risk, 540, 765 Women’s Health Initiative study, 540–541, 765, 945, 1236 Hormones and aging DHEA, 310–312 genetic programming theory, 445 growth hormone and insulin-like growth factor-1, 468–471 melatonin, 737–739 and menopause, 420–421, 764 thyroid hormones, 1188–1189 Hospice, 542–544 history of, 282, 368, 542–543 home care, 544 Medicare coverage, 486–487, 543, 544, 728 nursing home residents, 544, 846 prison population, 958–959 research study, 543–544 use, impact of, 543–544, 900 Hospital Audiences, 555 Hospital care, and medication misuse/abuse, 733 Hospital insurance, Medicare Part A, 728 Hostility, 545 components of, 545

health impact of, 545 measures of, 545 Hot flashes, 764 Housing, 546–548 adult foster care, 27 age-segregated, 547 architecture for older adults, 78–80 assisted living, 87–90, 548 continuing care retirement community (CCRC), 488, 1038–1039 coresidence with adult children, 902–903, 939 elder-friendly communities, 530 environmental assessment, 374–375 home modifications, 528–530 inflation, 584–585 naturally occurring retirement communities, 547 nursing homes, 547–548, 842–853 retirement communities, 1038–1039 smart house, 243–244, 706 specialized with supportive services, 1133–1136 symbolic significance of, 546 Howell, Trevor, 453 Hsien, 69 Human artificial chromosome (HAC), 440 Human factors engineering, 549–552 elements of, 549–550 home modifications, 550–551 mobility/transportation interventions, 550 technology/information systems, 551–552 Humanities and arts, 552–556 future view, 556 humanistic aging inquiries, 553–554 and intergenerational relationships, 556 programs, 555–556 and spirituality, 556 Humanities Programming for Older Adults, 556 Humor, 557–559 aging as topic of, 557–558 sense of, and aging, 558 therapeutic humor, 558–559 Huntington disease, neurotransmitter changes, 836 Huperazine, cognitive impairment treatment, 220 Hutchinson-Gilford syndrome, premature aging, 188, 972 Hyaline cartilage, 80 Hyaluronic acid, arthritis treatment, 80 Hybrid adenovirus/AAV vectors, 441 Hybrid retirement plans, 349, 1040 Hydergine, memory improvement, 747–748



February 7, 2006

13:2

Subject Index

Hydrocolloid dressing, pressure ulcer management, 951 Hydroxychloroquine, for rheumatoid arthritis, 81 Hyperglycemia and advanced glycation end-products, 32–33 in diabetes, 313 Hyperparathyroidism, 145–146 Hypertension, 559–562 and calcium deficiency, 146, 147 and cardiovascular disease, 167, 170 complications of, 167 and congestive heart failure, 166 diabetes risk factor, 315 drug treatment, 560–562 exercise benefits, 402 isolated systolic hypertension, 559–560 management, 167, 315 non-medical treatment, 560 risk and aging, 559–560 Hyperthermia, 14, 1183–1184 Hyperthyroidism Graves disease, 1190 and hair health, 477 Hypertriglyceridemia, 664 Hypochlorhydria, 430 Hypoglycemic agents, drug reactions, 923 Hypoparathyroidism, 145 Hypothalamus and biological clock, 737 functions of, 199 and sundown syndrome, 1157 Hypothermia, 14, 1182–1183 Hypothyroidism and hair health, 477 mechanism of, 1189–1190 Ictal phenomenon, 377 Idebenome, cognitive impairment treatment, 218 Illegal drug use, 732, 1150 Imaging, picture archiving/retrieval, 498 Immigrants groups and aging. See Minorities and aging Immortalization, senescence and transformation, 194, 1057–1060 Immune system, 565–568 aging and changes, 566–570 autoimmunity, 95–96 cell types, 565 components of, 565–566

and diseases of aging, 567–568 immunoglobulins, production of, 140, 565 immunological response, 13 Immune system disorders AIDS/HIV, 48–51 listing of, 96 See also Autoimmune disease Immunizations, 569–572 diphtheria, 571–572 influenza, 570, 587–588 pneumonia, 570–571 tetanus, 571–572 varicella zoster, 572 Implicit memory and learning, 573–575 aging and stability of, 756–757 implicit memory assessment, 574 learning, forms of, 574–575 Implicit motivation, 795 Impotence, 1069–1072 defined, 1070 penile implants, 1071 Viagra, 1070–1072 Income. See Economics of aging Incompetence, mental. See Competence Incontinence. See Fecal incontinence; Urinary incontinence Independence Plus waiver templates, 185 Independent living centers, 66 Independent living movement, 66 Index Medicus, 498 Indian Health Service (IHS), 824 Individual independent practice associations (IPAs), 506 Individual retirement arrangements (IRAs), 576–579 participation (1979–1996)(tables), 577–579 types of, 576, 1043 withdrawals and taxation, 576, 1048, 1171 Indomethacin, cognitive impairment treatment, 215 Industrial gerontology, 580–581 areas of study, 580–581 focus of, 580 Inequality, social stratification, 1115–1118 Infections and aging, 568–570 bladder, 632 and fever, 1184 immunization, 569–572 tuberculosis, 1196–1198

I-29


I-30


February 7, 2006

13:2

Subject Index

Inflammation and Alzheimer’s disease, 215 inflammatory markers, 135, 215 inflammatory response, centarians, 198 Inflammatory bowel disease, 431 Inflation, 582–585 housing, 584–585 impact of, 582–583 international view, 949 and long-term care insurance, 690 measures, 582 medical expenses, 583–584 and Social Security payments, 582 Infliximab, for rheumatoid arthritis, 81 Influenza, 585–588 complications of, 586 diagnosis, 586 epidemiology, 585 immunization, 570, 587–588 treatment, 586–587 Information-processing theory, 588–591 cognitive processes, 229, 230, 588–591 process-specific slowing, 589–590 Information systems health informatics, 496–499 Internet health information, 499–503 Informed consent, 383 Inhibition of return of attention, 94 Injury, 591–593 epidemiology, 591–592 falls, 592–593 prevention, 592–593 Inner ear, disorders of, 510 Insect models of aging, flies, 114–118, 395–396 Insight, mental status assessment, 772 Insomnia drug-related, 1087–1088 fatal familial insomnia, 954–955 persistent psychophysiological, 1086–1087 Instantiation, 762 Institute for the Future of Aging Services (IFAS), 62 Institutes for Learning in Retirement (ILR), 555 Institutionalization, 595–598 and caregiver distress, 172 impact of, 596–598 placement, reasons for, 595–596 Instrumental activities of daily living, 6, 182 Instrumental support, 1122 Insulin

injection and diabetes, 313, 315 insulin secretagogues, 315 in nonhuman aging models, 117–118 Insulin-like growth factors, and growth hormone, 468–471 Insulin resistance and calcium deficiency, 147 defined, 159 diabetes, 312–316 drug management, 315 lifestyle remedies, 159–160, 402 pathophysiology, 159 Insurance AARP products, 3 long-term care, 688–691 See also Health insurance Intelligence, 600–602 crystallized, 4, 22, 230 divergent thinking, 269 dual-processing model, 22 expertise and age, 22, 39–40 fluid, 4, 22, 40, 230 individual differences, 601 normal changes, 22, 600–601 practical, 230, 602 pragmatics of, 22 psychometric approach, 230, 428, 601 reversal of decline, 601–602 wisdom, 22, 1230–1234 Intelligent data analysis, 499 Interest groups AARP (The American Association of Retired Persons), 1–3 elderly political action, 933–934 intergenerational equity, 608, 878–879 Interference, 602–605 aging and vulnerability to, 602–603 and brain activity, 604–605 and dual-tasks, 604 and memory, 603–604 proactive/retroactive, 603 Intergenerational equity, 385, 607–609 gap and Social Security, 583, 607–608 interest groups, 608, 878–879 and tax policy for elderly, 1173 Intergenerational relationships, 609–613 conflict, sources of, 612 divorce, effects on, 328–329, 464–465 grandparent-grandchild relationships, 464–465, 610



February 7, 2006

13:2

Subject Index

and humanities and arts, 556 intergenerational stake concept, 437, 610 solidarity, dimensions of, 464–465, 610 types of, 612–613 See also Family relationships Intermittency, 1205 Internal-External (I-E) Scale, 671 International Association of Gerontology (IAG), 615 International Association of Homes and Services for the Ageing (IAHSA), 62 International Classification of Functioning, Disability, and Health (IFC), 615–617 on activities of daily living, 6 application of, 617 codes/qualifiers, 616–617 International Federation on Ageing (IFA), 618, 878 International migration, 447 Internet aging, images of, 44 applications, 619–621 caregivers, use of, 619–620 and doctor-patient relationships, 333 educational programs on, 620 electronic formats, 500 and family communication, 242–243 format/content, gearing toward older persons, 501–502, 551–552, 621 government resources on, 621 health information, 499–503, 620 and health promotion, 244–245 online support groups, 1161 social contact through, 501, 1103 telecommuting, 620–621 use, training older adults, 500–502 visual ease of use, 502 Interpersonal psychotherapy, 622–623, 993 Interviews psychological assessment, 987 surveys, 1163–1165 Intestines, disorders of, 431 Intimacy versus isolation, 21 Intracapsular hip fractures, 516–517 Intramedullary nails, 519 Intraocular pressure, glaucoma, 409–410 Intrinsic motivation, 796–797 Introversion, 623–624 measurement of, 624–625 Inventory of Complicated Grief, 108 Involutional melancholia, 765

I-31

Iowa Self-Assessment Inventory, 805 Iron deficiency anemia, 141 and hair, 476 Ischemic bowel disease, 431 Isolated systolic hypertension, 559–560 Isomerization, 624–627, 978 Japanese American elders, common illnesses of, 84 Job Training Partnership Act (JTPA), 366 Joint replacement surgery, for rheumatoid arthritis, 81 Joints, arthritis, 80–81 Judgment, mental status assessment, 772 Jungian psychology, introversion, 623–624 Kaposi sarcoma, 48 Katz Index of Independence in Activities of Daily Living, 6–7 Keratitis sicca, 406 Ketoacidosis, Type 1 diabetes, 313 Ketoconazole, drug interactions, 337 Kevorkian, Jack, 924, 925 Keys Amendment, 26 renal artery stenosis, 631 Kidney and urinary system, 630–632 acid-base balance, 4–5 acute renal failure, 631 aging and changes, 630–631 cancer, 632 chronic renal failure, 631 glomerulonephritis, 631 infections, 632 kidney stones, 146, 632 nephrotic syndrome, 631 renal transplantation, 631 sodium balance/osmolaity regulation, 1126–1127 urinary incontinence, 417–419, 631–632 urinary tract, 1205–1206 Ko Hung, 69 Korean American elders common illnesses of, 84 filial piety, 84 Korsakoff syndrome and autobiographical memory deficit, 741, 751 vitamin B deficiency, 1216 Kuhn, Maggie, 878


I-32


February 7, 2006

13:2

Subject Index

Labor force. See Employment; Older workers Laboratories, of National Institute on Aging, 818 Lacrimals, aging and changes, 406 Lamotrigine, seizure management, 378 Language, subsystems of, 71, 236–237, 634–635 Language comprehension, 633–634 discourse processing, 741–742 processing deficits, 633 Language disorders, 237–238 aphasia, 71–74, 237 and cogntive impairment, 237–238 communication disorders, 234–239 language of generalized intellectual impairment, 238 production disorders, 635–636 right hemisphere language disorders, 237–238 treatment, 238 word-finding difficulty, 237, 635, 1238 Language production, 634–636 disorders of. See Language disorders Laotian American elders, 85 Laser surgery, eye, 408–410 Lateral geniculate nucleus, 1212 Lawton, M. Powell, 79 Leadership Council of Aging Organizations, 64–65, 459 Learned helplessness, 636–638 animal models, 636–637 and homelessness, 526 media portrayal of, 45 Learned optimism, 638 Learning, 638–639 age and expertise, 39–40 attention, 92–95 cognitive processes, 229–231 efficiency, influences on, 639 and implicit memory, 573–575 improving, 639 information-processing theory, 588–591 Least restrictive care setting, 495, 1029 Lecithen, memory improvement, 747 Leflunomide, for rheumatoid arthritis, 81 Legal aid attorneys, 640 Legal guardians. See Guardianship/conservatorship Legal services, 639–640 See also Elder law Lehman, Harvey C., 269 Leisure, 641–642

activities, 641 health benefits, 642 psychological benefits, 641 Lens of eye aging and changes, 407, 1212 disorders of, 407 Lentivirus-mediated transgenesis, 130 Leptin, levels and abdominal fat, 135–136 Lerman, Liz, 555 Lesbian and Gay Aging Issues Network (LGAIN), 64, 538 Lesbians. See Homosexuality Leucocyte esterase test, 1205 Leukemia blood changes and aging, 141–142 chronic granulocytic leukemia, 141 chronic lymphocytic leukemia, 142 Levitra, 1071 Levodopa, drug interactions with, 337 Levothyroxine, drug interactions, 337, 339 Lewy body disease, 289, 295–298 diagnosis, 296, 906 etiology, 297–298 management, 296 neurotransmitter changes, 836 symptoms, 296 Life course perspective, 643–646 adult development, 21–23 concepts in, 644–645 continuity theory, 266–268 cross-cultural research questions, 277 developmental psychology, 306–308 developmental tasks, 308–310 history of, 645–646 issues in, 645–646 life events, 647–649 life expectancy, 649–650 life span scripts, 307 senescence and transformation, 1057–1060 trajectories of, 643–644 Life Enrichment and Renewal Network (LEARN), 555 Life events, 647–649 developmental view, 648–649 health outcomes, 647–648 life course transitions, 649 as stressors, 1119–1120, 1140–1141 Life expectancy, 649–650 defined, 650 increases, 650–651



February 7, 2006

13:2

Subject Index

women, 258, 650 See also Longevity Life extension, 651–654 anti-aging medicine, 68–69 diet restriction, 316–318, 652 future view, 653–654 growth hormone and insulin-like growth factor-1, 468–471 longevity genes, 652–653 and melatonin, 737–738 nematodes, 121 practical guidelines, 653 senescence and transformation, 1057–1060 Life review, 42, 654–655 benefits of, 655 experience of, 655 life review therapy, 655, 994 Life satisfaction, 10–11, 1145–1146, 1154 Life scripts, 750–751 Life span, 656 centarians, 196–198 defined, 656 long-lived human populations, 684–685 supercentarians, 196–197, 656 Life-span theory of control, 657–659 autonomy and aging, 97–99 control, maximization of, 657 control strategies, 657–658 empirical research, 658–659 future view, 659 goals in, 796 learned helplessness, 636–638 primary/secondary control, 657 successful aging, 1154–1155 Life-support, withdrawal, 393, 670 Limbic system, 200 Linked lives, 645 Lipase inhibitors, diabetes treatment, 315 Lipid peroxidation Alzheimer’s disease, 218 and membrane changes, 740 plant aging, 928 Lipofuscin, 122, 660–661 composition of, 660 deposition, spinal cord, 201, 204 microglia, 202 visualization method, 661 Lipoprotein analysis, 663 Lipoprotein lipase (LPL), 664 Lipoproteins, serum, 662–667

I-33

aging and changes, 663–664 apolipoprotein epsilon 4, 75–76 body weight and levels, 664–665 diet, effects on, 662, 665–667 drug therapy, 666–667 exercise effects, 667 genetic factors, 664–665 high-density (HDL), 662–666 and hormone replacement therapy, 945 low-density (LDL), 662–667 measurement of, 662–663 metabolizing enzymes, 664 very low-density (VLDLs), 663–664 Lippman, Walter, 43 Lithotripsy, 632 Live Well, Live Long program, 65 Liver and blood glucose regulation, 159 disorders of, 431 Living arrangements. See Housing Living wills/durable powers of attorney, 668–671 and competency, 383 functions of, 669–670 health care proxy, 668, 670 withdrawal of life support, 393, 670 Locus of control, 671–673 concepts/models, 672 empirical research, 672–673 learned helplessness, 636–637 measurement of, 671–672 perceptions and later life, 673 Loneliness, 674–675 defined, 674 lonely, profile of, 675 social isolation, 1101–1103 wards/guardianship, 473 Long-lived human populations, 684–685 centarians, 196–198, 684 high blood pressure benefits, 561 supercentarians, 196–197 Long-term care ethics, 685–687 legal regulation, 701–704 Medicaid coverage, 483, 485–487, 722, 724 National Association of Boards of Examiners for Long-Term Care Administrators, 813–814 National Long-Term Care Survey, 820–823 nursing homes, 842–853 public policy, 695–699 rehabilitation in, 1013–1014


I-34


February 7, 2006

13:2

Subject Index

Long-term care (continued) resource utilization groups, 1022–1023 rural elders, 1046 Long-term care insurance, 688–691 barriers to purchase, 689–690 inflation protection, 690 market, 688–689 nonrenewal issue, 690–691 partnerships for long-term care, 690 Long-Term Care Ombudsman Program (LTCOP), 692–694 evaluation of, 693 history of, 692 structure/staffing/funding, 692–693, 702–703 Long-term care workforce, 704–707 nursing home staff, 698–699, 848–849 personal assistant services, 911–913 Long-term memory, 755–757 autobiographical memory, 740–741 remote memory, 749–751 Longevity centarians, 196–198, 651–652 compression of morbidity, 257–259 disposable soma theory, 322–324 genetic factors, 652–653 increase, reasons for, 651 International Longevity Center (ILC), 618–619 long-lived human populations, 684–685 societal impact, 676–677 See also Life extension Longitudinal data sets, 677–679 access to data, 678–679 design issues, 677–678 future view, 679 Longitudinal research, 679–682 autoregressive models, 681 Baltimore Longitudinal Study of Aging, 101–104 Berlin Aging Study, 110–112 Canadian Longitudinal Study of Aging, 150 cluster analysis, 681 cross-sectional design, 680 Duke Longitudinal Studies of Aging, 346–347, 677 established populations for epidemiological studies of the elderly, 378–382 ethnographic study, 389 growth-curve mixture models, 681

Health and Retirement Study (HRS), 478–480 longitudinal data sets, 677–679 Longitudinal Retirement History Survey (LRHS), 678, 683 multilevel models, 681 multiple-indicator structural equation models, 681 National Long-Term Care Survey, 820–823 Normative Aging Study (NAS), 680, 838–839 panel design study, 679–680 sequential sampling, 680 simulation studies, 681–682 surveys, 1163–1165 temporal sampling, 681 on widowhood, 1226 Longitudinal Retirement History Survey (LRHS), 678, 683 Look-behind surveys, 850 Losartan, blood pressure control, 562 Loss, 707–709 bereavement, 107–109, 708 and disengagement, 23 dual process model, 1226 negative outcome, risk-factors, 709 role loss, 10, 707–708 of self-care activities, 1052–1053 social loss, 707–709 Lotka model, population aging, 301 Low-density (LDL) lipoprotein, 662–667 diet and particle size, 663 levels and risk, 663 Low-fat diet, and lipid levels, 665–666 Lung cancer and cigarette smoking, 155 reducing risk, 155, 157 Lungs, respiratory system, 1023–1025 Lymphocytes, immune system, 565–566 Lymphotoxin, 135 Lysosomal storage diseases, gene therapy, 439 Lysosomes gene therapy, 441–442 proteolysis/protein turnover, 981–982 Macrophages, 565, 567 Macula, 408–409 age-related macular degeneration, 408–409, 1214 diabetic retinopathy, 409



February 7, 2006

13:2

Subject Index

Madarosis, 406 Magnetic resonance imaging (MRI) angiography, 207 breast, 157 diffusion-weighted MRI, 206 Magnetic resonance spectroscopy (MRS), 712–716 aging brain, 714 Alzheimer’s disease, 714–715 Maillard reaction, 32–33 Major histocompatibility complex (MHC), 96, 566 Malnutrition risk common nutritional problems, 858 diet restriction, 317 Mammography cancer reduction statistics, 156 new techniques, 157 resistance to use, remedies, 156–157 Managed care fee-for-service plans, 506 health maintenance organizations (HMOs), 506–508 Medicaid beneficiaries, 724–725 Medicare beneficiaries, 484, 507, 728, 730 mental health services coverage, 771 point of services plans (POS), 506 preferred provider organizations (PPOs), 505 Program of All-Inclusive Care for the Elderly (PACE), 973–975 Managed care organizations (MCOs), Medicare plans, 485, 492, 494 Mandatory retirement, 42, 1035 Marital relationships, 716–719 and death. See Widowhood divorce, 327–329 emotional expression in, 357 and health status, 717–718 marital satisfaction, 718–719 necessaries legal doctrine, 422 older persons, statistics, 717 same-sex marriage, 537 spouse caregivers, 173 Mass media age stereotypes, 43 aging, images of, 44–47 mature market spending on, 264 women, portrayals, 45–46 Massage, 254 Masturbation, 1069 Matrix metalloproteinases, 261–262

I-35

Max Planck Society, 110 Meals on Wheels, 858–859, 861–863 Means test, 484, 1114, 1171 Medicaid, 720–726 adult day care payments, 17 adult foster care payments, 26 assisted living payments, 90 cash-and-counseling demonstration states, 183–184 coverage, scope of, 720 enrollment, 720, 722 expenditures (1985–2003)(table), 722–723 federal medical assistance percentages (table), 721 history of, 491, 505, 720, 948 home/community care based services payments, 487, 720 home modification payments, 529 Independence Plus waiver templates, 185 long-term care payments, 722, 724, 844, 845, 849–850 managed care population (1991–2003)(table), 724 nursing home payments, 722, 724 policy analysis, 931 Program of All-Inclusive Care for the Elderly (PACE), 488, 725, 973–975 spending down, 487, 696, 722 State Child Health Insurance Program (SCHIP), 725–726 supplemental health coverage/Medicare beneficiaries, 722, 728–729 waiver programs, 90, 178, 487, 697 Medical Act (1917), 504 Medical care, ambulatory and outpatient care, 59–60 Medical error, medication misuse/abuse, 733 Medical Outcome Study Shortform Health Survey, 806 Medicalization of dying, 280–282 Medicare, 349, 483–486, 727–731 cost-sharing, 729 coverage, scope of, 727–728 eligibility criteria, 727 expenditures, 730–731 financing, 730 future view, 731 health care services covered, 485–486 history of, 491–495, 505, 727, 948 home health services, 484–485, 487


I-36


February 7, 2006

13:2

Subject Index

Medicare (continued) Independence Plus waiver templates, 185 low-income program, 484 managed care plans (Medicare Advantage), 485, 492, 494, 728 Medicaid supplemental coverage, 722, 728–729 Medicare HMOs (Medicare + Choice), 484, 507, 729–730 Medigap, 484, 584, 729 nursing home payments, 483, 485, 845, 850 prescription drug benefit, 484, 493–494, 505, 728–729, 1106 Program of All-Inclusive Care for the Elderly (PACE), 488, 495, 973–975 prospective payment system (PPS), 484 services/items not covered, 729 Medicare Prescription Drug, Improvement, and Modernization Act (2003), 18, 484, 493–494, 505, 727, 731, 1106 Medication management, adherence, 15–17 Medication misuse/abuse, 732–734 illegal drugs, 732, 1150 medical error, 733 over-the-counter medications, 734, 1150 prescription drugs, 732–734, 1150 MEDLINE, 498 MEDLINEplus, 500 Megacolon, 418 Meglitinides, diabetes treatment, 315 Meibomian glands, 406 Melatonin, 737–739 aging and changes, 737–738 diet restriction effects, 737 functions of, 737 loss, effects of, 738–739 production of, 737 Memantine Alzheimer’s disease treatment, 54, 219 functions of, 739 Membranes, 739–740 aging and changes, 739–740 plant aging, 928 Memory, 755–758 and anxiety, 70 assessment, 230, 759–760, 775 autobiograhical, 740–741 and biography, 113 clinical assessment, 759–760 cognitive/non-cognitive moderators, 757 and depression, 303

discourse processing, 741–744 drug enhancement of, 747–748 episodic, 755–756 everyday, 744–747 explicit, 573–574, 742, 756 false, 758 implicit, 573–575, 756–757 and interference, 603–604 and language comprehension problems, 633, 635 long-term, 755–757 memory schema, 761–762 metamemory, 772–775 and mild cognitive impairment, 781 neurochemical correlates, 747–748, 833 neuroplasticity, 829–831 procedural, 756–757 prospective, 757 recency effect, 751 recognition, 743 remote, 749–751 semantic, 756 short-term, 755 source, 757–758 spatial, 752–753 terminal change, 1184–1185 word-finding difficulty, 1238 working, 743–744, 753–754, 755 Memory Compensation Questionnaire, 775 Memory Controllability Inventory, 775 Memory training/mnemonics, 763–764 method of loci, 763 peg word mnemonic, 763–764 Men Normative Aging Study (NAS), 680, 838–839 prostatic hyperplasia, 975–976 See also Gender differences Menopause, 419–421 and age stereotype, 765–766 cultural aspects, 765 hormone replacement therapy, 539–541, 944–945 and other hormones, 826 physical symptoms, 539–540, 764, 944 psychological aspects, 764–766, 765 Mental disorders. See Psychiatric/psychological disorders Mental health, 767–769 and aging, 767–768 biopsychosocial model, 768–769



February 7, 2006

13:2

Subject Index

elements of, 767 mental status examination, 771–772 and religiosity, 1018 Mental health services, 770–771 geriatic specialty services, 770 National Institute of Mental Health Epidemiologic Catchment Area Project, 815–817 reimbursement, 770–771 Mental status examination, 771–772 areas for assessment, 772 Mini-Mental Status Examination, 816, 844, 988 Mentorship, 436 Meperidine, drug reactions, 343 Mesenteric ischemia, 431 Metabolic acidosis, 5 Metabolic disorders, diabetes, 312–316 Metabolic syndrome of aging and abdominal fat, 135–136, 313 and diabetes, 313 exercise benefits, 402 Metabolism aging and regulation of, 371–372 bioenergetics, 370–371 calcium, 145–147 carbohydrate, 158–160 energy and bioenergetics, 370–371 Metamemory, 772–775 aging and changes, 774 assessment of, 774–775 cognitions in, 772–774 Metamemory in Adulthood, 775 Metastasis, 152 Metchnikoff, M. E., 461 Metformin, diabetes treatment, 315 Methionine sulfoxide reductase, 888 Method of loci, 763 Methotrexate, for rheumatoid arthritis, 81 Methuselah gene, 828 N-methyl-d-aspartate receptor blockers, cognitive impairment treatment, 219 Metoclopramide, drug reactions, 344 Metrifonate, Alzheimer’s disease treatment, 217 Mexican Americans, health immigrant effect, 74 Mice, biological aging models, 125–131 Michigan Alcoholism Screening Test-Geriatric Version, 988 Microglia aging and changes, 202 lipofuscin, 202

I-37

Middle ear, disorders of, 509–510 Middle-old, age range of, 264 Midlife crisis, 23, 309, 776–777 Midtown Manhattan Study, 647 Migration, 777–780 age patterns, 778 counterstream, 446 geographic mobility, 446–447 immigration to U.S., patterns, 386 interstate, 446–447 popular U.S. destinations, 446, 779 and population aging, 779–780, 937 and retirement, 778–779 seasonal, 447, 779 Milacemide, cognitive impairment treatment, 218 Milameline, cognitive impairment treatment, 217 Mild cognitive impairment, 780–782 amnestic, 53–54, 781 diagnostic criteria, 780–781 drug treatment, 217 language deficits in, 238 pre-dementia syndromes, 290–291, 782 subtypes of, 781–782 MindAlert program, 65 Mindfulness mediation, 234 Mini-Mental Status Examination (MMSE), 816, 844, 988 Mini Nutritional Assessment (MNA), 858 Minimum Data Sets, 596, 702, 806, 840, 844 Minorities and aging, 783–785 African American elders, 34–37, 784 Asian Indian American elders, 84–85, 784 bereavement practices, 108–109 caregivers, 173–174, 387, 785 Chinese American elders, 82–83 double-jeopardy hypothesis, 117, 387, 783–784 family relationships, 903 glaucoma, 409 Hawaiian American elders, 85–86 Hispanic elderly, 520–522, 784 Japanese American elders, 84 Korean American elders, 84 lesbian/gay/transgender/bisexual persons, 537–538 menopause, views of, 765 minority status, elements of, 387 Native American elders, 784, 823–825 Network of Multicultural Aging (NOMA), 64 Pacific Islander American elders, 85–86


I-38


February 7, 2006

13:2

Subject Index

Minorities and aging (continued) prison populations, 957–958 racial mortality crossover, 35–36 recruitment/retention in aging research, 786–788 respect, ethical framework, 687 social support, 1124–1125 socioeconomic status, 34–35, 82–83, 85, 521, 785, 947 Southeast Asian American elders, 85 technology, use of, 245–246 women workers, 1236 See also Ethnicity; specific minority groups Mirtazapine, withdrawal syndrome, 343–344 Misfolded proteins, 978 Mitochondrial DNA mutations, 789–790 and aging, 440, 789–790 allotopic expression, 441 deletion mutations, 790 duplications, 790 myopathies, types of, 789 point mutations, 789–890 reversals, gene therapy, 440 Mitochondrial membrane surface area, energy metabolism, 371–372 Mixed model HMOs, 506 MMPI Social Introversion Scale, 624 Mnemonics. See Memory training/mnemonics Mobile computing, 244 Mobility, 791–792 driving, 334–336 geographic, 446–447 human factors engineering, 550 loss, causes of, 791 measurement of, 791–792 transportation, 1193–1195 Modernization theory, 792–793 cross-cultural issues, 277–278, 793 Modified Card Sorting Test, 429 Money management. See Economics of aging Monoamine oxidase B inhibitors, cognitive impairment treatment, 218 Monoamines. See Catecholamines Monoclonal immunoglobulins, 140 Monocytes, 565 Mood, mental status assessment, 772 Mood disorders, cognitive theory of, 232–233 Morbidity, compression of, 257–259 Morioka, Shigeo, 619 Morning stiffness, rheumatoid arthritis, 81 Mortensen, Christian, 197

Mother’s Day Report, 869 Motivation, 794–797 and goal setting, 796–797 implicit/explicit motivation, 795 learned helplessness, 636–637 life-course trajectory, 795–796 and physiological needs, 795 research, historical view, 794 and self-esteem, 1056 and social cognitions, 1095–1096 and subjective well-being, 1146 Motor neuron disease, 292 Motor performance, 801–803 aging and changes, 799–803 and central nervous system, 798–801 coordination deficits, 799–800, 802–803 and highly-skilled persons, 803 motor variability, 801–802 practice effects, 801, 803 reaction time, 1006–1008 rigidity, 1044 slowing and information processing, 801 Mouth, oral health, 873–876 Movement, motor performance, 801–803 Mucopolysaccharidoses, 444 Muller, Charlotte, 619 Multichannel cochlear implants, 512 Multicompartment models, body composition, 142–143 Multidimensional functional assessment, 804–807 assessment instruments, 804–806 Multidirectionality, adult development, 307 Multilevel Assessment Instrument (MAI), 804–805, 988 Multilevel models, longitudinal research, 681 Multiphasic Environmental Assessment Procedure (MEAP), 375 Multiple-indicator structural equation models, longitudinal research, 681 Multiple sclerosis, cognitive impairment treatment, 217 Multitasking, 22 dual task situations, 94, 604, 634–635 Muscarinic agonists, cognitive impairment treatment, 217 Muscarinic receptors, 833 Muscle. See Skeletal muscle Musculoskeletal disorders arthritis, 80–81



February 7, 2006

13:2

Subject Index

osteomalacia, 881–882, 1215–1216 osteoporosis, 883–885 Musculoskeletal system, 808–810 aging and changes, 808–809 exercise benefits, 809 Mutations detection of, 1129 DNA and cancer, 152, 154 DNA repair theory, 330–331 evolutionary theory, 395–396 of genome stability, 1129–1130 mitochondrial DNA, 789–790 models for study of, 1129–1130 nematode aging model, 119–121 somatic mutations and genome instability, 1127–1130 wear-and-tear theories, 1224–1225 Mycosis fungoides, 477 Myeloblast, 141 Myeloproliferative disorders, 141 Myocardial infarction, 165–166 and atherosclerosis, 164, 165 causes, 165 diagnosis, 165 treatment, 165–166 Narrative analysis, 811–812 biography, 112–114 in gerontology practice, 812 and sense of self, 811–812, 917–918 Narrative thought, 552–553, 742 Nateglinide, diabetes treatment, 315 National Academy on an Aging Society (NAAS), 459 National Adult Day Services Association (NADSA), 18 National Archive of Computerized Data on Aging (NACDA), 678–679, 683 National Association of Area Agencies on Aging, 354, 812–813 National Association of Boards of Examiners for Long-Term Care Administrators, 813–814 National Association of Geriatric Education Centers (NAGEC), 452 National Center on Elder Abuse, 29 National Council on Aging, 63, 814–815 National Elder Abuse Incidence Study (NEAIS), 29–30 National Family Caregiver Support Program, 867, 868

I-39

National Hospice Study, 543–544 National Insitute of Mental Health Epidemiologic Catchment Area Project, 815–817 National Institute of Senior Centers (NISC), 815 National Institute on Aging, 458, 817–819 Biology of Aging Program, 819–820 epidemiology, demography, biometry program, 818–819 extramural programs, 817–818 intramural research, 818 laboratories of, 818 National Long-Term Care Survey, 820–823, 1165 policy/scientific applications, 822–823 National Nursing Home Resident Assessment Instrument, 1022 National Nursing Home Survey (NNHS), 852 National Retired Teachers Association (NRTA), 1 National Study of Assisted Living for Frail Elderly, 89 Native American elders, 823–825, 825 elderlies, status of, 824 Indian Health Service (IHS), 824 life expectancy increase, 784–785, 824 mortality/morbidity rates, 824–825 multiple jeopardy situation, 387 population aging, 824 premature aging of, 825 socioeconomic status, 825 Title IV aging programs, 812–813, 825 tribal membership criteria, 823 Native Hawaiian and Pacific Islander American elders, 85–86 Natural killer (NK) cells, 565, 567 Natural selection, 394 Naturally occurring retirement communities, 547 Necessaries legal doctrine, 422 Neglect and elderly self-neglect, 30 See also Elder abuse and neglect Nematodes, biological aging model, 119–122 Nephrotic syndrome, 631 Neramexine, cognitive impairment treatment, 218 Nerve growth factors and aging, 837 cognitive impairment treatment, 216 Nervous system, 198–205 AIDS/HIV, effects of, 48 autonomic nervous system, 204–205 central nervous system, 198–203 neuroplasticity, 829–831


I-40


February 7, 2006

13:2

Subject Index

Nervous system (continued) neurotrophic factors in aging, 837–838 peripheral nervous system, 203–204 Netherlands, euthanasia, 393 Network model HMOs, 506 Network of Multicultural Aging (NOMA), 64 Neural networks expertise simulations, 40 health informatics, 497, 498 Neural noise, 801 Neuraminidase inhibitors, influenza treatment, 587 Neuritic plaques, drug modulation of, 214–215 Neurochemical factors memory, 747–748 neuroendocrine theory of aging, 826–828 neurotransmitters and aging brain, 832–836 Neurodegenerative disease Alzheimer’s disease, 54–57 and dementia, 289–291 drug treatments, 214–220 and frontal lobe dysfunction, 427–429 and neurotrophic factors, 837–838 Parkinson’s disease, 904–907 prion diseases, 954–956 and seizures, 376 smell/taste losses, 1169 Neuroendocrine theory of aging, 826–828 genetic inactivation mechanisms, 828 glucocorticoid hormone increase, 827 growth hormone decrease, 469, 827 menopause, 826 neuroendocrine clocks, 445 Neurofibrillary tangles, drug modulation of, 214–215 Neuroglia aging and changes, 202 cells of, 202 Neuroleptic drugs and disruptive behavior, 325 drug interactions, 339 Lewy Body disease, 297 tardive dyskinesia, 343 Neurological disorders aphasia, 71–74 frontal lobe dysfunction, 427–429 Neurones, 510 Neurons, aging and changes, 202–203, 799 Neuropathic pain, management of, 894 Neuropeptides, 835–836 memory improvement, 748

and neurodegenerative disease, 836 types of, 836 Neuroplasticity, 829–831 aging and memory, 830–831 mechanisms of, 830 Neuroprotective agents, cognitive impairment treatment, 219 Neuroticism, 831–832 Neurotransmitters acetylcholine, 833 and aging brain, 513, 799, 832–836 Alzheimer’s disease and changes, 214, 833, 836 catecholamines, 833–835 drug modulation of, 216–217 gamma-aminobulyric acid, 835 glutamate, 835 and hemispheric asymmetries, 513 and memory decline, 748 neuropeptides, 835–836 Neurotrophic factors in aging, 837–838 and neurodegenerative disease, 837–838 New Ventures in Leadership (NVL) program, 64 News media, older anchor issues, 45 Nicotinic acid lipoprotein benefits, 667 sources of, 1216–1217 Nicotinic receptors, 833 Nimodipine, cognitive impairment treatment, 218 Nitrendipine, hypertension treatment, 560 Nitric oxide, and endothelial dysfunction, 169 NMDA receptor antagonist, Alzheimer’s disease treatment, 54 Nocturia defined, 1205 and diabetes, 314 and prostatic hyperplasia, 975–976 Nonadherence. See Adherence Nondeclarative memory, 756 Nonhuman aging models. See Biological aging models Nonsteroidal anti-inflammatory drugs (NSAIDs) Alzheimer risk reduction, 215 arthritis treatment, 80–81 drug reactions, 342 for pain management, 893 Nootropic agents cognitive impairment treatment, 219 memory improvement, 747–748 Norepinephrine aging and decreases, 834



February 7, 2006

13:2

Subject Index

and Alzheimer’s disease, 214 functions of, 834 and memory decline, 748 production of, 834 Normal retirement age (NRA), 1110, 1113 Normative Aging Study (NAS), 680, 838–839 areas of study, 838–839 Nortriptyline, depression treatment, 622–623 Nostalgia, life review, 655 Notional funds, 1040 Nuclear stenosis, 407 Nucleus basalis of Meynert, and Alzheimer’s disease, 214 Nurse practitioners, nursing home staff, 849, 851 Nurse Reinvestment Act (2002), 706–707 Nursing Home Initiative, 702 Nursing Home Quality Initiative (NHQI), 703 Nursing Home Reform Act (1987), 692, 701, 840–842, 844, 1028 Nursing homes, 547–548, 842–853 average length of stay, 848 behavior management, 105–106 certification/regulation compliance, 841–842 discharge planning, 848 disruptive behaviors, 324–326 elder abuse and neglect, 353 ethics, 685–687 facility characteristics, 844–845 falls, 592–593 future view, 851–853 history of, 843–844 hospice admissions, 544, 846 institutionalization, 595–598 legal regulation, 701–704 Long-Term Care Ombudsman Program (LTCOP), 692–694, 702–703 Medicaid coverage, 722, 724, 844, 845, 849–850 Medicare coverage, 483, 485, 845, 850 monitoring of, 850–851 Nursing Home Reform Act, 692, 701, 840–842 patient autonomy, 844 physical restraints, 1027–1029 quality improvement/quality assurance, 998–999 quality of care, 697–698 reduced use and adult day care, 19 resident characteristics, 847–848 resource utilization groups, 1022–1023 risk factors for admission, 845–846

I-41

special care units, 846–847, 1131–1132 workforce, 698–699, 848–849 Nursing, professional, 968–970 care, Medicare coverage, 728 decreasing supply of, 705 generalists, 970 geriatric nurses, 969–970 nurse practitioners, 849, 851 nursing home staff, 848–849 Parkinson disease specialists, 907 Nutrition, 854–859 common deficiencies, 858 deficiency and hair problems, 476 diet restriction, 316–318 dietary assessment methods, 857–858 Meals on Wheels, 858–859, 861–863 as metabolic regulator, 372 nutrition programs/services, 858–859 pressure ulcer management, 951 requirements and aging, 854–856 status, assessment of, 856–858 vitamins, 1215–1217 Nutrition Screening Initiative (NSI), 857 Obesity, 864–865 age and increase, 864 health risks, 864 and lipid levels, 664 and sleep apnea, 1083–1084 visceral adiposity. See Abdominal fat; Metabolic syndrome of aging Observed Tasks of Daily Living, 960 Obsessive-compulsive disorder, 70 Occipital lobe, 200 Okinawa (Japan), centarians, 197 Old-old, age range of, 264 Old-Old Study (Duke), 346 Older Adult Services and Information System (OASTS), 555, 1122–1123 Older Americans Act, 487, 866–868 Aging Network, 867 funding, 867–868 future view, 868 objectives of, 866–867, 930, 948 ombudsman program, 692 reauthorization proposal, 867–868 Title V, 366 Title VI programs, 812–813, 825 Older Americans Resources and Services ADL scale, 6


I-42


February 7, 2006

13:2

Subject Index

Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire (OARS MFAQ), 805–806 Older Women’s League (OWL), 868–870 educational campaigns, 869–870 Older workers, 362–363, 580–581, 870–871 adaptation to workplace, 870–871 bridge jobs, 349 challenges for, 870 discrimination, legal protection, 42, 43, 366, 580 ergonomics and older adults, 551, 870–871 human factors engineering, 551 industrial gerontology, 580–581 and job selection, 580–581 part-time work, 365, 871, 1036 performance and expertise, 39–40 performance appraisal, 580 productivity, 581, 966–968 in retail industry, 365, 1031–1032 self-employment, 365 stereotype of, 580 telecommuting, 620–621 training/retraining, 581 unemployment, 350, 365–366, 581 women in labor force, 362–363, 581, 1236 See also Employment Oldest-old, age range of, 264 Oligodendrocytes, 202 Ombudsman, Long-Term Care Ombudsman Program (LTCOP), 692–694 Omnibus Budget Reconciliation Act (1987) (OBRA), 697, 701, 705, 806, 999 Nursing Home Reform Act (1987), 692, 701, 840–842, 844 On Lok, 974 Oncogene sequencing, 154 Online Survey, Certification, and Reporting (OSCAR), 850 Opioid peptides, and memory decline, 748 Opioids addiction risk, 893–894 drug reactions, 342 for pain management, 893–894 Opportunistic infections, AIDS/HIV, 48 Optic nerve aging and changes, 409, 1212 glaucoma, 409–410, 1214 Optimism, learned, 638 Oral cavity, 873–876 aging and changes, 873–874

oral mucosa, 873–874 salivary glands, 874 teeth, 873 Oral health dental caries, 874–875 edentulousness, 875 health effects of, 875–876 Normative Aging Study, 838 oral cancer, 876 periodontal disease, 874, 875 Oregon, physician-assisted suicide, 369–370, 924–926 Organ transplantation AIDS/HIV exposure, 49 kidney, 631 liver, 431 Organizations in aging, 876–880 AARP (The American Association of Retired Persons), 1–3 American Association of Home and Services for the Aging (AAHSA), 61–62 American Federation for Aging Research (AFAR), 62 American Geriatrics Society, 63 American Society on Aging, 63–65 Association for Gerontology in Higher Education, 91–92 efficacy of, 879–880 European Academy for Medicine of Ageing (EAMA), 390–391 geriatric education centers, 451–452 geriatric psychiatry, 456 geriatric research, education, and clinical centers (GRECCs), 456–457 Gerontology Society of America, 458–460 history in U.S., 876–879 International Association of Gerontology, 615 International Federation on Ageing, 618 International Longevity Center (ILC), 618–619 National Association of Area Agencies on Aging, 812–813 National Council on Aging, 814–815 National Institute on Aging, 817–820 Older Women’s League (OWL), 868–870 roles of, 879 Orlistat, diabetes treatment, 315 Orthostasis, 166 Oseltamivir, influenza treatment, 587 Osmolality regulation/sodium balance, 1126–1127



February 7, 2006

13:2

Subject Index

Osteoarthritis, 80–81 symptoms of, 80 treatment, 80 Osteomalacia, 881–882 causes, 881, 1215–1216 treatment/prevention, 882, 1216 Osteopenia, 884 Osteophytes, 80 Osteoporosis, 883–885 calcium deficiency type, 146 calcium supplementation, 146, 520, 884 and corticosteroid use, 343 drug treatments, 520, 885 exercise benefits, 402 and hip fractures, 520, 883 hormone replacement therapy benefits, 885, 944 management of, 884–885 measurement of, 883–884 risk factors, 884 Vitamin D supplementation, 884–885 Otosclerosis, 509–510 Ototoxic drugs, 239 Outpatient care. See Ambulatory and outpatient care Ovarian cancer, hormone replacement therapy risk, 945 Ovaries, menopause, 420–421, 539 Over-the-counter medications, misuse/abuse, 734, 1150 Overactive bladder, 1206 Overflow incontinence, 418 Overuse injuries, 404 Oxalate, and kidney stones, 146 Oxalic acid, 146 Oxidative stress theory, 887–889 brain and aging, 1143–1144 diet restriction benefits, 888 drugs and modulation, 217–219 experimental results, 888 in nonhuman aging models, 116 plant aging, 928 reactive oxygen species (ROS), 887, 977 Oxiracetam, cognitive impairment treatment, 218 Oxotremorine, cognitive impairment treatment, 217 Pacemaker cells, decline and aging, 161, 162 Pacific Islander American elders, 85–86 common illnesses of, 86 ethnic groups of, 85

I-43

Pain intensity scales, 891 Pain/pain management, 890–895 alternative methods, 894 arthritis, 80–81 end-of-life care, 368 epidemiology, 890 fear of pain, 900 gate control theory, 890–891 of neuropathic pain, 894 outpatient care, 60 pain, classifications of, 890 pain and cognitive dysfunction, 892 palliative care, 890–895 patient assessment, 890–891 progressive steps in, 892–894 Paleolithic diet, 146, 147 Palliative care, 282, 899–901 ambulatory, 60 goals of, 368 information resources on, 370 pain/pain management, 890–895 See also End-of-life care Pancreas and blood glucose regulation, 159 and diabetes, 313 pancreatic duct stones, 431 Pancytopenia, 142 Panel design study, longitudinal research, 679–680 Panic disorder, 70 Panretinal photocoagulation, 409 Pap smear, 157 Paradigmatic thought, 552 Paraprofessional, long-term care workers, 705 Parasympathomimetic agents, glaucoma treatment, 410 Parathyroid hormone, 145, 885 Parens patriae, 29, 472 Parent-child relationships, 901–903 co-residence, 901, 902 demographic trends, 901–902 intergenerational stake concept, 437, 610 and minority elders, 903 quality, determinants of, 902–903 Parenting style, and generativity, 437 Parietal lobe, 200 Parkinson’s disease, 904–907 and cognitive impairment, 906 complications of, 905–906 with dementia, 289, 296


I-44


February 7, 2006

13:2

Subject Index

Parkinson’s disease (continued) and depression, 906 diagnosis, 905 L-dopa therapy, 905 epidemiology, 904 features of, 905 Lewy bodies, 295–298, 906 neurotransmitter changes, 834, 836 and sleep disruption, 1084 specialist nurses and management of, 907 voice/speech disorders in, 235, 236 Part-time employment, 365, 871, 1036 Partial seizures, 377 Participant observation, 388–389 Partners in Caregiving, 18 Paternalism, 383, 685–686 Pathfinder Profile, 806 Pathologic hip fractures, 516 Patient records, electronic, 497–498 Patient rights movement, 98 Patient Self-Determination Act (1991), 669, 844 Patient’s rights, 383 Patronizing speech, 636 Peak performance, and age, 39 Peg word mnemonic, 763–764 Pelvic floor exercises, 1206 Penile implants, 1071 Pension Benefit Guaranty Corporation (PBGC), 361, 1039, 1048 Pension Protection Act (1987), 361 Pensions, 907–910, 1039–1040 automatic enrollment, 1043 defined benefit plans, 910, 1039, 1042, 1048 defined contribution plans, 1039–1040, 1042, 1048 Employee Retirement Income Security Act (ERISA), 361–362, 909–910 history of, 876, 907–909 hybrid plans, 349, 1040 nontraditional plans, 349 public policies, 909–910 trends, impact of, 1040 See also Retirement, financial aspects Pentosidine, 138 Pentoxifylline, cognitive impairment treatment, 218–219 Peptic ulcers, 430 Peptides, fat-derived, 135–136 Perceptual speed, 757 reaction time, 1006–1008

Periampullary diverticula, 431 Periarticular osteopenia, 81 Periodontal disease, 874, 875 Periodontitis, 875 Peripheral artery disease, and homocysteine, 535 Peripheral nerves, 198, 203–204 aging and changes, 203–204 functions of, 203 Person-Centered Care model, 852 Person-environment fit, 768 Personal assistance services (PAS), 911–913 activities of, 182, 911 cash payments for care, 182–183 issues related to, 912 payment methods, 182–183, 911, 913 Personal care/personal attendant. See Personal assistance services (PAS) Personal digital assistants (PDAs), 244 Personality, 914–918 and cardiovascular disease, 164 of centarians, 197 cultural influences, 918 extraversion, 623 hostility, 545 humor, sense of, 558 introversion, 623–624 locus of control, 671–673 and loneliness, 674–675 neuroticism, 831–832 Normative Aging Study, 838 research areas, 914–915 rigidity, 1044 self-concept, 1054 self-esteem, 1055–1056 six foci model, 916–918 social-cognitive processing theories, 915–916 stability versus change issue, 915 and subjective well-being, 1146 trait theories, 915 wisdom, 1230–1234 Pets, 919–921 health benefits, 920 pet therapy, 920–921 Phacoemulsification, 407 Phacomorphic angle closure glaucoma, 407 Pharmacodynamics, 922–923 See also Drug interactions; Drug reactions Phenobarbital, drug interactions, 338, 339 Phenotypic aging, 153–154 Phenytoin, drug interactions, 338, 339



February 7, 2006

13:2

Subject Index

Phlebitis, 165 Phobia, and aging, 70 Phonology, 634 Phospholipid transfer protein (PLTP), 664 Phosphoribosyl transferase (HPRT) locus test, 1129 Photdynamic therapy, 408 Physical activity defined, 401 See also Exercise Physical restraints, 1027–1029 alternatives to, 1028–1029 prevalence of use, 1027 rationale for, 1028 settings used, 1027–1028 Physical therapy, for arthritis, 80 Physician-assisted suicide, 924–926 Oregon Death with Dignity Act, 369–370, 393, 926 See also Euthanasia Physostigmine cognitive impairment treatment, 215 memory improvement, 747 Pick’s disease, and frontotemporal dementia, 293, 428 Pineal gland melatonin, 737–739 and sundown syndrome, 1157 Pioglitazone, diabetes treatment, 315 Pioneer Movement, 851 Pioneer Network, 852 Piracetam cognitive impairment treatment, 218 memory improvement, 747–748 Pituitary gland functions of, 199 growth hormone and insulin-like growth factor-1, 468–471, 827 Plant aging, 927–929 DNA damage, 927 environmental influences, 928–929 membrane damage, 928 protein/enzyme deterioration, 927–928 Plaques atherosclerosis, 164 neuritic, 214–215 Plasma, blood component, 140 Plasmids, gene therapy, 440 Plasminogen activator inhibitor 1 (PAI-1), 136 Plasticity

I-45

brain, 1143 cognitive, 764 and development, 307 Pleasuring, 1072 Plenary guardianship, 472 Plunkett, Katherine, 656 Pneumonia immunization, 570–571 and influenza, 586 Point mutations, 789–890 Point of services plans (POS), 506 Policy analysis, 929–931 challenges, 930–931 conservative versus liberal, 929–930 methods, 929 policy choice clarification, 930 political factors, 931 Political behavior, 932–934 political action, 933–934 political attitudes, 932 voting participation, 932–933 Political economy of aging theory, 935 Polycystic ovary syndrome, and calcium deficiency, 147 Polycythemia rubra vera, 141 Polypharmacy and drug interactions, 337 and drug reactions, 342 Polysaccharide pneumococcal vaccine, 571 Polysomnogram, 1082–1083 Population aging, 936–940 baby boom generation, 100–101, 299, 937–939 and birth rate decline, 301, 937, 941 challenges related to, 939–940 developing countries, 939, 940–943 economics of. See Economics of aging and future health policy, 494–495 health care issue, 940, 943 Lotka model, 301 and migration, 779–780, 937 oldness, definitional aspects, 300 rapid, Asian countries, 938–939 Positive psychology, 638 Posterial vitreous detachment, 407–408 Postmenopausal hormone therapy. See Hormone replacement therapy Postmicturition dribble, 1205 Postmodern social theories, 793 Posttranslational modifications, proteins, 977–978


I-46


February 7, 2006

13:2

Subject Index

Posttraumatic stress disorder (PTSD), Normative Aging Study, 838 Postural hypotension and calcium channel blockers, 922 Parkinson’s disease, 906 Posture, aging and changes, 800 Potassium, requirements for older adults, 855 Potassium-sparing diuretics, drug interactions, 339 Poverty, 946–949 African American elders, 34–35, 947 anti-poverty programs, 948 Chinese American elders, 82 decline among older persons, 946–947 developing countries, 939, 949 and Hispanic elderly, 521, 947 homelessness, 525–527, 948–949 measurement, 947 Medicaid, 505, 720–726 and multiple jeopardy situation, 387 Native American elders, 825 rate, older population, 348, 946 as social problem, 1106 Southeast Asian American elders, 85 and women, 947–948, 1227 Practical intelligence, 230, 602 Practical Problems Test, 960 Practice, and expertise, 39–40 Practice standards, defined, 998 Pragmatics, language, 635 Pramiracetam, cognitive impairment treatment, 218 Preadmission screening and annual review for mental illness and mental retardation (PASSAR), 840 Preferred provider organizations (PPOs), 505 Premature aging Native Americans, 825 progeroid syndromes, 188–189, 971–973 Premenstrual syndrome, and calcium deficiency, 147 Prepaid health plans, Medicare Advantage plans, 485 Presbycusis, 238–239, 510 Presbyesophagus, 108 Prescribing cascade, 344 Prescription drugs inflationary prices, 584 Medicare coverage, 484, 493–494, 505, 728–729, 1106 misuse/abuse of, 732–734, 1150

Pressure ulcers, 950–951 incidence, 950 management/prevention, 950–951, 1217 and mortality, 950 wound assessment, 951 Prevention cancer control, 155–158 health beliefs, 480–482 Preventive health care, 952–954 guidelines for older persons, 953 Primary care physician, doctor-patient relationships, 332–334 Primary insurance amount (PIA), 1109–1110 Primary Mental Abilities Battery, 428 Primary prevention, cancer, 155–156 Primary progressive aphasia, 73, 292 Primates biological aging model, 123–125 menopause, 419–420 Print media, aging, images of, 44–45 Prion diseases, 954–956 of animals, 954 Creutzfeldt-Jakob disease, 954–956 fatal familial insomnia, 954–955 Gerstmann-Straussler-Scheinker disease, 954–955 protein-only hypothesis, 955–956 Prison populations, 272, 957–959 future view, 959 long-term care services, 958–959 minority groups, 957–958 Privacy rights, HIPAA rules, 687 Privatization, Social Security, 494, 495, 1112, 1115 Probenecid, for gout/pseudogout, 81 Problem-solving, 960–961 assessment of, 960 decline and aging, 22 improvement of, 960–961 problem-solving therapy, 962–964, 993 Procedural learning, 574–575 Procedural memory, 756–757 Process-dissociation procedure, 574 Procollagin, 260 Productive aging, 965–966 defined, 966 Productivity, 966–968 creativity and aging, 269–270 decline, myth of, 967 generativity, 435–437



February 7, 2006

13:2

Subject Index

Professional Environmental Assessment Protocol (PEAP), 375 Professionals and expertise, 39–40 New Ventures in Leadership (NVL) program, 64 Progeria (Hutchinson-Gilford syndrome), 188, 972 Progeroid syndromes, 971–973 cell aging in vivo models, 188–189 Cockayne syndrome, 444, 972 Down syndrome, 189, 971 progeria (Hutchinson-Gilford syndrome), 188, 972 Werner syndrome, 188–189, 971–972 Progestin, in hormone replacement therapy, 540, 944 Program of All-Inclusive Care for the Elderly (PACE), 973–975 funding, 17, 488, 495, 725, 974 goals of, 973 growth of, 60, 974 services, 974 Programmed cell death adoptosis, 76–77, 653 and free radicals, 889 genetic programming theories, 445–446 Progressive nonfluent aphasia, 292 Project AGE, 275, 389 Prokinetic agents, drug interactions, 337 Proliferative decline, aging cells, 186, 191–192 Propentophylline, cognitive impairment treatment, 218–219 Property tax exemptions, 523, 1172 Prospective memory, 757 Prospective payment system (PPS), Medicare, 484, 731 Prostaglandin analogues, glaucoma treatment, 410 Prostasomes, 152 Prostate assessment of, 1206 cancer, reducing risk, 156, 157 prostate-specific antigen (PSA), longitudinal studies, 102 prostatic hyperplasia, 975–976, 1206 Proteasome system, 979–981 Protecive services. See Adult protective services Protein, dietary, requirements and aging, 854 Protein-only hypothesis, prion diseases, 955–956 Proteins advanced glycation end-products, 31–33, 977–978

apolipoprotein epsilon 4, 75–76 asparagine-modifying reactions, 978 gene expression, 433–434 glycoxidation, 978 isomerization, 624–627, 978 misfolded, 978 noncovalent modifications, 978 posttranslational modifications, 977–978 racemization, 978, 1003–1005 turnover. See Proteolysis/protein turnover Proteolysis/protein turnover, 979–983 biomarker of aging, 982–983 lysosomal system, 981–982 proteasome/ubiquitin system, 979–981 protein degradation, 982–983 Proverb Interpretation Test, 428 PS1 gene, Alzheimer’s disease, 54–55 PS2 gene, 56 Pseudoaddiction, 893 Pseudogout, 81 Psychiatric/psychological disorders and aging, 767–768 anxiety, 69–70 assessment. See Psychological assessment depression, 303–305 geriatric psychiatry, 455–456 and homelessness, 526 and inadequate coping, 108 and menopause, 765–766 National Insitute of Mental Health Epidemiologic Catchment Area Project, 815–817 prevention effots, 769 psychotherapeutic interventions. See Psychotherapy and social isolation, 1102 stability and aging, 70 substance abuse/addictions, 1149–1151 underdiagnosis of, 992 Psychodynamic therapy, 994 Psychological assessment, 986–989 challenges and older persons, 986–987 clinical interview, 987 cognitive functioning assessment, 987–988 Diagnostic Interview Schedule (DIS), 816–817 DSM diagnostic system, 983–986 health assessment, 987 medication use assessment, 987 sensory assessment, 987

I-47


I-48


February 7, 2006

13:2

Subject Index

Psychological assessment (continued) symptoms checklists, 988 written report, 989 Psychological disorders. See Psychiatric/psychological disorders Psychological well-being activity theory, 9–13 African American elders, 36 and exercise, 403 and generativity, 437 and leisure, 641–642 and pets, 920 positive mental health, elements of, 767 and religiosity, 1018–1019 and social support, 1123–1124 subjective well-being, 1145–1148 Psychometric approach cognitive processes, 229–230, 428 wisdom, 1231–1232 Psychosocial interventions, 989–991 effectiveness of, 990–991 forms of, 990 Psychosocial theory Erikson’s stages, 21, 23 generativity, 21, 435–437 Psychotherapy, 992–995 for anxiety, 70 behavior management, 105–106 biographical forms, 113 for caregivers, 174–175 cognitive therapy, 232–234, 993–994 for complicated grief, 108 for depression, 233, 304, 994 effectiveness, 992–993 group therapy, 466–468, 994–995 interpersonal psychotherapy, 622–623, 993 life review therapy, 655, 994 problem-solving therapy, 962–964 psychodynamic therapy, 994 sex therapy, 1071–1072 short-term, 304, 994 support groups, 1161–1162 Psycyological well-being, subjective, 1145–1148 Public Opinion (Lippmann), 43 Public policy AARP Institute, 2 health care policies for older persons, 490–496 intergenerational equity, 385, 607–609

on long-term care, 695–699 and pensions, 909–910 policy analysis, 929–931 rural elders, 1046 Publications, of AARP, 1, 2 Pulmonary emboli, 165 Purkinje cells, 660–661, 799 Pyelonephritis, 632 Pyuria, 1205 Qi (vital energy), 254 QOLID (Quality of Life Instruments Database), 8 Qualitative gerontology. See Ethnographic research Quality improvement/quality assurance, 998–999 approaches to, 998 outcome-oriented methods, 999 process methods, 999 terms related to, 998 trends, 999 Quality of care, nursing homes, 850–851 Quality of life, 1000–1002 environment-related, 1000, 1001 health-related domains, 1000–1001 numeric values, 1001 subjective well-being, 1145–1148 successful aging, 1154–1155 Quinidine, drug interactions, 338, 339 Quinlin, Karen Ann, 393 Racemization, 978, 1003–1005 and aging, 1005 and human disease, 1004 Racial mortality crossover, 35–36 Radio transmission systems, 512 Raloxifene, 156, 885, 944 Randall, Ollie, 79 Rational-emotive therapy, 232 Rational suicide, 384 Rawls, John, 383 Reaction time, 1006–1008 Brinley plots, 1006–1008 changes and aging, 800 Reactive oxygen species (ROS), 887, 977 Reality orientation, 1009–1011 Reasonable accommodations, 67 Recency effect, 751 Reciprocal determinism, 105 Recognition memory, 743 Recombinant activated factor VI, stroke management, 208



February 7, 2006

13:2

Subject Index

Recombinant tissue plasminogen activator (rt-PA), stroke management, 207–208 Refractive disorders, 407 Refugees, Southeast Asian Americans, 85 Regenerative-care model, 852 Regnier, Victor, 79 Rehabilitation, 1012–1015 exercise, 1014 inpatient units, 1013 long-term care setting, 1013–1014 outcome of, 1014–1015 outpatient, 1014 Rehabilitation Act (1973), Title V, 66 Religion and aging, 1016–1019 health outcomes, 1018 religiosity and death anxiety, 284 religious participation patterns, 1017–1018 research on, 1016, 1018–1019 and subjective well-being, 1147 REM (rapid eye movement) sleep, 1082–1083 Reminiscence life review, 42, 654–655 narrative analysis, 811–812 reminiscence bump, 750 reminiscence group therapy, 994 Remote Associations Test, 603 geographical memory, 749–750 Remote memory, 749–751 assessment of, 749, 751 emotional factors, 750–751 reminiscence bump, 750 Renal artery stenosis, 631 Repaglinide, diabetes treatment, 315 Reperfusion techniques, for aphasia, 73 Replicative senescence and cell-cycle regulators, 193 cells, 186–187, 191–193, 566 and telomere loss, 1180 Research studies. See Aging research Resident Assessment Instrument (RAI), 840, 844 Resident Assessment Protocols (RAPS), 840 Resident-directed care model, 852 Residential settings adult foster care homes, 25–27 assisted living, 87–90 institutionalization, 595–598 nursing homes, 842–853 terms for, 87 Resiliency, widowhood, 1226–1227 Resistance training. See Strength training

I-49

Resource-based relative value scale, 731 Resource Centers on Minority Aging Research (RCMARs), 788 Resource utilization groups, 850, 1022–1023 RUG-III, 1022 RespectAbility program, 815 Respiratory system, 1023–1025 exercise response, 1024–1025 gas exchanges, 1024 pulmonary mechanics, 1023–1024 Respite care, 488, 1025–1027 research areas, 1026–1027 Restless leg syndrome, 1086 Restoration stresses, 108 Restraints. See Physical restraints Retail industry, older workers, 365, 1031–1032 Retailing/older consumer, 265, 1030–1032 entertainment/travel, 1031 health care products, 1030–1031 vulnerability, 1031 Retina aging and changes, 407–408, 1212 detachment, 408 floaters and flashes, 407–408 Retirement, 1032–1037 African American elders, 36 adjustment to, 1036 average age, 349 communities, 1038–1039 decisions, 364, 1034–1036 delayed retirement credit, 871 future view, 1036–1037 and geographic mobility, 446–447 Health and Retirement Study (HRS), 478–480 historical development, 1032–1034 income. See Retirement, financial aspects Longitudinal Retirement History Survey (LRHS), 683 mandatory, 42, 1035 and migration, 777–780 retirement communities, 1038–1039 Retirement Equity Act (1984), 361 Retirement, financial aspects economics of aging, 348–351 Employee Retirement Income Security Act (ERISA), 361–362 financial planning, 1041–1043 individual retirement arrangements (IRAs), 576–579, 1043


I-50


February 7, 2006

13:2

Subject Index

Retirement, financial aspects (continued) pensions, 907–910, 1039–1040 savings, 1048–1049 Reverse mortgage. See Home equity conversion Revised Memory and Behavior Problems Checklist, 988 Rey-Osterrieth Complex Figure Test, 429 Reye syndrome, 586 Rhegmatogenous retinal detachment, 408 Rhesus monkeys, biological aging model, 123–125 Rheumatoid arthritis and cardiovascular disease, 166 hip arthroplasty, 518–519 medical management, 81 symptoms of, 81 Rheumatoid factor, 81 Rhythms chronomes, 210–211 circadian, 211–212 menstrual cycle, 421 natural, types of, 209–210 See also Biological rhythms Riboflavin, deficiency, 1217 Ribot’s law, 749 Rickets, osteomalacia, 881–882 Rifampin, drug interactions, 338, 339 Right hemisphere language disorders, 237–238 Rigidity, 1044 dimensions of, 1044 Rimantadine, influenza treatment, 586–587 Rinaldo Amendment, 26 Risedronate, 885 Risk profiling, electronic, 498–499 Rivastigmine Alzheimer’s disease treatment, 54 cognitive impairment treatment, 216–217 Lewy Body disease, 296 RNA (ribonucleic acid), gene expression, 433–434 Robert Wood Johnson Foundation, 90, 183, 185, 815 Roberts, Ed, 66 Rodents, biological aging model, 125–129 Rolandic fissure, 72 Roles gender roles, 432 role loss, 10, 707–708 role sequences, 646 social breakdown theory, 1088–1089

Rosigitazone, diabetes treatment, 315 Roth IRAs, 576–577 Rubicon model, action phases, 657 Rural elders, 1045–1046 health services for, 1046 long-term care, 1046 public policy, 1046 and social isolation, 1101 sociocultural characteristics, 1045–1046 socioeconomic status, 1045 Rush, Benjamin, 455 Safe Home Income Plans (SHIP), 525 SAFEDRIVE, 335–336 SAGE (Services and Advocacy for GLBT Elders), 537 Sales tax, 1172 Salicylates, for pain management, 893 Salivary glands, 874 Same-sex marriage, 537 Sampling, surveys, 1163–1164 Sandwich generation, 170–171, 264 Sarcopenia, 402, 858 Sardinia, centarians, 197 Saunders, Cicely, 282, 542 Savings, 1048–1049 See also Pensions Saw palmetto, 254 Schemas and age stereotypes, 762 elements of, 761 memory, 761–762 and scripts, 761–762 Scopolamine, drug modulation of, 215 Scripts life scripts, 750–751 life span, 307 and schemas, 761–762 Scurvy, 1217 Search engines, 44, 498 Seasonal migration, 447, 779 Seasons of adulthood theory, 21 Seattle Longitudinal Study, 679–680 Secondary prevention, cancer, 156–157 Secretase, drug modulation of, 214 Section 202 Supportive Housing, 547 Seizures age and risk, 376 classification of, 377 epilepsy, 376–378



February 7, 2006

13:2

Subject Index

Selection, optimization, and compensation model, 1049–1051 goal-setting, 1049–1050 and successful aging, 1050 Selective estrogen receptor modulators (SERMs), 885, 944 Selective serotonin reuptake inhibitors (SSRIs) for depression, 304 withdrawal reaction, 343–344 Selegiline, cognitive impairment treatment, 218 Self, components of, 11 Self-care activities, 1051–1053 activities of daily living, 6–8 autonomy and aging, 97–99 and competence, 250–251 comprehensive geriatric assessment (CGA), 449–450 driving, 334–336 and home modifications, 528–530 loss, order of, 1052–1053 and mobility, 791–792 Self-concept, 1054 exchange theory, 398–399 and subjective well-being, 1146 Self-determination bioethics, 383–384 right to, 29 Self-efficacy, 23, 231 social capital/social cohesion, 1090–1092 Self-employment, 365 Self-esteem, 1054, 1055–1056 correlates in later life, 1055–1056 defined, 1055 research areas, 1056 and widowhood effects, 1227 Self-fulfilling prophesy, and age stereotypes, 46 Self-neglect, 30 Self-stereotypes, 43 Self-talk, 234 Semantic dementia, 292 Semantic memory assessment of, 756 word-finding difficulty, 237, 635, 756, 1238 Senescence and transformation cell aging, 186–195 homeostasis and aging, 531–533 induced immortalization, 1058–1060 mortality, stages of, 1060 spontaneous immortalization, 1057 tumor suppression, 1199–1201

I-51

Senior Center Humanities Program, 554 Senior centers, 1062–1064 history of, 1063–1064 services, 1062 workforce, 1062–1063 Senior Citizens’ Freedom to Work Act (2000), 366 Senior Community Service Employment Program (SCSEP), 366, 815 Senior companion program, 1064–1067 benefits of, 1065–1066 effectiveness, 1066 programs, 1064 services, 1065 Senior Environmental Employment (SEE), 815 Seniors in the Community: A Risk Evaluation Tool for Eating and Nutrition (SCREEN), 858 Sensation taste/smell, 1168–1170 touch, 1191–1192 Sensorimotor processing, aging and changes, 800 Sensory seizures, 377 Sensory system aging and changes, 799–800 taste/smell, 1168–1170 Sequential sampling, longitudinal research, 680 Serotonin aging and decreases, 834–835 and Alzheimer’s disease, 214 and memory decline, 748 production of, 834 Serum lupus erythematosus, DHEA, benefits of, 311 Service Outcome Screen, 806 Services industry, older workers, 365 Sex therapy, 1071–1072 Sexuality, 1067–1072 AIDS/HIV, 49–50 gender differences, 1068–1069 homosexuality, 537–538 impotence, 1069–1072 masturbation, 1069 myths related to elderly, 1067 pleasuring, 1072 Shepherd’s Centers, 555 Shields, Laurie, 868 Shingles, and varicella booster, 572 Shipley-Hartford Scale, 428 Shock, Nathan, 101 Shopping behaviors, retailing/older consumer, 265, 1030–1032


I-52


February 7, 2006

13:2

Subject Index

Short-term memory assessment of, 755 working memory, 753–754 Short-term psychotherapy, 304, 994 Sibling relationships, 1072–1074 bereavement, 1074 caregiving, 1073–1074 quality, influences on, 1073 twins, 1074 Sickness Impact Profile, 1001 Side-effects, drugs. See Drug reactions Similarity criteria, thinking, 3 Simmons, Leo, 274 Simplified employee pension (SEP IRAs), 576, 579, 1043 Simulation studies, longitudinal research, 681–682 Single Assessment Process (SAP), 805 Situational ethnicity, 386 Six foci model, personality, 916–918 Skeletal muscle, 1075–1077 aging and changes, 1075–1076 and blood glucose regulation, 159 injury, 1076 resistance exercise benefits, 402 Skilled nursing facilities. See Nursing homes Skin aging, 1077–1080 aging and changes, 21, 260–261, 1077–1080 collagen, 260, 1078–1079 elastin, 260–261 ground substance, 261 matrix metalloproteinases, 261–262 photoaging, 260, 261, 1079 pressure ulcers, 950–951 Skin-fold thickness measures, 857 Sleep, 1081–1084 aging and changes, 1081–1082, 1085–1086 and circadian rhythms, 1082 measurement of, 1082–1083 melatonin, 737–738 restless leg syndrome, 1086 Sleep apnea, 1083–1084 features of, 1086 management of, 1084, 1086 Sleep disorders, 1085–1088 circadian rhythm disorder, 1087 and depression, 303, 304, 1084, 1087 drug-related, 1087–1088 insomnia, 1084, 1086–1087 neurological basis, 1087

secondary, 1087 sleep apnea, 1083–1084, 1086 Sleletal muscle, strength decrease and aging, 402 Slowing, reaction time, 1006–1008 Smart house, 243–244, 706 Smell. See Taste/smell Snoring, and sleep apnea, 1083–1084 Social anxiety disorder, 70 Social breakdown theory, 1088–1089 Social capital/social cohesion, 1090–1092 definitions, 1090–1091 relationship to health, 1092 Social cognition and aging, 1094–1097 and beliefs/values, 1095 and cognitive processes, 1096–1097 and motivation/emotion, 1095–1096 social information processing, 1094–1095 Social-cognitive processing, personality theory, 915–916 Social competence, social breakdown theory, 1088–1089 Social comportment, disorder of, 292 Social death, 282 Social ethics, 384–385 quality of life issues, 384–385 Social gerontology theories, 1098–1100 activity theory, 9–13 continuity theory, 266–268 critical gerontology, 272–274 disengagement theory, 321–322 exchange theory, 396–399 future view, 1100 generativity, 435–437 issues addressed by, 1098 macrosocial level analysis, 1099–1100 microsocial level analysis, 1099 modernization theory, 792–793 political economy of aging, 935 selection, optimization, and compensation model, 1049–1051 social breakdown theory, 1088–1089 social cognition and aging, 1094–1097 socioemotional selectivity theory, 399, 659 Social/health maintenance organization (S/HMO), 488–489 Social interaction and adult foster care, 26–27 exchange theory, 396–399 family members. See Family relationships



February 7, 2006

13:2

Subject Index

friendship, 426–427 and group therapy, 466 and Internet, 501 reality orientation, 1009–1011 senior centers, 1062–1064 senior companion program, 1064–1067 social capital/social cohesion, 1090–1092 social support, 1121–1125 Social isolation, 1101–1103 at-risk persons, 1101–1102 and driving cessation, 334 Internet and reduction of, 501, 1103 loneliness, 674–675 Meals on Wheels benefit, 862 negative outcomes related to, 1102–1103 and suicide, 1155 Social learning theory, behavior management, 105–106 Social loss, 707–709 Social problem-solving therapy, 993 Social problems and aging, 1105–1107 Alzheimer’s disease, 1107 health care costs, 1106 history of, 1105–1106 poverty, 1106 Social Security, 348–349, 1107–1113 administration of, 1110–1111 benefit formula, 1109–1110 cost-of-living adjustments, 582 early retirement benefit, 1042, 1109 eligibility criteria, 1108–1109 financing of, 1110 future view, 583, 1111–1115 history of, 491, 876, 948, 1108 inflation, effects of, 583 intergenerational equity gap, 583, 607–608 privatization issue, 494, 495, 1112, 1115 recipient behavior, 1111 reform, 349, 1113–1115 Social Security Act (1935) Medicaid, 504–505, 720–726 Medicare, 483–486, 504–505, 727–731 passage of, 491, 876, 948, 1108 Title XX, 28 Social Security Block Grants (SSBG), 28 Social stratification, 1115–1118 age-based, 116–117 age/class/gender/race-ethnicity intersection, 117 society-wide systems, 1118

I-53

socioeconomic. See Poverty; Socioeconomic status Social stress, 1119–1121 chronic stressors, 1120 daily stressors, 1120–1121 life events, 1119–1120 Social support, 1121–1125 African American elders, 36 exchange theory, 396–399 gender differences, 1124 health benefits, 1123–1124 and marriage, 717 measurment of, 1122 minoritity groups, 1124–1125 social capital/social cohesion, 1090–1092 and socioeconomic status, 1125 and subjective well-being, 1147 types of, 1122 for widows, 108, 1227 Social withdrawal, disengagement theory, 321–322 Social workers, geriatric, 705–706 Socioeconomic status baby boom generation, 100 minorities and aging, 34–35, 82–83, 85, 521, 785, 947 rural elders, 1045 and social support, 1125 specialized housing with supportive services, 1134–1135 and suicide, 1155–1156 See also Poverty Socioemotional selectivity theory, 399, 659 Sodium balance/osmolaity regulation, 1126–1127 Sodium intake blood pressure management, 560 maximum level, 856 Somatic gene therapy, 440 Somatic mutations and genome instability, 1127–1130 Somatosensory system, aging and changes, 799–800 Sommers, Tish, 868 Source memory, 756, 757–758 Southeast Asian American elders common illnesses of, 85 ethnic groups of, 85 Spatial memory, 752–753 aging and changes, 753 Spatial vision, 1213


I-54


February 7, 2006

13:2

Subject Index

Special care units, 846–847, 1131–1132 activity programs, 1132 environmental features, 1132 family participation, 1132 staff training/supervision, 1131–1132 Specialized housing with supportive services, 1133–1136 Assisted Living Conversion Program (ALCP), 1136 continuing care retirement community (CCRC), 1038–1039, 1134–1135 for high-income persons, 1134–1136 for low-income persons, 1135 Speech, 1137 brain center of, 200 intelligibility/discrimination and hearing, 510 production, 1137 rapid and processing time, 633 rates, 633 subsystems of, 235 voice of elderly, 1137 word-finding difficulty, 237, 1238 Speech disorders, 235–236 apraxia of speech, 236 dysarthrias, 236 Spending down, 487, 696, 722 Spinal cord aging and changes, 201, 800 lipofuscin deposition, 201, 204 Spirituality as alternative treatment, 255 and end-of-life care, 369 and humanities and arts, 556 St. Christopher’s Hospice (London), 368, 542 St. John’s wort, 254 drug interactions, 338, 340 Stability theory, homeostasis, 531–532 Staff model HMOs, 507–508 State Child Health Insurance Program (SCHIP), 725–726 State regulation adult day care, 17–18 adult foster care, 26 advance directives, 669 elder mistreatment, 29 filial responsibility statutes, 422 Medicaid programs, 720 nursing homes, 702 partnerships for long-term care, 690

personal assistance services (PAS), 913 state taxes, 1171–1172 Statins cancer inhibitor, 156 cognitive impairment treatment, 216 lipoprotein benefits, 667 stroke management, 208 Status epilepticus, 377 Stem cells, 1138–1140 adult, 1139 aging and changes, 1139 cancer stem cell model, 154 characteristics of, 1138 embryonic, 1138–1139 therapy, 1139–1140 transgenic mice, aging model, 129–131 Stereotypes lesbian/gay/transgender/bisexual persons, 537–538 older people. See Age stereotypes Steroid injections, for gout/pseudogout, 81 Steroids, DHEA, 310–312 Stomach, disorders of, 430–431 Storytelling biography, 112–114 discourse and aging, 635 narrative analysis, 811–812 Strength training diabetes management, 314 musculoskeletal benefits, 402–403, 885 Streptococcus pneumoniae, immunization, 570–571 Stress and coping, 1140–1141 autonomic nervous system, 204–205 bereavement, 107–109 caregivers, 172–175, 903 chronic stress, 1120, 1142 daily stressors, 1120–1121 health outcomes, 481, 648 life events, 647–649, 1119–1120, 1140–1141 loss, 707–709 mediators/modulators, 648 physiological response, 13 regulatory resources for, 23 restoration stresses, 108 social stress, 1119–1121 stress-buffering hypothesis, 648 stress management methods, 1141 and subjective well-being, 1146–1147 sudden cardiac death, 828 widowhood, 1226–1228



February 7, 2006

13:2

Subject Index

Stress incontinence, 418, 631, 1205 Stress theory of aging, 1142–1144 brain aging, 1142–1143 free radicals and aging, 1143–1144 Stroke, 206–208 and aphasia, 71–74 and atherosclerosis, 164, 207 clinical evaluation, 207 complications of, 208 costs of, 206 epidemiology, 206 and homocysteine, 534–535 management, 207–208, 560 pathophysiology, 207 risk factors, 206 Stroop Color and Word Interference Test, 429, 604 Subjective well-being, 1145–1148 correlates of, 1146–1147 measurement of, 1145 Substance abuse/addictions, 1149–1151 addiction, diagnostic criteria, 1149 and AIDS/HIV, 49–50 alcohol use, 52–53 comorbidity, 1149 cross-addictions, 1151 as hidden epidemic of elderly, 1150 illegal drug use, 732, 1150 prevalence and elderly, 1149 SSI payment denial, 1160 treatment, 1151 types of substances used, 1149–1150 Substance P and memory decline, 748 and neurodegenerative disease, 836 Substantia nigra, 199 Successful aging, 1154–1155 activity theory, 9–13 adaptive capacity, 13–14 autonomy and aging, 97–99 competence, 250–251 compression of morbidity, 257–259 and control, 23, 657–659 cross-cultural research questions, 276 defined, 1154 and developmental tasks, 308–310 generativity, 435–437 life satisfaction, 10–11, 1154 measurement of, 1154–1155 quality of life, 1000–1002

I-55

selection, optimization, and compensation model, 1049–1051 subjective well-being, 1145–1148 wisdom, 1230–1234 Succinimide formation isomerization, 624–627 racemization, 1003–1005 Sudden cardiac death, 828 Suicide, 1155–1156 age factors, 1155 depression, 1155–1156 and grief, 108 physician-assisted, 924–926 prevention, 1156 rational suicide, 384 risk factors, 1155–1156 and social isolation, 1102 Sulfa drugs, drug reactions, 342 Sulfasalazine, for rheumatoid arthritis, 81 Sulfonylureas, diabetes treatment, 315 Sun exposure, photoaged skin, 260, 261, 1079 Sundown syndrome, 1156–1158 features of, 1157 treatment, 238, 1157–1158 Supercentarians, 196–197, 656 Superoxide dismutase, 217, 888 Superoxide radicals, 740 Supplemental health coverage Medicaid, 722 Medicare, 728 Supplementary Security Income Program (SSI), 720, 1158–1160 history of, 948, 1158–1160 SSI Modernization Project, 1160 Support groups, 1161–1162 effectiveness, 1162 features of, 1161 for lesbian/gay/transgender/bisexual persons, 537–538 online, 1161 for widows, 108, 1228 Surgery, post-operative delirium, 287 Surveys, 1163–1165 gerontological research, 1163–1165 and research design, 1164 Web-based forms, 499 Swallowing disorder causes of, 430 and communication impairment, 236 Swan-song phenomenon, 270


I-56


February 7, 2006

13:2

Subject Index

Swedish twin studies, 1165–1167 Sylvian fissure, 71 Symptom-syndrome-lesion theory, aphasia, 72 Synapse, neuroplasticity, 829–831 Syneresis, 407 Synovial fluid, 80 Syntax, 634–635 Synthetic catalytic mimetics, 121 Alpha-synuclein, in Lewy Body disease, 297–298 Synucleinopathies, 290, 297 System design, human factors engineering, 549–552 Systolic function, aging heart, 161, 167, 170, 560 T-lymphocytes, 565–566 Tacrine, memory improvement, 747 Tai-chi, 255 Tamoxifen, 156 Tardive dyskinisia, time-dependent factors, 343 Taste/smell, 1168–1170 aging and changes, 1168–1169 disease and losses, 1169 and medication use, 1169 Tau proteins, 214, 292, 293, 297 Tauopathies, 290, 293 Tax policy, 1170–1173 caregiver tax benefits, 1172 federal taxes, 1170–1171 intergenerational equity issue, 1173 property tax exemptions, 523, 1172 sales tax, 1172 and self-employed retirement accounts, 576, 1048, 1171 state/local taxes, 1171–1172 Technology and older adults, 1173–1176 assistive technology, 1174 caregiving technologies, 1176 communication technology, 242–247 design, gearing toward older persons, 501–502, 551–552, 621, 1175 enabling technologies, 1175–1176 health informatics, 496–499 and human factors engineering, 549–552 Internet applications, 619–621 Internet health information, 499–503 and modernization theory, 792–793 and socially isolated elders, 501, 1103 telemedicine/telegeriatrics, 1176–1178 universal design, 1174–1175

Technology gap, 245–247 Teeth aging and changes, 873 loss of, 875 Telecommunications telecommunications relay services (TRS), 67 Telecommunications Act (1996), 67 See also Communication technologies and older adults; Internet; Technology and older adults Telecommunications device for the deaf (TDD), 511 Telecommuting, 620–621 Telemedicine/telegeriatrics, 1176–1178 and aging-in-place, 244 clinical applications, 1177–1178 defined, 1176 educational applications, 1178 technologies for, 244 Telephone for hearing-impaired, 511 support groups, 1161 telephone reassurance programs, 1103 Television aging, images of, 45–47 cable TV, 47 gray market, 47 shows viewed by older persons, 46 Telogen effluvium, 476 Telomerase functions of, 1179–1180 modulation and disease treatment, 1181 Telomeres features of, 1179 whole-body interdiction of lengthening telomeres (WILT), 442 Telomeres and cellular senescence, 188, 193–194, 1179–1182 and cancer, 153, 1180–1182 telomere loss, 1180 Temoporal summation, auditory, 510–511 Temperature regulation abnormality, 1182–1184 fever, 1184 hyperthermia, 1183–1184 hypothermia, 1182–1183 impairment and age, 14 Temporal lobe, 200 Temporal sampling, longitudinal research, 681 Tension-free vaginal tape, 1206 Terminal change, 1184–1185 Terminal dribble, 1205



February 7, 2006

13:2

Subject Index

Terror management theory, 659 Tetanus, immunization, 571–572 Thalamus, functions of, 199 Thalassemia, 444 Thanatology, 1186–1187 history of, 1186–1187 modern study, 1187 Thematic Apperception Test (TAT), 623, 795 Therapeutic Environment Screening Scale, 375 Therapeutic humor, 558–559 Thiazolinediones, diabetes treatment, 315 Thinking and cognition. See Cognitive impairment; Cognitive processes Thompson, Marie McGuire, 79 Thought content, mental status assessment, 772 Thought-stopping, 106 Thrombocytopenia, 142 Thrombolytic agents, 165 stroke management, 207–208 Thrombophlebitis, 165 Thymus, 566 Thyroid disease clinical signs, 1189 pathology of, 1189 Thyroid gland, 1188–1190 aging and changes, 1188–1189 diagnosis, 1189–1190 hormone production/secretion, 1188 thyroid hormones, functions of, 1188 treatment, 1190 Thyroxine, 1190 Time-out, 106 Tip-of-tongue. See Word-finding difficulty Tissue transplantation, AIDS/HIV exposure, 49 Tonic-clonic seizures, 377 Total anticholinergic load, 343 Touch, 1191–1192 aging and changes, 1191–1192 Toxic shock syndrome, 586 Trail Making Test, 429 Training/education. See Education Training intensity, 401, 404 Trait theories, personality, 915 Transgender persons, stigmatization/stereotyping, impact of, 537–538 Transgene, 129 Transgenic models invertebrate, 131 mice, biological aging model, 129–131 transgenic line, production of, 129–131

I-57

Transient ischemic attack, 206–208 and dementia, 54 diagnosis, 206 duration of, 206 pathophysiology, 207 Transportation, 1193–1195 barriers to use, 1195 driving, 334–336 fixed-route services, 1194 human factors engineering, 550 public, 550, 1193–1194 special services, 1194–1195 travel trends, 1194 Transurethral resection of the prostate (TURP), 1206 Travel, older consumers, 264, 1031 Tremor, Parkinson’s disease, 905 Tricyclic antidepressants for depression, 304 drug interactions, 339 drug reactions, 923 Triperatide, 885 Tuberculosis, 1196–1198 epidemiology, 1197 latent (LTBI), 1197 prevalence and elderly, 1196 signs of, 1198 symptoms of, 1197–1198 transmission of, 1197 treatment, 1198 Tumor necrosis factor, and Alzheimer’s disease, 215 Tumor necrosis factor alpha inhibitors, for rheumatoid arthritis, 81 Tumor suppression, 1199–1201 Tunnel memories, 751 Turing maching, 588–589 Twin studies, 1202–1204 areas of study, 1202–1203 research approach, 1203–1204 Swedish twin studies, 1165–1167 Twins, relationship of, 1074 Type A personality, and cardiovascular disease, 164 Tyrosine phosphorylation, 135 Ubiquinol, 121 Ubiquitin system, 979–981 Ulcerative colitis, 431 Undernutrition. See Diet restriction


I-58


February 7, 2006

13:2

Subject Index

Unemployment population aging and rates of, 350, 365–366 reemployment and age, 366, 581 Uniform Data System for Medical Rehabilitation, 7 Universal design, 1174–1175 University Institute Kurt Boesch, 390 Urge incontinence, 418, 631, 1205 Urgency, urinary, 1205 Uric acid, gout, 81 Urinalysis, 1205 Urinary incontinence, 417–419 defined, 417 treatment, 418, 1206 types of, 418, 631–632, 1205 Urinary tract, 1205–1206 anomalies and older adults, 1205–1206 assessment of, 1205–1206 bladder infections, 632 incontinence. See Urinary incontinence prostate, 975–976, 1206 treatment of disorders, 1206 See also Kidney and urinary system Uterine cancer, hormone replacement therapy risk, 540, 765 Vaccinations. See Immunizations Valerian, 254 Values, and social cognitions, 1095 Valve replacement, 165 Varicella zoster, immunization, 572 Varicosities, 164–165 Vascular cognitive impairment, 54, 214, 289, 1208–1209 causes, 1209 drug treatment, 217, 1209 prevention, 1209 societal cost, 1209 subtypes, 1208 Vascular system, 168–170 arterial stiffness, 161–162, 164, 167, 169–170 components of, 163 endothelial dysfunction, 169 structural changes and aging, 168–169 Veins disorders of. See Venous disorders functions of, 163 Vendor payments operation of, 182 personal assistance services (PAS), 182 Venlafaxine, withdrawal syndrome, 343–344

Venography, 165 Venous disorders diagnosis, 165 and homocysteine, 535 and hormone replacement therapy, 945 lower leg skin problems, 1080 and pulmonary emboli, 165 types of, 164–165 Ventricular system, 201 Verbosity, 635–636 Very low-density (VLDLs) lipoprotein, 663–664 Vestibular system, aging and changes, 800 Veterans Study of Memory in Aging, 819 Veterans/veteran care, 1210–1211 comprehensive geriatric assessment, 806 geriatric research, education, and clinical centers (GRECCs), 456–457, 1211 Program of All-Inclusive Care for the Elderly (PACE), 974–975 Viagra, 1070–1072 effectiveness, 1070 side effects, 1070–1071 Victimization crime victims, 270–272 elder abuse and neglect, 352–354 and homelessness, 526 Victoria Plaza, 79 Videoconferening, 1178 Vietnamese American elders, 85 Vincamine, memory improvement, 747–748 Viral-mediated transgenesis techniques, 130 Visceral adiposity. See Abdominal fat; Metabolic syndrome of aging Visceral protein status, 857 Vision, 1212–1214 color vision, 1213 eye, 405–410, 1212 and Internet use, 502 spatial vision, 1213 tracking deficits, 1213 Visitabilty codes, 530 Visual-Verbal Test, 428 Vitamin A deficiency diseases, 1215 sources of, 1215 toxicity, 1215 Vitamin C deficiency diseases, 1217 pressure ulcer management, 951, 1217 sources of, 1217



February 7, 2006

13:2

Subject Index

Vitamin D and calcium metabolism, 145, 146 deficiency, causes of, 881–882 and osteomalacia, 881–882, 1215–1216 and osteoporosis, 884–885 requirements for older adults, 855 sources of, 1215 Vitamin E cognitive impairment treatment, 218 as free radical scavenger, 218 sources of, 1216 Vitamin K drug interactions, 340 functions of, 1216 Vitamins, 1215–1217 antioxidants, 889 deficiencies, 858 See also specific vitamins Vocal folds, atrophy of, 235 Voice changes and elderly, 235, 1137 disorders, 235–236 speech, 1137 Volunteerism, 1217–1219 AARP programs, 2 health benefits, 1218 NCOA programs, 815 senior companion program, 1064–1067 social policies related to, 1218 and subjective well-being, 1147 Volvulus, 431 Voting participation, 932–933 Vouchers, personal assistance services (PAS), 182 Wage pass-through, 706 Waiver programs, Medicaid, 90, 178, 487, 697 Walking exercise, 404 mature market spending on, 264 Wandering, 325, 1220–1223 assessment, 1221–1222 correlates of, 1220–1221 etiology, 1221 management of, 1222–1223 prevalence of, 1220 Warfarin drug interactions, 337, 339, 340 drug reactions, 342 stroke management, 208 Warren, Marjory, 448, 453

I-59

Wear-and-tear theories, 1224–1225 features of, 1225 lipofuscin, 660–661 Weather-related illness deaths and elderly, 14 hyperthermia, 1183–1184 hypothermia, 1182–1183 Wechsler Adult Intelligence Scale (WAIS), 428, 601 Weight. See Body weight Well-being. See Psychological well-being; Successful aging Werner syndrome, premature aging, 188–189, 971–972 Wernicke’s area, 200 Western Gerontological Society, 64 Whole-body interdiction of lengthening telomeres (WILT), 442 Widowhood, 1226–1228 bereavement, 107–109, 708–709, 1226–1228 cultural differences, 108–109, 1227 and devalued role, 708 economic strain, 1227 gender differences in rates, 107, 1226 gender differences in response, 709, 1227 resiliency, 1226–1227 and social support, 108, 1227 See also Bereavement; Loss Wireless technology, 246 Wisconsin Card Sorting Test, 428 Wisdom, 22, 1230–1234 assessment of, 1231–1232 Berlin Wisdom Model, 1232–1233 empirical findings, 1233 features of, 1230 personality-based approaches, 1231 and subjective well-being, 1147 Withdrawal reactions, 343–344 Women, 1235–1237 and caregiving, 170–173 divorce, economic effects, 328 family roles, 416–417 female reproductive system, 419–421 feminization of aging, 940 gender, study of, 432–433 high-density lipoprotein (HDL) levels, 663–664 hormone replacement therapy, 539–541, 944–945 identity at midlife, 436–437 institutionalization, 595


I-60


February 7, 2006

13:2

Subject Index

Women (continued) in labor force, 362–363, 581, 1236 life expectancy, 258, 650 majority in aging population, 302 menopause, 764–766 Older Women’s League, 868–870 paid leave, 412–413 and poverty, 947–948, 1227 prison population, 958 technology, use of, 245 TV representations, 45–46 urinary incontinence, 418 See also Gender differences Women’s Health and Aging Study, 818 Women’s Health Initiative, 540–541, 765, 945, 1236 Word-finding difficulty, 237, 635, 756, 1238 and aphasia, 72, 73 Workers, older. See Employment; Older workers Workforce Aging the New Econony study, 149–150 Workforce Investment Act (1998), 366 Working memory, 753–754

aging and changes, 743–744, 754 assessment of, 755 World Cities Project, 619 Worry, anxiety, 69–70 Worry Scale for Older Adults, 988 Wound healing, pressure ulcer management, 951, 1217 Wright, Irving S., 62 Writers, later-life topics, 555 WRN gene, 1130 Xanomeline, cognitive impairment treatment, 217 Xeroderma pigmentosum, 444 YAG laser iridotomy, 410 Yeast, biological aging model, 132–135 Yin/yang, 83, 254 Young-old, age range of, 264 Zanamivir, influenza treatment, 587 Zenker diverticulum, 430 Zinc, pressure ulcer management, 951

P1: OSO GRBT104-con-Index


February 7, 2006

10:40

CONTRIBUTOR INDEX

A Achenbaum, W. A., 792 Adachi, J. D., 881, 883 Aday, R. H., 957, 1062 Agich, G. J., 97 Aiken, J. M., 789 Albert, M., 747 Albert, S. M., 1000 Allen, J. E., 61, 813 Allen, P. A., 588 Allen, R. G., 186 Allen, R. S., 105 Allen, S., 542 Anderson, K. A., 840 Andrew, M., 1090 Angel, J., 520 Anguera, J. A., 801 Antonucci, T. C., 415 Applebaum, R. A., 998 Areán, P. A., 962 Arking, R., 114 Aronow, W. S., 533 Atchley, R. C., 9, 266 Ayala, A. R., 1188 B Balducci, L., 155 Baldwin, B. A., 324 Balin, A. K., 259 Bangert, A. S., 801 Barefoot, J. C., 545 Barratt, J., 618 Barzilai, N., 135 Bass, S. A., 965 Baynes, J. W., 31 Bechill, W., 1158 Beckett, N., 559

Béland, F., 423 Benbow, A., 499 Bengtson, V. L., 609, 1088, 1098 Bensing, K. M., 946 Beregi, E., 615 Bergman, H., 423 Biegel, D. E., 170 Binstock, R. H., 483, 607, 932 Birditt, K. S., 415 Blanchard-Fields, F., 1094 Blazer, D. G., 303, 815, 1155 Bluming, A. Z., 539 Bolkan, C. R., 914 Borden, E. A., 861 Borders, K., 692 Bosworth, H. B., 1184 Bourbonniere, M., 1027 Bowles, S. K., 336, 342, 732 Bradley, D. B., 1039 Branch, L. G., 1038 Bringle, J. R., 435 Brody, H., 198, 660 Broe, G. A., 289 Brooks, S. V., 1075 Brown, W. T., 443, 445, 971 Brownell, W., 44, 242 Bua, E., 789 Bucur, B., 588 Burgess, E. O., 1098 Burgio, L. D., 105 Butler, R. N., 41, 618, 654, 676, 817 C Cahill, K. E., 348 Calkins, M. P., 1131 Campbell, R. T., 677 Capezuti, E., 968 I-61


I-62


February 7, 2006

10:40

Contributor Index

Cartee, G. D., 158 Charness, N., 39 Chen, Y.-P., 523, 576 Chipperfield, J. G., 636, 671 Cicirelli, V. G., 1072 Cizza, G., 1188 Clarfield, A. M., 332 Clark, R. L., 348 Cohen, C. I., 525 Cohen, H. J., 139 Consedine, N. S., 355 Coogle, C. L., 1149 Cook, F. L., 43 Cooley, S. G., 1210 Cornélissen, G., 209 Coughlin, J. F., 1173 Cristofalo, V. J., 186, 191, 1057 Crystal, S., 100 Cuervo, A. M., 979 Curry, L., 685 Cutler, S. J., 270 Czaja, S. J., 549, 619 D Dax, E. M., 739 Degenholtz, H. B., 483 DeVaney, S. A., 1041 Devaraju-Backhaus, S., 427 Dixon, R. A., 772 Douglass, E. B., 91 Dugan, E., 432, 1235 Dupere, D., 899 Dwolatzky, T., 332 E Effros, R. B., 565 Ekerdt, D. J., 1032 Elder, G. H. Jr., 643 Engel, B. T., 417 Erber, J. T., 749 Estes, C. L., 490, 935 Evans, J. G., 975, 1215 Evans, L. K., 1027 F Faulkner, J. A., 1075 Feightner, J., 952 Feltmate, P. J. G., 376 Ferri, C., 992 Ferrucci, L., 101

Fillenbaum, G. G., 6, 683, 804 Finkelstein, D. B., 152 Flaherty, J. H., 253 Fleg, J. L., 101 Flicker, L., 780 Foner, A., 1115 Fortner, B., 283 Freter, S., 285 Freund, A. M., 1049 Friedland, R. B., 720, 727 Fries, B. E., 1022 Fries, J. F., 257 Fry, C. L., 274 Fulmer, T. T., 968 G Gafni, A., 977 Ganguli, M., 983 Gaugler, J. E., 840, 1025 Gauthier, S., 53 Gelwicks, L. E., 78 George, L. K., 647, 815, 1055 Geron, S. M., 929 Giangregorio, L., 881, 883 Giarrusso, R., 464 Gitlin, L. N., 374 Golant, S. M., 1133 Golden, C. J., 426, 427 Goldlist, B. J., 1182 Gonyea, J. G., 412 Gordon, M., 924 Gould, E., 503 Grabowski, D. C., 701, 1107 Gramlich, E. M., 1048 Grey, A. de, 439 Griffith, J. D., 1064 Grodstein, F., 944 Grossman, M., 292 Gubitz, G., 206 Guiamet, J. J., 927 Guo, Z., 329 H Halberg, F., 209 Harley, C. B., 1179 Harrington, C. R., 295, 954 Hartley, A. A., 92, 753 Hasher, L., 602 Havens, B., 247 Havighurst, R. J., 458



February 7, 2006

10:40

Contributor Index

Hawes, C., 87, 1064 Hazelton, L., 1156 Heaney, R. P., 145 Hebert, R. S., 368 Heckhausen, J., 21, 657, 776, 794 Hefti, F., 837 Heidorn, J., 901 Heidrick, M. L., 95 Henderson, L. C., 386 Hendricks, J., 396, 641, 966 Hennon, J. G., 451 Hertzog, C., 679 Hess, T. M., 761 Hikoyeda, N., 82 Hines, F. G., 39 Hinrichsen, G. A., 622 Hogan, D., 423 Holmes, H. H., 25 Hooker, K., 914 Horhota, M., 1094 Howard, C. S., 480 Howard, D. V., 573 Howlett, S. E., 160, 168 Hoyer, W. J., 763, 1238 Huber, R., 692 Hudson, R. B., 929 Hughes, M. E., 674 Hutchison, L. L., 87 Hyman, B. T., 75 I Ingraham, M. B., 861 Ingram, D. K., 137 J Jackson, J. S., 34 Jackson, S. T., 1137 Jasper, C. R., 1030 Jastrzembski, T., 39 Jazwinski, S. M., 132 Jecker, N. S., 392 Jelonek, S. J., 582 Jervis, L., 823 Johnson, M. M., 270 Johnson, S., 854 Johnson, T. E., 119, 651 Jonas, S., 403 Joseph, L. J. O., 662

K Kahana, B., 1101 Kahana, E., 595, 707 Kahn, A., 310 Kane, R. A., 911 Kapp, M. B., 384, 421, 639 Kart, C. S., 1115 Karunananthan, S., 423 Kasl-Godley, J., 1009 Kastenbaum, R. J., 460, 1155, 1186 Kaufman, S. R., 280 Kelly, M. E. M., 405 Kemnitz, J. W., 123 Kemper, S. J., 634 Kenyon, G. M., 112 Kerr, L. D., 80 Kimbell, A.-M., 1064 Kimmel, D. C., 537 Kirkwood, T. B. L., 322 Kleyman, P., 63 Kline, D., 1212 Klud, L. W., 576 Kornberg, T., 433 Kunkel, S. R., 43 Kunzmann, U., 1230 L Lai, C. K. Y., 1220 Langa, K. M., 478 Lantz, M. S., 352 Lashley, F. R., 48, 1196 Lautenschlager, N. T., 780 Lebowitz, B. D., 770 Lee, C. C., 549 Lee, M., 430 Leff, B., 59 Lenze, E. J., 69 Leventhal, H., 480 Levin, J., 1016 Levkoff, S. E., 786 Liebig, P. S., 582, 876, 1170 Lindeman, R. D., 630 Longino, C. F. Jr., 446 Lopez, O. L., 214 Lorenzini, A., 1057 Lowenson, J. D., 624, 1003 Lucas, J. A., 17 Lustig, C., 602 Lyle, S., 1138 Lynch, T. R., 466

I-63


I-64


February 7, 2006

10:40

Contributor Index

M Mabry, J. B., 609, 1088 MacKnight, C., 196, 791 Maddox, G. L., 52 Magai, C., 355 Mahoney, K. J., 182 Malone-Lee, J., 1205 Mandal, P. K., 712 Manheimer, R. J., 552 Manson, S. M., 823 Manton, K. G., 820 Margrett, J. A., 960 Markides, K. S., 783 Marks, L. N., 182 Markson, E. W., 764, 1105 Markwood, S., 812 Martin, G. M., 62 Martin-Matthews, A., 148 Martire, L. M., 989 Masel, M., 716 Masoro, E. J., 4, 142, 1126 Massoud, E., 508 McCarter, R. J. M., 370 McClearn, G. E., 125 McClure, R. J., 712 McConaghy, R. W., 523 McCormick, A. M., 152 McCracken, P. N., 1176 McCrae, R. R., 623, 831, 1054, 1140 McDowell, I., 319 McKenzie, D., 789 McNally, M., 873 McNamara, C., 312 McNeil, S. A., 569, 585 Meade, M. L., 744 Medeiros, K. de, 546 Medvedev, Z. A., 1224 Meigh, K. M., 234 Menne, H. L., 704 Metter, E. Jeffrey, 101 Mezey, M. D., 968 Michel, J.-P., 390 Miller, R. B., 327 Minicozzi, A., 503 Mitnitski, A. B., 496 Mitty, E. L., 842 Mobbs, C. V., 13, 826 Molnar, F. J., 334 Monk, T. H., 1081 Moody, H. R., 272, 384

Moore, J. T., 771 Mor, V., 542 Mora, P. A., 480 Morgan, R. E. Jr., 499 Morley, J. E., 456 Morrell, R. W., 499 Morrow-Howell, N., 1217 Moyers, P. A., 870 Mueller-Johnson, K., 901 Mulsant, B. H., 455 Mundorf, J., 44, 242 Mundorf, N., 44, 242 Murphy, M. D., 588 N Natarajan, G. C., 1023 Nelson, H. W., 692 Netting, F. Ellen, 692 Newall, N. E., 671 Nichols, N. R., 1142 Niemeyer, R. A., 283 Nikzad, K. A., 1025 Nishita, C. M., 528 Noelker, L. S., 704 Noh, S. R., 741 Noodèn, L. D., 927 O Ogawa, D. D., 490 Okochi, J., 615 Okun, M. A., 1145 Olshansky, S. J., 68 O’Rand, A. M., 361 P Palmore, E. B., 346, 557, 684, 1154 Panchalingam, K., 712 Papaioannou, A., 881, 883 Park, D. C., 744 Parkin, S. L., 814 Patterson, C., 952 Pedersen, N. L., 1165 Peek, M. K., 716 Perzynski, A. T., 321 Peters, R., 559 Pettegrew, J. W., 712 Phelan, J. P., 394 Phillips, C. D., 87 Pienta, A. M., 909 Pierce, R. I., 975



February 7, 2006

10:40

Contributor Index

Pignolo, R. J., 186, 191, 1057 Pillemer, K., 901 Plassman, B. L., 747, 1202 Poon, L. W., 638, 759 Post, L. F., 668 Poulin, M. J., 657 Powell, C., 904 Prinz, P., 1085 Pynoos, J., 528 Q Qualls, S. H., 767, 986 Quinn-Walsh, C. M., 801 R Rafuse, P. E., 405 Randall, W. L., 811 Rao, A. V., 139 Rebeck, G. W., 75 Reiter, R. J., 737 Reynolds, S. L., 28 Richardson, A., 329 Richardson, V. E., 1226 Rikke, B. A., 316 Rix, S. E., 362 Roberts, J., 922 Robinson, C. K., 123 Rockwood, K., 152, 452, 462, 1208 Rockwood, P. R., 515 Rogaeva, E., 54 Rolfson, D. B., 1176 Romeis, J. C., 506 Roper-Coleman, S. F., 21 Rose, Debra J., 798 Ross, J. B., 476 Rother, J., 1 Rowles, G. D., 25, 1045 Rubenstein, L., 448 Rubin, D. C., 740 Rubinstein, R. L., 546 Rudin, E., 135 Rudkin, L., 1121 Ryan, A. S., 662 Rybarczyk, B., 232 S Sadler, M., 376 Saxton, J., 214 Schaie, K. W., 3, 600, 1044 Scharp, V. L., 71, 234, 512

Schiffman, S. S., 1168 Schneider, K. G., 466 Schonfeld, L., 28 Schulz, R., 63, 100, 283, 759, 940, 989, 1145 Schutz, C. A., 458 Sechrist, J., 901 Segal, D. L., 986 Seidler, R. D., 801 Sergeant, J. F., 1032 Shake, M. C., 741 Shannon, A. R., 907 Shear, K., 107 Shuman, T. M., 940 Sierra, F., 1199 Silverstein, M., 464 Simon-Rusinowitz, L., 182 Simonsick, E. M., 864 Simonton, D. K., 269 Skaff, M. M., 1119 Skidmore, M. J., 1113 Smith, A. D., 229, 752, 755 Smith, J., 110, 306 Smith, M. J., 419 Smyer, M. A., 767 Snyder, D. L., 922 Sokolovsky, J. H., 388 Sonbolian, N. S., 1188 Sonntag, W. E., 468 Sorkin, D. H., 794 Sparrow, D., 1023 Spiro, A. III, 838 Staats, S., 919 Starr, B. D., 1067 Stepp, D. D., 91 Sterns, A. A., 580 Sterns, H. L., 263, 580, 1193 Sterns, R. S., 263, 1193 Stevens, A. B., 1161 Stevens, J. A., 591 Stevenson, D. G., 701 St George-Hyslop, P., 54 Stine-Morros, E. A. L., 741 Stone, L. O., 299 Strumpf, N. E., 1027 Suitor, J. J., 901 Sullivan, J. R. Jr., 163 T Takagi, E., 464 Takamura, J. C., 866

I-65


I-66


February 7, 2006

10:40

Contributor Index

Terry, A. V. Jr., 832 Thomas, D. R., 950 Thomas, V. S., 1051 Todd, C., 1062 Tompkins, C. A., 71, 234, 512 Tompkins, C. J., 91 Tonna, E. A., 808 Tresini, M., 186, 191, 1057 Turner, J. A., 907 U Uhlenberg, P., 777 V Vachon, R. A. III, 65 Van Haitsma, K. S., 1131 Vaupel, J. W., 649, 656 Verhaeghen, P., 1006 Verrillo, R. T., 1191 Vijg, J., 1127 Vilenchik, M. M., 259 Villareal, D. T., 401 Vokonas, P. S., 838 W Wallace, H. M., 1045 Wallace, R. B., 378 Walsh, E., 695 Walter, C. A., 129 Wang, E., 76 Warner, H. R., 152, 819, 887 Weiner, D. K., 890

Weiss, C., 59 Weitz, T., 490 Wellin, C., 490 Wells, D. G., 829 Wells, J. L., 1012 Whitbourne, S. K., 435 White, H. K., 163 White, M., 178 Whittington, F. J., 15 Wieland, D., 973 Wiener, J. M., 688, 695 Wilber, K. H., 472 Williams, M. M., 401 Willis, S. L., 250 Wingfield, A., 633 Wise, P. M., 419 Wolfson, C., 423 Wolinsky, F. D., 1163 Wrosch, C., 308 Wulf, H. C., 1077 Y Yang, F. M., 786 Yates, F. E., 531 Yeo, G., 82 Young, L., 868 Z Zarit, S. H., 1025 Zimmer, Z., 936 Zitner, D., 496

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