Review Healthy ageing: how is it dened and measured?

Blackwell Publishing, Ltd. Peel N, Bartlett H, McClure R

Nancye Peel
Centre of National Research on Disability and Rehabilitation Medicine, Mayne Medical School, University of Queensland, Herston, Queensland, Australia

literature [11], but appears also to underlie health policy development in the USA [3]. Healthy ageing is described as a lifelong process optimising opportunities for improving and preserving health and physical, social and mental wellness, independence, quality of life and enhancing successful life-course transitions [12]. While this denition depicts healthy ageing as a complex process of adaptation to physical, social and psychological changes across the lifespan, the concept needs to be looked at in terms of a measurable outcome to be empirically validated. Several well-known epidemiological studies of the aged at multiple centres have contributed valuable understanding about the process of ageing [13]. However, gerontological research has not yet reached a stage where there is good causal evidence of positive outcomes of ageing [14]. There appears to be no agreed standard by which healthy ageing can be measured, nor clear contextual discourse establishing the parameters of the entity [1517]. Thus, current health and social policy, which assumes the existence of a sound evidence base for healthy ageing, cannot be effectively implemented. An example of the confusion relating to the concept of healthy ageing is that, despite policy documents conceiving healthy ageing in positive terms, empirical research has largely been based on negative aspects; mortality, morbidity and disability [16]. Many studies of the aged population have examined functional status decline [18] or restricted assessment to individual diseasespecic outcomes, such as dementia [19]. Descriptive and evaluative research based on such pathology models neglects the vast heterogeneity in health status among older adults [20], and cannot adequately address the issue of healthy ageing [21]. Interest in healthy ageing requires researchers to shift their outcome measurement to focus on those persons who are ageing well. In keeping with the World Health Organizations (WHO) denition of health as not merely the absence of disease or inrmity [22], healthy ageing needs to be recognised by researchers as not simply the opposite of ageing with disease or functional impairment. Rowe and Kahn argue that within the category of the normal, non-disabled population, a distinction can be made between usual and successful ageing [23]. According to Rowe and Kahns denition, successful agers are the group with a low probability of disease and diseaserelated disability, high cognitive and physical functional capacity and active engagement with life [5, p. 433]. There is a need to clarify the denition of healthy ageing and specify its dimensions [24]. This paper presents the ndings of a review of healthy ageing studies to determine how the concept is currently dened and quantied. The
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Helen Bartlett
Australasian Centre on Ageing, University of Queensland, Brisbane, Queensland, Australia

Roderick McClure
School of Population Health, Mayne Medical School, University of Queensland, Herston, Queensland, Australia

A review of existing studies which dened and measured healthy ageing as an outcome was undertaken to clarify the term for the purposes of informing policy development and further research into positive health outcomes in older age. Studies which measured the prevalence of healthy (or successful) ageing in population-based settings were identied from a search of health and gerontology databases. Eighteen studies met the selection criteria. The arbitrary nature of the denition, populations sampled, domains selected and measures within the domains resulted in considerable variation between the studies in the proportion of the study population classied as healthy ageing, which ranged from 3% to 80%. The present review shows the need to establish a standard for dening and quantifying the concept of healthy ageing. Despite the differences, there was consensus in the studies that the multidimensional, positive health outcome should measure the capacity to function well and adapt to environmental challenges in domains assessing physical, mental and social well-being. Key words: measurement issues, older age, positive health outcomes.

Introduction
In recent years, as a response to demographic trends and social forces, policy decisions concerning ways to extend quality as well as length of life have become part of health and social agendas for many nations [1 4]. However, there is clearly some difculty in developing policy aimed at advancing quality ageing while there remains confusion as to the nature of the concept itself. Quality of life in older people has been variously conceptualised as successful [5], active [4], productive [6] and positive ageing [78]. For older people in particular, there is a health related dimension of quality of life [9], which is important to capture in health policy development. The term healthy ageing, which attempts to encapsulate this dimension, is particularly current in Australian [10] and European
Correspondence to: Nancye Peel, Mayne Medical School, University of Queensland. Email: n.peel@uq.edu.au Australasian Journal on Ageing, Vol 23 No 3 September 2004, Review 115119

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ndings are then synthesised to dene the parameters of the healthy ageing discourse so as to inform policy development and promote further scientic development of the eld [24].

Methods
Published population-based studies with a multidimension outcome measure of healthy or successful ageing were identied through searches of MEDLINE, PSYCINFO (psychological abstracts), SOCIOFILE (sociological abstracts) and AGELINE (gerontology abstracts). A selection criterion was that the study examine the prevalence of healthy ageing in a population-based sample. The outcome measure had to include an indicator of health functioning beyond subjective measures of well-being, such as life satisfaction or self-rated health, ascertained by a single item question. In accord with the WHO denition of older person [25], a criterion was that study participants be 60 years or older at the time of assessment of healthy ageing. The search covered the period from 1985 to 2002 and was conned to studies written in English.

Domains and measures Recognising the multidimensional nature of health as dened by WHO [22], the majority of studies selected measures across the domains of physical, mental and social functioning. The indicators used within the domains to measure outcome and the way they were aggregated into summary scores inuenced the resulting proportion of healthy agers in the study population. In line with conventional measures of health status, all studies included criteria in the key domain of physical health and functioning. Absence of disability was ascertained using activities of daily living (ADL) and/or physical performance scales as an indicator of healthy ageing in the majority of studies. Also included as a measure of physical health in some studies was the absence of disease or impairments [13,15,21,2627], and/ or the absence of mortality [13,19,2729]. While often categorised as a measure of physical functioning, the ability to perform both basic self-care ADL (e.g. bathing, dressing, eating) and instrumental ADL (e.g. shopping, managing transport and money) entails preservation of both cognitive and physical abilities and is also a measure of the ability to function in the social environment [9]. In addition to ADL measures, 11 studies included measures of mental health, most frequently a measure of cognitive functioning [15,19 20,26,2932]. Other measures of mental well-being included absence of psychiatric morbidity [13,2021,32], positive perceived health [29,31,33], life satisfaction [13,21,3233], and personality resources such as sense of control [21,26,33]. Social functioning indicators in 11 of the 18 studies included measures of social contact or participation [13,2021,26,32 35], and environmental security [21,33]. Persons living in residential care were classied in the unhealthy ageing group in several studies [19,29,31,35], or excluded from the initial population sample in other cross-sectional studies [21,36]. Another indicator used as a measure of ability to function independently in the community was limited use of home care services, formal or informal [29,35]. Because healthy ageing, at the very least, implies longevity, survival to the late adult years is a key outcome indicator. Of the selected studies, nine used cross-sectional data to calculate the percentage of the population classied as healthy agers, with the consequent limitation that mortality data could not be included as a component of unhealthy ageing. Longitudinal studies beginning late in life are also awed by selective mortality, by failing to include those who died before the age of 60 or 70 [13]. Only three of the selected studies included participants recruited before the age of 60 [13,15,28]. As shown in Table 1, the minimum age at which outcome was assessed in cross-sectional data ranged from 60 years [20,36] to 85 years [21,32]. Of the follow-up studies, two specied a minimum age threshold as a measure of longevity which ranged from 65 years [13] to 85 years [37]. The concept of survival
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Results
The 18 studies identied for inclusion in the review are outlined in Table 1, together with study descriptors, outcome denition and prevalence measures. The ndings are synthesised according to the major differences between the studies in relation to terminology, denition, domains and indicators used in the measurement of healthy ageing. The effects of these differences on outcome prevalence are discussed. Terminology Of the 18 studies outlined in Table 1, successful ageing was the term most commonly used, reecting the fact that the majority of studies were based on North American populations. Of the studies selected, 12 were from North America (10 from the USA and two from Canada), four from the UK and Europe, and one each from Australia and Asia. The term successful ageing has been criticised because success in Western culture is usually associated with economic achievement, employment status, income and assets [7]. Because of these materialistic connotations and in some cases, emphasis on psychosocial outcomes only, successful ageing is not considered appropriate for describing positive health outcomes in old age and healthy ageing is preferred [10]. Denitions As shown in Table 1, the denitions of healthy or successful ageing ranged from the primarily biological, such as survival with absence of morbidity, to the comprehensive, such as sustained well-being using a biopsychosocial model. Despite the wideranging approaches to the study of healthy ageing, the majority of the selected studies emphasised the maintenance of functional independence in their denition. The domains measured to determine outcome reected the operational denition chosen.
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Table 1: Studies quantifying healthy ageing outcome in older people

Author, year Vaillant, 2001 [13] Study, site, population descriptors Harvard Study of Adult Development, USA a) College male sophomores b) Core city male adolescents Age at outcome assessment a) Aged 75 80 at follow-up b) Aged 65 70 at follow-up Outcome denition and domains measured Successful ageing dened as survival to age 75 (a) or 65 (b) with a high level of well-being in six domains of functioning (objective and subjective physical health, mental health, active life, life satisfaction and social supports) Healthy ageing dened as remaining alive and free of chronic disease and symptoms in later life Successful ageing dened as the optimal state of overall functioning and well-being measured across physical, social and psychocognitive functioning and on feelings of well-being Successful ageing dened as sustained personal autonomy in domains of activities of daily living, ability to participate in valued activities and not having entered a nursing home during the period of observation Successful ageing dened as having a very good quality of extended life measured as achieving good scores in the major domains of quality of life: perceived well-being and autonomy; and activity; environment Successful ageing dened in terms of active life expectancy with criteria for successful ageing being good functional ability and high social participation Successful ageing dened as maintaining independence: being alive and living in the community with no cognitive impairment and no more than mild impairment on a functional scale Successful ageing dened as a high level of functioning with no difculties in activities of daily living and at most one difculty on physical performance measures Ageing successfully dened in terms of active life expectancy and measured as living to an advanced old age and having little or no disability prior to death Successful ageing dened as functioning in the community without disability, with excellent or good self-rated health and high cognitive ability Healthy ageing dened as surviving to late life free of major life-threatening illnesses and maintaining the ability to function physically and mentally Healthy agers (%) Happy-well: a) 62 /237 (26%) b) 95 /332 (29%)

Burke, 2001 [27]

Cardiovascular Health Study, four sites, USA Community-dwelling men and women aged 65+ at baseline Leiden 85+ Study, Netherlands Population-based men and women

Aged 68+ at follow-up

Healthy ageing: Men: 762 /1299 (59%) Women: 1459/2043 (71%) Successful ageing: 58 /599 (10%)

von Faber, 2001 [32]

Aged 85+ at survey

Ford, 2000 [35]

Survivors of previous survey, Cleveland, USA Non-institutionalised men and women aged 70+ at baseline

Aged 72+ at follow-up

Sustained independence: 98 /487 (20%)

Grundy, 1999 [21]

East London Health District Study, UK Men and women living at home

Aged 85+ at survey

Successful ageing: 21/620 (3.4%)

Avlund, 1999 [34]

Nordic Research on Ageing (NORA), Denmark Population-based men and women Canadian Study of Health and Ageing, Canada Population-based men and women aged 85+ at baseline WHO Health & Social Aspects of Ageing Project in Indonesia, Thailand and Sri Lanka Non-institutionalised men and women Established Populations for the Epidemiologic Study of the Elderly (EPESE), USA Community-based men and women aged 65+ at baseline Epidemiological survey of dementia, Canberra, Australia Population-based men and women Honolulu Heart Program Population-based men of Japanese ancestry aged 45 68 at baseline

Aged 75 at survey

Successful ageing: 23% of 220 men 22% of 257 women

Hogan, 1999 [19]

Aged 90+ at follow-up

Successful ageing: 73 /1045 (4.1%)

Lamb, 1999 [36]

Aged 60+ at survey

Successful ageing: Indonesia 79.8% of 1202 Thailand 74.4% of 1199 Sri Lanka 46.6% of 1200

Leveille, 1999 [37]

Men aged 80 Women aged 85 at time of death during follow-up Aged 70+ at survey

Successful ageing: 442 /1097 (40%)

Jorm, 1998 [31]

Successful ageing: Of 977, range was 44% of 70 year-olds to 6% in late 80s Healthy ageing: 610 /3154 (19%)

Reed, 1998 [15]

Aged 70+ at follow-up

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Table 1: (continued)
Author, year Baltes, 1997 [26] Study, site, population descriptors Berlin Ageing Study Population-based men and women Age at outcome assessment Aged 70 103 years at survey Outcome denition and domains measured Successful ageing dened as a high level of biological, psychological and social functioning and measured as being resource-rich above the median in Sensorimotor-Cognitive and PersonalitySocial domains Successful ageing dened as having minimal interruption of usual functioning; needing no assistance nor having difculty on a range of activity/mobility measures and little or no difculty on measures of physical performance Successful ageing dened as high levels of physical, mental and social functioning evaluated across four criteria: functional, affective, cognitive status and productive involvement Successful ageing dened as high level of functioning and measured as being in the upper tertile of both cognitive and physical functioning Successful ageing was dened as psychological, physical and social well-being and measured as a high score across three dimensions: perceived well-being, capacity for independent activity and existence of a private safety net Successful ageing was dened as maintaining independence in the community by living to an advanced age, continuing to function well at home and remaining mentally alert Healthy ageing dened as a high level of physical functioning and measured as scoring in the top 20% on assessment of the full spectrum of functioning Healthy agers (%) Successful ageing: 95 /485 (19.6%)

Strawbridge, 1996 [16]

Human Population Laboratory Alameda County Study, USA Population-based men and women aged 65+ at baseline

Aged 70+ at follow-up

Successful ageing: 125 /356 (35%)

Garfein, 1995 [20]

Americans Changing Lives (ACL) survey, USA Population-based men and women MacArthur Studies three EPESE sites, USA Population-based men and women Survivors of previous Fertility Study, USA Nationally representative sample of white American women

Aged 60+ at survey

Robust ageing: 67/1644 (4.5%)

Berkman, 1993 [30]

Aged 70 79 at survey

High functioning: 1313/4030 (32.6% of age eligible)

Day, 1993 [33]

Aged 77 87 at survey

Successful ageing: 19% of 489

Roos, 1991 [29]

Manitoba Longitudinal Study of Ageing, Canada Community-dwelling men and women aged 65 84 at baseline Human Population Laboratory Alameda County Study, USA Population-based men and women aged 46 70 at baseline

Aged 77 96 at follow-up

Successful ageing: 583 /2943 (20%)

Guralnik, 1989 [28]

Aged 65 89 at follow-up

Healthy ageing: 107/841 (12.7%)

was included in other studies with outcome denition in terms of maintaining/sustaining independent functioning [16,28,35], and remaining alive over the follow-up period [15,19,27,29]. The age at which the outcome was measured thus varied from the youngest-old to the oldest-old, with the consequent effect on the per cent of study populations meeting outcome criteria. In the majority of studies, age was signicantly associated with healthy ageing, with prevalence declining sharply with age from over 25% of 70 year-olds to 6% of 80 year-olds [15,29,31]. The evidence for sex differences in the proportion of healthy agers was inconclusive. Three studies [31,35 36] found that being male was a signicant predictor of healthy ageing, while the study of Burke et al. [27] found being female was signicantly related to continued health. Excluding those studies using same sex population samples [13,15,33], the remainder of the studies found that sex was not signicant in multivariate analysis models of predictors of healthy ageing.
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Other demographic characteristics besides age and sex may have inuenced outcome. In the study with a high proportion of healthy agers from 70 to 80% [36], the result could be explained not only by age at assessment but also by cultural factors. According to Lamb and Myers [36], the selected Asian populations may have survived many threats to health experiences at an earlier age, in a climate of social integration and esteem for older people which might buffer older persons from decline, and in productive work roles which may have contributed to greater physical tness and less risk for chronic disease. In the Honolulu Study [15], the ndings may have been related to certain cultural and environmental aspects of the cohort comprising men of Japanese ancestry. In the Harvard Study of Adult Development [13] it was likely that the group of Harvard sophomores would present a more favourable picture of healthy ageing in comparison with the core-city cohort, because the former were advantaged with respect to intelligence, educational and career attainment and nancial resources.
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Discussion
The arbitrary nature of the denition, populations sampled, follow-up periods, domains selected, constructs and threshold cut-off measures within the domains resulted in considerable variation between the studies in the proportion of the study population classied as healthy agers. In addition, many measures such as basic care ADL and depression scales are designed to identify the most impaired and do not permit distinction among persons who have no major impairments [20]. For some studies, cut-off scores on the measures selected were based on the distribution in the study population and adjusted to capture those functioning above the median [26], in the top tertile [30], quartile [13], or quintile [28]. Due to these measurement differences, the prevalence of healthy agers in the selected studies ranged from 3% [21] to 80% [36].

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Conclusion
The present review has shown the need to establish a standard for dening and quantifying the concept of healthy ageing to allow comparison of studies and facilitate further research into the predictors of positive health outcomes in older age. Despite the differences, there was consensus in the studies that the multidimensional, positive health outcome should measure the capacity to function well and adapt to environmental challenges in domains assessing physical, mental and social wellbeing. This review also showed that measures need to be age and culture specic to be able to discriminate, in a heterogeneous group, those functioning in the upper range of the health continuum.

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