Emerging lifestyles and proactive options for successful ageing

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Ageing International, Spring 2003, Vol. 28, No. 2, p. 155-180.

EMERGING LIFESTYLES ANDPROACTIVE OPTIONS FOR

SUCCESSFUL AGEING*EVA KAHANA, BOAZ KAHANA, AND KYLE KERCHER

Maintenance of functional health and high quality of late life are crucial concerns forgerontologists and health researchers, as rapidly growing numbers of very old adults facethe challenges and opportunities of increasing longevity and frailty in the twenty-firstcentury (Atchley, 1995; Institute of Medicine [IOM], 1991). The present formulationoutlines how older adults of tomorrow can enhance their own quality of life through abroad array of proactive adaptations. By recognizing and accepting older adults’ right to,and preference for, proactive involvement in shaping their own destiny, we can makeimportant strides toward facilitating elders’ successful ageing. Successful ageing, basedon our model, is an attainable goal within reach of even those aged traditionally relegatedto ranks of passive and stigmatized recipients of care.

Proactive Options for Successful Ageing among Robustand Frail Older Adults

Maintenance of functional health and high quality of late life are crucialconcerns for gerontologists and health researchers, as rapidly growing num-bers of very old adults face challenges of frailty in the twenty-first century(Atchley, 1995; Institute of Medicine [IOM], 1991). As older adults can ex-pect to attain greater longevity, both challenges of frail health and opportuni-ties for continued high levels of functioning must be considered among emer-gent lifestyles of the aged of the twenty-first century. The present formulationseeks to outline how older adults of tomorrow can enhance their own qualityof life through a broad array of proactive adaptations as they face chronichealth problems and frailty. The disability cascade is generally described asleading from chronic illness to physical impairments, to functional limitations,and ultimately to a loss of psychological well-being and social functioning,which are designated as poor quality of life indicators (Verbrugge, Reoma, &

156 Ageing International/Spring 2003

Gruber-Baldini, 1994). Researchers have generally been most interested inunderstanding the adverse consequences of this cascade, particularly in rela-tion to physical health and functional declines. However, our interests are in“proactive adaptations” that intervene at a later stage in the cascade, and thathave the potential for enhancing quality-of-life outcomes after physical de-clines have occurred.

There has been no shortage of efforts by gerontologists and social scien-tists to unravel components of successful ageing and even to provide adviceon ageing successfully (Featherman, Smith, & Peterson, 1990; Rowe & Kahn,1998; Baltes & Baltes, 1990). Among proponents of a productive ageing soci-ety, focus is typically on continued work-related contributions of older adultsas a means of maximizing human potential throughout the life course (Caro,Bass, & Chen, 1993). Maintenance of good physical health is seen by manyas the key to successful ageing, with good health habits improving one’schance of remaining healthy well into old age (Rowe & Kahn, 1998; Kahana,Lawrence, Kahana, Kercher, Wisniewski, Stoller, Tobin, & Stange, 2002).Critiques of health-focused approaches to successful ageing have noted theexclusionary nature of such models, as they place success within reach onlyfor older adults of means, social resources, and those enjoying good physicalhealth (Scheidt, Humpherys, Yorgason, 1999). To address these limitations,we have been in search of a model of successful ageing that can also includeolder persons who are not in good health and who are no longer engaged inwork activities.

The search for a model that addresses issues of successful ageing amongfrail as well as robust older adults began as part of a personal quest as we tookcare of the first author’s disabled, aged mother, who continued to remain cre-ative, spunky, and interested in others, even when facing serious illness andliving with disabilities. This model, based on preventive and correctiveproactivity (PCP), underscores the continuing role of “agency” in the lives ofolder adults (Kahana & Kahana, 1996). The model of successful ageing wepropose also has important empirical anchors (Kahana & Kahana, 2003). Wehave been conducting longitudinal research to understand adaptation to frailtyamong community-dwelling aged. Findings of our fourteen-wave longitudi-nal research served as an important foundation for our proactivity-based modelof health maintenance and successful ageing (Kahana & Kahana, 1996). Thismodel has been further refined as we added considerations of social and tem-poral contexts within which successful ageing occurs (Kahana & Kahana,2003).

Outline of the Proposed Successful Ageing Model

The goal of the present paper is to consider proactivity in late life and to“unpack” components of previously identified proactive adaptations and tobring attention to some new or “emergent” forms of proactivity, which are

Kahana, Kahana, and Kercher 157

likely to play a role in successful ageing for new cohorts of older adults en-countering the challenges of ageing during the twenty-first century. Our dis-cussion is predicated on the view that older adults continue to set goals andengage in proactive efforts to attain those goals as a means of constructingtheir own lives and maintaining their identities (Kahana & Kahana, 2003). Westart our discussion by briefly reviewing the model, which serves as the basisof new developments outlined in this paper.

Our comprehensive model of Successful Ageing (see Figure 1) specifieshow the stressors (component B) of chronic illness, long-term and recent lifeevents, and person-environment incongruence, in the absence of ameliorativebuffers, set off a chain of events leading to adverse quality of life outcomes(component F). This model reflects traditional hypotheses about the roles ofexternal resources (component E) and internal resources (component C) inameliorating adverse stress effects. Our model also emphasizes the bufferingroles of proactive behaviors (component D) in reducing (moderating) the ad-verse consequences of stressors on quality of life, and notes the influences ofboth the temporal and spatial context (component A). More specifically, wepropose that spatial influences (demographics and community) and temporalcontexts (history and biography) will have main effects on each of the stres-sors, buffers, and quality of life outcome components of our model.

Components and interrelationships of our model and their rationale havebeen reviewed in our prior publications (Kahana & Kahana, 1996, 2003). Inconsidering the model presented in Figure 1, we note that there are severalsimplifying assumptions made for ease of presentation. First, Figure 1 indi-cates (Path 1) that proactive adaptations (D) and external resources (E) “con-dition” (“moderate”) the effect of stress exposure (B) on quality of life out-comes (F)—i.e., that the adverse consequences of stress exposure onquality-of-life outcomes are reduced (“buffered”) when elderly persons haveexternal resources and engage in proactive adaptations. As part of testing thesepotential “buffering” (statistical interaction) effects, one would first test themain (direct) effects of D and E on F (i.e., test whether proactive adaptationsand external resources enhance quality-of-life outcomes). Based on conven-tional practice in representing interaction effects, and the need to reduce dia-gram “clutter,” we do not depict the direct paths from D and E to F.

Second, we have also simplified our conceptual model by focusing onunidirectional causal linkages. We recognize, however, that alternative direc-tions of causality are often plausible and may be tested in longitudinal studiesutilizing the proposed model. For example, in Figure 1 we depict stress expo-sure (B) as affecting proactive adaptations (D) (Path 2a). However, there areaspects of D, such as health promotion, that may affect B, such as the prob-ability of experiencing physical health declines (i.e., illness) (Path 2b). Like-wise, our final outcome variable, quality of life, may have a (reciprocal) causaleffect on many other components of our proposed model—illness, financialresources, marshalling support, self-esteem, and so on. Indeed, with the ex-


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ception of temporal and spatial context variables (component A), most of theother elements of our hypothesized model have potential reciprocal effectswith each other.

Guidelines for Empirical Tests of the Model

In presenting our model, we recognize the complex interrelationshipsamong stressors, quality-of-life outcomes, and the buffers that comprise inter-nal dispositions, external resources, and proactive adaptations. Nevertheless,we feel that a major strength of this formulation is our ability to put it toempirical test. Here, we briefly illustrate how such a test of our model may beaccomplished.

In conducting an initial, cross-sectional analysis, one must assume a unidi-rectional (non-reciprocal) causal order. As depicted in Figure 1, we propose aunidirectional causal sequence from A to F in which: (1) spatial context andtemporal context (A) affect all other components of our model (B, C, D, E,and F); (2) stress exposure (B) and internal resources (C) affect all remainingcomponents (D, E, and F); (3) proactive adaptations (D) affect the two re-maining components (E and F); and (4) external resources (E) affects qualityof life (F). Given this assumed causal order from A through F, a cross-sec-tional analysis would proceed via a series of multiple-regression analyses.First, one would regress, in turn, each of the three final quality-of-life out-come variables of component F—affective states, meaning in life, and main-tenance of valued activities and relationships—on all antecedent (predictor)variables—comprising components A, B, C, D, and E. This initial set of re-gression analyses would provide direct effects for all the predictor variableson quality-of-life outcomes. Moving backward one step in the assumed causalsequence, one would next regress each of the external resources (E) on allantecedent variables—thereby obtaining the direct effects of components A,B, C, and D on E. Subsequent analyses would proceed in similar fashion, eachtime moving back one step in the assumed causal sequence to select the next“outcome” variable to regress on all variables causally antecedent to the givenoutcome variable—i.e., variables of component D regressed on A, B, and C;and, finally, variables of either components B or C (for which we make noclaim of causal ordering) regressed on the set of predictor variables containedin component A.

In addition to providing tests of the main effects of predictor variables onother variables further down the causal chain (as described above), one canalso test for statistical interactions (i.e., moderating effects). More specifically,in order to assess the potential buffering (moderating) effects of proactiveadaptations (D) (Path 5) and external resources (E) (Path 1) on the stress ex-posure/quality-of-life causal association (i.e., the direct path between B andF), one would perform the same regression of quality-of-life outcome vari-ables on all antecedent variables (A, B, C, D, and E) as described previously,


but then add variables (i.e., “product terms”) that represent the potential inter-actions of D and E variables with B variables. If this set of product terms addssubstantial amounts of explained variance in quality-of-life outcomes beyondwhat the main effects of B, D, and E explain, then one would have evidencethat proactive adaptations and internal resources reduce (buffer) the adverseconsequences of stress exposure on quality of life. Alternatively, if one doesnot find evidence of buffering effects via statistical interactions—i.e., no mod-erating effects—then one can test to see if proactive adaptations and internalresources may buffer the adverse consequences of stress exposure on qualityof life via a mediational process; specifically, stress exposure activates proac-tive adaptations and internal resources that, in turn, bolster quality of life.Evidence for this mediational model would occur in the presence of signifi-cant direct effects of stress exposure (B) on proactive adaptations (D) andexternal resources (E), combined with significant direct effects of D and E onquality-of-life (E) outcomes—i.e., pathways that would all be tested as part ofthe regression analyses for “main effects” described earlier.

The cross-sectional regression analyses outlined above will provide accu-rate estimates of the various proposed causal pathways in Figure 1 only if theassumed causal sequences from A through F are, in fact, the correct causalordering of these variables. To move from a presumed causal order to empiri-cal tests of the causal order requires longitudinal analyses. In other words,longitudinal analyses allow one to consider the presence of potential recipro-cal effects. These more rigorous empirical tests may even suggest that someof the original, assumed unidirectional causal sequences are actually entirelyin the opposite direction. Such longitudinal analyses require more sophisti-cated techniques than standard multiple regression procedures, but their ap-plication to our proposed model is beyond the scope of the current article (butsee Collins and Sayer, 2001; Little, Schnabel, and Baumert, 2000).

Proactivity Model Buffers

In our orientation to buffers in our Proactivity Model (Figure 1), we viewelders as active agents who engage in both preventive and corrective pursuitsto maximize their quality of life. These proactive efforts are facilitated byposessing both external and internal resources.

Internal Resources

In our initial model (see Figure 1, component C), we considered disposi-tional characteristics, such as hopefulness, altruism, and self-esteem, as par-ticularly important internal resources, which could facilitate proactive adapta-tions and serve as buffers in ameliorating adverse impacts of stress (Kahana &Kahana, 1996). Each of the dispositional characteristics proposed can serveas an impetus for engaging in proactive adaptations (Path 3). Thus, hopeful-


ness or optimism is likely to lead to planning ahead and fostering health pro-moting behaviors among older adults (Seligman, 1975). Altruistic orienta-tions are likely to serve as motivational antecedents of helping others andvolunteering (Garfein & Herzog, 1995; Midlarsky & Kahana, 1994). Self-esteem in older adults has also been associated with competence in adaptationto stress in late life (Ranzijn, Keeves, Luszcz, & Feather, 1998).

External Resources

Social and financial resources were considered in our original model (seeFigure 1, component E) (Kahana & Kahana, 1996). Here we also add accessto health care and access to technology as important “emergent” external re-sources. Addition of these resources reflects recognition of structural influ-ences as well as individual initiative in accounting for availability of externalresources (Kahana & Kahana, 2003) (Paths 6a and 6b).

Financial resources. Long recognized as playing an important role in fa-cilitating adaptation to stress in late life, financial resources are an importantrequisite for utilizing formal health care services and for purchasing neededmedications (Crystal, 1996). Financial resources can also reinforce healthylifestyles by ensuring adequate nutrition and use of exercise facilities. Theycan also facilitate utilization of formal support services, including paid help-ers and environmental modifications, or moves to more appropriate housingto improve person-environment fit (Rioux, 1996).

Social resources. To the extent that older adults have access to friends andfamily and live in close proximity to those who can provide them with sup-port, they are more likely to receive aid (Cutrona, 1996; Antonucci & Akiyama,1995). In our model, we distinguish social resources from support received.We recognize that received support is based on both social resources, reflect-ing support availability, and on the older individual’s propensity to marshalsupport (Kahana & Kahana, 1996).

Access to technology. Access to technological resources is an increasinglyimportant external resource in today’s complex society and, thus far, has re-ceived very little research attention. Technological resources include a widearray of products, such as cellular phones, fax machines, microwaves, VCRs,DVDs, CD players, and video cameras. Personal computers provide access toe-mail and the Internet. Technological resources provide a means for mobiliz-ing many proactive adaptations. For example, technological resources can beused to modify the environment to decrease the impact of physical impair-ment (e.g., physically impaired older adults using a cordless telephone) (Brink,1997). Access to medical technology and assistive devices can also improvethe quality of life for older adult patients coping with chronic illness (Mann,Hurren, & Tomita, 1993).

Access to health care. Availability of a regular physician and physical prox-imity to health care providers allows access to health care (Forrest & Starfield,


1998; IOM, 1993; Starfield, 1998). Donabedian (1973) distinguished socio-organizational from geographic access to care. Patients with limited incomeand minority patients often lack regular health care providers and may rely onhospital emergency rooms for needed health care services (Kassirer, 1997).The profit-driven nature of managed care has been faulted for limiting accessto specialists, limiting high-cost treatments, and for reducing health care con-tinuity (Starfield, 1998). With extensive recruitment of older adults into HMOs,these elders may experience reduced health care access due to disruption incontinuity of their medical care (Flocke, Stange, & Zyzanski, 1997). Accessto health care should also be interpreted as access to high-quality, patient-responsive health care, wherein patients can readily access specialists andsophisticated diagnostic tests as their health needs might require (Kahana &Kahana, 2001).

A Taxonomy of Traditional and Emergent Types of Proactivity UsedPreventively and Correctively

Table 1 presents a taxonomy of proposed proactive adaptations. In ouroriginal formulation of proactive behaviors, we found it useful to distinguishpreventive vs. corrective functions of proactive behaviors (Kahana & Kahana,1996). We discussed three preventive adaptations (health promotion, helpingothers, and planning ahead) and three corrective adaptations (marshalling sup-port, role substitution/role engagement, and activity/environmentalmodificiation) that older adults are likely to engage in. The current formula-tion introduces three additional groups of proactive behaviors, which are in-creasingly utilized by new cohorts of older adults. For clarity of presentation,we will refer to the six proactive behaviors we described in our prior formula-tion as traditional adaptations and the three newly introduced adaptations asemergent adaptations (technology use, health care consumerism, and self-improvement). In making these distinctions, we acknowledge that there isfluidity and historical relativity in what is being labeled traditional or emer-gent at any one point in historical time. Our traditional vs. emergent adapta-tions are descriptive of the dawn of the twenty-first century.

Our original formulation divided proactive behaviors into preventive andcorrective adaptations. Preventive adaptations are undertaken to avert stres-sors and to build social resources (Figure 1, Paths 2b and 6a). Thus, for ex-ample, health-promoting behaviors, such as exercise, can help avoid or delaystressors of chronic illness. Helping others can build social resources for latertimes of need, and planning ahead can build financial resources. In contrast topreventive adaptations, which help build external resources, corrective adap-tations are typically activated by stressors (Figure 1, Path 2a) and can be fa-cilitated by existing internal and external resources (Figure 1, Paths 3 and 6b).Older adults will engage in corrective adaptations, such as role substitution, inresponse to social losses. In responding to illness situations, older adults typi-


cally marshall support and make environmental modifications in response tolack of person-environment fit. It should be noted that preventive adaptationscan occasionally serve as corrective functions, and conversely, corrective ad-aptations can also be used preventively. Thus, for example, physical exercise,which we generally consider to be a preventive adaptation, not only helps

Table 1

Traditional and Emergent Proactive Adaptations

TRADITIONAL ADAPTATIONS EMERGENT ADAPTATIONS

Preventive Adaptations Corrective Adaptations Preventive or CorrectiveAdaptations

1. Health Promotion 4. Marshalling Support 7. Technology Use(need disclosureand help seeking)

a. exercise a. from family

b. harmful substance b. from friendsavoidance c. from neighbors

c. safety awareness d. from paid helpers

d. preventive health e. from formal servicecare use providers

2. Helping Others 5. Role Substitution/ 8. Health Careproviding instrumental Role Engagement Consumerismand emotional support:

a. to family members a. work roles a. develop long-term

b. to friends b. organizational roles relationships with

c. to neighbors c. civic roles health care providers

d. to others (volunteering) d. family or friendship b. proactive informationroles use

c. effective communicationwith health care providers

d. advocate for self orsignificant other(s)

3. Planning Ahead 6. Environmental and 9. Self -improvementActivity Modification

a. financial a. safety enhancement a. educational efforts

b. environmental b. comfort enhancement b. enhancing appearance

c. lifestyle enhancement c. autonomy enhancement c. seeking spiritual or

d. health care personal growth

e. end of life

a. communicationenhancement

b. informationretrieval

c. convenienceenhancement

d. health monitoringor maintenance


forestall the onset of disease, but can also serve as a corrective adaptation,slowing further decline once chronic illness has been diagnosed (Penninx,Rejeski, Pandya, Miller, DiBari, Applegate, & Pahor, 2002). Conversely, cor-rective adaptations, such as environmental modifications, will not only helpdisabled older adults enhance person-environment fit, but can serve to pre-vent falls in the future (Tideiksaar, 1987). The preventive and corrective des-ignation thus refers to the predominant use of a given adaptation rather thanan absolute function of the specific proactive behavior.

In addition to previously described types of proactive adaptations, the cur-rent formulation allows us to consider emergent adaptations used by olderadults of the twenty-first century in responding to social change, such as tech-nology use, health care consumerism, and self-improvement. Because emer-gent adaptations encompass broad domains, it is more difficult to classifythem as primarily preventive or primarily corrective.

Health care consumerism has a strong corrective component as it is oftenactivated following an illness that requires more extensive health care utiliza-tion. Nevertheless, there is a preventive component involved in health careconsumerism in patients developing a long-term relationship with health careproviders, thereby anticipating health care needed, should they become ill.Self-improvements, such as educational efforts and seeking spiritual and per-sonal growth, appear generally preventive in orientation. Technology use spansdiverse preventive and corrective components. Maintaining communicationwith family and friends serves preventive functions by building social re-sources, whereas information retrieval is often utilized correctively to helpsolve medical or personal problems. Acknowledging the fluidity and evolv-ing nature of emergent proactive adaptations, we thus consider them as beingpreventive or corrective.

Unpacking Proactive Adaptations

A key contribution of the current formulation is the “unpacking” and speci-fication of components of the traditional and emergent proactive adaptationsproposed (Figure 1, component D). These adaptations have previously onlybeen discussed in general terms without noting the multi-dimensionality ofeach model component. As we outline diverse proactive adaptations, we alsopresent data on the prevalence of these adaptations among two samples ofolder adult respondents in our ongoing longitudinal study, which serves as abasis for our successful ageing model (Kahana et al., 2002).

The first sample is comprised of 427 elders who migrated to retirementcommunities in Clearwater, Florida. The initial wave of data was collected in1989. All respondents in this sample are white, reflecting the racial composi-tion of the retirement communities sampled. Respondents ranged in age from 75to 95 years of age, with a mean age of 83.9 years (SD = 4.4). Forty-four percent ofrespondents were married, and two-thirds were female. The second sample con-


sisted of 343 older adults who were living in Cleveland, Ohio, a large urbanarea, ageing in place. Seventy percent of these respondents are white, and 30percent are black. While this sample also ranged in age from 75 to 95, themean age was slightly younger compared to the Clearwater sample (80.5 years,SD = 4.4). Thirty-six percent of the Cleveland sample was married, and 72 per-cent were female. In the following discussion, we will designate findings relevantto each proactive adaptation discussed with headings of “study results.”

We will now turn to a detailed discussion of components of each of thenine proposed proactive adaptations (see Table 1). In introducing this discus-sion, it is useful to note that, in some cases, adaptations are best described interms of the type of activity they reflect (e.g., health promotion or activity modifi-cation). In other cases, the salient distinction relates to goals of the activity (e.g.,enhancing safety or comfort). A third designation relates to the targets of the activ-ity (e.g., marshalling support from family, friends, or from formal agencies).

Traditional Adaptations—Preventive

Health promotion. A number of health habits, including regular exercise,optimal weight maintenance, and avoidance of tobacco, have been shown toreduce the risk of developing chronic illness (Ory & Cox, 1994; Stuck et al.,1999). Additionally, safety awareness (e.g. wearing seat belts, using sunscreen)and preventive health care use have also been cited as comprising health-promoting, proactive behaviors (Gleich, 1995; Flocke, Stange, & Zyzanski,1998). Among diverse proactive efforts to promote health in late life, physicalactivity most consistently yields benefits for physical health and quality oflife. It has been suggested that regular exercise improves older adults’ flexibil-ity, balance, endurance, and muscle strength, which may help delay disability(Caldwell, 1996).

Study results: Based on a nine-year longitudinal follow-up of 1,000 old-old adults, we found that engaging in regular exercise was predictive of fewerinstrumental activities of daily living (IADL) limitations, greater longevity,positive affect, and meaning in life eight years later. These findings held upeven as we controlled for baseline outcomes, sociodemographic variables,and baseline health conditions (Kahana, King, Brown, DeCrane, Mackey,Monaghan, Raff, Wu, Kercher, & Stange, 1994).

Among older adults in our research who had relocated to Florida retire-ment communities, we found pursuit of healthy lifestyles to be more prevalentthan in the general population of elderly (Kahana & Kahana, 1996). Abouthalf of our respondents reported exercising regularly (defined as at least threetimes a week for at least twenty minutes each time). Respondents generallyengaged in low-impact exercises, particularly walking. One-quarter of bothsamples reported stretching at least one hour a week.

It is likely that exercise and healthy habits will be increasingly pursued bythe more highly educated, health and fitness-conscious cohorts of tomorrow.


For example, only 3 percent of Florida-based respondents currently smoke.Seventy-three percent of Cleveland respondents and 68 percent of Floridarespondents reported not drinking at all. The remaining respondents reportedmoderate drinking (up to two drinks per day on average), with very few par-ticipants reporting patterns of heavy drinking.

Helping others. Helping others comprises an important source of engage-ment and sense of “mattering” (Pearlin, 2001; Rosenberg & McCullough,1981) for older adults. Altruistic acts have been highly valued among thecurrent cohort of aged. Older adults continue to provide help to others, in-cluding family members, friends, and neighbors (Midlarsky & Kahana, 1994).

Study results: Helping others is not typically engaged in as a means ofbringing about reciprocal assistance from others. Nevertheless, our researchindicates that those older adults who provide help to friends and neighborsare, in fact, more likely to receive assistance from friends in later years whenthey may be experiencing stressors of ill health (Kahana & Borawski, 1997).Older adults in both the Florida and Cleveland-based samples typically pro-vide help to others several times a month. It is noteworthy that assistanceprovided to family members by the older adults did not serve as a significantpredictor of family members’ subsequent provision of aid to elders. It appearsthat norms of obligation, which exist in families, serve as the most importantdeterminants of aid given to elders.

Over 40 percent of respondents provided help to neighbors, typically interms of transportation or visiting. The Florida migrants were much more likelyto provide instrumental assistance to their friends and neighbors, whereas theirageing-in-place Cleveland-based counterparts were more likely to assist theirfamily members. Twenty percent of our Cleveland-based respondents assistedfriends and neighbors who were sick, while 40 percent of the Florida-basedrespondents helped friends and neighbors when sick. Less than 10 percent ofboth samples provided help with personal care (i.e., bathing or dressing).Twenty percent of Florida-based respondents and 30 percent of Clevelandrespondents report helping family members with household tasks. The Cleve-land-based elders were much more likely than the Florida elders to care forfamily members when sick (30 percent vs. 14 percent respectively) and toprovide family with financial assistance (40 percent vs. 25 percent respec-tively). Older adults also derive important meaning from assisting others whoare not personally known to them. Even in old age, 47 percent of our sampleperformed volunteer work.

Planning ahead. Planning ahead is considered to be an important aspectof proactivity because anticipation of future needs may help diminish prob-lems that will occur later (Moen & Erickson, 2001). Coping requires mobiliz-ing one’s resources before the occurrence of a stressful life event and thatsuch resource mobilization may even help avert the stressor (Aspinwall &Taylor, 1997). As shown in Table 1, there are diverse components of planningfor the future that are particularly relevant to elders. These range from finan-


cial to environmental, and lifestyle enhancement plans that allow for main-taining high quality of life even as older adults encounter normative stressorsof ageing (Lo & Brown, 1999). Additionally, older persons may also plan forcare and assistance when faced with frailty and ultimately for end-of-life care.

Lifelong planning is likely to help enhance financial and social resourcesof seniors (Atchley, 1995). Planning for the future by learning about optionsand resources in one’s environment can help older persons familiarize them-selves with services available to them should the need arise (Sörensen &Pinquart, 2000). Planning requires recognition that changes in both older adults’abilities and their circumstances may occur in the future. Migration to “planned”communities for most people involves planning ahead as part of an “amenitymove” (Wiseman & Roseman, 1979). In turn, such aged migrants may planahead for return-migration to the North, or to a more sheltered setting as theirability to live independently declines (Litwak & Longino, 1987).

Financial planning relates to maximizing resources available for future needs(Lo & Brown, 1999). Environmental planning is helpful to provide older adultswith housing and neighborhoods, which helps maximize congruence betweenpersonal needs and demands or amenities within one’s environment (Kahana,Lovegreen, Kahana, & Kahana, in press). Lifestyle enhancement plans mayalso include planning for new educational involvements or organizing annualfamily reunions. With increased anticipation of disability-free life expectancy,not all late-life planning revolves around anticipation of death or frailty. Yetplanning ahead ultimately also includes care and end-of-life plans, which canpotentially help forestall giving up autonomy in health care decision-making(Kapp, 1991).

With more educated, older cohorts and increased socialization into retire-ment planning, we can anticipate an increasingly “planful” cohort of eldersduring the new century (Freedman, 1999).

Study results: In our samples, many respondents have thought about whatthey would do if they should have a physical disability (76 percent of Floridaand 33 percent of Cleveland respondents), although most had not actuallymade concrete plans. The most commonly reported plans involve moves toreceive more care, including moves into: a nursing home (reported by 20percent of respondents in both the Cleveland- and Florida-based samples whosaid they had plans); an assisted living facility (14 percent of Florida andCleveland respondents); and to a family member’s home (12 percent of Cleve-land and 7 percent of Florida respondents). One-quarter of the Florida-basedrespondents reported that they have thought about moving from their retire-ment communities, largely because of greater need for services.

Traditional Adaptations—Corrective

Marshalling support. Marshalling support refers to actions taken by olderpeople to mobilize available social resources (Greene, Jackson, & Neighbors,


1993). Older adults generally first marshal support from informal resources,including family and kin (Cicirelli, 1991), and only when those efforts proveinsufficient do they turn to hiring paid helpers or enlisting the help of formalagencies (Cantor, 1979).

It is important to note that social resources are an important external re-source needed for successful marshalling of support. Nevertheless, older adultsmust engage in need disclosure and help-seeking in order to insure that theyactually receive support relevant to their needs (Pennebaker, 1995).

Study results: The extent to which people discuss their problems with familyand friends, and ask them for assistance, are measures of the extent to whichpeople marshal support. Thirty-seven percent of Florida-based respondentsand 57 percent of Cleveland-based respondents report discussing their prob-lems with friends or family (at least “somewhat”), and 32 percent and 40percent respectively, ask their family or friends for help with their problems(at least “somewhat”).

Role substitution/role engagement. Social identities, which are enacted inrole relationships, give purpose and meaning to lives of individuals (Thoits,1983). Efforts to choose suitable activities in accord with personal values andpreferences, and engage in new social activities and roles can go a long waytoward counteracting adverse effects of social losses (Herzog & House, 1991).Involvement in organizations or civic activities can represent very importantalternative sources of meaning for older adults who can no longer be involvedin work activities (Cutler & Hendricks, 2001). For older adults of the future,greater access to technology, work, volunteer, and distance-learning optionscan provide useful avenues of role engagement and role substitution as theysearch for meaningful involvement (Besl & Kale, 1996). Role substitution inour model designates proactive efforts to replace lost roles with alternative,meaningful social engagements.

Study results: In considering prevalence of role substitution among ourrespondents, data are currently not available to ascertain whether certain ac-tivities were undertaken to replace others. Nevertheless, available data on roleengagement suggests the likelihood that lost roles are being replaced by otherroles.

Many older adults report having hobbies (45 percent in Cleveland, 73 per-cent in Florida), participating in classes or clubs (35 percent and 31 percentrespectively), engaging in educational or self-improvement activities (20 per-cent and 12 percent), and participating in church activities (54 percent and 60percent). While most respondents in both samples do not work in the paidlabor market, as noted earlier, approximately one-third of the Cleveland- andFlorida-based older adults do volunteer activities. In terms of social interac-tions, 61 percent of the urban dwellers and 95 percent of the retirement com-munity dwellers report regularly visiting with people, and 42 percent of theurban dwellers and 43 percent of the retirement community dwellers regularlyprovide care for others.


Environmental and activity modifications. Environmental modification re-fers to adaptations designed to reduce task demand or burden on the impairedolder person by diminishing barriers and/or introducing prosthetic aids in thehome environment (e.g., removing throw rugs or installing grab bars in thebathroom) (Lawton, 1980). Goals of environmental modifications include in-creasing comfort, enabling continued activity, and enhancing safety (Kahanaet al., 1994). Older adults tend to spontaneously initiate environmental andactivity modifications to increase autonomy and comfort, whereas modifica-tions recommended and implemented by professionals tend to be geared to-ward enhancing safety (Kahana et al., 1994). The Americans With DisabilitiesAct has raised expectations of disabled older adults for continued functioningand social engagement with the aide of creative environmental modification(Owings, 2002; see also www.adaptiveenvironments.org).

In addition to modifying environments, older adults can also modify theway they do activities, to help them maintain active engagement even whenthey experience limitations. Thus, for example, doing activities more slowlyor selectively have been found useful (Baltes & Baltes, 1990; Kahana et al.,1994). Examples of such activity modifications include substituting walkingfor more demanding exercises such as jogging, or preparing meals in a seatedposition to decrease energy expenditure (Canadian Mortgage & Housing Cor-poration, 1992). Use of reminder lists can assist older persons with cognitivedeficits (Guerette, Nakai, Verran, & Sommerville, 1992). Use of assistive de-vices is another common way of enabling frail older adults to pursue valuedactivities. Older adults find it more acceptable to use products and devicesdesignated for ease of functioning for the general population than those tar-geted specifically for the aged (Pirkl, 1995). Big button phones and GoodGrip kitchen utensils reflect such products, which have found wide accep-tance among consumers of all ages (Lederman, 1994).

Study results: Data from our study reveal that 41 percent of the urbandwellers and 98 percent of the retirement community dwellers indicate usingdevices to help them manage in their homes. The reason for this large differ-ence is that the management in the retirement communities installed certainsafety devices in all the dwelling units, including rails in the bathroom (men-tioned by 95 percent of retirement community dwellers). Other common de-vices the retirement community dwellers use include a shower seat (40 per-cent), hand-held shower (37 percent), cane (34 percent), walker (20 percent),tall toilet seat (15 percent), and an amplifier for the phone (11 percent). Themost common devices in the homes of urban dwellers include rails, showerchair (21 percent), cane (15 percent), “potty chair” (10 percent), and walker(9 percent).

Respondents were also asked whether there were any devices or modifica-tions they needed but did not have. Twelve percent of Florida respondentsand 13 percent of Cleveland respondents said they had a need for a device.Among Florida respondents, the most commonly reported needed devices were


tall toilet seats (reported by 25 percent of those needing devices), grab bars(e.g., in and around the bathtub; 18 percent), and shower seats (10 percent).Cleveland respondents reported needing hearing aids (17 percent), wheel-chairs (12 percent), and “reachers” (10 percent) most often.

Emergent Proactive Adaptations—Preventive or Corrective

Different birth cohorts encounter very different socialization experiencesand life experiences. Socialization patterns of older birth cohorts emphasizedself-reliance, whereas there is greater acceptance of marshalling support attimes of need for younger birth cohorts (Rosow, 1974). The historic periodduring which old-old persons of today approached retirement occurred priorto several important changes in American society: the advent of preventiveorientations to health care, including a greater emphasis on health promotinglifestyles (Ory & DeFriese, 1998); the advent of managed care (Starfield, 1998);and the advent of health and information technology and computers

Gerontologists have expressed concern that the aged of tomorrow will ex-perience a growing schism between limited opportunity structures for con-tinuing engagement and their sustained capabilities and desires to find mean-ingful roles in society (Cutler & Hendricks, 2001; Freedman, 1999).Accordingly, proactive adaptations become increasingly necessary to retain ahigh quality of life, especially in terms of finding meaning in life and main-taining valued activities and relationships.

Of particular interest in considering emergent proactive adaptations of newcohorts of aged are strategies that were inaccessible to members of prior co-horts. In this paper, we focus on these new proactive adaptations. We thusconsider the emergent proactive adaptations of proactive health care consum-erism, technology use, and self-improvement (see Table 1). As noted in ourearlier discussion, emergent proactive adaptations encompass componentswhich are readily used preventively and others which serve primarily correc-tive functions.

Technology use. Proactive uses of modern technology can be importantsources of empowerment for older adults (Thursz, Nusberg, & Prather, 1995).Older adults are breaking stereotypes regarding their resistance to technologyuse (McMellon, Schiffman, & Sherman, 1997). Advanced technologies (e.g.,the Internet, health technology) have the potential to open avenues to infor-mation, communication, and services to older adults, and enhance their abil-ity to care for themselves and live independently.

As indicated in Table 1, components of technology use relevant to theaged include communication enhancement, information retrieval, convenienceenhancement, entertainment, and health monitoring. These components oftechnology use may be differentially applied by either preventive or correc-tive adaptations. Examples of communication enhancement include use of e-mail and voice messaging, which can open up avenues of communication


with family members (especially grandchildren), and with friends living at adistance. Enhanced communication with family and friends can play usefulroles in developing availability of support for times of need. Use of technol-ogy can also facilitate obtaining support correctively for dealing with caregivingburden and in dealing with other stressors (Lawhon & Ennis, 1995). A secondimportant use of technology, particularly of computers and the Internet, in-volves ready information retrieval which can enhance functioning in areasranging from making travel arrangements to obtaining shopping informationand providing price comparisons, to obtaining information relevant to healthmaintenance and medical care (White, McConnell, Clipp, Bynum, Teague,Navas, Craven, & Halbrecht, 1999).

The use of technology for convenience enhancement involves reliance onhousehold appliances, which can ease the burden of carrying out activities ofdaily living, particularly by the frail elderly. It can also directly enhance qual-ity of life by bringing entertainment into the home. Appliances enhancingconvenience, which are now commonly used by elders, include cell phonesand microwave ovens. New technology is also widely used to enhance enter-tainment options for older adults. Ranging from the ubiquitous television toVCRs, DVDs, and disc players, they provide a range of entertainment op-tions, which can add to meaningful and enjoyable lifestyles for many olderadults (Lederman, 1994).

Gerontechnology has been used correctively to monitor health and to re-duce the effects of age-related impairments through technological devices(Pinto, De Medici, Van Sant, Bianchi, Zlotnicki, & Napoli, 2000). The proac-tive use of gerontechnology can facilitate maintenance of independent livingeven among older persons suffering from serious chronic ailments.

Educational background has been shown to be the single most importantfactor facilitating the embracing of proactive technology use by older adults(White et al., 1999). Technology use is growing exponentially among theaged and it is an area where dramatic shifts are likely to occur as baby boomerswho are already savvy users of technology enter the ranks of the old.

Study results: In our own research, technology use has only recently be-come a focus. In the mid-1990s, Florida respondents were asked the extent towhich they used computers. At that time, very few respondents (4 percent)reported computer use. More recently we have reintroduced these questions,as technology use rapidly increases among all age groups. In 2000, 16 per-cent of the Cleveland sample reported having ready access to the Internet and13 percent reported using the Internet. Among these older adults reportingcomputer use, the majority only recently acquired access to computers.

Health care consumerism. Development of consumerism has been an im-portant cultural phenomenon of the post-World War II era (Gilleard & Higgs,1998). With the advent of managed care in the United States and the chal-lenges it poses to the doctor-patient relationship and to continuity of healthcare (Kahana, Stange, Meehan, & Raff, 1997), the need for proactivity in


obtaining health care has been further underscored. Proactive patients canobtain information about health care providers, health care options, and healthconditions (Hibbard & Jewett, 1996; Kahana & Kahana, 2001). Older adultsmay also seek to enhance the quality of their health care through advocacy forthemselves or their significant others (Rodwin, 1997).

Maintaining long-term personal relationships with primary care physiciansand other health care providers can ensure responsive care in the future whenhealth problems arise (Kahana & Kahana, 2001). Familiarity with the patientis likely to enhance both physician’s involvement and knowledge of patient’sbackground, values, and preferences.

Corrective adaptations of health care consumerism are needed after an olderperson has been diagnosed with a disease. They include gathering and usinginformation about health care options, communicating effectively with healthcare providers, and personally connecting with members of the health careteam to overcome unresponsive care. These adaptations involve taking initia-tive in information gathering about diagnosis, prognosis, and treatment op-tions.

To the extent that patients actively solicit information from physicians, fromother health care providers, or from family members involved in their care,they are likely to gain better control of their health care (Kahana & Kahana,2003). Active consumerism is likely to improve quality of life outcomes as itresults in collaborative care and an active alliance between patients and pro-viders (Aviv, Sepucha, Belkora, & Esserman, 2001). In this sense, our notionof health care consumerism is at variance with conflict-based models of con-sumerism (Haug & Lavin, 1983). Growing assertiveness of aged health careconsumers in expressing their needs is also likely to lead to changes in healthcare policy, resulting in greater responsiveness to consumers’ perspectives(Kizer, 2001).

Self-improvement. With increasing prospects of longer, disability-free life,and fewer demands to take responsibility for others, older cohorts of tomor-row can increasingly turn their attention to self-enhancement. They can seekto maximize their human potential throughout the lifecourse (Caro, Bass, &Chen, 1993). Older adults have become avid consumers of self-help and self-improvement books with focus on education and learning new skills, enhance-ment of one’s appearance, and spiritual fulfillment. Diverse self-improvementsall have the goal of developing, renewing, and improving personal abilitiesand qualities.

Education. Education may be referred to as the systematic imparting ofknowledge or skill. The prevalent educational model wherein all formal edu-cation is founded on youth (typically persons under age twenty-five) does notfit realities of our ageing society. In old age, engaging in education may pro-mote better cognitive functioning, a greater sense of control and self-efficacy,and even improved health (Franks, Herzog, Holmberg, & Markus, 1999).Educational proactivity can thus serve numerous preventive functions.


Older students participating in college classes (Kay, Jensen-Osinski, Beidler,& Aronson, 1983) have been found to both benefit from and make contribu-tions to the intergenerational experience. The rapid growth of the Elderhostelmovement, which provides short-term courses along with living accommoda-tions to older adults at universities, also attests to the growing interest of olderadults in participating in educational enterprises (Gelfand, 1993). Elderhostelalso broadens vistas of older adults through travel opportunities, includingchallenging expeditions to remote regions, which counter stereotypes of theaged traveler.

Improving appearance. New cohorts of older adults are seeking to main-tain an attractive physical appearance well into old-old age (Furnman, 1997).In addition to purchasing apparel with a fashion-conscious eye and consum-ing a large volume of beauty products (ranging from anti-wrinkle cream tohair color for men), older adults also opt for appearance-enhancing medicalinterventions. Thus, use of plastic surgery has increased dramatically in re-cent years among both men and women (Macready, 1997). Attesting to thisnew group of appearance conscious older adult, several new magazines, suchas Aging in Style, have been marketed to elders, particularly in states with asubstantial older population, such as Florida and Arizona.

Seeking personal and spiritual growth. There has been a major growth ofinterest in the gerontological literature in spirituality in late life (Fetzer Insti-tute, 1999; Koenig, 2001). Older adults seek spiritual growth even beyondinvolvement in organized religion, perhaps as a form of “gerotranscendance”(Tornstam, 1996). Older persons are thus viewed as increasingly focusingtheir interest in leaving a legacy or contributing to values of the coming gen-erations. Spiritual pursuits may range from meditation and reading poetry orbooks of spiritual value, to introducing spiritual content and interactions withothers. Older adults are also actively involved in seeking personal growth byjoining the ranks of avid readers of self-help books, which impart informationon better control of one’s emotions, or enhancement of personal relationshipsboth within and outside of the family. Working on genealogies and establish-ing contact with long ago friends exemplify such personal growth efforts.

Conclusions

Understanding changing options for proactive adaptations in late life helpsprovide a key to processes which facilitate maintenance of identity and goodquality of life in old age (Aspinwall & Taylor, 1997). We can thus make stridestoward understanding building blocks of successful ageing in the face of cu-mulative life stressors and normative life events, which pose challenges toolder adults.

Our first exposition of our model of successful ageing has provided a broadframework for considering the complex interrelationships between stressors,resources, human agency, and quality-of-life outcomes (Kahana & Kahana,


1996). Our second formulation contextualized elements of the successful age-ing model in terms of time and place, thereby helping us understand structuralconstraints as well as facilitators which may impact on successful ageing(Kahana & Kahana, 2003). The present paper takes the next step in projectingthe PCP model of successful ageing into the future by considering opportuni-ties and lifestyles available to, and pursued by, the aged of tomorrow.

In this paper, we offer a more comprehensive review of components ofproactive adaptation than previously provided, unpacking elements of bothtraditional preventive and corrective adaptations, as well as introducing emer-gent adaptations. We endeavor to take note of and discuss emergent proactiveadaptations, which are based on the changing social milieus older adults areliving in. The changing demographic profile of tomorrow’s aged, particularlyin terms of greater cultural, ethnic, and racial diversity, is also likely to lead tonew normative patterns in proactivity. Finally, the increasing options of eco-logical, family, and community contexts, within which the elderly of tomor-row will live, also open up options for increasing proactivity. We focus onsocialization experiences of new cohorts of aged, as well as period effectswhich shape their life experiences or lead to changing preventive and correc-tive adaptations engaged in by this group. Focus on human agency in ourmodel of successful ageing allows us to understand how older persons playan active role in shaping their own futures and lives by goal directed behav-iors (Settersten, 2001). Our formulation points to a direction for society tofurther recognize and to legitimize a broad spectrum of active roles for olderadults (Prager, 1995).

Policy makers and practitioners working with the aged need to recognizethe growing prevalence and broad range of proactive adaptations engaged inby older adults. Professional contributions to enhancing high quality of latelife for new cohorts of old-old adults could be most effective by developingand supporting options for active involvement and participation by older adultsin decision-making, rather than by traditional dependency-based approacheswherein “we do for” our elders.

For example, older adults in the United States today are often forced tochoose between breaking the law by purchasing more affordable medicationsfrom Canada versus not adhering to medication regimens due to the high costof prescriptions. Public policy facilitating health care consumerism can saveolder adults from such unacceptable choices. Growing assertiveness of eld-erly health care consumers in expressing their needs is also likely to lead tochanges in health care policy by demanding greater responsiveness to con-sumers’ perspectives (Kizer, 2001).

Policies and practices that facilitate access to technology and informationcan also enable older adults to gather information needed for meaningful plan-ning in areas ranging from housing options to end of life decisions. By recog-nizing and accepting older adults’ right to, and preference for, proactive in-volvement in shaping their own destiny, we can make important strides toward


facilitating elders’ successful ageing. Involvement of family and service agen-cies in supporting proactivity is particularly important for creating opportuni-ties for successful ageing to financially disadvantaged, frail, and impairedolder adults.

Ultimately, however, the major message of our paper relates to opening upvistas for proactivity and self-directed initiative for both well elderly and thosefacing challenges of social losses or frailty. Successful ageing, based on ourmodel, is an attainable goal within reach of even those aged traditionally rel-egated to ranks of passive and stigmatized recipients of care.

Biographical Notes

Corresponding author: Eva Kahana, Ph.D., Department of Sociology, CWRU Mather Memorial, Rm.226, 10900 Euclid Avenue, Cleveland, OH 44106-7124. E-mail: [email protected]

Acknowledgments: Research supported by a grant from NIA AG10738.

Eva Kahana, Ph.D., is the Robson Professor of Humanities, Chair of the Sociology Department, andDirector of the Elderly Care Research Center at Case Western Reserve University. The awards shehas received include the Gerontological Society of America (GSA) Distinguished MentorshipAward; Mary E. Switzer Distinguished Fellowship; Ohio Distinguished Gerontological Re-searcher; Distinguished Scholar Award, Section on Aging & the Life Course of the AmericanSociological Association (ASA); and Polisher Award of the GSA for her outstanding contri-bution to applied gerontology. She has published extensively in the area of stress, coping, andhealth of the aged.

Boaz Kahana, Ph.D. is a Professor of Psychology at Cleveland State University. Dr. Kahana has beenhonored throughout his career, including Fellow of the American Psychological Society, a HellerAward for Contributions to Gerontology, the State of Ohio Distinguished Gerontological Re-searcher Award, and a Publishers Prize for Research Excellence. His extensive list of publicationscovers the fields of psychology, coping, trauma, stress, and health of the aged.

Kyle Kercher, Ph.D., is an Associate Professor of Sociology at Case Western Reserve University. Dr.Kercher acts as statistical and research methods consultant to the School of Medicine, FrancesPayne Bolton School of Nursing, Mandel School of Applied Social Sciences, Department ofCommunication, and University Center on Aging and Health at Case Western Reserve University.Dr. Kercher has served as the co-director of the Education, Epidemiology, and Health ServicesResearch Administration for the Northeast, and serves as Director of the Invitational ResearchSeminar Series for Case Western Reserve University.

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* Invited Paper. Revised manuscript accepted for publication in June, 2002. ActionEditor: P.S. Fry.

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