Blueprint for Healthy Aging, Theoretical Models and Concepts

PLEASE DO NOT SUBMIT A BID IF YOU DO NOT HAVE EXPERIENCE WITH GRADUATE-LEVEL WRITING. MUST FOLLOW ALL INSTRUCTIONS MUST BE FOLLOWED, AND NO PLAGIARISM. USE ONLY SCHORLARY SOURCES AND ANSWER ALL QUESTIONS TO ASSIGNMENT
fastgood
ATTACHED FILE(S)
Week 3 – Assignment
Blueprint for Healthy Aging, Theoretical Models and Concepts
[WLOs: 2, 4] [CLOs: 2, 3, 4, 6, 8]
Your written assignment this week is to develop a draft of the second section of your Blueprint for Healthy Aging, Theoretical Models and Concepts. Specifically, you will analyze and apply relevant theoretical models and concepts covered from the biological, psychological, social, and cultural perspectives to provide context and understanding regarding the cause of the nature of and the potential solutions to the problem.
Based on your assigned readings covering each perspective, and additional research, you will write a two to three page paper integrating the at least three different perspectives as they relate to the specific problem you plan to address in your Blueprint. Your paper should include integration and application of specific concepts from each theoretical perspective to address the specific problem/issue and the framing of healthy aging and solutions to address the issue.
Required Resources
Text
Bengtson, V. L., Gans, D., Putney, N. M., & Silverstein, M. (Eds.). (2016).
Handbook of theories of aging
(3rd ed.). Springer.
· Chapter 7: Evolutionary Theory and Aging
· Chapter 11: Theories of Emotional Well-Being and Aging
· Chapter 12: Emotion-Cognition Links in Aging
· Chapter 13: Theories of Social Support in Health and Aging
· Chapter 14: Age Stereotypes’ Influence on Health: Stereotype Embodiment Theory
· Chapter 16: Theories of work and Retirement: Culture, Trust, and Social Contract
· Chapter 17: Families and Aging: Toward an Interdisciplinary Family-Level Approach
· Chapter 18: Theories of Social Connectedness and Aging
· Chapter 19: Long, Broad, and Deep: Theoretical Approaches in Aging and Inequality
Articles
Morack, J., Ram, N., Fauth, E. B., & Gerstorf, D. (2013). Multidomain trajectories of psychological functioning in old age: A longitudinal perspective on (uneven) successful aging.Developmental Psychology, 49(12), 2309-2324.
Multidomain Trajectories of Psychological Functioning in Old Age:
A Longitudinal Perspective on (Uneven) Successful Aging
Jennifer Morack
Pennsylvania State University
Nilam Ram
Pennsylvania State University and Max Planck Institute for
Human Development, Berlin, Germany
Elizabeth B. Fauth
Utah State University
Denis Gerstorf
Pennsylvania State University and Humboldt University
Life-span developmentalists have long been interested in the nature of and the contributing factors to
successful aging. Using variable-oriented approaches, research has revealed critical insights into the
intricacies of human development and successful aging. In the present study, we opted instead for a more
subgroup-oriented approach and examined multiple-indicator information of late-life change at the
person level. We applied latent profile analysis to 8-year longitudinal data pooled together across 4
Swedish studies of the oldest old (N � 1,008; Mage � 81 years at Time 1; 61% women). Results revealed
4 psychosocial aging profiles with uneven patterns of successful (and less successful) aging characterized
by distinct trajectories of change across indicators of depressive symptoms, social, and memory
functions: a preserved system integrity group of participants who maintained functioning across very old
age; an aging in isolation group with a persistent lack of social support, and 2 groups of people with
average well-being and social functions but distinctive memory profiles. A compromised memory group
was characterized by poor memory throughout late life, whereas participants in a memory failing group
exhibited dramatic memory declines late in life. The subgroups were also differentiated by sociodemo-
graphic characteristics, functional limitations, and mortality hazards, which may have served as ante-
cedents, correlates, or consequents of profile trajectories. We discuss the promises and challenges of
using subgroup-oriented approaches in the study of successful aging.
Keywords: successful aging, patterns of aging, old age, mortality, latent profile analysis
Life-span developmentalists are interested in identifying the key
components that allow people to lead happy and successful lives
(Baltes & Baltes, 1990; Lawton, 1983; Ryff & Singer, 1998). A
prominent model advanced by Rowe and Kahn (1997) defined
successful aging as a combination of low disease and disability,
high levels of cognitive and physical function, and high social
engagement. Empirical research testing these notions has primarily
used cross-sectional data to identify subgroups of people aging
more or less successfully based on these predefined criteria (e.g.,
Andrews, Clark, & Luszcz, 2002; Berkman et al., 1993; Garfein &
Herzog, 1995; Jorm et al., 1998). However, aging is a process that
evolves over time. Conceptual and operational definitions that
articulate the dynamic nature of the phenomenon may reveal more
nuanced patterns and forms of successful aging. For example,
This article was published Online First March 25, 2013.
Jennifer Morack, Department of Human Development and Family Stud-
ies, Pennsylvania State University; Nilam Ram, Department of Human
Development and Family Studies, Pennsylvania State University, and Max
Planck Institute for Human Development, Berlin, Germany; Elizabeth B.
Fauth, Department of Family, Consumer, and Human Development, Utah
State University; Denis Gerstorf, Department of Human Development and
Family Studies, Pennsylvania State University, and Institute of Psychol-
ogy, Humboldt University, Berlin, Germany.
We are grateful for the support provided by the National Institute on
Aging (NIA; Grants RC1-AG035645, NIA R21-AG032379, and NIA
R21-AG033109), the Max Planck Institute for Human Development,
and the Social Science Research Institute at the Pennsylvania State
University. We also acknowledge support for the original Swedish
studies: National Institutes of Health/NIA Grant R03 AG028471-01,
European Union project contract QLK6-CT-2001-02283; Research
Board in the County Council of Jönköping; FORSS; NIA Grant AG-
08861; MacArthur Foundation Research Network on Successful Aging;
The Axel and Margaret Axson Johnson’s Foundation; Swedish Council
for Social Research; Swedish Foundation for Health Care Sciences and
Allergy Research; and NIA Grant T32 AG20500. The content of the
article is solely the responsibility of the authors and does not neces-
sarily represent the official views of the funding agencies. We also
thank Stig Berg, Boo Johansson, Bo Malmberg, Gerald McClearn,
Nancy Pedersen, Steven Zarit, and researchers at the Institute for
Gerontology in Jönköping University, the Karolinska Institute, and the
Pennsylvania State University, who conceived of and completed the
original four studies.
Correspondence concerning this article should be addressed to Jennifer
Morack, Department of Human Development and Family Studies, Penn-
sylvania State University, 422 Biobehavioral Health Building, University
Park, PA 16802. E-mail: jhm191@psu.edu
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
Developmental Psychology © 2013 American Psychological Association
2013, Vol. 49, No. 12, 2309 –2324 0012-1649/13/$12.00 DOI: 10.1037/a0032267
2309
individuals who are functioning well at one point in time may
decline considerably afterward and no longer be defined as suc-
cessfully aging according to the Rowe and Kahn criteria. Another
concern is that using predefined criteria for successful aging may
constrain our ability to identify naturally occurring subgroups—
individuals who are aging well in distinct aspects of life. Such
“uneven” successful aging subgroups, with high functioning in
some but not all domains, are repeatedly identified with cross-
sectional data (e.g., Garfein & Herzog, 1995; Ko, Berg, Butner,
Uchino, & Smith, 2007; Smith & Baltes, 1997). These groups are
very informative, in that their existence may provide us with
suggestions for how interventions can be targeted for and tailored
to specific population segments (e.g., aimed at improving social
integration among individuals with overall preserved functioning
but a distinct lack of social support).
In this study, we capitalize on the Rowe and Kahn (1997)
definition of successful aging with a focus on different aspects of
psychosocial functioning, and we go several steps ahead by ex-
amining multiple profiles of successful aging as these evolve
across old and very old age. In particular, we use a subgroup-
oriented approach to understand whether and how we can distin-
guish subgroups of persons who show similarities and differences
in multidomain trajectories of psychological change. We are in-
terested in identifying a set of profiles with uneven patterns of
successful (and less successful) aging.
Approaches to the Study of Successful Aging
Research on interrelations among within-person changes has
primarily been carried out from a variable-oriented perspective.
Here studies describe developmental stability and change in a
particular variable and examine how between-person differences
in those changes are interrelated with other variables (e.g., how
changes in health relate to changes in depressive symptoms).
Relations among variables constitute the main focus of analysis,
and persons derive their importance from their rank ordering
within the overarching distribution of scores within the sample.
Such variable-oriented research has provided invaluable insights
into normative trajectories of change in a variety of different
domains and identified possible mechanisms underlying these
changes. For example, a myriad of empirical reports demonstrate
that well-being, on average, exhibits relative stability across most
of adulthood and old age, with larger decrements only observed
with the experience of major social or health-related losses (Ger-
storf et al., 2010; Lucas, 2007). In short, well-being appears to be
maintained over time and is thus, from this perspective, considered
a key component of successful aging.
A person- or subgroup-oriented approach provides a comple-
mentary perspective on the study of interrelations among within-
person changes (Magnusson, 1998). Here individuals or subgroups
of individuals constitute the main focus of analysis, and variables
derive their importance from the way they are embedded in the
overarching configuration (i.e., profile) of variables within a given
person or subgroup. For example, Aldwin, Spiro, Levenson, and
Cupertino (2001) used data from the Normative Aging Study to
classify men into groups with distinctively different age trajecto-
ries in physical and mental health. A subgroup-oriented study may
be particularly well suited to empirically test theories of successful
aging according to which some groups of people maintain func-
tioning across key domains in old age, whereas other groups of
people exhibit steep losses in a variety of different domains (Baltes
& Baltes, 1990; Rowe & Kahn, 1997; Ryff & Singer, 1998).
Studies of Successful Aging From a Subgroup-
Oriented Perspective
Aside from studies using theoretically or clinically relevant
criteria to define groups a priori (e.g., Berkman et al., 1993; Jorm
et al., 1998), many subgroup-oriented studies use exploratory
approaches such as cluster analysis, latent class, or latent profile
analysis (LPA) to identify subgroups within a given sample (e.g.,
Fiori & Jager, 2012; Gerstorf, Smith, & Baltes, 2006). A compre-
hensive overview of subgroup-oriented studies in adult develop-
ment and aging is given in the Appendix. It is important to note
that although not all of the studies in the Appendix focus on
successful aging specifically, each uses an approach that charac-
terizes subgroups of individuals across a variety of domains, and
the subgroups are often referred to by varying levels of aging well
or successfully or are ranked from higher functioning (i.e., suc-
cessful aging) to poorer functioning (i.e., less successful aging).
Several cross-sectional studies listed provided highly valuable
information about various forms of successful aging. For example,
Smith and Baltes (1997) applied cluster analysis to cross-sectional
data from older adults (aged 70 –103) in the Berlin Aging Study
and identified nine subgroups with distinctively different cross-
domain psychological profiles. Although typical findings from
variable-oriented studies suggest positive associations between
cognitive and social variables (e.g., individuals with poor cogni-
tion tend to have low levels of social embeddedness), one of Smith
and Baltes’s subgroups was characterized by low cognitive func-
tioning and high social embeddedness—an uneven successful ag-
ing group counterintuitive to the variable-oriented pattern. That the
subgroups were also differentiated by a multitude of variables not
used in the group extraction (e.g., health, survival) demonstrated
that the profiles provided valid and useful information that would
have been missed by a purely variable-oriented perspective.
Although longitudinal subgroup-oriented studies exist (e.g.,
Lövdén, Bergman, Adolfsson, Lindenberger, & Nilsson, 2005;
Maxson, Berg, & McClearn, 1996), very few directly examine the
differential aging of subgroups of individuals. Instead, profile
configurations at one point in time are often used to predict
whether and how those configurations change over time. For
example, Gerstorf et al. (2006) applied cluster analysis to data
from each of the first three waves of the Berlin Aging Study.
Analyses revealed highly similar subgroup profiles over time, and
after matching the profiles longitudinally, some two thirds of the
participants were found to exhibit stable profiles across time. The
groups also showed distinct levels and time-related changes on
cognitive, personality, and social domain indicators. Importantly,
profile grouping was a robust predictor of long-term outcomes
such as mortality, although the subgroup-defining variables were
not.
A notable exception of a subgroup-oriented study using longi-
tudinal data to examine age changes directly is the report from
Aldwin et al. (2001), who first estimated individual growth curves
for physical and mental health, and then entered the individual
estimates into univariate cluster analyses, one for physical health
and one for mental health. Our approach here is an extension of
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2310 MORACK, RAM, FAUTH, AND GERSTORF
this approach by simultaneously including changes occurring in
three domains within the profile discovery. Note that this is a
somewhat different approach than growth mixture modeling meth-
ods (e.g., Maggs & Schulenberg, 2004/2005; Nagin & Tremblay,
1999), which typically define groups based on repeated measures
of a univariate outcome. The approach used here explicitly iden-
tifies subgroup profiles based on multidimensional change.
The Present Study
We have two major research questions. The first is whether we
can identify different types of (un)successful aging using a
bottom-up approach and studying naturally occurring subgroups
characterized by multivariate trajectory profiles. Specifically, we
operationally define successful (psychosocial) aging as sustained
high-level functioning in three key domains: maintaining few
depressive symptoms, preserving social integration, and maintain-
ing good memory. These particular domains were selected because
they broadly represent central characteristics of individual func-
tioning and psychological development in old age. Depressive
symptoms refer to signs of clinically diagnosable depression and
provide an important indicator of mental health. Reporting no or
very few depressive symptoms over time is one central component
of happiness and quality of life (Diener & Seligman, 2002). Social
integration revolves around how connected and supported people
feel socially, including few feelings of loneliness, and represents a
key indicator of the perception of and satisfaction with one’s social
life (Cohen, 2004). Cognitive functioning refers to a broad array of
mental processes and capacities, with higher functioning consid-
ered a general purpose mechanism for adaptation and a resource
people draw from to master the challenges of everyday life (Baltes,
Lindenberger, & Staudinger, 2006). In particular, memory is the
ability of individuals to learn and retain information and is an
essential piece of everyday functioning and crucial for indepen-
dence later in life.
In our second research question, we corroborate the viability of
the profiles by examining how the grouping relates to a set of
variables that may have served as antecedents (age, education,
gender, marital status, and living arrangement), correlates (change
in functional limitations), or consequences (survival time). On the
basis of earlier studies (Gerstorf et al., 2006; Ko et al., 2007; Smith
& Baltes, 1997), we hypothesize that a sizable group of successful
agers indeed maintain psychosocial function throughout late life
and that they differ from their less successful peers in key sociode-
mographic and health factors. To examine these questions, we
applied LPA to 8-year longitudinal data pooled together across
four Swedish studies of the oldest old (N � 1,008; Mage � 81 years
at Time 1; 61% women) that obtained repeated measures of
depressive symptoms, social integration, and memory.
Method
Participants and Procedure
We make use of 8-year longitudinal data pooled across four
Swedish longitudinal studies of aging: Sex Differences in Health
and Aging study (GENDER; Gold, Malmberg, McClearn, Peder-
sen, & Berg, 2002), Swedish Octogenarian study (OCTO; Johans-
son & Zarit, 1995), Origins of Variance in the Oldest-Old: Octo-
genarian Twins study (OCTO-TWIN; McClearn et al., 1997), and
Swedish Nonagenarian study (NONA; Fauth, Zarit, Malmberg, &
Johansson, 2007). In the GENDER and OCTO-TWIN studies,
beginning in 1995 and 1990, respectively, representative samples
of twin-pairs in their 70s and 80s were recruited from the Swedish
Twin Registry, a population-based registry of all multiple births in
Sweden. In the OCTO and NONA studies, beginning in 1987 and
1999, respectively, participants in their 80s and 90s were recruited
from the municipality of Jönköping’s population registry (which
contains names and birth dates of all residents). At baseline as-
sessment, OCTO participants were aged 84, 86, 88, and 90 years
and NONA participants were aged 86, 90, and 94 years. All four
studies followed individuals for three occasions (OCTO-TWIN for
five occasions) at 2-year or 4-year (GENDER) intervals.
Our analyses used longitudinal data from the subsample of
1,008 participants who provided data on two or more occasions for
the three profile-defining indicators of depressive symptoms, so-
cial integration, and memory. These participants were aged be-
tween 69 and 95 years at their initial assessment (M � 81.2, SD �
5.6), were 61% women, and provided an average of 3.1 occasions
of data over 8 years. Relative to those not included here (N � 785
who did not contribute change information on either of the three
profile measures), our participants were younger (M � 81.1, SD �
5.9 vs. M � 84.0, SD � 5.9), F(1, 3526) � 104.54, p � .001; more
educated (M � 7.2, SD � 2.3 vs. M � 6.9, SD � 2.1), F(1, 48) �
9.98, p � .01; more likely married (41% vs. 32%), �2(1, N �
1,717) � 16.18, p � .001; and less likely to live in an institution
(9% vs. 38%), �2(1, N � 1,774) � 219.88, p � .001; whereas no
differences were found for gender. In addition, our subsample
reported fewer depressive symptoms (M � 0.5, SD � 0.4 vs. M �
0.7, SD � 0.5), F(1, 10) � 43.32, p � .001; more social integra-
tion (M � 3.4, SD � 0.5 vs. M � 3.2, SD � 0.6), F(1, 15) � 49.41,
p � .001; greater recall (M � 6.8, SD � 2.5 vs. M � 4.6, SD �
3.4), F(1, 1667) � 200.79, p � .001; and fewer disabilities (M �
1.1, SD � 1.8 vs. M � 4.0, SD � 3.9), F(1, 3274) � 410.99, p �
.001. Effect sizes for selectivity differences were in the small to
medium range (R2 � .20 for all comparisons).
Relative to participants who provided below the minimum two
waves of data for inclusion in our analysis (n � 165), participants
who provided three or more waves of data (n � 843) were younger
(M � 80.8, SD � 5.7 vs. M � 82.8, SD � 5.5), F(1, 535) � 16.41,
p � .001; less likely to live in an institution at Time 1 (7% vs.
19%), �2(1, N � 1,008) � 27.36, p � .001; performed better on
the recall test (M � 7.0, SD � 2.5 vs. M � 6.0, SD � 2.7), F(1,
112) � 17.66, p � .001; and had fewer disabilities (M � 0.9, SD �
1.7 vs. M � 1.9, SD � 2.4), F(1, 134) � 41.22, p � .001; but no
differences were found for education, marital status, gender, re-
porting of depressive symptoms, or social integration. Effect sizes
were in the small range (R2 � .04 for all comparisons).
Measures
Profile-defining measures. Measures from three domains
representing key areas of psychological functioning (depressive
symptoms, social integration, and memory) were used to identify
subgroups defined by multidimensional trajectory profiles. Each
measure was administered in the same manner in all studies and at
each wave, unless otherwise noted. Table 1 provides descriptive
information for each measure.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2311PSYCHOLOGICAL PROFILES AND SUCCESSFUL AGING
Depressive symptoms. An individuals’ level of depressive
symptoms was indexed by the average of responses to the 10 items
from the Center for Epidemiologic Studies Depression Scale (Rad-
loff, 1977) that were common across all four pooled studies. Using
a scale ranging from 0 (rarely or never) to 3 (most of the time),
participants rated how often during the past week they had expe-
rienced a variety of depressive symptoms (e.g., thought life had
been a failure, felt fearful or depressed; Cronbach’s � � .79).
Social integration. The average of responses to five items
measuring subjective support (three items) and loneliness (two
items; reverse coded) was used to index social integration (Cron-
bach’s � � .74). Participants were asked to rate four of these items
(e.g., “Do you have someone you can talk with?”; “Do you feel
you are part of a circle of friends?”) adapted from the UCLA
Loneliness Scale (Russell, 1982) plus one additional (global) item
(Malmberg, 1990) using a scale ranging from 1 (not at all) to 4
(nearly always; for details and measurement properties, see Femia,
Zarit, & Johansson, 2001).
Memory. Individuals’ memory was measured with a recall
subtest of the Memory in Reality Test (Johansson, 1988/1989).
Participants were presented and asked to memorize a list of 10
common objects (keys, medicine, wrist watch, comb, pencil,
matchbox, ring, eyeglasses, scissors, and glass). Memory was
indexed by the number of words from the list participants recalled
when prompted 30 min later (test–retest reliability � .73; for
details and measurement properties, see Fiske & Gatz, 2007).
Correlates. We examined whether the groups differed on a
variety of factors, including chronological age, years of education,
gender (0 � men, 1 � women), marital status (0 � married, 1 �
not married), and living arrangement (0 � ordinary housing, 1 �
living in an institution). Functional limitations assessed individu-
als’ ability to complete four personal activities of daily living
(bathing, dressing, toileting, and feeding; Katz, Ford, Moskowitz,
Jackson, & Jaffe, 1963) and four instrumental activities of daily
living (house cleaning, cooking, shopping, and going places out of
walking distance; Lawton, 1971). Participants were asked how
much difficulty they had performing those activities from 0 (com-
pletely independent) to 3 (unable to do the activity at all). Sum
scores of personal activities of daily living and instrumental ac-
tivities of daily living were calculated and then averaged to obtain
an overall functional limitation score (Fauth, Zarit, & Malmberg,
2008; Cronbach’s � � .82). Finally, survival time was assessed
with mortality information obtained from Swedish public health
records and quantified as the number of years between an individ-
ual’s last assessment and his or her date of death.
Statistical Analysis
In a preliminary step, growth models were used to derive inter-
cepts and linear rate of change for depressive symptoms, social
integration, and memory that quantified interindividual differences
in intraindividual trajectories for the three aspects of psychological
functioning. These six measures (level and rate of change for each
of the three profile defining variables) were then used in the LPA
to identify subgroups of individuals with distinct multidimensional
developmental trajectory configurations.
Growth models. Using a multilevel modeling framework,
growth curve models (e.g., McArdle & Nesselroade, 2003; Ram &
Grimm, 2007; Singer & Willett, 2003) summarized and extracted
information about initial levels and rates of change in depressive
symptoms, social integration, and memory. Models took the fol-
lowing form
Domainti � �0i � �1i�timeti� � eti, (1)
where person i’s score in a particular domain at time t, Domainti,
is a function of an individual-specific intercept parameter, �0i, and
an individual-specific linear slope parameter, �1i, that captures the
linear rate of change per year of time, and residual error, eti.
Following standard growth curve modeling procedures,
individual-specific intercepts, �0i, and linear slopes, �1i, (from the
Level 1 model give in Equation 1) were modeled as
�0i � �00 � u0i,
�1i � �10 � u1i,
(2)
(i.e., Level 2 model) where �00 and �01 are sample means and u0i
and u1i are individual deviations from those means. Using SAS
PROC MIXED with restricted maximum likelihood estimation and
standard missing at random assumptions (Little & Rubin, 1987),
we fitted the model separately for each of the three profile-defining
measures. Using Bayes empirical estimates (see Littell, Milliken,
Stroup, Wolfinger, & Schabenberger, 2006), we obtained level,
Table 1
Means, Standard Deviations, and Intercorrelations Among the Profile Defining Constructs and Correlates
Construct M SD 1 2 3 4 5 6
Profile defining
1. Depressive symptoms 0.5 0.4 —
2. Social integration 3.4 0.5 �.41� —
3. Memory 6.8 2.5 �.08� .25� —
Correlates
4. Age 81.1 5.8 �.45� .04 �.22� —
5. Years of education 7.2 2.3 .15� �.05 .08� �.14� —
6. Functional limitations 1.1 1.8 �.39� .20� �.31� .37� �.11� —
7. Gender (% women) 61.3
8. Marital status (% married) 41.2
9. Living arrangement (% institutionalized) 8.8
Note. N � 1,008.
� p � .05.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2312 MORACK, RAM, FAUTH, AND GERSTORF
�0i, and rate of change, �1i, scores for each domain for each
individual. Our objective was to reduce the longitudinal (up to 8
years) data across the three dimensions (depressive symptoms,
social integration, memory) down to six informative scores. Given
the short length of the individual time series, we did not include a
quadratic term in the models.
Latent profile analysis. The estimates of level and rate of
change for depressive symptoms, social integration, and memory
extracted above were then transformed to Z scores (to alleviate
concerns of differential weighting) and used to obtain a set of
subgroups defined by their multidimensional trajectory profiles.
Specifically, LPA uses latent mixture models to identify latent
classes based on mean differences in continuous, manifest vari-
ables. We applied LPA to determine the optimal number of sub-
groups in the data (Gibson, 1959; Ko et al., 2007; Lanza, Flaherty,
& Collins, 2003; Muthén, 2002). Following the standard approach,
we estimated profiles and group membership probabilities across a
number of alternative models (e.g., group differences in means
and/or variances; see Ram & Grimm, 2009). Any number of
models with different specifications can be run at the discretion of
the researchers and can be based on theory and expectations of the
group solution. Using Mplus (Muthén & Muthén, 2006) with
maximum likelihood estimation and standard missing at random
assumptions (Little & Rubin, 1987), we fitted a series of LPA
models with different numbers of classes (two to 10) and possible
group differences (means, variances) to the data. Although sub-
stantively similar groups were obtained when we allowed both
means and variances to differ across groups, we eventually chose
not to oversaturate the models with variance differences and rather
to prioritize the robustness of results in the face of a sizable
amount of sample attrition over time. Thus, only means were
allowed to differ across groups. Variances were constrained equal
across groups.
In identifying the optimal number of profile groups, we fol-
lowed the steps and criteria suggested by Ram and Grimm (2009).
First, model parameters were examined for any peculiarities with
estimates (e.g., convergence issues, out-of-bounds parameters),
and the interpretability of the groupings and estimates were
checked. Model solutions that were deemed inappropriate (e.g.,
convergence problems) were not considered further. Second, re-
maining models were compared via model fit criteria including the
Bayesian information criteria (BIC) and adjusted BIC. These fit
statistics allow for the comparison of models with different num-
bers of parameters and penalize for overfitting or having too many
parameters in a model. Better fitting models have lower BIC and
adjusted BIC (Nylund, Asparouhov, & Muthén, 2007). Third, we
considered the entropy statistic for each model, an indicator of the
precision of individual profile membership, with values greater
than or equal to .80 considered adequate and indicative that indi-
viduals are grouped into profiles that described their functional
configuration well (Muthén, 2004). Finally, the Vuong–Lo–
Mendell–Rubin likelihood ratio test (VLMR-LRT) was used to
compare the relative fit of models to similarly structured models
with one fewer group. To do so, this test applies a corrected
likelihood ratio distribution and provides a p value to test if a
model with c groups constitutes a significant improvement in fit
relative to a model with c � 1 groups (Lo, Mendell, & Rubin,
2001; Nylund et al., 2007). After determining the best model,
subgroup means were transformed back into their raw units.
Group differences. In the final set of analyses, several
regression-based methods were used to examine differences
among profile groups in relation to sociodemographic and health
variables. Specifically, analysis of variance was used to examine
group differences in age and education; cross-tabs to examine how
the groups differed with respect to gender, marital status, and
living arrangement; multilevel models of change to examine
group-level differences in longitudinal trajectories of functional
limitations; and Cox proportional hazard regression models (Cox,
1972) to test group-level differences in survival hazards.
Results
Subgroup Identification
We used LPA to identify subgroups of individuals differing in
their developmental trajectories across depressive symptoms, so-
cial integration, and memory. Table 2 shows various fit statistics
for models that allowed between two and 10 latent groups. Models
with eight and 10 latent groups were immediately eliminated due
to nonconvergence, leaving seven models to evaluate with the
statistical criteria. With the BIC and adjusted BIC, the nine-group
solution offered the best relative fit. Upon further examination,
however, many of the groups showed only marginal differences,
prompting us to continue examining the other models. For each
remaining model, entropy was greater than .80, indicating that all
profile solutions had adequate precision of individual profile mem-
bership. However, the significant VLMR-LRTs for the two-,
three-, and four-group models suggested further consideration of
these models—particularly the four-group model. Based on the
viability of interpretation and because the BIC and adjusted BIC
were smallest and the entropy value (.88) was the highest for the
four-class solution, this was selected as the final model. This was
further validated by the significant VLMR-LRT for the four-group
solution and the nonsignificant one for the five-group solution,
indicating a significant improvement in fit from a three- to four-
group solution but not from a four- to five-group solution. In sum,
our LPA analyses indicated that a four-class model of mean
differences provided an optimal description of the data. Table 3
provides an overview of subgroup differences in the six profile-
Table 2
Fit Statistics for Profile Solutions
Profile solution BIC ABIC Entropy VLMR-LRT p value
2 16445 16385 .84 .00
3 16253 16170 .84 .00
4 16077 15972 .88 .00
5 15939 15812 .88 .11
6 15825 15676 .86 .09
7 15742 15571 .87 .62
8a 15667 15474 .88 .09
9 15619 15403 .88 .41
10a 15631 15393 .89 .73
Note. The final model is indicated in bold. BIC � Bayesian information
criterion; ABIC � adjusted Bayesian information criterion; VLMR-LRT �
Vuong–Lo–Mendell–Rubin likelihood ratio test.
a Did not converge.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2313PSYCHOLOGICAL PROFILES AND SUCCESSFUL AGING
defining variables of level and linear rate of change.1 Correspond-
ing group-level trajectories of change over time are shown in
Figure 1.
Shown in the upper left panel of Figure 1, the largest profile
group consisted of 639 individuals (63% of sample). Means for
this group were at or above the sample average in all domain
indicators and remained so over time. Thus, we labeled the group
representing preserved system integrity. Calculated with the
sample-level distributions, effect-size metrics indicated that this
group’s depressive symptoms were around average at baseline
(0.454) and increased at a minor linear rate of change per year
(0.005). Social integration and memory were about 0.5 standard
deviation above average at baseline (3.505 and 7.586, respectively)
and declined at a linear rate that is to be expected for people in this
age range (�0.006 and �0.026, respectively).
A second profile group consisted of 176 individuals (18% of
sample) and was characterized by relatively low functioning across
all domains, particularly in social integration (see upper right panel
in Figure 1). This profile was labeled the aging in isolation group.
At baseline, this subgroup’s mean scores were about 1 standard
deviation above the total sample mean level of depressive symp-
toms (0.896), about 1.5 standard deviations below average in
social integration (2.492), and 0.5 standard deviation below the
sample average in memory (4.522). Over time, this group declined
in depressive symptoms about 0.5 standard deviation over the 8
years (linear slope � �0.016), but overall maintained a relatively
high level of depressive symptoms. Social integration increased
substantially over time (linear slope � 0.073; a little over 1
standard deviation over 8 years), but remained at a low level.
Finally, memory performance declined at a to-be-expected, mod-
erate rate (linear slope � �0.208).
A third profile group (lower left panel in Figure 1) consisted of
39 individuals (4% of sample) and is referred to as the memory
failing group. At baseline, this group’s depressive symptoms were
about 0.5 standard deviation lower than the sample average, and
their levels of social integration were just around the sample
average. Over time, the group maintained their average levels of
depressive symptoms, but declined around a 0.5 standard deviation
in social integration. The distinguishing feature of this group was
the severe loss in memory. This group started off in the average
range in memory, but then declined about 3 standard deviations
throughout the 8 years of study.
The fourth profile group (lower right panel in Figure 1) con-
sisted of 154 individuals (15% of sample) and was labeled the
compromised memory group. This group’s trajectories of depres-
sive symptoms and social integration were somewhat expected for
old and very old individuals and thus considered as normal aging
(i.e., around average at baseline and remained fairly stable over
time). Of particular interest, memory performance at baseline was
around 1.5 standard deviations below the sample average and
declined from there at a somewhat average rate (linear slope �
�0.318).
After deriving the four-group solution for the whole sample, we
ran two additional sets of LPAs to alleviate concerns that the four
groups were a by-product of our data configuration. First, we
examined the group profiles from only the younger and only the
older portions of our sample. The sample was divided in two based
on the median age of participants (Group 1 � 72– 84 years; Group
2 � 85–97 years), and we fitted the entire series of models to each
subsample. Results for the younger aged sample indicated a three-
group solution, with groups resembling the preserved system in-
tegrity (n � 405), aging in isolation (but with average recall; n �
59), and compromised memory (n � 40) groups. The older sample
was best represented by two groups resembling the preserved
system integrity (n � 355) and aging in isolation (n � 149) groups.
That three of the four groups emerged (with an expected age
selection), and that only the smallest group was missed, provides
some level of confidence in the profiles.
Second, we repeatedly split the full sample into random halves
and examined the four-group solutions for each half (similar to
bootstrapping). In all splits, the preserved system integrity, aging
in isolation, and compromised memory profiles were replicated.
However, the memory failing profile was always only replicated in
1 Follow-up analyses were performed to determine how each of the four
pooled studies was spread out across the subgroups. GENDER participants
(who were the youngest of the four studies) were predominantly in the
preserved system integrity group (N � 308; 93%). Participants from the
remaining studies were split up into the subgroups more evenly, as would
be expected from the overall subgroup sizes. Of the OCTO-TWIN partic-
ipants, 52% (or n � 239) were in the preserved system integrity and 22%
(or n � 239) in the compromised memory group. NONA participants were
primarily in the preserved system integrity group (57%, or n � 43),
whereas OCTO participants were mainly in the aging in isolation (42%, or
n � 61) and preserved system integrity groups (34%, or n � 49).
Table 3
Profiles of the Measures of the Four Subgroups Identified in the Latent Profile Analysis (N � 1,008)
Measure
Preserved system
integrity (n � 639; 63%)
Aging in isolation
(n � 176; 18%)
Memory failing
(n � 39; 4%)
Compromised memory
(n � 154; 15%)
Overall sample
average
Depressive symptoms domain
Level 0.454� 0.896� 0.268� 0.341� 0.501�
Rate of change 0.005� �0.016� 0.005 0.005� 0.001
Social domain
Level 3.505� 2.492� 3.376 3.233 3.281�
Rate of change �0.006� 0.073� �0.023� 0.014 0.010�
Memory domain
Level 7.586� 4.522� 6.262 1.439� 6.029�
Rate of change �0.026� �0.208� �1.062� �0.318� �0.145�
Note. Measures are in raw units. Rate of change � estimated yearly linear change.
� p � .05.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2314 MORACK, RAM, FAUTH, AND GERSTORF
one half of the split, but with a size comparable to what emerged
in the whole sample (n � 4% of total). All in all, the format of the
replications raised confidence that the four-group solution was
viable and may replicate in other samples.
Subgroup Differences in Sociodemographic
Characteristics and Health
Next, we explored the utility of the multidimensional profile
classifications by examining whether and how these groups dif-
fered in a variety of sociodemographic variables (age, education,
gender, marital status, living arrangements) and health indicators
(functional limitations, survival time).2 One-way analyses of vari-
ance indicated significant group differences in age, F(3, 1004) �
82.19, p � .001, and education, F(3, 998) � 5.24, p � .001 (see
Figure 2). Scheffé post hoc tests revealed that participants in the
preserved system integrity group were, on average, younger (M �
79.2, SD � 5.7) than the other groups and had received signifi-
cantly more education (M � 7.4, SD � 2.4) than the compromised
memory group (M � 6.8, SD � 1.6), F(3, 998) � 2.61, p � .05.
Chi-square tests of independence revealed group differences in
gender, �2(3, N � 1,008) � 11.35, p � .01; marital status, �2 (3,
N � 1,008) � 44.28, p � .001; and living arrangement, �2(3, N �
1,008) � 41.88, p � .001. Follow-up comparisons indicated that
the preserved system integrity group included fewer women
(57%), fewer institutionalized persons (5%), and more married
participants (49%) than both the aging in isolation and compro-
mised memory groups (see Figure 2). Post hoc analyses of status
found that the largest percentage of the aging in isolation group
and compromised memory group individuals were widowed (40%
2 For the analyses examining subgroup differences for the variables not
used in defining the profiles, a series of simulations were used where
individual subgroup membership probabilities were taken into account.
One hundred simulated data sets were made, and each was used for every
statistical test involving examining subgroup differences for the external
variables. Thus, 100 results were obtained for each test. The median test
statistic for each analysis was then examined to ensure that it was similar
to the result obtained when using the actual sample data. All median
statistics were very close to those from the sample data.
Figure 1. The four subgroups identified from latent profile analysis. Each graph represents a different
subgroup’s depressive symptoms, social integration, and memory trajectories. The preserved system integrity
group maintained average or above-average levels across all domains, whereas the aging in isolation group was
relatively low functioning across all domains, particularly in social integration. The memory failing group
declined around 3 standard deviations in memory, and the compromised memory group began at around 1.5
standard deviations below average in recall at baseline. Scaling is different for each variable (i.e., means and
standard deviations are not the same); therefore, comparisons across domains are not warranted. Also, linear
projections extending beyond the range of the scale have been truncated.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2315PSYCHOLOGICAL PROFILES AND SUCCESSFUL AGING
and 45%, respectively), compared to the preserved system integ-
rity group and memory failing group individuals who were pri-
marily married (49% and 41%, respectively).
A conditional growth model with dummy-coded variables for
the groups (with the preserved system integrity group serving as
the reference) examined group differences in both initial levels and
rates of change for functional limitations. Results revealed signif-
icant group differences in average level of functional limitations at
baseline, but not in linear rates of change. Figure 3 shows the
trajectories of functional limitations for each group. The preserved
system integrity and memory failing groups were around 0.5
standard deviation below average at baseline (0.657 and 0.952,
respectively, but not statistically distinguishable, p � .47). In
comparison, the aging in isolation and compromised memory
groups had slightly above-average baseline functional limitations
in our sample (2.962 and 2.773, respectively). Over 8 years, rank
order differences between groups were maintained.
In our final analysis, Cox (1972) proportional hazard regression
models (implemented via the PHREG procedure from the SAS
software package (SAS Institute, 1997; see also Allison, 1995)
were used to examine group differences in survival hazards, both
with and without controlling for age, education, and gender. With
the preserved system integrity group as the reference, analyses re-
vealed that the relative risks of dying were higher for each of the other
three groups: the aging in isolation group, �2(1, N � 1,008) � 28.30,
p � .001 (RR � 1.60, CI � [1.34, 1.89]); the memory failing group,
�2(1, N � 1,008) � 14.00, p � .001 (RR � 1.87, CI � [1.35, 2.60]);
and the compromised memory group, �2(1, N � 1,008) � 32.32,
p � .001 (RR � 1.70, CI � [1.42, 2.04]). The noted group
differences remained when controlling for age, gender, and edu-
cation. Kaplan–Meier survival curves over the 16-year follow-up
period shown in Figure 4 illustrate the group differences in sur-
Figure 2. Differences in subgroups for sociodemographic correlates. Midpoint values on the plots represent
rounded averages for each variable. The preserved system integrity group contained the youngest, most educated,
least percent women and institutional living, and greatest percent married individuals.
Figure 3. Time-related change in functional limitations for subgroups.
Individuals in the preserved system integrity and memory failing group
experienced the fewest functional limitations over time.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2316 MORACK, RAM, FAUTH, AND GERSTORF
vival probability. Participants in the preserved system integrity
group lived an average of 10 years after baseline assessment,
compared to an average of 8 years for the memory failing group,
6 years for the aging in isolation group, and 5 years for the
compromised memory group. Taken together, results show the
predictive validity of the subgroups over time, with subgroups of
individuals who maintain functioning across a variety of domains
in late life having better chances for survival.
Discussion
To examine a longitudinal conceptualization of successful ag-
ing, we made use of multiple-indicator, multiwave information at
the person level and asked directly whether different multivariate
configurations of change can be identified. First, we applied LPA
to 8-year longitudinal data from 1,008 oldest-old adults to distin-
guish four multidimensional profiles of change that capture dis-
tinct differences in trajectories of depressive symptoms, social
integration, and memory: a preserved system integrity group of
participants who maintained functioning across very old age; an
aging in isolation group with a persistent lack of social support;
and two groups of people with average well-being and social
functions but distinctive memory profiles: A compromised mem-
ory group was characterized by poor memory throughout late life,
whereas participants in a memory failing group experienced dra-
matic memory declines late in life. Second, we corroborated the
distinctiveness of the profiles by demonstrating group differences
in a variety of sociodemographic and health indicators that were
not involved in defining the profiles. We discuss how the longi-
tudinal multivariate profiles reflect various configurations of suc-
cessful and less successful aging very late in life. In doing so, we
consider how a subgroup-oriented approach offers both possibili-
ties and challenges for obtaining better understanding of the intri-
cacies of human development.
Subgroups
Preserved system integrity group. The largest profile group
consisting of 639 participants (63% of sample) was uniquely
characterized by average to above-average trajectories across the
psychological domains examined. The label preserved system in-
tegrity denoted that the three systems of functioning changed
together in a way that sustained effective psychosocial functioning
over time. In line with this interpretation, participants in this group
experienced better physical functioning, displaying fewer func-
tional limitations and living, on average, longer than individuals in
other groups. Of note is that participants in this profile were
relatively younger, more educated, and more likely to be a man,
married, and live on their own, each of which may be considered
protective against late-life declines. For example, having close
social relationships, especially marital partners, has been linked to
better health outcomes and a longer life (Seeman & Crimmins,
2001).
The high levels of functioning in the preserved system integrity
group illustrate the concept of successful aging and mirror the
high-functioning profile groups reported in several other
subgroup-oriented studies, such as the high-cognitive, high-social,
high-well-being group in Maxson et al. (1996); the general positive
profile in Smith and Baltes (1997); the overall positive profile in
Gerstorf et al. (2006); and the generally positive group in Ko et al.
(2007). We note that— consistent across studies, including our
own report—the majority of participants were grouped into the
profiles with across-domain high levels of functioning. For exam-
ple, Gerstorf et al. and Ko et al. reported that some 50% of their
samples were categorized as aging successfully. As an extension of
these reports, we defined our groups based on cross-sectional
differences at Time 1 when the average age of the sample was 81
years as well as based on up to 8 years of longitudinal change in
key domains of psychological functioning—a time frame that
should be long enough to exhibit change in this age range. We thus
found it striking that 63% of oldest-old participants were classified
into such a successful aging group who maintained their function-
ality over time. Of course, this finding can be taken to exemplify
the positively select nature of our sample of very old adults and
questions whether the finding extends to the overall population. At
the same time, we note that it was only through the use of a
subgroup-oriented approach that we were able to identify directly
the existence of such a successful-aging group and the persistence
of systemic integrity across very old age. It will be instructive to
explore whether bottom-up approaches are better geared toward
identifying successfully aging oldest-old than using strict a priori
criteria in a top-down manner (e.g., review by Depp & Jeste, 2006:
36% of participants identified as aging successfully).
Aging in isolation group. Compared to the preserved system
integrity group, the aging in isolation group (N � 176, 18% of
sample) exhibited poor functioning in all three domains. The label
aging in isolation was selected to highlight the distinctive lack of
social integration even in the context of poor functioning in other
domains. That is, despite needing support, this group did not
appear to be embedded in social networks that might provide that
support. Adding to the overall picture, participants in this group
were, compared to the other profiles, the most likely to not be
married (anymore) and to live in institutions, and participants also
had the highest level of functional limitations. Again, these char-
acteristics very closely match some of the profiles reported in
earlier subgroup-oriented studies, such as the overall negative
group in Maxson et al. (1996); the general negative profile in
Smith and Baltes (1997); and the extremely frail, lonely, depressed
Figure 4. Differences between subgroups in survival probabilities over
17 years. The preserved system integrity group lived longer on average
than the other profiles.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2317PSYCHOLOGICAL PROFILES AND SUCCESSFUL AGING
group in Smith and Baltes (1998). Our study adds another piece to
the puzzle by identifying social isolation as a distinctive charac-
teristic of poor functioning profile groups.
According to the criteria suggested by Rowe and Kahn (1997),
the aging in isolation profile could be considered the least suc-
cessful agers of the four groups identified here. For this group,
functioning was not preserved in any of the three domains of
health (high functional limitations), cognitive abilities (poor mem-
ory), and active engagement with life (low levels of social inte-
gration). Importantly, we note that this group included only 18% of
our sample, illustrating that poor functioning is not a necessary
characteristic of advanced old age.
Although difficult to examine and not explored in this study, it is
possible that loneliness and a lack of social support may have con-
tributed to poor functioning in the other domains (Berkman, Glass,
Brissette, & Seeman, 2000). In particular, research by Cacioppo,
Hawkley, Norman, and Bernsten (2011) suggests that social isolation
is related to elevated hazards for morbidity and mortality in older
adults through multiple biological pathways. The identification of this
group suggests that for a portion of older adults, social integration
may be a vital component of systemic function— one that provides a
potential lever for intervention. Participation in productive activities
and social support may buffer declines in other domains, whereas lack
thereof may burden overall functioning. However, with the data at
hand, we cannot draw any temporal inferences. As a consequence, it
is possible that depressive symptoms may have been a source for
reporting small social networks and feeling socially isolated (which
may or may not coincide with the objectively available support). Of
note is that from a variable-oriented perspective, the two constructs of
depressive symptoms and social integration showed only moderate
overlap (r � �.41 in the entire sample; r � �.35 in the aging in
isolation group).
Memory failing group. Participants in the memory failing
group (N � 39, 4% of sample) were characterized by average
levels of depressive symptoms and social integration throughout
the course of the study, combined with a dramatic decline in
memory. Such severe decrements in memory abilities may indicate
that participants were beginning to experience some form of de-
mentia (testing this was beyond the scope of the current analyses).
Interestingly, the memory failing group was comparable to the
preserved system integrity group on all external variables (age,
education, etc.). However, we do not rule out the possibility that
marker variables could be identified in larger samples. Our
follow-up analyses indicated that although the profile seems to
exist, the small subgroup size restricted our ability to extract it in
all subsamples. It is instrumental for future research to examine the
existence of such a group in more detail.
The precipitous memory declines distinctive of the memory
failing group match profiles reported by Lövdén, Bergman, et al.
(2005) from the Betula study. In particular, the authors showed
that particular groups of participants experienced a developmental
cascade of steep declines in several cognitive abilities (including
episodic and semantic memory) that eventually culminated in
dementia diagnosis and death. In both our study and the Betula
project, the size of the dementia-prone subgroup was relatively
small, suggesting that this is an expected scenario for only a small
portion of study samples, but not the large majority of participants
typically included in large macro-longitudinal studies. To the
extent that findings from our positively select subsample of Swed-
ish oldest old can be generalized to the larger population, it appears
that severe forms of memory decline may be less common than
often stereotypically expected. Our analysis of multidimensional
change profiles allowed for the identification of an uneven profile
of successful aging, with distinct declines in one domain in the
context of preserved functioning in other domains. If information
from Time 1 only had been used in the profile-defining stage,
participants in this group may have been lumped into the success-
ful aging profile because of above-average memory at baseline. In
our view, this provides an excellent example of the importance of
using longitudinal data to characterize successful aging groups.
Compromised memory group. The compromised memory
group (N � 154, 15% of sample) maintained fairly average levels of
depressive symptoms and social integration, but was uniquely char-
acterized by very poor memory ability throughout the course of the
study. Relative to the memory failing group, this group did not decline
dramatically in memory. Instead, those in this group already had low
ability levels at the start of observation and remained low over time.
They were also older than the rest of the sample and had the highest
mortality hazards. The compromised memory group resembles
groups reported from other subgroup-oriented studies, such as the
cognitively impaired and high external control group in Smith and
Baltes (1997) and the low-cognitive-functioning groups reported from
Ko et al. (2007) and Maxson et al. (1996).
Given that the profile-defining domains typically show a posi-
tive manifold, a disparate profile like the compromised memory
group provides another illustrative example of possible insights
gained by pursuing a subgroup-oriented approach that would have
been missed by a variable-oriented analysis. It remains an open
question, though, why (poor) levels of memory were maintained
over time. As suggested by more variable-oriented research (Ger-
storf, Lövdén, Röcke, Smith, & Lindenberger, 2007; Lövdén,
Ghisletta, & Lindenberger, 2005), it is possible that the relatively
stable and average levels of depressive symptoms and social
integration have protected against memory decline. The compro-
mised memory group provides another example of an uneven
profile, with distinctively low functioning in one domain (mem-
ory) and fairly typical functioning in other domains. Among the
questions to be addressed in future research is whether and how
uneven changes qualify as (un)successful aging.
Potentials and Challenges of a Subgroup-Oriented
Approach
Adopting a subgroup-oriented approach with multiple domains,
our study sheds additional light on questions about differential and
successful development in old age (e.g., Baltes, 1987; Birren,
1959; Dannefer, 2003; Riley, 1987). We identified multidimen-
sional configurations of psychological change that would be dif-
ficult to obtain with a variable-oriented approach. For example,
two subgroups of individuals showed average functioning in de-
pressive symptoms and social integration but distinctively differ-
ent trajectories of memory change (memory failing and compro-
mised memory groups). We provide direct evidence that
associations found at the sample level only apply to some sub-
groups of individuals but not to others—and thus continue to
highlight the risks of using between-person associations to sub-
stantiate within-person theory (Estes, 1956). Of course, we have
only gone partially in this direction. The models still rest on assump-
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2318 MORACK, RAM, FAUTH, AND GERSTORF
tions of within-group homogeneity, aggregate across individuals, and
probabilistically assign individuals to subgroup-level profiles that are
considered representative of individual-level profiles (rather than uti-
lizing probabilities of membership in all four profiles).
As alternatives to the variable-oriented stance gain momentum, our
study builds on the other subgroup-oriented studies of old age listed in
the Appendix. In particular, our extension makes use of data on
within-person changes across multiple domains of psychological
function to identify multidimensional-longitudinal, and arguably more
holistic, profiles. The earlier subgroup-oriented research rarely mod-
eled within-person change directly. Rather, they identified groups
from cross-sectional data and then used the grouping variable to
predict subsequent change. Addressing this gap in the application of
latent class methods, we identified profiles directly from the longitu-
dinal change scores. Also, in contrast to some group-based trajectory
models (Nagin & Odgers, 2010), that all individuals within a sub-
group follow the same developmental trajectory, we chose a statistical
approach that allowed for within-subgroup heterogeneity (see Ram,
Grimm, Gatzke-Kopp, & Molenaar, 2012, for discussion of the po-
tential hazards of both approaches).
The relative cost/utility of variable-oriented and subgroup-oriented
approaches must be considered. Although both types of analysis can
be done in the flash of an eye, the time-consuming and effortful nature
of multivariate long-term panel data must also be considered. Cer-
tainly, a multivariate analysis makes better use of the data than a
univariate analysis, but we ourselves still struggle with the added
utility of a purely subgroup-oriented approach. Case in point, we
interpreted and named the groups from a variable-oriented perspec-
tive, and following standard good practices, we evaluated the utility of
the profile groups by assessing how the categorical grouping variable
was related to a variety of antecedents, correlates, and outcomes in a
purely variable-oriented manner. In sum, the field still struggles to
take a subgroup-oriented approach without placing it within variable-
oriented interpretations and analysis.
A practical benefit of subgroup-oriented interpretation emerges
when considering potential interventions. Our results point toward
tailoring diagnostic and intervention efforts to individual needs. From
a clinical perspective, for example, assessments aimed at risk profiles
are often based on cross-sectional data or examine risk factors in a
univariate manner. Our findings suggest that profiles based on mul-
tidimensional, longitudinal data can highlight the specific risk and
protective factors that may be vital for achieving successful aging
outcomes, including quality of life, a delayed entry into institutional-
ization, and lower mortality hazards. For example, the aging in iso-
lation group may require interventions that aim to promote social
support, alleviate depressive symptoms, and enhance cognitive re-
serve, whereas the compromised memory or memory failing groups
may benefit from interventions fully devoted to enhancing cognitive
reserve or delaying future cognitive loss.
Limitations and Outlook
To broadly represent central characteristics of successful psy-
chosocial functioning, we selected three domains and well-
established indicators thereof from measures available in the four
Swedish studies of old age. Of course, the inclusion of both
additional domains (e.g., activities, motivation, personality, brain
efficiency) and additional indicators per domain (e.g., measures of
crystallized cognitive abilities) would likely paint a more refined
profile landscape. In particular, the measure of social integration
did not capture all aspects of what it means to be socially inte-
grated. Social integration is not just a lack of loneliness and feeling
a part of a group, but also being involved in an array of activities
and relationships with significant others (Cohen, 2004). As well,
we made use of linear change scores derived from biyearly re-
peated measures. Shorter time intervals and more frequent obser-
vations would allow for more refined assessments of within-person
change to put into the profile analyses. Particularly informative
may be change measures that quantify differences in the timing,
tempo, and asymmetry of developmental changes (see Grimm &
Ram, 2009; Visser, 2011). In this context, we also note that our
analyses of time-varying predictors (e.g., functional limitations)
did not allow for disentangling whether these served as precursors
or consequences of psychosocial profiles. We can only infer that
changes in psychosocial profiles were accompanied by changes in
functional health. In addition to the constraints invoked by the
available repeated measures, results found in our positively select
subpopulation of the oldest old in Sweden may not necessarily
generalize to other population segments. For example, participants
in the sample consistently reported very low levels of depressive
symptoms, which may not well characterize certain subpopulations
and/or the diversity of nations such as the United States where
tremendous differences prevail in socioeconomic, ethnic, and re-
source backgrounds. Finally, our pooling method did not allow for
description of how subgroups emerge and change over late adult-
hood. From the follow-up LPAs conducted on the younger and
older portions of the sample, it is possible that the number of
subgroups decreases with age, and this should be explored in more
detail in future work.
In closing, we note that our study departed from the Rowe and
Kahn (1997) model in several important ways. First, we defined
successful aging based entirely on psychosocial domains of func-
tioning. It was only in a second step that other key domains such
as physical health were considered. Second, rather than operation-
ally defining successful aging in a cross-sectional manner, we
directly modeled multiwave longitudinal data in three key domains
to identify groups of people who age more or less successfully.
Making use of a subgroup-oriented approach, our results revealed
four successful and less successful aging profiles with distinct
trajectories of change across indicators of depressive symptoms,
social integration, and memory. These profiles were also differen-
tiated by sociodemographic characteristics, functional limitations,
and mortality hazards that may have served as antecedents, corre-
lates, or consequences of the profile trajectories. We take these
insights to illustrate the utility of using multiple-indicator infor-
mation at the person level in advancing our understanding of the
differential aging and successful aging of individuals. Results also
provide impetus to further address the promises and challenges of
a subgroup-oriented approach.
References
Aldwin, C. M., Spiro, A., Levenson, M. R., & Cupertino, A. P. (2001).
Longitudinal findings from the Normative Aging Study: III. Personality,
individual health trajectories, and mortality. Psychology and Aging, 16,
450 – 465. doi:10.1037/0882-7974.16.3.450
Allison, P. D. (1995). Survival analysis using the SAS system: A practical
guide. Cary, NC: SAS Institute.
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2319PSYCHOLOGICAL PROFILES AND SUCCESSFUL AGING
Andrews, G., Clark, M., & Luszcz, M. (2002). Successful aging in the
Australian Longitudinal Study of Aging: Applying the MacArthur model
cross-nationally. Journal of Social Issues, 58, 749 –765. doi:10.1111/
1540-4560.00288
Baltes, P. B. (1987). Theoretical propositions of life-span developmental
psychology: On the dynamics between growth and decline. Develop-
mental Psychology, 23, 611– 626. doi:10.1037/0012-1649.23.5.611
Baltes, P. B., & Baltes, M. M. (Eds.). (1990). Successful aging: Perspec-
tives from the behavioral sciences. New York, NY: Cambridge Univer-
sity Press.
Baltes, P. B., Lindenberger, U., & Staudinger, U. M. (2006). Life-span
theory in developmental psychology. In R. M. Lerner & W. Damon
(Eds.), Handbook of child psychology: Vol. 1. Theoretical models of
human development (6th ed., pp. 569 – 664). New York, NY: Wiley.
Berkman, L. F., Glass, T., Brissette, I., & Seeman, T. E. (2000). From
social integration to health: Durkheim in the new millennium. Social
Science & Medicine, 51, 843– 857. doi:10.1016/S0277-9536(00)00065-4
Berkman, L. F., Seeman, T. E., Albert, M., Blazer, D., Kahn, R., Mohs, R.,
. . . Rowe, J. (1993). High, usual and impaired functioning in
community-dwelling older men and women: Findings from the MacAr-
thur Foundation Research Network on Successful Aging. Journal of
Clinical Epidemiology, 46, 1129 –1140. doi:10.1016/0895-
4356(93)90112-E
Birren, J. E. (1959). Principles of research on aging. In J. E. Birren (Ed.),
Handbook of aging and the individual: Psychological and biological
aspects (pp. 3– 42). Chicago, IL: University of Chicago Press.
Bosworth, H. B., & Schaie, K. W. (1997). The relationship of social
environment, social networks, and health outcomes in the Seattle Lon-
gitudinal Study: Two analytical approaches. Journals of Gerontology:
Series B. Psychological Sciences and Social Sciences, 52, P197–P205.
doi:10.1093/geronb/52B.5.P197
Cacioppo, J. T., Hawkley, L. C., Norman, G. J., & Bernsten, G. C. (2011).
Social isolation. Annals of the New York Academy of Sciences, 1231,
17–22. doi:10.1111/j.1749-6632.2011.06028.x
Cohen, S. (2004). Social relationships and health. American Psychologist,
59, 676 – 684. doi:10.1037/0003-066X.59.8.676
Cox, D. R. (1972). Regression models and life-tables. Journal of the Royal
Statistical Society: Series B. Methodological, 34, 187–220.
Dannefer, D. (2003). Cumulative advantage/disadvantage and the life
course: Cross-fertilizing age and social science theory. Journals of
Gerontology: Series B. Psychological and Social Sciences, 58, S327–
S337. doi:10.1093/geronb/58.6.S327
Depp, C. A., & Jeste, D. V. (2006). Definitions and predictors of successful
aging: A comprehensive review of larger quantitative studies. American
Journal of Geriatric Psychiatry, 14, 6 –20. doi:10.1097/01.JGP
.0000192501.03069.bc
Diener, E., & Seligman, M. E. (2002). Very happy people. Psychological
Science, 13, 81– 84. doi:10.1111/1467-9280.00415
Estes, W. K. (1956). The problem of inference from curves based on group
data. Psychological Bulletin, 53, 134 –140. doi:10.1037/h0045156
Evert, J., Lawler, E., Bogan, H., & Perls, T. (2003). Morbidity profiles of
centenarians: Survivors, delayers, and escapers. Journals of Gerontol-
ogy: Series A. Biological Sciences and Medical Sciences, 58, M232–
M237. doi:10.1093/gerona/58.3.M232
Fauth, E. B., Zarit, S. H., & Malmberg, B. (2008). Mediating relationships
within the disablement process model: A cross-sectional study of the
oldest-old. European Journal of Ageing, 5, 161–179. doi:10.1007/
s10433-008-0092-6
Fauth, E. B., Zarit, S. H., Malmberg, B., & Johansson, B. (2007). Physical,
cognitive, and psychosocial variables from the disablement process
model predict patterns of change in disability for the oldest-old. Geron-
tologist, 47, 613– 624. doi:10.1093/geront/47.5.613
Femia, E. E., Zarit, S. H., & Johansson, B. (2001). The disablement process
in very late life: A study of the oldest-old in Sweden. Journals of
Gerontology: Series B. Psychological Sciences and Social Sciences, 56,
P12–P23. doi:10.1093/geronb/56.1.P12
Fiori, K. L., Antonucci, T. C., & Cortina, K. S. (2006). Social network
typologies and mental health among older adults. Journals of Gerontol-
ogy: Series B. Psychological Sciences and Social Sciences, 61, P25–P32.
doi:10.1093/geronb/61.1.P25
Fiori, K. L., & Jager, J. (2012). Social support networks and health across
the lifespan: A longitudinal, pattern-centered approach. International
Journal of Behavioral Development, 36, 117–129. doi:10.1177/
0165025411424089
Fiori, K. L., Smith, J., & Antonucci, T. C. (2007). Social network types
among older adults: A multidimensional approach. Journals of Geron-
tology: Series B. Psychological Sciences and Social Sciences, 62, P322–
P330. doi:10.1093/geronb/62.6.P322
Fiske, A., & Gatz, M. (2007). The Apartment Test: Validity of a memory
measure. Aging, Neuropsychology, and Cognition, 14, 441– 461. doi:
10.1080/13825580600611294
Garfein, A. J., & Herzog, A. R. (1995). Robust aging among the young-old,
old-old, and oldest-old. Journals of Gerontology: Series B. Psycholog-
ical Sciences and Social Sciences, 50, S77–S87. doi:10.1093/geronb/
50B.2.S77
Gerstorf, D., Lövdén, M., Röcke, C., Smith, J., & Lindenberger, U. (2007).
Well-being affects changes in perceptual speed in advanced old age:
Longitudinal evidence for a dynamic link. Developmental Psychology,
43, 705–718. doi:10.1037/0012-1649.43.3.705
Gerstorf, D., Ram, N., Mayraz, G., Hidajat, M., Lindenberger, U., Wagner,
G. G., & Schupp, J. (2010). Late-life decline in well-being across
adulthood in Germany, the United Kingdom, and the United States:
Something is seriously wrong at the end of life. Psychology and Aging,
25, 477– 485. doi:10.1037/a0017543
Gerstorf, D., Smith, J., & Baltes, P. B. (2006). A systemic–wholistic
approach to differential aging: Longitudinal findings from the Berlin
Aging Study. Psychology and Aging, 21, 645– 663. doi:10.1037/0882-
7974.21.4.645
Gibson, W. A. (1959). Three multivariate models: Factor analysis, latent
structure analysis, and latent profile analysis. Psychometrika, 24, 229 –
252. doi:10.1007/BF02289845
Gold, C. H., Malmberg, B., McClearn, G. E., Pedersen, N. L., & Berg, S.
(2002). Gender and health: A study of unlike gender twins. Journals of
Gerontology: Series B. Psychological Sciences and Social Sciences, 57,
S168 –S176. doi:10.1093/geronb/57.3.S168
Grimm, K. J., & Ram, N. (2009). Nonlinear growth models in Mplus and
SAS. Structural Equation Modeling, 16, 676 –701. doi:10.1080/
10705510903206055
Hsu, H.-C., & Jones, B. L. (2012). Multiple trajectories of successful aging
of older and younger cohorts. The Gerontologist, 52, 843– 856. doi:
10.1093/geront/gns005
Johansson, B. (1988/1989). The MIR–Memory in Reality Test. Stockholm,
Sweden: Psykologiförlaget.
Johansson, B., & Zarit, S. H. (1995). Prevalence and incidence of dementia
in the oldest-old: A longitudinal study of a population-based sample of
84 –90-year-olds in Sweden. International Journal of Geriatric Psychi-
atry, 10, 359 –366. doi:10.1002/gps.930100504
Jorm, A. F., Christensen, H., Henderson, A. S., Jacomb, P. A., Korten,
A. E., & Mackinnon, A. (1998). Factors associated with successful
ageing. Australasian Journal on Ageing, 17, 33–37. doi:10.1111/j.1741-
6612.1998.tb00222.x
Katz, S., Ford, A. B., Moskowitz, R. W., Jackson, B. A., & Jaffe, M. W.
(1963). Studies of illness and the aged: The index of ADL: A standard-
ized measure of biological and psychosocial function. Journal of the
American Medical Association, 185, 914 –923. doi:10.1001/jama.1963
.03060120024016
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2320 MORACK, RAM, FAUTH, AND GERSTORF
Ko, K. J., Berg, C. A., Butner, J., Uchino, B. N., & Smith, T. W. (2007).
Profiles of successful aging in middle-aged and older married couples.
Psychology and Aging, 22, 705–718. doi:10.1037/0882-7974.22.4.705
Lanza, S., Flaherty, B. P., & Collins, L. M. (2003). Latent class and latent
transition analysis. In J. A. Schinka & W. F. Velicer (Eds.), Handbook
of psychology: Research methods in psychology (Vol. 2, pp. 663– 685).
New York, NY: Wiley.
Lawton, M. P. (1971). The functional assessment of older people. Journal
of the American Geriatric Society, 19, 465– 481.
Lawton, M. P. (1983). Environment and other determinants of well-being
in older people. The Gerontologist, 23, 349 –357. doi:10.1093/geront/23
.4.349
Littell, R. C., Milliken, G. A., Stroup, W. W., Wolfinger, R. D., &
Schabenberger, O. (2006). SAS for mixed models (2nd ed.). Cary, NC:
SAS Institute.
Little, R. J. A., & Rubin, D. B. (1987). Statistical analysis with missing
data. New York, NY: Wiley.
Litwin, H. (1995). The social networks of elderly immigrants: An analytic
typology. Journal of Aging Studies, 9, 155–174. doi:10.1016/0890-
4065(95)90009-8
Litwin, H. (2001). Social network type and morale in old age. The Ger-
ontologist, 41, 516 –524. doi:10.1093/geront/41.4.516
Lo, Y., Mendell, N. R., & Rubin, D. B. (2001). Testing the number of
components in a normal mixture. Biometrika, 88, 767–778. doi:10.1093/
biomet/88.3.767
Lövdén, M., Bergman, L., Adolfsson, R., Lindenberger, U., & Nilsson,
L.-G. (2005). Studying individual aging in an interindividual context:
Typical paths of age-related, dementia-related, and mortality-related
cognitive development in old age. Psychology and Aging, 20, 303–316.
doi:10.1037/0882-7974.20.2.303
Lövdén, M., Ghisletta, P., & Lindenberger, U. (2005). Social participation
attenuates decline in perceptual speed in old and very old age. Psychol-
ogy and Aging, 20, 423– 434. doi:10.1037/0882-7974.20.3.423
Lucas, R. E. (2007). Adaptation and the set-point model of subjective
well-being: Does happiness change after major life events? Current
Directions in Psychological Science, 16, 75–79. doi:10.1111/j.1467-
8721.2007.00479.x
Maggs, J. L., & Schulenberg, J. (2004/2005). Trajectories of alcohol use
during the transition to adulthood. Alcohol Research & Health, 28,
195–201.
Magnusson, D. (1998). The logic and implication of a person approach. In
R. B. Cairns, L. R. Bergman, & J. Kagan (Eds.), Methods and models for
studying the individual (pp. 33– 63). Thousand Oaks, CA: Sage.
Malmberg, B. (1990). Access to resources in different age-cohorts: Impli-
cations for activity level, loneliness and life satisfaction (Unpublished
doctoral dissertation). Linköping University, Linköping, Sweden.
Manton, K. G., & Land, K. C. (2000). Multidimensional disability/
mortality trajectories at ages 65 and over: The impact of state depen-
dence. Social Indicators Research, 51, 193–221. doi:10.1023/A:
1006966525964
Manton, K. G., Siegler, I. C., & Woodbury, M. A. (1986). Patterns of
intellectual development in later life. Journal of Gerontology, 41, 486 –
499. doi:10.1093/geronj/41.4.486
Maxson, P. J., Berg, S., & McClearn, G. (1996). Multi-dimensional pat-
terns of aging in 70-year-olds: Survival differences. Journal of Aging
and Health, 8, 320 –333. doi:10.1177/089826439600800302
McArdle, J. J., & Nesselroade, J. R. (2003). Growth curve analysis in
contemporary psychological research. In J. Schinka & W. Velicer (Eds.),
Comprehensive handbook of psychology: Volume 2. Research methods
in psychology (pp. 447– 480). New York, NY: Pergamon Press.
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. doi:10.1126/science.276.5318.1560
Muthén, B. (2002). Beyond SEM: General latent variable modeling. Be-
haviormetrika, 29, 81–117. doi:10.2333/bhmk.29.81
Muthén, B. (2004). Latent variable analysis. Growth mixture modeling and
related techniques for longitudinal data. In D. Kaplan (Ed.), The Sage
handbook of quantitative methodology for the social sciences (pp. 345–
368). Thousand Oaks, CA: Sage.
Muthén, L. K., & Muthén, B. O. (2006). Mplus user’s guide (4th ed.). Los
Angeles, CA: Muthén & Muthén.
Nagin, D. S., & Odgers, C. L. (2010). Group-based trajectory modeling in
clinical research. Annual Review of Clinical Psychology, 6, 109 –138.
doi:10.1146/annurev.clinpsy.121208.131413
Nagin, D., & Tremblay, R. E. (1999). Trajectories of boys’ physical
aggression, opposition, and hyperactivity on the path to physically
violent and nonviolent juvenile delinquency. Child Development, 70,
1181–1196. doi:10.1111/1467-8624.00086
Neugarten, B. L., Havighurst, R. J., & Tobin, S. S. (1968). Personality and
patterns of aging. In B. L. Neugarten (Ed.), Middle age and aging (pp.
173–177). Chicago, IL: University of Chicago Press.
Nylund, K. L., Asparouhov, T., & Muthén, B. (2007). Deciding on the
number of classes in latent class analysis and growth mixture modeling:
A Monte Carlo simulation study. Structural Equation Modeling, 14,
535–569. doi:10.1080/10705510701575396
Radloff, L. S. (1977). The CES-D Scale: A self-report depression scale for
research in the general population. Applied Psychological Measurement,
1, 385– 401. doi:10.1177/014662167700100306
Ram, N., & Grimm, K. J. (2007). Using simple and complex growth
models to articulate developmental change: Matching method to theory.
International Journal of Behavioral Development, 31, 303–316. doi:10
.1177/0165025407077751
Ram, N., & Grimm, K. J. (2009). Growth mixture modeling: A method for
identifying differences in longitudinal change among unobserved
groups. International Journal of Behavioral Development, 33, 565–576.
doi:10.1177/0165025409343765
Ram, N., Grimm, K. J., Gatzke-Kopp, L. M., & Molenaar, P. C. M. (2012).
Longitudinal mixture models and the identification of archetypes. In B.
Laursen, T. D. Little, & N. A. Card (Eds.) Handbook of developmental
research methods (pp. 481–500). New York, NY: Guilford Press.
Riley, M. W. (1987). Aging, health, and social change: An overview. In
M. W. Riley & J. D. Matarazzo (Eds.), The aging dimension: Perspec-
tives in behavioral medicine (pp. 1–14). Hillsdale, NJ: Erlbaum.
Rowe, J. W., & Kahn, R. L. (1997). Successful aging. The Gerontologist,
37, 433– 440. doi:10.1093/geront/37.4.433
Russell, D. (1982). The measurement of loneliness. In L. A. Peplau & D.
Perlman (Eds.), Loneliness: A sourcebook of current theory, research
and therapy (pp. 81–104). New York, NY: Wiley.
Ryff, C. D., & Singer, B. (1998). The contours of positive human health.
Psychological Inquiry, 9, 1–28. doi:10.1207/s15327965pli0901_1
SAS Institute. (1997). SAS/STAT software: Changes and enhancements
through Release 6.12. San Diego, CA: Academic Press.
Seeman, T. E., & Crimmins, E. (2001). Social environment effects on
health and aging. Annals of the New York Academy of Sciences, 954,
88 –117. doi:10.1111/j.1749-6632.2001.tb02749.x
Singer, B., Ryff, C. D., Carr, D., & Magee, W. J. (1998). Linking life
histories and mental health: A person-centered strategy. Sociological
Methodology, 28, 1–51. doi:10.1111/0081-1750.00041
Singer, J. D., & Willett, J. B. (2003). Applied longitudinal data analysis:
Methods for studying change and event occurrence. New York, NY:
Oxford University Press.
Smith, J., & Baltes, M. M. (1998). The role of gender in very old age:
Profiles of functioning and everyday life patterns. Psychology and
Aging, 13, 676 – 695. doi:10.1037/0882-7974.13.4.676
Smith, J., & Baltes, P. B. (1997). Profiles of psychological functioning in
the old and oldest old. Psychology and Aging, 12, 458 – 472. doi:
10.1037/0882-7974.12.3.458
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2321PSYCHOLOGICAL PROFILES AND SUCCESSFUL AGING
Visser, I. (2011). Seven things to remember about hidden Markov models:
A tutorial on Markovian models for time series. Journal of Mathematical
Psychology, 55, 403– 415. doi:10.1016/j.jmp.2011.08.002
Wickrama, K. A. S., Mancini, J. A., Kwag, K., & Kwon, J. (2012).
Heterogeneity in multidimensional health trajectories of late old years
and socioeconomic stratification: A latent trajectory class analysis. Jour-
nals of Gerontology: Series B. Psychological Sciences and Social Sci-
ences, 68, 290 –297. doi:10.1093/geronb/gbs111
Wong, J. D., & Hardy, M. A. (2009). Women’s retirement expectations:
How stable are they? Journals of Gerontology: Series B. Psycholog-
ical Sciences and Social Sciences, 64, 77– 86. doi:10.1093/geronb/
gbn010
Zarit, S. H., Johansson, B., & Berg, S. (1993). Functional impairment and
co-disability in the oldest old: A multidimensional approach. Journal of
Aging and Health, 5, 291–305. doi:10.1177/089826439300500301
Appendix
Examples of Studies Applying a Subgroup- or Subgroup-Oriented Approach
Study Wave N Group defining domains External variables Grouping method Group findings
Cross-sectional studies
Kansas City Study of
Adult Life
(Neugarten et al.,
1968)
1 59 Activity, personality, well-
being
Predefined top-down
procedure
Eight groups characterized
primarily by personality
and also activity and well-
being
MacArthur Studies on
Successful Aging
(Berkman et al.,
1993)
1 1,354 Cognition, functional health Psychosocial,
physiological,
sociodemographic
Predefined by
successful aging
criteria
Three groups: high, middle,
and low functioning
Swedish Octogenarian
study (Zarit et al.,
1993)
1 320 Cognition, functional
health, sensory
functioning
Examination of
disability base
rates and degree
of codisability
Three groups: no significant
impairments, impairments
in instrumental activities
of daily living only, and
codisability
Americans’ Changing
Lives Survey
(Garfein & Herzog,
1995)
1 1,644 Cognition, functional
health, productivity,
well-being
Health, personality,
psychosocial,
sociodemographic
Predefined robust
aging criteria for
each domain
Groups identified for each
domain (four groups for
each domain except
functional health with five
groups)
Data from study on
Russian Jewish
immigrants in
Israel (Litwin,
1995)
1 259 Social network Social support,
sociodemographic
Cluster analysis Four social network types
Seattle Longitudinal
Study (Bosworth &
Schaie, 1997)
1 387 Social integration Health,
sociodemographic
Cluster analysis Four groups characterized
by levels of social
integration
Berlin Aging Study
(Smith & Baltes,
1997)
1 510 Cognition, self and
personality, social
integration
Health, mortality,
sociodemographic,
well-being
Cluster analysis Nine groups characterized
by differing levels across
all group defining
domains
Epidemiological
survey in Canberra
(Jorm et al., 1998)
1 997 Cognition, health Health habits,
personality,
sociodemographic,
verbal intelligence
Predefined by
successful aging
criteria
Three groups: successful
aging, usual aging, and
diseased aging
Berlin Aging Study
(Smith & Baltes,
1998)
1 508 Cognition, health, self and
personality, socioeconomic
status, social integration,
well-being
Age, gender Cluster analysis Eleven groups characterized
by differing levels across
all group defining
domains; categorized by
desirability level
(Appendix continues)
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2322 MORACK, RAM, FAUTH, AND GERSTORF
Appendix (continued)
Study Wave N Group defining domains External variables Grouping method Group findings
Data from Israeli
Central Bureau of
Statistics (Litwin,
2001)
1 2,079 Social network Morale,
sociodemographic
Cluster analysis Five social network types
Australian
Longitudinal Study
of Aging (Andrews
et al., 2002)
1 1,043 Cognition, functional health Health, lifestyle,
psychological
status,
sociodemographic
Predefined by
successful aging
criteria
Three groups: higher,
intermediate, and lower
functioning
New England
Centenarian Study
(Evert et al., 2003)
1 424 Health Gender Predefined top-down
procedure
Three groups
characterized by age of
onset of age-related
illness
Americans’ Changing
Lives Study (Fiori
et al., 2006)
1 1,669 Social network Mental health,
sociodemographic
Cluster analysis Five social network types
Berlin Aging Study
(Fiori et al., 2007)
1 516 Social network Morbidity,
sociodemographic,
well-being
Cluster analysis Six social network types
Health and Aging
Study (Ko et al.,
2007)
1 287
couples
Cognition, health,
personality, social
support
Age, well-being Latent profile
analysis
Two- and four-group
solutions characterized
by differing degrees of
successful aging
Wisconsin
Longitudinal Study
(Fiori & Jager,
2012)
1 6,824 Social support Mental and
physical health,
sociodemographic
Latent class analysis Six groups: differing
social support networks
Longitudinal studies
Duke Longitudinal
Study of Aging
(Manton et al.,
1986)
11 267 Cognition Mental health,
physical health,
sociodemographic
Grade of
membership
model
Five groups characterized
by differing cognitive
abilities over time
Health-70 Study
(Maxson et al.,
1996)
3 335 Cognition, health, social
contacts, well-being
Mortality,
socioeconomic
status, gender
Cluster analysis Five groups characterized
by differing levels
across all group
defining domains
Wisconsin
Longitudinal Study
(Singer et al.,
1998)
3 1,172 Depression, well-being Multiple life
history variables
Predefined by
history of
depression and
current well-being
Four groups: depressed/
unwell, healthy,
vulnerable, and resilient
National Long-Term
Health Survey
(Manton & Land,
2000)
4 20.000 Functional health Medical conditions,
mortality, gender
Grade of
membership
model
Seven groups
characterized by
disability state
Normative Aging
Study (Aldwin et
al., 2001)
4 1,515 Mental and physical health Health behaviors,
mortality,
personality,
sociodemographic
Cluster analysis Four mental health groups
and six physical health
groups characterized by
health trajectories
Betula Study (Lövdén
et al., 2005)
3 500 Cognition Age, education,
gender
Cluster analysis Six baseline groups
characterized by
differing cognitive
levels; stable
membership
Berlin Aging Study
(Gerstorf et al.,
2006)
3 132 Cognition, self and
personality, social
integration
Health, mortality,
sociodemographic,
well-being
Cluster analysis Three baseline groups
characterized by
differing levels across
all group defining
domains; fairly stable
over time
National Longitudinal
Survey of Mature
Women (Wong &
Hardy, 2009)
4 1,064 Retirement expectations Employment,
health,
sociodemographic
Latent class analysis Four groups characterized
by retirement
expectation patterns
(Appendix continues)
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2323PSYCHOLOGICAL PROFILES AND SUCCESSFUL AGING
Received September 5, 2012
Revision received December 4, 2012
Accepted December 12, 2012 �
New Editors Appointed, 2015–2020
The Publications and Communications Board of the American Psychological Association an-
nounces the appointment of 6 new editors for 6-year terms beginning in 2015. As of January 1,
2014, manuscripts should be directed as follows:
● Behavioral Neuroscience (http://www.apa.org/pubs/journals/bne/), Rebecca Burwell, PhD,
Brown University
● Journal of Applied Psychology (http://www.apa.org/pubs/journals/apl/), Gilad Chen, PhD,
University of Maryland
● Journal of Educational Psychology (http://www.apa.org/pubs/journals/edu/), Steve Graham,
EdD, Arizona State University
● JPSP: Interpersonal Relations and Group Processes (http://www.apa.org/pubs/journals/psp/),
Kerry Kawakami, PhD, York University, Toronto, Ontario, Canada
● Psychological Bulletin (http://www.apa.org/pubs/journals/bul/), Dolores Albarracín, PhD,
University of Pennsylvania
● Psychology of Addictive Behaviors (http://www.apa.org/pubs/journals/adb/), Nancy M. Petry,
PhD, University of Connecticut School of Medicine
Electronic manuscript submission: As of January 1, 2014, manuscripts should be submitted
electronically to the new editors via the journal’s Manuscript Submission Portal (see the website
listed above with each journal title).
Current editors Mark Blumberg, PhD, Steve Kozlowski, PhD, Arthur Graesser, PhD, Jeffry
Simpson, PhD, Stephen Hinshaw, PhD, and Stephen Maisto, PhD, will receive and consider new
manuscripts through December 31, 2013.
Appendix (continued)
Study Wave N Group defining domains External variables Grouping method Group findings
Taiwan Longitudinal
Survey on Aging
(Hsu & Jones,
2012)
4–5 4,817 Chronic disease, depressive
symptoms, economic
satisfaction, physical
functioning, social
support and participation
Life satisfaction,
self-rated health,
sociodemographic
Multiple trajectory
model analysis
Four successful aging
groups each for a
younger and an older
cohort
Health and
Retirement Study
(Wickrama et al.,
2012)
5 1,945 Depressive symptoms,
memory problems,
physical illness, physical
impairment
Socioeconomic
status (childhood
and adult),
sociodemographic
Latent trajectory
class analysis
Three groups with
different
multidimensional health
patterns
T
hi
s
do
cu
m
en
t
is
co
py
ri
gh
te
d
by
th
e
A
m
er
ic
an
P
sy
ch
ol
og
ic
al
A
ss
oc
ia
ti
on
or
on
e
of
it
s
al
li
ed
pu
bl
is
he
rs
.
T
hi
s
ar
ti
cl
e
is
in
te
nd
ed
so
le
ly
fo
r
th
e
pe
rs
on
al
us
e
of
th
e
in
di
vi
du
al
us
er
an
d
is
no
t
to
be
di
ss
em
in
at
ed
br
oa
dl
y.
2324 MORACK, RAM, FAUTH, AND GERSTORF
REVIEW Open Access
On the ethics of healthy ageing: setting
impermissible trade-offs relating to the
health and well-being of older adults on
the path to universal health coverage
Kebadu Mekonnen Gebremariam1* and Ritu Sadana2
Abstract
This article aims to clarify the moral underpinning of the policy framework of Healthy Ageing. It is a policy adopted
by the World Health Organization designed to operate in alignment with the United Nations (UN) framework of the
Sustainable Development Goals (SDGs) and the urgency given for the achievement of Universal Health Coverage
(UHC). It particularly reflects on what, if anything, justifies protecting the most basic rights to health and well-being
of older adults from possible policy trade-offs on the path to UHC.
It argues that the dignity of older adults―under which are nested more specific ideas of self-respect, respect for
autonomy, as well as the ethical priority for living well―underpins a categorical moral injunction against imposing
the familiar utilitarian calculus as the default criterion for policy trade-offs across age groups. Respect for the dignity
of older persons marks the moral threshold that every society ought to uphold even under conditions of relative
resource scarcity.
The moral constraint on permissible policy trade-offs relating to the health of older adults must reflect an understanding
of older persons as active agents in the social structure of (their) well-being, not merely as passive vessels through which
a good healthy life may or may not occur. We argue that there are three main domains where trade-offs are
unacceptable from the moral point of view: it is impermissible (1) to prioritise key service(s) across different
(vulnerable) age groups on the basis of actual or future contribution to society, (2) to prioritise across different age
groups when co-prioritisation is warranted by the ethical theory, and (3), to always prioritise (by default) services that
improve well-being over those that foster respect for dignity and autonomy.
Keywords: Healthy ageing, Impermissible trade-offs, Dignity, Autonomy, Living-well
Introduction
Context and focus
Demographic landscape
Research has indicated that as of 2018 the number of
older persons aged 60 or over reached 1 billion for the
first time [1] and, projections showed that, by the year
2030 there will be more older people than the number
of children under 9. While in 2015 about 13% of the
global population was 60 years and above, which is
expected to almost double by 2050 and to more than triple
by 2100, rising from 962 million in 2017 to 2.1 billion in
2050 and 3.1 billion older adults in 2100 [2]. That means
by the year 2050 there will be 106 older persons for every
100 children in the world. In China, for example, the
proportion of older persons is expected to rise to 33.9%
of the total population in 2050 (SAGE China Wave 1),
whereas in India the proportion is expected to reach
19% by 2050 (SAGE India report). Regional differences
are also projected to widen, where for instance European
population aged 60-plus will hit 34% by 2050 while, in
contrast, the proportion in sub-Saharan Africa is expected
to be much lower [3].
In developing countries, increased life expectancy is
due largely to actions against the major causes of
© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
* Correspondence: kebadum@gmail.com
1Department of Philosophy, Addis Ababa University, Algeria St, P.O.Box 1176,
Addis Ababa, Ethiopia
Full list of author information is available at the end of the article
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140
https://doi.org/10.1186/s12939-019-0997-z
mortality at younger ages, the success of which is made
sustainable by development programs that helped raise
hundreds of millions of people out of abject poverty.
The convergence of significantly reduced infant and
maternal mortality with an improved overall wellbeing
results in the fact that most people can now expect to
live longer. In high income countries where life expec-
tancy has been on the ascending since the industrial
revolution, continuing increases in longevity are now
mainly attributed to the improvement and maintenance
of well-being at older ages.
This demographic transition to older population age
structures will certainly catalyse profound social and
economic changes and challenges, with direct impli-
cation for health and sustainable development exacer-
bating the already complex problems regarding the
establishment of just and sustainable institutions. On
average the global life expectancy at age 60 is esti-
mated to be 20 additional years [4]. However, global
averages are deceptive as they mask absolute differ-
ences in health status across and within countries
with respect to life expectancy as well as risk to dis-
ease and disabilities at older age. Research indicated
that between countries there is a range of 38 years for
life expectancy at birth, 37 years for healthy life expect-
ancy at birth, and 13 years for life expectancy at age 60
and above [5]. In a similar vein, care needs are far higher
for people older than 65 years living in sub-Saharan Africa
than people of similar ages in more developed countries.
According to WHO estimates, in Ghana more than 50%
of people between the age of 65 and 75 years require as-
sistance with daily activities, while the percentage
jumps to 65% for those 75 years and older. In South
Africa, more than 35 and 45% respectively require as-
sistance; whereas in Switzerland, of those at similar ages,
the percentage is less than 5 and 20%, respectively [6]. As
these examples demonstrate, at older age the people with
the greatest health needs tend to also be those with the
least access to institutional, social and financial resources
that might help to meet them [7]. Most of the available
care for older persons in sub-Saharan Africa is provided
by families where female relatives constitute the over-
whelming majority of care givers [8]. The upshot is that,
given existing health inequities partly driven by socio-
economic disadvantages accumulated over the life course,
urgent action is needed at all critical stages in life, without
at the same time neglecting the legitimate claims and
most pressing needs of older adults [9].
Commitments As part of the effort at operationalising
the UN Sustainable Development Goals (SDGs) that are
of particular relevance to health, such as “Goal 3: Ensure
healthy lives and promote wellbeing for all at all ages”,
all UN Member States unanimously pledged to commit
to the achievement of universal health coverage (UHC)
by 2030. UHC is consequently defined as a system of
ensuring that all people can use the promotive, preven-
tive, curative, rehabilitative and palliative health services
they need, of sufficient quality to be effective, while also
ensuring that the use of these services does not expose
individuals to financial hardship [10]. Achieving UHC is
one of the key policy objectives set by the global com-
munity aimed at ameliorating the critical gap that figures
the commitment to ensure the highest achievable health
at all ages is measured against the reality of extreme
inequalities in access to health within and across so-
cieties. According to the World Health Organization’s
factsheet on UHC, the figures for 2016 indicate that at
least 400 million people globally lack access to one or
more essential health services. In addition, every year an
estimated 100 million people are pushed into poverty
and 150 million people suffer financial catastrophe due
to out-of-pocket expenditure on health services, wherein
out-of-pocket payments constitute on average 32% of
each country’s health expenditure [11]. Households with
older persons over the age of 50 are often hit by fi-
nancial hardships much harder than households with
younger age groups. That is because ageing correlated
multiple morbidities and the corresponding need for
health care is unmatched by insufficient resources owing
to the gradual decline in household income. Despite that
and contrary to conventional wisdom, scientific data in-
dicated that the ageing of people could be affordable and
could be of great benefit for both developing and deve-
loped countries due to the social capital of older adults
as well as accrued wealth across the longer life-course
(hence the talk of a third demographic dividend) [12].
Health policies and strategies The stated global com-
mitment to ensure UHC subsequently requires that each
country establishes a fair and equitable path to UHC
through a national strategy and action plan that operates
in alignment with the global commitments, while at the
same time being specific enough to respond to the
country’s unique situation. In response to challenges
specific to improving the health and well-being of
older adults, the World Health Organization sought to
provide technical support by producing a number of
global strategic frameworks, reports and policy guidelines.
Some of those documents specifically respond to the
most pressing need to render existing services suffi-
ciently inclusive of older adults, which does not just
mean providing them with greater access to services that
are designed for younger adults [13]. Whereas a just
distribution of resources can be effected within nations
and efficiency improved, for most countries the ratio of
resources to need will nevertheless remain to have
significant disparity. In balancing such disparity, critical
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 2 of 16
choices are to be made concerning which services to
prioritise and who to include first. That requires a prin-
cipled guideline on setting priorities and on distinguish-
ing the set of services that can possibly be traded-off
from those services deemed to be most basic that
their provision is morally required under all conceiv-
able circumstances.
Since this article is principally concerned with demar-
cating the moral boundaries of permissible trade-offs
involving the health and wellbeing of older persons,
three principal WHO documents immediately fall within
its purview. These are, the final Report of the WHO
Consultative Group on Equity and Universal Health
Coverage (2014), the 2015 World Report on Ageing and
Health, and the Global Strategy and action plan on
ageing and health (2016). This is not to say that regional
policy frameworks or national legislations relevant to
older people have little significance for strengthening the
rights to health and wellbeing of older persons. How-
ever, most regional or national policies and legislations
overlook significant aspects of the need to put in place a
principled path to priority setting and policy trade-offs.
Although national constitutions and regional protocols
provided an important framework for anchoring the
rights of older persons, only a handful made explicit
reference to older persons’ protective status–for in-
stance, the Constitution of Philippines designates
older people as a priority group, while underscoring
the need for employing a holistic approach to their
health (Government of the Philippines, 1987).
Ethical guidance is required precisely because no over-
arching framework for priority setting and trade-offs is
available that is specific to the right to health of older
persons. Whereas the WHO framework on trade-offs is
grounded on prioritising services not age groups, and
that a reference to prioritising the ‘worse-off’ often blurs
the distinction between economic inequalities and in-
equalities in health status on the one hand, and between
absolute and relative worseness on the other.
Ethical guidance The ethical guidance that this article
advances shall draw from important conceptual distinc-
tions in moral philosophy; more substantive debates
regarding health inequalities and inequities and what it
means to optimise the use of limited resources; and from
moral and legal analyses relating to the normative im-
plications of defining health as a right. We shall not
carry out a comprehensive theoretical repackaging of all
WHO documents relating to ageing and health, only
those whose underlying ethos is relevant to priority
setting. To that effect, we recognise that a compre-
hensive conceptual groundwork is needed, a task that
admittedly lies outside the scope of this article. We
do, however, believe that the arguments advanced
here should be central to such undertaking and the
analytical approach used here sets the tone for the
future task of developing a comprehensive normative
framework underpinning the WHO framework for
ageing and health.
The proposed ethical guidance begins by expounding
the overarching conceptual scheme within which the
WHO’s operative term―Healthy Ageing is to be found,
then identifies the specific area where the WHO’s
approach to ageing and health needs some basic ethical
guidance. It highlights the urgency not to lose sight of
important ethical or moral concerns attached to how
older persons ought to be treated, including which
interests of theirs to be taken seriously by their
fellows, either in their personal standing as free and
equal members of the moral community or in their
shared fellowship and the solidarity expressed through
the apparatus of the state.
There is a perceptible gap between the WHO’s
conceptual model for Healthy Ageing and the afore-
mentioned WHO documents that confer policy guide-
line. The more substantive part will then attempt at
bridging that gap; it does that first by making explicit
the unspoken assumptions of the theoretical model
for Healthy Ageing. Then it sets up a moral theory
against which the WHO framework and its unspoken
assumptions can be weighed. Having done that, the
established moral theory will finally mount a defence
of specific policy trade-offs that it identifies as imper-
missible from the moral point of view. Impermissibility
is a condition of complete moral prohibition that admits
no degrees. If something is declared impermissible, it im-
plies that whatever is prohibited must not under any
(non-catastrophic) circumstances be violated.
Establishing the conceptual groundwork for the
framework of healthy ageing
Three cardinal questions
Towards the end of his first ground-breaking work―-
the Critique of Pure Reason, the German philosopher
Immanuel Kant stated that the substantive kernel of
any philosophical endeavour, whether speculative or
practical, boils down to resolving either of the follow-
ing three fundamental questions: “what can I know?”,
“what ought I to do?”, and “what may I hope for?”.
The first question is principally epistemic, in the
sense that it examines the nature, scope and justifica-
tion of knowledge under which can operate any par-
ticular field of inquiry. Answers to the question “what
ought I to do?” settles practical considerations that
pertain to the nature and the proper motive for a
course of action that one is either permitted, obli-
gated, or for that matter forbidden, to do.
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 3 of 16
That is precisely where thin concepts such as ‘right
and wrong’, ‘good and bad’, ‘permissible and impermis-
sible’, and ‘respect and violation’, or substantively thick
concepts such as fairness, justice, kindness, generosity,
selfishness, and impartiality find their proper reflective
platform. And thirdly, Kant reasoned that “what ought I
to do?” engenders a deeper question of meaning and
significance of acting as one ought―a philosophical inves-
tigation that is both speculative and practical all at once.
Most philosophical problems are composite in nature
for they include a mix of each of the three questions,
their difference is mainly in emphasis. Similarly, we must
recognise that the aforementioned WHO documents on
Healthy Ageing cut across the three Kantian lines of
philosophical questioning. However, for the sake of
simplicity, we can describe what each document princi-
pally seeks to investigate in terms of one of the three
philosophical questions that each document predomi-
nantly seeks to answer. The World report on ageing and
health systematically captures what we can and do know
about ‘ageing and health’, and in so doing further arti-
culates the challenges presented by the rapidity with
which the world’s population is ageing. Drawing from a
body of knowledge emanating from multidisciplinary
research on ageing and health, the report identifies key
areas of immediate concern “and builds a strategic
framework for taking public-health action, with a menu
of practical next steps that can be adopted for use in
countries at all levels of economic development.” [14]
The Global Strategy and action plan on ageing and
health, on the other hand, makes explicit the principles
that underpin an adequate national strategy and plan of
action necessary for fostering Healthy Ageing. To fulfil
its vision for realising a world in which everyone can live
a long and healthy life (‘what may we hope for’), and
focusing on five strategic objectives, the Strategy seeks to
implement 5 years plan of action (2016–2020) for
ensuring a Decade of Healthy Ageing from 2020 to 2030
at which point “functional ability is fostered across the life
course and where older people experience equal rights
and opportunities and can live lives free from age-based
discrimination.” [15] The underlying principles are:
human rights, equity, equality and non-discrimination on
the basis of age, gender equality, and inter-generational
solidarity. Whereas the key areas for national actions that
the Strategy sets out to accomplish include establishing
national frameworks towards Healthy Ageing, strengthe-
ning national capacities to formulate evidence-based
policy, and combating ageism.
In a nutshell, what may we hope to achieve is the
highest achievable health for all through the scheme of
Universal Health Coverage and optimize healthy ageing.
What ought we to do? A generic reply could be, en-
suring a fair and equitable path to UHC that is inclusive
of older persons. And that is precisely what the third
WHO document ― the final Report of the WHO
Consultative Group on Equity and Universal Health
Coverage ― seeks to establish. It recognises that cri-
tical choices are to be made as to which services to
prioritise, whom to include first, and how to shift
from out-of-pocket payments towards a system of
prepayment that does not render getting needed and
effective services conditional upon the person’s ability
to pay. Consequently, the report identifies three areas
of strategic action: (1) categorising services into priority
classes―guided by principles of cost-effectiveness, priority
to the worse off and financial risk protection; (2) expand-
ing coverage for high-priority services to everyone while
devising fair and equitable ways of eliminating out-of-
pocket payments; and (3) ensuring that disadvantaged
groups are not left behind.
The path to UHC is an arduous journey that involves
continuous improvement, since each country expe-
riences some form of resource or structural constraint,
requiring prioritisation and trade-offs at every step of
the way. In moving towards a progressive realisation,
some trade-offs are therefore unavoidable. With that in
mind, the Report on Equity and UHC identifies five par-
ticular scenarios in which trade-offs are generally un-
acceptable. The first three unacceptable trade-offs
correlate to the first strategic action and its attendant
principles, whereas the other two correspond to each of
the remaining two strategic actions.
In contrast to the first two WHO documents, the final
Report on Equity and UHC is construed in general terms
and thus makes no specific reference to older adults. But
substantively the latter hits the right notes for it con-
cerns itself with the topic of fairness and trade-offs on
the path to UHC. In addition, the Report identified five
generic impermissible trade-offs that national policies
should dispense with on the path to UHC. Since our
specific concern is identifying which of the legitimate
concerns for the health and well-being of older adults
are impermissible for trade-offs, that poses some
methodological problems. In settling our specific con-
cern for older adults, two possible analytic approaches
can be taken.
One approach may be to identify unacceptable trade-
offs attendant upon the health of older persons on the
grounds of fairness (and the overlapping concern for
equity), and then fine-tune the list so that it aligns with
the ethical reasoning that underpins the five specific
trade-offs that the Report on Equity and UHC declared
unacceptable. Even though the report on Equity and
UHC addresses health policy issues affecting societies
across the board, one may argue that we can identify
those issues and concerns that uniquely affect older per-
sons on similar, equity-based, grounds. Such analytic
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 4 of 16
route runs the risk of being procrustean, in the sense
that it might compel us to stretch the normative scope
of fairness under which are to be nested all fundamental
moral concerns relating to the health and well-being of
older persons. And, on the flip side, this approach ap-
pears to neglect some impermissible trade-offs that are
grounded on moral principles that do not in the first in-
stance reflect equity or fairness.
Or we could proceed in the other direction: begin by
independently formulating valid ethical and moral stan-
dards that warrant stringent normative constraints
against trade-offs on the health and well-being of older
persons, then look to see if we find compelling the con-
crete convictions about unacceptable trade-offs itemised
in the report on equity and UHC. This potentially per-
mits the deployment of basic ethical and moral judgments,
that are nested on principles other than the requirement
of fairness, in defence of the claim that some of the spe-
cific rights to health and well-being of older persons are
impermissible for trade-offs. This appears to be a promis-
ing approach for discovering some compelling moral rea-
sons for protecting the claims of older persons, claims
that do not figure in existing policy documents; but the
judgements thus established need to be oriented to-
wards policy making.
The required moral framework should therefore pursue
an integrated approach that allows for examining the spe-
cific concern for fairness within the broader moral
reasoning about what we owe to older persons.
A PATH to UHC inclusive of older adults: a
theoretical overture on trade-offs and
impermissibility
Moral norms and principles that underpin UHC as a
critical policy framework that every country ought to
adopt may differ from ethical considerations relevant for
regulating UHC’s progressive realisation. Progressive
achievement of Universal Health Coverage implies pri-
oritisation of services and deciding who to include first,
further requiring a principled approach to permissible
trade-offs when two or more priority items compete for
primacy given actual structural or resource constraints.
We ought to first identify the key concepts pertinent to
such demarcation.
The concern for setting the moral boundaries to per-
missible trade-offs relating to the health and well-being
of older persons can be attached to the specific domain
of morality within which impermissibility is to be found.
Ethical and moral standards are characterised by a set of
considerations or normative conditions that establish
what is morally permissible, required, or is impermis-
sible to do. What is morally permitted for a person to do
may or may not be morally required. But all things that
one is morally required to do must also be permitted,
otherwise the entire moral enterprise would be self-
defeating. Impermissibility is a special variation of moral
requirement that invokes a unique set of principles.
Moral imperatives differ in their normative force, and
impermissibility is a normative condition that warrants
the stringent moral force. It is often invoked in the dis-
course on basic human rights, specifically attached to re-
spect for life and liberty of persons and to the notion of
respect for human dignity. Moral impermissibility re-
flects the unique purchase that basic moral imperatives
have in guiding practical life, precisely, as normative side-
constraints on the rational pursuit of either individual or
otherwise collective ends.
Clearly, the public-health framework of Healthy Ageing
needs to make certain generalisations, whereas the moral
side-constraint we seek to prescribe makes sure that pol-
icy choices do not violate the rights of individuals. How
can we then decide about the right path to UHC that is
inclusive of older adults, which at the same time does
not infringe on their fundamental rights? Again, provid-
ing the full answer to this question is beyond the scope
of this article, it only seeks to show with reasonable cer-
tainty the wrong path that the public-health framework
should avoid. We can certainly know what is plainly un-
just or morally wrongful without, at the same time, com-
mitting ourselves to declaring with finality what, for a
particular country, the perfect path to UHC would be
like.
In what follows we clarify relevant conceptual distinc-
tions crucial for developing the underlying ethical frame-
work which allows us to identify impermissible trade-
offs on the rights to health and wellbeing of older
persons.
Two distinctions in ethics and morality
How ought we to live
The terms ethics and morality are often used inter-
changeably both in the academic philosophical literature
as well as in practical policy instruments. In their strict
senses, however, the “ethical” and “moral” connote dis-
tinct meanings admitting subtle but meaningful norma-
tive differences than meets the eye. Morality concerns
with how we ought to treat each other and our duties in
this regard, whereas ethical standards prescribe how
ought we to live ourselves if we are to ‘live well’ and
have a ‘good life’. It must, however, be noted that dis-
tinction does not entail separation. Ethics and morality
share the exact same normative sphere in the same way
the two heads of conjoined twins (of ‘dicephalic parapa-
gus’ sort with shared vital organs) may share the same
body frame below the neck. Although dicephalic twins are
considered as distinct persons in their own right, each
twin cannot claim absolute sovereignty over the lower
body and for that reason cannot survive without the other.
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 5 of 16
So in the same way, ethics and morality maybe the two
separate heads of the same normative value system.
The received view asserts that ethical life partly re-
quires observing moral principles such that how “I ought
to live certainly encompasses my concern with how I
ought to treat others.” But scholars often disagree over
the extent to which our moral responsibility towards
others informs our ethical responsibilities to ourselves.
In a nutshell, two implications obtain from the concep-
tual nexus between the ethical and the moral:
One suggests that how I should value my life is not
ethically optional in the same way my duties to others
are not; and secondly, my ethical responsibilities
towards myself confers an overriding reason for me to
act such that I am not required to neglect how my life
goes in order to fulfil my moral obligations to/
regarding others [16].
According to Ronald Dworkin, “my concern with how
ought I to live must in some sense have an overriding
reason for me to act, such that the ultimate value to my
personal life is neither exclusively nor primarily a func-
tion of how I treat others.” [17] And secondly, morality
connects with human aspiration quite positively given
that we conceive of our ethical responsibility to live well
as generating the scope of morality’s constraining power
in practical life.
Living well and the good life The above sketched rela-
tion between ethical and moral value judgments can be
systematically explained in terms of a distinction within
ethics that is also familiar in morals, namely the distinc-
tion between the right and the good―between living
well and having a good life, between duty and conse-
quence respectively. The main take away is that, the
value to one’s life is measured not only by the amount of
a good life that it produces either to oneself or to others,
but primarily in how rightly it was lived irrespective of
its product value. Living well consists in the perform-
ance value, while the good life is characterised by the
end product that life bestows upon individuals.
“Living well means striving to create a good life,
but only subject to certain constraints essential
to human dignity.” Whereas well-being is a
static concept definable in terms of the set of
minimal conditions that make up the good life
“independently of the process through which it was
created or of any other feature of its history.” In
contrast to the notion of the good life, living well
is a dynamic concept. How well one’s life goes is
determined by the value of the “rising to the
challenge of having a life to lead.” [18]
Responsibility to the self It is objectively important to
live well―compatible with the value of leading a critic-
ally good life whose estimate is not reducible to self-
reported (i.e. subjective impression or experience of)
well-being. There are objective standards on what a cri-
tically good life constitutes. In principle, a good life does
not imply that one lives well and vice-versa. A person
may be said to have summarily lived a good life with no
or minimal striving to do so; and, on the other hand,
one could be said to have lived well even though his was
a life lived in poverty and misery. A Machiavellian prince
who lived in material abundance and cultural and artistic
sophistication may represent the first. Conversely, one
could name a Van Gogh, Nietzsche, Nicola Tesla, or a
William Blake as an epitome of the latter type.
However, it is appropriate to issue one caveat here: the
unexamined life often undermines a critically good life.
That is because one who leads a life without meaningful
relationships, projects or challenges, without passions or
a critical conception of the good that one deems worth
pursuing—marking time to his or her death simply with
an endless pursuit of hedonistic pleasure, has neverthe-
less not had a good life. Life is not supposed to just be
good (defined in terms of one’s subjective impression of
well-being), but critically good. This is therefore to say
that, the ultimate value of life is adverbial; it is charac-
terised by the performance value of striving for a good
life, which is radically different from a life entirely
devoted to prudential avoidance or minimising the
chances of living a bad one. To live well one should
venture out and engage in the adventures of life and risk
having a bad one.
Living well presupposes an objective measure of the
good life. On the flip side, disregarding one’s responsibi-
lities to strive for a life of meaning is in turn detrimental
to one’s actual well-being.
Duties to others Analogous to the two distinct ways in
which living well connects with well-being, our moral
duties to others also connect with ethical responsibility
in two distinct ways. The first is that, discharging one’s
moral duties to others is one plausible path through
which the person can live well. That is to say, pursuing a
moral life is something individuals should have reason
to value and strive to live accordingly. Secondly, moral
life produces critical goodness to the life of the moral-
agent herself.
One’s duties to others may relate either to the
provision, protection and promotion of the essential
components to their well-being, or to respecting the
things in life that they have reason to value. The
provision of basic health care through the system of
UHC signifies the first, whereas respecting and fostering
autonomy and dignity may signify the latter. In most
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 6 of 16
cases our overriding moral duty relates to the second,
namely to what makes their lives go well in contrast to
the simple advancement of their well-being. The ethical
primacy of living well over well-being warrants priori-
tising respect for dignity and autonomy over the advance-
ment of wellbeing. We certainly have a responsibility to
promote the well-being of others, but we have an over-
riding duty of respect for the things that render the lives
of others go well even if that turns out to be detrimental
to their wellbeing. Our moral duties as individuals sets the
background for what we are collectively required to do via
public policy.
We now proceed to showing how the above reflections
can help unpack and critically analyse the conceptual
model for Healthy Ageing adopted by the World Health
Organization.
Healthy ageing and the two distinctions in ethics and
morality
The WHO framework for healthy ageing appears to
reflect, albeit implicitly, the above described crucial
distinctions in ethics in the manner commensurate with
public health policy. In particular, The World Report on
Ageing and Health defines healthy ageing as “the process
of developing and maintaining the functional ability that
enables well-being in older age.” Using two dynamic
concepts, namely intrinsic capacity (IC) and functional
ability (FA), the Report outlines a systematic approach
for objectively improving the well-being of older persons
that also takes seriously the significance of living an
authentic life characterised simply as the sort of life
older people have a reason to value. Accordingly, intrin-
sic capacity is defined as the composite of all the phy-
sical and mental capacities that an individual can draw
on at any given point in his or her life. Functional ability,
on the other hand, is characterised by a set of health-
related attributes that enable people to be and do what
they have reason to value; it is composed of the intrinsic
capacity of the individual, relevant socio-environmental
determinants and the interaction of the individual with
those characteristics [19].
The next logical step is to ask: what, if anything, we
owe to older persons with respect to their health and
well-being? A generic answer may be that, what we owe
to older persons must be consistent with the recognition
that the ultimate value of life is adverbial, that is, the
performance value or the ‘rising to the challenge of
having a life to lead.’ It ought to reflect the value that
older persons are not “simply passive vessels in which a
good life may or may not occur”, and that “having a bad
life does not always mean not having lived well.” [20]
Our concern for the health and well-being of older
persons ought to be motivated by the same under-
standing of value such that the fundamental reason for
improving their health and well-being is to foster the
pursuit of meaning, as attested by a reasonable norma-
tive control, in their own life. Respect for older persons
requires that we take seriously their right to pursue a life
according to what they have reason to value, regardless
of their station in life or their current health status. Our
basic moral responsibility regarding their health should
not therefore be constrained by their chances for leading
an objectively good or bad life but must relate to their
(functional) ability to live, a possibly good or bad life,
well. That is to say that the moral significance of
having a good life is ultimately grounded on the ex-
tent to which creating a good life contributes to living
well, i.e. to the struggle to live according to what one has a
reason to value.
* The phrase that one has “a reason to value” can
carry two contrasting meanings: either in the
descriptive (explanatory) or in the normative sense. In
the descriptive sense, it may mean that the person is
living a life which he actually values commensurate
with a non-arbitrary value system. Having a reason to
value can, on the other hand, be normative in the
sense that it designates the life one values as one
ought. In this sense, ‘having a reason’ implies a
criterion for what counts as an objectively good life,
or at least what is reasonable to value as such.
The capabilities approach advanced by Amartya Sen,
adopts the first interpretation arguing that public
policy should preserve and promote the capacities to
function in ways consistent with negative freedoms,
which means either abstaining from interfering with
or removing obstacles from, the individuals’ free
adoption of life paths and value systems that they
deem for themselves as reasonable. This approach to
value is concerned only with those capacities to
perform valuable functioning that serve as the
legitimate basis for government action and therefore
warrant protection via public policy. One advantage of
this approach is that it recognises that there is a social
determinant to what individuals may actually have a
reason to value.
Two points warrant making here. First, with respect to
the WHO’s account of healthy ageing, we should inter-
pret references to “having a reason to value” primarily in
the descriptive sense of the term (connoting citizens’
minimally reasonable actual preferences). Secondly, the
capabilities approach can accommodate the value of
negative freedoms (“freedoms-from”) including respect
for autonomy and dignity―those moral side constraints
set up to safeguard the person’s normative control over
central domains of one’s life. It is plausible to include
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 7 of 16
these essential safeguards to the individual’s capability to
function as appropriate policy goals, without having to
concede that such freedoms-from are, themselves,
capabilities. However, although the capabilities model
confers a plausible guidance to public policy, it is how-
ever incomplete without an underpinning moral theory
that establishes side-constraints as ends in themselves
which will consequently set the criteria for determining
when health inequalities are unfair or wrongful. Therein
lies the significance of this paper.
A plausible account of the underpinning moral theory
must begin with the recognition that one’s opportunity
for leading a good life is partly influenced by the social,
economic and political circumstances into which the
person is born. And it goes without saying that, with
respect to safeguards to personal freedom and a life
worthy of human dignity, natural endowments and one’s
initial place in the social strata (excluding hierarchies
that are grounded in competence) are arbitrary from the
moral point of view. In a decent society, regardless of
their initial station in life, individuals will be granted the
opportunity to create for themselves a life that is both
minimally good and optimally functional. This moral
dictum is also pertinent to arbitrary distinctions based
on age.
Facts about the ageing process can also inform our
moral point of view. Naturally intrinsic capacity (IC)
tends to decline with increasing age; nonetheless, a mix
of personal, environmental and structural factors will
determine each individual’s trajectory of functional abi-
lity (FA). As it happens, for those with declining or
significant lose in capacity due to multiple morbidities
generally considered to be incidental to ageing, proper
interventions at different points during their life course
can improve and foster all-things-considered positive
value in well-being sufficient for living well. Having a
bad life due to declining health does not always imply
not having lived well. That is to mean, it matters to
have normative control over one’s life despite advanced
age and even under the circumstances of severe decline
in capacity.
Health is one crucial aspect of well-being, and as a
basic human need and right, it certainly ought to be
protected, promoted and advanced. Yet the significance
of a long and healthy life is both inherent as well as
instrumental, that is to say there is no point to prolong
life for the sake of going on living unless we subscribe to
the underlying notion that longer and healthy life opens
doors for a life of meaning, vitality and excellence–that
is a life worthy of human dignity, of which poor health
or a life cut short could undermine or foreclose. It
implies that, the responsibility of every society to
improve the health and well-being of all its members is
underpinned by the normative priority for what constitutes
living well (a life worthy of human dignity). This certainly
means that not all health concerns matter equally.
Similarly, Daniel Hausman wrote that “how much on
average a health deficiency matters to individuals
need not equal the extent to which that deficiency
matters to public health policy.” [21]
Healthy ageing characterised as a life worthy of human
dignity
There are two mutually reinforcing components to a life
worthy of human dignity: authenticity and self-respect.
Authenticity reflects a “special, personal responsibility
for identifying what counts as success” in one’s life and
the striving to lead such life “through a coherent narra-
tive” commensurate with one’s own image of herself
[22]. It requires that the person has autonomy over the
essential domains of his or her life. Self-respect requires
that one takes seriously the objective and intrinsic im-
portance of one’s living well, which entails recognising
the objective and equal importance of living-well for
oneself as well as recognising the same for others. Thus,
self-respect integrates our moral duties regarding others
with one’s own ethical responsibility for living well.
Certainly, self-respect permits that “I can respect others
and hold that their lives is as objectively important as
mine without at the same time taking equal interest and
investment in their lives as I do in my own.” Such basic
recognition for the objective significance of the lives of
others can plausibly serve as a common thread that sets
the moral background for public health policy. For
instance, a health policy is deemed implausible if its
provisions or omissions are predicated on the denial or
infringement of respect to the objective significance of
the lives of older people.
Self-respect and authenticity warrant the dignified
respect and difference with which we ought to treat
persons irrespective of the morally arbitrary features that
drive a wedge between them. Moreover, the argument
from dignity reflects that what we may be morally
permitted, required or prohibited to do to others, and in
particular to older adults, set the background for what
we may be permitted, required or prohibited to do to
them through the apparatus of the state [23].
Our duties regarding older persons, may either be
general or specific, respectively reflecting both the
respect they are owed as equal members of the moral
community and the imperative to safeguard their
specific vulnerabilities to various forms of indignities.
That may involve (i) the duty of care, (ii) the duty not to
create unreasonable risk of harm to older people inclu-
ding the impermissibility of deliberately causing them
harm, (iii) the limited duty of forbearance from imposing
unintended but foreseeable harm on them while pur-
suing other goals, and (iv) treating older persons in ways
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 8 of 16
that denote a manifest denial of their equal moral status.
In making policy decisions that concern the health of
older persons we must keep in mind the difference in
normative force between violating a negative duty (not
to intentionally harm or wrong others, represented by ‘ii’
and ‘iv’), and infringing on our positive duties by mere
omission [24].
However, infringement of a positive moral duty is not
axiomatically less troubling than a violation of negative
duties. Disinclining to discharge one’s duty of care for
older persons, for instance, might engender an attitude
towards them as if their life is of less moral worth than
their younger fellows. This example illustrates that some
refusals to discharge one’s duty of care are morally
impermissible, if done for reasons that clearly signify the
view that older persons count for less.
A case in point is the cost-effectiveness analysis that
was specifically applied to renal dialysis in Thailand. For
acute cases of kidney failure, the availability of dialysis
often proves to have life-saving significance for the
patient. But it certainly is far too expensive in resource-
poor settings, costing 30 times the GDP per capita per
healthy life year in Thailand. To put that in perspective,
the cost for dialysis in Thailand is equivalent to 300
times as many healthy life years if spent on TB interven-
tions, which commonly benefits younger age groups
[25]. The principle of human dignity prohibits the re-
fusal to accord older persons equal moral status which
would be the case if Thailand were to prioritise invest-
ment on TB interventions based solely on the grounds
of cost-effectiveness (presuming that kidney failure dis-
proportionately affects older adults). What is more, the
reasoning that underpins the specific cost-effectiveness
metric (i.e. in terms of gain in healthy life year per
capita) appears to conflict with the principle of respect
for human dignity and its underlying moral ethos. That
is to say, it may lead to policies that do not regard the
lives of all citizens as holding equal moral standing.
When used as the principal criteria for selecting
programs for a national health policy, cost-effectiveness
estimates sometimes conflict with some basic moral
principles, primarily with the principle of respect for the
dignity of persons [26]. If we take, for example, end-of-
life palliative care for older patients, it may appear as
strikingly far too expensive than a society might be
willing to invest particularly if the value of such care is
defined in terms of gains in healthy life years in contrast
to alternative (and perhaps more invasive) medical inter-
ventions. But if societies decide to divest from it in
favour of services that could potentially earn more
healthy life years either for older persons themselves or
for others, such a decision will certainly amount to
estimating the inherent value of persons on the basis
of health outcomes potentially leaving older persons
vulnerable to the kind of treatment as if they count
for less or nothing at all. As a basic moral principle,
respect for the dignity of persons generates that cru-
cial litmus test for determining whether and when
cost-effectiveness analysis is a permissible criterion
for priority setting.
To put the that in context, in most sub-Saharan coun-
tries non-profit foundations constitute the major source
of institutional care for older people (discounting inte-
grated family care). That clearly indicates the relative neg-
lect given to the care of older persons. Moreover, research
has indicated that such model of care is unsustainable.
The system relies primarily on volunteer care-givers, and
services are resourced through cash and in-kind donations
in the form of geriatric training, medical supplies and
technical support. For instance, the Care for Aged
Foundation in Ghana which operates mainly within Ga
East municipality holds 3000 older people on a waiting
list. Similarly, HelpAge International’s Better Health for
Older People in Africa programme in the United
Republic of Tanzania manages to support only 4500
older people all over the country, with care provided by
450 trained volunteers. Although Mauritius, Seychelles
and South Africa have made great strides in investing
on the health of older persons, the provision of care
still falls short of demand while continued expansion
will prove difficult to sustain given the general lack of
commitment [27].
Similarly, respect for autonomy is another moral
principle that figures prominently within the discourse
on interpersonal moral duties which also seamlessly
coalesces with the individual rights persons have against
their political community. Earlier, autonomy was de-
scribed as a normative condition for authenticity―the
second essential component to a life worthy of human
dignity. According to some promising accounts of
personal autonomy, that there are two dimensions to an
autonomous life: the social dimension of autonomy and
the temporal dimension. The first proclaims that the
social environment that one lives, and the personal rela-
tionships and deep attachments one establishes not only
affect how one exercises her autonomy but that they are
constitutive to it. And secondly, the identification of
autonomous persons as self-sufficient rational choosers
who can self-determine their own destiny must also take
into account the fact that individuals exercise their au-
tonomy over time [28].
Autonomy and healthy ageing
The autonomy of older persons should be conceptua-
lised along the social and temporal dynamics. What this
means in that, considering that autonomy is constitu-
tively relational and is exercised over time (diachronic),
a reduced intrinsic capacity and functional ability at
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 9 of 16
older age does not necessarily imply a proportionally
diminished value in autonomy. We can promote and
enhance older persons’ autonomy by improving the
environmental dynamic in which they live. Moreover, a
plausible, and empirically informed, public health policy
must take into account the fact that individuals (particu-
larly true for older persons) exercise their autonomy
over time.
Such understanding of autonomy can strengthen the
WHO’s conceptual framework for healthy ageing and be
of vital importance to developing person-centred and
integrated care, including a nuanced policy on dementia
and on the provision of palliative care. It does that by
challenging the received view according to which social
engagement is merely instrumental to enhancing auto-
nomy. Misconceptions about the nature and value of
autonomy reinforce ageist norms and practices either by
overlooking older people’s need for social engagement as
a basic constituent to their autonomy or by erroneously
thinking that an episodic loss in the capacity for auto-
nomy, for instance due to an onset of dementia, amounts
to automatic termination of their right to autonomy.
However, the idea that autonomy is exercised over time
should not be construed as an argument for ignoring older
person’s current state of mind, desires and choices. One’s
episodic choices ought to still be respected, including a
range of choices from simple matters that pertain to
organising one’s daily routine to matters of grave con-
sequence such as choices relating to unbearably painful
and invasive medical procedures. These legitimate in-
terests in autonomy crucially inform the moral limits to
paternalistic interventions in the name of older person’s
well-being.
Human rights and healthy ageing
A human right can simply be defined as any fundamen-
tal right that we have in virtue of our basic equality as
human beings, regardless of one’s accident of birth in-
cluding membership to society. Human rights protect
what is considered to be essential to a life worthy of
human dignity. A human right-claim is not contingent,
in the sense that it can be earned or granted and so in
the same way can be forfeited or withdrawn. It is often
declared that human rights are inalienable to the human
person, that is to say, even if a person’s human right is
impermissibly violated one does not thereby lose that
right [29]. The moral grip that human rights have is,
therefore, categorical. The right to health is only in-
directly referred to under Art. Twenty-five of The
Universal Declaration of Human Rights, which declares
that “everyone has a right to a standard of living adequate
for the health and well-being of himself and his family.”
The primacy of living well and the inalienability of
human rights both reflect the normative separateness of
individuals. We have seen earlier how the interpretation
of living well yields a plausible route to the identification
and grounding of our duties to others, and consequently
hold that living well requires human dignity. In a strikingly
similar way, UDHR is premised on the idea that human
rights “derive from the inherent dignity of the human per-
son.” However, a human right to health is too vague a
concept that it permits multiple interpretations over its
precise scope and normative grip, in which case the most
reasonable approach is to investigate the extent to which
health inequalities signify social and economic injustices.
Opportunities to a healthy life is one of the areas in which
societies can insure that substantive inequalities due to
circumstances of birth, social and environmental factors
do not morph into injustices; hence, the right to health
and well-being of older persons can be approached
from that general vantage point, precisely as one of
the principal yardsticks of the just society.
If, on the contrary, we want the human rights idea to
be distinctively informative about the claims peculiarly
held by older persons, we ought to primarily identify the
specific prohibitions and limitations prescribed by the
rights approach to health and look to see if any of those
moral prohibitions exclusively protect older adults [30].
References to ageing and older people have traditionally
been limited within international human right treaties
and instruments. But human rights language is increas-
ingly being integrated into the topic of ageing and
health. Notably, the Madrid International Plan of Action
on Aging (2002) emphasises the imperative to safeguard
for older persons the rights and freedoms enshrined
under the international human rights instruments,
including “the elimination of all kinds of violence and
discrimination against older persons.” [31] In any case, a
rights approach to healthy ageing must minimally re-
cognise the following list of rights, some of which can be
found listed under the UN Principles for Older Persons:
right to a dignified life in older age; rights to liberty,
independence and autonomy; rights to care and safety;
the right to universal, affordable and quality health care;
right to give free and informed consent on health
matters; rights of older persons for and in receiving
long-term care; right not to be subjected to cruel,
inhuman or degrading treatment or punishment, while
under institutional or home care; right to community
participation; and equality and non-discrimination for
reasons of age, including inclusion in health research
and the right to participate in clinical trials.
Healthy ageing and social justice
At the outset of this section, we noted that there are two
analytic routes towards conceptualising the nature,
content and justification of the basic moral claims
older persons have against others and society that are
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 10 of 16
impermissible for trade-offs. In the preceding para-
graphs, we attempted to shade light on the topic by adop-
ting the second theoretical approach which required
clarifying basic conceptual distinctions necessary for
establishing a substantive moral theory according to which
specific judgements about the inviolable claims of older
persons are to be made.
In what follows, we quickly return to the first ap-
proach that seeks to identify unacceptable trade-offs
attendant upon the health and well-being of older
persons on the grounds of fairness. Health inequality is
1 area of concern for social justice, “it certainly is a very
important part of our understanding of health equity,
which is a broader notion.” [32] Inequality in health out-
comes, although relevant, is not in itself indicative of
injustice or inequity; it is therefore more promising to
evaluate (the violation of) justice in health first by looking
at whether institutions of society generally adhere to
procedural fairness, i.e. the process through which health
outcomes are brought about. For that reason, equality of
opportunity in health care has inescapable relevance to
social justice in regard to health. It is pertinent to note
that health equity is a complex concept that includes
concerns about health outcomes, the capability to achieve
good health, procedural fairness in distribution of health
care and the interplay between the analysis of inequalities
in health and broader issues of social justice [33].
In contrast to the human rights approach to healthy
ageing, social justice requires that one belongs to a po-
litical community and is owed recognition and difference
in virtue of that membership. For human rights ap-
proach what is at stake is our human fellowship and our
duties to each other in that regard, while social justice
confers grounds for partiality to one’s own (nationals)
compatriots in their capacity as free and equal members
of a given society. Conceptualising health equity within
the broader concerns of social justice provides a con-
venient platform for examining the pathways through
which socio-economic and social determinants of health
inequalities generate health inequities, and thus warrant
remedial action [34]. It is important not to conflate prin-
ciples that underpin global equality of opportunity for
health at older age with considerations of social justice
relevant to similar concerns of fairness in health within
national boundaries. In general, global responsibilities to
overcome unfair barriers to the health of older adults
across nations tend to be weaker and less robust in
contrast to the self-same responsibilities within a given
nation; what is more, the distinction in normative force
between the international and within national contexts
may also generate a difference in focus with respect to
specific areas of concern that warrant action.
John Rawls’ theory of Justice as Fairness provides in-
valuable insight in that regard. He defends two principles
of justice, namely: the principle of equal liberty, and the
difference principle underwritten by a fair equality of
opportunity [35]. The second principle is more pertinent
to the topic of specific concern to this paper, namely the
proper moral demarcation between permissible and
impermissible inequalities of concern and moral weight
between the well-being of older persons and people in
other age groups.
The principle of fair equality of opportunity justifies the
importance of establishing a framework of universal health
coverage. The difference principle, on the other hand,
declares that relative inequalities in socio-economic status
(the social determinants of health) are permissible only to
the extent that they serve the least advantaged groups in
society to be as well-off as possible. Consequently, the
difference principle has a role to play in regulating the
path to UHC. Inequalities in health status among individ-
uals can be addressed simply by prioritising the well-being
of the least well-off (it seems plausible to include older
persons within the category of the least advantaged groups
due to the overall decline in their powers of self-direction)
. The principle confers priority to the least advantaged
subject to the proviso that such prioritisation does not
undermine the value of equal liberty or the requirement
of fair equality of opportunity (ex. UHC), reflecting the
lexical ordering of principles [36].
Countries with an established national legal recourse
to universal health coverage still need to address key
issues of fairness attached to socio-economic determi-
nants of health, which includes setting a benchmark for
the provision of the social basis of self-respect without
which individuals will have critically diminished overall
functioning. There is on exhaustive list of what consti-
tutes the social bases of self-respect, but any plausible
theory of self-respect will inescapably have to make
recourse to the concept of living well.
In practical terms, the ethical framework advanced
here can underpin the moral salience of taking ser-
iously the social reality in which many older persons
in the world live. The distribution of the benefits and
burdens of social life figures as the principal topic of
social justice, and older-persons’ vulnerability must be
weighed higher to potential positive benefits due to
their respective implications for living well. Research
has indicated that in most parts of the developing
world vulnerability of older persons has been more
severe than meets the eye, and even where sufficient
data is available the problem has often times been
overlooked by policy makers. The domains that shape
vulnerability at older age must be analysed in ways
that we can clarify pathways to “bad ends” and to
identify possible points of intervention. In general, the
framework of vulnerability in later life follows the
following path: it begins with the risk of being exposed to
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 11 of 16
a threat, where the probability of a threat actualizing into
a harmful outcome depends on factors that either enhance
or erode the person’s defensive shields or coping mecha-
nisms. Therefore, an older person’s risk of harm may
begin with exposure to threats but a bad outcome (in
terms of reduced well being or health status) is a com-
pound effect of such exposure and socio-economic deter-
minants that shape an individual’s capacity to cope with
the threat to which one is exposed [37].
Each stage in the vulnerability function is constituted
by structural and relational determinants. Structural vul-
nerability has to do with the socio-political and institu-
tional infrastructures that may affect the capability of
older persons to withstand difficulties; social realities of
urban migration in majority agrarian societies, inad-
equate infrastructure including health care in rural areas,
housing, poverty, and low quality of environment may
count as domains of structural vulnerability. Whereas in-
adequate social networks or lack thereof, loneliness, dis-
crimination and social marginalisation (on the basis of
age, sex, disability, ethnicity and religion) may count as
principally relational vulnerabilities. Both types of
vulnerabilities often figure in tandem, as for example:
“83 per cent of Ethiopia’s population lives rurally, but
migration to urban areas for work, family support and
medical care increasingly brings older persons to city
centres. Regardless of location, though, Ethiopia’s
older persons are vulnerable to poverty, food
insecurity, limited access to social and health services,
and limited options for livelihoods diversification and
security. They are further subject to the double
protection bind of both needing care and protection
in their older years and needing to support children,
grandchildren, and ageing spouses in their care. The
impact of the HIV pandemic combined with acute
economic stress has resulted in changed family
structures across Ethiopia. The loss of middle
generations has created family structures where
almost half of Ethiopia’s orphaned children are cared
for by grandparents.” [38]
There is a growing realization that structural and rela-
tional factors disproportionately affect older persons
partly due to their reduced functioning and partly
because of the relatively low priority they receive in
developmental and social safety net programs. The
above example illustrates not only the significance of
social realities in tailoring the contextual application of
principles of social justice but also the ethical impli-
cations of the failure of society to address them. What
that means is that success or failure can drive a wedge
between just and unjust societies. With respect to deci-
sions about public policy in resource scarce contexts
where a slight alteration would have life altering conse-
quences, decision makers must therefore take seriously
the lexical ordering of principles of social justice and
confer priority to the least well-off members of society.
Impermissible trade-offs and the ethical priority
for living-well
This paper recognises the validity of the five unacceptable
trade-offs identified in the final report of the WHO Con-
sultative Group on Equity and Universal Health Coverage
[39]. It also recognises that those five unacceptable trade-
offs are established on broader grounds of justice as
fairness and the special concern it confers to the least
advantaged. The ethical framework defended here can
underpin some of them, whereas the rest are stipulated in
terms of general principles of practical reason and can
therefore be established without the need to make explicit
recourse to moral considerations.
We shall not pursue a pointed remark on each of the
five unacceptable trade-offs, partly for reasons of space
and partly for the reason that they are not designed in
the first instance to address our specific concern for the
health and well-being of older persons [40].
The ethical priority for living well, and the central role
that respect for human dignity plays in articulating as well
as underpinning our moral duties regarding others, sanc-
tions against discriminating persons from the scheme of
UHC on arbitrary grounds such as their designated place
in the social hierarchy. It matters from the moral point of
view that we take seriously the inherent worth of all
human beings, regardless of their station in life.
The concept of living well has both general and spe-
cific interpretations. Generally living well consists in
striving to make a life that one a reason to value. But in
specific terms, what constitutes living well for young
adults differs in in content from what living well might
consist in for older persons. Early adulthood epitomises
the point at which one’s capacities for self-direction
begins to peak, whereas a declining trajectory in capaci-
ties is typically correlated with older age. The inherent
quality of their respective life, therefore, necessitates a
specific articulation of what it means for each category
of persons to live-well. “Young adult” and “older person”
are phase sortals, in the same way “caterpillar” and
“butterfly” are. When we reach the age of 65, we ceased
to be adults simpliciter, but we don’t thereby cease to be
persons. Such specification does not, however, contradict
whatever normative work living well does in general–
underpinning the categorical and non-optional ethical
responsibilities to oneself, in addition to grounding the
moral primacy of respecting human dignity and auton-
omy over the provision of basic needs.
Human dignity, as does the idea of living well, manifests
a general-specific Janus face. As a general normative
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 12 of 16
concept, human dignity protects persons from humiliating
and degrading treatments including the prohibition of
treating persons merely as a means or as if they morally
count for less or nothing at all. It does these works for
older people as well. But the exact content of these nor-
mative functions ought to be articulated in accordance
with what it means for older persons to live well and lead
a life of dignity and authority.
The inherent quality of older age can be captured by
two distinctive features: the first relates to the familiar
association of ageing with non-trivial decline in capaci-
ties, and the second is the fact that at older age attribu-
tions of value and meaning to one’s life must ultimately
take the point of view of the entire spectrum of life–in-
cluding not only the life lived up to the point older age
eventuates but also a reasonable account of what is in
store for him/her until life’s eventual ending. In relation
to that, a plausible conception of human dignity ought
to elucidate the normative significance of the capacities
that survive the general decline attendant upon ageing,
determining the threshold for decline in the capacity for
self-direction that would leave the dignity of older
persons intact. Similarly, we ought to evaluate the
significance of preserving dignity at older age not only
for their pursuit of meaning at that particular juncture
in their life but at the same time for the preservation of
value and meaning of life as a whole.
Three impermissible trade-offs
Viewed from both the general and specific modes of
construal, we submit that the ethical primacy for living
well underpins that the following trade-offs relating to
the health and well-being of older persons are morally
impermissible.
1. It is impermissible to prioritise services across
different age groups on the basis of actual or future
contribution to society
This needs some unpacking. If, for instance, two
comparable sets of health services or interventions
need prioritising and that each presumably target
different age groups with relatively comparable
scale of vulnerability, it will be wrongful to employ
however implicitly the social worth criteria
according to which actual or potential future
contribution to society dictate the principal focus of
social investment. The ethical framework defended
in this article rejects as impermissible the utilisation
of the social worth criterion in the determination of
health care priorities across age groups.
The equal objective moral significance of each
individual’s life must not be forsaken on account of
differences in social worth amongst groups of
individuals. Evidently, some segments of society
such as women and children, and people on the
lowest economic strata are more vulnerable than
others. Such differences on the scale of vulnerability
can be an adequate criterion for selecting services
into priority classes but cannot be utilised for
prioritising services across age groups. If we were to
choose between two life-saving interventions, one
benefiting infants, children or young adults and the
other older persons, it appears to be intuitively
plausible to favour the younger age group over
older persons. Such preference has been the modus
operandi of health policy financing both at the
national and international levels. But the intuitive
drive to put women and children first in health care
policy suffers from an implicit bias towards
perceptions of social worth. Concrete examples can
be found in many national health service strategies.
For instance, Ethiopia’s essential health service
package (ESHP) aims to provide essential health
care primarily targeting free coverage for
tuberculosis; maternal care and family planning;
immunization services; HIV/AIDS; leprosy; fistula;
and epidemics (Federal Ministry of Health 2005).
The omission of non-communicable chronic
diseases, typically affecting older persons,
demonstratively reveals implicit biases in favour of
younger age groups. When done at the expense of
others, such pattern of prioritisation constitutes a
violation of the inherent dignity of the human
person. Certainly, sustainable investment in
maternal, new born or child health programs are
noble pursuits; but the point highlighted here is
that, that should not be done at the expense of
older adults who in some measure also count
amongst the most vulnerable age groups.
2. It is impermissible to prioritise across age groups
when co-prioritisation is warranted by the
ethical theory
This rule is a logical consequent of the point
illustrated by the above example. The process of
defining high priority services is generally neutral
about age group, gender, health status, and other
markers of distinction generally considered to be
arbitrary from the moral point of view. One
example maybe the provision of anti-HIV drugs. In
terms of healthy life years, these drugs greatly bene-
fit younger patients as opposed to the benefit in
healthy life years for older adults. People accrue the
full benefit of these drugs if they are younger and
are expected to have more healthy life years given
the current life expectancy. However, it is
unacceptable to prioritise coverage for this service
on the basis of age. A plausible health policy that
takes seriously the equal inherent worth of all
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 13 of 16
human beings must by definition co-prioritise life-
saving and life sustaining drugs or interventions
regardless of the amount of the actual gain in
healthy life years for the individual. On the
horizontal dimension of co-prioritisation, one can
speak about services that should be conferred equal
status within a given age group. Evidently, both
infectious and non-communicable diseases affect
older persons and can equally be life threatening. In
this case, co-prioritisation is warranted by the moral
theory. However, the Ethiopian essential health
services package (a national baseline for UHC) has
ignored the latter in favour of infectious diseases.
Perhaps the underlying reason has to do with the
fact that infectious and communicable diseases have
crosscutting effects, hence requiring precedence
from the public health point of view. Whereas, the
moral framework defended in this paper overrules
public health norms and practices when they
conflict with the equal worth principle.
3. Services that improve well-being ought not always
get primacy (by default) over services that foster
autonomy and dignity. Contrariwise, the general
rule is that respect for autonomy and dignity hold
primacy over services that improve well-being at
the expense of the first.
It is impermissible to prioritise critically important
services that may add more life years to older adults
if the added years in functioning imply a life spent
with indignity, severely degraded autonomy and
normative control over the essential domains of
one’s life. Here’s where the conception of the
dignity of older persons adopts the specific
construal. At older age, an improvement in health
and well-being must follow the path of dignified
daily functioning. That is to mean, regardless of
overall benefits in improving well-being any health
intervention that severely compromises older
persons’ psychological and bodily integrity is
considered wrongful, hence impermissible, from the
moral point of view. For instance, in line with many
customary sub-Saharan norms, family solidarity and
obligation constitute the core elements of older
people’s understanding of their own autonomy and
dignity [41]. Inter-generational relations and per-
ceptions of one’s legacy are considered to be key to
older persons’ self-respect. These norms favour
strengthening long-term home care for older
persons, since it perceptively preserves older
persons’ sense of dignity and autonomy. However,
research also indicated that institutional care is
more conducive for preserving and improving
health related well-being, while older persons at
home care are more susceptible to elder abuse, even
in African societies, than meets the eye [42]. In this
scenario, the ethical framework defended here
favours prioritizing long-term home care despite its
reduced effect on preserving wellbeing in
comparison to institutional care. One caveat is that
the framework for long-term home care should
include innovative safeguards against elder abuse.
There is one caveat here, which is that, in that
context a second-best choice must be available
which can balance an improved well-being with the
maintenance of dignity and autonomy. Even the
seemingly positive idea of quantifying the value of a
health policy option in terms of the added “healthy
life years” that it makes available to the individual
can have catastrophic consequences if adopted for
priority setting. Suppose for example, there is a
certain intervention X for a terminal medical
condition Y that may be known to be effective in
adding 12 relatively healthy life years to an older
person but at the cost of a loss in just one function-
ing that renders older persons incontinent
throughout the entire added life years. Now
suppose that there is an alternative costly
intervention Z that adds a comparably meagre 4
healthy life years but without the indicated side
effect. Although on average well-being is greatly
improved under X, however, considering the
possibility of leading an autonomous and dignified
life, it is impermissible to deny older persons the
opportunity to opt for Z.
Conclusion
The claims defended here in this paper pivot on one
underlying thesis, which is that the public provision of
health ought to reflect the idea that older persons have an
equal moral standing. This paper prescribes that we take
seriously that preserving older persons’ specific dignity
partly requires retrospective look back at their past such
that we are required to treat them in ways that do not de-
grade their enduring status as rational and autonomous
members of the moral community. Although the general
framework of dignity and autonomy remain the same,
what makes an action or behaviour autonomous differs in
content depending on to whom it applies. A simplistic set
of markers may adequately explain what counts for a
pre-adolescent child to be autonomous (given that in
most countries the legal age of maturity is traditionally set
for the age of 18). Whereas in adulthood, a more stringent
criteria maybe made applicable. However, a person
suffering from dementia will not suddenly lose his
rights for autonomy. Instead, the onset of dementia
compels the requirement for a reflective adjustment in the
cognitive, behavioural and volitional markers of auto-
nomy. This is therefore to say that, we should treat older
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 14 of 16
persons with recognition and difference to the fact that
progressive decline in capacity and functioning does not
imply a loss or decline in their moral worth on which their
fundamental rights and dignity are predicated.
Acknowledgements
A previous version of this manuscript was presented by the corresponding
author at the Ethox Centre, Nuffield Department of Population Health,
University of Oxford, 19 October, 2017. We thank Michael Dunn, Mira
Schneiders and all the participants to the presentation at Oxford for helpful
criticisms. We would also like to thank the two anonymous reviewers for
their analytical, perceptive and enriching comments.
Authors’ contributions
KMG carried out the conceptual analysis, formulated the underpinning
normative framework, and drafted the manuscript. RS initiated the study,
participated in its design and coordination, clarified the policy framework of
Healthy Ageing, and helped to draft the manuscript. Both authors read and
approved the final manuscript.
Authors’ information
Kebadu Mekonnen Gebremariam (Ph.D) is Assistant Professor at the Department
of Philosophy, Addis Ababa University, Ethiopia. Algeria St., P.O.Box 1176, Addis
Ababa, Ethiopia. Email: kebadum@gmail.com. Kebadu holds an MA in political
and economic philosophy from the University of Bern, and a doctorate (Ph.D) in
philosophy from the Centre for Ethics of the University of Zurich.
Ritu Sadana (Sc.D) is a Senior Policy Advisor, Department of Ageing and Life
Course, World Health Organization, 20 avenue Appia– 1211 Geneva 27–
Switzerland. Email: sadanar@who.int. Ritu holds a MSc focusing on health
systems and policies research methods, from the University of California Los
Angeles (UCLA), and a doctorate (ScD) focusing on health policy,
epidemiology, and economics from Harvard University. Ritu Sadana is a staff
member of the World Health Organization and along with Kebadu
Mekonnen Gebremariam, they are alone responsible for the views expressed
in this publication; these do not necessarily represent the decisions, policy or
views of the World Health Organization.
Funding
The authors received no financial support for writing this manuscript nor have
indirectly benefited from this work.
Availability of data and materials
Not applicable.
Ethics approval and consent to participate
Not applicable.
Consent for publication
Not applicable.
Competing interests
The authors confirm that there are no known conflicts of interest
associated with this manuscript and there has been no financial support
for this work that could have influenced its outcome.
Moreover, the authors declare that this manuscript is original, has not
been published before and is not currently being considered for
publication elsewhere.
We confirm that the manuscript has been read and approved by all named
authors and that there are no other persons who satisfied the criteria for
authorship but are not listed. We further confirm that the order of authors
listed in the manuscript has been approved by all of us.
We confirm that we have given due consideration to the protection of
intellectual property associated with this work and that there are no
impediments to publication, including the timing of publication, with
respect to intellectual property. In so doing we confirm that we have
followed the regulations of our institutions concerning intellectual property.
Author details
1Department of Philosophy, Addis Ababa University, Algeria St, P.O.Box 1176,
Addis Ababa, Ethiopia. 2Ageing and Life Course, World Health Organization,
20 Avenue Appia, 1211 Geneva 27, Switzerland.
Received: 29 January 2019 Accepted: 5 June 2019
References
1. United Nations. World population prospects: The 2015 revision, key
findings and advance tables. Working Paper No. ESA/P/WP.241. New
York: UN DESA; 2015.
2. United Nations. https://www.un.org/en/sections/issues-depth/ageing/.
Accessed 4 May 2019.
3. WHO (2013). China- study on global ageing and adult health- 2007/10,
Wave 1. Study on Global AGEing and Adult Health (SAGE). http://apps.who.
int/healthinfo/systems/surveydata/index.php/catalog/13
4. WHO (2015). Global health observatory data repository. Retrieved April 10,
2019, from http://apps.who.int/gho/data/view.main.700?lang=en
5. WHO (2017a). Global strategy and plan of action on ageing and health.
69th World Health Assembly.
6. WHO. Towards long-term care systems in sub-Saharan Africa, WHO series
on long-term care; 2017b. p. 4.
7. Aboderin IA, Beard JR. Older people’s health in sub-Saharan Africa. Lancet.
2015;385(9968):e9–e11. https://doi.org/10.1016/S0140-6736(14)61602-0.
8. Scheil-Adlung X. Long term care protection for older persons: a review of
coverage deficit in 46 countries. Geneva: International Labour Organizaion;
2015; Aboagye E, Ageyemang OS, Tjerbo T (2013). Elderly demand for
family-based care and support: evidence from a social intervention strategy.
Glob J Health Sci. 6(2):94–104. doi:10.5539/gjhs.v6n2p94
9. Kuruvilla S, Sadana R, et al. A life-course approach to health: synergy with
sustainable development goals. Bull World Health Organ. 2018;96:42–50
https://doi.org/10.2471/BLT.17.198358.
10. World Health Organization. Sustainable health financing, universal coverage,
and social health insurance. WH A58.33. 2005. http://apps.who.int/
medicinedocs/documents/s21475en/s21475en.pdf.
11. World Health Organization (2016). Universal health coverage (UHC)
factsheet. http://www.who.int/mediacentre/factsheets/fs395/en/
12. Linda PF. Investing in health to create a third demographic dividend. The
Gerontologist. 2016;56(2):S176–7 From https://doi.org/10.1093/geront/
gnw035. See also Bloom D. Börsch-Supan A. McGee P., & Seike A. (2012).
Population ageing: Macro challenges and policy responses. Global
population ageing: Peril or promise. Paper presented at the World
Economic Forum, Geneva.
13. Sadana R, Sucat A, Beard J. Universal health coverage must include
older people. Bull World Health Organ. 2018;96:2–2A https://doi.org/10.
2471/BLT.17.204214.
14. World Report on Ageing and Health. World Health Organization, 2015.
http://apps.who.int/iris/bitstream/10665/186463/1/9789240694811_eng.
pdf?ua=1. The report identifies four priority areas for action: aligning health
systems to the older populations; developing systems of long-term care;
creating age-friendly environments; and improving measurement,
monitoring and understanding.
15. WHO. The Global Strategy and Plan of Action on Ageing and Health;
2016. p. 9.
16. For example, Kant famously stated that “the humanity [dignity] in one’s
person is the object of the respect which he can require of every human
being, but which he must not forfeit.” He must not forfeit his dignity not
primarily for reasons of consistency, but because it is required of him
to treat his own life as an end in itself. Immanuel Kant, The
Metaphysics of Morals, Part II: Metaphysical Principles of Virtue (1797),
in Immanuel Kant’s Ethical Philosophy. Trans. James W. Ellington
(Indianapolis, IN.: Hackett, 1983) p. 97.
17. Dworkin R. What Is a Good Life? The New York Review of Books, February
10, 2011 Issue: 1–10, at p. 5; 2011.
18. Ronald Dworkin “What Is a Good Life?”, 7. In a famous thought experiment
familiarly termed as “the experience machine”, Robert Nozick brilliantly
refutes the notion that what underpins the value of life is subjectively felt-
experience of well-being. See Robert Nozick (1974), Anarchy, State and
Utopia. Basic Books. A version of the thought experiment is discussed in a
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 15 of 16
previous work of his, The Examined Life: Philosophical Meditations. Simon &
Schuster, 1989.
19. WHO. World Report on Ageing and Health; 2015. p. 240.
20. Dworkin R. Justice for Hedgehogs. Cambridge: Harvard University Press; 2011:200.
21. Hausman DM. Valuing Health: Well-Being, Freedom and Suffering, vol. 158.
Oxford: Oxford University Press; 2015.
22. Dworkin R. Justice for Hedgehogs. Cambridge: Harvard University Press;
2011:128.
23. Nozick R. Anarchy, State and Utopia. Basic Books. 1974:6.
24. Thomson JJ. “Some Ruminations on Rights”, University of Arizona Law
Review, 19; reprinted in Thomson JJ (1986), Rights, Restitution, and Risk.
Cambridge: Harvard University Press; 1977:49–65.
25. Teerawattananon Y, Mugford M, Tangcharoensathien V. Economic
evaluation of palliative management versus peritoneal dialysis and
haemodialysis for end-stage renal disease: evidence for coverage decisions
in Thailand. Value Health. 2007;10:61–72 This estimate is based on the
WHO-CHOICE project and a study on dialysis in Thailand. See WHO Cost
effectiveness and strategic planning (WHO-CHOICE). Website of the World
Health Organization; Available from: http://www.who.int/choice/
costeffectiveness/en.
26. Kevany S, Matthews M. Diplomacy and Health: The End of the Utilitarian Era.
Int J Health Policy Manage. 2017;6(4):191–4 On the need to shift from cost-
effectiveness analysis (CEA) towards a more inclusive approach to global
health interventions.
27. WHO (2017b). Towards long-term care systems in sub-Saharan Africa. (WHO
series on long-term care); Aboderin I, Hoffman J (2011). Caregiving in contexts
of poverty in sub-Saharan Africa: critical perspectives on debates and realities.
Keynote paper presented at the Festival of International Conferences on
Caregiving, Disability, Aging and Technology, Toronto, Canada, 2011.
28. Baumann H. Reconsidering Relational Autonomy: Personal Autonomy for
Socially Embedded and Temporarily Extended Selves. Analyse Kritik. 2008;30:
445–68; Also see John Christman, Relational Autonomy, Liberal
Individualism, and the Social Constitution of Selves, in: Philosophical Studies
117 (2004): 143–164; (2009) The Politics of Persons: Individual Autonomy and
Socio-Historical Selves, Cambridge: Cambridge University Press; Oshana, M.
(2006), Personal Autonomy in Society, Aldershot.
29. Kamm FM. Intricate Ethics: Rights, Responsibilities, and Permissible Harm.
Oxford: Oxford University Press; 2008; Joel Feinberg (1980) Rights, Justice
and the Bounds of Liberty: Essays in Social Philosophy, Princeton University
Press; Ronald Dworkin (1978), Taking Rights Seriously, Cambridge, M.A:
Harvard University Press; Judith Jarvis Thomson (1986), Rights, Restitutions
and Risk, Cambridge, M.A: Harvard University Press. For a description of
human rights along these lines
30. United Nations. Political declaration and Madrid international plan of action
on ageing. 2002. https://www.un.org/esa/socdev/documents/ageing/
MIPAA/political-declaration-en.pdf.
31. United Nations (UN). Political Declaration and Madrid International Plan of
Action on Ageing, Presented at the Second World Assembly on Ageing,
Madrid, Spain, April 8–12, 2002. New York: United Nations; 2002. Retrieved
March 29, 2019, from http://www.un.org/en/events/pastevents/pdfs/
Madrid_plan.pdf
32. Sen A. Why Health Equity? In: Anand S, Peter F, Sen A, editors. Public
Health, Ethics, and Equity. Oxford: Oxford University Press; 2004. p. 21–43.
ep. 25; Sen A., Equality of What?. In:McMurrin S. Tanner Lectures on Human
Values, Vol. 1. Cambridge: Cambridge University Press, 1980; G. A. Cohen,
Equality of What? On Welfare, Goods, and Capabilities. Louvain Economic
Review 56 (3/4)-1990: 357–382.
33. Sen A. Why Health Equity? In: Anand S, Peter F, Sen A, editors. Public
Health, Ethics, and Equity. Oxford: Oxford University Press; 2004. p. 31.
34. Sadana R, Blas E, Budhwari S, Koller T, Paraje G. Healthy Ageing: Raising
Awareness of Inequalities, Determinants, and What Could Be Done to
Improve Health Equity. Gerentologist. 2016;56(S2):S178–93.
35. Rawls J. A Theory of Justice. Cambridge: Harvard University Press; 1971. For
a global approach to the Difference Principle, see Rawls (2001) The Law of
Peoples: With, The Idea of Public Reason Revisited. Cambridge, M.A: Harvard
University Press
36. Norman Daniels, Bruce Kennedy, and Ichiro Kawachi (2004), “Health and
Inequality, or, Why Justice is Good for Our Health”. In Sudhar Anand et al.
(eds.), op.cit. p. 77.
37. Schröder-Butterfill E, Marianti R. A framework for understanding old-age
vulnerabilities. Ageing Soc. 2006;26(1):9–35.
38. HelpAge International and Cordaid. A study of older people’s livelihoods in
Ethiopia. London and The Hague; 2011. p. 6.
39. World Health Organization. Making fair choices on the path to universal
health coverage: final report of the WHO consultative group on equity
and universal health coverage. 2014. http://www.who.int/iris/handle/
10665/112671.
40. For an insightful defence of the five unacceptable trade-offs, see Ole Frithjof
Norheim. Five Unacceptable Trade-offs on the Path to Universal Health
Coverage. Int J Health Policy Manage. 2005;4(11):711–4.
41. van Des Geest S. Respect and reciprocity: care of elderly people in rural
Ghana. J Cross Cult Gerontol. 2002;17(1):3–31; van Des Geest S (2016). Will
families in Ghana continue to care for older people? Logic and
contradiction in policy. In: Hoffman J and Pype K, editors. Ageing in sub-
Saharan Africa: spaces and practices of care. Bristol: Policy Press, 2016;
Aboderin I, Hoffman J (2015). Families, intergenerational bonds, and aging
in sub-Saharan Africa. Can J Aging. 34(3):282–9. doi: 10.1017/
S0714980815000239.
42. Ferreira M. Elder abuse in sub-Saharan Africa: what policy and legal
provisions are there to address the violence? J Elder Abuse Negl. 2004;16(2):
17–32. https://doi.org/10.1300/J084v16n02_02; Pillemer K, Burnes D, Riffin C,
Lachs MS (2016). Elder abuse: global situation, risk factors, and prevention
strategies. Gerontologist 56 Suppl 2:S194–205. doi: 10.1093/geront/gnw004.
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published
maps and institutional affiliations.
Gebremariam and Sadana International Journal for Equity in Health(2019) 18:140 Page 16 of 16
BioMed Central publishes under the Creative Commons Attribution License (CCAL). Under
the CCAL, authors retain copyright to the article but users are allowed to download, reprint,
distribute and /or copy articles in BioMed Central journals, as long as the original work is
properly cited.

Place your order
(550 words)

Approximate price: $22

Calculate the price of your order

550 words
We'll send you the first draft for approval by September 11, 2018 at 10:52 AM
Total price:
$26
The price is based on these factors:
Academic level
Number of pages
Urgency
Basic features
  • Free title page and bibliography
  • Unlimited revisions
  • Plagiarism-free guarantee
  • Money-back guarantee
  • 24/7 support
On-demand options
  • Writer’s samples
  • Part-by-part delivery
  • Overnight delivery
  • Copies of used sources
  • Expert Proofreading
Paper format
  • 275 words per page
  • 12 pt Arial/Times New Roman
  • Double line spacing
  • Any citation style (APA, MLA, Chicago/Turabian, Harvard)

Our guarantees

Delivering a high-quality product at a reasonable price is not enough anymore.
That’s why we have developed 5 beneficial guarantees that will make your experience with our service enjoyable, easy, and safe.

Money-back guarantee

You have to be 100% sure of the quality of your product to give a money-back guarantee. This describes us perfectly. Make sure that this guarantee is totally transparent.

Read more

Zero-plagiarism guarantee

Each paper is composed from scratch, according to your instructions. It is then checked by our plagiarism-detection software. There is no gap where plagiarism could squeeze in.

Read more

Free-revision policy

Thanks to our free revisions, there is no way for you to be unsatisfied. We will work on your paper until you are completely happy with the result.

Read more

Privacy policy

Your email is safe, as we store it according to international data protection rules. Your bank details are secure, as we use only reliable payment systems.

Read more

Fair-cooperation guarantee

By sending us your money, you buy the service we provide. Check out our terms and conditions if you prefer business talks to be laid out in official language.

Read more