The Future of Human Healthspan: Demography, Evolution, Medicine, and Bioengineering: Task Group Summaries (2008)

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Changes in Social Contexts to Enhance Functional Status of the Elderly TASK GROUP DESCRIPTION Background Longevity is the largely unexpected consequence of improvements to general living conditions that came from applications of science and tech- nology. Bob Fogel and Dora Costa (1997) coined the term “technophysio evolution” to refer to improvements in biological functioning that are the direct consequence of such advances. They point out that agricultural technologies that were developed mostly in the early 20th century vastly improved the quality and sustainability of the food supply. Subsequent im- provements in nutrition were so dramatic that average body size increased by 50 percent and life expectancy doubled. The working capacity of vital organs also greatly improved. Yet across the same time period there have been relatively few system- atic applications of technology and science, including social science, aimed at improving subjective well-being across eight, nine, and even ten decades of life. Indeed, most technological advances currently on the horizon are designed to compensate for age-related impairments like cardiac disease and cognitive decline rather than to improve subjective well-being. There is good reason to expect that improvements in subjective well-be- ing would not only improve quality of life but would likely reap significant gains in physical functioning as well. In scores of studies subjective well-be- ing has been linked to physical and functional abilities. Indeed, many (e.g., Sapolsky, 2004) have argued that chronic stress in modern life contributes 49 

50 the future of human healTHspan to reduced psychological and physical well-being. Blackburn and colleagues have documented shortened telomeres in caregivers of chronically ill rela- tives. And the converse: social support has been found to be strongly associ- ated with health and productivity (Berkman, 2000). There is some evidence that positive social relationships may protect against dementia (Fratiglioni, 2000). Happier people appear to live longer and healthier lives (Levy et al., 2000). One finding in particular is clear: high levels of education strongly predict functional health. In order to ensure that added years are satisfying, healthy, and meaningful, it is important to consider ways that scientific and technological advances can contribute to lifelong learning and socioemo- tional functioning. At a macro level, too, the attention of economists, demographers, and sociologists is needed. Societies have not adjusted to increased life expectan- cy. The social norms that guide individuals through life have changed little across the years that life expectancy increased, a phenomenon Riley referred to as structural lag (Riley et al., 1994). This mismatch likely underutilizes the citizenry of the nation. Federal entitlement programs have changed little since their inception despite increases in average life expectancy. Regulations surrounding Social Security have remained largely unchanged, implicitly presuming that people should work for 40 years, and then retire for decades. Medicare reimburses hospital bills but does not reimburse many services that would allow people with disabilities to live at home. Initial Challenges to Consider • What is education? Highly educated people show minimal age-re- lated declines in functional status whereas people with less than high school education show steady declines beginning in early adulthood (House et al., 1990). Income contributes to these outcomes but education appears key. What is education? Years spent in the classroom are obviously a gross indicator of education. It is important to gain a better understanding of the cognitive, neural, and behavioral mechanisms that account for improved functioning associated with more years of education. • How can work/life changes improve subjective healthspan? Technol- ogy may offer ways to provide effective continued education throughout life. This will be particularly important for work performance in the future. The speed of transfer of new technologies from discovery to the public is increasing, demanding continual new learning, an area known to decline with age. 

CHANGES IN FUNCTIONAL STATUS OF THE ELDERLY 51 • With increases in life expectancy, societies will need aging people to maintain engagement in workplaces, neighborhoods, and families. Can science and technology strengthen families? Families are morphing from horizontal shapes with many siblings, cousins, aunts, and uncles to more vertical family forms. Can technologies strengthen family relations across generations and geographical distances? Cell phones and e-mail changed culture. What are the limits of communications technology to subjective well-being? • Social functioning is essential to well-being. How can technological and biological advances improve sensation and perception such that social interactions are facilitated into advanced years (e.g., hearing aids, visual aids)? • How can social programs, such as social insurance programs, be modified to optimize human capital? Education again becomes key. If a shift in responsibility to patient is to work, science education must be improved. Initial References Berkman, L. F. 2000. Social support, social networks, social cohesion and health. Social Work Healthcare 31(2):3-14. Epel, E. S., E. H. Blackburn, J. Lin, F. S. Dhabhar, N. E. Adler, J. D. Morrow, and R. M. Cawthon. 2004. Accelerated telomere shortening in response to life stress. Proceedings of the National Academy of Sciences U.S.A. 101(49):17312–17315. Fogel, R. W., and D. L. Costa. 1997. A theory of technophysio evolution, with some implications for forecasting population, health care costs, and pension costs. Demography 34(1):49-66. Fratiglioni, L. 2000. Influence of social network on occurrence of dementia: A community- based longitudinal study. Lancet 355(9212):1315-1319. Glass, T. A., T. E. Seeman, A. R. Herzog, R. Kahn, and L. F. Berkman. 2000. Change in productive activity in late adulthood: MacArthur studies of successful aging. Journals of Gerontology B—Psychological Sciences and Social Sciences 50B(2):S65-S76. House, J. S., R. C. Kessler, A. R. Herzog, R. P. Mero, A. M. Kinney, and M. J. Breslow. 1990. Age, socioeconomic status, and health. The Milbank Quarterly 68(3):383-411. Levy, B. R., M. D. Slade, S. R. Kunkel, and S. V. Kasl. 2000. Longevity increased by positive self perceptions of aging. Journal of Personality and Social Psychology 83(2):261-270. Riley, M. W., R. L. Kahn, and A. Foner (eds.). 1994. Age and Structural Lag: Society’s Failure to Provide Meaningful Opportunities in Work, Family, and Leisure. New York: John Wiley. Sapolsky, R. M. 2004. Organism stress and telomeric aging: An unexpected connection. Proceedings of the National Academy of Sciences U.S.A. 101(50):17323-17324 

52 the future of human healTHspan Task Group Members • Richard Allman, University of Alabama at Birmingham • Eileen Crimmins, University of Southern California • Corey Keyes, Emory University • Steven Kou, Columbia University • Kenneth Langa, University of Michigan • Duncan Moore, University of Rochester • Greg O’Neill, National Academy on an Aging Society • Sara Peckham, Wellness Coordinator • Teresa Seeman, University of California, Los Angeles • Rachel VanCott, Massachusetts Institute of Technology TASK GROUP SUMMARY By Rachel VanCott, Graduate Student in Science Writing, Massachusetts Institute of Technology Mr. McGuire: I want to say one word to you. Just one word. Benjamin: Yes, sir. Mr. McGuire: Are you listening? Benjamin: Yes, I am. Mr. McGuire: Plastics. Benjamin: Just how do you mean that, sir?                From The Graduate (1967) An Aging Society Requires Social Plasticity After three days of discussion, this task group started their presentation with a joke from the movie The Graduate and a nod to ideas introduced in the keynote address just days before. People are living longer, said group spokesperson Kenneth Langa, but they’re living those longer lives according to an outdated set of social norms. Today’s social structures support a lifecourse that leads to stagnation: Education is confined to the early years of a person’s life, his adult years are dominated by repetitive work, and leisure finds a place only at the end of life, during retirement. The task group had been charged with considering how changing social contexts could improve the functional status and sub- jective health of the elderly. To do that the group looked beyond retirement and across the lifespan. 

CHANGES IN FUNCTIONAL STATUS OF THE ELDERLY 53 They considered how increasing options for education, work, and leisure throughout life might extend health. Through their discussions the group decided that the key to a society that keeps individuals engaged and learning throughout life is a restructuring of the lifecourse: a move toward social plasticity. The main focus of the group’s work was figuring out how to break down barriers between the life stages and allow opportunities for educa- tion, work, and leisure to permeate the lifespan, summarized Langa, who is a professor of general medicine and of the Institute for Social Research at the University of Michigan. Day 1: Restructuring Education The task group spent much of their first meeting discussing education, and the first question of the presentation voiced a knowledge gap that the group identified early in the conference. “What is it about education early in life and possibly later in life that allows people to maintain their minds, brains, and bodies optimally?” asked Langa, “Is it the formal process of education? Is it about the social interactions that happen in the education process? How do we optimize the active ingredients?” Several group members noted that it might not be education itself that results in high levels of functioning later in life. Those who succeed in higher education might have other characteristics associated with better late-life health. For example, the drive that leads people to seek and com- plete higher education may also encourage other behaviors, like disciplined exercise habits, which lead to better health. While the group members weren’t sure how many factors contribute to the relationship between education and high functioning in later life, several of them argued that the relationship has been shown to exist. There is plenty of research that shows that education itself has a significant impact on the brain, said Langa. “A more highly educated person can sustain more damage to the brain . . . as circuits start to fail, the brain [of an educated individual] can reroute to use other circuits.” So even without knowing how and if the formal education process is directly responsible for functional enhancement, public policy decisions that make higher education available to people of any age might be a good place to start, suggested Greg O’Neill, group leader and director of the National Academy on an Aging Society. The group discussed several factors that make accessing education at older ages difficult, including transporta- tion issues and the social stigma of attending school as an adult. The group 

54 the future of human healTHspan also identified the rising cost of higher education as a potential barrier that public policy decisions could impact. “The government is giving funding for young people who want to go to school but not for older people who want educational experience,” said Steven Kuo, an associate professor of industrial engineering and operations research at Columbia University. Brian Hofland, program director of the international aging team of the Atlantic Philanthropies Incorporated, spoke up, explaining that programs do exist to serve that purpose. For example, he said, the Council for Adult and Experiential Learning, a nonprofit organization based in Chicago, Illinois, has a program called Lifelong Learning Accounts (LiLA), which allows employers to match funds that the employee could use for higher education or training purposes. Teresa Seeman, a professor of geriatrics at the University of California, Los Angeles, argued that older adults seeking higher education still have less financial aid options than young adults. But educational opportunities don’t occur exclusively in the classroom. Seeman mentioned the existence of a number of small programs that offer the chance for older adults to gain various new skills or knowledge. O’Neil also mentioned a learning oppor- tunity far from the classroom—the organization Encore! sends volunteers who have previously worked with the Peace Corps out on short-term assign- ments where they can use their skills and experience and in turn continue to learn more about the world and about themselves. However, as promising as the opportunities for alternative types of learning sound, Seeman said, they haven’t been evaluated with regard to their impact on a person’s physical or mental health. Seeman’s comment reflected a concern that would surface again and again over the three days of group discussion. Many organizations in the private and public sectors are proposing and producing ways to keep older adults learning longer, but if the results of these programs aren’t objectively evaluated, scientists and policy makers will be unable to answer the press- ing questions surrounding this issue. Is formal education that happens later in life as beneficial as education obtained as a young adult? Do alternative learning opportunities that teach skills and self-knowledge provide the same cognitive benefits as formal education? Day 2: Restructuring Work and Leisure On the second day the group returned to an issue they had touched on during the first day: work and retirement. 

CHANGES IN FUNCTIONAL STATUS OF THE ELDERLY 55 “We know the modal age of retirement was 62, which is starting to creep up.” said Eileen Crimmins, who is a professor of gerontology at the Davis School of Gerontology at the University of Southern California and director of the USC/UCLA Center on Biodemography and Population Health. “People want to retire at some point,” she said, “but they like the idea of having jobs and flextime. We know what people want to do and we kind of know what people have to do.” What people have to do, the group agreed, is continue working later in life. That might mean later retirement or second careers or part-time work while in retirement. To encourage continued work older adults would need more options, including the chance for midcareer retraining and the opportunity to have different types of intellectually or socially meaningful part-time jobs as a second career. Opportunities like working with Experience Corps, a program funded by AmeriCorps that trains older adults to act as tutors for struggling city- school students, might provide the type of opportunity that could keep the elderly socially and intellectually engaged while they earn a small stipend. But Experience Corps, like other programs, hasn’t been evaluated for the health impact it has on the adults who tutor. In addition to a lack of appealing job options, transportation can be a major barrier to continued work, particularly in the case of older adults who may be unable to drive or rely on public transportation to take them to work and social gatherings, especially in extreme climates. The group discussed technology-fueled alternative work ideas like microjobs—jobs that can be done in 10 to 15 minutes from a home computer—or work at call centers, or programs in which call-center calls can be redirected to home phones. Outside of offering greater opportunities for work in the home, tech- nology might also enhance the social life of the elderly by allowing them to stay in touch with family and friends, or allow them to maintain autonomy longer through use of smart house systems that could monitor their move- ments and alert family if their movement patterns change. Alternatively, a new type of intergenerational living group, or urban housing center, for the elderly might help older adults remain socially engaged even if their families live far away. But just like the examples that the group had discussed previously, technological innovations and alternative living arrangements have not been assessed for their potential as tools that help the elderly maintain their subjective well-being. 

56 the future of human healTHspan Recommendations In the final presentation Langa concluded with the group’s recom- mendation. “We need to gather data about what older adults actually want in terms of new opportunities for ongoing engagement, productivity, and learning into older age,” he said. “What are the preferences of people, and are there differences in preference over various social groups? Are there sig- nificant differences across class, across socioeconomic status?” Langa also introduced the concern that had become a theme in this task group’s discussion. “We don’t think we have a great sense of what the currently existing programs are,” he said. “We’d like to put that informa- tion together and gather what’s out there in terms of current programs . . . evaluate these programs and their consequences in terms of health and healthspan.” The group also suggested that a prize, designed to award pro- grams that successfully improve the functional status of the elderly, might spur further research. Overall, the group suggested that our social structures need greater plasticity so that they can better meet the needs of both our aging society as a whole and the needs of individuals as they grow and change. Organiza- tions that are already working toward this kind of plasticity must be recog- nized and encouraged if we want to see an increased human healthspan and push the limits of human health.