The Old and the Restless

Richard Suzman, associate director for the Behavioral and Social Research Program at the National Institute on Aging, studies why the elderly are becoming increasingly healthy.

Just a few years ago, most people saw modern medicine’s great success, dramatically longer life spans for human beings, as something of a mixed blessing. By the year 1977, the expert consensus held that while doctors could extend life of a sort for individuals perhaps indefinitely, medical science could not extend vitality. People who lived beyond the age of 80, the experts argued, could expect their remaining lifetime to be one of dramatically increasing disability. The ability to see, hear, move, and finally even comprehend reality would begin slipping away from even the hardiest of us as we ended our fourth score on this Earth. Popular fiction, absorbing that analysis into our cultural gestalt, increasingly painted a dystopian future in which elderly people, too feeble to actually function but too well-cared for to pass away, would be all but stacked up like cords of wood as their great-great grandchildren scurried about to pay the bills sent out by warehouses for the living dead.

But a funny thing happened on the way to the warehouse. Far from becoming increasingly crippled as we aged, the elderly became increasingly healthy. “Between 1982 and 1999 the prevalence of disability actually declined,” said Richard Suzman, associate director for the Behavioral and Social Research Program at the National Institute on Aging, a part of the National Institutes of Health. “There was lots of disbelief. Now that’s become pretty well accepted, and that was a very important line of inquiry for policy makers in this country.”

It’s important because if the number of older Americans with chronic disabilities continues to decline by about 1.5 percent a year, then even though the average age of the population is rising, instead of having to deal with the economic, sociological, and political ramifications of 20 million chronically disabled elderly people in America in the year 2050, there will be only 7 million, roughly the same number that exist today. While it’s not clear that those declines can continue for the next 46 years – much of the existing reduction may be due to improvements in medical treatments, such as the increasingly routine use of joint-replacement surgery that will eventually peak without possibility of further significant improvement – many researchers suspect that continued changes in health-related behaviors can cause the disability rate to continue its decline. Obviously, genetics plays a significant role in all this, along with environment and socioeconomic status, but the relationship of these variables is not always clear.

And it’s this relationship that consumes Suzman, especially the ties between factors such as health, disability, and economics. The relationship between retirement and health hadn’t really been adequately explored until he helped set up the NIA-sponsored Health and Retirement Study in 1992. The data provided solid evidence that a wealthier elderly person is more likely to be healthy, but it also found that poor health in childhood led to lifelong reductions in wealth, and that as far as health was concerned, parental wealth was more important than one’s own. Cause and effect can actually shift places in this complex equation.

Cacioppo

Such trends will play a critical role in the economics and policy of the nation, according to Suzman. For example, if we’re less likely to develop disabilities as we grow older, we’re more likely to work longer before retiring. But that would open up a completely new assortment of problems. Nobody really knows what effect a significantly older workforce would have on safety and productivity. As a result, there is major interest in studying the way older people function in work and other environments.

The term “environmental press” refers to the aspects of an environment that restrict instead of aid a resident of that environment. Jeffrey W. Elias, head of the cognitive aging program at the NIA’s Behavioral and Social Research Program, or BSR, uses the term “technological press” to describe the same sorts of issues directly related to technology. For example, Elias said computers aren’t always the great engines of productivity they’re supposed to be, but rather a frustrating and scary hindrance to getting through the day. “Sometimes the computer actually becomes hazardous,” he said, giving the example of “phising,” in which a person provides sensitive financial information over a poorly secured browser and has his or her bank account drained. “Obviously we’ve got a major interest in making sure this doesn’t happen to older people, so we need to study the relationship of technology to behavior and health.”

And technology is only one of the factors that influence health in the elderly. “For instance, you’ve got things like personality factors,” Elias said. “We think a great many of the aspects of our personalities lead us in certain directions for things like seeking out health care and making good decisions, but how does age change things like health literacy?

“A lot of what BSR tries to do is translate or apply work in different areas,” he said. “If we know that emotional regulation in later life plays a role in some decisions, how does that relate to when people buy a car at 65 or long term health insurance? We’re also looking at things like the influence of genetics, which obviously plays a large role in all this, but that role varies significantly depending on a number of variables. For instance, it seems that at lower socioeconomic levels, the environmental influence may be more important than the genetic influence.”

Suzman agreed. “We’ve got increasing numbers of longitudinal studies that are getting DNA,” he said. One perspective is that being able to measure some of the genetic variation should allow us to pinpoint and describe the social influences more accurately. It’s clear that there are going to be a lot of spurious findings in this area and we’re going to need multiple confirmations. About 10 years ago, I used to joke that at some point we’d find the gene for wealth accumulation. And, well, we have now funded a very high-risk but innovative study using the Danish twin study data that is looking at genes and the proteins they code for in terms of potential precursors for economic related behaviors. The field is moving very rapidly.”

Suzman, who received his PhD in social psychology from Harvard University after studying social anthropology at Oxford University, attributes much of that movement to significant changes over the past few years in the way we do science in the United States. “At the moment, the sciences are in a highly interdisciplinary mode in which the integration and synthesis that goes on at the interfaces and at the boundaries is where a lot of the most exciting stuff is happening,” he said. “And the moment you see the development of new fields with double-barreled names, you’re there: Bio-demography. Neuroeconomics. Behavioral economics. It seems at those intersections we are getting some of the most innovative and exciting new approaches.”

While Suzman argued that the increasing emphasis in interdisciplinary studies within the BSR is just a sign of the times, colleagues say much of the shift is due to Suzman’s persistence and respect within the community.

“Twenty years ago, researchers looked at old people and looked at young people. What Richard has done is develop theories and methods where age is treated as a theoretical variable rather than just a question of generalizability or methodological value,” said APS Board Member John T. Cacioppo, The University of Chicago. “He’s gotten people to go across disciplines, fostering the integration of research through such techniques as the introduction of biomarkers into surveys.

“He’s doing things that are right on track with where the discipline of psychology is moving,” Cacioppo said. “It used to be that different fields didn’t talk to each other very much. But age is a variable that cuts across every different discipline. He has taken the lead in doing that and hasn’t limited it to, for instance, Alzheimer’s. He is a leader and viewed, appropriately, as a pioneer.”

APS Fellow and Charter Member Laura L. Carstensen, Stanford University, agreed. “One of the things [Suzman’s] been really good at is pulling psychology together with economics, using basic research to improve the integrity of both disciplines,” she said.

In fact, Suzman is credited within NIA for developing the agency’s signature Economics of Aging program, one of the first of its kind to look at socioeconomic factors and health. The program got a big boost in 2002 when one of the researchers associated with the movement, APS Fellow Daniel Kahneman, Princeton University, won a Nobel Prize in Economic Sciences for integrating psychological research with economic theory. Suzman said such advances mean new avenues for research. “The whole field of neuroeconomics – which relates very much to decision-making – is burgeoning. Do people go through chains of calculations for all the equations that can be developed to make various decisions, or are there short-circuits, or do they rely more on emotional avenues?”

Suzman said that part of the reason for the reinvigoration of behavioral and social sciences research in aging is a willingness to try new approaches. “We are very open to basic research, especially when combined with trying to solve some practical problems,” he said. He pointed to the book by Donald E. Stokes, Pasteur’s Quadrant: Basic Science and Technological Innovation, as a straightforward argument that there need be no real distinction between basic and applied research in many cases. “The problem there is that obviously if you’re trying to solve a practical problem, such as getting a person to the moon, that’s not really basic research,” Suzman said. “But I do think that certainly focusing on trying to solve some of the big practical problems is also a very good way to get basic research done – since more often than not more basic research is needed before one can solve the problem – and we’d like to see much more basic research as part of our portfolio.”

With all that in mind, BSR has identified seven research areas that will receive particular emphasis in the coming years. These include questions about health disparities, aging minds, increasing health expectancy, retirement, interventions and behavior change, genetics, behavior, and the social environment, and the efficiency of the health systems.

In particular, the questions that relate to personal behavior and lifestyle choices pose an increasing challenge in a free society. When so many factors under individual control can affect quality of life and longevity – smoking, exercising, following medical advice – how can we influence people to simply take better care of themselves? How can we better motivate people to make investments in retirement plans such as a 401-k? Should we raise the retirement age if we’re all going to remain healthy and presumably able to work for far longer than our grandparents did, and what will that mean to a younger generation who may be kept out of the workforce longer?

Suzman said the answers will not come exclusively from psychology, although they all have a psychological component. Answering them will mean embracing the use of new tools, such as functional magnetic resonance imaging, or fMRI, which is giving researchers the ability to actually watch some of the mechanics of our thought processes. Together with a new cooperative research environment in which diverse experts sit at the same table and examine each other’s data, he is convinced those questions can be answered, and, in the process, help scholars from many disciplines answer their own pressing questions. “Trade is valuable to both trading partners,” Suzman said. “There’s going to be a lot of trade that’s valuable to both psychology and all the other fields we’re going to be working with.”

For more information on NIA’s Behavioral and Social Research Program, visit www2.nia.nih.gov/research/extramural/behavior.