Nursing's capacity to optimally care for older adults depends on expanding the gerontological science that underlies the development of best practices, educational changes, and policy directions (National Hartford Center for Gerontological Nursing Excellence, 2019). The American Geriatrics Society challenged professionals to expand educational, clinical, advocacy, and research efforts that address healthy aging from a broad perspective (Friedman et al., 2019). Research into behavioral interventions that facilitate the ability of older adults to age well and remain independent is needed (Johns Hopkins University School of Nursing, 2019). Specifically, person-centered approaches that focus on older adults' personal goals, autonomy, engagement, optimal functioning, resilience, dignity, and life satisfaction are needed.
Citizen science, sometimes called public scholarship or participatory science, is one way to involve older adults in developing knowledge (Tuckett, Banchoff, Winter, & King, 2017). Den Broeder, Devilee, Van Oers, Schuit, and Wagemakers (2019) describe the value of citizen science in better aligning practice and policy with reality. Engaging older adults in research about processes they use to exert control in their daily lives can contribute new perspectives. Furthermore, national organizations that address ageism and aging issues stress the importance of exhibiting the contributions of older adults to shift policy, practice, and societal norms (American Society on Aging, 2019; FrameWorks Institute, 2017). By using the expertise of older adults in research, awareness about their potential contributions may increase and help reframe the dialogue about their value to society.
The purpose of the current article is to present Engaging With Aging (EWA), a framework that emanates from the personal and prior professional experiences of a nonagenarian “superager,” rather than from existing theory or research. Superagers are “resilient healthy older adults who take control of their lives, maintain optimism and social connections, and embrace healthy lifestyles” (Piore, 2019). EWA focuses on day-to-day living, age-related changes, related impact areas, and adaptive strategies. It began with a case study of one person's own aging, was developed into a blog, and later advanced as a framework for future scholarship and research. The EWA framework is presented as a purposeful strategy that older adults can use to enhance their adaptive ability (Figure 1). Future development of the EWA framework as well as its limitations are described.
The process of engaging with aging.
Enhancing Successful Aging
Understanding how and why some older adults adapt to the challenges of aging better than others is central to promoting aging well (Friedman et al., 2019). Although scholars have yet to agree on the definition of aging well, it is conceptualized and operationalized as multidimensional and includes successful, effective, and optimal aging (Woods et al., 2016). Although a comprehensive review of the literature is beyond the scope of this article, a brief examination provides contextual background for the EWA framework.
Rowe and Kahn's (1997) classic approach to successful aging addressed avoiding disease and disability, high cognitive and physical function, and engagement with life. Other constructs that represent successful aging include the use of active cognitive strategies and social engagement as well as individual character traits such as adaptability, optimism, and resilience (Harmell, Jeste, & Depp, 2014). Physiological functioning, life satisfaction, social engagement, and personal and external resources are dimensions of successful aging (Cosco, Prina, Perales, Stephan, & Brayne, 2014). In a meta-analysis, Kim and Park (2017) found that successful aging had four domains: (a) disease and disability avoidance, (b) high cognitive and physical functioning, (c) engagement in activities, and (d) positive psychological adaptation in later life.
Theoretical perspectives about successful aging that go beyond physiological decline and frailty to include social, psychological, and interpersonal factors as well as normative and positive aspects of aging are needed. Healthy aging and well-being can also be viewed as an integrative process involving autonomy, environmental mastery, personal growth, positive relations with others, purpose in life, and self-acceptance (Ryff, 2013). Similarly, dimensions of aging well among women age ≥80 who participated in the Women's Health Initiative include resilience, self-control, self-mastery, emotional well-being, life satisfaction, and social support (Woods et al., 2016).
“Healthy aging involves pivoting to age's influence on our physical, mental, and social needs and expectations” (Jacobs, 2019, p. 47), implying the need for a compensatory, action-oriented approach to managing age-related changes that includes cognitive processes and adaptive strategies. Proactivity models of successful aging include active, preventive, and corrective strategies used to adapt to the challenges and normative stressors of aging (e.g., functional limitations, illness, social losses) (Kahana, Kelley-Moore, & Kahana, 2012; Stowe & Cooney, 2015). Similarly, the selection, optimization, and compensation model addresses processes used by older adults as they seek to optimize the use of available capacities and resources and are compensated with satisfaction and a sense of greater control (Donnelan, 2015; Freund, 2008; Ouwehand, de Ridder, & Bensing, 2007). However, Nguyen, Leanos, Natsuaki, Rebok, and Wu (2018) argue that addressing compensatory mechanisms used by older adults to minimize decline is not enough and recognize that older adults have the potential to grow and adapt to functional changes associated with aging by learning new skills and subsequently maintaining independence in their daily lives.
Although the causes and subsequent implications of age-related changes are described in the literature from a physiological system, a structural and functional perspective (Smith & Cotter, 2016), less attention is given to the interaction of these normative changes with the overlay of pathology that often affects daily living. There is a need to expand knowledge about how older adults experience and cope with the normal age-related changes that impact daily living to reframe the dialogue about growing older from a positive and life course development perspective. A deeper understanding of adapting to age-related changes would serve as a basis for generating action-oriented approaches that older adults could use to optimize functional status, maintain independence, and attain personal fulfillment. Furthermore, the voices of older adults can provide valuable insights about aging well and should be included in the development of theoretical models and strategies (Jopp et al., 2015; Kusumastuti et al., 2016; Tkatch et al., 2017). To fill this gap, the EWA framework is proposed as a way to build knowledge about the processes older adults may use in daily living.
The Origin of Engaging with Aging
Carnevali formulated the EWA approach to provide a perspective for older adults' personal management of their daily living as age-related changes and pathology enter their lives and progress (Primomo & Belza, 2019). EWA had its genesis in an 18-month field study (Little & Carnevali, 1967). Insights from that research triggered years of further explorations and evolution that focused on health-related daily living as a domain for nursing care planning (Little & Carnevali, 1976) and diagnostic reasoning (Carnevali, 1996; Carnevali, Mitchell, Woods, & Tanner, 1984; Carnevali & Thomas, 1993). Later, health-related daily living and the diagnostic reasoning process for nursing care planning were applied to populations of older adults (Carnevali & Patrick, 1993) and those with cancer (Carnevali & Reiner, 1990).
When Carnevali experienced her own aging, her previous work shaped her approach to daily living challenges, yet she was not bound by it. Her process was intuitive at first, as age-related changes emerged and initially progressed, but then more conscious and purposeful as these changes became increasingly invasive of daily living. In her 90s, an encounter with a nursing academic leader led to the development of a weekly blog about her experiences with engaging with aging (Engaging With Aging, 2017; access https://engagingwithagingblog.wordpress.com) (Table 1). The EWA framework provides further explication and formalization of underlying elements and processes and their relationships.
Descriptive Quotation from the Engaging with Aging Blog
Engaging with Aging Framework
EWA is a perspective and set of processes that older adults can proactively use to manage their daily living in the face of emerging and progressing maturational developments and the incidence of pathology. Choosing to engage with aging involves an attitude, one of proactivity and taking charge rather than passivity. It is older-adult initiated, executed, and evaluated and involves persistent self-awareness and attention to details in a person's daily living environment.
Clinical Reasoning: A Process Used in Engaging With Aging
Clinical reasoning is embedded in the EWA framework. Clinical reasoning is a cognitive process used to gather, synthesize, and evaluate information into a broad personal context, and generate alternative actions to address a health-related problem (Carnevali & Thomas, 1993; Holder, 2018; Simmons, 2010). Age-related changes, like pathology, create ongoing, physiological, psychological, and functional challenges and affect the balance between requirements and resources, creating a moving rather than static situation. Applying clinical reasoning in EWA involves:
- identifying objective and subjective manifestations of an emerging or progressing age-related change;
- seeking information about the age-related change's genesis, nature, and patterns of progression to explain and offer guidance for recognizing and understanding its origins, current emergence, and expectations for what lays ahead;
- identifying areas of impact of age-related change within the older adult and in the daily living situation and on internal and external resources, noting specifically the kinds of changes, difficulties, risks, and reactions being generated;
- considering prognostic patterns that offer realistic expectations of the trajectory and associated adaptations for the days and months ahead;
- creating adaptive strategies and setting expectations for the trajectory of age-related change; and
- evaluating adaptations with attention to safety, efficiency, and degree of satisfaction, and modifying them as needed.
Daily Living as a Perspective for Engaging with Aging
EWA's perspective addresses daily living with aging from two viewpoints. First, daily living is viewed as a balance between perceived requirements and the resources for meeting those requirements. The second focuses on the nature and relationships of three elements associated with daily living: age-related changes, the areas of impact age-related changes have on daily living (i.e., impact areas), and adaptive strategies (Table 2). EWA is initiated, executed, and evaluated by the individual to the extent that capacities permit. This perspective can be used by those who help when the older adult needs assistance; the older adult, however, remains at the center of it all.
Definition of Key Terms in the Engaging with Aging (EWA) Framework
Daily living is the environment within which older adults constantly experience their aging and focus their engagement efforts. Daily living is viewed as being a fluid balance between the older adult's perceived requirements for daily living and the resources available for meeting those requirements. Requirements include the physical, cognitive, and emotional tasks and experiences that require the expenditure or use of internal or external resources. This involves activities the older adult sees as necessary and those that are desired, as well as experiences and reactions to them. It also involves roles and relationships with self and the expectations of others.
Resources are made up of two categories. Internal resources include all the physical, cognitive, and emotional capacities the older adult has available at any point in time. External resources encompass available assets that include people, housing, finances, community, environments, services, and equipment. Each resource is considered in terms of availability, accessibility, usability, and sustainability.
Nature and Levels of the Balance Between Requirements and Resources
Balance in daily living is viewed as a sensitive status where increases, decreases, or changes in requirements or resources create needs and adaptations in relevant others. Balance can change from day to day as well as moment to moment. There is also an ongoing trajectory that changes over time as aging progresses or pathology intervenes. EWA balance in daily living is older adult–perceived, although others (e.g., care partners) may also seek to define it. The two views may not be congruent. In EWA, ideal aging is related to the older adult's personal satisfaction with the nature, degree, and level of the existing balance, so the solution to the equation is unlikely to be static.
Age-Related Changes, Their Impact on Daily Living, and Adaptive Strategies
EWA provides a perspective on how older adults can specifically and individually identify age-related changes, use them as a basis for making adaptations to create whatever social roles and activities are possible, and identify satisfying alternatives when the optimum is no longer possible. In EWA, the field of engagement is that of generic daily living, where social roles and activities are elements but not always the highest priority. EWA proposes a specific relationship between age-related changes and their impact areas on mundane and less frequent activities of daily living. It encourages the older adult to become increasingly aware of specifics and linkages as a basis for creating adaptive strategies and involves cognitive activities.
Purposeful management of daily living with age-related changes requires older adults and care partners to acquire some level of: (a) knowledge of normal age-related changes, and specific manifestations associated with their emergence and progression; (b) recognition of the manifestations of emerging and progressing age-related changes in their own lives; (c) purposeful, specific linkage of an age-related change to impact areas of their daily living and lifestyle; and (d) creation of practical adaptive strategies.
Breaking Age-Related Changes into Functional Elements
For EWA to be efficient, age-related changes need to be broken down into descriptions that are specific to what the older adult is experiencing. Instead of routinely accommodating to age-related changes intuitively, an older adult using the EWA framework looks for and consciously notices associated difficulties and discomforts, and then puts them into words. The automaticity associated with everyday activities that has been built up over many decades makes this kind of observation and thinking difficult to achieve and sustain. Table 3 illustrates the process of analyzing an age-related change and provides a description of risks and impact areas associated with changes in balance or stability as well as adaptive strategies used to achieve more control.
Sample Structure for Engaging with an Age-Related Change (ARC)
Pathologies, Normal Aging, and Daily Living
Pathologies may be present as older adults enter the latter stages of their life span and will likely occur during the advancing years. Age-related changes interact with pathologies and add complexity to all elements of managing daily living. In the EWA perspective, conflating normal age developments with pathology is seen as counterproductive. Viewing aging as normal and pathology as abnormal would seem to be logical and obvious. However, when age-related changes are strongly disliked by older adults and negatively regarded by society, there is a reluctance to accept age-related changes as normal. They coexist and can overlap in manifestations (e.g., age-related change of weakening hand grip and arthritis in hands and fingers).
The diagnosis and treatment of pathologies affects elements of the daily living balance. New medical diagnoses and prognoses carry emotional weight. The pathology can alter physical, cognitive, and emotional functional capacities. Diagnostic and treatment activities create new demands and expectations on the requirements and resources sides of the balance equation. Visits to clinical facilities for tests and treatments take time, energy, and transportation, weighing on strength and stamina. Needing to learn about the pathology and its treatment places demands on cognitive skills and courage. Pathologies and their treatment can alter existing role relationships and demand different ones. When older adults have internal and external resources to spare, maintaining a working balance is sometimes possible, although it may be at a lower level. For those starting with a precarious balance, the changes can make maintaining stability difficult, even at lower levels.
In summary, the EWA framework involves older adults' knowledge about age-related maturational changes and pathologies and their impact on daily living; balancing the requirements of daily living with internal and external resources; and creating compensatory strategies to purposely manage daily living, maintain independence, and experience life satisfaction. The framework emerged intuitively based on the critical reflection of an older adult and resembles a clinical reasoning approach applied to health-related daily living.
EWA Framework and Selected Approaches to Successful Aging
The EWA framework is consistent with research that focuses on older adults' potential to enhance their functional independence by learning new skills (Nguyen et al., 2018). Life course perspectives acknowledge that successful aging is an ongoing developmental process involving individual effort as well as support from others, and is variable depending on the individual's background and life experiences (Stowe & Cooney, 2015). The model of selection, optimization, and compensation for successful aging (Freund, 2008; Ouwehand et al., 2007) is particularly relevant to the cognitive activities and adaptive strategies described in EWA. Selecting goals that are realistic based on the impact of age-related change, using cognitive processes and active behaviors that optimize internal and external resources and abilities, and compensating for or managing loss and maintaining function, even if at lower levels (Donnelan, 2015), are processes reflected in the EWA framework.
Limitations of Engaging with Aging
A major limitation of the EWA framework is that it has not yet been tested or used in research. EWA was developed by a healthy, educated, White, female nonagenarian. The EWA perspective and processes may not necessarily be the same as those identified by older men, individuals with cognitive or physical pathologies, those with low health literacy, and people from different cultures or other socioeconomic groups. An additional consideration is that the language used to communicate EWA might not be universally understood. However, anecdotal comments by the growing number of EWA blog readers (N = 700) validate the use of EWA processes to manage daily living.
Future Development of EWA
The EWA framework can serve as a foundation for future investigators to advance knowledge about how older adults can purposefully engage with the aging process to manage daily living. In contrast, the EWA blog that began in 2017 (access https://engagingwithagingblog.wordpress.com) was created for a readership of older adults to share experiences and adaptive approaches as points of departure for readers to participate in their own aging.
Simultaneously with the development of the EWA framework, Su et al. (2019) conducted a thematic analysis of the EWA blog. Five major themes emerged from their analysis of 67 blog posts: identification of age-related changes; response to the age-related changes; approaches and strategies to address the age-related changes; outcomes of the approaches and strategies; and characteristics of the age-related changes process. As expected, the themes are reflected in the EWA framework, providing a degree of corroboration and shedding light on how a resilient and functional older adult can grow and thrive.
Investigation is needed to discover and predict specific linkages between age-related changes and specific impact areas in daily living as well as those that are associated with different kinds of pathology. Research is also needed to determine if older adults who embrace the perspective and processes described in the EWA framework report enhanced functional performance, life satisfaction, emotional well-being, and other indicators of successful, effective, and optimal aging.
EWA's utility for older adults who live independently as well as those in different levels of care should be examined. Specific questions include how to adapt the language used to describe EWA to make it accessible to older adults, especially those from diverse cultural and ethnic backgrounds, or those who have cognitive impairments or low health literacy.
Because EWA emerged from an older adult's experience with aging, it can be viewed as a form of citizen science. Involving older adults in designing and conducting research may lead to discovering new ways to support them and their care partners. For example, Teng et al. (2019) found that an online virtual community provided a forum for older adults to discuss aging-related health issues and management strategies.
The EWA framework is an attempt to reframe aging as a part of the life span during which older adults continue to grow as they adapt to age-related changes. Based on a nonagenarian's approach to aging, it provides a structure to expand knowledge about how older adults can gain new insights and learn new skills to manage daily living challenges in a reasoned and purposeful way. To promote healthy aging, a deeper understanding is needed of the processes older adults can use to successfully manage their daily living when faced with ongoing age-related changes. It is particularly important that this come from the perspective of those encountering the changes in their lives. Older adults are and can be active agents in purposefully inventorying their internal capacities and external resources to derive realistic, workable, and satisfactory adaptive strategies that allow them to age well. As experts on their own aging, they can also contribute directly to the underlying science through citizen science approaches. Further development of EWA may lead to the discovery of nursing interventions that support and facilitate successful aging in older adults.
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Descriptive Quotation from the Engaging with Aging Blog
|Aging in the latter years of the lifespan may be likened to a river, threading its way through the terrain of daily living to eventually reach the sea. Long or short, the river of aging can have stretches of quiet stillness where the current is hardly noticeable. But there also can be white water where the current picks up and water splashes over and around visible and invisible obstacles and even abruptly cascades down in waterfalls. Some aging river riders allow themselves to be carried along on this river, whatever it brings. Others choose to study the river, pick up a paddle and purposefully navigate it. Engaging wit h Aging offers one way to approach navigating one's personal river of aging.|
Definition of Key Terms in the Engaging with Aging (EWA) Framework
|EWA||A perspective, an attitude, a framework, and set of processes that older adults may proactively use to manage their daily living in the face of emerging and progressing maturational developments and the incidence of pathology.|
|Age-related changes||Normal, progressive maturational developments and bodily changes associated with aging.|
|Impact areas||Specific capacities and areas of daily living that are affected by an identified age-related change and the changes, difficulties, risks, and discomfiture (i.e., a feeling of unease or embarrassment) being generated in each area.|
|Adaptive strategies||Personal management planning using data gathered about the age-related change and impact areas that: (a) make use of functional capacities and resources; (b) seek to minimize unwanted outcomes; and (c) create a balance between demands and resources.|
|Internal resources||Include all physical, cognitive, and emotional capacities the older adult has available at any point in time.|
|External resources||Encompass available assets of people, housing, finances, community, environments, services, equipment, etc.|
Sample Structure for Engaging with an Age-Related Change (ARC)
|Current status: Walks safely with walker, one hand on a solid surface, or a person supporting from the right side. Unsafe in a dark environment. Precarious with turning and inclines (anterior, posterior, and lateral). Easily thrown off balance with uneven surfaces or encountering unobserved objects on the floor. Pulled off balance by lifting or carrying objects or changing heel height on shoes. Stairs require bilateral assistance.|
|Risk Activity||Impact Areas||Adaptations|
|Centering||Moving from sitting to standing||Center before taking first step|
|Picking up/carrying objects||Think “center” when picking up object and again before moving; hold object close when moving; use walker seat to transport objects|
|Hugging||Brace hand/body against firm edge; teach huggers about centering|
|Turning||Frequent turning in kitchen activities||Keep nose and toes facing same way; use mantra “nose and toes”; use walker or hand on solid surface|
|Darkness||Inability to move about in the dark||Locate light switches in any room|
|Disorientation||Plan ahead for lighting/nightlights|
|Bending over||Bed making||Brace lower legs against mattress|
|Retrieving dropped objects||Sit in walker to retrieve|
|Wiping up spills||Sit in walker to wipe up|