After a dip attributed to the COVID-19 pandemic, the average life expectancy in the United States has inched back up to 77.5 years. This is roughly three decades longer than the average lifespan at the beginning of the 20th century, before Americans benefited from a series of life-extending advances in medicine and public health.

Simply living longer, however, is not the ultimate goal for everyone—especially if it means enduring poor health, mobility issues, and other functional challenges. Fortunately, science offers new ways that may help people have a better chance than ever before to bypass such age-related impediments.

For insights on how society views older adults and ways to lead healthier, fuller lives as we age, Yale Medicine Magazine spoke with Thomas Gill, MD, Humana Foundation Professor of Medicine (Geriatrics) and professor of epidemiology (chronic diseases) and of investigative medicine, and director of the Yale Program on Aging; Becca Levy, PhD, professor of public health (social and behavioral sciences) and psychology; and Mary Tinetti, MD, Gladys Phillips Crofoot Professor of Medicine (Geriatrics).

Is disability inevitable as we age?

Thomas Gill Older persons may develop significant functional limitations or disability at some point, usually in the setting of an illness or injury, but in most cases they’ll recover. The likelihood of developing disability generally increases with age, and it’s more common shortly prior to death. However, I wouldn’t necessarily consider it an inevitable part of the aging process.

What are some strategies that can help prevent the onset and progression of disability and functional decline in older people?

TG There’s compelling evidence for the value of physical activity. Several years ago, Yale was one of eight sites for the LIFE [Lifestyle Interventions and Independence for Elders] study, which was a multicenter clinical trial that evaluated whether a structured physical activity program could prevent the onset of major mobility disability, which is defined as the inability to walk a quarter mile. In a rigorously designed clinical trial, persons who were randomized to the structured physical activity program versus an educational intervention had substantially lower rates of major mobility disability. There are countless numbers of epidemiological studies demonstrating that older persons who are physically active experience benefits in cognition and physical function, reductions in hospitalizations, and a myriad of other positive outcomes.

Mary Tinetti This topic is closely related to early research that I was involved in when I was a fellow and new geriatric researcher in the 1980s. At that time, almost no work had been done on falls, because it was considered an inevitable part of aging. We started looking at whether we could predict who was likely to fall, and if we could identify the factors that put people at fall risk. We identified that every year about one out of three older adults fall, and about one out of 10 suffer a serious injury, such as a head injury or a hip fracture.

We found that the factors that put people at risk for falling include not only all the sensory changes that happen with age, but also conditions in the brain, the musculoskeletal system, and the cardiovascular system that increase with aging, and, very importantly, medications. Even more importantly, it’s the chronic burden of medications that increases risk. And, finally, another factor is the activity that people are doing. Most of us will fall when we ski, many of us will fall when we walk on ice, but a much smaller percentage fall when they’re doing their usual daily activities. We found that as you increase the number of risk factors, the likelihood of falling with usual activities will increase.

In our second set of studies, we found that if you intervene on as many of those factors as you can, through medication reduction, exercise, and making the environment safer, you could decrease the risk of falling. Then we went on to show that you could embed this understanding in the community so that fall prevention could be included in the care of older adults. We showed that you could decrease the likelihood of an older adult having to go to the emergency department or be admitted to the hospital because of a fall by about 10%. That doesn’t sound like a lot, but in public health, 10% is an important change.

Another observation was that it’s not just the physical effect of falls, it’s the psychological effect. We identified how confident people felt in their ability to do their daily activities without a fall. The more confident they were, the less likely they were to fall during a usual daily activity. So when we talk about fall prevention, we also talk about decreasing the fear that occurs as a result of anxiety about falling.

The word “inevitable” is often used in discussions about aging, which speaks to our perception on aging and how we tend to pathologize it. What has your research shown about the ways that negative and positive age stereotypes affect the health of older people?

Becca Levy Our research has shown that when we take in negative age stereotypes that are generated by our culture—for example, from social media and advertisements—they can harm our cognitive, physical, and mental health in later life. We’ve also found that when we take in positive messages about aging, they can have a beneficial impact on those same health outcomes. Among the affected outcomes are cardiovascular incidents, Alzheimer’s disease biomarkers, memory performance, stress levels, and longevity. These findings have been replicated by researchers in a number of different countries.

In your book Breaking the Age Code, you discuss the ramifications of ageism. How does ageism affect our society?

BL Ageism is one of the most pernicious, far-reaching, and accepted forms of discrimination that exists, and it can impact many different domains, such as education, the workforce, and health care. In the workplace, ageism can impact the hiring of older people and the opportunities for training they’re given. Also, the firing of people often happens based on older age. There was a recent survey that found that 64% of older Americans report experiencing ageism in the workplace, and among those, 90% report that it’s common.

There’s also a lot of evidence that ageism can operate in health care. A survey found that one out of five older people report experiencing ageism in health care interactions. We also know that there’s a tendency for clinical trials to exclude people over a certain age, so it’s difficult to know whether those treatments can improve the health of older people and how to best improve their health with those treatments.

Is ageism the reason behind the lack of diversity in clinical research?

TG I think there’s strong evidence that older persons are underrepresented in clinical trials. Drugs are typically tested in middle-aged or young older persons, but then they’re prescribed to persons who are much older, without strong evidence of benefit. It’s a bit more challenging to enroll the older segment of the population in many clinical trials for a variety of reasons. They often have other chronic conditions, which may be exclusion criteria for trials. Those exclusion criteria may not be justified, but the pharmaceutical industry is typically trying to reduce the noise [factors that could skew the results] so they can isolate an effect of their agent of interest. That’s a bit more challenging in older persons, but the flip side is that older persons often have the most to gain from the treatments that are available, because they have higher rates of developing the outcomes that these agents are designed to prevent or slow.

How can we dismantle ageism both as individuals and as a society?

BL Unfortunately, ageism operates in many sectors of our society, but we can dismantle it in each of these. I can give you examples for two domains: health care and the workplace. In health care, we could improve education so that all health care providers are trained in how to care for a diversity of older patients and are trained [in] how to avoid ageism in interactions. We could also think about places to intervene so health care providers could assess and screen for age beliefs and exposure to ageism, and then prescribe ways to overcome it when they interact with patients. In the workplace, one of the places that we could intervene on a structural level is diversity, equity, and inclusion programs. Most of them don’t include overcoming ageism or age inclusivity as diversity goals. There was one survey showing that in 77 countries, only 8% of workplaces included age as a diversity inclusion category in these programs.

The ideal is to eliminate ageism so individuals do not encounter it, but until that happens it’s important to strengthen our tools to resist it on an individual level, too. For the book, I developed a set of exercises based on my research that can help people of any age think about how to challenge ageism. It’s called the ABC Method. The “A” is for increasing awareness of ageism, because we know that ageism often operates without our awareness. The “B” is for placing blame where blame is due by helping people recognize that ageism can be an upstream factor that impacts health rather than blaming age itself for a problem. The “C” is to challenge ageism on a structural and personal level; think about ways to flip it around, so some of those negative age beliefs become positive age beliefs.

Overcoming ageism is clearly important to providing better health care to older adults. What other steps can we take?

MT Older adults accumulate multiple chronic conditions, and their life circumstances change. Until now, health care has been predicated on managing individual diseases as silos. For some people, if you have one or two conditions and you don’t have any functional limitations, that works quite well. The more functional impairments and chronic conditions you accumulate, the less evidence there is of the benefit of each individual intervention.

Older adults say that taking care of their multiple conditions is often more burdensome than the conditions themselves. And when you start accumulating all those conditions, what you want out of your health care varies. I might want to live for as long as possible even if I’m less functional; for somebody else, maybe function is most important. So it made sense to us that we should identify what people’s priorities are in the face of all this uncertainty and complexity, and see if we can align care better with each individual’s priorities in a way that’s feasible in our fast-paced, ever-changing health care environment.

To address this issue, we spent about a year meeting with older adults, care partners, and health professionals of every type, and developed Patient Priorities Care to identify people’s priorities using SMART (specific, measurable, actionable, realistic, and time-bound) goals to inform clinical decision-making. This takes decision-making from one disease at a time and raises it up to achieving each individual person’s goal. Let’s say the most important thing for me, given all my health conditions, is to be able to walk a mile a day so that I can go to my favorite market. I know my heart disease and arthritis might be contributing to my ability to do it, but the fact that my neighborhood is unsafe also contributes. As a health professional, I’m going to consider how what I have to contribute is either going to help or not help achieve the goal, and every member of the health care team does that.

It sounds as if we need an age-friendly health care system.

MT Several years ago, I was part of a national effort to identify all the clinical models that had looked at the care of older adults to determine which seemed to have better functional outcomes, less unnecessary health care utilization, and improved quality of life. From this work, we developed this concept of the Four Ms. The first “M” is to ask about and act on what matters most to each individual. The second “M” is medications, because although older adults are underrepresented in the trials, they’re overwhelmingly the major users of those medications. The third “M” is mobility, which is really a marker for function. For older adults, people of all ages, what matters most to them is their function. But we don’t measure function. We have a $3 trillion health care system that doesn’t ask what matters most to people in a systematic way. The fourth “M” is for mentation, which includes cognition and mood in all settings. There are now over 2,500 health care systems that are moving toward an age-friendly designation by the John A. Hartford Foundation and the Institute for Healthcare Improvement. Getting back to the ABCs
[that Professor Levy mentioned], I think the age-friendly health system has at least done the “A” that involves increasing the awareness of what needs to be done.

There’s been a lot of focus on the biology, including the genetics, of Alzheimer’s disease and dementia. What has your research uncovered about the relationship between genetics and positive versus negative beliefs about aging?

BL In our research, we previously had shown that positive age beliefs can improve cognitive performance in older persons. I was interested in knowing whether we could extend this to people who have been born with the risky gene for dementia, APOE4. About a quarter of us are born with the APOE4 gene, but only about half of the people born with it develop dementia. We found that older persons who have the risky gene but who assimilated positive age beliefs from their culture were 49% less likely to develop dementia than those who had taken in negative age beliefs. In fact, their risk was as low as people who were not born with APOE4.

Geroscience, which examines the biology of aging and age-related disease, is a relatively new field. What have we learned so far?

TG Several years ago, a set of investigators led by the National Institute on Aging identified what they considered to be the hallmarks of aging, which include (among others) mitochondrial function, metabolism, inflammation—a lot of different factors that have been shown, particularly in animal models and increasingly in human studies, to accelerate the aging process. A fundamental tenet of geroscience is that we’re not going to be able to improve health span, which means keeping people living healthier longer, unless we address the fundamental biological processes of aging. If you take a traditional disease-specific approach and you eliminate heart disease, for example, lifespan and health span will increase only modestly. The reason is that the person will die from another common condition, such as cancer. Even if you eliminate heart disease and cancer, you will have only an incremental improvement in both life expectancy and health span, because other chronic conditions will rise to the top.

There have been studies in model systems and animals showing that if you can delay or slow the biological aging process, which underlies many chronic conditions, you could have substantial improvements in health span. So a lot of work is underway to flesh out these hallmarks or mechanisms of aging with the goal of identifying specific targets for new pharmacologic interventions. The trials that have been completed or are underway in humans are early stage. Because bringing a new drug to market takes many years, there’s a lot of interest in repurposing medications that are already approved for other conditions. Geroscience represents a paradigm shift from a disease-specific approach to a more biologically oriented approach to slow aging and ultimately increase health span.