Perceptions of Determinants of Successful Aging Among Older U.S. Veterans: Results from the National Health and Resilience in Veterans Study Julia Rozanova, Ph.D., Paraskevi Noulas, Psy.D., Steven M. Southwick, M.D., Robert H. Pietrzak, Ph.D., M.P.H.
Objective: To conduct a qualitative study of older American veterans’ subjective perceptions of factors that contribute to successful physical, emotional, and cognitive aging. Methods: A nationally representative sample of 2,025 veterans aged 60 or older (range: 60e96; 96.9% male, 39.4% combat veterans) participated in the National Health and Resilience in Veterans Study. Using qualitative analysis software, the authors coded responses to three open-ended questions, inductively developed categories, aggregated similar categories into factors, and grouped factors into broader themes. Results: A total of 53, 56, and 61 categories of responses was identified in response to questions about successful physical, cognitive, and emotional aging, respectively, with 10 aggregate factors linking these categories. The most prominent theme overall was “What you do,” which received 2,295, 2,210, and 1,247 mentions for each of these domains of successful aging, with health behaviors the most common factor for both successful physical and cognitive aging and social engagement the most common for successful emotional aging. The theme “Who you are” was the second-most common factor (discerned from 376, 247, and 943 total mentions, respectively), with the factors that comprise this theme—personality and explanatory style, moral compass, and emotional dispositions—more commonly endorsed for successful emotional aging. External factors such as healthcare were least commonly endorsed across all domains. Conclusion: Older U.S. Veterans emphasize health behaviors, social engagement, and dispositional characteristics as key determinants of successful aging. Prevention and treatment initiatives that target these potentially modifiable factors may help promote successful aging in this growing segment of the population. (Am J Geriatr Psychiatry 2015; -:-e-) Key Words: Successful aging, older U.S. veterans, inductive thematic analysis
Received November 19, 2013; revised August 26, 2014; accepted September 12, 2014. From the Department of Sociology (JR), Yale University, New Haven, CT; and the VA Connecticut Healthcare System and Department of Psychiatry (PN), U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder and Department of Psychiatry (SMS, RHP), Yale School of Medicine, New Haven, CT. Send correspondence and reprint requests to Julia Rozanova, Ph.D., Department of Sociology, Yale University. P.O. Box 208265, New Haven, CT 06520-8265. e-mail: [email protected] Ó 2015 American Association for Geriatric Psychiatry http://dx.doi.org/10.1016/j.jagp.2014.09.006
Am J Geriatr Psychiatry
-:-, -
2015
1
Perceptions of Determinants of Successful Aging among Older U.S. Veterans
INTRODUCTION Rowe and Kahn first proposed the concept of successful aging in 1987, defining it as aging in a way that is better than simply “normal.”1,2 Their model identified three components of successful aging: freedom from disease and disability, high cognitive and physical functioning, and social and productive engagement. Since this original definition, there have been numerous efforts to refine and operationalize this construct with increased emphasis on older persons’ perceptions of successful aging and high functioning in late life.3e6 Refining definitions and identifying determinants of successful aging is important because the population of adults over 65 is rapidly increasing. According to the World Health Organization, the absolute number of older adults worldwide will increase from 605 million to 2 billion by the year 2050.7 This is of great concern, because older adults often require a disproportionate share of healthcare resources and services.8,9 Aging of the U.S. veteran population presents a particular challenge, because 43.0% are currently over the age of 65 and this number is estimated to double over the next 30 years.10 Although a growing number of studies have examined successful aging in community-dwelling older adults,11e15 far less is known about successful aging in military veterans.16e18 To better understand and evaluate the prevalence and correlates of successful aging and psychological resilience in a large, contemporary, and nationally representative veteran sample, in 2011 we launched the National Health and Resilience in Veterans Study (NHRVS). The NHRVS baseline survey included a comprehensive range of self-report measures of disease and disability, such as physical health difficulties, substance abuse history, trauma/psychiatric history, current psychological distress, and psychosocial variables that may promote successful aging and the ability to adapt to illnesses and negative life events (e.g., resilience, optimism, religiosity, gratitude, purpose in life, social connectedness, and altruism). In an initial quantitative study,19 we found that 82% of 2,025 U.S. veterans aged 60e96 rated themselves as aging successfully (i.e., score of 7 or higher on a 1e10 rating scale) and that physical health difficulties (i.e., somatic symptoms, disability in instrumental activities of daily living, and
2
number of current medical conditions) and current psychological distress (i.e., depressive and posttraumatic stress disorder symptoms) were most strongly negatively related to successful aging. Notably, after adjustment for these risk factors, protective psychosocial characteristics (i.e., resilience, gratitude, purpose in life, and community integration) were found to be strongly positively related to successful aging. Results of this study suggest that 8 in 10 older U.S. veterans report aging successfully and that despite the deleterious effects of physical and mental health difficulties, protective psychosocial factors such as resilience, gratitude, and purpose in life may help promote successful aging in this population. In addition to quantitative scales, the NHRVS baseline survey also included a qualitative component that inquired about older veterans’ subjective perceptions of factors that are most important in successful physical, emotional, and cognitive aging. Qualitative research is often used to complement quantitative research because it allows a deeper and more nuanced understanding than is possible by using quantitative survey questions alone.20,21 To date, qualitative methods have been used to study successful aging in several elderly populations. For example, Reichstadt et al.22 asked two primary open-ended questions to 72 older adults living in retirement communities in San Diego County: “How would you define successful aging?” and “What are the necessary components of successful aging?” Thirty-three factors related to successful aging were identified, and four major themes emerged from their qualitative analysis, which extended findings derived from a quantitative survey in this same population.23 Specifically, older adults reported that successful aging involved a positive attitude and adaptability, good health, an environmental and social support system, and engagement in meaningful and stimulating activities. Other qualitative studies of successful aging have been conducted in a sample of older adults with health conditions such as HIV24 and in regional samples such as older men residing in Manitoba, Canada.25 Qualitative analyses of older persons’ perceptions of successful aging have revealed an emphasis on psychosocial factors such as resilience, positive adaptation, and social resources, which moves beyond a strictly biomedical focus to a more multidimensional and socially relevant framework of successful aging.
Am J Geriatr Psychiatry
-:-, -
2015
Rozanova et al. Building on our quantitative findings,19 the purpose of this study was to elucidate a general, nationally representative perspective of older veterans’ perceptions of determinants of successful physical, mental, and cognitive aging in their own words. Specifically, we analyzed qualitative responses from a nationally representative sample of 2,025 older U.S. veterans, thereby increasing the findings’ potential resonance with the broader population of older veterans in the United States.
METHODS Participants A total of 2,025 veterans aged 60e96 participated in NHRVS, a nationally representative web-based survey of 3,157 U.S. veterans conducted in October to December 2011. The NHRVS sample was drawn from KnowledgePanel, a probability-based, online, nonvolunteer access survey panel of more than 80,000 households that covers approximately 98% of U.S. households, including cell phoneeonly households. It is developed and maintained by GfK Knowledge Networks, Inc., a survey research firm based in Menlo Park, California. This survey panel sample, like any community-based probability sample, excluded institutionalized individuals (i.e., those living in special healthcare facilities or hospitals or currently incarcerated). All participants provided informed consent, and the study was approved by the Human Subjects Subcommittee of the VA Connecticut Healthcare System. Most of the sample was male (1,962 [96.9%]), and 795 (39.4%) were combat veterans. Data Management and Analysis Using a qualitative research methodology described by Silverman,26 which is rooted in an inductive approach to textual data, we thematically analyzed qualitative responses, which ranged from one to several words to a sentence in length, to three open-ended questions: “In your view, what factors are most important to successful physical [emotional, cognitive] aging?” The phrasing of these questions was inspired by prior work on successful aging in the geriatric mental health literature, which suggests that high physical, emotional, and cognitive functioning are key aspects of successful aging.4,5,19,27e29 In line with the
Am J Geriatr Psychiatry
-:-, -
2015
inductive approach to analyzing qualitative data, we intentionally chose to avoid forcing any a priori selected theory on our analysis of veterans’ responses. We extracted all responses to each of these three questions and put them into single Microsoft Word (https://products.office.com/en-us/word; Microsoft, Redmond, WA) files. We then imported these three Word files into the NVivo9 qualitative data management software program (http://www.qsrinternational. com/products_nvivo.aspx; QSR International, Burlington, MA). Because the goal of this study was to construct a broad, nationally representative portrayal of veterans’ views about successful aging, we analyzed each file inductively and anonymously from respondents by reading and attaching categories (intuitive descriptions of what the response says at face value) to each response within it. We often used the respondents’ verbatim words as labels for primary categories. For example, the first of the 2,025 responses in the data file corresponding to the successful physical aging question was “diet and physical exercise.” We inductively derived two primary categories from this response, “diet” and “physical exercise,” and used them to code subsequent answers in this data file that, at face value, had the same meaning. For example, we coded the next answer, “walk 6 to 12 miles each day,” as “physical exercise.” To ensure rigor and trustworthiness of the codings, the first and second authors coded half of each data file independently and developed unique category structures. Then, all four authors compared the two category structures and responses coded under each category for each data file. Differences were minimal (or¼75 years is associated with greater resource utilization following coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2009; 9:827e831 9. Besdine R, Boult C, Brangman S, et al: Caring for older Americans: the future of geriatric medicine. American Geriatrics Society Task Force on the Future of Geriatric Medicine. J Am Geriatr Soc 2005; 53(6 Suppl):S245eS256 10. U.S. Census Bureau: American Community Survey Reports: Washington, DC: 2011. http://factfinder2.census.gov. Accessed October 14, 2014 11. Thompson W, Charo L, Vahia I, et al: Association between higher levels of sexual function, activity, and satisfaction and self-rated successful aging in older postmenopausal women. J Am Geriatr Soc 2011; 59:1503e1508 12. Moore D, Sitzer D, Depp C, et al: Self-administered cognitive screening for a study of successful aging among communitydwelling seniors: a preliminary study. Int J Geriatr Psychiatry 2007; 22:327e331 13. Horder H, Frandin K, Larsson M: Self-respect though ability to keep fear of frailty at a distance: successful ageing from the perspective of community-dwelling older people. Int J Qual Stud Health Well-Being 2013; 8:1e10
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2015
14. Kahana E, Kelley-Moore J, Kahana B: Proactive aging: a longitudinal study of stress, resources, agency, and well-being in late life. Aging Mental Health 2012; 16:438e451 15. Seeman T, Crimmins E, Huang M-H, et al: Cumulative biological risk and socio-economic differences in mortality: MacArthur Studies of Successful Aging. Soc Sci Med 2004; 58: 1985e1998 16. Katz I: Mental health needs of older veterans. Am J Geriatr Psychiatry 2014; 22:527e530 17. Thorp S, Sones H, Glorioso D, et al: Older patients with schizophrenia: does military veteran status matter? Am J Geriatr Psychiatry 2012; 20:248e256 18. Burnett-Zeigler I, Zivin K, Ilgen M, et al: Depression treatment in older adult veterans. Am J Geriatr Psychiatry 2012; 20: 228e238 19. Pietrzak R, Tsai J, Kirwin P, et al: Successful aging among older veterans in the United States. Am J Geriatr Psychiatry 2014; 22: 551e563 20. Pope C, Mays N: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health. Br Med J (Int Ed) 1995; 311:42e45 21. Kisely S, Kendall E: Critically appraising qualitative research: a guide for clinicians more familiar with quantitative techniques. Australasian Psychiatry 2011; 19:364e367 22. Reichstadt J, Depp C, Palinkas L, et al: Building blocks of successful aging: a focus group study of older adults’ perceived contributors to successful aging. Am J Geriatr Psychiatry 2007; 15:194e201 23. Montross L, Depp C, Daly J, et al: Correlates of self-rated successful aging among community-dwelling older adults. Am J Geriatr Psychiatry 2006; 14:43e51 24. Malaspina L, Woods S, Moore D, et al: Successful cognitive aging in persons living with HIV infection. J Neurovirol 2011; 17: 110e119 25. Tate R, Swift A, Bayomi D: Older men’s lay definitions of successful aging over time: the Manitoba follow-up study. Int J Aging Hum Dev 2013; 76:297e322 26. Silverman D: Analyzing talk and text, in Handbook of Qualitative Research. Edited by Denzin N, Lincoln Y. Thousand Oaks, CA, Sage, 2000, pp 821e834
9
Perceptions of Determinants of Successful Aging among Older U.S. Veterans 27. Depp CA, Jeste DV: Definitions and predictors of successful aging: a comprehensive review of larger quantitative studies. Am J Geriatr Psychiatry 2006; 14:6e20 28. Ng TP, Broekman BF, Niti M, et al: Determinants of successful aging using a multidimensional definition among Chinese elderly in Singapore. Am J Geriatr Psychiatry 2009; 17:407e416 29. Jeste DV, Depp CA, Vahia IV: Successful cognitive and emotional aging. World Psychiatry 2010; 9:78e84 30. Berkman L, Glass T, Brissette I, et al: From social integration to health: Durkheim in the new millennium. Soc Sci Med 2000; 51: 843e857 31. Menec V: The relation between everyday activities and successful aging: a 6-year longitudinal study. J Gerontol Ser B Psychol Sci Soc Sci 2003; 58B:S74eS83 32. Bangen K, Meeks T, Jeste D: Defining and assessing wisdom: A review of the literature. Am J Geriatr Psychiatry 2013; 21:1254e1266 33. Gwee X, Nyunt M, Kua E, et al: Reliability and validity of a selfrated analogue scale for global measure of successful aging. Am J Geriatr Psychiatry 2014; 22:829e837 34. Chatters L, Taylor R, Woodward A, et al: Social support from church and family members and depressive symptoms among older African
10
35.
36.
37.
38. 39. 40.
Americans [published online ahead of print May 2, 2014]. Am J Geriatr Psychiatry. http://dx.doi.org/10.1016/j.jagp.2014.04.008 Wang V, Depp C, Ceglowski J, et al: Sexual health and function in later life: a population-based study of 606 older adults with a partner [published online ahead of print Mar 19, 2014]. Am J Geriatr Psychiatry. http://dx.doi.org/10.1016/j.jagp.2014.03.006 Jang Y, Yoon H, Chiriboga D, et al: Bridging the gap between common mental disorders and service use: the role of self-rated mental health among African Americans [published online ahead of print March 3, 2014]. Am J Geriatr Psychiatry. http://dx. doi.org/10.1016/j.jagp.2014.02.010 Hendrie H, Lindgren D, Hay D, et al: Comorbidity profile and healthcare utilization in elderly patients with serious mental illness. Am J Geriatr Psychiatry 2013; 21:1267e1276 Peel N, McClure R, Bartlett H: Behavioral determinants of healthy aging. Am J Prevent Med 2005; 28:298e304 Phelan E, Larson E: Successful aging—where next? J Am Geriatric Soc 2002; 50:1306e1308 Reichstadt J, Sengupta G, Depp CA, et al: Older adults’ perspectives on successful aging: qualitative interviews. Am J Geriatr Psychiatry 2010; 18:567e575
Am J Geriatr Psychiatry
-:-, -
2015
Objective: To conduct a qualitative study of older American veterans’ subjective perceptions of factors that contribute to successful physical, emotional, and cognitive aging. Methods: A nationally representative sample of 2,025 veterans aged 60 or older (range: 60e96; 96.9% male, 39.4% combat veterans) participated in the National Health and Resilience in Veterans Study. Using qualitative analysis software, the authors coded responses to three open-ended questions, inductively developed categories, aggregated similar categories into factors, and grouped factors into broader themes. Results: A total of 53, 56, and 61 categories of responses was identified in response to questions about successful physical, cognitive, and emotional aging, respectively, with 10 aggregate factors linking these categories. The most prominent theme overall was “What you do,” which received 2,295, 2,210, and 1,247 mentions for each of these domains of successful aging, with health behaviors the most common factor for both successful physical and cognitive aging and social engagement the most common for successful emotional aging. The theme “Who you are” was the second-most common factor (discerned from 376, 247, and 943 total mentions, respectively), with the factors that comprise this theme—personality and explanatory style, moral compass, and emotional dispositions—more commonly endorsed for successful emotional aging. External factors such as healthcare were least commonly endorsed across all domains. Conclusion: Older U.S. Veterans emphasize health behaviors, social engagement, and dispositional characteristics as key determinants of successful aging. Prevention and treatment initiatives that target these potentially modifiable factors may help promote successful aging in this growing segment of the population. (Am J Geriatr Psychiatry 2015; -:-e-) Key Words: Successful aging, older U.S. veterans, inductive thematic analysis
Received November 19, 2013; revised August 26, 2014; accepted September 12, 2014. From the Department of Sociology (JR), Yale University, New Haven, CT; and the VA Connecticut Healthcare System and Department of Psychiatry (PN), U.S. Department of Veterans Affairs National Center for Posttraumatic Stress Disorder and Department of Psychiatry (SMS, RHP), Yale School of Medicine, New Haven, CT. Send correspondence and reprint requests to Julia Rozanova, Ph.D., Department of Sociology, Yale University. P.O. Box 208265, New Haven, CT 06520-8265. e-mail: [email protected] Ó 2015 American Association for Geriatric Psychiatry http://dx.doi.org/10.1016/j.jagp.2014.09.006
Am J Geriatr Psychiatry
-:-, -
2015
1
Perceptions of Determinants of Successful Aging among Older U.S. Veterans
INTRODUCTION Rowe and Kahn first proposed the concept of successful aging in 1987, defining it as aging in a way that is better than simply “normal.”1,2 Their model identified three components of successful aging: freedom from disease and disability, high cognitive and physical functioning, and social and productive engagement. Since this original definition, there have been numerous efforts to refine and operationalize this construct with increased emphasis on older persons’ perceptions of successful aging and high functioning in late life.3e6 Refining definitions and identifying determinants of successful aging is important because the population of adults over 65 is rapidly increasing. According to the World Health Organization, the absolute number of older adults worldwide will increase from 605 million to 2 billion by the year 2050.7 This is of great concern, because older adults often require a disproportionate share of healthcare resources and services.8,9 Aging of the U.S. veteran population presents a particular challenge, because 43.0% are currently over the age of 65 and this number is estimated to double over the next 30 years.10 Although a growing number of studies have examined successful aging in community-dwelling older adults,11e15 far less is known about successful aging in military veterans.16e18 To better understand and evaluate the prevalence and correlates of successful aging and psychological resilience in a large, contemporary, and nationally representative veteran sample, in 2011 we launched the National Health and Resilience in Veterans Study (NHRVS). The NHRVS baseline survey included a comprehensive range of self-report measures of disease and disability, such as physical health difficulties, substance abuse history, trauma/psychiatric history, current psychological distress, and psychosocial variables that may promote successful aging and the ability to adapt to illnesses and negative life events (e.g., resilience, optimism, religiosity, gratitude, purpose in life, social connectedness, and altruism). In an initial quantitative study,19 we found that 82% of 2,025 U.S. veterans aged 60e96 rated themselves as aging successfully (i.e., score of 7 or higher on a 1e10 rating scale) and that physical health difficulties (i.e., somatic symptoms, disability in instrumental activities of daily living, and
2
number of current medical conditions) and current psychological distress (i.e., depressive and posttraumatic stress disorder symptoms) were most strongly negatively related to successful aging. Notably, after adjustment for these risk factors, protective psychosocial characteristics (i.e., resilience, gratitude, purpose in life, and community integration) were found to be strongly positively related to successful aging. Results of this study suggest that 8 in 10 older U.S. veterans report aging successfully and that despite the deleterious effects of physical and mental health difficulties, protective psychosocial factors such as resilience, gratitude, and purpose in life may help promote successful aging in this population. In addition to quantitative scales, the NHRVS baseline survey also included a qualitative component that inquired about older veterans’ subjective perceptions of factors that are most important in successful physical, emotional, and cognitive aging. Qualitative research is often used to complement quantitative research because it allows a deeper and more nuanced understanding than is possible by using quantitative survey questions alone.20,21 To date, qualitative methods have been used to study successful aging in several elderly populations. For example, Reichstadt et al.22 asked two primary open-ended questions to 72 older adults living in retirement communities in San Diego County: “How would you define successful aging?” and “What are the necessary components of successful aging?” Thirty-three factors related to successful aging were identified, and four major themes emerged from their qualitative analysis, which extended findings derived from a quantitative survey in this same population.23 Specifically, older adults reported that successful aging involved a positive attitude and adaptability, good health, an environmental and social support system, and engagement in meaningful and stimulating activities. Other qualitative studies of successful aging have been conducted in a sample of older adults with health conditions such as HIV24 and in regional samples such as older men residing in Manitoba, Canada.25 Qualitative analyses of older persons’ perceptions of successful aging have revealed an emphasis on psychosocial factors such as resilience, positive adaptation, and social resources, which moves beyond a strictly biomedical focus to a more multidimensional and socially relevant framework of successful aging.
Am J Geriatr Psychiatry
-:-, -
2015
Rozanova et al. Building on our quantitative findings,19 the purpose of this study was to elucidate a general, nationally representative perspective of older veterans’ perceptions of determinants of successful physical, mental, and cognitive aging in their own words. Specifically, we analyzed qualitative responses from a nationally representative sample of 2,025 older U.S. veterans, thereby increasing the findings’ potential resonance with the broader population of older veterans in the United States.
METHODS Participants A total of 2,025 veterans aged 60e96 participated in NHRVS, a nationally representative web-based survey of 3,157 U.S. veterans conducted in October to December 2011. The NHRVS sample was drawn from KnowledgePanel, a probability-based, online, nonvolunteer access survey panel of more than 80,000 households that covers approximately 98% of U.S. households, including cell phoneeonly households. It is developed and maintained by GfK Knowledge Networks, Inc., a survey research firm based in Menlo Park, California. This survey panel sample, like any community-based probability sample, excluded institutionalized individuals (i.e., those living in special healthcare facilities or hospitals or currently incarcerated). All participants provided informed consent, and the study was approved by the Human Subjects Subcommittee of the VA Connecticut Healthcare System. Most of the sample was male (1,962 [96.9%]), and 795 (39.4%) were combat veterans. Data Management and Analysis Using a qualitative research methodology described by Silverman,26 which is rooted in an inductive approach to textual data, we thematically analyzed qualitative responses, which ranged from one to several words to a sentence in length, to three open-ended questions: “In your view, what factors are most important to successful physical [emotional, cognitive] aging?” The phrasing of these questions was inspired by prior work on successful aging in the geriatric mental health literature, which suggests that high physical, emotional, and cognitive functioning are key aspects of successful aging.4,5,19,27e29 In line with the
Am J Geriatr Psychiatry
-:-, -
2015
inductive approach to analyzing qualitative data, we intentionally chose to avoid forcing any a priori selected theory on our analysis of veterans’ responses. We extracted all responses to each of these three questions and put them into single Microsoft Word (https://products.office.com/en-us/word; Microsoft, Redmond, WA) files. We then imported these three Word files into the NVivo9 qualitative data management software program (http://www.qsrinternational. com/products_nvivo.aspx; QSR International, Burlington, MA). Because the goal of this study was to construct a broad, nationally representative portrayal of veterans’ views about successful aging, we analyzed each file inductively and anonymously from respondents by reading and attaching categories (intuitive descriptions of what the response says at face value) to each response within it. We often used the respondents’ verbatim words as labels for primary categories. For example, the first of the 2,025 responses in the data file corresponding to the successful physical aging question was “diet and physical exercise.” We inductively derived two primary categories from this response, “diet” and “physical exercise,” and used them to code subsequent answers in this data file that, at face value, had the same meaning. For example, we coded the next answer, “walk 6 to 12 miles each day,” as “physical exercise.” To ensure rigor and trustworthiness of the codings, the first and second authors coded half of each data file independently and developed unique category structures. Then, all four authors compared the two category structures and responses coded under each category for each data file. Differences were minimal (or¼75 years is associated with greater resource utilization following coronary artery bypass grafting. Interact Cardiovasc Thorac Surg 2009; 9:827e831 9. Besdine R, Boult C, Brangman S, et al: Caring for older Americans: the future of geriatric medicine. American Geriatrics Society Task Force on the Future of Geriatric Medicine. J Am Geriatr Soc 2005; 53(6 Suppl):S245eS256 10. U.S. Census Bureau: American Community Survey Reports: Washington, DC: 2011. http://factfinder2.census.gov. Accessed October 14, 2014 11. Thompson W, Charo L, Vahia I, et al: Association between higher levels of sexual function, activity, and satisfaction and self-rated successful aging in older postmenopausal women. J Am Geriatr Soc 2011; 59:1503e1508 12. Moore D, Sitzer D, Depp C, et al: Self-administered cognitive screening for a study of successful aging among communitydwelling seniors: a preliminary study. Int J Geriatr Psychiatry 2007; 22:327e331 13. Horder H, Frandin K, Larsson M: Self-respect though ability to keep fear of frailty at a distance: successful ageing from the perspective of community-dwelling older people. Int J Qual Stud Health Well-Being 2013; 8:1e10
Am J Geriatr Psychiatry
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2015
14. Kahana E, Kelley-Moore J, Kahana B: Proactive aging: a longitudinal study of stress, resources, agency, and well-being in late life. Aging Mental Health 2012; 16:438e451 15. Seeman T, Crimmins E, Huang M-H, et al: Cumulative biological risk and socio-economic differences in mortality: MacArthur Studies of Successful Aging. Soc Sci Med 2004; 58: 1985e1998 16. Katz I: Mental health needs of older veterans. Am J Geriatr Psychiatry 2014; 22:527e530 17. Thorp S, Sones H, Glorioso D, et al: Older patients with schizophrenia: does military veteran status matter? Am J Geriatr Psychiatry 2012; 20:248e256 18. Burnett-Zeigler I, Zivin K, Ilgen M, et al: Depression treatment in older adult veterans. Am J Geriatr Psychiatry 2012; 20: 228e238 19. Pietrzak R, Tsai J, Kirwin P, et al: Successful aging among older veterans in the United States. Am J Geriatr Psychiatry 2014; 22: 551e563 20. Pope C, Mays N: Reaching the parts other methods cannot reach: an introduction to qualitative methods in health. Br Med J (Int Ed) 1995; 311:42e45 21. Kisely S, Kendall E: Critically appraising qualitative research: a guide for clinicians more familiar with quantitative techniques. Australasian Psychiatry 2011; 19:364e367 22. Reichstadt J, Depp C, Palinkas L, et al: Building blocks of successful aging: a focus group study of older adults’ perceived contributors to successful aging. Am J Geriatr Psychiatry 2007; 15:194e201 23. Montross L, Depp C, Daly J, et al: Correlates of self-rated successful aging among community-dwelling older adults. Am J Geriatr Psychiatry 2006; 14:43e51 24. Malaspina L, Woods S, Moore D, et al: Successful cognitive aging in persons living with HIV infection. J Neurovirol 2011; 17: 110e119 25. Tate R, Swift A, Bayomi D: Older men’s lay definitions of successful aging over time: the Manitoba follow-up study. Int J Aging Hum Dev 2013; 76:297e322 26. Silverman D: Analyzing talk and text, in Handbook of Qualitative Research. Edited by Denzin N, Lincoln Y. Thousand Oaks, CA, Sage, 2000, pp 821e834
9
Perceptions of Determinants of Successful Aging among Older U.S. Veterans 27. Depp CA, Jeste DV: Definitions and predictors of successful aging: a comprehensive review of larger quantitative studies. Am J Geriatr Psychiatry 2006; 14:6e20 28. Ng TP, Broekman BF, Niti M, et al: Determinants of successful aging using a multidimensional definition among Chinese elderly in Singapore. Am J Geriatr Psychiatry 2009; 17:407e416 29. Jeste DV, Depp CA, Vahia IV: Successful cognitive and emotional aging. World Psychiatry 2010; 9:78e84 30. Berkman L, Glass T, Brissette I, et al: From social integration to health: Durkheim in the new millennium. Soc Sci Med 2000; 51: 843e857 31. Menec V: The relation between everyday activities and successful aging: a 6-year longitudinal study. J Gerontol Ser B Psychol Sci Soc Sci 2003; 58B:S74eS83 32. Bangen K, Meeks T, Jeste D: Defining and assessing wisdom: A review of the literature. Am J Geriatr Psychiatry 2013; 21:1254e1266 33. Gwee X, Nyunt M, Kua E, et al: Reliability and validity of a selfrated analogue scale for global measure of successful aging. Am J Geriatr Psychiatry 2014; 22:829e837 34. Chatters L, Taylor R, Woodward A, et al: Social support from church and family members and depressive symptoms among older African
10
35.
36.
37.
38. 39. 40.
Americans [published online ahead of print May 2, 2014]. Am J Geriatr Psychiatry. http://dx.doi.org/10.1016/j.jagp.2014.04.008 Wang V, Depp C, Ceglowski J, et al: Sexual health and function in later life: a population-based study of 606 older adults with a partner [published online ahead of print Mar 19, 2014]. Am J Geriatr Psychiatry. http://dx.doi.org/10.1016/j.jagp.2014.03.006 Jang Y, Yoon H, Chiriboga D, et al: Bridging the gap between common mental disorders and service use: the role of self-rated mental health among African Americans [published online ahead of print March 3, 2014]. Am J Geriatr Psychiatry. http://dx. doi.org/10.1016/j.jagp.2014.02.010 Hendrie H, Lindgren D, Hay D, et al: Comorbidity profile and healthcare utilization in elderly patients with serious mental illness. Am J Geriatr Psychiatry 2013; 21:1267e1276 Peel N, McClure R, Bartlett H: Behavioral determinants of healthy aging. Am J Prevent Med 2005; 28:298e304 Phelan E, Larson E: Successful aging—where next? J Am Geriatric Soc 2002; 50:1306e1308 Reichstadt J, Sengupta G, Depp CA, et al: Older adults’ perspectives on successful aging: qualitative interviews. Am J Geriatr Psychiatry 2010; 18:567e575
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2015
