ROBERTA RIPORTELLA-MULLER
INTERNATIONAL RESEARCH ON AGING: SOME SELECTED ISSUES
Brody, Jacob A. and George L. Maddox, eds. 1988. Epidemiology and Aging: An International Perspective. New York: Springer Pub. Co. 233 pp. Ciba Foundation Symposium 134. 1988. Research and the Ageing Population. Chichester, UK: John Wiley & Sons Ltd.. 264 pp. Maddox, George L. and E.W. Busse, eds. 1987. Aging: The Universal Human Experience. New York: Springer. 668 pp. Kallio, V. 1982. Medical and Social Problems o f the Disabled. World Health Organization, Regional Office for Europe, Copenhagen, EURO Reports and Studies 73, World Health Organization. 35 pp. Report of a WHO Scientific Group on Senile Dementia 1986. Dementia in Later Life: Research and Action. World Health Organization, Technical Report Series 730, World Health Organization, Geneva. 74 pp. Report on a WHO meeting. 1982. Services to Prevent Disability in the Elderly. World Health Organization, Regional Office for Europe, Copenhagen, EURO Reports and Studies 83, World Health Organization, Denmark. 33 pp. Skeet, Muriel. 1983. Protecting the Health o f the Elderly. World Health Organization, Regional Office for Europe, Copenhagen, Public Health in Europe 18, World Health Organization, Denmark. 125 pp.
INTRODUCTION This paper is a review of recent symposia collections and World Health Organization (WHO) publications related to the process of aging and focuses more on their epidemiological, as opposed to their biomedical, contributions. After presenting the range of topics covered in each publication, the review considers several key issues that these publications raise. These issues are the controversy regarding the concepts of disease and senescence and their respective roles in the aging process; the usefulness of the epidemiological approach; methodological problems; and the role of cross-cultural research in informing our understanding of aging and aging populations. Finally, the review considers the effectiveness of the organization of the publications and of individual writing styles in providing coherent sets of information. Journal of Cross Cultural Gerontology 5: 301-314, 1990. © 1990 Kluwer Academic Publishers. Printed in the Netherlands.
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All of the publications are either collections of papers presented at international symposia or meetings of WHO working groups, or summaries of such meetings. Due to the nature of these types of meetings, the publications all represent (at the time of their publication) the most current, and in some cases otherwise unpublished, research and discussions about aging. The publications reviewed cover a wide variety of topics concerning aging and aging populations in the international arena from basic science, social science, and applied perspectives. TOPICS COVERED Several publications have recently been released by the World Health Organization, all dealing with various aspects of the issues of aging populations. The most comprehensive of these is the 1983 publication, Protecting the Health of the Elderly: A Review of WHO Activities (Skeet 1983). This is a summary of reports from WHO meetings, since 1958, that related to the care of the elderly. It covers the development of health care for the elderly from an international and multidisciplinary perspective. The publication is arranged into seven chapters covering principal issues with which WHO has been concerned: the process of aging; establishing priorities in research; aging societies; clinical studies; research programs; planning and providing services; and education and training. Reports within these chapters deal with some of the problems researchers have identified, such as the predominance of women at older ages and the chronic problems they face in a variety of cultural settings. The other three WHO publications all examine specific issues. Each is a report of a technical or scientific meeting convened to address its topic, describes what is known about the covered topic and makes proposals for coordinated research efforts. While Dementia in Later Life: Research and Action (WHO Scientific Group on Senile Dementia 1986) is an in-depth appraisal of its topic, Medical and Social Problems of the Disabled (Kallio 1982) and Services to Prevent Disability in the Elderly (WHO meeting 1982) are short, concise summaries. Dementia in Later Life: Research and Action contains nine sections: introduction; diagnostic considerations; burden of the dementias; the epidemiology of senile dementia; Alzheimer's disease: the search for causes; prevention and treatment; coping with dementia; international collaborative research on dementias; and conclusions and overall strategic issues. Medical and Social Problems of the Disabled is a report based on technical discussions at the 31st session of the Regional Committee for Europe, that were the Regional Office's contribution to the International Year of Disabled Persons. It is divided into six sections: concepts and definitions; medical and social problems of disabled persons; specific problems related to disability and rehabilitation in the European region; salient points of two United Nations meetings in Europe during the Intemational Year of Disabled Persons; discussion and comments by national representatives; and summary.
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Services to Prevent Disability in the Elderly represents the summary of a working group convened specifically to: "review the nature of existing services and available manpower;, identify some of the main deficiencies in the existing disability prevention services; and make recommendations for action as a follow-up to the International Year of Disabled Persons in 1981 and the United Nations World Assembly on Aging in 1982; and interdisciplinary studies in priority areas of prevention and rehabilitation for the elderly, including prevention of impairment, disability and handicap, the consequences of disease" (pp. 1-2). The publication is arranged into nine substantive sections: introduction; the role of the consumer; self-care and self-help groups; surveillance and screening of elderly people; assessment of disability; performance in activities of daily living; rehabilitation and the provision and use of aids; utilization of health and social services; organization of services; the primary care model; and conclusions and recommendations. Aging: The Universal Human Experience (Maddox and Busse) is a collection of the highlights of the 1985 Congress of the Intemational Association of Gerontology. According to its editors, this volume reflects the multidisciplinary nature of gerontology and geriatrics and includes papers on biology, clinical medicine, psychological and behavioral science, and the social sciences, policy and practice. The text is divided into seven sections covering an overview of the association; basic and clinical research; demography and epidemiology; multidimensional assessment of older persons; psychological and behavioral research; basic and social scientific research; housing and living environments; policy, planning, and practice; and ethical issues in aging societies. Research and the Ageing Population (1988) is a collection of works from the Ciba Foundation's 265th symposium. Its major objective - "to review progress in research relevant to the elderly and to consider its significance for planning for the provision of care for elderly people, taking demographic, social and economic factors into account" (p. xi) is reflected in the diversity of papers in the volume. The individual articles are not organized into sections; each stands on its own - except for the informative discussant comments which followed each paper's presentation at the symposium. They cover topics on the relationship between aging and disease, demographic issues, specific mental and physical disorders associated with aging, and some policy/planning issues. Another report from the 1985 Congress of the International Association of Gerontology is Brody and Maddox's (1988) Epidemiology and Aging: An International Perspective. This volume is organized into sections, though it consists of an unusual assortment of papers. The volume opens with a clear, comprehensive review chapter on epidemiology and the challenge of aging. The second part of the volume is largely descriptive and illustrates basic epidemiological research in various countries, especially, Sweden, Japan, the United Kingdom and the U.S. A unique and informative paper in this section is the presentation of different data collection efforts currently underway at the Epidemiology, Demography and Biometry Program at the National Institute on Aging (NIA) (Cornoni-Huntley, White, Cartwright, Brock and Brody). Part III
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deals with the epidemiology of psychiatric disorders in the elderly while the final part of the book deals with applications of epidemiology to planning and policy. KEY ISSUES Disease Versus Senescence: Does It Matter?
Regardless of which, if any, theory of aging one adopts as the truth, there is little doubt of the inevitability of death. The reader is referred to Kirkwood (Ciba Foundation) for a comprehensive, intelligible (for the nongeneticist or aging theorist) presentation of the various theories of aging, and for some insight into the disposable soma theory. This theory suggests that "senescence occurs because through natural selection a strategy is favored in which organisms invest fewer resources in the maintenance and repair of somatic cells and tissues than are necessary for indefinite survival of the individual. This 'disposable soma theory' provides a broad predictive framework within which to assess the relevance of models with which to investigate specific mechanisms of aging" (p. 193). By acknowledging the difficulty for experimental study to determine reasons for aging where random damage (extrinsic factors) influences mechanisms of aging, and through a summary of explanations for the species' need for senescence, Kirkwood makes a substantial contribution to the epidemiology of aging. The search for the causes of aging continues as the potential gain in life expectancy and/or quality of life remaining is too great a prize to abandon. Arguments espoused in the various publications fuel the controversy regarding the relative roles of disease and 'the natural course of aging' in the process of aging. One of the most lively debates takes place within the discussion section for Evans' (Ciba Foundation) paper on the relationship between aging and disease. Evans is not accepting of clinical medicine's distinction in human aging between 'normal' and 'pathological.' Evans would prefer us to view the interaction between intrinsic (mainly genetic) and extrinsic (environmental) factors without prior assumptions about a condition (Alzheimer's in this example) being a disease. T.F. Williams offers the view that it is useful to identify a change which is not universal or inevitable, which may be preventable or modifiable; such changes would not be considered part of the aging process. It is easy to see how this distinction is useful for the clinician. The only reason to give something a diagnostic label is to facilitate the treatment process. (The discussion of the issue of societal needs for labels is not considered here.) One reason to call something a 'normal part of aging' is because there is nothing one could/should do about it. This allows us, perhaps, to accept the inevitability of bodily changes associated with aging. Brody, in a separate discussion about the health needs of the aged, suggests that there exists, "The need to identify those age-dependent diseases and
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conditions which produce the greatest hardship and cost and pursue them from the point of view of postponement and palliation rather than cure" (p. 214); this supports Williams' concern for pursuing processes amenable to prevention activities. Williams and Katzman (among others at the discussion) agree that the progress for cures won't come about unless the process is [italics author's] seen as a disease process. Evans' response to the discussion provides evidence of a concern over which research issues get further funding, " T h i s smacks of politics rather than of science! Translating 'senile dementia' into Alzheimer's disease has undoubtedly produced public and financial support for research that would not otherwise have been forthcoming. But this is merely an example of the terminology being used to solve a problem that it created in the first place. If dementia had not been for so may years categorized as 'normal aging' the relevant research might have been started decades ago" (p. 47). While evidence presented in Phair, Hsu and Hsu (Ciba Foundation) indicates that underlying disease, not senescence of host resistance, leads to severe infection in aging, and with it increased chances for death, the issue of why the elderly do have more underlying disease processes is not adequately addressed. Phair and colleagues cite an underlying disease, tuberculosis (TB), as an example of a cohort-related illness with high prevalence rates among today's elderly who had been raised in major industrial countries. An argument for a cohort effect would conclude that future cohorts not similarly exposed when young would not necessarily exhibit high rates of TB as they age. There appears to be a clear relationship between age and increasing incidence for many diseases, and there is no doubt about age's relationship with mortality. The commentors (in the lively discussion) concluded, for the most part, that something about aging relates to disease, and for accepting Brody's definition for what are age-dependent diseases - namely, diseases whose incidence continues to rise in a geometric or exponential fashion as a function of age (cited in Katzman in Ciba Foundation). It would appear that the amelioration of various endpoints of aging will be the current research priority for at least these researchers, and whether it is caused by disease or senescence will be a continuing debate.
The Usefulness of the Epidemiological Approach One of the differences between and within the publications is in how epidemiological methods are applied. Several investigators (Part II Brody and Maddox) highlight the continued utility of the type of traditional epidemiological research which provides descriptions of health and disease in the elderly. In his commentary, Wallace (Brody and Maddox) argues that these should not be abandoned in favor of more complex analytic activities. Some suggest epidemiology's usefulness as a research methodology is its ability to shape health promotion/disease prevention programs, "if one pillar of our policy is indeed health maintenance, then it follows that we have to use technology to learn what it is that keeps us healthy as we age. The appropriate
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technology for assessing this, unequivocally in human populations, is the epidemiological method for investigating health and disease" (Macfayden in Maddox and Busse, p. 21). Similarly, Brody and Maddox (in their preface) assert that the rigorous methodology makes epiderniology well suited for design and evaluation of health promotion and disease prevention programs. Davies (Brody and Maddox) accepts a WHO Scientific Group 1984 definition of the endpoint for epidemiological research to be "loss of autonomy"; others have translated that loss into "at risk" (cf. Taylor in Maddox and Busse), "active life expectancy" (Branch in Brody and Maddox), "home care needs" (Frengley, Lefton, and Mion in Maddox and Busse), and "institutionalization" (Branch in Brody and Maddox). In these instances, epidemiology would be called upon to assess risk factors for these life occurrences, with the assumption that early identification of those at risk will allow for more appropriate monitoring/prevention activities. Taylor (Maddox and Busse) is critical of our reliance on the risk group approach because of a concern that the potential pool of people falling into some risk category is too large to monitor. Epidemiological research is useful for its ability to translate knowledge about the course of disease in specific populations into policy implications. Though traditional epidemiology seems removed from policy analysis, some of the papers presented in Brody and Maddox (Branch; George, Blazer, WinfieldLaird, Leaf and Fishbach; Shapiro) impressively apply basic epidemiological findings to inform policy. The Epidemiology Catchment Area Program (ECAP) consists of multisite collaborative research projects initiated in part as a response to the need for basic epidemiological and health service information about psychiatric morbidity in the U.S. (George et al. in Brody and Maddox). Using case illustrations - such as the descriptive study which showed a small minority of elderly using the greatest health care dollars - Shapiro (Brody and Maddox) argues persuasively for the applicability of epidemiological research. This type of policy research leads to the appreciation of the skills of the epidemiologist and what s/he can bring to pressing aging policy questions.
Methodological Problems The more notable, pervasive methodological problems - for purposes of understanding how much research can ever inform us about the process of aging - are reflected by the following two comments: "How can one standardize for genetic variability when searching for environmental variability?" Evans (in Brody and Maddox); and "But when you project your experience and interest to facing the elderly population, you may have run up against the limits to which conventional experimental designs can be applied in studies of the aged. You have emphasized the presence of heterogeneity: as age advances, the comorbidities combine; you have a flaring of possible presentations, almost to infinity, such that each patient in the end may represent a unique and individual phenomenon ..." (Solomons in Wenger in Ciba Foundation, p. 125). A variety of methodological problems are present in many of the works, for example: sample size, sample selection, and the availability of selective
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information. The inattention of the original research papers to their research's potential methodological limitations is troublesome. The papers which are reviews of others' research are more sensitive to these potential problems, especially in noting, in other published works, the nongeneralizability of findings from small size clinical samples. The dilemma is the inevitability of selected groups when using clinical material (Evans as noted by Davies in Brody and Maddox). Besides being limited to small clinic populations, another impediment to finding representative samples, voiced by Riggs (Ciba Foundation), might be successful educational campaigns which make it difficult to find unbiased populations not following any of the current recommendations. This raises two interesting questions: Are we implementing untested intervention programs too soon? And, how much new data are needed to confirm relationships which have already been indicated strongly enough to encourage the development of prevention programs in the first place (or, why still carry out the research)? The second of these is undoubtedly more profound. It is apparent that all of the research reviewed here assumes more research is needed before we can be sure which interventions would work best for which populations and why they are still concerned with what causes the problem/disease in the first place. Even in those studies where sample size is adequate, the social survey sampling tradition with its reliance on geographic dispersion may not be appropriate in all instances (Maddox in Brody and Maddox). There are at least three problems with this tradition. First, since it is hard to do clinical evaluations on such a dispersed population, the survey must rely on measures of functional health (self-assessments) rather than on clinical assessments. Second, individuals are extracted from the particular context in which they live so crucial confounding factors are potentially missing. And third, the findings are not necessarily generalizable to the specific population in the catchment area for which planning agencies make policies. Maddox is insightful to question whether this necessary trade-off between social survey sampling traditions and clinical sampling allows the research to answer the questions for which solutions can be implemented by some caring bureaucrat. A different type of data limitation facing the field, noted in Brody (Ciba Foundation), concerns selective information contained in the large national data sets which inform much of our knowledge about the relationships between age, disease, and disability. The National Health Interview Survey (NHIS), for example, may be lacking critical measures. While data from the NHIS show arthritis as a leading cause of disability, the instrument does not give critical estimates of the impact of dementia and mental disease on disability. An emerging research concern is related to using the elderly as research subjects. The last section in Maddox and Busse has three excellent chapters on ethical issues in geriatrics though none of these relate to this issue. Wallace (in Brody and Maddox) does raise the problem of "informed consent" when the potential for impaired cognition is strong. The issue of informed consent and other issues relating to research subjects - such as random assignment to groups when there are strong indications of success for one of the groups - need to be
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given serious reflection by all researchers, with attention to the special concerns for the aged. Throughout the papers there is a consistent call for longitudinal analyses (for example: Fox in Ciba Foundation; Fries in Wenger in Ciba Foundation; Svanborg in both Ciba Foundation and Brody and Maddox). Longitudinal analyses may allow for a more precise distinction between manifestations of aging and the symptoms produced by definable diseases and disorders, though it may not solve the political dilemma surrounding this distinction. One problem with cross-sectional analyses of the aged is that they are necessarily the study of survivors. Further, without longitudinal analyses, cohort-related illnesses (TB, mentioned above) might be confused for age-related illnesses. Mortimer (Brody and Maddox) proposes the establishment of comparative longitudinal studies of elderly persons in selected developed and developing countries to provide data on the nature of mental decline during aging, possible differences in age-specific incidence of mental decline between countries, and types of diseases predisposing older persons to mental impairments. In the absence of longitudinal data, there is the need to combine views based on cross-sectional data with the life course perspective of different generations (Elder, 1985 cited in Fox in Ciba Foundation). Longitudinal studies produce their own sets of methodological complications. Murphy (Brody and Maddox) acknowledges some logistical problems such as long-term funding and staffing. For some conditions thought to be associated with aging (e.g. osteoporosis), changes from year to year may be too small to detect unless longitudinal means over a lifetime (Riggs and Melton in Ciba Foundation); following a cohort through a lifetime compounds the logistical problems. Gutman, Stark, Uyeno and Lane (Maddox and Busse) describe dayto-day technical challenges encountered in a prospective longitudinal study of clients admitted to British Columbia's long-term care program in 1978. The usefulness of community-based research is addressed in a few papers. Gutman and colleagues (Maddox and Busse) provide a thorough assessment of the advantages and disadvantages of doing what you can with available clinical data. Hatano, Matsuzaki, Shibata, Shichita, Haga, Maeda, Shimonaka, Hayashi (Brody and Maddox), in their paper describing a longitudinal, prospective community-based study of a healthy elderly population in Japan, present tips on how to initiate community-based research. These workable strategies provide useful starting points for other researchers. Another methodological issue raised in a few of the papers concerns the overabundance of data for community, as opposed to institutionalized, populations (Wallace in Brody and Maddox). Murphy (Brody and Maddox) states that researchers shouldn't omit institutionalized elderly when studying the incidence/prevalence of psychological disorders since the single most important cause for institutionalization in the first place is a psychological disorder. None of the papers in these collections contains a sample of institutionalized elderly, though Blazer and colleagues (Brody and Maddox 1988) note that both community and institutionalized populations are included in their study, and the results from the latter will be presented elsewhere.
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Multidimensional Assessment and Measurement Tools
The concern about varying diagnostic criteria and assessment tools is expressed often (discussants in Arie in Ciba Foundation; Murphy in Brody and Maddox). Some are concerned with patient versus clinical assessments (e.g., Williams in Andrews in Ciba Foundation). While Havens (Maddox and Busse) is critical of the lack of standardization of tools for cross-national comparison, Murphy (Brody and Maddox) goes even deeper into this issue with the plea to, "Please stop inventing new clinical interview schedules that are not directly comparable with others already in use" (p. 113). Another calls attention to problems with numerous multidimensional functional assessment tools based on many Activity of Daily Living (ADL) schemes currently in use; these are said to offer only bits and pieces rather than a comprehensive data base which can be used for comparative purposes (Hermanova in Maddox and Busse). A whole section of Maddox and Busse is devoted to the multidimensional assessment of older persons. Multidimensional assessment tools are attentive to the need of assessing all aspects of the individual's life - mental, physical, social and functional. Havens (Maddox and Busse) summarizes the usual components of multidimensional assessments. These include: general health, functioning ability in everyday activities, well-being, cognitive functioning, coping behavior or ability, social skills or functioning, social or informal supports, and economic security. The different requirements of screening tools as opposed to clinical assessments is recognized by the authors in this section (Fillenbaum; Taylor; and Pannill and Fisk); Branch's chapter addresses the mismatch between populationbased studies and the requirements of clinical practice. Pannill and Fisk present a functional assessment screening technique used and tested in a geriatrics clinic. Researchers have recently begun considering "active functional years of life remaining" since it is a central issue raised by the increasing longevity of the elderly population. Brody (Ciba Foundation) reports the growing concern that much of that gain in longevity is gained in years dependent (for each functional year gained there are 3.5. dependent years). Again, some lively comments arose in the discussion session stating that Americans are overly concerned with this phenomenon of active life expectancy because of our concern with burden (Williams in Brody in Ciba Foundation), and the implications of the imposition of our value of nondependent status as a must for elderly who may feel differently. It seems that more time and effort should be devoted to resolving the issue of the utility of such a measurement. Many of the papers that address the problem of varying criteria and tools are concerned with diagnosis problems for mental illnesses. Mortimer (Brody and Maddox) notes that the diagnostic criteria for dementias differ and that they are very broad and allow for considerable interpretation. Similarly, Blazer and colleagues (Brody and Maddox) complain that the DSM (the psychiatric classification of diseases) criterion for schizophrenia that requires that the first
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delusional episode occur before age 45 limits identification (and consequently treatment) of those who might otherwise fit DSM criteria.
The Role of Cross-Cultural Research The importance of cross-cultural research is a recurrent theme in these works; a variety of reasons for this is noted. "The developing countries of the world provide an extraordinarily rich variety of cultural, political, socioeconomic and geographic characteristics in which to undertake cross-national studies. These could provide information that will be comparable between countries and will allow the exploration of the significance of tradition, culture, ethnicity and other variables in the individual expression of aging" (Andrews in Ciba Foundation p. 31). Katzman (Ciba Foundation) suggests the need to distinguish for varying populations the interaction between life events and genetic disposition. Mortimer (Brody and Maddox) notes that demographic changes in the developing world should result in considerable increases in the absolute number and prevalence of dementias which will put a strain on limited health care resources. The lessons of the developed world, already experiencing the rapid aging of its populations, should assist the developing world in predicting future patterns and needs. A number of papers are particularly informative about aging from a crosscultural perspective. The WHO (1983) review of international research provides a good basis for understanding global differences in health status presenting data from less developed countries with varying age structures. The article by Myers and Manton (Maddox and Busse) contains and argues for the utility of very detailed life tables for 11 countries. Mortimer (Brody and Maddox) uses the similar patterns of age-specific prevalence rates of dementias in the U.S., Denmark, Finland, and New Zealand to support the claim that there may be a single syndrome causing dementia whose risk factors are not specific to particular geographic regions. As Mortimer notes, these results may have something to do with the fact that all are developed countries with populations that have high life expectancies and are predominantly white. Until comparable data are available from developing countries to support or dispute this, no firm conclusions can be drawn. Andrews' (Ciba Foundation) article on health and aging in the developing world presents findings from a cross-national study conducted in the Republic of Korea, the Philippines, Fiji, and Malaysia relating to physical and mental health, functional ability and family support. The overall demographic, physical, mental health and social pattems and trends associated with aging were found to be consistent throughout the four countries. Andrews notes that these are countries which show a pattern of increasing urbanization, industrialization and technological and social change. Andrews goes beyond comparing rates to suggest that different lifestyles between east and west may translate into different ways of dealing with the issues of aging. For example, European countries have a relatively high
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proportion of people 60 or above who live alone whereas only 5% of the elderly in the Philippines and 2% in the other far and southeastern countries studied live alone. The importance of the family in these latter societies was very evident about three quarters of those over 60 live with children, often in extended family situations. Two other papers present international perspectives on family support for the elderly. Information about the demographic transition in Japan and a reflective assessment of how this transition is affecting the ability of families to support elders in need is presented by Maeda (Maddox and Busse). Somewhat problematic is the conclusion drawn by Paillat (Maddox and Busse) based on minimal data (though evident trends) from a longitudinal survey of elderly in France: "When a population undergoes changes of this magnitude, the time has come for a sweeping reappraisal of the social protection of the elderly, including a reallocation of roles within the family as well as of families within our society" (p. 600). The changes noted were in the composition of families, a change from four to three-generational families, stresses put on the pension system with two generations of retirees, and a difficult situation for the middleaged woman who has a retired mother, a widowed grandmother, and her own family. Though these data seem consistent with trends in the U.S., as presented (without any discussion) the data do not seem to warrant rushing in to change the social order, and remind one of the caution needed when using others' research (intemational or not) for comparative purposes. A number of interesting methodological issues regarding cross-cultural research are raised. Wallace (Brody and Maddox) asserts the need for systematic health and disease nomenclature for worldwide application in hopes of more accurately describing the total health status, including functionality, of the aged. During a discussion, Solomons (Ciba Foundation) wonders whether crossnational comparisons of chronologically similar age cohorts is a legitimate strategy and proposes using comparable phases of the lifespan in terms of expected mortality. Another discussant questions the feasibility of doing crossnational longitudinal surveys in elderly populations in developing countries; Solomons thinks it would be difficult because of tracking problems (caused by greater mobility and mortality of such populations). The problem of selection might be more critical for aging research in developing nations; older people in developing societies are even more highly selected than their counterparts in the developed world since they have survived strong forces of mortality in childhood and adult life. It is interesting that though there is much discussion about methods of assessment (see above), little attention is paid to the cultural biases inherent in the labelling of a phenomenon as a medical problem. All of the researchers start at the baseline that something is a problem and that interventions will be necessary. Labelling becomes a cross-cultural problem as well. It is easy for researchers to assume the entities about which they conduct their research are diseases because western medicine has created labels for them. Mortimer (Brody and Maddox) acknowledges that social stigma may decrease reporting, therefore
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prevalence estimates of dementia in Taiwan and China (one tenth of western countries) may be low. Mortimer surmises this may be out of respect to elders. It may also be that problems in social functioning for older people are not considered abnormal or problematic in these cultures. Two further cultural comparisons indicating different prevalence rates possibly due to labelling problems are noted by Mortimer (Brody and Maddox): Japanese studies consistently report higher prevalence of multi-infarct dementia, which is the opposite of diagnosis patterns in the U.S. and Western-Europe, where more dementias of the Alzheimer's type are reported; and NY psychiatrists are more likely to give an organic diagnosis than London psychiatrists who give more functional diagnoses. The importance of cross-cultural longitudinal analyses to determine the role played by cultural, ethnic, and environmental influences in mental (Mortimer in Brody and Maddox) and physical functioning of the aged are a persistent theme throughout these papers. More precise in-depth analyses of what is meant by cultural - in what ways it might affect disease and how diseases become problems for the elderly - is needed. ORGANIZATION AND WRITING STYLE A final concern is the effectiveness of the organization of the publications and of individual writing styles in providing coherent sets of information. The varying quality of the individual articles contained in the collections necessitates some scrutiny of writing style. Information that is not well presented or confusing is of little use to the reader and does not contribute to our growing knowledge base. Among the best works are those which include clear introductory statements (for example: Hatano et al.; George et al.; Mortimer; Murphy; all in Brody and Maddox; Taylor in Maddox and Busse). Along the same lines, the otherwise excellent volume on Epidemiology and Aging (Brody and Maddox, 1988) suffers from a lack of abstracts. Given the diverse group of readers, which includes medical clinicians, other practitioners, social scientists, and interested lay people, and the variety of substantive areas covered in the collected volumes, how well each topic is presented at the outset will guide the individual reader to determine whether a particular article is within the range and scope of his/her interests. The reader can be distracted from useful information contained within by the lack of a clear introduction to where the paper is going (e.g., Katzman in Ciba Foundation; Wenger in Ciba Foundation); even a review chapter should state clearly that it is precisely this. The most informative are those articles which are able to synthesize the current state of knowledge about a selected issue, use this synthesis as background for their current research results, and incorporate the findings of their own work. For example: Leaf, Berkman, Weissman, Holzer, HI, Tischler, and Meyers (Brody and Maddox), in their paper on the epidemiology of late-life depression, present a general overview of the epidemiology of mental illness, noting common methodological problems, findings from studies both within and outside of the U.S., and findings from new U.S. studies. They then proceed to
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provide detail for their current ECAP in New Haven, including research design and results, and pull all of the data, theirs and those from previous research, together to comment on what these data suggest about mental illness in late-life. Another excellent review is Evans' (Brody and Maddox) article on the epidemiology of dementias. It is one of the finer pieces showing the true workings of an epidemiologist as s/he tries to present evidence, piece by piece, for competing theories while remarking on possible confounding or noncomparability factors between studies. The presentation style also contributes to how informative a paper is. Some of the technical articles pay attention to details such as providing an adequate description of samples and/or including clear concise tables (e.g., Andrews in Ciba Foundation; Davies in Brody and Maddox). The usefulness of attention to the technical aspects of research is also evident in one of the four WHO reports. Dementia in Later Life: Research and Action provides more concrete suggestions, pulling together an existing knowledge base more adequately. In contrast, the other WHO reports are somewhat disappointing both in writing style, organization, and content. One hopes for a more global perspective from WHO, at least the acknowledgement of country-specific data limitations. In some instances, references are not easily identifiable within the text (Skeet). It is also not clear why certain topics are presented to the exclusion of others. More detail with regard to what studies were done and where, and guided by what driving force would have added to the strength of these reviews. This is not intended to imply that the WHO publications are not useful, they are. A critical contribution of the historical review (Skeet), often times glossed over by others, is the consideration of the issue of geriatric training, with concern that current medical school curricula are deficient. Among the most useful contributions of Medical and Social Problems of the Disabled are the clear operational definition of disability and age-specific (children, adults, elderly) prevalence and incidence data. The three collections (Brody and Maddox; Ciba Foundation; Maddox and Busse) use discussant or section summary comments which are pivotal to the richness of these works. Discussant comments are used consistently in the Ciba Foundation volume, while summary chapters in the Brody and Maddox's collection and section introductory chapters in Maddox and Busse's collection are provided in some cases. While the summary and introductory chapters are useful, the discussants' viewpoints have a wonderful sense of immediacy about them. The reader is privy to reflections that are unique to oral discourse and rarely found in written works where words are so carefully chosen, and people are less likely to espouse a potentially unfavorable position. The discussions also give the authors the opportunity to reflect on aspects of their studies that they had chosen not to present or hadn't given thought to previously. All research could benefit from intellectual discussion. Inherent in the nature of collections of symposia are some disadvantages. Firstly, in some ways the information contained in them might be better suited for an organized textbook. This is particularly true when basic methodological
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issues are repeated in the introduction section of each separate article. Given that the volumes may not be read in their entirety, however, this repeated attention to detail may be necessary. Nevertheless, though not quite textbooks, we can assume these volumes will be used as such in formal classes and informally by interested readers and academic researchers. Therefore, more consideration should be given to this issue of presentation. Secondly, if these each represent individual research articles, would the articles not stand better on their own in appropriate journals? The usefulness of a collected volume should be in its ability to pull together and articulate diverse areas, but this cohesiveness between chapters is sorely lacking. Where are the bridges between substantive areas? Collections from symposia too easily result in a collection of papers presented. The common threads - a unifying purpose, a theme which each author addresses - are missing. Organization of the various articles by type and an introduction to these various groupings would be helpful in this regard but are inconsistent. Ciba Foundation is not organized by type at all; the groupings in Maddox and Busse are not always persuasive. Abstracts could serve this purpose admirably but again are not used uniformly. Thirdly, the diverse nature of a collection means that no one topic is covered in exacting detail; this is good for the person who wants an overview, but insufficient for the scholar looking for a definitive and comprehensive synthesis of the state of the art in a particular field. Nevertheless, some of the individual articles are of sufficient depth to satisfy even the most meticulous of researchers (Blazer et al.; Leaf et al. in Brody and Maddox; Mor in Ciba Foundation). All of the publications reviewed are useful for their respective audiences. The collections are more suited for academic audiences; the WHO publications, for those in academic environments as well as for those who work with the elderly in the field. The materials reviewed here cover a wide variety of topics concerning international views of aging populations from basic and medical science, social science, and applied perspectives. While individual researchers will be drawn to particular publications guided by their own interests and agendas, these works complement each other well and together describe the current state of international aging research. ACKNOWLEDGEMENTS The author gratefully acknowledges Dr. Maija L. Selby and Dr. Daniel Muller for providing comments on an earlier draft.
Multipurpose Arthritis Center Department of Social Medicine School of Medicine Center for Health Promotion and Disease Prevention University of North Carolina at Chapel Hill
INTERNATIONAL RESEARCH ON AGING: SOME SELECTED ISSUES
Brody, Jacob A. and George L. Maddox, eds. 1988. Epidemiology and Aging: An International Perspective. New York: Springer Pub. Co. 233 pp. Ciba Foundation Symposium 134. 1988. Research and the Ageing Population. Chichester, UK: John Wiley & Sons Ltd.. 264 pp. Maddox, George L. and E.W. Busse, eds. 1987. Aging: The Universal Human Experience. New York: Springer. 668 pp. Kallio, V. 1982. Medical and Social Problems o f the Disabled. World Health Organization, Regional Office for Europe, Copenhagen, EURO Reports and Studies 73, World Health Organization. 35 pp. Report of a WHO Scientific Group on Senile Dementia 1986. Dementia in Later Life: Research and Action. World Health Organization, Technical Report Series 730, World Health Organization, Geneva. 74 pp. Report on a WHO meeting. 1982. Services to Prevent Disability in the Elderly. World Health Organization, Regional Office for Europe, Copenhagen, EURO Reports and Studies 83, World Health Organization, Denmark. 33 pp. Skeet, Muriel. 1983. Protecting the Health o f the Elderly. World Health Organization, Regional Office for Europe, Copenhagen, Public Health in Europe 18, World Health Organization, Denmark. 125 pp.
INTRODUCTION This paper is a review of recent symposia collections and World Health Organization (WHO) publications related to the process of aging and focuses more on their epidemiological, as opposed to their biomedical, contributions. After presenting the range of topics covered in each publication, the review considers several key issues that these publications raise. These issues are the controversy regarding the concepts of disease and senescence and their respective roles in the aging process; the usefulness of the epidemiological approach; methodological problems; and the role of cross-cultural research in informing our understanding of aging and aging populations. Finally, the review considers the effectiveness of the organization of the publications and of individual writing styles in providing coherent sets of information. Journal of Cross Cultural Gerontology 5: 301-314, 1990. © 1990 Kluwer Academic Publishers. Printed in the Netherlands.
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All of the publications are either collections of papers presented at international symposia or meetings of WHO working groups, or summaries of such meetings. Due to the nature of these types of meetings, the publications all represent (at the time of their publication) the most current, and in some cases otherwise unpublished, research and discussions about aging. The publications reviewed cover a wide variety of topics concerning aging and aging populations in the international arena from basic science, social science, and applied perspectives. TOPICS COVERED Several publications have recently been released by the World Health Organization, all dealing with various aspects of the issues of aging populations. The most comprehensive of these is the 1983 publication, Protecting the Health of the Elderly: A Review of WHO Activities (Skeet 1983). This is a summary of reports from WHO meetings, since 1958, that related to the care of the elderly. It covers the development of health care for the elderly from an international and multidisciplinary perspective. The publication is arranged into seven chapters covering principal issues with which WHO has been concerned: the process of aging; establishing priorities in research; aging societies; clinical studies; research programs; planning and providing services; and education and training. Reports within these chapters deal with some of the problems researchers have identified, such as the predominance of women at older ages and the chronic problems they face in a variety of cultural settings. The other three WHO publications all examine specific issues. Each is a report of a technical or scientific meeting convened to address its topic, describes what is known about the covered topic and makes proposals for coordinated research efforts. While Dementia in Later Life: Research and Action (WHO Scientific Group on Senile Dementia 1986) is an in-depth appraisal of its topic, Medical and Social Problems of the Disabled (Kallio 1982) and Services to Prevent Disability in the Elderly (WHO meeting 1982) are short, concise summaries. Dementia in Later Life: Research and Action contains nine sections: introduction; diagnostic considerations; burden of the dementias; the epidemiology of senile dementia; Alzheimer's disease: the search for causes; prevention and treatment; coping with dementia; international collaborative research on dementias; and conclusions and overall strategic issues. Medical and Social Problems of the Disabled is a report based on technical discussions at the 31st session of the Regional Committee for Europe, that were the Regional Office's contribution to the International Year of Disabled Persons. It is divided into six sections: concepts and definitions; medical and social problems of disabled persons; specific problems related to disability and rehabilitation in the European region; salient points of two United Nations meetings in Europe during the Intemational Year of Disabled Persons; discussion and comments by national representatives; and summary.
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Services to Prevent Disability in the Elderly represents the summary of a working group convened specifically to: "review the nature of existing services and available manpower;, identify some of the main deficiencies in the existing disability prevention services; and make recommendations for action as a follow-up to the International Year of Disabled Persons in 1981 and the United Nations World Assembly on Aging in 1982; and interdisciplinary studies in priority areas of prevention and rehabilitation for the elderly, including prevention of impairment, disability and handicap, the consequences of disease" (pp. 1-2). The publication is arranged into nine substantive sections: introduction; the role of the consumer; self-care and self-help groups; surveillance and screening of elderly people; assessment of disability; performance in activities of daily living; rehabilitation and the provision and use of aids; utilization of health and social services; organization of services; the primary care model; and conclusions and recommendations. Aging: The Universal Human Experience (Maddox and Busse) is a collection of the highlights of the 1985 Congress of the Intemational Association of Gerontology. According to its editors, this volume reflects the multidisciplinary nature of gerontology and geriatrics and includes papers on biology, clinical medicine, psychological and behavioral science, and the social sciences, policy and practice. The text is divided into seven sections covering an overview of the association; basic and clinical research; demography and epidemiology; multidimensional assessment of older persons; psychological and behavioral research; basic and social scientific research; housing and living environments; policy, planning, and practice; and ethical issues in aging societies. Research and the Ageing Population (1988) is a collection of works from the Ciba Foundation's 265th symposium. Its major objective - "to review progress in research relevant to the elderly and to consider its significance for planning for the provision of care for elderly people, taking demographic, social and economic factors into account" (p. xi) is reflected in the diversity of papers in the volume. The individual articles are not organized into sections; each stands on its own - except for the informative discussant comments which followed each paper's presentation at the symposium. They cover topics on the relationship between aging and disease, demographic issues, specific mental and physical disorders associated with aging, and some policy/planning issues. Another report from the 1985 Congress of the International Association of Gerontology is Brody and Maddox's (1988) Epidemiology and Aging: An International Perspective. This volume is organized into sections, though it consists of an unusual assortment of papers. The volume opens with a clear, comprehensive review chapter on epidemiology and the challenge of aging. The second part of the volume is largely descriptive and illustrates basic epidemiological research in various countries, especially, Sweden, Japan, the United Kingdom and the U.S. A unique and informative paper in this section is the presentation of different data collection efforts currently underway at the Epidemiology, Demography and Biometry Program at the National Institute on Aging (NIA) (Cornoni-Huntley, White, Cartwright, Brock and Brody). Part III
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deals with the epidemiology of psychiatric disorders in the elderly while the final part of the book deals with applications of epidemiology to planning and policy. KEY ISSUES Disease Versus Senescence: Does It Matter?
Regardless of which, if any, theory of aging one adopts as the truth, there is little doubt of the inevitability of death. The reader is referred to Kirkwood (Ciba Foundation) for a comprehensive, intelligible (for the nongeneticist or aging theorist) presentation of the various theories of aging, and for some insight into the disposable soma theory. This theory suggests that "senescence occurs because through natural selection a strategy is favored in which organisms invest fewer resources in the maintenance and repair of somatic cells and tissues than are necessary for indefinite survival of the individual. This 'disposable soma theory' provides a broad predictive framework within which to assess the relevance of models with which to investigate specific mechanisms of aging" (p. 193). By acknowledging the difficulty for experimental study to determine reasons for aging where random damage (extrinsic factors) influences mechanisms of aging, and through a summary of explanations for the species' need for senescence, Kirkwood makes a substantial contribution to the epidemiology of aging. The search for the causes of aging continues as the potential gain in life expectancy and/or quality of life remaining is too great a prize to abandon. Arguments espoused in the various publications fuel the controversy regarding the relative roles of disease and 'the natural course of aging' in the process of aging. One of the most lively debates takes place within the discussion section for Evans' (Ciba Foundation) paper on the relationship between aging and disease. Evans is not accepting of clinical medicine's distinction in human aging between 'normal' and 'pathological.' Evans would prefer us to view the interaction between intrinsic (mainly genetic) and extrinsic (environmental) factors without prior assumptions about a condition (Alzheimer's in this example) being a disease. T.F. Williams offers the view that it is useful to identify a change which is not universal or inevitable, which may be preventable or modifiable; such changes would not be considered part of the aging process. It is easy to see how this distinction is useful for the clinician. The only reason to give something a diagnostic label is to facilitate the treatment process. (The discussion of the issue of societal needs for labels is not considered here.) One reason to call something a 'normal part of aging' is because there is nothing one could/should do about it. This allows us, perhaps, to accept the inevitability of bodily changes associated with aging. Brody, in a separate discussion about the health needs of the aged, suggests that there exists, "The need to identify those age-dependent diseases and
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conditions which produce the greatest hardship and cost and pursue them from the point of view of postponement and palliation rather than cure" (p. 214); this supports Williams' concern for pursuing processes amenable to prevention activities. Williams and Katzman (among others at the discussion) agree that the progress for cures won't come about unless the process is [italics author's] seen as a disease process. Evans' response to the discussion provides evidence of a concern over which research issues get further funding, " T h i s smacks of politics rather than of science! Translating 'senile dementia' into Alzheimer's disease has undoubtedly produced public and financial support for research that would not otherwise have been forthcoming. But this is merely an example of the terminology being used to solve a problem that it created in the first place. If dementia had not been for so may years categorized as 'normal aging' the relevant research might have been started decades ago" (p. 47). While evidence presented in Phair, Hsu and Hsu (Ciba Foundation) indicates that underlying disease, not senescence of host resistance, leads to severe infection in aging, and with it increased chances for death, the issue of why the elderly do have more underlying disease processes is not adequately addressed. Phair and colleagues cite an underlying disease, tuberculosis (TB), as an example of a cohort-related illness with high prevalence rates among today's elderly who had been raised in major industrial countries. An argument for a cohort effect would conclude that future cohorts not similarly exposed when young would not necessarily exhibit high rates of TB as they age. There appears to be a clear relationship between age and increasing incidence for many diseases, and there is no doubt about age's relationship with mortality. The commentors (in the lively discussion) concluded, for the most part, that something about aging relates to disease, and for accepting Brody's definition for what are age-dependent diseases - namely, diseases whose incidence continues to rise in a geometric or exponential fashion as a function of age (cited in Katzman in Ciba Foundation). It would appear that the amelioration of various endpoints of aging will be the current research priority for at least these researchers, and whether it is caused by disease or senescence will be a continuing debate.
The Usefulness of the Epidemiological Approach One of the differences between and within the publications is in how epidemiological methods are applied. Several investigators (Part II Brody and Maddox) highlight the continued utility of the type of traditional epidemiological research which provides descriptions of health and disease in the elderly. In his commentary, Wallace (Brody and Maddox) argues that these should not be abandoned in favor of more complex analytic activities. Some suggest epidemiology's usefulness as a research methodology is its ability to shape health promotion/disease prevention programs, "if one pillar of our policy is indeed health maintenance, then it follows that we have to use technology to learn what it is that keeps us healthy as we age. The appropriate
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technology for assessing this, unequivocally in human populations, is the epidemiological method for investigating health and disease" (Macfayden in Maddox and Busse, p. 21). Similarly, Brody and Maddox (in their preface) assert that the rigorous methodology makes epiderniology well suited for design and evaluation of health promotion and disease prevention programs. Davies (Brody and Maddox) accepts a WHO Scientific Group 1984 definition of the endpoint for epidemiological research to be "loss of autonomy"; others have translated that loss into "at risk" (cf. Taylor in Maddox and Busse), "active life expectancy" (Branch in Brody and Maddox), "home care needs" (Frengley, Lefton, and Mion in Maddox and Busse), and "institutionalization" (Branch in Brody and Maddox). In these instances, epidemiology would be called upon to assess risk factors for these life occurrences, with the assumption that early identification of those at risk will allow for more appropriate monitoring/prevention activities. Taylor (Maddox and Busse) is critical of our reliance on the risk group approach because of a concern that the potential pool of people falling into some risk category is too large to monitor. Epidemiological research is useful for its ability to translate knowledge about the course of disease in specific populations into policy implications. Though traditional epidemiology seems removed from policy analysis, some of the papers presented in Brody and Maddox (Branch; George, Blazer, WinfieldLaird, Leaf and Fishbach; Shapiro) impressively apply basic epidemiological findings to inform policy. The Epidemiology Catchment Area Program (ECAP) consists of multisite collaborative research projects initiated in part as a response to the need for basic epidemiological and health service information about psychiatric morbidity in the U.S. (George et al. in Brody and Maddox). Using case illustrations - such as the descriptive study which showed a small minority of elderly using the greatest health care dollars - Shapiro (Brody and Maddox) argues persuasively for the applicability of epidemiological research. This type of policy research leads to the appreciation of the skills of the epidemiologist and what s/he can bring to pressing aging policy questions.
Methodological Problems The more notable, pervasive methodological problems - for purposes of understanding how much research can ever inform us about the process of aging - are reflected by the following two comments: "How can one standardize for genetic variability when searching for environmental variability?" Evans (in Brody and Maddox); and "But when you project your experience and interest to facing the elderly population, you may have run up against the limits to which conventional experimental designs can be applied in studies of the aged. You have emphasized the presence of heterogeneity: as age advances, the comorbidities combine; you have a flaring of possible presentations, almost to infinity, such that each patient in the end may represent a unique and individual phenomenon ..." (Solomons in Wenger in Ciba Foundation, p. 125). A variety of methodological problems are present in many of the works, for example: sample size, sample selection, and the availability of selective
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information. The inattention of the original research papers to their research's potential methodological limitations is troublesome. The papers which are reviews of others' research are more sensitive to these potential problems, especially in noting, in other published works, the nongeneralizability of findings from small size clinical samples. The dilemma is the inevitability of selected groups when using clinical material (Evans as noted by Davies in Brody and Maddox). Besides being limited to small clinic populations, another impediment to finding representative samples, voiced by Riggs (Ciba Foundation), might be successful educational campaigns which make it difficult to find unbiased populations not following any of the current recommendations. This raises two interesting questions: Are we implementing untested intervention programs too soon? And, how much new data are needed to confirm relationships which have already been indicated strongly enough to encourage the development of prevention programs in the first place (or, why still carry out the research)? The second of these is undoubtedly more profound. It is apparent that all of the research reviewed here assumes more research is needed before we can be sure which interventions would work best for which populations and why they are still concerned with what causes the problem/disease in the first place. Even in those studies where sample size is adequate, the social survey sampling tradition with its reliance on geographic dispersion may not be appropriate in all instances (Maddox in Brody and Maddox). There are at least three problems with this tradition. First, since it is hard to do clinical evaluations on such a dispersed population, the survey must rely on measures of functional health (self-assessments) rather than on clinical assessments. Second, individuals are extracted from the particular context in which they live so crucial confounding factors are potentially missing. And third, the findings are not necessarily generalizable to the specific population in the catchment area for which planning agencies make policies. Maddox is insightful to question whether this necessary trade-off between social survey sampling traditions and clinical sampling allows the research to answer the questions for which solutions can be implemented by some caring bureaucrat. A different type of data limitation facing the field, noted in Brody (Ciba Foundation), concerns selective information contained in the large national data sets which inform much of our knowledge about the relationships between age, disease, and disability. The National Health Interview Survey (NHIS), for example, may be lacking critical measures. While data from the NHIS show arthritis as a leading cause of disability, the instrument does not give critical estimates of the impact of dementia and mental disease on disability. An emerging research concern is related to using the elderly as research subjects. The last section in Maddox and Busse has three excellent chapters on ethical issues in geriatrics though none of these relate to this issue. Wallace (in Brody and Maddox) does raise the problem of "informed consent" when the potential for impaired cognition is strong. The issue of informed consent and other issues relating to research subjects - such as random assignment to groups when there are strong indications of success for one of the groups - need to be
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given serious reflection by all researchers, with attention to the special concerns for the aged. Throughout the papers there is a consistent call for longitudinal analyses (for example: Fox in Ciba Foundation; Fries in Wenger in Ciba Foundation; Svanborg in both Ciba Foundation and Brody and Maddox). Longitudinal analyses may allow for a more precise distinction between manifestations of aging and the symptoms produced by definable diseases and disorders, though it may not solve the political dilemma surrounding this distinction. One problem with cross-sectional analyses of the aged is that they are necessarily the study of survivors. Further, without longitudinal analyses, cohort-related illnesses (TB, mentioned above) might be confused for age-related illnesses. Mortimer (Brody and Maddox) proposes the establishment of comparative longitudinal studies of elderly persons in selected developed and developing countries to provide data on the nature of mental decline during aging, possible differences in age-specific incidence of mental decline between countries, and types of diseases predisposing older persons to mental impairments. In the absence of longitudinal data, there is the need to combine views based on cross-sectional data with the life course perspective of different generations (Elder, 1985 cited in Fox in Ciba Foundation). Longitudinal studies produce their own sets of methodological complications. Murphy (Brody and Maddox) acknowledges some logistical problems such as long-term funding and staffing. For some conditions thought to be associated with aging (e.g. osteoporosis), changes from year to year may be too small to detect unless longitudinal means over a lifetime (Riggs and Melton in Ciba Foundation); following a cohort through a lifetime compounds the logistical problems. Gutman, Stark, Uyeno and Lane (Maddox and Busse) describe dayto-day technical challenges encountered in a prospective longitudinal study of clients admitted to British Columbia's long-term care program in 1978. The usefulness of community-based research is addressed in a few papers. Gutman and colleagues (Maddox and Busse) provide a thorough assessment of the advantages and disadvantages of doing what you can with available clinical data. Hatano, Matsuzaki, Shibata, Shichita, Haga, Maeda, Shimonaka, Hayashi (Brody and Maddox), in their paper describing a longitudinal, prospective community-based study of a healthy elderly population in Japan, present tips on how to initiate community-based research. These workable strategies provide useful starting points for other researchers. Another methodological issue raised in a few of the papers concerns the overabundance of data for community, as opposed to institutionalized, populations (Wallace in Brody and Maddox). Murphy (Brody and Maddox) states that researchers shouldn't omit institutionalized elderly when studying the incidence/prevalence of psychological disorders since the single most important cause for institutionalization in the first place is a psychological disorder. None of the papers in these collections contains a sample of institutionalized elderly, though Blazer and colleagues (Brody and Maddox 1988) note that both community and institutionalized populations are included in their study, and the results from the latter will be presented elsewhere.
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Multidimensional Assessment and Measurement Tools
The concern about varying diagnostic criteria and assessment tools is expressed often (discussants in Arie in Ciba Foundation; Murphy in Brody and Maddox). Some are concerned with patient versus clinical assessments (e.g., Williams in Andrews in Ciba Foundation). While Havens (Maddox and Busse) is critical of the lack of standardization of tools for cross-national comparison, Murphy (Brody and Maddox) goes even deeper into this issue with the plea to, "Please stop inventing new clinical interview schedules that are not directly comparable with others already in use" (p. 113). Another calls attention to problems with numerous multidimensional functional assessment tools based on many Activity of Daily Living (ADL) schemes currently in use; these are said to offer only bits and pieces rather than a comprehensive data base which can be used for comparative purposes (Hermanova in Maddox and Busse). A whole section of Maddox and Busse is devoted to the multidimensional assessment of older persons. Multidimensional assessment tools are attentive to the need of assessing all aspects of the individual's life - mental, physical, social and functional. Havens (Maddox and Busse) summarizes the usual components of multidimensional assessments. These include: general health, functioning ability in everyday activities, well-being, cognitive functioning, coping behavior or ability, social skills or functioning, social or informal supports, and economic security. The different requirements of screening tools as opposed to clinical assessments is recognized by the authors in this section (Fillenbaum; Taylor; and Pannill and Fisk); Branch's chapter addresses the mismatch between populationbased studies and the requirements of clinical practice. Pannill and Fisk present a functional assessment screening technique used and tested in a geriatrics clinic. Researchers have recently begun considering "active functional years of life remaining" since it is a central issue raised by the increasing longevity of the elderly population. Brody (Ciba Foundation) reports the growing concern that much of that gain in longevity is gained in years dependent (for each functional year gained there are 3.5. dependent years). Again, some lively comments arose in the discussion session stating that Americans are overly concerned with this phenomenon of active life expectancy because of our concern with burden (Williams in Brody in Ciba Foundation), and the implications of the imposition of our value of nondependent status as a must for elderly who may feel differently. It seems that more time and effort should be devoted to resolving the issue of the utility of such a measurement. Many of the papers that address the problem of varying criteria and tools are concerned with diagnosis problems for mental illnesses. Mortimer (Brody and Maddox) notes that the diagnostic criteria for dementias differ and that they are very broad and allow for considerable interpretation. Similarly, Blazer and colleagues (Brody and Maddox) complain that the DSM (the psychiatric classification of diseases) criterion for schizophrenia that requires that the first
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delusional episode occur before age 45 limits identification (and consequently treatment) of those who might otherwise fit DSM criteria.
The Role of Cross-Cultural Research The importance of cross-cultural research is a recurrent theme in these works; a variety of reasons for this is noted. "The developing countries of the world provide an extraordinarily rich variety of cultural, political, socioeconomic and geographic characteristics in which to undertake cross-national studies. These could provide information that will be comparable between countries and will allow the exploration of the significance of tradition, culture, ethnicity and other variables in the individual expression of aging" (Andrews in Ciba Foundation p. 31). Katzman (Ciba Foundation) suggests the need to distinguish for varying populations the interaction between life events and genetic disposition. Mortimer (Brody and Maddox) notes that demographic changes in the developing world should result in considerable increases in the absolute number and prevalence of dementias which will put a strain on limited health care resources. The lessons of the developed world, already experiencing the rapid aging of its populations, should assist the developing world in predicting future patterns and needs. A number of papers are particularly informative about aging from a crosscultural perspective. The WHO (1983) review of international research provides a good basis for understanding global differences in health status presenting data from less developed countries with varying age structures. The article by Myers and Manton (Maddox and Busse) contains and argues for the utility of very detailed life tables for 11 countries. Mortimer (Brody and Maddox) uses the similar patterns of age-specific prevalence rates of dementias in the U.S., Denmark, Finland, and New Zealand to support the claim that there may be a single syndrome causing dementia whose risk factors are not specific to particular geographic regions. As Mortimer notes, these results may have something to do with the fact that all are developed countries with populations that have high life expectancies and are predominantly white. Until comparable data are available from developing countries to support or dispute this, no firm conclusions can be drawn. Andrews' (Ciba Foundation) article on health and aging in the developing world presents findings from a cross-national study conducted in the Republic of Korea, the Philippines, Fiji, and Malaysia relating to physical and mental health, functional ability and family support. The overall demographic, physical, mental health and social pattems and trends associated with aging were found to be consistent throughout the four countries. Andrews notes that these are countries which show a pattern of increasing urbanization, industrialization and technological and social change. Andrews goes beyond comparing rates to suggest that different lifestyles between east and west may translate into different ways of dealing with the issues of aging. For example, European countries have a relatively high
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proportion of people 60 or above who live alone whereas only 5% of the elderly in the Philippines and 2% in the other far and southeastern countries studied live alone. The importance of the family in these latter societies was very evident about three quarters of those over 60 live with children, often in extended family situations. Two other papers present international perspectives on family support for the elderly. Information about the demographic transition in Japan and a reflective assessment of how this transition is affecting the ability of families to support elders in need is presented by Maeda (Maddox and Busse). Somewhat problematic is the conclusion drawn by Paillat (Maddox and Busse) based on minimal data (though evident trends) from a longitudinal survey of elderly in France: "When a population undergoes changes of this magnitude, the time has come for a sweeping reappraisal of the social protection of the elderly, including a reallocation of roles within the family as well as of families within our society" (p. 600). The changes noted were in the composition of families, a change from four to three-generational families, stresses put on the pension system with two generations of retirees, and a difficult situation for the middleaged woman who has a retired mother, a widowed grandmother, and her own family. Though these data seem consistent with trends in the U.S., as presented (without any discussion) the data do not seem to warrant rushing in to change the social order, and remind one of the caution needed when using others' research (intemational or not) for comparative purposes. A number of interesting methodological issues regarding cross-cultural research are raised. Wallace (Brody and Maddox) asserts the need for systematic health and disease nomenclature for worldwide application in hopes of more accurately describing the total health status, including functionality, of the aged. During a discussion, Solomons (Ciba Foundation) wonders whether crossnational comparisons of chronologically similar age cohorts is a legitimate strategy and proposes using comparable phases of the lifespan in terms of expected mortality. Another discussant questions the feasibility of doing crossnational longitudinal surveys in elderly populations in developing countries; Solomons thinks it would be difficult because of tracking problems (caused by greater mobility and mortality of such populations). The problem of selection might be more critical for aging research in developing nations; older people in developing societies are even more highly selected than their counterparts in the developed world since they have survived strong forces of mortality in childhood and adult life. It is interesting that though there is much discussion about methods of assessment (see above), little attention is paid to the cultural biases inherent in the labelling of a phenomenon as a medical problem. All of the researchers start at the baseline that something is a problem and that interventions will be necessary. Labelling becomes a cross-cultural problem as well. It is easy for researchers to assume the entities about which they conduct their research are diseases because western medicine has created labels for them. Mortimer (Brody and Maddox) acknowledges that social stigma may decrease reporting, therefore
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prevalence estimates of dementia in Taiwan and China (one tenth of western countries) may be low. Mortimer surmises this may be out of respect to elders. It may also be that problems in social functioning for older people are not considered abnormal or problematic in these cultures. Two further cultural comparisons indicating different prevalence rates possibly due to labelling problems are noted by Mortimer (Brody and Maddox): Japanese studies consistently report higher prevalence of multi-infarct dementia, which is the opposite of diagnosis patterns in the U.S. and Western-Europe, where more dementias of the Alzheimer's type are reported; and NY psychiatrists are more likely to give an organic diagnosis than London psychiatrists who give more functional diagnoses. The importance of cross-cultural longitudinal analyses to determine the role played by cultural, ethnic, and environmental influences in mental (Mortimer in Brody and Maddox) and physical functioning of the aged are a persistent theme throughout these papers. More precise in-depth analyses of what is meant by cultural - in what ways it might affect disease and how diseases become problems for the elderly - is needed. ORGANIZATION AND WRITING STYLE A final concern is the effectiveness of the organization of the publications and of individual writing styles in providing coherent sets of information. The varying quality of the individual articles contained in the collections necessitates some scrutiny of writing style. Information that is not well presented or confusing is of little use to the reader and does not contribute to our growing knowledge base. Among the best works are those which include clear introductory statements (for example: Hatano et al.; George et al.; Mortimer; Murphy; all in Brody and Maddox; Taylor in Maddox and Busse). Along the same lines, the otherwise excellent volume on Epidemiology and Aging (Brody and Maddox, 1988) suffers from a lack of abstracts. Given the diverse group of readers, which includes medical clinicians, other practitioners, social scientists, and interested lay people, and the variety of substantive areas covered in the collected volumes, how well each topic is presented at the outset will guide the individual reader to determine whether a particular article is within the range and scope of his/her interests. The reader can be distracted from useful information contained within by the lack of a clear introduction to where the paper is going (e.g., Katzman in Ciba Foundation; Wenger in Ciba Foundation); even a review chapter should state clearly that it is precisely this. The most informative are those articles which are able to synthesize the current state of knowledge about a selected issue, use this synthesis as background for their current research results, and incorporate the findings of their own work. For example: Leaf, Berkman, Weissman, Holzer, HI, Tischler, and Meyers (Brody and Maddox), in their paper on the epidemiology of late-life depression, present a general overview of the epidemiology of mental illness, noting common methodological problems, findings from studies both within and outside of the U.S., and findings from new U.S. studies. They then proceed to
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provide detail for their current ECAP in New Haven, including research design and results, and pull all of the data, theirs and those from previous research, together to comment on what these data suggest about mental illness in late-life. Another excellent review is Evans' (Brody and Maddox) article on the epidemiology of dementias. It is one of the finer pieces showing the true workings of an epidemiologist as s/he tries to present evidence, piece by piece, for competing theories while remarking on possible confounding or noncomparability factors between studies. The presentation style also contributes to how informative a paper is. Some of the technical articles pay attention to details such as providing an adequate description of samples and/or including clear concise tables (e.g., Andrews in Ciba Foundation; Davies in Brody and Maddox). The usefulness of attention to the technical aspects of research is also evident in one of the four WHO reports. Dementia in Later Life: Research and Action provides more concrete suggestions, pulling together an existing knowledge base more adequately. In contrast, the other WHO reports are somewhat disappointing both in writing style, organization, and content. One hopes for a more global perspective from WHO, at least the acknowledgement of country-specific data limitations. In some instances, references are not easily identifiable within the text (Skeet). It is also not clear why certain topics are presented to the exclusion of others. More detail with regard to what studies were done and where, and guided by what driving force would have added to the strength of these reviews. This is not intended to imply that the WHO publications are not useful, they are. A critical contribution of the historical review (Skeet), often times glossed over by others, is the consideration of the issue of geriatric training, with concern that current medical school curricula are deficient. Among the most useful contributions of Medical and Social Problems of the Disabled are the clear operational definition of disability and age-specific (children, adults, elderly) prevalence and incidence data. The three collections (Brody and Maddox; Ciba Foundation; Maddox and Busse) use discussant or section summary comments which are pivotal to the richness of these works. Discussant comments are used consistently in the Ciba Foundation volume, while summary chapters in the Brody and Maddox's collection and section introductory chapters in Maddox and Busse's collection are provided in some cases. While the summary and introductory chapters are useful, the discussants' viewpoints have a wonderful sense of immediacy about them. The reader is privy to reflections that are unique to oral discourse and rarely found in written works where words are so carefully chosen, and people are less likely to espouse a potentially unfavorable position. The discussions also give the authors the opportunity to reflect on aspects of their studies that they had chosen not to present or hadn't given thought to previously. All research could benefit from intellectual discussion. Inherent in the nature of collections of symposia are some disadvantages. Firstly, in some ways the information contained in them might be better suited for an organized textbook. This is particularly true when basic methodological
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issues are repeated in the introduction section of each separate article. Given that the volumes may not be read in their entirety, however, this repeated attention to detail may be necessary. Nevertheless, though not quite textbooks, we can assume these volumes will be used as such in formal classes and informally by interested readers and academic researchers. Therefore, more consideration should be given to this issue of presentation. Secondly, if these each represent individual research articles, would the articles not stand better on their own in appropriate journals? The usefulness of a collected volume should be in its ability to pull together and articulate diverse areas, but this cohesiveness between chapters is sorely lacking. Where are the bridges between substantive areas? Collections from symposia too easily result in a collection of papers presented. The common threads - a unifying purpose, a theme which each author addresses - are missing. Organization of the various articles by type and an introduction to these various groupings would be helpful in this regard but are inconsistent. Ciba Foundation is not organized by type at all; the groupings in Maddox and Busse are not always persuasive. Abstracts could serve this purpose admirably but again are not used uniformly. Thirdly, the diverse nature of a collection means that no one topic is covered in exacting detail; this is good for the person who wants an overview, but insufficient for the scholar looking for a definitive and comprehensive synthesis of the state of the art in a particular field. Nevertheless, some of the individual articles are of sufficient depth to satisfy even the most meticulous of researchers (Blazer et al.; Leaf et al. in Brody and Maddox; Mor in Ciba Foundation). All of the publications reviewed are useful for their respective audiences. The collections are more suited for academic audiences; the WHO publications, for those in academic environments as well as for those who work with the elderly in the field. The materials reviewed here cover a wide variety of topics concerning international views of aging populations from basic and medical science, social science, and applied perspectives. While individual researchers will be drawn to particular publications guided by their own interests and agendas, these works complement each other well and together describe the current state of international aging research. ACKNOWLEDGEMENTS The author gratefully acknowledges Dr. Maija L. Selby and Dr. Daniel Muller for providing comments on an earlier draft.
Multipurpose Arthritis Center Department of Social Medicine School of Medicine Center for Health Promotion and Disease Prevention University of North Carolina at Chapel Hill
