Print version ISSN 1414-3283
Interface (Botucatu) vol.4 no.se Botucatu 2008
Envelhecimento bem-sucedido: trajetórias de um constructo e novas fronteiras
Envejecimiento exitoso: trayectorias de un constructo y nuevas fronteras
Ângela Maria Machado de LimaI,i; Henrique Salmazo da SilvaII; Ricardo GalhardoniII
ISanitary doctor. Gerontology Program, School of Arts, Sciences and Humanities, Universidade de São Paulo (EACH/USP). <firstname.lastname@example.org>
IIUndergraduate students, Gerontology Program EACH/USP. <email@example.com>; <firstname.lastname@example.org>
Translated by Carolina Silveira Muniz Ventura
Translation from Interface - Comunicação, Saúde, Educação, Botucatu, v.12, n.27, p. 795-807, Out./Dez. 2008.
This article focuses on different conceptions of successful aging, emphasizing the process of aging as a heterogeneous experience that implies different strategies for achieving wellbeing and quality of life. Studies valuing the aging process as part of the course of human life and the role of subjectivity and health self-perception, as key concepts for understanding wellbeing and health in old age, were selected. Data in the literature suggest that the experience of successful aging values elderly people's own perceptions: they are the protagonists of interventions and possess judgment about wellbeing and quality of life. Even in the presence of comorbidities and diminished functional ability, it is possible to identify elderly people who report high levels of satisfaction and good quality of life. We propose questions that seek to improve investigations and elaborate this construct within gerontology, bearing in mind the size and complexity of this topic.
Key words: Aging. Old age. Aged. Quality of life. Health.
Este artigo enfoca diferentes concepções de envelhecimento bem-sucedido, enfatizando o processo de envelhecimento como uma experiência heterogênea, que implica diferentes estratégias para a obtenção de bem-estar e qualidade de vida. Foram selecionados estudos que valorizam o processo de envelhecimento como parte do curso de vida humano, o papel da subjetividade e a auto-avaliação em saúde, como conceitos-chave para compreender o bem-estar e saúde na velhice. Os dados da literatura sugerem que a experiência do envelhecimento bem-sucedido valoriza a percepção dos próprios idosos, protagonistas de intervenções e dotados de julgamentos sobre bem-estar e qualidade de vida. Mesmo na presença de co-morbidades e diminuição da funcionalidade é possível identificar idosos que referem altos níveis de satisfação e boa qualidade de vida. Propomos questões que buscam aprimorar investigações e a elaboração deste constructo em gerontologia, tendo em vista a amplitude e complexidade do tema.
Palavras-chave: Envelhecimento. Velhice. Idoso. Qualidade de vida. Saúde.
Este artículo aborda diferentes concepciones de envejecimiento bien llevado, enfatizando el proceso como una experiencia heterogénea que implica diferentes estrategias para la obtención del bienestar y calidad de vida; seleccionando estudios que evalúan el proceso de envejecimiento como parte del curso de vida humana, el papel de la subjetividad y la auto-evaluación en salud como conceptos clave para abarcar el bienestar y la salud en la vejez. Los datos obtenidos sugieren que este proceso resalta la percepción de los ancianos protagonistas de intervenciones. Proponemos cuestiones que tratan de perfeccionar investigaciones y la elaboración de este constructo en Gerontología.
Palabras clave: Envejecimiento. Vejez. Anciano. Calidad de vida. Salud.
"Um velho saudável não é apenas uma ficção de poeta "
(A healthy old person is not only a poet's fiction)
Successful aging is one of the broadly disseminated themes in the means of communication, services, research and texts that inform laws and public policies in the field of gerontology. In this area, it is believed that active life should be added to chronological time, a need identified as the product of efforts undertaken in the last years, largely related to an increase in science production, technology and healthcare practices to the elderly. It is desirable that aging occurs with quality and maintenance of the elderly individuals' autonomy, in an effort to preserve their participation in society, and to minimize the possibilities of social exclusion (Teixeira, Neri, 2008; Lima, 2005, 2003; Holstein, Minkler, 2003; Kahn, 2003; Paschoal, 2002).
In the present discussion, we view old age and the aging process as two complementary and inseparable spheres. It is worth mentioning that we consider aging as a process that, in the individual level, implies multiple life trajectories and, in the collective level, is constructed under different sociocultural influences, such as: access to educational opportunities, adoption of health care, and the undertaking of actions throughout the life course, extending into the late phases of life, like old age. In this sense, while aging is defined as a multifaceted sociovital process that happens along the entire life course, old age denotes the state of "being old", a condition that results from the aging process that generations have experienced and experience within diverse social, political and individual contexts. In other words, these terms refer to specific aspects of the vital human cycle, in such a way that moving between the notions of "old age" and "aging process" becomes fundamental to develop the theoretical-conceptual reflection that we present below, concerning aging, successful old age and elderly individuals' well-being.
In European countries, data presented by Baltes, Smith (2006) show that individuals older than 85 years have higher risk of presenting multiple chronic-degenerative diseases and other pathologies. For example, the results obtained by these authors indicate that 50% of the individuals aged 90 years or older suffer from Alzheimer's Disease, a neurodegenerative illness that is associated with dementia, progressive loss of cognitive and functional abilities and high health costs. In addition, Baltes, Smith (2006) present evidences according to which very old individuals spend the end of their lives with high indexes of functional disability, dependence and loneliness. The authors believe that investing in the multiple factors involved in the aging process and in more actions to promote social inclusion may have positive influences on successive cohorts of elderly people.
In the scope of old age, resources and interventions are hardly justified if they are not targeted at the well-being and quality of life of the individuals who age. These principles are becoming more and more relevant in the context of the well-known accelerated growth of the Brazilian population (Camarano, 2006; Kalache et al., 1987).
Well-established estimates indicate that, up to the year 2025, the number of Brazilian elderlies will exceed thirty million, with different types of old age, that is, constructed by means of diverse trajectories, sometimes with high levels of comorbidities and chronic diseases, sometimes with health and well-being (Lima, 2003; Debert, 1999; Berquó, 1996).
On the other hand, the discussion about successful aging is relatively new. The first gerontological studies were developed in the 1950s and 1960s by researchers from European countries, because, at that time, it was already possible to find a large proportion of healthy elderly individuals in those communities (Teixeira, Neri, 2008; Glass, 2003; Neri, 2001). The most positive beliefs about the aging process allowed many theoretical lines to participate in this discussion, demystifying the inevitable paradigm, valid at the time, of growth, stability and contraction, regarding the vital human cycle (Neri, 2001). In other words, gerontological investigations enabled to modify the notion according to which aging is directly associated with the organism's deterioration. It could begin to be seen as a stage of the vital cycle, as important as any other, with its virtues and challenges (Masoro apud Groisman, 2002; Uchoa, Firmo, Lima-Costa, 2002; Debert, 1999; Erikson, 1998).
In short, based on the scientific and empirical knowledge that has been accumulated up to the present moment, we are entitled to state that aging is not synonymous with disease, inactivity and general contraction in development although the negative beliefs and attitudes regarding old age are still hegemonic in some cultural contexts, mainly among the Western societies, and possibly, among some contemporary Eastern societies. Thus, there are new values and concepts under construction which are disseminated in different contexts of the world, with an ever-growing globalized economy (Neri, 2006; Bosi, 2005; Beauvoir, 1990). In the scope of attitudes and stereotypes, considering that all elderly people are wise or that all are incapable is equally negative (Neri, 2006; Debert, 1999). In the gerontological literature, aging is considered a progressive and multifactorial event, and old age, a potentially successful experience, but also a heterogeneous one, experienced with less or more quality of life.
To Rowe and Kahn (1998), successful aging would be composed of three factors: engagement to life; maintenance of high levels of functional and cognitive abilities and low probability of disease; and capacity to practice healthy habits in order to reduce risks. In fact, these factors are essential, but this view runs the risk of attributing less importance to the sociocultural and collective dimensions, placing the responsibility for successful aging on the private and individual scope, based only on self-control (Kahn, 2003).
In a study in the municipality of São Paulo, Ramos et al. (1993) and Ramos (2003) found higher indexes of chronic diseases, dependence in daily activities and cognitive decline among elderly individuals living in peripheral and impoverished regions, when compared to elderly people living in central regions, localities whose populations have a better socioeconomic level. These data suggest that the social conditions are intrinsic or directly related to the individuals' health status.
The discussion about healthy aging must take into account the interaction of multiple factors: physical and mental health, independence in daily life, social integration, family support and economic independence, among others.
Since the 1980s, there have been many international initiatives that value the possibility of viewing aging as a positive process, a moment in life to exercise well-being, pleasure and quality of life. The active aging policy proposed by the World Health Organization (OMS, 2005) is a concrete example of these recommendations, as it emphasizes that aging well is not only an individual question, but a process that must be facilitated by public policies and by the increase in social and health initiatives throughout the life course. The policy's creation is based on the presupposition that, to age in a healthy and successful way, it is necessary to increase the opportunities so that the individuals can choose healthier lifestyles and also control their own health status. In this way, the definition of active aging is presented as the "optimization of health, participation, security opportunities, with the aim of improving quality of life as people get older"1 (OMS, 2005, p.13). Important terms for this policy are: autonomy, independence, quality of life, and healthy life expectation, even in cases in which some degree of functional disability is involved.
In light of what was mentioned above, our questions are: (a) what is the perception of the elderly about the aging process and what strategies do they use to maintain their well-being and quality of life? (b) does the notion of successful aging apply only to healthy and socially engaged elderly individuals? (c) what are the evidences that are present in the literature?
Taking these questions as points-of-departure, we incite a conceptual discussion about the possibilities of construction of successful aging, and present some lines of thought from the gerontological literature that approach different categories of elderly subjects, and in what way they refer to and establish the meanings about the aging process.
1All the quotations present in the text were translated from Portuguese into English.
To achieve this, we selected studies that value the role of subjectivity and self-rating in health as key concepts to understand well-being and health in old age. We identified these studies in a random way, prioritizing recent contributions that view human aging as a complex sociovital phenomenon. In this direction, we used such tools as a subsidy to contribute to the construction of the notion of successful old age.
The aging process, perceptions and strategies for the attainment of well-being and quality of life
Just as the discussion about successful aging is relatively new, the question of subjectivity started to play an important role in the health area after studies conducted in 1970 (Paschoal, 2002). To this author, subjectivity represents an indispensable measure that correlates with the general status of well-being and with objective health indicators. Such importance invites us to reflect on the subjective dimension that is present in the aging process.
The gerontological literature provides strong evidence that suggest that the perception of satisfaction with life tends to be seen as positive among the elderly (Queiroz, Neri, 2007). In the majority of times in which the objective assessment (carried out through examinations and/or by professionals) is compared with the assessment made by the elderly individual (the way in which he/she sees him/herself), these dimensions potentially complement each other and enrich the assessment that was objectively conducted, because the elderly have unique information that would be neither reported by the family, nor observed through the standardized assessment applied by a trained professional (Neri, 2007; Kikuchi, 2005).
Uchôa, Firmo and Lima-Costa (2002) investigated elderly individuals from the community and discovered that the subjects did not state that they were or perceived themselves as "old", because the very concept of old age is related to decline, stagnation and disease. The study's key informants, who were generally caregivers and family members, had beliefs about the aging process that were more negative than those of the elderly. Groisman (2002) mentions that many researchers have difficulties in defining what is part of the natural aging process and what is part of the process of becoming ill. In this context, some terms that are common today in the gerontological environment emerge, such as senescence and senility, respectively related to what is conceived as "healthy aging" and "pathological aging".
The findings of Uchôa, Firmo and Lima-Costa (2002) regarding the subjective perception of aging are also mentioned by Debert (1999). In this discussion, the term quality of life has become an important construct to the understanding of subjectivity. However, up to the middle of the 1990s, little was mentioned about quality of life concerning the aspect of "subjective self". Subjectivity is definitely incorporated into the definition of quality of life after 1995, when this concept is revised by WHO specialists. In general lines, they define it as the individual's subjective perception of his/her position in life within the context of culture and the systems of values in which he/she lives and in relation to his/her objectives, expectations, standards and worries (Alleyne, 2001; WHOQOL, 1995).
This concept was broadened after the Second World War and was gradually integrated into the notions of socioeconomic and human development and into people's perception of their lives (Paschoal, 2002). This author argues that, in addition to the objective measures, conducted by devices and/or trained observers, now there are subjective measures, in which the individual is asked to give his/her opinion about the quality of his/her life, or about private aspects, such as: health, functional capacities and social relationships, among others.
To Neri (2007), a good quality of life in mature age overcomes the limits of individual responsibility and must be seen in light of multiple aspects, that is, a satisfactory old age will not be an attribute of the biological, psychological or social individual; rather, it results from the interaction among people who are undergoing changes and are living in society, and also from their intra-, extra-individual and community relations. In a previous work, this author argues that the following factors would be involved in well-being during old age: having greater chance of longevity; having good levels of physical and mental health; high levels of satisfaction with life; having control in social dimensions; sense of productivity, participation and accomplishment of activities; cognitive self-efficacy; social status; having good economic resources; continuity in family and occupational roles; maintenance of informal social relationships and of the relations network (Neri, 1993). Based on gerontological studies like the ones mentioned above, we defend, in this text, that well-being and quality of life in old age are complex and multifactorial constructs; they involve multiple variables, associated both with the individual and collective dimensions of aging.
Some studies, besides investigating well-being and quality of life indicators in old age, provide data that clarify the contexts in which the elderly can use strategies to maintain those attributes. Such strategies are mechanisms used by the elderly to compensate for possible losses and maintain functional, social and psychological independence (Baltes, Smith, 2006; Diogo, Neri, Cachioni, 2004; Baltes, Smith, 1995; Baltes, Baltes, 1990). To exemplify how the study of strategies can be fruitful, Baltes and Smith (2006) report that, once, a pianist aged around 80 years was asked how he could continue playing with such skill. Some of the answers were: the selection of a smaller number of keys and the effective handling of hands and fingers, in such a way that he could continue playing the piano with a performance that was similar to the one he had when he was young. This illustration is applied to the theoretical model constructed by Baltes and Baltes (1990), defined by the activities of selection, optimization and compensation, which represent possibilities of plasticity concerning the elderly individual's functional reserves. It is broadly disseminated among theorists and researchers who study the psychological dimension of aging.
With the decline in functional capacities, the elderly would use strategies to maintain their personal performance in tasks they already performed, that is, they would employ behaviors that aim to: 1) compensate for the normative losses of the aging process, and 2) improve the methods and form with which they carry out those tasks. To the authors, selection presupposes that the elderly tend to accomplish the tasks in which they believe they have a good or an optimal performance, excluding or avoiding those in which they have difficulties. Optimization indicates the maintenance of the abilities that are still preserved, adopting methods to maintain or improve them. Compensation suggests the utilization of behaviors in order to compensate for the affected abilities, as is the case of mnemonic strategies used to maintain efficiency in the acquisition and recovery of new information.
Data presented by Rothermund and Brandstädter (2003) in a four-year longitudinal study with individuals aged 58-81 years suggest that the utilization of compensatory efforts occurs with higher frequency in the groups of younger elderly subjects, that is, between the sixth and seventh decades of life. The older subjects reported that they use less this type of strategy, maybe because they present a lower functional reserve to maintain the same level of performance and, consequently, less personal control over the abilities. However, the sensation of control over functional abilities performance (physical ability, mental efficiency, physical appearance and daily competence) did not correlate positively with subjective perception and satisfaction with personal performance, which remained stable for all the researched groups of elderly individuals.
To Rothermund and Brandstädter (2003), this suggests that, with the normative losses caused by aging, the elderly would accept their performance level, adapting themselves and attributing less importance and a lower standard to the functional domains. These resources, even when used in a heterogeneous way, reveal that it is possible to attenuate the deficits and losses that are typical of the aging process. To Baltes and Smith (2006), the individuals who use selection, optimization and compensation are among the elderly who feel better and are more active. Besides the data provided here, further studies are necessary to identify how the elderly, in their multiple sociocultural and individual contexts, use and benefit from the factors that have already been observed in the literature.
According to Antonucci (2001), social support is one of the most significant resources used by the elderly. It involves the perception of the received support, the sense of control over social relationships, and the perspective of exchanges that include affective, emotional and material factors. In research conducted in the French community, Antonucci, Fuhrer, Dartigues (1997) show that perception and satisfaction with the received social support were positively correlated with lower indexes of depressive symptoms.
The maintenance of social contacts with old friends and the preservation of positive emotions regarding relationships, even in the presence of reduction in the relations network, are positive findings in the context of relationships or interactions in old age, as well as the possibility of receiving distance support and maintaining distance contacts with their children, friends and relatives (Erbolato, 2002).
To Uchôa, Firmo and Lima-Costa (2002), the children form the primary support network, but when they do not play this role for some reason, the elderly search for it in friends and neighbors. To the researchers, it was clear that the financial question is related to health, and retirement, even when modest, provides a minimum of autonomy. More than receiving the benefits of the contacts and social support networks, the elderly, according to projections about the Brazilian population, are gradually becoming providers in households in which three or more generations live, enabling the payment of expenses and providing instrumental support for the younger generations (Sommerhalder, 2007; Debert, Simões, 2006).
Other lines of investigation, composed of psychological studies, describe, among other themes, models of coping with non-normative events of the life course. These models can be useful to explore behaviors of elderly individuals who live in contemporary Western societies (Batistone, Fortes, Yassuda, 2007; Neri, 2007; Neri, Fortes, 2006; Poon, 2003).
These authors characterize those events as unexpected or unpredictable, and evaluate them with the presence of damages, loss, onus or with great changes that play a critical role in development, being experienced with strong intensity by the individual, like, for example: becoming ill, winning the lottery, having a car accident, among others.
Normative life events in this model, on the contrary, are viewed as expected changes within the context of Western societies. They can be better controlled, as there are opportunities for previous adaptation. Some examples are retirement, widowhood, the children's emancipation in adult age, etc. To Batistone, Fortes and Yassuda (2007), the life events that represent stressful experiences and require the individuals' adaptation in relation to the environment are relatively similar for adults and elderly individuals; the difference lies on the types of events that are present in old age. Throughout the life cycle, the non-normative life events tend to increase, just like, in old age, the incidence of chronic stressors associated with physical health are more intense and demand greater adaptation when compared to the loss of family members, presenting negative implications for the execution of daily life and self-care activities. The elderly use coping strategies, modifying the meaning of the events or handling the effects of the situation. The perception of control over stressful events increases the sense of personal competence, and is one of the important factors associated with quality of life (Neri, Fortes, 2006).
In the line of psychological well-being in aging, Goldstein (1993) suggests that spirituality and religiosity are some of the richest and most used strategies by the elderly in view of the intensification of the sense of finitude or proximity to death. The belief in transcendence would bring comfort, a sensation of generativeness and psychological well-being, dimensions that emerge as positive in mature adult life and in old age.
According to Ryff and Keies (1995), psychological well-being in aging is constructed by six key dimensions: self-acceptance, positive relations with others, autonomy, environmental mastery, purpose in life, and personal growth. This model is based on six positive psychological propositions, among which happiness and successful old age are indispensable variables. The results described by the authors, in a comparative study of elderly individuals and young adults in the US community, are that older individuals would present high values in almost all dimensions, except for purpose in life and personal growth. These results objectively reinforce the belief in the finitude sensation, presenting direct implications for psychological well-being.
Another theoretical proposition, Carstensen's (1995) socioemotional selectivity theory, explores how the elderly recognize their own finitude and modify the meanings of the relationships, oriented to positive emotions (Erbolato, 2006; Cartensen, 1995).
According to Goldfarb (1998), with the increased sensation of finitude, the elderly would use reminiscences, memories and recovery of facts from the past, which are utilized for the present context, allowing them to re-evaluate who they are, reinvent their life history and experience socioemotional comfort. Data presented by Pasuphathi and Mansour (2006), about the exposure of youths and mature adults in programs that aimed to stimulate the self-report of personal crises and heterogeneous life experiences, reveal that age was linearly associated with greater possibility of integration of the reported contents into the participants' self-biographic history. This finding shows that, with aging, the narratives tend to be more integrative and present positive association with the reports' connection and constitution of life history.
It is worth mentioning that the investigation into aging as a phase of the vital cycle is relatively well developed in the psychology of aging and has influenced several gerontological studies. This fact allowed us to present the results of these studies in detail here.
However, according to many authors, sometimes the terms successful aging, quality of life, satisfaction with life, and subjective well-being end up being used in an indiscriminate form or as synonyms (Paschoal, 2006; Revicki, 2004; Neri, 1993). For example, in his doctoral dissertation, Paschoal (2002) systematically surveyed the works that had, in the title, the terms quality of life and elderly individuals, and found, in Brazil, 289 publications. Analyzing these publications, the author found out that only ten really studied quality of life. The others either presented the theme in a superficial way or only cited, in their titles, the theme quality of life. The same is happening with the question of successful aging at the moment. In the next section, we will focus on the question according to the view through which it was originally coined in the international literature (Kahn, 2003; Baltes, Baltes, 1990).
Successful aging: healthy or socially engaged elderly individuals?
According to Rowe and Kahn (1998), healthy and socially engaged aging is possibly one of the greatest predictors of successful aging. Individuals with high levels of comorbidities and who suffer from illnesses that drastically limit the interaction with the environment would present more difficulty concerning adaptations and the maintenance of well-being and quality of life.
Theories formulated by researchers who study social gerontology investigated the elderly people's social engagement and the conceptual models of the suggested alternatives of relationship between the elderly and the society. The most disseminated theories in the gerontological literature in this dimension which, up to the current moment, have presented implications about studies and interventions are: activity theory and disengagement theory. In opposed poles, the first theory postulates that aging in an adequate way is characterized by engagement in social activities, so that the inactivity related to the stereotypes of aging, retirement, and loss of social contacts is not installed in the life of the elderly. Disengagement theory suggests that, with the progressive increase in age, people tend to disconnect from society, from social contacts, from decision-making contexts and from some social tasks that used to be required before (Siqueira, 2002).
In light of the social theories that try to open ways to understand social relations and social engagement in old age, we know that subjectivity tends to be a good indicator of quality of life. As a result, it enables to evaluate to what extent old age can be perceived as a successful stage of life. In this sense, nowadays, much is postulated about the utilization of subjectivity as an integral part of instruments that assess quality of life, or as an ally to assess quality of life. As we mentioned above, many instruments have been recently developed, and they value the subject's opinion. These instruments can be classified into two types: general, which measure quality of life in a globalized way, like WHOQOL, and some specific instruments, like the Mini-Mental State Examination (MMSE), which assess aspects of the global cognitive status. An example can be found in the literature, in a testimony that corroborates our idea: "Joaquina is a 94-year-old woman that has been in bed for some months. She tells us that she broke one leg and, two months later, she broke the other one, but, surprisingly, she rates her health as very good' " (Uchôa, Firmo, Lima-Costa, 2002, p.29).
Evidences presented by Diogo et al. (2004) indicate that the situation of dependence is multifaceted and presents multiple dimensions social, psychological, ecological, economic, political and others. To the authors, the challenge to the well-being of elderly lying in bed and caregivers is the fact that the professionals should also promote initiatives to stimulate the self-care of the caregivers of elderly individuals, as they are frequently overloaded with the task of providing care. Karsh (2003) presents data from Brazilian studies and verifies that a large part of the caregivers are aged 50 or older, the majority are women and close relatives (daughters and wives). The functional capacity of the people who provide the care can be partially affected, which leads us to find that they present increased risk for the development of diseases like: depression, cardiopathies, hypertension, among others. To the author, old age with dependence is frequently hidden and is not the target of specific public policies. The role of providing care is delegated exclusively to the family (Karsh, 2003). Legal devices, such as the Elderly Statute, which was consolidated in 2004, present norms that suggest patronizing protection for the elderly, because in this document the elderly are defined as ill and dependent, a panorama that is not always true. Besides, attributing to the family the responsibility for providing care could be accompanied by actions that promoted the elderly individual's global care and also offered formal assistance and support services to the elderly and their family (Neri, 2005).
We agree with what we discussed above and defend that the elderly can use, in different degrees, their capacities and abilities. It is not rare to find, in the gerontological professional practice, elderly individuals with intermediate levels of dependence and who mention high levels of satisfaction with life and subjective well-being, as we argued above. Successful old age, at this point, would not be a state of "nirvana" and/or a total equilibrium of personal abilities. The aging experience is adaptive, and this fact may indicate that individuals with some degree of limitation can adapt and present other assessment standards about successful aging (Rothermund, Brandstädter, 2003; Neri, 2001).
Duarte (2007) suggests that there are groups of elderly individuals with predisposition to achieve high levels of functional disability or reduction in functional abilities. They should be classified as fragile elderly. This conception seems to be useful, mainly if we consider the need of planning concerning the provided care and risk management in aging; however, other approaches could broaden this conception by considering, also, levels of plasticity and variability of subjective factors that compose the aging process and which would possibly present more significant implications about the speed and time in which the abilities are reduced. Viewing the functional disability process as some kind of sentence to the risk groups reduces the space for creation of alternatives that value new modalities of abilities evaluation and adaptation. Besides the susceptibility to functional disability, it is necessary to investigate how people can live their days with high well-being standards and low levels of objective functional abilities, taking into account: level of locomotion, presence of comorbidities and chronic-degenerative diseases, cognitive reserve, performance in daily life activities, sociability patterns and others.
Another reflection we suggest with the present text is that programs and interventions targeted at aging should be compatible with the profile of the assisted elderly. Thus, professionals must employ different strategies to monitor the needs of the elderly, including, when it is the case, using questionnaires and validated scales to aid in the understanding of each individual's demand and measure his/her subjectivity. Planning, needs assessment, monitoring and the obtained results are indispensable to assistance practices (Alkema, Reyes, Wilber, 2006).
Salmazo-Silva (2006) analyzed the implications of the participation of recently enrolled elderly people in conviviality centers, in terms of cognitive and psychosocial aspects. The author showed that the very motivation to participate in these programs signals good cognitive status, high levels of satisfaction with life and low indexes of depressive symptoms. This result is also confirmed in Mercadante's (2002) reflections. This author suggests that the community is a possibility for the exercise of new social roles, new decision contexts and for the attribution of importance to the individual.
Despite the fact that Salmazo-Silva's (2006) study did not measure the amplitude of the programs for elderly individuals who have health limitations and who are in vulnerability conditions, it is believed that, as Bowling et al. (2007) suggest, there is a considerable number of elderly people who inform high levels of quality of life even in the presence of functional and physical health disability. The authors found, in a sample of 999 English elderly, that approximately 31% presented significant decline in functional abilities. Of these, 62% rated their health as good. Among other factors, the following predicted positive self-rating of health: having greater perception of control over life, and higher levels of social involvement. These data strengthen the idea that, even in vulnerable conditions, there are protective factors, either intrinsic or extrinsic. In the study conducted by Bowling et al. (2007), social involvement also emerged as an important dimension in the context of elderly individuals with functional limitations. We can say that these data value the reach of this variable both for independent and dependent elderly individuals.
It is a fact that aging can be a pleasurable experience that involves quality of life. Nevertheless, we believe that there is not a single pattern of old age, and that this experience must be generically considered as successful or unsuccessful, less or more guided by fixed behaviors and by engaged lifestyles, like participating in third age programs or starting certain types of activities. Aging, as we have already mentioned, is a complex and heterogeneous phenomenon that involves individual and social responsibility issues.
In this text we propose that the experience of old age is constructed with the perception of the elderly themselves, protagonists of interventions and people who have judgments, beliefs and different views on what well-being and quality of life are, in interaction with other elderly individuals throughout the entire life course (Teixeira, Neri, 2008; Neri, 2006; George, 2001).
We also highlight that this discussion constitutes a fertile theme for investigation that has not been much explored yet. It is possible to state that, among gerontology professionals and researchers, there is the challenge of mapping the trajectories of the concepts of aging and old age, as well as the factors involved in well-being, especially in late old age (people aged 80 or older).
We also do not know yet how the views of successful aging and old age presupposed in gerontological research lines would be re-directed, as well as the conceptual delimitation of successful aging as opposed to or agreeing with the notions of productive aging, active aging, positive old age and/or optimal aging (Glass, 2003).
Interdisciplinary interlocution between psychological, social and biomedical studies that aim to understand the aging process has become more and more necessary. This exercise that is, at the same time, theoretical and carried out by means of empirical research may contribute to the understanding of resilience, of the resources that are employed in coping with stress and to the comprehension of the levels of plasticity of the organic systems, in different possibilities of "successful old ages". Data from ethnographic, cross-cultural, longitudinal and generational cohort studies will be interesting resources to support the understanding of some of the questions that have already been raised. According to Chammé (1996), the dichotomy that exists between the health/disease process was historically constructed, in specific sociocultural contexts. This author draws our attention to the fact that the conceptions about what being healthy in aging means still experiment limitations that are partly related, and which can be apprehended with the theoretical context available in gerontology. This is a limit that needs to be faced by the most recent gerontological studies.
Finally, we propose that reflections on the care provided for the elderly are developed, as well as on the care offered to those who age or the interventions targeted at healthy or vulnerable elderly individuals. Actions and programs could be organized, for example, by the principle of decision sharing (Diogo et al., 2004). We suggest that broadened interventions are studied so that we can understand representations implied in what is conceived as successful aging, which, we can assume, has diverse meanings and is under constant revision and this moves the construct of successful aging to the proposition of emancipated old age, because it is resignified or reconstructed throughout dynamic and intersubjective aging processes.
The authors Ângela Maria Machado de Lima, Henrique Salmazo Silva and Ricardo Galhardoni worked together in all the steps of the paper's production.
ALLEYNE, G.A.O. Health and the quality of life. Rev. Panam. Salud Publica, v. 9, n. 1, p. 1-6, 2001.
ALKEMA, G.E.; REYES, J.Y.; WILBER, K.H. Characteristics associated with home - and community - based service utilization for medicare managed care consumers. Gerontologist, v. 46, n. 2, p. 173-82, 2006.
ANTONUCCI, T.C. Social relations: an examination of social networks, social support, and sense of control. In: BIRREN, J.E.; SCHAIE, K. W. (Orgs.). Handbook of the psychology of aging. 5.ed. San Diego: Academic Press, 2001. p. 427-48.
ANTONUCCI, T.C.; FUHRER, R.; DARTIGUES, J-F. Social relations and depressive symptomatology in a sample of community - dwelling french older adults. Psychol. Aging, v. 12, n. 1, p. 189-95, 1997.
BALTES, P.B.; BALTES, M.M. Successful aging: perspective from the behavioral sciences. Cambridge: Cambridge University Press, 1990.
BALTES, P.B.; SMITH, J. Novas fronteiras para o futuro do envelhecimento: a velhice bem-sucedida do idoso jovem aos dilemas da quarta idade. A Terceira Idade, v. 17, n. 36, p. 7-31, 2006.
______. Psicologia da sabedoria: origem e desenvolvimento. In: NERI, A.L. (Ed.). Psicologia do envelhecimento. Campinas: Papirus, 1995. p. 41-71.
BATISTONE, S.S.T.; FORTES, A.C.G.; YASSUDA, M.S. Aspectos psicológicos do envelhecimento. In: FORLENZA, O. (Org.). Psiquiatria geriátrica: do diagnóstico precoce à reabilitação. São Paulo: Atheneu, 2007. p. 32-7.
BEAUVIOUR, S. A velhice. Rio de Janeiro: Nova Fronteira, 1990.
BERQUÓ, E.S. Algumas considerações demográficas sobre o envelhecimento da população no Brasil. In: SEMINÁRIO INTERNACIONAL MPAS - ENVELHECIMENTO POPULACIONAL: UMA AGENDA PARA O FINAL DO SÉCULO, 1., 1996, Brasília. Anais... Brasília: Ministério da Previdência e Assistência Social, Secretaria da Assistência Social, 1996. p. 16-34.
BOSI, E. Memória e sociedade. São Paulo: Companhia das Letras, 2005.
BOWLING, A. et al. Quality of life among older people with poor functioning: the influence of perceived control over life. Age Ageing, v. 36, p. 310-5, 2007.
CAMARANO, A.A. Envelhecimento da população brasileira: uma contribuição demográfica. In: FREITAS, E.V. et al. (Eds.). Tratado de geriatria e gerontologia. 2.ed. Rio de Janeiro: Guanabara Koogan, 2006. p. 88-105.
CARSTENSEN, L.L. Motivação para o contato social ao longo da vida: uma teoria da seletividade sócio-emocional. In: NERI, A.L. (Org.). Psicologia do envelhecimento. Campinas: Papirus, 1995. p. 111-44.
CHAMMÉ, S.J. Modos e modas da doença e do corpo. Saúde Soc., v. 5, n. 2, p. 61-76, 1996.
DEBERT, G.G. A reinvenção da velhice: sociabilização e processos de reprivatização do envelhecimento. São Paulo: Editora da Universidade de São Paulo, 1999.
DEBERT, G.G.; SIMÕES, J.A. Envelhecimento e velhice na família contemporânea. In: FREITAS, E.V. et al. (Eds.). 2.ed. Tratado de Geriatria e Gerontologia. Rio de Janeiro: Guanabara Koogan, 2006. p. 1366-73.
DIOGO, M.J-E.; NERI, A.L.; CACHIONI, M. Saúde e qualidade de vida na velhice. Campinas: Alínea, 2004.
DUARTE, Y.A.O. Indicadores de fragilização na velhice para o estabelecimento de medidas preventivas. A terceira idade, v. 18, n. 38, p. 7-24, 2007.
ERBOLATO, R.M.P.L. Relações sociais na velhice. In: FREITAS, E.V. et al. (Eds.). Tratado de geriatria e gerontologia. 2.ed. Rio de Janeiro: Guanabara Koogan, 2006. p. 1342-31.
ERIKSON, E. O ciclo de vida completo. Porto Alegre: Artes Médicas, 1998.
GEORGE, L.K. The social psychology of health. In: BINSTOCK, R.H.; GEORGE, L.K. (Orgs.). Handbook of aging and the social sciences. 5.ed. San Diego: Academic Press, 2001. p. 217-35.
GLASS, T. Successful aging. In: TALLIS, R.C.; FILLIT, H.M. (Eds.). Brocklehurt's textbook of geriatric medicine and gerontology. 6.ed. New York: Churchill Livingstone, 2003. p. 173-99.
GOLDFARB, D.C. Corpo e temporalidade: aporte para a clínica do envelhecimento. Rev. Kairós, v. 1, p. 1-8, 1998.
GOLDSTEIN, L.L. Desenvolvimento do adulto e religiosidade: uma questão de fé. In: NERI, A.L. (Org.). Qualidade de vida e idade madura. Campinas: Papirus, 1993. p. 83-107.
GROISMAN, D. A velhice, entre o normal e o patológico. Hist. Cienc. Saúde-Manguinhos, v. 9, n. 1, p. 61-78, 2002.
HOLSTEIN, M.B.; MINKLER, M. Self, society and the "new gerontology ". Gerontologist, v. 43, n. 6, p. 787-96, 2003.
KALACHE, A.; VERAS, R.P.; RAMOS, L.R. O envelhecimento da população mundial: um desafio novo. Rev. Saúde Pública, v. 21, n. 3, p. 200-10, 1987.
KAHN, R.L. Successful aging: intended and unintended consequences of a concept. In: POON, L.W.; GUELDNER, S.H.; SPROUSE, B.M. (Eds.). Successful aging and adaptation with chronic diseases. New York: Springer Publishing Company, 2003. p. 55-82.
KARSH, U.M. Idosos dependentes: famílias e cuidadores. Cad. Saúde Pública, v. 19, n. 3, p. 861-6, 2003.
Kikuchi, E. L. Auto avaliação da saúde. In: JACOB FILHO, W. (Ed.). Avaliação global do idoso: manual da Liga de Gamia. São Paulo: Atheneu, 2005. p. 25-31.
LIMA, A.M.M. Saúde no envelhecimento: uma questão de justiça social. Revés do avesso, v. 14, p. 8-11, 2005.
LIMA, A.M.M. Saúde no envelhecimento: o autocuidado como questão. 2003. Tese (Doutorado) - Faculdade de Medicina, Universidade de São Paulo, São Paulo. 2003.
NERI, A.L. Qualidade de vida na velhice e subjetividade. In: ______. (Org.). Qualidade de vida na velhice: enfoque multidisciplinar. Campinas: Alínea, 2007. p. 13-59.
______. Atitudes em relação à velhice: questões científicas e políticas. In: FREITAS, E.V. et al. (Eds.). Tratado de geriatria e gerontologia. 2.ed. Rio de Janeiro: Guanabara Koogan, 2006. p. 1316-23.
______. As políticas de atendimento aos direitos da pessoa idosa expressas no estatuto do idoso. Terceira idade, v. 16, n. 34, p. 7-24, 2005.
______. O fruto dá sementes: processos de amadurecimento e envelhecimento. In: ______. (Org.). Maturidade e velhice: trajetórias individuais e sócio-culturais. Campinas: Papirus, 2001. p. 11-52.
______. Qualidade de vida no adulto maduro: interpretações teóricas e evidências de pesquisa. In: ______. (Org.). Qualidade de vida e idade madura. Campinas: Papirus, 1993. p. 7-55.
NERI, A.L.; FORTES, A.C.G. A dinâmica do estresse e enfrentamento na velhice e sua expressão no prestar cuidados a idosos no contexto da família. In: FREITAS, E.V. et al. (Eds.). Tratado de geriatria e gerontologia. 2.ed. Rio de Janeiro: Guanabara Koogan, 2006. p. 1277-88.
MERCADANTE, E. Comunidade como um novo arranjo social. Rev. Kairós, v. 5, n. 2, p. 17-34, 2002.
ORGANIZAÇÃO MUNDIAL DA SAÚDE OMS Envelhecimento ativo: uma política de saúde. Brasília: Organização Pan-Americana de Saúde, 2005.
PASCHOAL, S.M.P. Qualidade de vida na velhice. In: FREITAS, E.V. et al. (Eds.). Tratado de geriatria e gerontologia. Rio de Janeiro: Guanabara Koogan, 2002. p. 79-84.
______. Qualidade de vida do idoso: construção de instrumento de avaliação através do método de impacto clínico. 2002. Tese (Doutorado) - Faculdade de Medicina, Universidade de São Paulo, São Paulo. 2002.
PASUPHATI, M.; MANSOUR, E. Adult age differences in autobiografical reasoning in narratives. Psychol. Aging, v. 42, p. 798-808, 2006.
POON, L.W. et al. (Eds.). Coping with comorbidity. In: POON, L.W.; GUELDNER, S.H.; SPROUSE, B.M. (Eds.). Successful aging and adaptation with chronic diseases. New York: Springer Publishing Company, 2003. p. 116-50.
QUEIROZ, N.C.; NERI, A.L. Relações entre bem-estar psicológico e satisfação com a vida na meia-idade e na velhice. Envelhecimento e Saúde, v. 13, n. 3, p. 64, 2007.
RAMOS, L.R. et al. Perfil do Idoso em uma área metropolitana na região sudeste do Brasil: Resultados de um inquérito domiciliar. Rev. Saúde Pública, v. 27, n. 2, p. 87-94, 1993.
RAMOS, L.R. Fatores determinantes do envelhecimento saudável em idosos residentes em centro urbano: Projeto Epidoso, São Paulo. Cad. Saúde Pública, v. 19, n. 3, p. 793-8, 2003.
REVICKI, D. Advances in quality of life theory and research. Qual. Life Res., v. 13, p. 869-70, 2004.
ROTHERMUND, K.; BRANDTSTÄDTER, J. Coping with deficits and loses in later life: from compensatory action to accommodation. Psychol. Aging, v. 18, n. 4, p. 896-905, 2003.
ROWE, J.W.; KAHN, R. Successful aging. New York: Pantheon Books, 1998.
RYFF, C.D.; KEYES, C.L.M. The structure of psychological well-being revisited. J. Pers. Soc. Psychol., v. 69, n. 4, p. 719-27, 1995.
SALMAZO-SILVA, H. A influência de projetos sócio-culturais nos aspectos cognitivos e psicossociais dos idosos de Ermelino Matarazzo. 2006. Monografia (Trabalho de Iniciação Científica) - Escola de Artes, Ciências e Humanidades, Universidade de São Paulo, São Paulo. 2006.
SIQUEIRA, M.E.C. Teorias sociológicas do envelhecimento. In: FREITAS, E.V. et al. (Eds.). Tratado de geriatria e gerontologia. Rio de Janeiro: Guanabara Koogan, 2002. p. 47-57.
SOMMERHALDER, C. Adaptação à realidade socioeconômica da terceira idade: a família e a necessidade de suporte. In: FORLENZA, O.V. (Org.). Psiquiatria geriátrica: do diagnóstico precoce à reabilitação. São Paulo: Atheneu, 2007. p. 32-7.
TEIXEIRA, I.N.D.A.O.; NERI, A.L. Envelhecimento bem-sucedido: uma meta no curso da vida. Psicol. USP, v. 19, n. 1, p. 81-94, 2008.
THE WHOQOL GROUP. The world health organization quality of life assessment: position paper from the world health organization. Soc. Sci. Med., v. 41, p. 1403-9, 1995.
UCHÔA, E.; FIRMO, J.O.A.; LIMA-COSTA. Envelhecimento e saúde: experiência e construção cultural. In: MINAYO, M.C.; COIMBRA, C.E.A. (Orgs.). Antropologia, sociedade e cultura. Rio de Janeiro: Fiocruz, 2002. p. 25-35.
i Address: Avenida Arlindo Bettio, 1000. Ermelindo Matarazzo, São Paulo, SP 03.828-000.