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Successful Aging and Its Discontents: A Systematic Review of the Social Gerontology Literature Marty Martinson, DrPH*,1 and Clara Berridge, MSW2

1Department of Health Education, San Francisco State University, California. 2School of Social Welfare, University of California, Berkeley.

*Address correspondence to Marty Martinson, DrPH, Department of Health Education, San Francisco State University, 1600 Holloway Avenue, HSS Building, Room 326, San Francisco, CA 94132. E-mail: [email protected]

Received January 10 2014; Accepted March 28 2014.

Decision Editor: Rachel Pruchno, PhD

Purpose of the Study: The purpose of this study was to analyze the range of critiques of successful aging models and the suggestions for improvement as expressed in the social gerontology literature. Design and Methods: We conducted a systematic literature review using the follow- ing criteria: journal articles retrieved in the Abstracts in Social Gerontology, published 1987–2013, successful aging/ageing in the title or text (n = 453), a critique of successful aging models as a key component of the article. Sixty-seven articles met the criteria. Qualitative methods were used to identify key themes and inductively configure mean- ings across the range of critiques. Results: The critiques and remedies fell into 4 categories. The Add and Stir group sug- gested a multidimensional expansion of successful aging criteria and offered an array of additions. The Missing Voices group advocated for adding older adults’ subjective meanings of successful aging to established objective measures. The Hard Hitting Critiques group called for more just and inclusive frameworks that embrace diversity, avoid stigma and discrimination, and intervene at structural contexts of aging. The New Frames and Names group presented alternative ideal models often grounded in Eastern philosophies. Implications: The vast array of criteria that gerontologists collectively offered to expand Rowe and Kahn’s original successful model is symptomatic of the problem that a

Special Issue: Successful Aging

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Research Article Special Issue: Successful Aging

Advance Access publication May 9, 2014

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normative model is by definition exclusionary. Greater reflexivity about gerontology’s use of “successful aging” and other normative models is needed.

Key words: Successful aging, Social gerontology, Critical gerontology

Successful aging currently holds a prominent position in social gerontology research (Alley, Putney, Rice, & Bengtson, 2010). It became an increasingly popular model following Rowe and Kahn’s introduction of the distinction between “usual” and “successful” aging (1987) and their subsequent work that explicated the three key components of successful aging: the avoidance of disease and disability, the mainte- nance of cognitive and physical function, and social engage- ment (1997). Over the past two decades, successful aging research has expanded beyond these end point criteria with the development of models that describe processes that can lead to successful aging (for a history of successful aging mod- els, see Pruchno, Wilson-Genderson, Rose, & Cartwright, 2010). As Villar (2012) described, Rowe and Kahn’s model “boosted interest in the biological, behavioural and social factors which determine the attainment of ageing well, and has encouraged the adoption of a new, preventive and optimistic approach to the final decades of life” (p.  1089). Over time, successful aging has been modified and inter- preted in many different ways to the point where it is widely acknowledged that there is no agreed upon definition of the concept (Bowling & Iliffe, 2006; Ferri, James, & Pruchno, 2009; McLaughlin, Jette, & Connell, 2012). Nevertheless, it appears in social gerontology research as frequently as the theories that dominate the field (Alley et al., 2010).

Although successful aging models are prominently posi- tioned, they have also been contested. One of the earliest critiques of Rowe and Kahn’s model appeared in a 1998 letter to the editor in The Gerontologist, in which social gerontologist Matilda Riley called the model “seriously incomplete” (p.  151) for its sole focus on individual suc- cess and its neglect of the structural and social factors that influence aging. For over two decades, social gerontologists have grappled with the ways in which successful aging has and has not captured the personal, social, economic, and political contexts of aging. Challenges to successful aging frameworks range from those that suggest minor modifica- tions to those that more deeply critique the core ideologies embedded in the construct.

As Cole (1995) observed, “the growth of an intellec- tually rich social gerontology depends on the continued willingness to foster greater interactions between empiri- cal research, interpretation, critical evaluation, and reflex- ive knowledge” (p. S343). This study takes a step toward building these “greater interactions” by creating a cohesive summary of the critical questions raised since successful

aging’s 1987 introduction. Although much of the published research on successful aging includes an overview of the model and some mention of the gaps or weaknesses in one or more successful aging frameworks, there has not yet been a systematic review of the full range of concerns and cri- tiques expressed over time about the concept. Such a review can be useful in further building reflexive knowledge. By identifying and analyzing the range of critiques of successful aging, we may be better able to foster the intellectually rich social gerontology that Cole speaks of and further develop a dynamic science of aging that translates into practices and policies that are supportive of people as they age. To that end, we conducted a systematic review of the literature on successful aging to answer the following question: Within the social gerontology literature published since 1987, what concerns have been expressed about successful aging mod- els and what suggestions for improvement have been made?

Methods

In this systematic literature review, we examined peer- reviewed articles in the Abstracts in Social Gerontology (ASG) database published between January 1987 and December 2013. Certainly, notable critiques of success- ful aging have been published in scholarly publications that are not included in the ASG database (Belgrave & Sayed, 2013; Calasanti, Slevin, & King, 2006; Katz, 2013); however, we narrowed our search to the ASG because it provided a broad range of interdisciplinary research in social gerontology including, for example, biological, psychological, sociological, economic, cul- tural, and critical studies in aging. We searched for arti- cles that had successful aging/ageing in the title or all text (n  =  453), then selected those that included a cri- tique of successful aging models as a key component of the article. Using the earlier criteria, we identified 67 articles, which included empirical studies, theoretical analyses, and editorials.

As a configurative review, qualitative methods were used to analyze the data in order to identify key themes and inductively configure meanings across the range of critiques of successful aging (Gough, Oliver, & Thomas, 2012). We conducted initial coding to name the key points made in each paper’s critiques of successful aging and the proposed ideas for improved models. In a second round of axial cod- ing, we inductively identified key themes across codes and

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then named broader connections across these themes that represented a higher level of abstraction. To enhance inter- rater reliability, the two authors individually coded a subset of 15 articles and met to discuss and compare their analyses and identify common codes. We did the same thing when placing the articles into key theme groupings and continued with the analysis when we were confident that the codes and categories were well defined.

Although the articles across categories sometimes over- lapped in terms of their critiques of successful aging (e.g., the focus on physiological aspects of aging, the cultural biases and limitations of criteria, the denigration of people with disabilities or illness), they were placed in categories that were distinguished by the recommendations made for addressing those shortfalls. Four categories emerged: Add and Stir, Missing Voices, Hard Hitting Critiques, and New Frames and Names. The final stage of analysis involved synthesizing these categories to offer an explanation for what this body of research suggested about social gerontol- ogy’s relationships to successful aging.

Findings

Theme 1: Add and Stir Sixteen of the 67 reviewed articles accepted the idea that successful aging could stand as a model but identified sev- eral gaps in current models. Two kinds of solutions emerged from these critiques: loosen the criteria given the very low prevalence of successful aging using existing criteria and expand the model by adding missing criteria. By keeping a successful aging model as the baseline and offering a multi- tude of additions to address the gaps, these critiques took a kind of Add and Stir approach.

A Prevalence Problem The results of Bowling and Iliffe’s (2006) study of the prevalence of successful aging in Britain using a biomedi- cal model, expanded biomedical model, social function- ing model, psychological resources model, and lay model derived from criteria found in the literature revealed rates of 16%–24%. Similarly, using four time points of the Health and Retirement Survey, McLaughlin, Connell, Heeringa, Li, and Roberts (2010) calculated the prevalence of successful aging based on Rowe and Kahn’s model and found that no more than 11.9% of people aged 65 and older met the cri- teria in any year. A follow-up study compared increasingly relaxed criteria and found prevalence rates of 3.3%–33.5% (McLaughlin et al., 2012). The researchers articulated con- cerns about successful aging criteria being too narrow to be of use for public health purposes “unless one wishes to limit the study of healthy aging to those with near-perfect health” (p. 787). McLaughlin and coworkers recommended

lowering the threshold or loosening the criteria while pre- serving the foundation of Rowe and Kahn’s model.

Hank (2011) replicated the study of McLaughlin and coworkers (2010) in a comparison of European countries and Israel. He found that the U.S. rate of 11.9% ranked it in the middle of other countries. National income inequal- ity was positively associated with lower rates of successful aging, and welfare states played a likely role in enabling or hampering successful aging. Hank (2011) acknowledged the value of relaxing Rowe and Kahn’s criteria and also called for “policy interventions supporting individuals’ opportunities for successful aging” (p. 230).

Additional Criteria Several scholars identified gaps in various successful aging models and recommended additional criteria. Like others, Young, Frick, and Phelan (2009) critiqued the emphasis on physiological aspects of aging in Rowe and Kahn’s successful aging constructs. They offered a graded approach that included physiological, psychological, and social dimensions. Young and coworkers defined success- ful aging as a state in which a person uses physical and social adaptive strategies “to achieve a sense of well-being, high self-assessed quality of life, and a sense of personal fulfillment even in the context of illness and disability” (p. 88–89). Other empirically based critiques of the Rowe and Kahn model have called for its expansion by adding the following: subjective criteria (Coleman, 1992); spiritu- ality (Crowther, Parker, Achenbaum, Larimore, & Koenig, 2002); marital status and quality (Ko, Berg, Butner, Uchino, & Smith, 2007); positive as opposed to pathological health characteristics (Kaplan et al., 2008); and broader multidi- mensional constructs encompassing cognitive and affec- tive status, physical health, social functioning, engagement and life satisfaction (Tze Pin, Broekman, Niti, Gwee, & Fe Heok, 2009), and leisure activity (Lee, Lan, & Yen, 2011).

Researchers have also suggested modifications to Baltes and Baltes’ (1990) selective optimization with compensa- tion model of successful aging. Steverink, Lindenberg, and Ormel (1998) proposed the Social Production Function Theory to better integrate social context with behavior. More recently, Villar (2012) proposed infusing criteria for successful aging with a multifaceted generativity concept incorporating social, community, and personal develop- ment. He contended that gains coexist with losses and that generation—in addition to loss regulation or mainte- nance—must be factored into successful aging.

Theme 2: The Missing Voices

Almost half (30) of the 67 critiques of successful aging models focused on the Missing Voices—the subjective

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definitions of successful aging from older adults. Similar to the Add and Stir group, these authors critiqued the nar- rowness of successful aging criteria. In contrast to the Add and Stir critiques, this group explicitly named the need for additional successful aging criteria that were derived from the perspectives of elders.

Compare and Contrast Given the disparity between self-rated rates of successful aging and established criteria, several researchers called for the addition of successful aging criteria generated by older adults’ subjective measures. Strawbridge, Wallhagen, and Cohen (2002) reported a significant difference between self-ratings and ratings based on Rowe and Kahn’s crite- ria (50.3% vs. 18.8%). Cernin, Lysack, and Lichtenberg (2011) similarly found that 63% of African American elders in their sample reported aging successfully compared with 30% who met the Rowe and Kahn criteria. Phelan, Anderson, LaCroix, and Larson (2004) also found that subjective meanings of successful aging differed from those of the published literature and that the multidimensional perceptions of older adults (which encompassed physi- cal, functional, social, and psychological health) were not fully represented in any successful aging model. Based on data from the Manitoba Follow-up Study, researchers found that lay persons’ definitions may be relatively con- sistent over time and should be taken into account (Tate, Swift, & Bayomi, 2013). Pruchno, Wilson-Genderson, and Cartwright (2010) proposed a two-part model of subjective and objective measures. This included objective measures of having few chronic conditions, maintaining functional ability, and experiencing little pain, and subjective ratings of how successfully one has aged, how well one is aging, and how one would rate one’s life these days.

Three studies reported that avoidance of disability or chronic physical illness was not predictive of subjective suc- cessful aging. Strawbridge and coworkers (2002) found that functional status specifically was not predictive of subjec- tive successful aging. Montross and coworkers (2006) simi- larly found that 92% of their sample viewed themselves as successfully aging, despite the fact that the majority expe- rienced disability and chronic physical illness. Romo and coworkers (2013) examined subjective rates of successful aging among an ethnically diverse sample of older adults with late-life disability, the majority of whom reported that they had aged successfully.

This body of research that compared objective and subjective measures identified a wide range of subjectively defined criteria that should be added to current success- ful aging conceptualizations, including several dimensions of emotional well-being and spirituality (Lewis, 2011); comportment and acceptance of change (Rossen, Knafi,

& Flood, 2008); self-acceptance and self-contentment (Reichstadt, Sengupta, Depp, Palinkas, & Jeste, 2010); self- care, accepting the aging process, and financial well-being (Hilton, Gonzalez, Saleh, Maitoza, and Anngela-Cole, 2012); and living with family, and receiving emotional care (Hsu, 2007). As a whole, and similar to the Add and Stir group, this group of critiques presented a dizzying array of missing components offered to strengthen current success- ful aging conceptualizations.

Cultural Relevance and Variability For over a decade, researchers have critiqued the lack of cultural breadth of successful aging models and asserted the need to better capture subjective meanings of success- ful aging from diverse cultural perspectives. Soondool and Soo-Jung (2008) suggested additional subjective cri- teria including “success of adult children” and “a positive attitude toward life” (p.  1061) after examining meanings of successful aging among low-income elders in South Korea. Lewis (2011) interviewed Alaskan Natives Elders in southwest Alaska and found that successful aging was best defined through a culturally congruent concept of elderhood and its four key components as articulated by the study participants. Hilton and coworkers (2012) found culturally embedded meanings expressed by older Latinos that were absent from criteria used in dominant models, and they called for greater clarity on the multiple dimen- sions and processes of successful aging.

Many have critiqued the Western, white, middle class bias in successful aging conceptualizations (Kendig, 2004; Ng et  al., 2011). Two studies challenge Rowe and Kahn’s (1997) and Phelan and coworkers’ (2004) meas- ures of successful aging in terms of their cross-cultural relevance to Japanese Americans (Iwamasa & Iwasaki, 2011; Matsubayashi, Ishine, Wada, & Okumiya, 2006). Iwamasa and Iwasaki (2011) generated a model with six components that shared broad similarities with existing measures of physical, psychological, social, and cognitive health but included culturally specific dimensions of these measures that differed in meaning from existing measures. The Japanese Americans’ approach to independence, for example, focused more on a collectivist concern for oth- ers and “adjusting one’s needs to maintain group harmony” (p. 274) rather than taking a more individualistic focus on oneself. Iwamasa and Iwasaki’s model also included crite- ria of financial security and spirituality. Ng and coworkers (2011) examined Chinese cultural contexts of successful aging and recommended a model that included both car- ing and productive forms of engagement as substitutes for Rowe and Kahn’s engagement with life component.

Adding new dimensions to cultural analyses of successful aging, Torres (1999, 2001, 2003, 2006, 2009) explored the

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complexity of value orientations that underlie definitions of successful aging for older adults who migrated between cultures—Iranians who migrated to Sweden. Torres (2006) found great variability not only in how people define suc- cessful aging but also in how they arrive at those defini- tions and what understandings are imbedded within those definitions. This intracultural approach problematized cul- turally specific notions of successful aging as her findings demonstrated not only intercultural differences but also differences within cultures. As Torres asserted, “although cultural values might guide the way in which people make sense of what constitutes a good old age, these values do not necessarily predispose people to conceive of successful aging in any one particular way” (p.  20). Torres thereby challenged the relevance of culture-specific and static meas- ures of successful aging, and she called for a broadening of gerontological frameworks of successful aging (Torres, 2001).

Overall, these Missing Voices critiques challenged the lack of subjective meanings and consequential cultural relevance in dominant models of successful aging. As with the Add and Stir group, this group of critiques called for changes to the models but kept the broader notion of suc- cessful aging as an ideal relatively intact.

Theme 3: Hard Hitting Critiques

Fourteen articles, ranging in publication date from 1990 to 2013, presented critiques of the “assumptions, con- ceptualization, and application” (Scheidt, Humpherys, & Yorgason, 1999, p. 277) of the successful aging paradigm and raised serious concerns about its continued usage in gerontology and biomedicine (Dillaway & Byrnes, 2009). These articles were notable for the breadth and depth of their critiques of successful aging and thus became a major component of the literature review findings. The Hard Hitting Critiques were grounded in a variety of disciplines including critical gerontology, critical studies, feminist dis- ability studies, narrative gerontology, and critical discourse analysis. Although the critiques varied in their particular focus, they shared one or more key concerns about success- ful aging, including its individualistic approach, implied ageism and ableism, neoliberal contexts, negative influ- ences on society and the lived experiences of older adults, and impacts on social justice. Furthermore, they rejected the notion of “successful” aging more broadly and called for alternative frameworks.

Individualism This literature articulated repeated concerns about the indi- vidual focus of the successful aging paradigm as unrealis- tic and exclusionary (Angus & Reeve, 2006; Holstein &

Minkler, 2003; Morell, 2003; Scheidt et  al., 1999; Stone, 2003). Critics argued that representing aging—and in particular, physical and cognitive health—as being within the control of individuals through the adoption of spe- cific behaviors and attitudes, reflected a medicalized view of aging that ignored social, economic, and cultural con- texts of people’s lives (Clarke & Griffin, 2008; Dillaway & Byrnes, 2009; Leibing, 2005), including the inequities in life chances by class, gender, race, ability, and other intersect- ing social locations (Minkler, 1990). Scheidt and coworkers (1999) provided an early critique of the narrow, individual- istic view of the successful aging perspective and noted that successful aging failed to take into account the sociostruc- tural contexts of aging that “play a powerful determinative role in how we age” (p. 278).

Over the years, critics have repeatedly argued that these broader contexts, such as access to education, employment, quality housing conditions, healthy food, and recreation, work in favor of the most privileged populations and make them more likely to age successfully, whereas marginalized (less privileged) groups are less likely to experience such success (Dillaway & Byrnes, 2009; Holstein & Minkler, 2003). Furthermore, describing successful aging as an end point erroneously constructs aging as “not a broad bioso- cial process that involves the development of new roles, viewpoints, and many interrelated social contexts but, rather, a game which can be won or lost on the basis of whether individuals are diagnosed as successful or usual” (Dillaway & Byrnes, 2009, p. 706).

Ageism and Ableism Several critics noted the often-unrecognized and inter- twined ageism and ableism that are inherent in successful aging models (Holstein & Minkler, 2003; Minkler, 1990; Morell, 2003; Stone, 2003). Successful aging names the avoidance of disease and disability as the ideal and implic- itly good aging, whereas the presence of usual aging pro- cesses is deemed undesirable or bad aging. This binary of successful versus unsuccessful aging is said to create a “new ageism” (Angus & Reeve, 2006, p.  143) or “polar- ized ageism” (attributed to Cole, 1992 and McHugh, 2003 in Rozanova, Northcott, & McDaniel, 2006). As Holstein and Minkler (2003) pointed out, “normative terms such as successful aging are not neutral; they are laden with comparative, either-or, hierarchically ordered dimensions” (p.  791). Others explained that by naming the avoidance of disease and disability as success, successful aging carries an “implied hostility toward aging bodies” (Morell, 2003, p. 69) and, in particular, toward disabled or diseased bodies that are by default deemed failures. This creates a powerful dichotomy that “values cognitive and physical ability while denigrating any kind of disability” (Stone, 2003, p. 62) and

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blaming elders with disabilities and illness for their con- ditions and subjecting them to moral judgments by soci- ety (Clarke & Griffin, 2008; Holstein & Minkler, 2003; Morell, 2003; Rozanova et al., 2006).

Neoliberal and Conservative Contexts Many of the Hard Hitting Critiques highlighted successful aging’s neoliberal ideological underpinnings. By focusing the responsibility on individuals to maintain physical and cognitive function, the successful aging paradigm reflects and serves efforts to limit the state’s responsibility to pro- vide social and other supports for elders and people with disabilities and, notably, to address the social and structural inequities that create illness and disability in the first place (Dillaway & Byrnes, 2009; Minkler, 1990; Morell, 2003; Scheidt et  al., 1999; Sinding & Gray, 2005). As Holstein and Minkler (2003) described, this further marginalizes older populations who rely on safety net programs:

Policies promoting increased Medicare coverage for home modifications and assistive devices, as well as increased Supplemental Social Security Income payments that would bring elderly and disabled recipients above the poverty line, may well suffer at the hands of a popu- lace and a legislature that has bought the stereotypes of a new breed of successfully aging seniors who no longer need much in the way of government support. (p. 793)

Dillaway and Byrnes (2009) emphasized the historical con- texts in which successful (and productive) aging paradigms first emerged. The rise of these paradigms in the 1980s and 1990s coincided with a rising conservatism that sought to place blame for U.S.  economic crises on the welfare state and, in particular, on Social Security and Medicare. Because these models appear to blame aging individuals for their failure to avoid disability or dependence, their timely emer- gence “may have facilitated and bolstered” (p.  708) the government’s increasing anxiety about the burden of the aging population and been used as “tools for furthering negative conceptualizations of aging and reducing the pub- lic burden of aging individuals” (pp. 708–709).

Influences, Applications, and Internalizations Scheidt and coworkers (1999) raised early concern about the successful aging model’s placement of moral value on the individual’s ability to avoid illness and disability and the “value transfer to the public domain” (p.  278). More recently, several studies demonstrated that there has indeed been a value transfer of these moral hierarchies to the pub- lic as people internalize, integrate, and sometimes resist the ideal as they negotiate their own aging identities. Media portrayals of old age reflect and reproduce successful aging discourses. Rozanova and coworkers (2006) found a

powerful narrative of successful aging in The Globe & Mail newspaper’s portrayal of aging. This narrative, often cap- tured through interviews with older adults, focused on per- sonal control, the avoidance of disease and disability, and a valuing of successful over unsuccessful agers. Rozanova’s (2010) subsequent research linked successful aging, polar- ized ageism, and the neoliberal contexts of individual responsibility and cost containment. As she explained,

[T]he newspaper texts highlight individuals’ public duty to age successfully…and bring a morally-laden message that an ideal aging citizen is someone who chooses to age successfully, that remains youthful as long as pos- sible, contributes to the economy as a smart consumer and as an active participant in productive activities, and stays healthy to avoid accessing healthcare and other public services. (p. 220)

Leibing’s (2005) examination of Brazil’s print media from 1967 to 2002 revealed similar critical concerns about popular presentations of successful aging. Brazilian elders “are trapped [by] a propagated self-sufficiency, necessary for positive aging” (p. 29) and the irony that many live in poverty with severely insufficient social programs to meet basic needs.

Successful aging’s value transfer has also occurred in the context of antiaging technologies. Flatt, Settersten, Ponsaran, and Fishman (2013) found that antiaging practi- tioners’ stated goals for antiaging medicine mirrored Rowe and Kahn’s three components of successful aging. This troubling parallel between successful aging and antiaging medicine “reflects the success of successful aging models in shaping popular conceptions of what aging is and an ethos of management and control over the aging process” (p. 1). Further, it “highlights some of the most problematic social, cultural, and economic consequences of efforts made to reconceptualize old age” (ibid). Brooks (2010) investi- gated women’s attitudes about antiaging technologies and identified linkages between individualism, expectations of femininity, consumer capitalism, and successful aging. For many women, successful aging means “not only maintain- ing a healthy, active body through diet and exercise, but a young looking body (and face) through surgery and injecta- bles” (p.  251). Leibing (2005) described a similar conflu- ence in Brazil of successful aging, medicalization, antiaging technologies, and popular views of femininity and virtue.

Older adults with illness or disabilities face particularly challenging negotiations with normative ideals that deem them unsuccessfully aging. Women who have had breast cancer reported feeling the burden of a “spunky survivor- ship” narrative, defined as positive thinking, engagement in health promoting behaviors, and a “proscription against identifying with frailty” (Sinding & Gray, 2005, p.  159).

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Researchers found that this narrative was imbedded with normative values of successful aging, which raised concerns about the “difficult moral underpinnings” of this survivor- ship narrative that deems “cancer recurrence as failure” (ibid) and can leave women feeling isolated, blamed, and with little room to express feelings of discomfort or fear. Clarke and Griffin (2008) similarly found that successful aging norms mean that older adults with multiple chronic conditions “who are physically unable to attain the medi- calized ideal of healthiness and the social ideal of attrac- tiveness are at risk of being labeled morally irresponsible and socially undesirable” (p. 1092). These normative ideals thereby can negatively influence how people with chronic conditions or disabilities perceive their own aging bodies.

Alternative Approaches for Social Justice For over two decades, critiques of successful aging have articulated concerns related to social justice and equity. They posit that successful aging unwittingly harms older adults more than it helps them through its effects on aging policy and aging identities (Dillaway & Byrnes, 2009; Holstein & Minkler, 2003; Leibing, 2005; Scheidt et  al., 1999). Scholars presented broad recommendations for a more just, realistic, and empowering framework for under- standing old age. Several called for a nondichotomized view of aging that recognizes the full diversity of the popu- lation including those with disabilities and illness (Minkler, 1990; Morell, 2003; Scheidt et al., 1999). Addressing age- ism and ableism simultaneously is central to this strategy. As Stone (2003) argued, “[W]e are not likely to see old peo- ple being treated as important members of society until we see a change in attitudes towards disability” (p.  59) that does not pathologize it but rather sees disability as “part of the human experience and all people as interdependent” (p. 65).

Similarly, Morell (2003) advocated for a model of embodied empowerment that recognizes “the interplay of power and vulnerability” (p. 69) in late life, embraces dis- ability and death “as acceptable and respectable human experiences” (p. 71), decreases the stigma and fear of dis- ability, illness, and death, and lets older adults define their own needs and desires. This right to self-determination is essential for people to flourish as they age (Stone, 2003). New paradigms are called for that more fully reflect the lived experiences of older adults and are informed by empirical evidence that integrates qualitative methods and community-based participatory research with older adults (Dillaway & Byrnes, 2009; Holstein & Minkler, 2003).

Finally, critics noted that social justice-oriented mod- els of aging must account for the structural influences on aging experiences and identify policies, institutions, and community-centered strategies that can bolster economic

security, safe housing and neighborhoods, antidiscrimina- tion, and the protection of dignity and identity (Angus & Reeve, 2006; Minkler, 1990; Morell, 2003; Scheidt et  al., 1999; Stone, 2003).

Theme 4: New Frames and Names

Another subset (n = 7) of the critical literature rejected the basic tenets of successful aging. They shared with the Hard Hitting Critiques a critique of the broad notion of successful aging, its unrealistic portrayal of old age as being without disease and disability, and a concern for how it contrib- utes to internalized ageism and elders’ inability to deal with changes as they age. As a solution, this group presented alternative ideal models—New Frames and Names—that focused largely on the individual, albeit in more holistic ways than traditional successful aging models. These new models embraced loss and integrated spiritual and other qualities of meaning and identity, often with explicit influences from Eastern philosophies such as Buddhism. Proposed models included balanced aging (Butler, Fujii, & Sasaki, 2011), resilient aging (Harris, 2008; Harris & Keady, 2008; Wild, Wiles, & Allen, 2013), harmonious aging (Liang & Luo, 2012), and other holistic, meaning- based, and spiritual models (Jianbin, 2010; Leder, 1999).

These critics rejected successful aging as exclusionary and limiting and sought more universal models that give all individuals an equal chance to age with dignity. Jianbin (2010) contrasted his own integrative model, which supports aging individuals in making sense of their lives, to the many expanded models of successful aging that add spirituality criteria to Rowe and Kahn’s model but do not “qualitatively rectify its theoretical core” (p. 187). Liang and Luo (2012) asserted that successful aging models are ageist, create “a disharmony between body and mind” (p. 328), are imbed- ded with capitalist and consumerist ideals, and do not reflect non-Western values. As an alternative to successful aging, they offered a model of harmonious aging that acknowl- edges the challenges and opportunities of aging and “empha- sizes the interdependent nature of human beings” (p. 327).

Harris (2008) asserted that the exclusive model of suc- cessful aging should be replaced with the more inclusive model of resilient aging because, she argued, resilience is attainable by all older adults. Wild and coworkers (2013) presented a more comprehensive conceptualization of resil- ience that incorporates several components, including the interdependence of individual and social forms resilience; meanings of resilience derived from elders; the influences of social structures and power inequities; the many “hid- den resilience resources” of marginalized communities that often remain under the radar of traditional models of resil- ience; and a critical awareness of how resilience models can

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be used against older adults to blame people for their cur- rent situations. Wild and coworkers’ model extended far beyond the individual and captured ecological conceptual- izations of resilient aging.

Overall, the New Frames and Names rejected successful aging models and offered in response alternatives that they argued reflected more holistic, integrated, inclusive, and globally relevant understandings of aging.

Discussion

Successful aging models represent a dominant construct within social gerontology. This systematic review of the social gerontology literature examined the concerns that have been expressed over the last two decades about suc- cessful aging. Results revealed four general prescriptions in response to what many agreed were limited and ill-defined frameworks of successful aging. The Add and Stir group suggested a multidimensional expansion of conceptualiza- tions of successful aging and offered a vast array of addi- tions to complete the model. The Missing Voices group advocated for adding older adults’ subjective meanings of successful aging to the objective measures developed through (notably different) gerontological expertise. The Hard Hitting Critiques drew out fundamental and ideolog- ical problems of successful aging and called for more just and inclusive frameworks that embrace the full diversity of aging, avoid stigma and discrimination, and intervene to improve the social, political, and economic contexts of aging. The New Frames and Names proposed alternative ideals for aging that challenged the foundations of exist- ing models, yet often maintained a focus on an individual ideal. Overall, these groups presented overlapping critiques but offered four different types of recommendations about what social gerontology should do with successful aging— expand it, personalize it, scrap it, or reframe and rename it.

Social gerontologists generally strive to promote an age-integrated society, recognize the influences of socio- structural conditions on aging processes, and acknowledge the diversity in aging (Hooyman & Kiyak, 2011; Riley & Riley, 1994). It is no wonder, given the field’s proclivity to the social, that social gerontologists have continually chal- lenged and sought to expand this concept of successful aging that, at its inception, was grounded in a reductionist, physiological understanding of aging. This is why Matilda Riley challenged it in 1998, and, as shown in this review, why numerous others have done so since. Most of these critiques begin with the premise that defining something called successful aging as the avoidance of disability and disease, maintenance of cognitive and physical function, and engagement with life fails to capture the full experi- ences and contexts of aging. Although successful aging

researchers’ shift to identifying the processes of success- ful aging signified a new angle, they remained grounded in the same ideal. Some may say that social gerontology has done its job to address the shortfalls of successful aging with the remedies of the Add and Stir and Missing Voices approaches. By expanding criteria for successful aging, a larger and more diverse group falls within the parameters of success. However, as we reviewed the vast array of addi- tives to this increasingly blurry concept based on a physi- ological model that still “fails to develop adequately the social structural opportunities necessary for success” (Riley, 1998, p. 151), we could not help but wonder how this con- ceptual chaos helps gerontologists to achieve our goals.

Across all four categories of successful aging critiques, there was a clear concern about the small ratio of older adults who meet the various versions of successful aging cri- teria. Many authors criticized the concept’s construction of a successful versus unsuccessful aging dichotomy—a dichot- omy that maps onto the dichotomy of the decline-and-loss model of yesterday versus the positive aging paradigm that is popular today. These dichotomies are arguably two sides of the same judgmental coin. Critics from all four catego- ries also pointed to the cultural bias of successful aging, with its implied sense of individual accomplishment that is incompatible with the cultural understandings of life and aging held by many people across the world—including within the United States—who come from diverse cultural contexts. When the data show us that the criteria for and meanings of successful aging exclude most people and are increasingly unclear, social gerontologists are faced with this question: Should we continue to relax the criteria and add new dimensions to the concept of successful aging in order to allow for less failure, which in turn will decrease conceptual clarity (a kind of refined chaos)? Or, should we move toward the development of more realistic and useful concepts that better capture the personal as well as social, political, and economic contexts of aging that social ger- ontologists seek to understand and address?

Although many in the field have asserted that the model is insufficient due to its narrow and elusive conceptualiza- tion of aging, others go a step further to say that it is dan- gerous, that it further marginalizes people, and that it can negatively influence people’s self-identities. Given two dec- ades of investment in the successful aging paradigm, and two decades of expressed concerns about that paradigm, social gerontologists are faced with an ethical dilemma. As social gerontologist Gunhild Hagestad reflected on her decades-long career so candidly at the 2013 Gerontological Society of America annual scientific meeting, “We produce a view of aging that we do not agree with.”

Given all of these concerns about the limitations of successful aging, why do we hold onto this construct?

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Certainly, it has been helpful in understanding what people can do to increase their likelihood of experiencing good health (narrowly defined) as they age. But at what cost, and to whom? How does a normative ideal that does not account for broader social structural conditions, has a vast array of definitions, and leaves out the majority of older adults in the United States and across the world, help us to support and empower people as they age? Certainly, the public and private funding for successful aging research has supported a vast infrastructure of successful aging research and programming. At the same time, researchers in every field will likely concur with Hagestad’s (2013) honest asser- tion that “paradigms are much tied to funding and lock us more than we should have the conscious to live with.” Given the infrastructure that grows around a paradigm like successful aging, moving away from it in the face of its shortfalls is admittedly difficult.

Nevertheless, it is essential that we ask the critical ques- tions about why this model has attained such prominence despite the conceptual chaos about what it means and to whom it really pertains. In his “Quo Vadis of Gerontology,” Tornstam (1992) explored the reasons why we remain tied to gerontological models despite their increasingly evident shortfalls. There he described the often blinding influence of society’s predominant values and assumptions about old age that are imbedded in gerontological ideas and theories. The emphasis on productivity and independence within normative ideals of aging (e.g., successful aging, productive aging, and active aging), Tornstam noted as an example, is deeply rooted in the predominant value orientation of midlife, white, middle class men. This “overflow of presup- positions from society to gerontology” makes it difficult to see outside of limited social frameworks and can “make us cling to our theories even when our data contradict the the- ories” (p. 322). We see this today with continued attempts to refine and reinforce notions of successful aging even though the data show “the ludicrousness of this notion and the imposition of Western values that it represents” (Torres, 2006, p. 2).

These gerontological models are seemingly locked in place because of ideological influences as well. Several of the Hard Hitting Critiques pointed out the troubling con- gruence between successful aging’s focus on individual behavioral interventions and neoliberal ideological con- cerns about the costs of the aging population. The use of successful aging paradigms has paralleled, and in many ways supported, a shift in attention from creating environ- ments that enhance people’s lives as they age to educat- ing people about what kinds of individual behaviors they should employ to increase their likelihood of aging suc- cessfully. Katz (2013) warned of the broader implications of this gerontological focus on individual lifestyle when

he noted, “On the surface the popularity of the success- ful aging paradigm is due to its person-centered explana- tions, but in a deeper sense such popularity arises because the paradigm ‘defeats the political lobbying for more social support and resources’ (Dillaway & Byrnes, 2009, p. 708)” (paragraph 17). If such a prominent model in social ger- ontology serves this function in policy and practice, and simultaneously undermines the self-identities of aging per- sons who feel compelled to meet societal standards for suc- cess, it is time to reconsider our commitment to it.

Reconsidering our commitment is one step. Moving toward new models and paradigms is another. This is argu- ably the essential task at hand. Tornstam (1992) challenged gerontologists to “burst the borders” (p. 323) of these con- fining paradigms by letting older adults define their own needs, values, meanings, and even research questions. He also proposed exploring new paradigms by turning existing ones inside out. Consistent with many suggestions made in the successful aging critiques reviewed here, this involves shifting our attention from productivity, independence, avoidance of disability, and individual responsibility, and instead placing value, for example, on unproductiveness, interdependency, disability, and social responsibility. This may at first seem like a radical idea, but it could lead to some compelling new ideas that address the critiques raised here.

Furthermore, we must acknowledge that there is not one ideal way of being old and, therefore, attempts to construct ideal models are doomed to failure. Ideal models presuppose that there is one agreed upon set of criteria that is appropriate for old people to strive toward. This review of the critiques of successful aging over the past 25 years suggests that iden- tifying ideal models of individual aging is not only impossi- ble but it is also destructive. Such ideals serve to devalue the vast diversity that inevitably sits outside of their constructed parameters. It is time to move away from successful aging and the broader paradigm of ideal models in which it exists, and focus our work on creating the conditions in which peo- ple can thrive, on their own terms, as they age.

Limitations

There are missing voices in this review because we did not extend this review beyond the ASG. Some of the most criti- cal contributions may not appear in ASG, be published in books, and outside the field in journals of medical sociol- ogy or anthropology (e.g., Belgrave & Sayed, 2013). This review was also limited to articles published in English, which may potentially miss important critiques in other languages, and particularly those spoken in countries with less individualistic visions of life (and hence, later life) than the temporarily dominant culture in countries like the United States.

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Conclusion

This review of the critical literature in social gerontology on successful aging revealed a widespread and longstanding struggle to apply the normative concept to a diverse older pop- ulation. A number of gerontologists have earnestly attempted to reshape Rowe and Kahn’s original model in a way that captures health and social disparities in later life, but the vast array of additional criteria that they collectively offer is symptomatic of the basic problem—that a normative model is by definition exclusionary. Perhaps the most troubling issue is the evidence that models of successful aging are working against the intentions of social gerontologists by contributing to, rather than dismantling, ageism. After 25 years of critique and repeated attempts to rectify the multiple anomalies to the models, it is time to resist successful aging terminology (Dillaway & Byrnes, 2009)  and “dare to question the holy cows that our ‘traditional’ theories constitute” (Tornstam, 1992, p.  322). To repeat Cole’s (1995) words, “the growth of an intellectually rich social gerontology depends on the continued willingness to foster greater interactions between empirical research, interpretation, critical evaluation, and reflexive knowledge” (p. S343). Without such interactions, we run the risk of maintaining parallel universes with critical discourses about successful aging running alongside success- ful aging research and programs. Let’s bring these discourses together into one boldly reflexive conversation.

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