The Healthy and Successful Aging of Our Discipline

To the Editor: We read with great interest Friedman and colleagues' article "Failing to focus on healthy aging: A frailty of our discipline," in which the relative dearth of literature on healthy and successful aging (HSA) is discussed.1 As strong proponents of examining positive aspects of aging (in addition to lower levels of functioning), it is encouraging to see these views in print, although we have some comments on the relationship between frailty and HSA and the relative presence of HSA literature. Friedman and colleagues suggest that, "Successful aging could be characterized as a counterbalance to frailty. For example, it can be defined as good physiological reserves." We suggest that psychosocial outcomes and reserves must also be taken into consideration. The relationship between frailty and successful aging has been previously addressed in the Canadian Geriatrics Journal,2 highlighting the similarities and differences between these closely related constructs. Rather than sharing the opposite end of the same continuum, HSA occupies a space that captures physical and cognitive functioning and delaying the onset of disease but augments these perspectives with aspects of psychosocial functioning.3, 4 Reviews of lay perspectives that highlight the importance of psychosocial components, such as coping mechanisms and social networks, support these views.5, 6 Friedman and colleagues use "healthy" and "successful" aging terms, acknowledging the absence of a consensus term.7 Frailists have generally accepted "frailty" as the operative term, whereas HSA has no universally accepted term. Different groups have adopted different terms despite capturing similar phenomena as HSA; for example, the World Health Organization has identified "active aging" as its term of choice, which has led to an increase in the use of "active aging" in the European literature. Consequently, these articles may not be indexed under HSA. Friedman and colleagues present two figures showing the frequency of articles captured by frailty and healthy or successful aging key words in Medline, suggesting that frailty is the more popular topic. After using British and American spellings (ageing and aging) in the search strategy ("healthy aging" [all fields] OR "healthy ageing" [all fields] OR "successful aging" [all fields] OR "successful ageing" [all fields]), the frequency of the key words was found to be more similar than Friedman and colleagues depicted (Figure 1). Examining these trends each year from 1993 to 2014 reveals that the only notable difference is a bump in the HSA literature in 2014. Friedman and colleagues suggest that, with the burgeoning older population, an increased focus on fostering better aging trajectories is warranted but has yet to reach its full potential. We completely agree. That said, the HSA paradigm faces challenges that the frailty paradigm does not in terms of scope (including biomedical and psychosocial components) and conceptualization (absence of a consensus definition). There are many constituent components of HSA, capturing components similar to frailty (e.g., physiological functioning and reserve), as well as psychosocial components (e.g., social engagement and psychological well-being), but it is encouraging that HSA research is keeping pace with frailty and that both are on the rise. Further articulation of the HSA literature and greater focus on fostering better aging trajectories can ensure that the discipline ages well. Conflict of Interest: All authors declare no conflicts of interest. Author Contributions: Cosco: concept, writing first draft. Kuh: editing, approval of final draft. Sponsor's Role: None.

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