A principal dancer at the Grand Opera of Paris teaches a master class for young professional dancers, transferring knowledge, skill, and passion for his art to a new generation. In middle adulthood, expertise reaches its height.

chapter outline

·   PHYSICAL DEVELOPMENT

·   Physical Changes

·   Vision

·   Hearing

·   Skin

·   Muscle–Fat Makeup

·   Skeleton

·   Reproductive System

· ■  BIOLOGY AND ENVIRONMENT  Anti-Aging Effects of Dietary Calorie Restriction

· ■  CULTURAL INFLUENCES  Menopause as a Biocultural Event

·   Health and Fitness

·   Sexuality

·   Illness and Disability

·   Hostility and Anger

·   Adapting to the Physical Challenges of Midlife

·   Stress Management

·   Exercise

·   An Optimistic Outlook

·   Gender and Aging: A Double Standard

·   COGNITIVE DEVELOPMENT

Changes in Mental Abilities

·   Cohort Effects

·   Crystallized and Fluid Intelligence

·   Individual and Group Differences

·   Information Processing

·   Speed of Processing

·   Attention

·   Memory

·   Practical Problem Solving and Expertise

·   Creativity

·   Information Processing in Context

· ■  SOCIAL ISSUES: EDUCATION  The Art of Acting Improves Memory in Older Adults

·   Vocational Life and Cognitive Development

·   Adult Learners: Becoming a Student in Midlife

·   Characteristics of Returning Students

·   Supporting Returning Students

On a snowy December evening, Devin and Trisha sat down to read the holiday cards piled high on the kitchen counter. Devin’s 55th birthday had just passed; Trisha would turn 48 in a few weeks. During the past year, they had celebrated their 24th wedding anniversary. These milestones, along with the annual updates they received from friends, brought the changes of midlife into bold relief.

Instead of new births, children starting school, or a first promotion at work, holiday cards and letters sounded new themes. Jewel’s recap of the past year reflected growing awareness of a finite lifespan, one in which time had become more precious. She wrote:

·  My mood has been lighter ever since my birthday. There was some burden I laid down by turning 49. My mother passed away when she was 48, so it all feels like a gift now. Blessed be!

George and Anya reported on their son’s graduation from law school and their daughter Michelle’s first year of university:

·  Anya is filling the gap created by the children’s departure by returning to college for a nursing degree. After enrolling this fall, she was surprised to find herself in the same psychology class as Michelle. At first, Anya worried about handling the academic work, but after a semester of success, she’s feeling more confident.

Tim’s message reflected continuing robust health, acceptance of physical changes, and a new burden: caring for aging parents—a firm reminder of the limits of the lifespan:

·  I used to be a good basketball player in college, but recently I noticed that my 20-year-old nephew, Brent, can dribble and shoot circles around me. It must be my age! But I ran our city marathon in September and came in seventh in the over-50 division. Brent ran, too, but he opted out a few miles short of the finish line to get some pizza while I pressed on. That must be my age, too!

The saddest news is that my dad had a bad stroke. His mind is clear, but his body is partially paralyzed. It’s really upsetting because he was getting to enjoy the computer I gave him, and it was so upbeat to talk with him about it in the months before the stroke.

Middle adulthood, which begins around age 40 and ends at about 65, is marked by narrowing life options and a shrinking future as children leave home and career paths become more determined. In other ways, middle age is hard to define because wide variations in attitudes and behaviors exist. Some individuals seem physically and mentally young at age 65—active and optimistic, with a sense of serenity and stability. Others feel old at age 40—as if their lives had peaked and were on a downhill course.

Another reason middle adulthood eludes definition is that it is a contemporary phenomenon. Before the twentieth century, only a brief interval separated the tasks of early adulthood from those of old age. Women were often widows by their mid-fifties, before their youngest child left home. And harsh living conditions led people to accept a ravaged body as a natural part of life. As life expectancy—and, with it, health and vigor—increased over the past century, adults became more aware of their own aging and mortality.

In this chapter, we trace physical and cognitive development in midlife. In both domains, we will encounter not just progressive declines but also sustained performance and compensating gains. As in earlier chapters, we will see that change occurs in manifold ways. Besides heredity and biological aging, our personal approach to passing years combines with family, community, and cultural contexts to affect the way we age.

PHYSICAL DEVELOPMENT

Physical development in middle adulthood is a continuation of the gradual changes under way in early adulthood. Even the most vigorous adults notice an older body when looking in the mirror or at family photos. Hair grays and thins, new lines appear on the face, and a fuller, less youthful body shape is evident. During midlife, most individuals begin to experience life-threatening health episodes—if not in themselves, then in their partners and friends. And a change in time orientation, from “years since birth” to “years left to live,” adds to consciousness of aging (Neugarten,  1968b ).

These factors lead to a revised physical self-image, with somewhat less emphasis on hoped-for gains and more on feared declines (Bybee & Wells,  2003 ; Frazier, Barreto, & Newman,  2012 ). Prominent concerns of 40- to 65-year-olds include getting a fatal disease, being too ill to maintain independence, and losing mental capacities. Unfortunately, many middle-aged adults fail to embrace realistic alternatives—becoming more physically fit and developing into healthy, energetic older adults. Although certain aspects of aging cannot be controlled, people can do much to promote physical vigor and good health in midlife.

 Physical Changes

As she dressed for work one morning, Trisha remarked jokingly to Devin, “I think I’ll leave the dust on the mirror so I can’t see the wrinkles and gray hairs.” Catching sight of her image, she continued in a more serious tone. “And look at this fat—it just doesn’t want to go! I need to fit some regular exercise into my life.” In response, Devin glanced soberly at his own enlarged midriff.

At breakfast, Devin took his glasses on and off and squinted while reading the paper. “Trish—what’s the eye doctor’s phone number? I’ve got to get these bifocals adjusted again.” As they conversed between the kitchen and the adjoining den, Devin sometimes asked Trisha to repeat herself. And he kept turning up the radio and TV volume. “Does it need to be that loud?” Trisha would ask. Apparently Devin couldn’t hear as clearly as before.

In the following sections, we look closely at the major physical changes of midlife. As we do so, you may find it helpful to refer back to  Table 13.1  on  page 435 , which provides a summary.

Vision

By the forties, difficulty reading small print is common, due to thickening of the lens combined with weakening of the muscle that enables the eye to accommodate (adjust its focus) to nearby objects. As new fibers appear on the surface of the lens, they compress older fibers toward the center, creating a thicker, denser, less pliable structure that eventually cannot be transformed at all. By age 50, the accommodative ability of the lens is one-sixth of what it was at age 20. Around age 60, the lens loses its capacity to adjust to objects at varying distances entirely, a condition called  presbyopia  (literally, “old eyes”). As the lens enlarges, the eye rapidly becomes more farsighted between ages 40 and 60 (Charman,  2008 ). Corrective lenses—or, for nearsighted people, bifocals—ease reading problems.

A second set of changes limits ability to see in dim light, which declines at twice the rate of daylight vision (Jackson & Owsley,  2000 ). Throughout adulthood, the size of the pupil shrinks and the lens yellows. In addition, starting at age 40, the vitreous (transparent gelatin-like substance that fills the eye) develops opaque areas, reducing the amount of light reaching the retina. Changes in the lens and vitreous also cause light to scatter within the eye, increasing sensitivity to glare. Devin had always enjoyed driving at night, but now he sometimes had trouble making out signs and moving objects (Owsley,  2011 ). And his vision was more disrupted by bright light sources, such as headlights of oncoming cars. Yellowing of the lens and increasing density of the vitreous also limit color discrimination, especially at the green–blue–violet end of the spectrum (Paramei,  2012 ). Occasionally, Devin had to ask whether his sport coat, tie, and socks matched.

Besides structural changes in the eye, neural changes in the visual system occur. Gradual loss of rods and cones (light- and color-receptor cells) in the retina and of neurons in the optic nerve (the pathway between the retina and the cerebral cortex) contributes to visual declines. By midlife, half the rods (which enable vision in dim light) are lost (Owsley,  2011 ). And because rods secrete substances necessary for survival of cones (which enable daylight and color vision), gradual loss of cones follows.

Middle-aged adults are at increased risk of  glaucoma , a disease in which poor fluid drainage leads to a buildup of pressure within the eye, damaging the optic nerve. Glaucoma affects nearly 2 percent of people over age 40, more often women than men. It typically progresses without noticeable symptoms and is a leading cause of blindness. Heredity contributes to glaucoma, which runs in families: Siblings of people with the disease have a tenfold increased risk, and it occurs three to four times as often in African Americans and Hispanics as in Caucasians (Guedes, Tsai, & Loewen,  2011 ; Kwon et al.,  2009 ). Starting in midlife, eye exams should include a glaucoma test. Drugs that promote release of fluid and surgery to open blocked drainage channels prevent vision loss.

Hearing

An estimated 14 percent of Americans between ages 45 and 64 suffer from hearing loss, often resulting from adult-onset hearing impairments (Center for Hearing and Communication,  2012 ). Although some conditions run in families and may be hereditary, most are age-related, a condition called  presbycusis (“old hearing”).

As we age, inner-ear structures that transform mechanical sound waves into neural impulses deteriorate through natural cell death or reduced blood supply caused by atherosclerosis. Processing of neural messages in the auditory cortex also declines. Age-related cognitive changes—in processing speed, attention, and memory—that we will take up shortly are also associated with hearing loss (Lin et al.,  2011 ). The first sign, around age 50, is a noticeable decline in sensitivity to high-frequency sounds, which gradually extends to all frequencies. Late in life, human speech becomes more difficult to make out, especially rapid speech and speech against a background of voices (Humes et al.,  2012 ). Still, throughout middle adulthood, most people hear reasonably well across a wide frequency range. And African tribal peoples display little age-related hearing loss (Jarvis & van Heerden,  1967 ; Rosen, Bergman, & Plester,  1962 ). These findings suggest factors other than biological aging are involved.

A worker uses a grinder to smooth a metal surface in a steel manufacturing facility. Men’s hearing declines more rapidly than women’s, a difference associated with several factors, including intense noise in some male-dominated occupations.

Men’s hearing tends to decline earlier and more rapidly than women’s, a difference associated with cigarette smoking, intense noise and chemical pollutants in some male-dominated occupations, and (at older ages) high blood pressure and cerebrovascular disease, or strokes that damage brain tissue (Heltzner et al.,  2005 ; Van Eyken, Van Camp, & Van Laer,  2007 ). Government regulations requiring industries to implement such safeguards as noise monitoring, provision of earplugs, pollution control, and regular hearing tests have greatly reduced hearing damage, but some employers do not comply fully (Daniell et al.,  2006 ; Ohlemiller,  2008 ).

Most middle-aged and elderly people with hearing difficulties benefit from sound amplification with hearing aids. When perception of the human voice is affected, speaking to the person patiently, clearly, and with good eye contact, in an environment with reduced background noise, aids understanding.

Skin

Our skin consists of three layers: (1) the epidermis, or outer protective layer, where new skin cells are constantly produced; (2) the dermis, or middle supportive layer, consisting of connective tissue that stretches and bounces back, giving the skin flexibility; and (3) the hypodermis, an inner fatty layer that adds to the soft lines and shape of the skin. As we age, the epidermis becomes less firmly attached to the dermis, fibers in the dermis thin, cells in both the epidermis and dermis decline in water content, and fat in the hypodermis diminishes, leading the skin to wrinkle, loosen, and feel dry.

In the thirties, lines develop on the forehead as a result of smiling, furrowing the brow, and other facial expressions. In the forties, these become more pronounced, and “crow’s-feet” appear around the eyes. Gradually, the skin loses elasticity and begins to sag, especially on the face, arms, and legs (Khavkin & Ellis,  2011 ). After age 50, “age spots,” collections of pigment under the skin, increase. Blood vessels in the skin become more visible as the fatty layer thins.

Because sun exposure hastens wrinkling and spotting, individuals who have spent much time outdoors without proper skin protection look older than their contemporaries. And partly because the dermis of women is not as thick as that of men, women’s skin ages more quickly (Makrantonaki & Xouboulis,  2007 ).

Muscle–Fat Makeup

As Trisha and Devin make clear, weight gain—“middle-age spread”—is a concern for both men and women. A common pattern of change is an increase in body fat and a loss of lean body mass (muscle and bone). The rise in fat largely affects the torso and occurs as fatty deposits within the body cavity; as noted earlier, fat beneath the skin on the limbs declines. On average, size of the abdomen increases 7 to 14 percent. Although a large portion is due to weight gain, age-related changes in muscle–fat makeup also contribute (Stevens, Katz, & Huxley,  2010 ). In addition, sex differences in fat distribution appear. Men accumulate more on the back and upper abdomen, women around the waist and upper arms (Sowers et al.,  2007 ). Muscle mass declines very gradually in the forties and fifties, largely due to atrophy of fast-twitch fibers, responsible for speed and explosive strength.

Yet, as indicated in  Chapter 13 , large weight gain and loss of muscle power are not inevitable. With age, people must gradually reduce caloric intake to adjust for the age-related decline in basal metabolic rate (see  page 440 ). In a longitudinal study of nearly 30,000 U.S. 50- to 79-year-old women diverse in SES and ethnicity, a low-fat diet involving increased consumption of vegetables, fruits, and grains was associated with greater initial weight loss and success at maintaining that loss over a seven-year period (Howard et al.,  2006 ). In nonhuman animals, dietary restraint dramatically increases longevity while sustaining health and vitality. Currently, researchers are identifying the biological mechanisms involved and studying their relevance to humans (see the Biology and Environment box on the following page).

Furthermore, weight-bearing exercise that includes resistance training (placing a moderately stressful load on the muscles) can offset both excess weight and muscle loss. Within the same individual, strength varies between often-used and little-used muscles (Macaluso & De Vito,  2004 ; Rivlin,  2007 ). Consider Devin’s 57-year-old friend Tim, who for years has ridden his bike to and from work and jogged on weekends, averaging an hour of vigorous activity per day. Like many endurance athletes, he maintained the same weight and muscular physique throughout early and middle adulthood.

Skeleton

As new cells accumulate on their outer layers, the bones broaden, but their mineral content declines, so they become more porous. This leads to a gradual loss in bone density that begins around age 40 and accelerates in the fifties, especially among women (Clarke & Khosla,  2010 ). Women’s reserve of bone minerals is lower than men’s to begin with. And following menopause, the favorable impact of estrogen on bone mineral absorption is lost. Reduction in bone density during adulthood is substantial—about 8 to 12 percent in men and 20 to 30 percent in women (Seeman,  2008 ).

Loss of bone strength causes the disks in the spinal column to collapse. Consequently, height may drop by as much as 1 inch by age 60, a change that will hasten thereafter. In addition, the weakened bones cannot support as much load: They fracture more easily and heal more slowly. A healthy lifestyle—including weight-bearing exercise, adequate calcium and vitamin D intake, and avoidance of smoking and heavy alcohol consumption—can slow bone loss in postmenopausal women by as much as 30 to 50 percent (Cooper et al.,  2009 ).

When bone loss is very great, it leads to a debilitating disorder called osteoporosis. We will take up this condition shortly when we consider illness and disability.

Reproductive System

The midlife transition in which fertility declines is called the  climacteric.  In women, it brings an end to reproductive capacity; in men, by contrast, fertility diminishes but is retained.

Reproductive changes in Women.

The changes involved in women’s climacteric occur gradually over a 10-year period, during which the production of estrogen drops. As a result, the number of days in a woman’s monthly cycle shortens from about 28 in her twenties and thirties to perhaps 23 by her late forties, and her cycles become more irregular. In some, ova are not released; when they are, more are defective (see  Chapter 2 ,  page 53 ). The climacteric concludes with  menopause , the end of menstruation and reproductive capacity. This occurs, on average, in the early fifties among North American, European, and East Asian women, although the age range extends from the late thirties to the late fifties (Avis, Crawford, & Johannes,  2002 ; Rossi,  2005 ). Women who smoke or who have not borne children tend to reach menopause earlier.

Following menopause, estrogen declines further, causing the reproductive organs to shrink in size, the genitals to be less easily stimulated, and the vagina to lubricate more slowly during arousal. As a result, complaints about sexual functioning increase, with about 35 to 40 percent of women reporting difficulties, especially among those with health problems or whose partners have sexual performance difficulties (Lindau et al.,  2007 ; Walsh & Berman,  2004 ). The drop in estrogen also contributes to decreased elasticity of the skin and loss of bone mass. Also lost is estrogen’s ability to help protect against accumulation of plaque on the walls of the arteries, by boosting “good cholesterol” (high-density lipoprotein).

The period leading up to and following menopause is often accompanied by emotional and physical symptoms, including mood fluctuations and hot flashes—sensations of warmth accompanied by a rise in body temperature and redness in the face, neck, and chest, followed by sweating. Hot flashes—which may occur during the day and also, as night sweats, during sleep—affect more than 50 percent of women in Western industrialized nations (Nelson,  2008 ). Typically, they are not severe: Only about 1 in 12 women experiences them every day.

Biology and Environment Anti-Aging Effects of Dietary Calorie Restriction

An Okinawan grandfather and grandson enjoy an afternoon of kite flying. Before World War II, residents of Okinawa consumed a restricted diet that was associated with health benefits and longer life. Recent generations no longer show these advantages, possibly due to the introduction of Westernized food to Okinawa.

For nearly 70 years, scientists have known that dietary calorie restriction in nonprimate animals slows aging while maintaining good health and body functions. Rats and mice fed 30 to 40 percent fewer calories than they would freely eat beginning in early life show various physiological health benefits, lower incidence of chronic diseases, and a 60 percent increase in length of life (Fontana,  2009 ). Mild to moderate calorie restriction begun after rodents reach physical maturity also slows aging and extends longevity, though to a lesser extent. Other studies reveal similar dietary-restriction effects in mice, fleas, spiders, worms, fish, and yeast.

Nonhuman Primate Research

Would primates, especially humans, also benefit from a restricted diet? Researchers have been tracking health indicators in rhesus monkeys after placing some on regimens of 30 percent reduced calories at young, middle, and older ages. More than two decades of longitudinal findings revealed that, compared with freely eating controls, dietary-restricted monkeys were smaller but not overly thin. They accumulated body fat differently—less on the torso, a type of fat distribution that reduces middle-aged humans’ risk of heart disease.

Calorie-restricted monkeys also had a lower body temperature and basal metabolic rate—changes that suggest they shifted physiological processes away from growth to life-maintaining functions. Consequently, like calorie-restricted rodents, they seemed better able to withstand severe physical stress, such as surgery and infectious disease (Weindruch et al.,  2001 ).

Among physiological processes mediating these benefits, two seem most powerful. First, calorie restriction inhibited production of free radicals, thereby limiting cellular deterioration, which contributes to many diseases of aging (see  page 433  in  Chapter 13 ) (Carter et al.,  2007 ; Yu,  2006 ). Second, calorie restriction reduced blood glucose and improved insulin sensitivity, offering protection against diabetes and cardiovascular disease. Lower blood pressure and cholesterol and a high ratio of “good” to “bad” cholesterol in calorie-restricted primates strengthened these effects (Fontana,  2008 ).

Nevertheless, long-term tracking of the monkeys’ age of death revealed no difference in length of survival between the calorie-restricted and control groups, regardless of the age at which restriction began. Limiting food intake delayed the onset of age-related diseases, including cancer, cardiovascular disease, and arthritis, but it did not extend the monkeys’ longevity (Mattison et al.,  2012 ). In sum, the calorie-restricted monkeys benefited from more years of healthy life, not from an extended lifespan.

Human Research

Prior to World War II, residents of the island of Okinawa consumed an average of 20 percent fewer calories (while maintaining a healthy diet) than mainland Japanese citizens. Their restricted diet was associated with a 60 to 70 percent reduction in incidence of deaths due to cancer and cardiovascular disease. Recent generations of Okinawans no longer show these health and longevity advantages (Gavrilova & Gavrilov,  2012 ). The reason, some researchers speculate, is the introduction of Westernized food, including fast food, to Okinawa.

Similarly, normal-weight and overweight people who have engaged in self-imposed calorie restriction for 1 to 12 years display health benefits—reduced blood glucose, cholesterol, and blood pressure and a stronger immune-system response than individuals eating a typical Western diet (Fontana et al.,  2004 ,  2010 ; Redman et al.,  2008 ). Furthermore, in the first experiment involving random assignment of human participants to calorie-restricted and nonrestricted conditions, the restricted group again displayed improved cardiovascular and other health indicators, suggesting reduced risk of agerelated disease (Redman & Ravussin,  2011 ).

Because nonhuman primates (unlike nonprimate animals) show no gains in length of life, researchers believe that calorie restriction is also unlikely to prolong human longevity. But the health benefits that accrue from limiting calorie intake are now well-established. They seem to result from a physiological response to food scarcity that evolved to increase the body’s capacity to survive adversity.

Nevertheless, very few people would be willing to maintain a substantially reduced diet for most of their lifespan. As a result, scientists have begun to explore calorie-restriction mimetics—agents such as natural food substances, herbs, and vigorous exercise regimens—that might yield the same health effects as calorie restriction, without dieting (Rizvi & Jha,  2011 ). These investigations are still in their early stages.

Although menopausal women tend to report increased irritability and less satisfying sleep, research using EEG and other neurobiological measures finds no links between menopause and changes in quantity or quality of sleep (Lamberg,  2007 ; Young et al.,  2002 ). Also, most studies reveal no association between menopause and depression in the general population (Soares,  2007 ; Vesco et al.,  2007 ; Woods et al.,  2008 ). Rather, women who have a previous history of depression, are physically inactive, or are experiencing highly stressful life events are more likely to experience depressive episodes during the climacteric. In view of these findings, sleep difficulties or depression should not be dismissed as temporary byproducts of menopause: These problems merit serious evaluation and treatment.

As  Figure 15.1  illustrates, compared with North American, European, African, and Middle Eastern women, Asian women report fewer menopausal complaints, including hot flashes (Obermeyer,  2000 ). Asian diets, which are low in fat and high in soy-based foods (a rich source of plant estrogen) may be involved.

Hormone Therapy.

To reduce the physical discomforts of menopause, doctors may prescribe  hormone therapy , or low daily doses of estrogen. Hormone therapy comes in two types: (1) estrogen alone, or estrogen replacement therapy (ERT), for women who have had hysterectomies (surgical removal of the uterus); and (2) estrogen plus progesterone, or hormone replacement therapy (HRT), for other women. Combining estrogen with progesterone lessens the risk of cancer of the endometrium (lining of the uterus), which has long been known as a serious side effect of hormone therapy.

FIGURE 15.1 Percentage of menopausal women in different regions of the world reporting hot flashes.

Findings are derived from interviews with large samples in each region. Women in Asian nations, especially Japanese women, are less likely to suffer from hot flashes, perhaps because they eat soy-based foods, a rich source of plant estrogen. See the Cultural Influences box on  page 508  for additional evidence on the low rates of menopausal symptoms among Japanese women.

(Adapted from Obermeyer, 2000; Shea, 2006.)

Hormone therapy is highly successful at counteracting hot flashes and vaginal dryness. It also offers some protection against bone deterioration. Nevertheless, more than twenty experiments, in which nearly 43,000 perior postmenopausal women had been randomly assigned to take hormone therapy (ERT or HRT) or a sugar pill for at least one year and were followed for an average of seven years, revealed an array of negative consequences. Hormone therapy was associated with an increase in heart attack, stroke, blood clots, breast cancer, gallbladder disease, and deaths from lung cancer. ERT, when compared with HRT, intensified the risk of blood clots, stroke, and gallbladder disease. And women age 65 and older taking HRT showed an elevated risk of Alzheimer’s disease and other dementias (Marjoribanks et al.,  2012 ).

On the basis of available evidence, women and their doctors should make decisions about hormone therapy carefully. Women with family histories of cardiovascular disease or breast cancer are advised against it. Fortunately, the number of alternative treatments is increasing. A relatively safe migraine-headache medication, gabapentin, substantially reduces hot flashes, perhaps by acting on the brain’s temperature regulation center. At high doses, which still appear safe, gabapentin is nearly as effective as hormone therapy. Several antidepressant drugs and black cohosh, an herbal medication, are helpful as well (Guttuso,  2012 ; Thacker,  2011 ). Alternative medications are also available to protect the bones, although their long-term safety is not yet clear.

Women’s Psychological Reactions to menopause.

How do women react to menopause—a clear-cut signal that their childbearing years are over? The answer lies in how they interpret the event in relation to their past and future lives.

For Jewel, who had wanted marriage and family but never attained these goals, menopause was traumatic. Her sense of physical competence was still bound up with the ability to have children. Physical symptoms can also make menopause a difficult time (Elavsky & McAuley,  2007 ). And in a society that values a youthful appearance, some women respond to the climacteric with disappointment about a loss of sex appeal (Howell & Beth,  2002 ).

Many women, however, find menopause to be little or no trouble, regard it as a new beginning, and report improved quality of life (George,  2002 ; Mishra & Kuh,  2006 ). When more than 2,000 U.S. women were asked what their feelings were about no longer menstruating, nearly 50 percent of those currently experiencing changes in their menstrual cycles, and 60 percent of those whose periods had ceased, said they felt relieved (Rossi,  2005 ). Most do not want more children and are thankful to be freed from worry about birth control. And highly educated women usually have more positive attitudes toward menopause than those with less education (Pitkin,  2010 ).

Compared with previous generations, the baby-boom generation seems more accepting of menopause (Avis & Crawford,  2006 ). Their strong desire to cast aside old, gender-stereotyped views (such as menopause as a sign of decay and disease), their more active approach to seeking health information, and their greater willingness to openly discuss sexual topics may contribute to their generally positive adaptation.

African-American women, who generally view menopause as normal, inevitable, even welcome, experience less irritability and moodiness during this transition than Caucasian-American women.

Other research suggests that African-American and Mexican-American women hold especially favorable views. In several studies, African-American women experienced less irritability and moodiness than Caucasian Americans (Melby, Lock, & Kaufert,  2005 ). They rarely spoke of menopause in terms of physical aging but, instead, regarded it as normal, inevitable, and even welcome (Sampselle et al.,  2002 , p. 359). Several African Americans expressed exasperation at society’s readiness to label as “crazy” middle-aged women’s authentic reactions to work- or family-based stressors that often coincide with menopause. Among Mexican-American women who have not yet adopted the language (and perhaps certain beliefs) of the larger society, attitudes toward menopause are especially positive (Bell,  1995 ). And in an investigation of more than 13,000 40- to 55-year-old U.S. women diverse in ethnicity, other factors—SES, physical health, lifestyle factors (smoking, diet, exercise, weight gain), and especially psychological stress—overshadowed menopausal status and three common symptoms (hot flashes, night sweats, and vaginal dryness) in impact on self-rated quality of life (Avis et al.,  2004 ).

The wide variation in physical symptoms and attitudes indicates that menopause is not just a hormonal event; it is also affected by cultural beliefs and practices. The Cultural Influences box on  page 508  provides a cross-cultural look at women’s experience of menopause.

Reproductive Changes in Men.

Although men also experience a climacteric, no male counterpart to menopause exists. Both quantity and motility of sperm decrease from the twenties on, and quantity of semen diminishes after age 40, negatively affecting fertility in middle age (Sloter et al.,  2006 ). Still, sperm production continues throughout life, and men in their nineties have fathered children. Testosterone production also declines with age, but the change is minimal in healthy men who continue to engage in sexual activity, which stimulates cells that release testosterone.

Nevertheless, because of reduced blood flow to and changes in connective tissue in the penis, more stimulation is required for an erection, and it may be harder to maintain. The inability to attain an erection when desired can occur at any age, but it becomes more common in midlife, affecting about 34 percent of U.S. men by age 60 (Shaeer & Shaeer,  2012 ).

An episode or two of impotence is not serious, but frequent bouts can lead some men to fear that their sex life is over and undermine their self-image. Viagra and other drugs that increase blood flow to the penis offer temporary relief from erectile dysfunction. Publicity surrounding these drugs has prompted open discussion of erectile dysfunction and encouraged more men to seek treatment (Berner et al.,  2008 ). But those taking the medications are often not adequately screened for the host of factors besides declining testosterone that contribute to impotence, including disorders of the nervous, circulatory, and endocrine systems; anxiety and depression; pelvic injury; and loss of interest in one’s sexual partner (Montorsi,  2005 ). Although drugs for impotence are generally safe, a few users have experienced serious vision loss (O’Malley,  2006 ). In men with high blood pressure or atherosclerosis, the medications heighten the risk of constricting blood vessels in the optic nerve, permanently damaging it.

ASK YOURSELF

REVIEW Describe cultural influences on the experience of menopause.

CONNECT Compare ethnic variations in attitudes toward menopause with ethnic variations in reactions to menarche and early pubertal timing ( pages 368  and  370  in  Chapter 11 ). Did you find similarities? Explain.

APPLY Between ages 40 and 50, Nancy gained 20 pounds. She also began to have trouble opening tightly closed jars, and her calf muscles ached after climbing a flight of stairs. “Exchanging muscle for fat must be an inevitable part of aging,” Nancy thought. Is she correct? Why or why not?

REFLECT In view of the benefits and risks of hormone therapy, what factors would you consider, or advise others to consider, before taking such medication?

Cultural Influences Menopause as a Biocultural Event

For these rural Mayan women of the Yucatán, menopause brings freedom. After decades of childbearing, Mayan women welcome menopause, describing it as “being happy” and “free like a young girl again.”

Biology and culture join forces to influence women’s response to menopause, making it a biocultural event. In Western industrialized nations, menopause is “medicalized”—assumed to be a syndrome requiring treatment. Many women experience physical and emotional symptoms (Chrisler,  2008 ; Houck,  2006 ). The more symptoms they report, the more negative their attitude toward menopause tends to be.

Yet change the circumstances in which menopause is evaluated, and attitudes change as well. In one study, nearly 600 men and women between ages 19 and 85 described their view of menopause in one of three contexts—as a medical problem, as a life transition, or as a symbol of aging (Gannon & Ekstrom,  1993 ). The medical context evoked many more negative statements than the other contexts.

Research in non-Western cultures reveals that middle-aged women’s social status also affects the experience of menopause. In societies where older women are respected and the mother-in-law and grandmother roles bring new privileges and responsibilities, complaints about menopausal symptoms are rare (Fuh et al.,  2005 ). Perhaps in part for this reason, women in Asian nations report fewer discomforts (Shea,  2006 ). And their symptoms usually differ from those of Western women.

Though they rarely complain of hot flashes, the most frequent symptoms of Asian women are back, shoulder, and joint pain, a possible biological variation from other ethnic groups (Haines et al.,  2005 ; Huang,  2010 ). In midlife, women in Asian cultures attain peak respect and responsibility. Typically their days are filled with monitoring the household economy, attending to grandchildren, caring for dependent parents-in-law, and employment. Asian women seem to interpret menopausal distress in light of these socially valued commitments. In Japan, neither women nor their doctors consider menopause to be a significant marker of female middle age. Rather, midlife is viewed as an extended period of “socially recognized, productive maturity” (Menon,  2001 , p. 58).

A comparison of rural Mayan women of the Yucatán with rural Greek women on the island of Evia reveals additional biocultural influences on the menopausal experience (Beyene,  1992 ; Beyene & Martin,  2001 ; Mahady et al.,  2008 ). In both societies, old age is a time of increased status, and menopause brings release from child rearing and more time for leisure activities. Otherwise, Mayan and Greek women differ greatly.

Mayan women marry as teenagers. By 35 to 40, they have given birth to many children but rarely menstruated because of repeated pregnancies and breastfeeding. They also experience menopause up to 10 years earlier than their counterparts in developed nations, perhaps because of additional physical stressors, such as poor nutrition and heavy physical work. Eager for childbearing to end, they welcome menopause, describing it with such phrases as “being happy” and “free like a young girl again.” None report hot flashes or any other symptoms.

Like North Americans, rural Greek women use birth control to limit family size, and most report hot flashes and sweating at menopause. But they regard these as temporary discomforts that will stop on their own, not as medical symptoms requiring treatment. When asked what they do about hot flashes, the Greek women reply, “Pay no attention,” “Go outside for fresh air,” and “Throw off the covers at night.”

Does frequency of childbearing affect menopausal symptoms, as this contrast between Mayan and Greek women suggests? More research is needed to be sure. At the same time, the difference between North American and Greek women in attitudes toward and management of hot flashes is striking (Melby, Lock, & Kaufert,  2005 ). This—along with other cross-cultural findings—highlights the combined impact of biology and culture on menopausal experiences.

 Health and Fitness

In midlife, nearly 85 percent of Americans rate their health as either “excellent” or “good”—still a large majority, but lower than the 95 percent figure in early adulthood (U.S. Department of Health and Human Services,  2012c ). Whereas younger people usually attribute health complaints to temporary infections, middle-aged adults more often point to chronic diseases. As we will see, among those who rate their health unfavorably, men are more likely to suffer from fatal illnesses, women from nonfatal, limiting health problems.

In addition to typical negative indicators—major diseases and disabling conditions—our discussion takes up sexuality as a positive indicator of health. Before we begin, it is important to note that our understanding of health in middle and late adulthood is limited by insufficient research on women and ethnic minorities. Most studies of illness risk factors, prevention, and treatment have been carried out on men. Fortunately, this situation is changing. For example, the Women’s Health Initiative (WHI)—a commitment by the U.S. federal government, extending from 1993 to 2005, to study the impact of various lifestyle and medical prevention strategies on the health of nearly 162,000 postmenopausal women of all ethnic groups and SES levels—has led to important findings, including health risks associated with hormone therapy, discussed earlier. Two five-year extensions, involving annual health updates from 115,000 WHI participants in 2005–2010, and 94,000 participants in 2010–2015, continue to yield vital information.

Sexuality

Frequency of sexual activity among married couples tends to decline in middle adulthood, but for most, the drop is slight. In the National Social Life, Health, and Aging Project, a nationally representative sample of 3,000 U.S. middle-aged and older adults was surveyed about their sex lives. Even in the latter years of midlife (ages 57 to 64), the overwhelming majority of married and cohabiting adults were sexually active (90 percent of men and 80 percent of women) (Waite et al.,  2009 ). About two-thirds reported having sex several times a month, one-third once or twice a week.

Longitudinal research reveals that stability of sexual activity is far more typical than dramatic change. Couples who have sex often in early adulthood continue to do so in midlife (Dennerstein & Lehert,  2004 ; Walsh & Berman,  2004 ). And the best predictor of sexual frequency is marital happiness, an association that is probably bidirectional (DeLamater,  2012 ). Sex is more likely to occur in the context of a good marriage, and couples who have sex often probably view their relationship more positively.

Nevertheless, intensity of sexual response diminishes in midlife due to physical changes of the climacteric. Both men and women take longer to feel aroused and to reach orgasm (Bartlik & Goldstein,  2001 ; Walsh & Berman,  2004 ). If partners perceive each other as less attractive, this may contribute to a drop in sexual desire. Yet in the context of a positive outlook, sexual activity can become more satisfying. Devin and Trisha, for example, viewed each other’s aging bodies with acceptance and affection—as a sign of their enduring and deepening relationship. And with greater freedom from the demands of work and family, their sex life became more spontaneous. The majority of married people over age 50 say that their sex life is an important component of their relationship (Waite et al.,  2009 ). And most find ways to overcome difficulties with sexual functioning. One happily married 52-year-old woman commented, “We know what we are doing, we’ve had plenty of practice (laughs), and I would never have believed that it gets better as you get older, but it does” (Gott & Hinchliff,  2003 , p. 1625; Kingsberg,  2002 ).

When surveys include both married and unmarried people, a striking gender difference in age-related sexual activity appears. The proportion of U.S. men with no sexual partners in the previous year increases only slightly, from 8 percent in the thirties to 12 percent in the late fifties. In contrast, the rise for women is dramatic, from 9 percent to 40 percent—a gender gap that becomes even greater in late adulthood (Laumann & Mahay,  2002 ; Lindau et al.,  2007 ; Waite et al.,  2009 ). A higher male mortality rate and the value women place on affection and continuity in sexual relations make partners less available to them. Taken as a whole, the evidence reveals that sexual activity in midlife, as in earlier periods, is the combined result of biological, psychological, and social forces.

Illness and Disability

As  Figure 15.2  shows, cancer and cardiovascular disease are the leading causes of U.S. deaths in middle age. Unintentional injuries, though still a major health threat, occur at a lower rate than in early adulthood, largely because motor vehicle collisions decline. Despite a rise in vision problems, older adults’ many years of driving experience and greater cautiousness may reduce these deaths. In contrast, falls resulting in bone fractures and death nearly double from early to middle adulthood (U.S. Census Bureau,  2012 ).

FIGURE 15.2 Leading causes of death among people age 45 to 64 in the United states.

Men are more vulnerable than women to each leading cause of death. Cancer is the leading killer of both sexes, by a far smaller margin over cardiovascular disease for men than for women.

(Adapted from U.S. Census Bureau, 2012.)

As in earlier decades, economic disadvantage is a strong predictor of poor health and premature death, with SES differences widening in midlife (Smith & Infurna,  2011 ). And largely because of more severe poverty and lack of universal health insurance, the United States continues to exceed most other industrialized nations in death rates from major causes (OECD,  2012 ). Furthermore, men are more vulnerable than women to most health problems. Among middle-aged men, cancer deaths exceed cardiovascular disease deaths by a small margin; among women, cancer is by far the leading cause of death (refer again to  Figure 15.2 ). Finally, as we take a closer look at illness and disability in the following sections, we will encounter yet another familiar theme: the close connection between psychological and physical well-being. Personality traits that magnify stress—especially hostility and anger—are serious threats to health in midlife.

FIGURE 15.3 Incidence of 10 leading cancer types among men and women in the united states, 2012.

(From R. Siegel, D. Naishadham, & A. Jemal, 2012, “Cancer Statistics, 2012,” CA: A Cancer Journal for Clinicians, 62, p. 13. Copyright © 2012 American Cancer Society, Inc. Reproduced with permission of Wiley Inc.)

Cancer.

From early to middle adulthood, the death rate due to cancer multiplies tenfold, accounting for about one-third of all midlife deaths in the United States. Although the incidence of many types of cancer is currently leveling off or declining, cancer mortality was on the rise for many decades, largely because of a dramatic increase in lung cancer due to cigarette smoking. Lung cancer is the most common cause of cancer deaths in both genders, worldwide. In the past two decades, its incidence dropped in men; 50 percent fewer smoke today than in the 1950s. In contrast, lung cancer has just begun to decrease in women after a long period of increase, due to large numbers of women taking up smoking in the decades after World War II (American Cancer Society,  2012 ).

Cancer occurs when a cell’s genetic program is disrupted, leading to uncontrolled growth and spread of abnormal cells that crowd out normal tissues and organs. Why does this happen? Mutations of three main kinds contribute to cancer. Some result in oncogenes (cancer genes) that directly undergo abnormal cell duplication. Others interfere with the activity of tumor suppressor genes so they fail to keep oncogenes from multiplying. And a third type of mutation disrupts the activity of stability genes, which normally keep genetic alterations to a minimum by repairing subtle DNA mistakes that occur either during normal cell duplication or as a result of environmental agents (Ewald & Ewald,  2012 ). When stability genes do not function, mutations in many other genes occur at a higher rate.

Each of these cancer-linked mutations can be either germ-line (due to an inherited predisposition) or somatic (occurring in a single cell, which then multiplies) (see  page 52  in  Chapter 2  to review). Recall from  Chapter 13  that according to one theory, error in DNA duplication increases with age, either occurring spontaneously or resulting from the release of free radicals or breakdown of the immune system. Environmental toxins may initiate or intensify this process.

Figure 15.3  shows the incidence of the most common types of cancer. For cancers that affect both sexes, men are generally more vulnerable than women. The difference may be due to genetic makeup, exposure to cancer-causing agents as a result of lifestyle or occupation, and men’s greater tendency to delay going to the doctor. Although the relationship of SES to cancer varies with site (for example, lung and stomach cancers are linked to lower SES, breast and prostate cancers to higher SES), cancer death rates increase sharply as SES decreases and are especially high among low-income ethnic minorities (Clegg et al.,  2009 ). Poorer medical care and reduced ability to fight the disease, due to inadequate diet and high life stress, underlie this trend.

Overall, a complex interaction of heredity, biological aging, and environment contributes to cancer. For example, many patients with familial breast cancer who respond poorly to treatment have defective forms of particular tumor-suppressor genes (either BRCA1 or BRCA2). Women with these mutations are especially likely to develop early- onset breast cancer, before age 30 (Ripperger et al.,  2009 ). But their risk remains elevated throughout middle and late adulthood, when breast cancer rises among women in general. Genetic screening is available, permitting prevention efforts to begin early. Nevertheless, breast cancer susceptibility genes account for only 5 to 10 percent of all cases; most women with breast cancer do not have a family history (American Cancer Society,  2012 ). Other genes and lifestyle factors—including alcohol consumption, overweight, physical inactivity, never having had children, use of oral contraceptives, and hormone therapy to treat menopausal symptoms—heighten their risk.

People often fear cancer because they believe it is incurable. Yet nearly 60 percent of affected individuals are cured—free of the disease for five years or longer. Survival rates, however, vary widely with type of cancer (Siegel, Naishadham, & Jemal,  2012 ). For example, they are relatively high for breast and prostate cancers, intermediate for cervical and colon cancers, and low for lung and pancreatic cancers.

Applying What We Know Reducing Cancer Incidence and Deaths

Intervention	Description
Know the seven warning signs of cancer.	The signs are change in bowel or bladder habits, sore that does not heal, unusual bleeding or discharge, thickening or lump in a breast or elsewhere in your body, indigestion or swallowing difficulty, obvious change in a wart or mole, nagging cough or hoarseness. If you have any of these signs, consult your doctor immediately.
Schedule regular medical checkups and cancer-screening tests.	Women should have a mammogram and Pap test every one to two years. Beginning at age 50, men should have an annual prostate screening test. Both men and women should be screened periodically for colon cancer, as recommended by their doctor.
Avoid tobacco.	Cigarette smoking causes 90 percent of lung cancer deaths and 30 percent of all cancer deaths. Smokeless (chewing) tobacco increases risk of cancers of the mouth, larynx, throat, and esophagus.
Limit alcohol consumption.	Consuming more than one drink per day for women or two drinks per day for men increases risk of cancers of the breast, kidney, liver, head, and neck.
Avoid excessive sun exposure.	Sun exposure causes many cases of skin cancer. When in the sun for an extended time, wear sunglasses, use sunscreen that protects against both UVA and UVB rays, and cover exposed skin.
Avoid unnecessary X-ray exposure.	Excessive exposure to X-rays increases risk of many cancers. Most medical X-rays are adjusted to deliver the lowest possible dose but should not be used unnecessarily.
Avoid exposure to industrial chemicals and other pollutants.	Exposure to nickel, chromate, asbestos, vinyl chloride, radon, and other pollutants increases risk of various cancers.
Weigh the benefits versus risks of hormone therapy.	Because estrogen replacement increases risk of uterine and breast cancers, carefully consider hormone therapy with your doctor.
Maintain a healthy diet.	Eating vegetables, fruits, and whole grains, while avoiding excess dietary fat and salt-cured, smoked, and nitrite-cured foods, reduces risk of colon and rectal cancers.
Avoid excessive weight gain.	Overweight and obesity increase risk of cancers of the breast, colon, esophagus, uterus, and kidney.
Adopt a physically active lifestyle.	Physical activity offers protection against cancers at all body sites except the skin, with the strongest evidence for cancers of the breast, rectum, and colon.

Source: American Cancer Society, 2012.

Breast cancer is the leading malignancy for women, prostate cancer for men. Lung cancer ranks second for both sexes; it causes more deaths (largely preventable through avoiding tobacco) than any other cancer type. It is followed closely in incidence by colon and rectal cancer. Scheduling annual medical checkups that screen for these and other forms of cancer and taking the additional steps listed in Applying What We Know above can reduce cancer illness and death rates considerably. An increasing number of cancer-promoting mutations are being identified, and promising new therapies targeting these genes are being tested.

Surviving cancer is a triumph, but it also brings emotional challenges. During cancer treatment, relationships focus on the illness. Afterward, they must refocus on health and full participation in daily life. Unfortunately, stigmas associated with cancer exist (Daher,  2012 ). Friends, family, and co-workers may need reminders that cancer is not contagious and that with patience and support from supervisors and co-workers, cancer survivors regain their on-the-job productivity.

Cardiovascular Disease.

Despite a decline over the last few decades (see  Chapter 13 ), each year about 25 percent of middle-aged Americans who die succumb to cardiovascular disease (U.S. Department of Health and Human Services,  2012c ). We associate cardiovascular disease with heart attacks, but Devin, like many middle-aged and older adults, learned of the condition during an annual checkup. His doctor detected high blood pressure, high blood cholesterol, and atherosclerosis—a buildup of plaque in his coronary arteries, which encircle the heart and provide its muscles with oxygen and nutrients. These indicators of cardiovascular disease are known as “silent killers” because they often have no symptoms.

When symptoms are evident, they take different forms. The most extreme is a heart attack—blockage of normal blood supply to an area of the heart, usually brought on by a blood clot in one or more plaque-filled coronary arteries. Intense pain results as muscle in the affected region dies. A heart attack is a medical emergency; over 50 percent of victims die before reaching the hospital, another 15 percent during treatment, and an additional 15 percent over the next few years (Go et al.,  2013 ). Among other, less extreme symptoms of cardiovascular disease are arrhythmia, or irregular heartbeat. When it persists, it can prevent the heart from pumping enough blood and result in faintness. It can also allow clots to form within the heart’s chambers, which may break loose and travel to the brain. In some individuals, indigestion-like pain or crushing chest pain, called angina pectoris, reveals an oxygen-deprived heart.

Applying What We Know Reducing the Risk of Heart Attack

Intervention	Risk Reduction
Quit smoking.	Five years after quitting, greatly reduces risk compared to current smokers. Chemicals in tobacco smoke damage the heart and blood vessels and greatly increase the risk of atherosclerosis.
Reduce blood cholesterol level.	Reductions in cholesterol average 10 percent with transition to a healthy diet.
Treat high blood pressure.	Places added force against the artery walls, which can damage the arteries over time. Combination of healthy diet and drug therapy can lower blood pressure substantially.
Maintain ideal weight.	Greatly reduced risk for people who maintain ideal body weight compared to those who are obese.
Exercise regularly.	Greatly reduced risk for people who maintain an active rather than a sedentary lifestyle. In addition to contributing to healthy weight, lowers cholesterol and blood pressure and helps prevent type 2 diabetes, which is strongly linked to heart disease.
Drink an occasional glass of wine or beer. a	Modestly reduced risk for people who consume small-to-moderate amounts of alcohol. Believed to promote high-density lipoproteins (a form of “good cholesterol” that lowers “bad cholesterol”) and to prevent clot formation.
If medically recommended, take low-dose aspirin.	Modestly reduced risk for people with a previous heart attack or stroke, by lowering the likelihood of blood clots (should be doctor advised; long-term use can have serious side effects).
Reduce hostility and other forms of psychological stress.	People under stress are more likely to engage in high-risk behaviors, such as overeating and smoking, and to display high-risk symptoms, such as high blood pressure.

a Recall from  Chapter 13  that heavy alcohol use increases the risk of cardiovascular disease as well as many other diseases.

Source: Go et al., 2013.

Today, cardiovascular disease can be treated in many ways—including coronary bypass surgery, medication, and pacemakers to regulate heart rhythm. To relieve arterial blockage, Devin had angioplasty, a procedure in which a surgeon threaded a needle-thin catheter into his arteries and inflated a balloon at its tip, which flattened fatty deposits to allow blood to flow more freely. Unless Devin took other measures to reduce his risk, his doctor warned, the arteries would clog again within a year. As Applying What We Know above indicates, adults can do much to prevent heart disease or slow its progress.

Some risks, such as heredity, advanced age, and being male, cannot be changed. But cardiovascular disease is so disabling and deadly that people must be alert for it where they least expect it—for example, in women. Because men account for over 70 percent of cases in middle adulthood, doctors often view a heart condition as a “male problem” and frequently overlook women’s symptoms, which tend to be milder, more often taking the form of angina than a heart attack (Go et al.,  2013 ). In follow-ups of victims of heart attacks, women—especially African-American women, who are at increased risk—were less likely to be offered drugs to treat blood clots and costly, invasive therapies, such as angioplasty and bypass surgery (Lawton,  2011 ; Mosca, Conner, & Wenger,  2012 ; Poon et al.,  2012 ). As a result, treatment outcomes—including rehospitalization and death—tend to be worse for women, particularly black women.

Osteoporosis.

When age-related bone loss is severe, a condition called  osteoporosis  develops. The disorder, affecting about 10 million U.S. adults, 80 percent of whom are women, greatly magnifies the risk of bone fractures. An estimated 55 percent of people over age 50 are at risk for osteoporosis because they have bone density levels low enough to be of concern, and 12 percent have been diagnosed with it (American Academy of Orthopaedic Surgeons,  2009 ). After age 70, osteoporosis affects the majority of people of both sexes. Although we associate it with a slumped-over posture, a shuffling gait, and a “dowager’s hump” in the upper back, this extreme is rare. Because the bones gradually become more porous over many years, osteoporosis may not be evident until fractures—typically in the spine, hips, and wrist—occur or are discovered through X-rays.

A major factor related to osteoporosis is the decline in estrogen associated with menopause. In middle and late adulthood, women lose about 50 percent of their bone mass, about half of it in the first 10 years following menopause—a decline that, by the late sixties, is two to five times greater than in men (Bonnick,  2008 ). The earlier a woman reaches menopause, the greater her chances of developing osteoporosis related to estrogen loss. In men, the age-related decrease in testosterone—though much more gradual than estrogen loss in women—contributes to bone loss because the body converts some to estrogen.

Heredity plays an important role. A family history of osteoporosis increases risk, with identical twins more likely than fraternal twins to share the disorder (Ralston & Uitterlinden,  2010 ). People with thin, small-framed bodies are more likely to be affected because they typically attain a lower peak bone mass in adolescence. In contrast, higher bone density makes African Americans less susceptible than Asian Americans, Caucasians, Hispanics, and Native Americans (Cauley,  2011 ). An unhealthy lifestyle also contributes: A diet deficient in calcium and vitamin D (essential for calcium absorption), excess intake of sodium and caffeine, and physical inactivity reduce bone mass. Cigarette smoking and alcohol consumption are also harmful because they interfere with replacement of bone cells (Body et al.,  2011 ; Langsetmo et al.,  2012 ).

When major bone fractures (such as the hip) occur, 10 to 20 percent of patients die within a year (Marks,  2010 ). Osteoporosis usually develops earlier in women than in men, so it has become known as a “women’s disease.” Men are far less likely to be screened and treated for it, even after a hip fracture. Compared with women, men with hip fractures tend to be older and to lack a history of interventions aimed at preserving bone density. Probably for these reasons, the one-year mortality rate after hip fracture is nearly twice as great for men as for women—a gap that widens with age (Haentjens et al.,  2010 ).

Physical inactivity increases the chances of osteoporosis. More than half of people over age 50, mostly women, are at risk. Weight-bearing exercise and strength training are recommended for both prevention and treatment.

To treat osteoporosis, doctors recommend a diet enriched with calcium and vitamin D, weight-bearing exercise (walking rather than swimming), resistance training, and bone-strengthening medications (American Academy of Orthopaedic Surgeons,  2009 ). A better way to reduce lifelong risk is through early prevention: maximizing peak bone density by increasing calcium and vitamin D intake and engaging in regular exercise in childhood, adolescence, and early adulthood.

Hostility and Anger

Whenever Trisha’s sister Dottie called, she seemed like a powder keg ready to explode. Dottie was critical of her boss at work and dissatisfied with the way Trisha, a lawyer, had handled the family’s affairs after their father died. Inevitably, Dottie’s anger surfaced, exploding in hurtful remarks: “Any lawyer knows that, Trisha. How could you be so stupid! I should have called a real lawyer.” “You and Devin are so stuck in your privileged lives that you can’t think of anyone else. You don’t know what work is.”

After listening as long as she could bear, Trisha would warn, “Dottie, if you continue, I’m going to hang up…. Dottie, I’m ending this right now!”

At age 53, Dottie had high blood pressure, difficulty sleeping, and back pain. In the past five years, she had been hospitalized five times—twice for treatment of digestive problems, twice for an irregular heartbeat, and once for a benign tumor on her thyroid gland. Trisha often wondered whether Dottie’s personal style was partly responsible for her health problems.

That hostility and anger might have negative effects on health is a centuries-old idea. Several decades ago, researchers first tested this notion by identifying 35- to 59-year-old men who displayed the Type A behavior pattern—extreme competitiveness, ambition, impatience, hostility, angry outbursts, and a sense of time pressure. They found that within the next eight years, Type As were more than twice as likely as Type Bs (people with a more relaxed disposition) to develop heart disease (Rosenman et al.,  1975 ).

Later studies, however, often failed to confirm these results. Type A is actually a mix of behaviors, only one or two of which affect health. Current evidence pinpoints hostility as a “toxic” ingredient of Type A, since isolating it from global Type A consistently predicts heart disease and other health problems in both men and women (Aldwin et al.,  2001 ; Eaker et al.,  2004 ; Matthews et al.,  2004 ; Smith et al.,  2004 ). The risks of high blood pressure, atherosclerosis, and stroke are several times greater in adults scoring high on hostility measures than in those scoring low (Räikkönen et al.,  2004 ; Williams et al.,  2002 ; Yan et al.,  2003 ).

Expressed hostility in particular—frequent angry outbursts; rude, disagreeable behavior; critical and condescending nonverbal cues during social interaction, including glares; and expressions of contempt and disgust—predicts greater cardiovascular arousal, coronary artery plaque buildup, and heart disease (Haukkala et al.,  2010 ; Julkunen & Ahlström,  2006 ; Smith & Cundiff,  2011 ; Smith et al.,  2012 ). As people get angry, heart rate, blood pressure, and stress hormones escalate until the body’s response is extreme.

Of course, people who are repeatedly enraged are more likely to be depressed and dissatisfied with their lives, to lack social supports, and to engage in unhealthy behaviors. But hostility predicts health problems even after such factors as smoking, alcohol consumption, overweight, general unhappiness, and negative life events are controlled (Smith & Mackenzie,  2006 ).

Another unhealthy feature of the Type A pattern, which also predicts heart disease, is a socially dominant style, evident in rapid, loud, insistent speech and a tendency to cut off and talk over others (Smith,  2006 ; Smith, Gallo, & Ruiz,  2003 ). And because men score higher in hostility and dominance than women (Dottie is an exception), emotional style may contribute to the sex differences in heart disease described earlier.

Can Dottie preserve her health by bottling up her hostility instead of expressing it? Repeatedly suppressing overt anger or ruminating about past anger-provoking events is also associated with high blood pressure and heart disease (Eaker et al.,  2007 ; Hogan & Linden,  2004 ). A better alternative, as we will see, is to develop effective ways of handling stress and conflict.

 Adapting to the Physical Challenges of Midlife

Middle adulthood is often a productive time of life, when people attain their greatest accomplishments and satisfactions. Nevertheless, it takes considerable stamina to cope with the full array of changes this period can bring. Devin responded to his expanding waistline and cardiovascular symptoms by leaving his desk twice a week to attend a low-impact aerobics class and by reducing job-related stress through daily 10-minute meditation sessions. Aware of her sister Dottie’s difficulties, Trisha resolved to handle her own hostile feelings more adaptively. And her generally optimistic outlook enabled her to cope successfully with the physical changes of midlife, the pressures of her legal career, and Devin’s cardiovascular disease.

Stress Management

TAKE A MOMENT…  Turn back to  Chapter 13 ,  pages 449 – 450 , and review the negative consequences of psychological stress on the cardiovascular, immune, and gastrointestinal systems. As adults encounter problems at home and at work, daily hassles can add up to a serious stress load. Stress management is important at any age, but in middle adulthood it can limit the age-related rise in illness and, when disease strikes, reduce its severity.

Applying What We Know on the following page summarizes effective ways to reduce stress. Even when stressors cannot be eliminated, people can change how they handle some and view others. At work, Trisha focused on problems she could control—not on her boss’s irritability but on ways to delegate routine tasks to her staff so she could focus on challenges that required her knowledge and skills. When Dottie phoned, Trisha learned to distinguish normal emotional reactions from unreasonable self-blame. Instead of interpreting Dottie’s anger as a sign of her own incompetence, she reminded herself of Dottie’s difficult temperament and hard life. And greater life experience helped her accept change as inevitable, so that she was better-equipped to deal with the jolt of sudden events, such as Devin’s hospitalization for treatment of heart disease.

Notice how Trisha called on two general strategies for coping with stress, discussed in  Chapter 10 : (1) problem-centered coping, in which she appraised the situation as changeable, identified the difficulty, and decided what to do about it; and (2) emotion-centered coping, which is internal, private, and aimed at controlling distress when little can be done about a situation. Longitudinal research shows that adults who effectively reduce stress move flexibly between problem-centered and emotion-centered techniques, depending on the situation (Zakowski et al.,  2001 ). Their approach is deliberate, thoughtful, and respectful of both themselves and others.

Stress management in middle adulthood helps limit the age-related rise in illness. This midlifer reduces stress by periodically leaving her high-pressure office environment to work in a tranquil, picturesque setting.

Notice, also, that problem-focused and emotion-focused coping, though they have different immediate goals, facilitate each other. Effective problem-focused coping reduces emotional distress, while effective emotion-focused coping helps people face problems more calmly and, thus, generate better solutions. Ineffective coping, in contrast, is largely emotion-centered and self-blaming, impulsive, or escapist.

Constructive approaches to anger reduction are a vital health intervention (refer again to Applying What We Know). Teaching people to be assertive rather than hostile and to negotiate rather than explode interrupts the intense physiological response that intervenes between psychological stress and illness. Sometimes it is best to delay responding by simply leaving a provocative situation, as Trisha did when she told Dottie that she would hang up after one more insult.

Applying What We Know Managing Stress

Strategy	Description
Reevaluate the situation.	Learn to differentiate normal reactions from those based on irrational beliefs.
Focus on events you can control.	Don’t worry about things you cannot change or that may never happen; focus on strategies for handling events under your control.
View life as fluid.	Expect change and accept it as inevitable; then many unanticipated changes will have less emotional impact.
Consider alternatives.	Don’t rush into action; think before you act.
Set reasonable goals for yourself.	Aim high, but be realistic about your capacities, motivation, and the situation.
Exercise regularly.	A physically fit person can better handle stress, both physically and emotionally.
Master relaxation techniques.	Relaxation helps refocus energies and reduce the physical discomfort of stress. Classes and self-help books teach these techniques.
Use constructive approaches to anger reduction.	Delay responding (“Let me check into that and get back to you”); use mentally distracting behaviors (counting to 10 backwards) and self-instruction (a covert “Stop!”) to control anger arousal; then engage in calm, self-controlled problem solving (“I should call him rather than confront him personally”).
Seek social support.	Friends, family members, co-workers, and organized support groups can offer information, assistance, and suggestions for coping with stressful situations.

As noted in  Chapter 13 , people tend to cope with stress more effectively as they move from early to middle adulthood. They may become more realistic about their ability to change situations and more skilled at anticipating stressful events and at preparing to manage them (Aldwin, Yancura, & Boeninger,  2010 ). Furthermore, when middle-aged adults surmount a highly stressful experience, they often report lasting personal benefits as they look back with amazement at what they were able to accomplish under extremely trying conditions. A serious illness and brush with death commonly brings changes in values and perspectives, such as clearer life priorities, a greater sense of personal strength, and closer ties to others. Interpreting trauma as growth-promoting is related to more effective coping with current stressors and with increased physical and mental health years later (Aldwin & Yancura,  2011 ; Carver,  2011 ). In this way, managing intense stress can serve as a context for positive development.

But for people who do have difficulty handling midlife’s challenges, communities provide fewer social supports than for young adults or senior citizens. For example, Jewel had little knowledge of what to expect during the climacteric. “It would have helped to have a support group so I could have learned about menopause and dealt with it more easily,” she told Trisha. Community programs addressing typical midlife concerns, such as those of adult learners returning to college and care-givers of elderly parents, can reduce stress during this period.

LOOK AND LISTEN

Interview a middle-aged adult who has overcome a highly stressful experience, such as a serious illness, about how he or she coped. Inquire about any resulting changes in outlook on life. Do the adult’s responses fit with research findings?

Exercise

Regular exercise, as noted in  Chapter 13 , has a range of physical and psychological benefits—among them, equipping adults to handle stress more effectively and reducing the risk of many diseases. Heading for his first aerobics class, Devin wondered, Can starting to exercise at age 50 counteract years of physical inactivity? His question is important: Nearly 70 percent of U.S. middle-aged adults are sedentary, and half of those who begin an exercise program discontinue it within the first six months. Even among those who stay active, fewer than 20 percent exercise at levels that lead to health benefits (U.S. Department of Health and Human Services,  2011c ).

A person beginning to exercise in midlife must overcome initial barriers and ongoing obstacles—lack of time and energy, inconvenience, work conflicts, and health factors (such as overweight). Self-efficacy—belief in one’s ability to succeed—is just as vital in adopting, maintaining, and exerting oneself in an exercise regimen as it is in career progress (see  Chapter 14 ). An important outcome of starting an exercise program is that sedentary adults gain in self-efficacy, which further promotes physical activity (McAuley & Elavsky,  2008 ; Wilbur et al.,  2005 ). Enhanced physical fitness, in turn, prompts middle-aged adults to feel better about their physical selves. Over time, their physical self-esteem—sense of body conditioning and attractiveness—rises (Elavsky & McAuley,  2007 ; Gothe et al.,  2011 ).

The exercise format that works best depends on the beginning exerciser’s characteristics. Normal-weight adults are more likely to stick with group classes than are overweight adults, who may feel embarrassed and struggle to keep up with the pace. Overweight people do better with an individualized, home-based routine planned by a consultant (King,  2001 ). However, adults with highly stressful lives are more likely to persist in group classes, which offer a regular schedule and the face-to-face support of others (King et al.,  1997 ). Yet when stressed people do manage to sustain a home-based program, it substantially reduces stress—more so than the group format (King, Taylor, & Haskell,  1993 ). Perhaps succeeding on their own helps stressed adults gain better control over their lives. A small digital monitor that tracks physical activity and gives feedback motivates inactive middle-aged adults to increase their activity levels (King et al.,  2008 ). And most say they enjoy using the device.

In cities across the United States, barriers to physical activity are being overcome through the creation of attractive, safe parks and trails. But low-SES adults need greater access to convenient, pleasant exercise environments.

Accessible, attractive, and safe exercise environments—parks, walking and biking trails, and community recreation centers—and frequent opportunities to observe others using them also promote physical activity. Besides health problems and daily stressors, low-SES adults often mention inconvenient access to facilities, expense, unsafe neighborhoods, and unclean streets as barriers to exercise—important reasons that activity level declines sharply with SES (Taylor et al.,  2007 ; Wilbur et al.,  2003 ). Interventions aimed at increasing physical activity among low-SES adults must address these issues in addition to lifestyle and motivational factors.

An Optimistic Outlook

What type of individual is likely to cope adaptively with stress brought on by the inevitable changes of life? Researchers interested in this question have identified a set of three personal qualities—control, commitment, and challenge—that, together, they call  hardiness  (Maddi,  2005 ,  2007 ,  2011 ).

Trisha fit the pattern of a hardy individual. First, she regarded most experiences as controllable. “You can’t stop all bad things from happening,” she advised Jewel after hearing about her menopausal symptoms, “but you can try to do something about them.” Second, Trisha displayed a committed, involved approach to daily activities, finding interest and meaning in almost all of them. Finally, she viewed change as a challenge—a normal, welcome, even exciting part of life.

Hardiness influences the extent to which people appraise stressful situations as manageable, interesting, and enjoyable. These optimistic appraisals, in turn, predict health-promoting behaviors, tendency to seek social support, reduced physiological arousal to stress, and fewer physical and emotional symptoms (Maddi,  2006 ; Maruta et al.,  2002 ; Räikkönen et al.,  1999 ; Smith, Young, & Lee,  2004 ). Furthermore, high-hardy individuals are likely to use active, problem-centered coping strategies in situations they can control. In contrast, low-hardy people more often use emotion-centered and avoidant coping strategies—for example, saying, “I wish I could change how I feel,” denying that the stressful event occurred, or eating and drinking to forget about it (Maddi,  2007 ; Soderstrom et al.,  2000 ).

In this and previous chapters, we have seen that many factors act as stress-resistant resources—among them heredity, diet, exercise, social support, and coping strategies. Research on hardiness adds yet another ingredient: a generally optimistic outlook and zest for life.

Gender and Aging: A Double Standard

Negative stereotypes of aging, which lead many middle-aged adults to fear physical changes, are more likely to be applied to women than to men, yielding a double standard (Antonucci, Blieszner, & Denmark,  2010 ). Though many women in midlife say they have “hit their stride”—feel assertive, confident, versatile, and capable of resolving life’s problems—people often rate them as less attractive and as having more negative personality characteristics than middle-aged men (Canetto, Kaminski, & Felicio,  1995 ; Denmark & Klara,  2007 ; Kite et al.,  2005 ).

These effects appear more often when people rate photos as opposed to verbal descriptions of men and women. The ideal of a sexually attractive woman—smooth skin, good muscle tone, lustrous hair—may be at the heart of the double standard of aging. Some evidence suggests that the end of a woman’s ability to bear children contributes to negative judgments of physical appearance, especially by men (Marcus-Newhall, Thompson, & Thomas,  2001 ). Yet societal forces exaggerate this view. For example, middle-aged people in media ads are usually male executives, fathers, and grandfathers—handsome images of competence and security. And many more cosmetic products designed to hide signs of aging are offered for women than for men.

At one time in our evolutionary history, this double standard may have been adaptive. Today, as many couples limit childbearing and devote more time to career and leisure pursuits, it has become irrelevant. Some recent surveys suggest that the double standard is declining—that more people are viewing middle age as a potentially upbeat, satisfying time for both genders, sometimes even more so for women than for men (Menon,  2001 ; Narayan,  2008 ). Models of older women with lives full of intimacy, accomplishment, hope, and imagination are promoting acceptance of physical aging and a new vision of growing older—one that emphasizes gracefulness, fulfillment, and inner strength.

ASK YOURSELF

REVIEW Cite evidence that biological aging, individual heredity, and environmental factors contribute to osteoporosis.

CONNECT According to the lifespan perspective, development is multidimensional—affected by biological, psychological, and social forces. Provide examples of how this assumption characterizes health at midlife.

APPLY During a routine physical exam, Dr. Furrow gave 55-year-old Bill a battery of tests for cardiovascular disease but did not assess his bone density. In contrast, when 60-year-old Cara complained of chest pains, Dr. Furrow opted to “wait and see” before initiating further testing. What might account for Dr. Furrow’s different approaches to Cara and Bill?

REFLECT Which midlife health problem is of greatest personal concern to you? What steps can you take now to help prevent it?

COGNITIVE DEVELOPMENT

In middle adulthood, the cognitive demands of everyday life extend to new and sometimes more challenging situations. Consider a typical day in the lives of Devin and Trisha. Recently appointed dean of faculty at a small college, Devin was at his desk by 7:00 A.M. In between strategic-planning meetings, he reviewed files of applicants for new positions, worked on the coming year’s budget, and spoke at an alumni luncheon. Meanwhile, Trisha prepared for a civil trial, participated in jury selection, and then joined the other top lawyers at her firm for a conference about management issues. That evening, Trisha and Devin advised their 20-year-old son, Mark, who had dropped by to discuss his uncertainty over whether to change his college major. By 7:30 P.M., Trisha was off to an evening meeting of the local school board. And Devin left for a biweekly gathering of an amateur quartet in which he played the cello.

Middle adulthood is a time of expanding responsibilities—on the job, in the community, and at home. To juggle diverse roles effectively, Devin and Trisha called on a wide array of intellectual abilities, including accumulated knowledge, verbal fluency, memory, rapid analysis of information, reasoning, problem solving, and expertise in their areas of specialization. What changes in thinking take place in middle adulthood? How does vocational life—a major arena in which cognition is expressed—influence intellectual skills? And what can be done to support the rising tide of adults who are returning to higher education in hopes of enhancing their knowledge and quality of life?

 Changes in Mental Abilities

At age 50, when he occasionally couldn’t recall a name or had to pause in the middle of a lecture or speech to think about what to say next, Devin wondered, Are these signs of an aging mind? Twenty years earlier, he had taken little notice of the same events. His questioning stems from widely held stereotypes of older adults as forgetful and confused. Most cognitive aging research has focused on deficits while neglecting cognitive stability and gains.

As we examine changes in thinking in middle adulthood, we will revisit the theme of diversity in development. Different aspects of cognitive functioning show different patterns of change. Although declines occur in some areas, most people display cognitive competence, especially in familiar contexts, and some attain outstanding accomplishment. As we will see, certain apparent decrements in cognitive aging result from weaknesses in the research itself! Overall, the evidence supports an optimistic view of adult cognitive potential.

The research we are about to consider illustrates core assumptions of the lifespan perspective: development as multidimensional, or the combined result of biological, psychological, and social forces; development as multidirectional, or the joint expression of growth and decline, with the precise mix varying across abilities and individuals; and development as plastic, or open to change, depending on how a person’s biological and environmental history combines with current life conditions. You may find it helpful to return to  pages 9 – 10  in  Chapter 1  to review these ideas.

Cohort Effects

Research using intelligence tests sheds light on the widely held belief that intelligence inevitably declines in middle and late adulthood as the brain deteriorates. Many early cross-sectional studies showed this pattern—a peak in performance at age 35 followed by a steep drop into old age. But widespread testing of college students and soldiers in the 1920s provided a convenient opportunity to conduct longitudinal research, retesting participants in middle adulthood. These findings revealed an age-related increase! To explain this contradiction, K. Warner Schaie ( 1998 , 2005) used a sequential design, combining longitudinal and cross-sectional approaches (see  page 38  in  Chapter 1 ) in the Seattle Longitudinal Study.

FIGURE 15.4 Cross-sectional and longitudinal trends in verbal ability, illustrating cohort effects.

The steep cross-sectional decline is largely due to better health and education in younger generations. When adults are followed longitudinally, their verbal scores rise during early and middle adulthood and gradually decline during later years. However, this longitudinal trend does not hold for all abilities.

(From K. W. Schaie, 1988, “Variability in Cognitive Functioning in the Elderly,” in M. A. Bender, R. C. Leonard, & A. D. Woodhead [Eds.], Phenotypic Variation in Populations, p. 201. Adapted with kind permission from Springer Science+Business Media B. V. and K. W. Schaie.)

In 1956, people ranging in age from 22 to 70 were tested cross-sectionally. Then, at regular intervals, longitudinal follow-ups were conducted and new samples added, yielding a total of 5,000 participants, five cross-sectional comparisons, and longitudinal data spanning more than 60 years. Findings on five mental abilities showed the typical cross-sectional drop after the mid-thirties. But longitudinal trends for those abilities revealed modest gains in midlife, sustained into the fifties and the early sixties, after which performance decreased gradually.

Figure 15.4  illustrates Schaie’s cross-sectional and longitudinal outcomes for just one intellectual factor: verbal ability. How can we explain the seeming contradiction in findings? Cohort effects are largely responsible for this difference. In cross-sectional research, each new generation experienced better health and education than the one before it (Schaie,  2011 ). Also, the tests given may tap abilities less often used by older individuals, whose lives no longer require that they learn information for its own sake but, instead, skillfully solve real-world problems.

Crystallized and Fluid Intelligence

A close look at diverse mental abilities shows that only certain ones follow the longitudinal pattern identified in  Figure 15.4 . To appreciate this variation, let’s consider two broad mental abilities, each of which includes an array of specific intellectual factors.

The first of these broad abilities,  crystallized intelligence , refers to skills that depend on accumulated knowledge and experience, good judgment, and mastery of social conventions—abilities acquired because they are valued by the individual’s culture. Devin made use of crystallized intelligence when he expressed himself articulately at the alumni luncheon and suggested effective ways to save money in budget planning. On intelligence tests, vocabulary, general information, verbal comprehension, and logical reasoning items measure crystallized intelligence.

In contrast,  fluid intelligence  depends more heavily on basic information-processing skills—ability to detect relationships among visual stimuli, speed of analyzing information, and capacity of working memory. Though fluid intelligence often combines with crystallized intelligence to support effective reasoning and problem solving, it is believed to be influenced less by culture than by conditions in the brain and by learning unique to the individual (Horn & Noll,  1997 ). Intelligence test items reflecting fluid abilities include spatial visualization, digit span, letter–number sequencing, and symbol search. (Refer to  page 302  in  Chapter 9  for examples.)

Don Clarke, who flew attack helicopters in the U.S. army, fulfilled a long-held dream when he became an emergency medical service helicopter pilot. Flying search-and-rescue missions requires Clarke, now in his early sixties, to make use of complex mental abilities that are at their peak in midlife.

Many cross-sectional studies show that crystallized intelligence increases steadily through middle adulthood, whereas fluid intelligence begins to decline in the twenties. These trends have been found repeatedly in investigations in which younger and older participants had similar education and general health status, largely correcting for cohort effects (Horn, Donaldson, & Engstrom,  1981 ; Kaufman & Horn,  1996 ; Park et al.,  2002 ). In one such investigation, including nearly 2,500 mentally and physically healthy 16- to 85-year-olds, verbal (crystallized) IQ peaked between ages 45 and 54 and did not decline until the eighties! Nonverbal (fluid) IQ, in contrast, dropped steadily over the entire age range (Kaufman,  2001 ).

The midlife rise in crystallized abilities makes sense because adults are constantly adding to their knowledge and skills at work, at home, and in leisure activities. In addition, many crystallized skills are practiced almost daily. But does longitudinal evidence confirm the progressive falloff in fluid intelligence? And if so, how can we explain it?

Schaie’s Seattle Longitudinal Study.

Figure 15.5  shows Schaie’s longitudinal findings in detail. The five factors that gained in early and middle adulthood—verbal ability, inductive reasoning, verbal memory, spatial orientation, and numeric ability—include both crystallized and fluid skills. Their paths of change confirm that midlife is a time when some of the most complex mental abilities are at their peak (Willis & Schaie,  1999 ). According to these findings, middle-aged adults are intellectually “in their prime,” not—as stereotypes would have it—“over the hill.”

Figure 15.5 Longitudinal trends in six mental abilities, from the seattle longitudinal study.

In five abilities, modest gains occurred into the fifties and early sixties, followed by gradual declines. The sixth ability—perceptual speed—decreased steadily from the twenties to the late eighties. And late in life, fluid factors (spatial orientation, numeric ability, and perceptual speed) showed greater decrements than crystallized factors (verbal ability, inductive reasoning, and verbal memory).

(From K. W. Schaie, 1994, “The Course of Adult Intellectual Development,” American Psychologist, 49, p. 308. Copyright © 1994 by the American Psychological Association. Reprinted with permission of American Psychological Association.)

Figure 15.5  also shows a sixth ability, perceptual speed—a fluid skill in which participants must, for example, identify within a time limit which of five shapes is identical to a model or whether pairs of multidigit numbers are the same or different. Perceptual speed decreased from the twenties to the late eighties—a pattern that fits with a wealth of research indicating that cognitive processing slows as people get older (Schaie,  1998 ,  2005 ). Also notice in  Figure 15.5  how, late in life, fluid factors (spatial orientation, numeric ability, and perceptual speed) show greater decrements than crystallized factors (verbal ability, inductive reasoning, and verbal memory). These trends have been confirmed in short-term longitudinal follow-ups of individuals varying widely in age (McArdle et al.,  2002 ).

Explaining Changes in Mental Abilities.

Some theorists believe that a general slowing of central nervous system functioning underlies nearly all age-related declines in cognitive performance (Salthouse,  1996 ,  2006 ). Many studies offer at least partial support for this idea. For example, Kaufman ( 2001 ) reported that scores on speeded tasks mirror the regular, age-related decline in fluid-task performance. Researchers have also identified other important changes in information processing, some of which may be triggered by declines in speed.

Before we turn to this evidence, let’s clarify why research reveals gains followed by stability in crystallized abilities, despite a much earlier decline in fluid intelligence, or basic information-processing skills. First, the decrease in basic processing, while substantial after age 45, may not be great enough to affect many well-practiced performances until quite late in life. Second, as we will see, adults can often compensate for cognitive limitations by drawing on their cognitive strengths. Finally, as people discover that they are no longer as good as they once were at certain tasks, they accommodate, shifting to activities that depend less on cognitive efficiency and more on accumulated knowledge. Thus, the basketball player becomes a coach, the once quick-witted salesperson a manager.

Individual and Group Differences

The age trends just described mask large individual differences. Some adults, because of illness or unfavorable environments, decline intellectually much earlier than others. And others sustain high functioning, even in fluid abilities, at advanced ages.

Adults who use their intellectual skills seem to maintain them longer. In the Seattle Longitudinal Study, declines were delayed for people with above-average education; complex, self-directed occupations; and stimulating leisure pursuits that included reading, traveling, attending cultural events, and participating in clubs and professional organizations. People with flexible personalities, lasting marriages (especially to a cognitively high-functioning partner), and absence of cardiovascular and other chronic diseases were also likely to maintain mental abilities well into late adulthood (Schaie,  1996 , 2000,  2011 ; Yu et al.,  2009 ). And being economically well-off was linked to favorable cognitive development, undoubtedly because SES is associated with many of the factors just mentioned.

Several sex differences also emerged, consistent with those found in childhood and adolescence. In early and middle adulthood, women outperformed men on verbal tasks and perceptual speed, while men excelled at spatial skills (Maitland et al.,  2000 ). Overall, however, changes in mental abilities over the adult years were remarkably similar for the two sexes, defying the stereotype that older women are less competent than older men.

Furthermore, when the baby-boom generation, now middle-aged, was compared with the previous generation at the same age, cohort effects were evident. On verbal memory, inductive reasoning, and spatial orientation, baby boomers performed substantially better, reflecting generational advances in education, technology, environmental stimulation, and health care (Schaie,  2011 ; Willis & Schaie,  1999 ). These gains are expected to continue: Today’s children, adolescents, and adults of all ages attain substantially higher mental test scores than same-age individuals born just a decade or two earlier—differences that are largest for fluid-ability tasks (Flynn,  2007 ,  2011 ; Zelinski & Kennison,  2007 ).

Finally, adults who maintained higher levels of perceptual speed tended to be advantaged in other cognitive capacities. As we turn to information processing in midlife, we will pay special attention to the impact of processing speed on other aspects of cognitive functioning.

 Information Processing

Many studies confirm that as processing speed slows, certain basic aspects of executive function, including attention and working memory, decline. Yet midlife is also a time of great expansion in cognitive competence as adults apply their vast knowledge and life experience to problem solving in the everyday world.

Speed of Processing

Devin watched with fascination as his 20-year-old son, Mark, played a computer game, responding to multiple on-screen cues in rapid-fire fashion. When Devin tried it, though he practiced over several days, his performance remained well behind Mark’s. Similarly, on a family holiday in Australia, Mark adjusted quickly to driving on the left side of the road, but after a week, Trisha and Devin still felt confused at intersections, where rapid responses were needed.

These real-life experiences fit with laboratory findings. On both simple reaction-time tasks (pushing a button in response to a light) and complex ones (pushing a left-hand button to a blue light, a right-hand button to a yellow light), response time increases steadily from the early twenties into the nineties. The more complex the situation, the more disadvantaged older adults are. Although the decline in speed is gradual and quite small—less than 1 second in most studies—it is nevertheless of practical significance (Der & Deary,  2006 ; Dykiert et al.,  2012 ).

What causes this age-related slowing of cognitive processing? Researchers agree that changes in the brain are responsible but disagree on the precise explanation (Hartley,  2006 ; Salthouse & Caja,  2000 ). According to the  neural network view , as neurons in the brain die, breaks in neural networks occur. The brain adapts by forming bypasses—new synaptic connections that go around the breaks but are less efficient(Cerella,  1990 ). In support of this hypothesis, aging is accompanied by withering of the myelin coating on neural fibers within the cerebral cortex, especially in the frontal lobes and the corpus callosum. Reduced myelination appears as small, high-intensity bright spots within fMRIs (Raz et al.,  2007 ). The bright spots, a sign of deteriorating neuronal connections, are believed to be caused by reduced cerebral blood flow (often associated with high blood pressure and atherosclerosis). Extent of myelin breakdown, however, does not consistently predict decrements in reaction time or other cognitive functions (Rodrigue & Kennedy,  2011 ).

Another approach to age-related cognitive slowing, the  information-loss view , suggests that older adults experience greater loss of information as it moves through the cognitive system. As a result, the whole system must slow down to inspect and interpret the information. Imagine making a photocopy, then using it to make another copy. Each subsequent copy is less clear. Similarly, with each step of thinking, information degrades. The older the adult, the more exaggerated this effect (Myerson et al.,  1990 ). Complex tasks, which have more processing steps, are more affected by information loss. Possibly, multiple neural changes that vary across individuals underlie such information loss and associated declines in processing speed (Hartley,  2006 ; Salthouse,  2011 ).

What is clear is that processing speed predicts adults’ performance on many tests of complex abilities. The slower their reaction time, the lower people’s scores on tests of memory, reasoning, and problem solving, with relationships greater for fluid- than crystallized-ability items (Finkel et al.,  2007 ; Salthouse,  2006 ). Indeed, as adults get older, correlations between processing speed and other cognitive performances strengthen (see  Figure 15.6 ). This suggests that processing speed contributes broadly to declines in cognitive functioning, which become more widespread and pronounced with aging (Li et al.,  2004 ).

Yet as  Figure 15.6  shows, processing speed correlates only moderately with older adults’ performances, including fluid-ability tasks. And it is not the only major predictor of age-related cognitive changes. Other factors—declines in vision and hearing and in attentional resources, inhibition, working-memory capacity, and use of memory strategies—also predict diverse age-related cognitive performances (Hartley,  2006 ; Luo & Craik,  2008 ). Nevertheless, processing speed, as we will see in the following sections, does contribute to the decrements in attention and memory just mentioned (Levitt, Fugelsang, & Crossley,  2006 ). But disagreement persists over whether age-related cognitive changes have just one common cause, best represented by processing speed, or multiple independent causes.

Furthermore, processing speed is a weak predictor of the skill with which older adults perform complex, familiar tasks in everyday life, which they continue to do with considerable proficiency. Devin, for example, played a Mozart quartet on his cello with great speed and dexterity, keeping up with three other players 10 years his junior. How did he manage? Compared with the others, he more often looked ahead in the score (Krampe & Charness,  2007 ). Using this compensatory approach, he could prepare a response in advance, thereby minimizing the importance of speed. In one study, researchers asked 19- to 72-year-olds to perform a variety of typing tasks and also tested their reaction time. Although reaction time slowed with age, typing speed did not change (Salthouse,  1984 ). Like Devin, older typists look further ahead in the material to be typed, anticipating their next keystrokes. Knowledge and experience can also compensate for impairments in processing speed. Devin’s many years of playing the cello undoubtedly supported his ability to play swiftly and fluidly.

FIGURE 15.6 Age-related changes in correlations of processing speed with measures of fluid and crystallized intelligence.

Correlations are higher at younger and at older ages. During childhood, gains in processing speed support development of other abilities and are related to mental test performance (see  Chapter 9 ,  page 302 ). As people age, declines in processing speed limit many abilities, but more so for fluid than crystallized skills. Note, however, that even at the oldest ages, correlations between processing speed and other abilities are moderate.

(From S.-C. Li et al., 2004, “Transformations in the Couplings Among Intellectual Abilities and Constituent Cognitive Processes Across the Life Span,” Psychological Science, 15, p. 160. Copyright © 2004, Sage Publications. Reprinted by Permission of SAGE Publications.)

Because older adults find ways to compensate for cognitive slowing on familiar tasks, their reaction time is considerably better on verbal items (indicating as quickly as possible whether a string of letters forms a word) than on nonverbal items (responding to a light or other signal) (Hultsch, MacDonald, & Dixon,  2002 ; Verhaeghen & Cerella,  2008 ). Finally, as we will see in  Chapter 17 , older adults’ processing speed can be improved through training, though age differences remain.

Attention

Studies of attention focus on how much information adults can take into their mental systems at once; the extent to which they can attend selectively, ignoring irrelevant information; and the ease with which they can adapt their attention, switching from one task to another as the situation demands. When Dottie telephoned, Trisha sometimes tried to prepare dinner or check her e-mail inbox while talking on the phone. But with age, she found it harder to engage in the two activities simultaneously.

Consistent with Trisha’s experience, laboratory research reveals that sustaining two tasks at once, when at least one of the tasks is complex, becomes more challenging with age. Older adults have difficulty even when they have recently engaged in extensive practice of one of the activities and it is therefore expected to be automatic (Maquestiaux et al.,  2010 ). An age-related decrement also occurs in the ability to focus on relevant information and to switch back and forth between mental operations, such as judging one of a pair of numbers as “odd or even” on some trials, “more or less” on others (Kramer & Kray,  2006 ; Verhaeghen & Cerella,  2008 ).

These declines in attention might be due to the slowdown in information processing described earlier, which limits the amount of information a person can focus on at once (Allen, Ruthruff, & Lien,  2007 ; Verhaeghen,  2012 ). Reduced processing speed may also contribute to a related finding: a decrement with age in the ability to combine many pieces of visual information into a meaningful pattern. When the mind inspects stimuli slowly, they are more likely to remain disconnected (Pilz, Bennett, & Sekuler,  2010 ; Plude & Doussard-Roosevelt,  1989 ). This problem, in turn, can intensify attentional difficulties.

As adults get older, inhibition—resistance to interference from irrelevant information—is also harder (Gazzaley et al.,  2005 ; Hasher, Lustig, & Zacks,  2007 ). On continuous performance tasks, in which participants are shown a series of stimuli on a computer screen and asked to press the space bar only after a particular sequence occurs (for example, the letter K immediately followed by the letter A), performance declines steadily from the thirties into old age, with older adults making more errors of commission (pressing the space bar in response to incorrect letter sequences). And when extraneous noise is introduced, errors of omission (not pressing the space bar after a K–A sequence) also rise with age (Mani, Bedwell, & Miller,  2005 ). In everyday life, inhibitory difficulties cause older adults to appear distractible—inappropriately diverted from the task at hand by a thought or a feature of the environment.

Again, adults can compensate for these changes. People highly experienced in attending to critical information and performing several tasks at once, such as air traffic controllers and pilots, know exactly what to look for. As a result, they show smaller age-related attentional declines (Tsang & Shaner,  1998 ). Similarly, older adults focus on relevant information and handle two tasks proficiently when they have extensively practiced those activities over their lifetimes (Kramer & Madden,  2008 ).

Conductors and teachers must focus on relevant information within a complex field of stimulation and divide their attention among competing tasks—well-practiced skills that may help slow age-related declines in attention.

Finally, practice can improve the ability to divide attention between two tasks, selectively focus on relevant information, and switch back and forth between mental operations. When older adults receive training in these skills, their performance improves as much as that of younger adults, although training does not close the gap between age groups (Bherer et al.,  2006 ; Erickson et al.,  2007 ; Kramer, Hahn, & Gopher,  1998 ).

Memory

Memory is crucial for all aspects of information processing—an important reason that we place great value on a good memory in middle and late adulthood. From the twenties into the sixties, the amount of information people can retain in working memory diminishes. Whether given lists of words or digits (verbal tasks) or serial location stimuli (spatial tasks involving retaining each location on a screen of a series of stimuli), middle-aged and older adults recall less than young adults, although verbal memory suffers much less than spatial memory (Hale et al.,  2011 ; Old & Naveh-Benjamin,  2008a ). Verbal memory may be better preserved because the older adults tested have previously formed and often used verbal representations of the to-be-learned information (Kalpouzos & Nyberg,  2012 ). The necessary spatial representations, in contrast, are far less familiar.

These changes are affected by a decline in use of memory strategies. Older individuals rehearse less than younger individuals—a difference believed to be due to a slower rate of thinking (Salthouse,  1996 ). Older people cannot repeat new information to themselves as quickly as younger people. A reduction in basic working-memory capacity is another influence, leading to difficulties in retaining to-be-remembered items and processing them at the same time (Basak & Verhaeghen,  2011 ).

Memory strategies of organization and elaboration, which require people to link incoming information with already stored information, are also applied less often and less effectively with age (Dunlosky & Hertzog,  2001 ; Troyer et al.,  2006 ). An additional reason older adults are less likely to use these techniques is that they find it harder to retrieve information from long-term memory that would help them recall. For example, given a list of words containing parrot and blue jay, they don’t immediately access the category “bird,” even though they know it well (Hultsch et al.,  1998 ). Why does this happen? Greater difficulty keeping one’s attention on relevant information seems to be involved (Hasher, Lustig, & Zacks,  2007 ). As irrelevant stimuli take up space in working memory, less is available for the memory task at hand.

But keep in mind that the memory tasks given by researchers require strategies that many adults seldom use and may not be motivated to use, since most are not in school (see  Chapter 9 ,  page 306 ). When a word list has a strong category-based structure, older adults organize as well as younger adults do (Naveh-Benjamin,  2000 ; Naveh-Benjamin et al.,  2005 ). And when given training in strategic memorizing, middle-aged and older people use strategies willingly, and they show improved performance over long periods, though age differences remain (Derwinger, Neely, & Bäckman,  2005 ).

Furthermore, tasks can be designed to help older people compensate for age-related declines in working memory—for example, by slowing the pace at which information is presented or cuing the link between new and previously stored information (“To learn these words, try thinking of the category ‘bird’”) (Hay & Jacoby,  1999 ). In one study, adults ranging in age from 19 to 68 were shown a video and immediately tested on its content (a pressured, classroomlike condition). Then they were given a packet of information on the same topic as the video to study at their leisure and told to return three days later to be tested (a self-paced condition) (Beier & Ackerman,  2005 ). Performance declined with age only in the pressured condition, not in the self-paced condition. And although topic-relevant knowledge predicted better recall in both conditions, it did so more strongly in the self-paced condition, which granted participants ample time to retrieve and apply what they already knew.

LOOK AND LISTEN

Ask several adults in their fifties or early sixties to list their top three everyday memory challenges and to explain what they do to enhance recall. How knowledgeable are these midlifers about effective memory strategies?

As these findings illustrate, assessing older adults in highly structured, constrained conditions substantially underestimates what they can remember when given opportunities to pace and direct their own learning. (Refer to the Social Issues: Education box on the following page for a “dramatic” illustration.) When we consider the variety of memory skills we call on in daily life, the decrements just described are limited in scope. General factual knowledge (such as historical events), procedural knowledge (such as how to drive a car or solve a math problem), and knowledge related to one’s occupation either remain unchanged or increase into midlife.

Social Issues: Education The Art of Acting Improves Memory in Older Adults

These community-theater actors master their lines through deep, elaborate processing of goal-oriented segments of dialogue. Teaching these script-learning techniques to aging adults yields lasting gains in memory performance.

Actors face a daunting task: They must memorize massive quantities of dialogue and then reproduce it accurately and spontaneously, as if they genuinely mean what they say. No wonder the most common question asked of actors is, “How did you learn all those lines?”

Interviews with professional actors reveal that most don’t memorize lines in the way students typically learn a historic speech or a poem in school—by rote, or rehearsing the lines many times. Instead, they focus on the meaning of the words, an approach that produces much better recall. First, they analyze the script for the character’s intentions, breaking it down into what they call “beats”—small, goal-directed chunks of dialogue. Then they represent the role as a sequence of goals, one leading to the next. When actors recall this chain of goals, lines become easier to remember (Noice & Noice,  2006 ). For example, one actor divided a half-page of dialogue into three beats: “to put [the other character] at ease,” “to start a conversation with him,” “to flatter/draw him out.”

To create a beat sequence, actors engage in extensive elaboration of dialogue segments. For example, to the line, “Perhaps he’s in love with me but doesn’t know it,” an actor might create a visual image of an uncertain lover, relate the material to a past love affair of her own, and match her own mood to feeling tone of the statement. Deep elaborative processing of the dialogue segment, along with analysis of its beat goal, yields substantial verbatim recall without rote memorization.

Actors’ script learning is so successful that on stage, they are free to “live in the moment,” focusing on communicating authentic meaning through action, emotion, and utterance while speaking verbatim lines. This intermodal integration of spoken word with facial expression, tone of voice, and body language contributes further to script retention.

Can aging adults benefit from exercises that teach the essence of acting—thorough mastery of a script, enabling complete immersion in performance? To find out, researchers gave middle-aged and older adults nine 90-minute cognitively demanding group sessions of theater training over a month’s time. Each session required them to analyze the goals of brief scenes so they could become fully engrossed in acting out their meaning (Noice, Noice, & Staines,  2004 ). Compared with no-intervention controls, theater-training participants showed greater gains on tests of working-memory capacity, word recall, and problem solving—improvements still evident four months after the intervention ended.

The theater training required highly effortful intermodal processing, which may explain its cognitive benefits. fMRI research indicates that deeply processing verbal meanings strongly activates certain areas in the frontal lobes of the cerebral cortex in middle-aged adults, restoring them to patterns close to those of young adults (Park,  2002 ). These findings lend neurobiological support to the power of acting, with its challenging intermodal processing of meaning, to enhance human memory.

Furthermore, middle-aged people who have trouble recalling something often draw on decades of accumulated metacognitive knowledge about how to maximize memory—reviewing major points before an important presentation, organizing notes and files so information can be found quickly, and parking the car in the same area of the parking lot each day. Research confirms that aging has little impact on metacognitive knowledge and the ability to apply such knowledge to improve learning (Hertzog & Dunlosky  2011 ; Schwartz & Frazier,  2005 ).

In sum, age-related changes in memory vary widely across tasks and individuals as people use their cognitive capacities to meet the requirements of their everyday worlds.  TAKE A MOMENT…  Does this remind you of Sternberg’s theory of successful intelligence, described in  Chapter 9 —in particular, his notion of practical intelligence (see  page 311 )? Intelligent people adapt their information-processing skills to fit with their personal desires and the demands of their environments. Therefore, to understand memory development (and other aspects of cognition) in adulthood, we must view it in context. As we turn to problem solving, expertise, and creativity, we will encounter this theme again.

Practical Problem Solving and Expertise

One evening, as Devin and Trisha sat in the balcony of the Chicago Opera House awaiting curtain time, the announcement came that 67-year-old Ardis Krainik, the opera company’s general director and “life force,” had died. After a shocked hush, members of the audience began turning to one another, asking about the woman who had made the opera company into one of the world’s greatest.

Starting as a chorus singer and clerk typist, Ardis rose rapidly through the ranks, becoming assistant to the director and developing a reputation for tireless work and unmatched organizational skill. When the opera company fell deeply in debt, Ardis—now the newly appointed general director—erased the deficit within a year and restored the company’s sagging reputation. She charmed donors into making large contributions, attracted world-class singers, and filled the house to near capacity.

Ardis’s story is a dramatic one, but all middle-aged adults encounter opportunities to display continued cognitive growth in the realm of  practical problem solving , which requires people to size up real-world situations and analyze how best to achieve goals that have a high degree of uncertainty. Gains in expertise—an extensive, highly organized, and integrated knowledge base that can be used to support a high level of performance—help us understand why practical problem solving takes this leap forward.

The development of expertise is under way in early adulthood and reaches its height in midlife, leading to highly efficient and effective approaches to solving problems that are organized around abstract principles and intuitive judgments. Saturated with experience, the expert intuitively feels when an approach to a problem will work and when it will not. This rapid, implicit application of knowledge is the result of years of learning, experience, and effortful practice (Birney & Sternberg,  2006 ; Krampe & Charness,  2007 ). It cannot be assessed by laboratory tasks or mental tests that do not call on this knowledge.

Expertise is not just the province of the highly educated and of those who rise to the top of administrative ladders. In a study of food service workers, researchers identified the diverse ingredients of expert performance in terms of physical skills (strength and dexterity); technical knowledge (of menu items, ordering, and food presentation); organizational skills (setting priorities, anticipating customer needs); and social skills (confident presentation and a pleasant, polished manner). Next, 20- to 60-year-olds with fewer than two to more than ten years of experience were evaluated on these qualities. Although physical strength and dexterity declined with age, job knowledge and organizational and social skills increased (Perlmutter, Kaplan, & Nyquist,  1990 ). Compared to younger adults with similar years of experience, middle-aged employees performed more competently, serving customers in especially adept, attentive ways.

Age-related advantages are also evident in solutions to everyday problems (Denney,  1990 ; Denney & Pearce,  1989 ).  TAKE A MOMENT…  Consider the following dilemma:

·  What would you do if you had a landlord who refused to make some expensive repairs you want done because he or she thinks they are too costly?

· a. Try to make the repairs yourself.

· b. Try to understand your landlord’s view and decide whether they are necessary repairs.

· c. Try to get someone to settle the dispute between you and your landlord.

· d. Accept the situation and don’t dwell on it. (Cornelius & Caspi,  1987 , p. 146)

In this example, the preferred choice is (b), a problem-centered approach that involves seeking information and using it to guide action. From middle age on, adults place greater emphasis on thinking through a practical problem with multiple potential solutions—trying to understand it better, interpreting it from different perspectives, and solving it through logical analysis. On such tasks, middle-aged and older adults select strategies that (as rated by independent judges) are at least as good as and sometimes better than those of young adults (Kim & Hasher,  2005 ; Mienaltowski,  2011 ). Perhaps for this reason, they are more rational decision makers—less likely than young adults to select attractive-looking options that, on further reflection, are not the best.

Creativity

As noted in  Chapter 13 , creative accomplishment tends to peak in the late thirties or early forties and then decline, but with considerable variation across individuals and disciplines. Some people produce highly creative works in later decades: In her early sixties, Martha Graham choreographed Clytemnestra, recognized as one of the great full-length modern-dance dramas. Igor Stravinsky composed his last major musical work at age 84. Charles Darwin finished On the Origin of Species at age 50 and continued to write groundbreaking books and papers in his sixties and seventies. Harold Gregor, who painted the dazzling image on the cover of this book, continues to invent new styles and to be a highly productive artist at age 83. And as with problem solving, the quality of creativity may change with advancing age—in at least three ways.

First, youthful creativity in literature and the arts is often spontaneous and intensely emotional, while creative works produced after age 40 often appear more deliberately thoughtful (Lubart & Sternberg,  1998 ). Perhaps for this reason, poets produce their most frequently cited works at younger ages than do authors of fiction and nonfiction (Cohen-Shalev,  1986 ). Poetry depends more on language play and “hot” expression of feelings, whereas story- and book-length works require extensive planning and molding.

Second, with age, many creators shift from generating unusual products to combining extensive knowledge and experience into unique ways of thinking (Abra,  1989 ; Sasser-Coen,  1993 ). Creative works by older adults more often sum up or integrate ideas. Mature academics typically devote less energy to new discoveries in favor of writing memoirs, histories of their field, and other reflective works. And in older creators’ novels, scholarly writings, and commentaries about their paintings and musical compositions, learning from life experience and living with old age are common themes (Beckerman,  1990 ; Lindauer, Orwoll, & Kelley,  1997 ; Sternberg & Lubart,  2001 ).

In midlife, creativity often shifts to more altruistic goals. Author Masha Hamilton’s travels to northeastern Kenya to research her novel, The Camel Bookmobile, led her to help organize the Camel Book Drive. It has funded the purchase of camels, books, and equipment for nomadic schools in the area.

Finally, creativity in middle adulthood frequently reflects a transition from a largely egocentric concern with self-expression to more altruistic goals (Tahir & Gruber,  2003 ). As the middle-aged person overcomes the youthful illusion that life is eternal, the desire to give to humanity and enrich the lives of others increases.

Taken together, these changes may contribute to an overall decline in creative output in later decades. In reality, however, creativity takes new forms.

Information Processing in Context

Cognitive gains in middle adulthood are especially likely in areas involving experience-based buildup and transformation of knowledge and skills. As the evidence just reviewed confirms, processing speed varies with the situation. When given challenging real-world problems related to their expertise, middle-aged adults are likely to win out in both efficiency and excellence of thinking. Furthermore, on tasks and test items relevant to their real-life endeavors, intelligent, cognitively active midlifers respond as competently and nearly as quickly as their younger counterparts do!

By middle age, people’s past and current experiences vary enormously—more so than in previous decades—and thinking is characterized by an increase in specialization as people branch out in various directions. Yet to reach their cognitive potential, adults must have opportunities for continued growth. Let’s see how vocational and educational environments can support cognition in midlife.

ASK YOURSELF

REVIEW How do slowing of cognitive processing, reduced working-memory capacity, and difficulties with inhibition affect memory in midlife? What can older adults do to compensate for these declines?

CONNECT In which aspects of cognition did Devin decline, and in which did he gain? How do changes in Devin’s thinking reflect assumptions of the lifespan perspective?

APPLY Asked about hiring middle-aged sales personnel, a department store manager replied, “They’re my best employees!” Why does this manager find older employees desirable, despite age-related declines in processing speed, attention, and working memory?

 Vocational Life and Cognitive Development

Vocational settings are vital contexts for maintaining previously acquired skills and learning new ones. Yet work environments vary in the degree to which they are cognitively stimulating and promote autonomy. And inaccurate, negative stereotypes of age-related problem-solving and decision-making skills can result in older employees being assigned less challenging work.

Recall from  Chapter 13  that cognitive and personality characteristics affect occupational choice. Once a person is immersed in a job, it influences cognition. In a study of a large sample of U.S. men in diverse occupations, researchers asked about the complexity and self-direction of their jobs. During the interview, they also assessed cognitive flexibility, based on logical reasoning, awareness of both sides of an issue, and independence of judgment. Two decades later, the job and cognitive variables were remeasured, permitting a look at their effects on each other (Schooler, Mulatu, & Oates,  2004 ). Findings revealed that complex work augmented later cognitive flexibility more than cognitive flexibility influenced preference for complex work.

Similar findings emerged in large-scale studies carried out in Japan and Poland—cultures quite different from the United States (Kohn,  2006 ; Kohn et al.,  1990 ; Kohn & Slomczynski,  1990 ). In each nation, having a stimulating, nonroutine job helped explain the relationship between SES and flexible, abstract thinking. Furthermore, people in their fifties and early sixties benefit cognitively from challenging work just as much as those in their twenties and thirties (Avolio & Sosik,  1999 ; Miller, Slomczynski, & Kohn,  1985 ).

Mentally stimulating work requires middle-aged and older adults to grapple with novel situations. Research suggests that continuously confronting complex, novel tasks contributes importantly to cognitive development, predicting gains in cognitive flexibility and reducing the age-related decline in fluid abilities (Bowen, Noack, & Staudinger,  2011 ). Once again, we are reminded of the plasticity of development. Cognitive flexibility is responsive to work experiences well into middle adulthood and perhaps beyond. Designing jobs to promote intellectual stimulation and challenge may be a powerful means of fostering higher cognitive functioning later in the lifespan.

 Adult Learners: Becoming a Student in Midlife

Adults are returning to undergraduate and graduate study in record numbers. During the past three decades, students age 25 and older in U.S. colleges and universities increased from 27 to 39 percent of total enrollment, with an especially sharp rise in those over age 35 (U.S. Department of Education,  2012 ). Life transitions often trigger a return to formal education, as with Devin and Trisha’s friend Anya, who entered a nursing program after her last child left home. Early marriage (which often disrupts women’s educational pathways), divorce, widowhood, a job layoff, a family move, a youngest child reaching school age, older children entering college, and rapid changes in the job market are other events that commonly precede reentry (Hostetler, Sweet, & Moen,  2007 ; Moen & Roehling,  2005 ). Among a sample of African-American women, additional motivations included serving as a role model for children and enriching their ethnic community as a whole (Coker,  2003 ).

This 50-year-old, a full-time undergraduate at Mount Holyoke College, is one of many nontraditional students in U.S. colleges and universities. Appropriate academic advising and encouragement from family members, friends, and faculty help middle-aged learners succeed.

Characteristics of Returning Students

About 60 percent of adult learners are women (U.S. Department of Education,  2012 ). As Anya’s fear of not being able to handle class work suggests (see  page 501 ), reentry women report feeling especially self-conscious, inadequate, and hesitant to talk in class (Compton, Cox, & Laanan,  2006 ). Their anxiety stems partly from not having practiced academic learning for many years and partly from negative aging and gender stereotypes—erroneous beliefs that traditional-age students are smarter or that men are more logical and therefore more academically capable. And for minority students, ethnic stereotypes about ability to learn and prejudicial treatment are also factors (Coker,  2003 ).

Role demands outside of school—from children, spouses, other family members, friends, and employers—pull many returning women in conflicting directions. Those reporting high psychological stress typically are single parents with limited financial resources, or married women with high career aspirations, young children, and nonsupportive partners (Deutsch & Schmertz,  2011 ; Padula & Miller,  1999 ). When couples fail to rework divisions of household and child-care responsibilities to accommodate the woman’s return to school, marital satisfaction declines (Sweet & Moen,  2007 ). As a classmate remarked to Anya, “I tried keeping the book open and reading, cooking, and talking to the kids. It didn’t work. So I had to say to Bill, ‘Can’t you put in a load of laundry once in a while, get home earlier on just some nights?’ He forgets—I went through his going to graduate school!”

Because of multiple demands on their time, mature-age women tend to take fewer credits, experience more interruptions in their academic programs, and progress at a slower pace than mature-age men. Role overload is the most common reason for not completing their degrees (Jacobs & King,  2002 ). But many express high motivation to work through those difficulties, referring to the excitement of learning, to the fulfillment academic success brings, and to their hope that a college education will improve both their work and family lives (Kinser & Deitchman,  2007 ).

LOOK AND LISTEN

Interview a nontraditional student on your campus about the personal challenges and rewards of working toward a degree at a later age.

Supporting Returning Students

As these findings suggest, social supports for returning students can make the difference between continuing in school and dropping out. Adult students need family members and friends who encourage their efforts and enable them to find time for uninterrupted study. Anya’s classmate explained, “My doubts subsided when one day, Bill volunteered, ‘You take your books and do what you need to do. I can cook dinner and do the laundry.’” Institutional services for returning students are also essential. Personal relationships with faculty, peer networks enabling adults to build a social community with other nontraditional students who understand their daily struggles, conveniently scheduled evening and Saturday classes, online courses, and financial aid for part-time students increase the chances of academic success.

Applying What We Know Facilitating Adult Reentry to College

Sources of Support	Description
Partner and children	Value and encourage educational efforts. Help with household tasks to permit time for uninterrupted study.
Extended family and friends	Value and encourage educational efforts.
Educational institution	Provide orientation programs and literature that inform adult students about services and social supports. Provide counseling and intervention addressing academic weaknesses, self-doubts about success, and matching courses to career goals. Facilitate peer networks through regular meetings, phone, and online contacts. Promote personal relationships with faculty. Encourage active engagement and discussion in classes and integration of course content with real-life experiences. Offer evening, Saturday, and off-campus classes and online courses. Provide financial aid for part-time students. Initiate campaigns to recruit returning students, including those from low-income families and ethnic minority groups. Help students with young children find child-care arrangements and provide on-campus child care.
Workplace	Value and encourage educational efforts. Offer flexible work schedules to make possible coordination of work, class, and family responsibilities.

Although nontraditional students rarely require assistance in settling on career goals, they report a strong desire for help in choosing the most appropriate courses and for small, discussion-based classes that meet their learning and relationship needs. Academic advising and professional internship opportunities are vital. Students from low-SES backgrounds often need special assistance, such as academic tutoring, sessions in confidence building and assertiveness, and—in the case of ethnic minorities—help adjusting to styles of learning that are at odds with their cultural background.

Applying What We Know above suggests ways to facilitate adult reentry to college. When support systems are in place, most returning students reap great personal benefits and do well academically. Succeeding at coordinating education, family, and work demands leads to gains in self-efficacy and admiration from family members, friends, and co-workers (Chao & Good,  2004 ). Nontraditional students especially value forming new relationships, sharing opinions and experiences, and relating subject matter to their own lives. Their greater ability to integrate knowledge results in an enhanced appreciation of classroom experiences and assignments. And their presence in college classes provides valuable intergenerational contact. As younger students observe the capacities and talents of older classmates, unfavorable stereotypes of aging decline.

After finishing her degree, Anya secured a position as a parish nurse with creative opportunities to counsel members of a large congregation about health concerns. Education granted her new life options, financial rewards, and higher self-esteem as she reevaluated her own competencies. Sometimes (though not in Anya’s case) these revised values and increased self-reliance can spark other changes, such as a divorce or a new intimate partnership (Esterberg, Moen, & Dempster-McClain,  1994 ). In middle adulthood as in earlier years, education transforms development, often profoundly reshaping the life course.

ASK YOURSELF

REVIEW In view of the impact of vocational and educational experiences on midlife cognitive development, evaluate the saying “You can’t teach an old dog new tricks.”

CONNECT Most high-level government and corporate positions are held by middle-aged and older adults rather than by young adults. What cognitive capacities enable mature adults to perform these jobs well?

APPLY Marcella completed one year of college in her twenties. Now, at age 42, she has returned to earn a degree. Plan a set of experiences for Marcella’s first semester that will increase her chances of success.

REFLECT What range of services does your institution offer to support returning students? What additional supports would you recommend?

SUMMARY

Physical DeveloPment

Physical changes ( p. 502 )

Describe the physical changes of middle adulthood, paying special attention to vision, hearing, the skin, muscle–fat makeup, and the skeleton.

· ● The gradual physical changes begun in early adulthood continue in midlife, contributing to a revised physical self-image, with less emphasis on hoped-for gains and more on feared declines.

· ● Vision is affected by presbyopia (loss of the accommodative ability of the lens), reduced vision in dim light, increased sensitivity to glare, and diminished color discrimination. After age 40, risk of  glaucoma , a buildup of pressure in the eye that damages the optic nerve, increases.

· ● Age-related hearing loss, or presbycusis, begins with a decline in detection of high frequencies and then spreads to other tones. Eventually, human speech becomes harder to decipher. 

· ● The skin wrinkles, loosens, and dries. Age spots develop, especially in women and in people exposed to the sun.

· ● Muscle mass declines and fat deposits increase, with notable sex differences in fat distribution. A low-fat diet and regular exercise, including resistance training, can offset both excess weight and muscle loss.

· ● Bone density declines, especially in women after menopause. Height loss and bone fractures can result.

Describe reproductive changes in both sexes during middle adulthood.

· ● The climacteric in women, which occurs gradually as estrogen production drops, concludes with menopause, often accompanied by emotional and physical symptoms. These reactions, however, vary widely with ethnicity, SES, physical health, psychological stress, and other factors.

· ● Hormone therapy can reduce the discomforts of menopause, but its use increases the risk of cardiovascular disease, certain cancers, and cognitive declines.

· ● Although sperm production continues throughout life, quantity of semen diminishes and erections become harder to attain and maintain. Drugs are available to combat impotence.

Health and Fitness ( p. 508 )

Discuss sexuality in middle adulthood and its association with psychological well-being.

· ● Frequency of sexual activity among married couples declines only slightly in middle adulthood. Intensity of sexual response diminishes due to physical changes of the climacteric. Most married people over age 50 find ways to overcome difficulties with sexual functioning.

· Discuss cancer, cardiovascular disease, and osteoporosis, noting risk factors and interventions.

· ● The death rate from cancer multiplies tenfold from early to middle adulthood. A complex interaction of heredity, biological aging, and environment contributes to cancer. Today, nearly 60 percent of affected individuals are cured. Regular screenings and various preventive steps can reduce the incidence of cancer and cancer deaths.

· ● Despite a decline in recent decades, cardiovascular disease remains a major cause of death in middle adulthood, especially among men. Symptoms include high blood pressure, high blood cholesterol, atherosclerosis, heart attack, arrhythmia, and angina pectoris. Quitting smoking, reducing blood cholesterol, exercising, and reducing stress can decrease risk and aid in treatment.

· ● Osteoporosis affects 12 percent of people over age 50; most are postmenopausal women. Adequate calcium and vitamin D, weight-bearing exercise, resistance training, and bone-strengthening medications can help prevent and treat osteoporosis.

· Discuss the association of hostility and anger with heart disease and other health problems.

· ● Expressed hostility, a component of the Type A behavior pattern, predicts heart disease and other health problems, largely due to physiological arousal associated with anger. Anger suppression is also related to health problems; a better alternative is to develop effective ways of handling stress and conflict.

Adapting to the Physical Challenges of Midlife ( p. 514 )

· Discuss the benefits of stress management, exercise, and an optimistic outlook in dealing effectively with the physical challenges of midlife.

· ● Effective stress management includes both problem-centered and emotion-centered coping, depending on the situation; constructive approaches to anger reduction; and social support. In middle adulthood, people tend to cope with stress more effectively, often reporting lasting personal benefits.

· ● Regular exercise offers physical and psychological advantages, making it worthwhile for sedentary middle-aged people to begin exercising. Developing a sense of self-efficacy, choosing an appropriate exercise format, and having access to accessible, attractive, and safe exercise environments promote physical activity. 

· ● Hardiness is made up of three personal qualities: control, commitment, and challenge. By inducing a generally optimistic outlook, hardiness helps people cope with stress adaptively.

Explain the double standard of aging.

· ● Although negative stereotypes of aging discourage both men and women, middle-aged women are more likely to be viewed unfavorably, especially by men. New surveys suggest that this double standard is declining.

COGNITIVE DEVELOPMENT

Changes in Mental Abilities ( p. 517 )

· Describe cohort effects on intelligence revealed by Schaie’s Seattle Longitudinal Study.

· ● Early cross-sectional research showed a peak in intelligence test performance at age 35 followed by a steep decline, whereas longitudinal evidence revealed modest gains in midlife. Using a sequential design, Schaie found that the cross-sectional, steep drop-off largely resulted from cohort effects, as each new generation experienced better health and education.

· Describe changes in crystallized and fluid intelligence in middle adulthood, and discuss individual and group differences in intellectual development.

· ● Crystallized intelligence, which depends on accumulated knowledge and experience, gains steadily through middle adulthood. In contrast, fluid intelligence, which depends more on basic information-processing skills, begins to decline in the twenties.

· ● In the Seattle Longitudinal Study, perceptual speed shows steady, continuous decline. But other fluid skills, in addition to crystallized abilities, increase through middle adulthood, confirming that midlife is a time of peak performance on a variety of complex abilities.

· ● Large individual differences among middle-aged adults remind us that intellectual development is multidimensional, multidirectional, and plastic. Illness and unfavorable environments are linked to intellectual declines; stimulating occupations and leisure pursuits, flexible personalities, lasting marriages, good health, and economic advantage predict favorable cognitive development.

· ● Women outperform men on verbal tasks and perceptual speed, whereas men excel at spatial skills. Gains in certain intellectual skills by the baby-boomers relative to the previous generation reflect advances in education, technology, environmental stimulation, and health care.

Information Processing ( p. 520 )

How does information processing change in midlife?

· ● Speed of cognitive processing slows with age. According to the neural network view, as neuronal connections deteriorate, the brain adapts by forming new, less efficient synaptic connections. The information-loss view states that older adults experience greater loss of information as it moves through the cognitive system, resulting in slower processing to interpret the information.

· ● As processing speed slows, people perform less well on memory, reasoning, and problem-solving tasks, especially fluid-ability items. But other factors also predict age-related cognitive performances.

· ● Middle-aged people show declines in ability to divide their attention, focus on relevant stimuli, and switch from one task to another as the situation demands. Inhibition becomes harder, at times prompting distractibility. 

· ● Adults in midlife retain less information in working memory, largely due to a decline in use of memory strategies. But training, improved design of tasks, and metacognitive knowledge enable older adults to compensate for age-related decrements.

Discuss the development of practical problem solving, expertise, and creativity in middle adulthood.

· ● Middle-aged adults display continued growth in practical problem solving, largely due to gains in expertise. Creativity becomes more deliberately thoughtful and often shifts from generating unusual products to integrating ideas, and from concern with self-expression to more altruistic goals.

Vocational Life and Cognitive Development ( p. 525 )

Describe the relationship between vocational life and cognitive development.

· ● Well into middle adulthood, stimulating, complex work augments flexible, abstract thinking. It also reduces the age-related decline in fluid abilities.

Adult Learners: Becoming a Student in Midlife ( p. 526 )

Discuss the challenges that adults face in returning to college, ways to support returning students, and benefits of earning a degree in midlife.

· ● Adults are returning to college and graduate school in record numbers. The majority are women, often motivated by life transitions. Returning students must cope with a lack of recent practice at academic work, stereotypes of aging and ethnicity, and demands of multiple roles.

· ● Social support from family and friends and institutional services suited to their needs can help returning students succeed. Further education results in enhanced competencies, new relationships, intergenerational contact, and reshaped life paths.

Important Terms and Concepts

climacteric ( p. 504 )

crystallized intelligence ( p. 518 )

fluid intelligence ( p. 518 )

glaucoma ( p. 503 )

hardiness ( p. 516 )

hormone therapy ( p. 506 )

information loss view ( p. 520 )

menopause ( p. 504 )

neural network view ( p. 520 )

osteoporosis ( p. 512 )

practical problem solving ( p. 524 )

presbycusis ( p. 503 )

presbyopia ( p. 502 )

Type A behavior pattern ( p. 513 )

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PSYC 645

Case Presentation Template

(Use the template below as a guide for both the content and organization of your case presentation assignments. Be sure to include an APA-formatted title page and references page.)

 

I. Key Clinical Issues

A. Client Demographics [This section includes a summary of demographic characteristics like age, gender, employment information, ethnicity/race, SES, marital status, and other significant relationships that the client discusses.]

B. Presenting Problem [This section includes information about the problem(s) that the client reports, the history of the problem(s), and why he/she came for help. The presenting problem can be anything from a single symptom to a full blown disorder. If the relevant information is provided in the case file, then discuss when the problem started, how it developed, and the impact it is having on the client’s life/functioning. Be sure to briefly review the results of any relevant psychological or neuropsychological testing. Another important element of the problem history is why the client is coming in for assistance/what the client is looking to accomplish. Is it by his/ her own choice, or did someone else require him/her to come (e.g., loved one, court)?]

 

II. Diagnosis

A. Diagnostic Impressions: [Based on the specific information provided in the case file, use the current edition of the DSM to identify every plausible disorder the client might be experiencing. For each possible disorder, write a sentence or two summarizing specific DSM criteria that the client appears to meet as well as supporting examples from the case file to explain why you think the client meets the criteria. Identify all potential disorders, including the one you think it is.]

1. Disorder #1

2. Disorder #2

3. Etc.

B. Differential Diagnosis: [For all disorders from above, rule out the ones that cannot be justified by identifying the specific criteria from the DSM that you used to eliminate them. For each disorder that you decide to rule out, explain which diagnostic criteria the client is missing using data from the case file to support your rationale (e.g., “symptoms should persist at least 6 months, while his only have been present for 2 months”).]

1. Disorder #1

2. Disorder #2

3. Etc.

C. Full DSM Diagnosis [Based on the information provided in the case file, use the current version of the DSM to accurately diagnose the client.]

1. Identify the final diagnosis that you have selected after ruling out the other possibilities. To build an argument in support of your diagnosis, briefly describe each diagnostic criterion in the current version of the DMS for the chosen disorder in your own words, and then use specific examples from the client’s case file to demonstrate how he/she meets each one. In all real-world cases, clients express a wide range of symptoms, so it sometimes is difficult to determine a diagnosis. Keep in mind that there is not necessarily a “correct” answer. The important thing is that you carefully review all of the clinical information and provide a persuasive argument about why the particular diagnosis that you chose is appropriate.

2. If necessary, identify any missing criteria that would warrant a provisional diagnosis (i.e., if the client does not meet one or more of the criteria of the disorder that you have chosen, then mention it here). If key criteria are missing, then the diagnosis that you give above would be “Provisonal.”

3. Please bear in mind that there may be only one appropriate diagnosis, so do not feel compelled to include more than one. If you do include more than one diagnosis, provide a persuasive rationale using data from the clinical file to support each one.

 

III. Etiology of the Problem/Disorder [In this section, identify and explain two causal theories of why the current problem/disorder developed or is being maintained. One of the theories has to be biological (e.g., neurotransmitter dysfunction, brain structure abnormalities etc.), and the other has to be psychosocial (e.g., behavioral, cognitive-behavioral, psychodynamic, family systems etc.). Substantiate each theory that you choose using specific examples from the case file and at least one scholarly source to support your rationale. If you cannot justify the etiological theory using case information, then explain what additional information you would need to support your theory. For example, for a biological theory, you cannot just say that one potential cause is “genetics.” You have to provide data from the case to support a genetic theory, and if you cannot build an argument using case data, then you have to explain what additional information you would need to support a genetic theory.]

A. Biological Theory: (Identify ONE biological theory of causation (or maintenance), and then cite information from the case file AND at least one scholarly source to support your rationale). If you cannot justify the etiological theory using case information, then explain what additional information you would need to support your theory.

B. Psychosocial Theory: (Idenitfy ONE psychosocial theory of causation (or maintenance), and cite information from the case file AND at least one scholarly source to support your rationale). If you cannot justify the etiological theory using case information, then explain what additional information you would need to support your theory.

 

IV. Treatment Recommendations [Based on your views of etiology described above, briefly identify and describe two treatment approaches that you would use—one related to each of the theories you described in the Etiology section above. Specifically, you must explain ONE treatment you would use to address the biological cause that you identified, and ONE treatment you would use to address the psychosocial cause that you identified. When making your treatment recomnedations, make sure that they 1) directly address the causal theories presented in the Etiology section, 2) are relevant to the case, 3) are able to be implemented by the client, and 4) are supported by scholarly sources.]

A. Biological Intervention: (Identify ONE biological treatment recommendation that you would use to address the biological cause that you listed above, and cite at least one scholarly source to support your choice. Make sure that there is an explicit, logical rationale to support the link between your biological treatment recommendation and the the biological cause that you posit in the Etiology section above).

B. Psychosocial Intervention: (Identify ONE psychosocial treatment recommendation that you would use to address the psychosocial cause that you listed above, and cite at least one scholarly source to support your choice. Make sure that there is an explicit, logical rationale to support the link between your psychosocial treatment recommendation and the the psychosocial cause that you posit in the Etiology section above).

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Assignment 1: Outlining a Logic Model

A logic model is a tool that can be used in planning a program. Using a logic model, social workers can systematically analyze a proposed new program and how the various elements involved in a program relate to each other. At the program level, social workers consider the range of problems and needs that members of a particular population present. Furthermore, at the program level, the logic model establishes the connection between the resources needed for the program, the planned interventions, the anticipated outcomes, and ways of measuring success. The logic model provides a clear picture of the program for all stakeholders involved.

To prepare for this Assignment, review the case study of the Petrakis family, located in this week’s resources. Conduct research to locate information on an evidence-based program for caregivers like Helen Petrakis that will help you understand her needs as someone who is a caregiver for multiple generations of her family. You can use the NREPP registry. Use this information to generate two logic models for a support group that might help Helen manage her stress and anxiety.

First, consider the practice level. Focus on Helen’s needs and interventions that would address those needs and lead to improved outcomes. Then consider the support group on a new program level. Think about the resources that would be required to implement such a program (inputs) and about how you can measure the outcomes.

Submit the following:

· A completed practice-level logic model outline (table) from the Week 7 Assignment handout

· A completed program logic model outline (table) in the Week 7 Assignment Handout

· 2–3 paragraphs that elaborate on your practice-level logic model outline. Describe the activities that would take place in the support group sessions that would address needs and lead to improved outcomes

· 2–3 paragraphs that elaborate on your program-level logic model and address the following:

• Decisions        that would need to be made about characteristics of group membership
• Group        activities
• Short-        and long-term outcomes
• Ways        to measure the outcomes

References (use 3 or more)

Dudley, J. R. (2014). Social work evaluation: Enhancing what we do. (2nd ed.) Chicago, IL: Lyceum Books.

· Chapter 6, “Needs Assessments” (pp. 107–142)

Plummer, S.-B., Makris, S., & Brocksen S. (Eds.). (2014a). Sessions: Case histories. Baltimore, MD: Laureate International Universities Publishing. [Vital Source e-reader].

Read the following section:

· “The Petrakis Family”

Document: Randolph, K. A. (2010). Logic models. In B. Thyer (Ed.), The handbook of social work research methods (2nd ed., pp. 547–562). Thousand Oaks, CA: Sage. (PDF)

Copyright 2010 by Sage Publications, Inc.
Reprinted by permission of Sage Publications, Inc. via the Copyright Clearance Center.

United Way of America. (1996). Excerpts from Measuring program outcomes: A practical approach. Retrieved from http://web.archive.org/web/20130514153340/http://www.unitedwayslo.org/ComImpacFund/10/Excerpts_Outcomes.pdf

Document: Week 7: Developing A Logic Model Outline Assignment Handout (Word document)

The Petrakis Family

Helen Petrakis is a 52-year-old heterosexual married female of Greek descent who says that she feels overwhelmed and “blue.” She came to our agency at the suggestion of a close friend who thought Helen would benefit from having a person who could listen. Although she is uncomfortable talking about her life with a stranger, Helen said that she decided to come for therapy because she worries about burdening friends with her troubles. Helen and I have met four times, twice per month, for individual therapy in 50-minute sessions.

Helen consistently appears well-groomed. She speaks clearly and in moderate tones and seems to have linear thought progression; her memory seems intact. She claims no history of drug or alcohol abuse, and she does not identify a history of trauma. Helen says that other than chronic back pain from an old injury, which she manages with acetaminophen as needed, she is in good health.

Helen has worked full time at a hospital in the billing department since graduating from high school. Her husband, John (60), works full time managing a grocery store and earns the larger portion of the family income. She and John live with their three adult children in a 4-bedroom house. Helen voices a great deal of pride in the children. Alec, 27, is currently unemployed, which Helen attributes to the poor economy. Dmitra, 23, whom Helen describes as smart, beautiful, and hardworking, works as a sales consultant for a local department store. Athina, 18, is an honors student at a local college and earns spending money as a hostess in a family friend’s restaurant; Helen describes her as adorable and reliable.

In our first session, I explained to Helen that I was an advanced year intern completing my second field placement at the agency. I told her I worked closely with my field supervisor to provide the best care possible. She said that was fine, congratulated me on advancing my career, and then began talking. I listened for the reasons Helen came to speak with me.

I asked Helen about her community, which, she explained, centered on the activities of the Greek Orthodox Church. She and John were married in that church and attend services weekly. She expects that her children will also eventually wed there. Her children, she explained, are religious but do not regularly go to church because they are very busy. She believes that the children are too busy to be expected to help around the house. Helen shops, cooks, and cleans for the family, and John sees to yard care and maintains the family’s cars. When I asked whether the children contributed to the finances of the home, Helen looked shocked and said that John would find it deeply insulting to take money from his children. As Helen described her life, I surmised that the Petrakis family holds strong family bonds within a large and supportive community.

Helen is responsible for the care of John’s 81-year-old widowed mother, Magda, who lives in an apartment 30 minutes away. Until recently, Magda was self-sufficient, coming for weekly family dinners and driving herself shopping and to church. But 6 months ago, she fell and broke her hip and was also recently diagnosed with early signs of dementia. Through their church, Helen and John hired a reliable and trusted woman to check in on Magda a couple of days each week. Helen goes to see Magda on the other days, sometimes twice in one day, depending on Magda’s needs. She buys her food, cleans her home, pays her bills, and keeps track of her medications. Helen says she would like to have the helper come in more often, but she cannot afford it. The money to pay for help is coming out of the couple’s vacations savings. Caring for Magda makes Helen feel as if she is failing as a wife and mother because she no longer has time to spend with her husband and children.

Helen sounded angry as she described the amount of time she gave toward Magda’s care. She has stopped going shopping and out to eat with friends because she can no longer find the time. Lately, John has expressed displeasure with meals at home, as Helen has been cooking less often and brings home takeout. She sounded defeated when she described an incident in which her son, Alec, expressed disappointment in her because she could not provide him with clean laundry. When she cried in response, he offered to help care for his grandmother. Alec proposed moving in with Magda.

Helen wondered if asking Alec to stay with his grandmother might be good for all of them. John and Alec had been arguing lately, and Alec and his grandmother had always been very fond of each other. Helen thought she could offer Alec the money she gave Magda’s helper.

I responded that I thought Helen and Alec were using creative problem solving and utilizing their resources well in crafting a plan. I said that Helen seemed to find good solutions within her family and culture. Helen appeared concerned as I said this, and I surmised that she was reluctant to impose on her son because she and her husband seemed to value providing for their children’s needs rather than expecting them to contribute resources. Helen ended the session agreeing to consider the solution we discussed to ease the stress of caring for Magda.

The Petrakis Family

Magda Petrakis: mother of John Petrakis, 81

John Petrakis: father, 60

Helen Petrakis: mother, 52

Alec Petrakis: son, 27

Dmitra Petrakis: daughter, 23

Athina Petrakis: daughter, 18

In our second session, Helen said that her son again mentioned that he saw how overwhelmed she was and wanted to help care for Magda. While Helen was not sure this was the best idea, she saw how it might be helpful for a short time. Nonetheless, her instincts were still telling her that this could be a bad plan. Helen worried about changing the arrangements as they were and seemed reluctant to step away from her integral role in Magda’s care, despite the pain it was causing her. In this session, I helped Helen begin to explore her feelings and assumptions about her role as a caretaker in the family. Helen did not seem able to identify her expectations of herself as a caretaker. She did, however, resolve her ambivalence about Alec’s offer to care for Magda. By the end of the session, Helen agreed to have Alec live with his grandmother.

In our third session, Helen briskly walked into the room and announced that Alec had moved in with Magda and it was a disaster. Since the move, Helen had had to be at the apartment at least once daily to intervene with emergencies. Magda called Helen at work the day after Alec moved in to ask Helen to pick up a refill of her medications at the pharmacy. Helen asked to speak to Alec, and Magda said he had gone out with two friends the night before and had not come home yet. Helen left work immediately and drove to Magda’s home. Helen angrily told me that she assumed that Magda misplaced the medications, but then she began to cry and said that the medications were not misplaced, they were really gone. When she searched the apartment, Helen noticed that the cash box was empty and that Magda’s checkbook was missing two checks. Helen determined that Magda was robbed, but because she did not want to frighten her, she decided not to report the crime. Instead, Helen phoned the pharmacy and explained that her mother-in-law, suffering from dementia, had accidently destroyed her medication and would need refills. She called Magda’s bank and learned that the checks had been cashed. Helen cooked lunch for her mother-in-law and ate it with her. When a tired and disheveled Alec arrived back in the apartment, Helen quietly told her son about the robbery and reinforced the importance of remaining in the building with Magda at night.

Helen said that the events in Magda’s apartment were repeated 2 days later. By this time in the session Helen was furious. With her face red with rage and her hands shaking, she told me that all this was my fault for suggesting that Alec’s presence in the apartment would benefit the family. Jewelry from Greece, which had been in the family for generations, was now gone. Alec would never be in this trouble if I had not told Helen he should be permitted to live with his grandmother. Helen said she should know better than to talk to a stranger about private matters.

Helen cried, and as I sat and listened to her sobs, I was not sure whether to let her cry, give her a tissue, or interrupt her. As the session was nearing the end, Helen quickly told me that Alec has struggled with maintaining sobriety since he was a teen. He is currently on 2 years’ probation for possession and had recently completed a rehabilitation program. Helen said she now realized Alec was stealing from his grandmother to support his drug habit. She could not possibly tell her husband because he would hurt and humiliate Alec, and she would not consider telling the police. Helen’s solution was to remove the valuables and medications from the apartment and to visit twice a day to bring supplies and medicine and check on Alec and Magda.

After this session, it was unclear how to proceed with Helen. I asked my field instructor for help. I explained that I had offered support for a possible solution to Helen’s difficulties and stress. In rereading the progress notes in Helen’s chart, I realized I had misinterpreted Helen’s reluctance to ask Alec to move in with his grandmother. I felt terrible about pushing Helen into acting outside of her own instincts.

My field instructor reminded me that I had not forced Helen to act as she had and that no one was responsible for the actions of another person. She told me that beginning social workers do make mistakes and that my errors were part of a learning process and were not irreparable. I was reminded that advising Helen, or any client, is ill-advised. My field instructor expressed concern about my ethical and legal obligations to protect Magda. She suggested that I call the county office on aging and adult services to research my duty to report, and to speak to the agency director about my ethical and legal obligations in this case.

In our fourth session, Helen apologized for missing a previous appointment with me. She said she awoke the morning of the appointment with tightness in her chest and a feeling that her heart was racing. John drove Helen to the emergency room at the hospital in which she works. By the time Helen got to the hospital, she could not catch her breath and thought she might pass out. The hospital ran tests but found no conclusive organic reason to explain Helen’s symptoms.

I asked Helen how she felt now. She said that since her visit to the hospital, she continues to experience shortness of breath, usually in the morning when she is getting ready to begin her day. She said she has trouble staying asleep, waking two to four times each night, and she feels tired during the day. Working is hard because she is more forgetful than she has ever been. Her back is giving her trouble, too. Helen said that she feels like her body is one big tired knot.

I suggested that her symptoms could indicate anxiety and she might want to consider seeing a psychiatrist for an evaluation. I told Helen it would make sense, given the pressures in her life, that she felt anxiety. I said that she and I could develop a treatment plan to help her address the anxiety. Helen’s therapy goals include removing Alec from Magda’s apartment and speaking to John about a safe and supported living arrangement for Magda.

(Plummer 20-22)

Plummer, Sara-Beth, Sara Makris, Sally Brocksen. Sessions: Case Histories. Laureate Publishing, 02/2014. VitalBook file.

Assignment 2: Safety and Agency Responsibility

When you walk into a human services organization, do you think about your safety? What about when you prepare to make a home visit or attend a meeting in the community? As a social worker, you may find yourself in situations in which your personal safety is at risk. Although you, as an administrator, cannot prepare for every situation, you should be proactive and put a plan into place to address issues related to workplace violence in the event that it occurs.

For this Assignment, focus on the Zelnick et al. article on workplace violence and consider what plan you might want to have in place if you were an administrator having to address a similar workplace violence situation.

Assignment (2–pages in APA format):

· Draft a plan for a human services organization explaining how to address traumatic emergency situations. Include both how to respond to the emergency and how to address any long-term effects. 

· Finally, based on this week�s resources and your personal experiences, explain your greatest concern about the safety of mental health professionals working in a human services organization.

References (use 2 or more)

Northouse, P. G. (2018). Introduction to leadership: Concepts and practice (4th ed.). Washington, DC: Sage.

• Review Chapter 10,      “Listening to Out-Group Members” (pp. 217-237)
• Chapter 11,      “Managing Conflict” (pp. 239-271)
• Chapter 13,      “Overcoming Obstacles” (pp. 301-319)

Zelnick, J. R., Slayter, E., Flanzbaum, B., Butler, N., Domingo, B., Perlstein, J., & Trust, C. (2013). Part of the job? Workplace violence in Massachusetts social service agencies. Health & Social Work, 38(2), 75–85.

Note: You will access this article from the Walden Library databases.

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