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Chapter 7. Psychological Aspects of Normal Aging
PSYCHOLOGICAL ASPECTS OF NORMAL AGING: INTRODUCTION

Research on psychological aspects of normal aging is now mature and middle-aged. Major longitudinal studies have
collected data for up to 50 years of repeated observations, versions of the Handbook of the Psychology of Aging and
chapters reviewing the psychology of normal aging have been written for up to 30 years, and the handbook is now in
its 6th edition. In this chapter we take a life span approach that is focused on adult development and aging (Siegler
2007a). Thus, it is possible to cite previously published chapters on the normal psychology of aging for geriatric
psychiatry (Poon and Siegler 1991; Siegler 1980; Siegler and Poon 1989; Siegler et al. 1996, 2004) and to focus here on
the exciting data that recently have become available from mature longitudinal studies and from cross-sectional
studies in cognition and neuropsychology, as well as personality and behavioral medicine, that routinely cross
disciplinary boundaries. Since the last edition of this textbook, a series of edited volumes have presented reviews in
areas of the psychology of normal aging (Birren and Schaie 2006; Carstensen and Hartel 2006; Costa and Siegler 2004)
and of health and aging (Aldwin et al. 2007; Markides 2007); these reviews have updated the detailed information
presented in the previously published chapters cited above. Attention to how ethnic factors may shape normal
psychology of aging are now well recognized (Jackson et al. 2004), and ethnic variations in dementia are being
considered (Dilworth-Anderson et al. 2005a, 2005b), as are discussions of cognitive changes with aging (integrated
with neuroimaging and neurosciences [Madden and Whiting 2004; Pierce et al. 2004]), including work in motivation,
emotion, and social functioning (Carstensen et al. 2006). Summaries from these recent volumes are presented in this
chapter.
These summaries will allow us to use the pages allotted to highlight new findings from ongoing research programs. We
start with the Seattle Longitudinal Study (SLS) (Schaie 1996, 2005), which focuses on understanding adult intellectual
development at its core with a much broader and more complete picture of multiple cohorts of aging persons ages
18–88. Next we discuss findings from the Georgia Centenarian Studies (Poon et al., in press), a series of studies of the
extremely aged with comparison populations in their 60s and 80s, presenting data primarily on cognition, personality,
coping, and the role of health status and psychological functioning. As we move to studies of personality, we present
40-year follow-up data from the UNC Alumni Heart Study (Brummett et al. 2006b; Siegler 2007b), which examine
whether young adult measures predict midlife status and whether detailed measures during midlife help explain health
and survival as members of the baby boom cohort reach their age 60 transition. We then look at personality predictors
of midlife hypertension (Siegler 2007b) and review findings from the Maine-Syracuse Studies of the impact of
hypertension on cognitive and neuropsychological measures (Dore et al. 2007; Elias et al. 2004). We also review some
new findings in the coping literature and consider the major common stressor of caregiving as a way to illustrate
important research in ethnic differences and models of stress that relate psychosocial variables to disease outcomes.
One might reasonably ask why such a chapter on normal psychology of aging is still needed in a modern 21st-century
view of geriatric psychiatry. Clinicians will always need to know the limits of expectable behavior with age in terms of
their own expectations as well as expectations of patients and their families. With the benefit of longitudinal findings
and particular attention to what we have learned from centenarian studies, we hope to provide a useful set of
benchmarks.
[Dr. Siegler's work on this chapter was supported by grant R01-HL55356 from the National Heart, Lung and Blood
Institute (NHLBI), with additional support by the National Institute on Aging (NIA), and by NHLBI grant P01-HL36587
and NIA grant AG19605 to Dr. Redford Williams and the Duke Behavioral Medicine Research Center. In addition, the
authors received support for their work on this chapter from the following NIA grants: AG023113 (Dr.
Dilworth-Anderson); R37-AG02163 and R01-AG011622 (Dr. Madden); P01-AG17533 (Dr. Martin and Dr. Poon);
R01-AG0855 (Dr. Schaie); and R37-AG024102 (Dr. Willis).
The authors thank Dr. Redford Williams and Dr. Beverly Brummett for sharing prepublication copies of their work and
Susan Boos for coordinating the chapter.]
INTELLECTUAL AND COGNITIVE DEVELOPMENT
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Course of Adult Intellectual Development

The development of intellectual competence in childhood and adolescence follows a fairly uniform path, with new
stages of competence and differentiation of functioning occurring within a relatively narrow age band. By contrast,
there are widely divergent individual trajectories over the life course of adult intelligence. However, over the 50-year
course of the SLS (Schaie 1996, 2005), sufficient evidence has been gathered to reach some rather definitive
conclusions on a number of core questions:
Does intelligence change uniformly through adulthood, or are there different life course ability patterns? The answer
remains quite unambiguous: Uniform patterns of developmental change across the entire ability spectrum are not
observed for the tests actually given or for the inferred latent ability constructs. Hence, it is only fair to warn those
who would like to assess change in intellectual competence by means of an omnibus IQ-like measure that such an
approach will not be very helpful to either thoughtful clinicians or basic researchers. Such global measures have little
practical utility in monitoring changes (or differences) in intellectual competence for individuals or groups.
From the extensive longitudinal data on the primary mental abilities used in the SLS, it can be concluded that the
abilities of verbal meaning (recognition vocabulary), spatial orientation, and inductive reasoning reach a peak plateau
in midlife from the 40s to the early 60s, whereas number and word fluency peak earlier and show very modest decline
beginning in the 50s. The steepness of late-life decline is greatest for number and least for the reasoning ability. Verbal
meaning declines last but also shows steeper decline than the other abilities from the 70s to the 80s (see Figure 7–1).
More limited data on the multiply marked latent construct estimates (obtained only in the fifth through seventh study
cycles) suggest that a shift in peak ages of performance has been seen and is continuing, and that we now see these
peaks occurring in the 50s for inductive reasoning and spatial orientation and in the 60s for verbal ability and verbal
memory. By contrast, perceptual speed peaks in the 20s and numeric ability in the late 30s. Even by the late 80s,
declines for verbal ability and inductive reasoning are modest, but they are severe in very old age for perceptual speed
and numeric ability, with spatial orientation and verbal memory in between (see Figure 7–2).
FIGURE 7–1. Longitudinal age changes for the primary mental abilities.
Source. Schaie KW: Developmental Influences on Adult Intelligence: The Seattle Longitudinal Study. New York, Oxford University
Press, 2005, p. 116. Reprinted with permission.
FIGURE 7–2. Longitudinal age changes for the latent ability constructs.
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At what age is there on average a reliably detectable decrement in ability, and what is its magnitude? For some ability
markers, statistically significant but extremely modest average changes have been observed in the 50s. Nevertheless,
it should be stressed that individual decline before age 60 is likely to represent a symptom of or a precursor to
neuropathological age changes. On the other hand, it is clear that by the mid-70s significant average decrement can be
observed for all abilities and that by the 80s average decrement is severe except for verbal ability. In the SLS,
statistically significant decrement was found for number and word fluency by age 60 and for space and reasoning by
age 67, but for verbal meaning only by age 81. At the latent construct level, statistically significant decrement is first
observed by age 60 for spatial ability, numeric ability, and perceptual speed; by age 67 for inductive reasoning; and by
age 74 for verbal ability and verbal memory.
The SLS data suggest that it is during the period of the late 60s and 70s that many people begin to experience
noticeable ability declines. Even so, it is not until the 80s are reached that the average older adult will fall below the
middle range of performance for young adults. Hence, it turns out that for decisions relating to the retention of
individuals in the workforce, chronological age is not a useful criterion for groups and is certainly not useful for
individuals. This conclusion has of course been the rationale for largely abandoning mandatory retirement in the United
States.
What are the patterns of generational differences, and what is their magnitude? The facts of individual aging must also
be considered within the context of profound changes over time in environmental and social support systems. In the
SLS, the impact of these changes on intellectual development has been documented by charting cohort (generational)
differences on the intellectual performance measures. These studies have clearly demonstrated that there are
substantial generational trends in intellectual performance. The form of these generational trends has been positive for
verbal meaning, space, and reasoning, but it is concave for number (with peak performance for the 1924 cohort and
decline thereafter) and convex for word fluency (with lowest performance for the 1931 cohort and return to the 1889
baseline thereafter) (see Figure 7–3).
FIGURE 7–3. Cumulative cohort differences for the primary mental abilities.
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An understanding of cohort differences is important in order to account for the discrepancy between longitudinal
(within-group) age changes and the cross-sectional (between-group) age differences. In general, it was found that
cross-sectional findings will overestimate within-individual declines whenever there are positive cohort gradients and
will underestimate decline in the presence of negative cohort gradients. Curvilinear cohort gradients will lead to
temporary dislocations of age-difference patterns and will over- or underestimate age changes, depending on the
direction of differences over a particular time period. The slowing of the cohort difference trend suggests that in the
next 20 or 30 years concurrently measured age differences will become substantially smaller over that age range
where there is little or no within-participant decline. This is fortunate, because there is a need to retain people to
higher ages in the labor force because of the demographic reality of the aging of the baby boomers. Stereotypes about
age decline will obviously be reinforced less in the absence of the dramatic shifts in ability base levels that were
observed for cohorts entering adulthood in the first half of the twentieth century.
What accounts for individual differences in age-related change in adulthood? Some individuals, either because of the
early onset of neuropathology or the experience of particularly unfavorable environments, begin to decline in their 40s,
whereas a favored few maintain a full level of functioning into very advanced age. All individuals do not decline in
lockstep. Although linear or quadratic forms of decline may best describe the average aging of large groups, individual
decline occurs far more frequently in a stair-step fashion. Individuals may have unfavorable experiences, to which they
respond with a modest decline in cognitive functioning but then tend to stabilize for some time, perhaps repeating this
pattern repeatedly before their demise. Moreover, the sequence of decline of abilities is not uniform across individuals
but may depend in any one individual on the circumstances of use and disuse of particular skills. Thus, in actuarial
studies of the SLS core battery, it was observed that virtually all individuals had significantly declined on one ability by
age 60, but virtually no one had declined on all five abilities even by age 88.
Genetic endowment, of course, will account for a substantial portion of individual differences (Schaie 2005, Chapter 16;
Schaie and Zuo 2001). Nevertheless, there are many other important sources of individual differences in intellectual
aging that have been implicated in our studies. To begin with, the onset of intellectual decline seems to be markedly
affected by the presence or absence of a variety of chronic diseases; cardiovascular disease, diabetes, cancers,
arthritis, and other inflammatory diseases have all been identified as risk factors for the occurrence of cognitive
decline, as is a low level of overall health. On the other hand, high levels of cognitive functioning seem to be
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associated with survival after treated malignancies and with late onset of cardiovascular disease and arthritis. Those
persons who function at high cognitive levels are also more likely to seek earlier and more competent medical
intervention in the disabling conditions of late life. They also are more likely to comply effectively with preventive and
ameliorative regimens that tend to stabilize their physiological infrastructure. Perhaps even more importantly, they
are less likely to engage in high-risk lifestyles, and they will respond more readily to professional advice that
maximizes their chances for survival and reduction of morbidity. On the other hand, there does not seem to be a high
relation between cognitive competence and systematic adoption of effective health behaviors. However, the more
able individuals tend to engage in more effective medication use. Findings from the UNC Alumni Heart Study suggest
that some personality factors may also be at work, as discussed later in this chapter.
Can age-related ability change be modified through behavioral interventions? Since the 1970s, a number of cognitive
training studies have examined the question of the modifiability of age-related decline in independent-living elders
without dementia (Ball et al. 2007; Schaie and Willis 1986; Verhagen et al. 1992). The target of these interventions has
been abilities (verbal memory, perceptual speed, inductive reasoning) showing early age-related decline in the
mid-60s. On the basis of findings of small-scale training studies, the Advanced Cognitive Training in Vital Elders
(ACTIVE) (Ball et al. 2002; Jobe et al. 2001) randomized, controlled clinical trial was conducted, and findings of the
5-year follow-up have been recently reported (Willis et al. 2006). Elders were randomly assigned to one of three
interventions focusing on the abilities of inductive reasoning, verbal memory, or speed of processing or a control group.
Booster training was provided to a random subset of each training intervention at 1 year and 3 years after training.
Significant training effects for each of the interventions were found immediately after training and maintained at
5-year follow-up; effects were specific to the ability trained. Booster training significantly improved performance on
the ability trained above the nonboosted intervention condition. At 5-year follow-up, those trained on reasoning
reported significantly less difficulty performing instrumental tasks of daily living; those receiving booster training on
speed of processing were faster at performing speeded tasks of daily living. Trainees in all interventions (compared
with the control group) reported a higher level of quality of life 5 years after training (Wolinsky et al. 2006).
Cognitive Functioning Among the Oldest Old

Data on the oldest old come from the set of studies included in the Georgia Centenarian Studies (Poon et al. 2007).
This section reviews three pertinent questions regarding cognitive functions in very old age: 1) Is dementia inevitable
as one ages? 2) Is maintenance of high cognition an important contributor to longevity? and 3) What phenotypes of
cognitive abilities can be employed to classify cognition among the oldest old?
Dementia
Prevalence of dementia is found to be about 1.5% in adults in their mid to late 60s. Both prevalence and incidence rise
to as high as 25%–30% in the oldest old. If one lives to be very old, an interesting question is whether dementia is
inevitable. If dementia is inevitable, then the development of dementia may be part of the normative process as one
ages. If the development of dementia is found not to be universal, then one may conclude that the development of
dementia is pathological and not normal aging.
Empirical data from centenarian studies do not support the assertion that dementia is inevitable in aging (Gondo and
Poon 2007). The prevailing finding from centenarian studies is that dementia prevalence ranged from 42% to 80%
(Akisaka 2000; Andersen-Ranberg et al. 2001; Asada et al. 1996; Beregi and Klinger 1989; Choi et al. 2003; Gondo et
al. 2006; Hagberg et al. 2001; Inagaki 1995; Karasawa 1985; Poon et al., in press; Powell 1994; Ravaglia et al. 1999;
Robine et al. 2003; Silver et al. 2001; Sobel et al. 1995). A lower prevalence of 27% was reported by the Swedish
Centenarian Study; however, after considering nonparticipants, the investigators estimated that the prevalence could
be as high as 42% (Samuelsson et al. 1997). It is interesting to note that only one study to date did report a 100%
dementia rate in the assessment of community-dwelling centenarians (Blansjaar et al. 2000). Kliegel et al. (2004)
found that about half of their centenarians in the Heidelberg Centenarian Study showed moderate to severe cognitive
impairment but that one-quarter were cognitively intact. Results of the Heidelberg study also demonstrated that
cognitive decline was slightly but significantly accelerated in the last 6 months before death. Finally, a recent Japanese
study reported that 24.3% of their centenarian sample had no dementia, 13.8% were classified to "probably" have no
dementia, and 61.8% were classified as having mild to severe dementia (Gondo et al. 2006). Gender effects were
reported in the Japanese study, indicating that men were generally functioning cognitively better than women.
Issues surrounding factors contributing to the development of dementia in old age are controversial beyond whether
dementia is inevitable. The wide range of reported dementia prevalence in different parts of the world could be due to
the use of different criteria in diagnosing dementia, the use of nonrepresentative samples, and differential genetic and
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environmental factors affecting dementia in different geographic areas or cultures. Another potential contributor to the
varying rates is that the female-to-male ratio among centenarians varied greatly, from 1:1 in Sardinia, Italy, to 12:1 in
regions of South Korea. Because women tend to have a higher dementia prevalence (Andersen-Ranberg et al. 2001;
Beregi and Klinger 1989; Choi et al. 2003; Gondo et al. 2006; Hagberg et al. 2001; Ravaglia et al. 1999; Robine et al.
2003; Sobel et al. 1995), the gender ratio could significantly affect the dementia prevalence of a sample or population.
The time is ripe to better understand contributing factors to dementia prevalence within and between cultures and
ethnicities.
Cognitive Function and Longevity
Does a high level of cognitive functioning contribute to longevity? A review by Gondo and Poon (in press) provided
supportive evidence in both longitudinal and centenarian studies. A series of studies that collected intelligence test
data among children showed a strong relationship between high childhood intelligence and low mortality in middle and
old age (Batty et al. 2006; Deary et al. 2006; Hart et al. 2005; Shenkin et al. 2004; Whalley and Deary 2001; Whalley et
al. 2000). Similarly, the Terman cohort study (Friedman and Martin 2007), which examined the life course of
intellectually gifted children over seven decades, found that mortality rates of these gifted children were significantly
lower than those of their birth cohorts in the general population (see also Siegler 1980 for a review of these studies).
Bosworth and Siegler (2002) reviewed nine studies that evaluated the relationship between terminal decline of
cognitive function and death. Although they were not able to confirm this relationship in a consistent manner, they did
verify that lower cognitive function is predictive of mortality. Ghisletta et al. (2006) and Rabbitt et al. (2006) reported
similar relationship of cognitive functioning and mortality among well-controlled, representatively sampled
longitudinal studies. Data from the Nun Study (Snowdon et al. 1999) showed that subjects with higher linguistic
abilities tended to live 7 years longer than their cohorts with lower linguistic abilities. Wilson et al. (2007) provide data
from the Rush Memory and Aging Project and found an increased rate of cognitive decline within the final 3.5 years of
life.
The facilitative effect of higher cognitive function on longer survival among the very long lived (centenarians) was also
demonstrated. Poon et al. (2000) examined predictors of number of days of survival beyond 100 years among 105
centenarians from the Georgia Centenarian Study. They found cognition was one of four significant predictors. The
others were gender, father's age of death, and nutrition sufficiency. Cognitive status measured by the Short Portable
Mental Status Questionnaire was one of five significant predictors of survival among 800 centenarians in the French
Centenarian Study (Robine et al. 2003). The other predictors were residential condition, health status, activities of
daily living, and instrumental activities of daily living. Similarly, data from the Tokyo Centenarian Study (Gondo et al.
2006) showed that Clinical Dementia Rating score had a significant influence on survival. Taken together, cognitive
functioning is an important contributor to survival in the general population as well as in the oldest old.
Phenotypic Classification of Cognitive Functions Among the Oldest Old

There is large within- and across-subject variability in the cognitive performances of the oldest old (Hagberg et al.
2001). Although the progression of pathological changes is correlated with cognitive performances, recent studies
reported a significant amount of variability in the concordance between pathology and performance (Gold et al. 2000;
Haroutunian et al. 1998; Nagy et al. 1997). The seminal findings from these studies were that there were excellent
correlations between normal and severe dementia with cognitive functions; however, the relationships were
ambiguous in the moderate stages.
There are no commonly agreed-upon criteria for the classification of phenotypes of oldest old that take into account
their cognitive ability and neuropathology (Gondo and Poon, in press). However, studies that examined premorbid
cognitive performances and pathological diagnosis at postmortem autopsy may be helpful with the formulation of
criteria. Mizutani and Shimada (1992) autopsied 27 centenarians, 11 of whom had not developed dementia. Some
degree of brain degeneration was observed in 8 of the 11 centenarians without dementia, but there were no apparent
anatomical changes in the brains of the remaining three. The researchers termed those neuropathologically and
behaviorally dementia-free centenarians "supernormal." The autopsies performed with the New England Centenarian
Study (Silver et al. 2002) and the Aichi Centenarian Study (Ding et al. 2006) reported, respectively, 4 out of 14 cases
and 4 out of 6 cases of centenarians without dementia that met the criteria of supernormal, with the remaining
centenarians, although dementia free at time of death, having brain neuropathology that pointed to pathological
progression of dementia at autopsy. These centenarians could be classified as maintaining normal cognitive reserves.
The supernormal and "cognitive reserve" centenarians were both dementia free, although the second group presented
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some neuropathological degenerations. The second group could perform normally with everyday functions and
communication; however, this group may have had difficulty with more complex tasks.
Finally, as noted earlier, 40%–80% of centenarians could be classified as having some degree of dementia. Most of
these centenarians would have developed dementia at an advanced age, because early-onset dementia has been
estimated to develop on average at 80 years. The final two phenotypes could be identified as "late-onset dementia"
(defined as dementia with accompanying neuropathology developed at advanced age) and "early-onset dementia"
(defined as dementia accompanying neuropathology developed at earlier age). In conclusion, although there is large
individual diversity among the oldest old in both cognitive performance and neuropathological status, the four
proposed phenotypes (supernormal, cognitive reserve, late-onset dementia, and early-onset dementia) could provide
some guidelines in understanding the diversity.
Neuroimaging Data on Normal Aging

The rapidly developing field of neuroimaging can provide valuable data on the relation between pathological and
normal aging. The identification of dementia and other brain disorders from neuroimaging has been described
elsewhere (Buckner et al. 2004; Hoffman 1997; Marcus et al. 2007; Steffens 1997). Here we focus on the highlights of
current neuroimaging research in normal aging and some implications for the practicing physician.
The goal of neuroimaging research in aging is to characterize structural and functional age-related changes in the brain
as well as how these changes are manifest in cognitive performance. Behavioral studies of cognitive performance have
yielded a complex pattern of age-related decline in many—but not all—abilities. The state of this field is represented in
the recent editions of The Handbook of Aging and Cognition (Craik and Salthouse 2000). Within this broad area of
cognition, relevant reviews are available in specific areas of perception (Baltes and Lindenberger 1997; Schneider and
Pichora-Fuller 2000; Scialfa 2002), processing speed (Madden 2001; Salthouse 1996; Salthouse and Madden 2007),
attention (Kramer and Madden 2008; Madden 2007; Madden and Whiting 2004), language (Burke and Shafto 2008),
and memory (Pierce et al. 2004; Zacks et al. 2000). A general trend of this research is that cognitive abilities that
depend on perceptual speed and contextual memory tend to decline significantly with age, even for healthy adults,
whereas abilities that rely on semantic knowledge and highly overlearned patterns decline less or may even improve.
This trend has been expressed as different types of distinctions, such as crystallized versus fluid abilities (Cattell 1971;
Horn 1982), aging-resilient versus aging-sensitive abilities (Lindenberger 2001), and pragmatics versus mechanics
(Baltes and Lindenberger 1997).
A specific illustration of the type of cognitive change to be expected during normal aging is a longitudinal study of
Swedish twins, reported by Finkel et al. (2007). These authors obtained estimates of longitudinal change across
several testing occasions that were up to 16 years apart from a sample of twins who were 50–88 years of age at initial
testing. Participants performed a battery of cognitive tests representing four domains: verbal abilities, spatial abilities,
memory, and processing speed, which were each defined by a composite of tests. The results indicated that although
some longitudinal decline occurred for all four domains, the decline was most pronounced for the spatial and speed
domains. In addition, speed was a leading statistical indicator of change in both the spatial and memory domains (fluid
ability) but not of change in the verbal domain (crystallized ability).
Pierce et al. (2004) proposed that when interpreting these types of changes in cognitive ability, it is important to
recognize that they represent an adaptation on the part of older adults to a changing neurological environment. These
authors classified failures of memory as seven "sins," including three sins of omission—transience (forgetting over
time), absent-mindedness, blocking (e.g., tip-of-the-tongue states)—and four sins of commission—misattribution,
suggestibility, bias, and persistence. Pierce et al. emphasized that age-related increases that occur in these types of
errors can be viewed as useful byproducts of otherwise adaptive features of memory. That is, the goal of memory is to
support the encoding, retention, and retrieval of task-relevant information, not to preserve all incidental details of the
environment. The neurological changes that occur with advancing age may lead to an increased reliance on adaptive
strategies that maximize available cognitive resources but also leave older adults more vulnerable to the resulting loss
of some forms of memory information (see also McDaniel et al. 2008).
Neuroimaging studies have characterized the age-related changes in brain structure and function relevant for the
cognitive changes expressed in the behavioral measures. One edited volume summarizes current work in this area
(Cabeza et al. 2005), as do several individual articles and book chapters (Cabeza 2001, 2002; Dennis and Cabeza 2008;
Raz et al. 1998, 2005). Age-related change is prominent in both structural and functional imaging measures. Volumetric
studies of gray matter have established that age-related decline occurs in cortical volume, with concomitant increase
in ventricular size. A theme across many of these studies is that age-related volumetric decline is more pronounced for
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prefrontal regions than for more posterior cortical regions (Raz 2005; Raz et al. 2005). These findings have led to a
frontal lobe hypothesis of cognitive aging (Dempster 1992; West 1996), which proposes that the cognitive changes
associated with aging are the result of reduced frontal lobe efficiency. The degree to which reduced frontal lobe
functioning can serve as an explanatory construct, however, is debated (Greenwood 2000; Tisserand and Jolles 2003).
Age-related declines also occur, for example, in the volume and structure of posterior and sensory brain regions, such
as gray matter near the primary visual cortex (Salat et al. 2004). In addition, although the division of the cerebral
cortex into lobes is a useful pedagogical device, most cognitive tasks appear to rely on widely distributed cortical
networks (Mesulam 1990; Tisserand et al. 2005).
Age-related decline in cerebral white matter volume is also observed, although it is not clear whether the trajectory of
decline is comparable to that of gray matter. In addition, the magnitude of age-related decline in white matter appears
to be sensitive to the proportion of study participants with hypertension or related cardiovascular disease. Increasing
the proportion of these individuals tends to increase the degree of estimated age-related decline (Raz 2005). White
matter hyperintensities, evident in T2-weighted structural magnetic resonance imaging (MRI), also increase in number
and volume with age (Gunning-Dixon and Raz 2000; Raz et al. 2007; Yetkin et al. 1993). These hyperintensities are
also correlated with hypertension and cardiovascular risk factors and represent decreased integrity of white matter
(Oosterman et al. 2004; Raz et al. 2003; Soderlund et al. 2006; van den Heuvel et al. 2006).
Diffusion tensor imaging (DTI), in which the directionality and rate of molecular diffusion of water are measured (Mori
and Zhang 2006), is a structural imaging method that is informative regarding age-related changes in white matter.
This imaging modality is valuable because rather than relying on an ordinal-scale measure of pathology (e.g., number
of hyperintensities), it provides an interval-scale measure of the range of white matter integrity throughout the brain.
Studies using DTI have demonstrated that the integrity of white matter declines with age (Moseley 2002; Sullivan and
Pfefferbaum 2006). This decline is also more prominent in the prefrontal regions but occurs posteriorly as well (Head
et al. 2004; Salat et al. 2005).
Functional neuroimaging studies of aging complement these structural findings. Functional imaging has been
conducted with both positron emission tomography (PET) and functional MRI, which measure cortical activation during
task performance. Although many of the technological advances in neuroimaging have occurred in recent years,
interest in the effects of normal aging dates to the first studies in the 1950s (Kety 1956). Neuroimaging of simple
perceptual tasks, such as passively viewing checkerboards, has suggested that age-related decline occurs in both the
amplitude (Buckner et al. 2000) and spatial extent (Huettel et al. 2001) of activation in primary visual (striate) cortex.
By using appropriate control tasks, functional neuroimaging studies have identified age-related decline in brain regions
associated with specific components of cognitive function. Many of these studies have found that age-related reduction
of task-related activation in visual sensory regions is accompanied by age-related increased activation of prefrontal
regions (Cabeza et al. 2004; Grady et al. 1994; Madden et al. 2005; McIntosh et al. 1999). This pattern has led to the
suggestion that older adults compensate for deficiencies at a sensory/perceptual level by the recruitment of prefrontal
regions associated with higher-order cognitive strategies. This type of theory is being investigated currently in a
variety of task domains. One important issue is whether age-related increased activation is in fact compensatory, in
which case better-performing older adults would exhibit relatively greater activation (Cabeza et al. 2002). In some
instances, however, worse-performing older adults exhibit relatively greater activation, which may represent increased
effort or task difficulty rather than compensation (Nielson et al. 2002). However this issue is resolved, current
neuroimaging research suggests that 1) decline in activation is not the whole story, and 2) there is a high degree of
plasticity of function in the aging brain (Craik 2006; Craik and Bialystok 2006; Grady 1998; Grady et al. 2006).
Ultimately, the contribution of neuroimaging will rely on relating the neuroimaging measures to behavioral measures.
Although this may be intuitively obvious, the association of a particular brain structure or activation with a behavioral
measure is still a correlational approach, and methodological and statistical care is required to identify causal relations
in the data. Researchers are currently developing improved methods for analyzing the functional connectivity among
brain regions in the context of specific task domains (Grady 2005; Ramnani et al. 2004). Structural imaging measures,
such as white matter integrity from DTI, can be included in statistical models of age-related changes in cognitive
function (Bucur et al. 2008; Colcombe et al. 2005; Madden et al. 2007). Functional imaging measures are being
combined with behavioral measures in novel ways, for example, to distinguish remembered and forgotten items
(Daselaar et al. 2006; Dennis et al. 2007).
For the practicing clinician, these theoretical developments are not always directly relevant but do lead to useful
implications. First, cognitive change occurs throughout later adulthood; some decline in perceptual speed and fluid
abilities will be evident even in healthy individuals. Second, significant changes in brain structure and function may
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also occur in individuals without noticeable cognitive impairment, although at some point impaired cognitive function
will be reflected in the brain measures. Third, health status is a relevant variable, and to the degree that cardiovascular
disease and other comorbidities can be avoided, age-related decline is likely to be minimized. Fourth, the brain and
central nervous system are constantly adaptive, and this adaptation is expressed in measures of older adults' brain
function as well as in behavioral measures of cognitive performance.
Work in psychology of aging is becoming integrated across traditional areas. Work in cognition generally reports some
decrements, although typically there is maintenance of emotional functioning. Although this is not surprising to the
practicing psychiatrist, it is a new approach in psychology that comes from attempts to understand the aging mind.
Carstensen et al. (2006) review the relevant literature, and the nub of their argument is that older persons are
motivated to be selective and use their cognitive processing resources to meet emotional needs. Carstensen et al.
provide a framework that can accommodate gains as well as losses seen in cross-sectional aging studies.
PERSONALITY, COPING, AND BEHAVIORAL MEDICINE DEVELOPMENTS

Personality Developments
The unequivocal assertion that personality does not change over time is beginning to be challenged, particularly with
the advent of more sophisticated statistical methods that allow for the test of individual growth curves and
trajectories. A number of studies have pointed out that neuroticism appears to decline with age (Mroczek and Spiro
2003; Small et al. 2003) and that agreeableness and conscientiousness appear to increase over time (Helson et al.
2002; Small et al. 2003). Terracciano et al. (2005) reported that openness declined across adulthood, neuroticism
declined up to age 80, and for extraversion there was first stability and then decline, whereas there was an increase in
agreeableness and conscientiousness up to age 70.
Additional attention is being paid to possible cohort differences in personality. Twenge (2000), for example, reported
an increase of neuroticism in more recent cohorts, but this has not been replicated in other studies (Terracciano et al.
2006). The Terracciano et al. (2006) study, however, did report cohort effects for personal relations, with later-born
cohorts declining more than one T-score point per decade. In relation to this finding, Robinson and Jackson (2001) also
reported a decline in trust among Americans born after the 1940s.
Continuity of personality and social preferences is expected across the adult life course; thus, changes have potential
diagnostic significance and make knowledge about expected trajectories important. Although the work on cognitive
development reviewed previously finds generally good patterns by domain of performance, individual differences in
personality predict physical disease, which in turn has consequences for cognitive performance, which then leads to
greater incidence of disease. This can be well illustrated with work on hypertension.
Findings from the UNC Alumni Heart Study indicate a relationship, dependent on covariates in the model, between
personality in early middle age (approximately age 40) and incident hypertension 11–15 years later. The behavioral
predictors of hypertension are well known and include age, education, exercise, family history, overweight, and obesity
in the UNCAHS cohort. Hostility also predicted hypertension, but this effect was mediated only by overweight and
obesity. This same pattern was seen for Neuroticism facet scale score findings of N5 (Impulsiveness) for overall N
(Neuroticism). Because hypertension is a silent disease, it was also more likely in more conscientious persons and in
Conscientiousness facets of C1 (Competence) and C3 (Dutifulness). Aside from Conscientiousness and its facets, only
job strain and A4 (Anger) score predicted hypertension with all traditional covariates in the model. Because UNCAHS is
a mail survey, hypertension was tested on 2 days—when first reported and when treatment first reported—to model
how it would have been defined had we been able to measure blood pressure directly, where normal pressures with
treatment are considered hypertension (Siegler 2007b). Midlife hypertension confers increased risk for later coronary
heart disease and stroke and vascular dementia.
Elias et al. (2004) present 30 years of research on the impact of age and hypertension on normal cognitive functioning,
a study that started in 1974. A summary of the findings is presented here. They found that almost all abilities are
affected by hypertension and that antihypertensive treatments may not prevent this decline. After 30 years, questions
remain about subtypes of disease and of treatments. Overall estimates of the impact of changes in blood pressure on
summary indicators of Wechsler Adult Intelligence Scale performance and speed indicate that being hypertensive
carried a 74% increased risk of poor performance, with a 67% increase in risk of poor speeded performance compared
with estimates for 10 years of age at 58% and 85%, respectively, with a 20 mmHg increase in systolic blood pressure
conferring 18% and 22% increases in risk. (Cross-sectional normative data are presented in Dore et al. 2007.) These
are useful data derived from the Maine-Syracuse Longitudinal Study stratified by age and education showing level of
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mean –1.5 standard deviation of change, indicating an estimate of the level of performance that could be considered
mild cognitive impairment, which may represent a heightened risk for Alzheimer's disease. Cognitive and
neuropsychological measures in the battery were also evaluated by proportion of variance accounted for by age,
education, and gender separately and together, as well as additional variance caused by disease indexed by depression
and health indicators including risky behaviors like smoking and prevalent disease. On average, health variables added
about 3%. These data underscore the importance of long-term chronic disease assessment and management for
geriatric psychiatry.
Mroczek et al. (2006) cast traditional concerns of stability and change in personality with age into theoretical terms
and note that the changes can be both positive and negative and respond to developing health conditions in adaptive
ways. Work in this area still looks to see if nonnormative changes have medical consequences that should raise the
level of suspicion in an insightful clinician. Theoretically, Hooker and McAdams (2003) have incorporated social
processes into trait psychology, although empirical findings will take time to emerge. Latent growth curves are
providing new techniques to evaluate sophisticated developmental patterns of change. Our own work on hostility
(Siegler et al. 2003) finds the normative pattern of declining hostility with age is replicated longitudinally and
cross-sectionally (Siegler 2007b) but reflects only 75% of the population; in a very small group (3.5%), hostility
actually increases from age 18 to 60 years, whereas the remainder decline slowly. Differences in such trajectories have
definite health consequences. At age 60, those who increased in hostility were more likely to be hypertensive, to be
depressed, and to have cancer (Siegler 2007b), as shown in Figure 7–4.
FIGURE 7–4. Classes of hostility and cumulative disease.
HT = hypertension; DEP = depression; CAN = cancer.
Source. Siegler IC: "Psychology of Aging and the Public Health." 2007 Developmental Health Award, Division 20 and Division 38.
Invited address presented at the Annual Meeting of the American Psychological Association, San Francisco, CA, August 2007.
Reprinted with permission.
Work in behavioral medicine is based on a search for the biological and physiological mechanisms that relate
psychosocial constructs such as personality to disease (Siegler 1989). All of these are variants of a stress model that
involves neuroendocrine, immune, inflammatory, and cardiovascular reactivity paradigms. These are illustrated in a
model by R.B. Williams (2007) (see Figure 7–5).
FIGURE 7–5. A model of psychosocial mediators of health events.
10 of 23 4/15/09 9:53 AM
CHD = coronary heart disease.
Source. Williams RB: "Coping Skills Training in Different Cultures: The LifeSkills Experience." Poster presented at the First
Conference of the Central Eastern European Society of Behavioral Medicine, Pecs, Hungary, August 20–22, 2007. Reprinted with
permission.
There are normative age differences in all of these biological indicators (see Hazzard et al. 1999; Markides 2007) and
fewer longitudinal age change data to evaluate. Recent published chapters have worked to integrate aging data into
these frameworks for cardiovascular and social risk domains (Berg et al. 2007), neuroendocrine parameters (Epel et al.
2007), and all of the systems that respond to chronic stressors such as caregiving (Young and Vitaliano 2007).
Research is moving toward personalized medicine that will take genes and gene environment interactions into effect
(R.B. Williams 2007).
A useful illustration of how this model works in an aging population is provided by emerging findings from our recently
completed study of the impact of caregiving (Duke Caregiving Study: Brummett et al. 2005, 2006a, 2007b, 2008;
Dilworth-Anderson et al. 2005a). The broad objectives of this research are to identify factors in the social (e.g., being a
caregiver for a relative with Alzheimer's disease) and physical (e.g., neighborhood characteristics) environments that
interact to affect biological and behavioral characteristics that lead to poorer physical and mental health and to
evaluate variants in genes that regulate function of the neurotransmitter serotonin as moderators of the impact of
these environmental factors on health and disease.
We found that caregivers who expressed a higher level of concern about crime in their neighborhood had higher levels
of fasting blood glucose and glycosylated hemoglobin (a measure of average blood glucose over the past 2–3 months)
than either caregivers with low crime concerns or matched control subjects with high or low crime concerns. These
findings suggest that among the millions of Americans with caregiving responsibilities for a relative with Alzheimer's
disease, those who live in neighborhoods that engender concerns about crime are at higher risk for developing type 2
diabetes and the other diseases, such as heart disease, to which it leads (Brummett et al. 2005). In a structural
equation model, we found that caregivers of a relative with Alzheimer's disease report poorer sleep quality indirectly
through reduced social support and increased levels of negative emotions, compared with matched control subjects
who do not have caregiving responsibilities (Brummett et al. 2006a) and that these differences in sleep quality are
related to monoamine oxidase-A alleles associated with less transcriptional activity and with depression (Brummett et
al. 2007b) in caregiving men. Poor sleep quality in women was associated with the S allele in the serotonin transporter
gene (5-HTTLPR) (Brummett et al. 2007a). Gender effects in response to caregiving were seen in the UNCAHS, where
for middle-aged caregivers, caregiving was associated with diabetes for men and depression for both men and women
in models controlling for age and income. Age increased risk of disease, whereas income was protective (Siegler et al.
2006).
A literature is developing that finds consistent personality mortality associations. Not only does hostility in college
predict premature mortality in the UNCAHS (Siegler 2007), we have also found that optimists compared with
pessimists were more likely to survive 40 years after college entry (Brummett et al. 2006b). Friedman and Martin
(2007) review conscientiousness as a critical construct in survival and an integrated way to think about personality as
a system, whereas our own work is finding new implications for the facets of openness to experience in coronary
patients (Jonassaint et al. 2007). The behavioral medicine literature focuses more on negative constructs (hostility,
neuroticism, and pessimism), whereas survival studies focus more on the more positive traits. Whether the individual
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constructs or the broader domains prove more useful (R.B. Williams et al. 2003; Suls and Bunde 2005), the findings are
starting to show the general trends seen above. What do long-term survivors actually look like?
Personality in Centenarians
In order to survive successfully into very old age, individuals appear to need a highly resilient or robust personality.
Several centenarian studies appear to point this out. For example, the New England Centenarian Study noted that
centenarians were very stress-resilient individuals (Perls and Silver 1999). Findings from the Georgia Centenarian
Study also noted that a particular cluster of personality traits was more likely to be found among centenarians:
relatively high levels of extraversion, emotional stability, and conscientiousness (Martin et al. 2006). High ratings of
emotional stability also were found in centenarian studies in Sweden (Samuelsson et al. 1997) and Japan (Shimonaka
et al. 1996). A longitudinal follow-up showed that centenarians had decreased scores in sensitivity but higher scores in
openness (Martin et al. 2002) after an 18-month follow-up testing. The results suggest that centenarians may
compensate for physical and functional decline by having robust personality traits and by becoming less sensitive and
more open-minded.
Coping Developments
There is considerable interest to study coping behaviors in centenarians. This group of "expert survivors" (Poon et al.
1992) faces accelerated changes in a number of functioning domains, such as activities of daily living, and considerable
losses of peers and family members. How do individuals at such an advanced age cope with these changes? The
results obtained so far suggest that centenarians are less likely to use "active behavioral" coping styles (Martin et al.,
in press). Active behavioral coping refers to all specific actions individuals take when being confronted with stressors
or events. For example, seeking professional advice and talking with family and friends constitute active strategies. It
is not surprising that centenarians are less likely to use active behavioral coping, because their resources are more
limited. Although centenarians are restricted in their active behaviors, the level of active cognitive coping does not
appear to diminish (Martin et al., in press). Centenarians may not be able to do something about a problem, but they
surely can think about it as much as any other age group. Along the same lines, Martin et al. (2001) pointed out that it
may not be the general coping modes (i.e., active behavioral, active cognitive, or avoidance) that play an important
role. Rather, it may be specific "molecular" coping behaviors that distinguish the oldest old from other age groups. For
example, centenarians are more likely to use religious coping and acceptance, whereas they are less like to worry
about a problem (Martin et al. 2001). A centenarian study in Barbados also noted that successful adaptation and coping
among centenarians were positively related to high levels of religiosity (Archer et al. 2005).
Coping With Caregiving in Diverse Populations

In the face of the growing numbers of people with Alzheimer's disease and related issues such as testing, assessment,
and care, Peggye Dilworth-Anderson, Ramón Valle, Sam Fazio, and Teresa Radebaugh convened a conference in 2004
and published papers from this conference that address the 5 million Americans who have Alzheimer's disease. Of
particular concern in the discussions and published papers is that what is known about aging and Alzheimer's disease is
a function of the people studied, and currently little is known about diverse populations. It is important to further
understand the heterogeneity of Alzheimer's disease, because heterogeneity may be within the disease as well as
within the population. Including diverse populations in Alzheimer's disease research can provide opportunities for
diagnosis, care, and treatment for everyone.
Further, despite many years of Alzheimer's disease research, our understanding of the effects of this disease on family
caregivers is still limited for ethnic minorities. For example, we know, based on current evidence, that 1) the burden of
Alzheimer's disease is greater among African Americans, among whom age-specific prevalence of dementia is
14%–100% higher than that found among European Americans; 2) first-degree relatives of African Americans who
have Alzheimer's disease have a 43.7% cumulative risk of getting the disease compared with 26.9% for whites, and
among blacks, spouses have an 18.5% cumulative risk of getting the disease compared with 10.4% for whites (Green
et al. 2002); 3) African Americans are less likely to institutionalize relatives with dementia (43.7%), compared with
whites (89.6%) (Stevens et al. 2004), and 29% of African American families provide care for their older family
members compared with 24% of white families (Dilworth-Anderson et al. 2006); 4) African American caregivers are
more likely to care for more than one dependent adult in their families, spending an average of 20.6 hours per week
providing care; 5) African American caregivers tend to underutilize formal services; 6) 66% of African American
caregivers are employed full- or part-time; and 7) African American caregivers are more likely to be middle-aged
daughters rather than spouses, whereas white caregivers are as likely to be a spouse as an adult child (Hinrichsen and
Ramirez 1992). These conditions would suggest that caregivers of African American elders are particularly vulnerable
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to poor emotional and physical health outcomes. Using data published from the Resources for Enhancing Alzheimer's
Caregivers Health (REACH), investigators addressed these vulnerabilities, as well as those in other groups, through a
multicomponent intervention (Belle et al. 2006). Their findings show that compared with minimal support provided in
a control group, their multicomponent intervention statistically significantly improved the quality of life (as measured
by indicators of depression, burden, social support, self-care, and patient problem behaviors) for white and Hispanic
caregivers but not for African American caregivers. However, they found statistically significant quality-of-life changes
with this intervention among African American spouse caregivers, in contrast to African American adult children in the
caregiver role. Given that adult children provide the majority of care in black families (unlike in white and Hispanic
families), additional research is needed to better identify and address their emotional and physical health
vulnerabilities through interventions.
Limited information on psychological coping poses further concerns for understanding how diverse groups respond to
and address the stress and strain of caregiving. Evidence shows that caregivers suffer emotionally from a variety of
stressors because of the physical demands of assisting care recipients with daily activities (Alzheimer's Association
and National Alliance for Caregiving 2004). Of particular concern is the type and degree of caregiver stress associated
with caring for elders with dementia who often have behavioral and physical health problems (Haley et al. 2004;
Hooker et al. 2002; Schulz and Martire 2004). Information on addressing emotional coping and well-being among
dementia caregivers in diverse groups suggests that a sociocultural perspective is needed to understand the diversity
issues that are involved. A sociocultural perspective takes into consideration an ethnic and cultural group's history,
values, beliefs, and ways of thinking. It is also characterized by what is often described as the "historical memory" of a
group as evidenced by customs, rituals, and ways of expressing themselves. Work from our Duke Caregiving Study
found that African Americans have different cultural reasons for providing care for relatives with Alzheimer's disease
and that this varies by educational level (Dilworth-Anderson et al. 2005a). Findings show that race and ethnicity
appear to influence significantly the expression of depression, and depression is not always synonymous across
cultures. Hence, it has been suggested that the application of standard mood inventories in African American groups
may contribute to the observation of lower prevalence rates of depression in this group when compared with white
samples (Harrelson et al. 2002). Studies of depression in caregivers of patients with Alzheimer's disease have also
underscored the racial and ethnic differences in depressive symptomatology.
In some studies, it appears that African American caregivers of patients with Alzheimer's disease are often reported as
less depressed when compared with white caregivers (Haley et al. 1996); however, both groups show other negative
health outcomes from caregiving over time, such as increased physical symptoms (Roth et al. 2001). Findings by
Dilworth-Anderson et al. (1999) show that very few African American caregivers experience depression assessed by
the Center for Epidemiologic Studies Depression Scale (Radloff 1977); however, by using Derogatis's (1993) global
index on distress, their findings did document that about 18% of the caregivers were emotionally distressed. These
distressed caregivers received less social support, were in poorer physical health, and experienced more caregiving
problems than caregivers who were not distressed (Dilworth-Anderson et al. 1999). Thus, to be appropriately sensitive
to depression expression among African Americans and possibly other racial and ethnic groups, researchers need to
rethink how best to measure depression with culture in mind. Both conceptual and methodological issues, therefore,
will need to be revisited as we approach understanding emotional well-being among diverse groups of caregivers.
Behavioral Interventions
Research on the role of social factors in aging has benefited from the flowering of integrated theoretical work in
emotion and motivation by Carstensen and her colleagues and has been the basis for behavioral intervention studies.
Not only has there been great progress in basic research in the psychology of normal aging, but major intervention
studies also have been completed and reported. Willis et al. (2006) present the results of a cognitive training
intervention for normally aging persons (ACTIVE) that suggests that cognitive training can be beneficial; Gitlin et al.
(2003) present REACH for interventions to reduce the stress of caregiving; and Berkman et al. (2003) and Lett et al.
(2007) present ENRICHD, which attempted to modify depression and social support to reduce the impact of coronary
heart disease. These three large clinical trials show the beginnings of applications of decades of findings in psychology
to help mitigate the impact of age-related changes in the population. Williams LifeSkills (V.P. Williams and Williams
1999) teaches coping skills and has been found to reduce coronary heart disease risk indicators (Bishop et al. 2005).
This approach is currently being tested as a framework to help caregivers. Randomized clinical trials with behavioral
interventions are difficult to conduct because individuals who are randomly assigned to the control group can
sometimes provide an intervention for themselves. The results of these behavioral interventions are less important
than the fact that they are entering the realm of tested scientific practice. This represents an important
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acknowledgment of the role of psychosocial factors in disease as well as an optimism that something can be done to
reduce the burden.
IMPLICATIONS FOR THE PRACTICE OF GERIATRIC PSYCHIATRY

The practice of geriatric psychiatry is healthy (Cohen 2005). There are still major gaps in our knowledge of how to
define normal aging in frail institutionalized populations that have been defined as "abnormally" aging—however, this
work is beginning (Buckman et al. 2007; Tyas et al. 2007; Welsh-Bohmer et al. 2006). Population-based national
studies generally do not have sufficiently rich measurement batteries; thus, there is a growing group of older impaired
persons and their caregivers who could benefit from more study. Similarly, we do not have a "psychology of aging with
Alzheimer's disease" or "aging with multi-infarct dementia." If these disorders are soon cured, we will not need one.
Until then, multiple generations of aging persons can be expected to live longer, more complex lives, and geriatric
psychiatrists may have two or three generations in the same family as patients, needing to understand multiple
trajectories of normal aging processes.
KEY POINTS
Individual decline in cognitive performance before age 60 generally is not normal aging. By the mid-70s, average
decrement is observed for all abilities, and by the 80s this decrement is severe except for verbal ability.
Empirical data from centenarian studies suggest that dementia is not inevitable.
Cognitive abilities that depend on perceptual speed and contextual memory tend to decline with age, even for healthy
adults, whereas abilities that rely on semantic knowledge and highly overlearned patterns decline less or may even
improve.
Continuity of personality and social preferences is expected across the adult life span; thus, changes have potential
diagnostic significance.
The effects of Alzheimer's disease and of caregiving for relatives with Alzheimer's disease vary in diverse populations.
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SUGGESTED READINGS
Carstensen LL, Hartel CR (eds): When I'm 64. Washington, DC, National Academies Press, 2006
Costa PT Jr, Siegler IC (eds): Recent Advances in Psychology and Aging. Amsterdam, Elsevier, 2004
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Gondo Y, Poon LW: Biopsychosocial approaches to longevity, in Annual Review of Gerontology and Geriatrics. Edited by Poon LW,
Perls T. New York, Springer, 2007, pp 129–149
Schaie KW: Developmental Influences on Adult Intelligence: The Seattle Longitudinal Study. Oxford, UK, Oxford Press, 2005
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JAMA 296:2805–2814, 2006
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69:131–137, 2007
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Chapter 7. Psychological Aspects of Normal Aging

PSYCHOLOGICAL ASPECTS OF NORMAL AGING: INTRODUCTION

INTELLECTUAL AND COGNITIVE DEVELOPMENT

Course of Adult Intellectual Development

Cognitive Functioning Among the Oldest Old

Cognitive Function and Longevity

Phenotypic Classification of Cognitive Functions Among the Oldest Old

Neuroimaging Data on Normal Aging

PERSONALITY, COPING, AND BEHAVIORAL MEDICINE DEVELOPMENTS

FIGURE 7–4. Classes of hostility and cumulative disease.

HT = hypertension; DEP = depression; CAN = cancer.

FIGURE 7–5. A model of psychosocial mediators of health events.

CHD = coronary heart disease.

Coping With Caregiving in Diverse Populations

IMPLICATIONS FOR THE PRACTICE OF GERIATRIC PSYCHIATRY

Andersen-Ranberg K, Vasegaard L, Jeune B: Dementia is not inevitable: a population-based study of Danish

14:410–423, 2004 [PubMed]

PM. New York, Marcel Dekker, 1997, pp 503–532

Copyright © 2009 American Psychiatric Publishing, Inc. All Rights Reserved.

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