CC BY
0
JQY|< ) JOURNAL OF CLINICAL MEDICINE OF KAZAKHSTAN
Original Article
(E-ISSN 2313-1519)
DOI: https://doi.org/10.23950/jcmk/9736
Attitudes toward successful aging
in individuals with chronic disease
aged 65 or over
Aykut Aydin1 , Aylin Aydin Sayilan2
'Labour Economics and Industrial Relations Department, Faculty ofEconomics and Administrative Sciences, Kirklareli University, Kirklareli, Turkey 2Nursing Department, School of Health Science, Kirklareli University, Kirklareli, Turkey
Abstract
Aim: To determine the relationship between attitudes toward aging and old age, and successful aging in individuals with chronic disease aged 65 or over.
Material and methods: The Attitude Scale toward Aging and Elderliness and the Successful Aging Scale were employed in this descriptive, cross-sectional, comparative study. Data were expressed as frequency, percentage, mean, and standard deviation and were analyzed using the Kolmogorov-Smirnov test, the t test, One-Way ANOVA, and Pearson correlation analysis. p values <0.05 were regarded as significant.
Results: Individuals with chronic disease had greater difficulty in accepting old age, greater social exhaustion, greater abilities to cope with problems, and higher successful aging scores.
Conclusion: This study shows that despite their negative attitudes toward old age, individuals with chronic disease had greater abilities to cope with problems and aged more successfully.
Key words: chronic illness, successful aging, geriatrics
Received: 2021-01-13. Accepted: 2021-02-27
© 0
This work is licensed under a Creative Commons Attribution 4.0 International License
J Clin Med Kaz 2021; 18(2):39-43
Corresponding author: Aylin Aydin Sayilan. E-mail: aylin.sayilan@klu.edu.tr; ORCID: 0000-0003-0576-8732
Introduction
Old age is one of the turning points in an individual's life, and one that entails physical, social, psychological, and mental adaptation problems [1].
Every stage in old age, the last of the developmental periods, is affected by the positive or negative aspects of the previous stage. Simultaneously coping with one or more chronic diseases has a particular impact on the individual's attitude to age and aging [2].
Old age is described as a time of isolation, withdrawal and decay, and is evaluated as a physiological process involving difficulties in coping with numerous adverse internal and external factors, finally resulting in death [3].
The increase in the elderly population has also led to greater awareness of old age. Both birth and death rates are falling in many parts of the world [4]. Individuals' attitudes to aging and old age have been described as one of the markers of quality of life [5]. Positive attitudes are reflected in the elderly individual's quality of life
and physical and psychological well-being. However, outcomes may differ among individuals with chronic disease. Increased awareness of aging in recent years has given rise to the concept of successful aging. This involves a healthy lifestyle and the ability to cope with problems [6,7].
Studies suggest that an individual's attitude toward aging is a basic indicator in the perception of old age [8]. In addition, age, nutritional status, family support, exercise and physical independence have all been emphasized as highly important factors in successful aging [9,10]. At the same time, Hartley et al. (2017) reported the imminent emergence of an aging population, that the concept of successful aging is becoming increasingly important in consequence, that relevant risk groups need to be identified, and that precautionary measures can be taken beforehand [11].
The literature describes active aging as more of an individual but highly important concept, and one of growing importance. However, the effect of the
presence of chronic disease on active and successful aging has not previously been examined. The number of individuals with chronic disease is known to increase in line with age, but their attitudes to aging and old age, and their successful aging status are unclear. The present study was therefore intended to determine the relationship between attitudes to age and aging, and successful aging among individuals with chronic disease aged 65 or over.
Material and methods Type of research
A descriptive, cross-sectional and comparative study.
Research population and sampling
All individuals (n:118) aged 65 or over hospitalized at the XXX Education and Research Hospital Internal Diseases Clinic, Turkey, between 01.01.2020 and 01.06.2020, and consenting to participate were included in the study. Data were collected using the face-to-face interview method, a process lasting approximately 20 min. The final response rate was 75.2%.
Inclusion criteria:
- Literate individuals consenting to take part,
- Aged 65 or over,
- With mini mental test scores of 24 or more,
- With no communication or mental difficulties, and
- Not using anxiolytic or psychiatric medications were enrolled.
Exclusion criteria:
- Patients not meeting the inclusion criteria were excluded.
Data Collection Tools
The research data were collected using a questionnaire prepared by the authors, the Successful Aging Scale, and the Attitudes to Aging Scale (ASAE).
Information Form: This form consisted of 11 questions involving age, sex, education, occupation, marital status, number of children, income, type of family, and presence and nature of chronic disease.
Attitude Scale toward Aging and Elderliness (ASAE): This five-point Likert-type scale (strongly disagree, disagree, unsure, agree, strongly agree) consists of 45 items and four subscales. Its validity and reliability were studied by Otrar [6]. The total score is calculated (min 45 max 225). Three items are reverse scored (items 30, 32 and 43). Higher scores on the scale indicate more negative attitudes.
The scale's Cronbach Alpha value in this study was 0.93 (Difficulty in Accepting Aging subscale 0.87, Social Exhaustion Perception 0.87, Difficulty in Coping with Life 0.85, and Negative Image 0.48)
Successful Aging Scale: The validity and reliability of this scale were studied by Hazer and Ozsungur [7]. This seven-point Likert-type scale (strongly agree, agree, partly agree, uncertain, partly disagree, disagree, and strongly disagree) contains 10 questions and consists of two subscales - Healthy Aging (three items) and Coping with Problems (seven items). The lowest possible score on the scale is 10, and the highest possible score is 70, with higher scores indicating more successful aging.
The scale's Cronbach Alpha value in this study was 0.89, while subscale values were Coping with Problems 0.85, and Healthy Aging 0.86.
Data Evaluation: SPSS 23.0 software was used for statistical analyses. In addition to descriptive methods such as frequency, percentage, mean, and standard deviation, the Kolmogorov-Smirnov test was applied to assess normality of distribution. The t test and One-Way ANOVA were applied to compare normally distributed variables between the groups, while relationships between numerical variables were assessed using Pearson correlation analysis. p values <0.05 were regarded as statistically significant.
Ethics
Ethical approval was received from the XXX University Health Sciences Institute (P180R01) ethical committee before commencement of the study, institutional permission was obtained from the institution where the research was performed, and written and verbal informed consent was obtained from the participants.
Results
The mean age of the elderly individuals in the study was 73.70±5.51 years (min:68, max:85), and 54.2% were men. In addition, 88.1% of the participants were married, 46.3% were educated to primary school level, 63.7 were of average economic status, 78.8% were retired, 67.8% lived in a nuclear family, and 64.4% had at least one chronic disease.
In terms of total ASAE and subscale scores, the mean Difficulty in Accepting Aging score was 36.85±9.17, the mean Social Exhaustion Perception score was 46.55±10.76, the mean Difficulty in Coping with Life score was 33.77±7.3, the mean Negative Image score was 25.46±6.39, and the total scale score was 142.64±29.96.
In terms of total Successful Aging Scale and subscale scores, the mean Coping with Problems score was 19.53±6.85, the mean Healthy Aging score was 8.33±3.86, and the mean total scale score was 27.86±9.81 (Table 1).
Elderly Individuals' Attitude Scale toward Aging and Elderliness and Successful Aging Scale Subscale Scores (n=118)
Variables Mean± SD Min-Max
Attitude Scale toward Aging and Elderliness 142.64±29.96 (60-214)
Difficulty Coping with Old Age 36.85±9.17 (14-53)
Social Exhaustion Perception 46.55±10.76 (19-63)
Difficulty in Coping with Life 33.77±7.3 (10-47)
Negative Image 25.46±6.39 (11-70)
Successful Aging Scale 27.86±9.81 (10-56)
Coping with Problems 19.53±6.85 (7-43)
Healthy Aging 8.33±3.86 (3-19)
Elderly Individuals' Attitude Scale toward Aging and Elderliness and Successful Aging Scale Scores by Various Characteristics
Sociodemographic characteristic n Attitude Scale toward Aging and Elderliness Successful Aging Scale
Difficulty Coping with Old Age Mean±SD Social Exhaustion Perception Mean±SD Difficulty in Coping with Life Mean±SD Negative Image Mean±SD Total Scale Score Mean±SD Coping with Problems Mean±SD Healthy Aging Mean±SD Total Scale Score Mean±SD
Sex
Female 54 37.22±9.42 47.07±10.76 33.61±7.81 24.96±5.07 142.87±30.49 20.42±7.31 8.64±3.92 29.07±10.61
Male 64 36.54±9.02 46.10±10.82 33.90±6.91 25.89±7.33 142.45±29.75 18.78±6.39 8.06±3.82 26.84±9.05
p=0.692 p=0.630 p=0.828 p=0.434 p =0.940 p=0.195 p =0.415 p =0.220
Presence of Chronic Disease
Yes 76 40.59±6.98 50.47±9.55 36.56±6.19 26.94±6.90 154.57±25.41 21.40±6.65 9.46±3.28 30.86±9.20
No 42 30.09±8.85 39.45±9.13 28.71±6.44 22.78±4.23 121.04±25.28 16.14±5.88 6.28±3.04 22.42±8.54
p=0.000 p=0.000 p=0.000 p=0.001 p=0.000 p=0.000 p=0.000 p=0.000
Type of family
Extended family 80 37.20±8.51 47.60±9.94 34.46±6.93 25.56±4.71 144.82±27.05 19.05±5.99 7.96±3.65 27.01±8.82
Nuclear family 38 36.13±10.51 44.34±12.16 32.31±7.92 25.26±9.03 138.05±35.27 20.55±8.36 9.10±4.23 29.65±11.56
p=0.557 p=0.125 p=0.137 p=0.813 p=0.253 p=0.267 p =0.135 p=0.173
Table 3
Correlations between the Attitude Scale toward Aging and Elderliness and the Successful Aging Scale
Attitude Scale toward Aging and Elderliness
Successful Aging Scale
Coping with Problems Healthy Aging
Difficulty Coping with Old Age
r=-0.413 p=0.000
r=-0.427 p=0.000
r=-0.292 p=0.001
Social Exhaustion Perception
r=-0.479 p=0.000
r=-0.486 r=-0.356
p=0.000 p=0.000
Difficulty in Coping with Life
Negative Image r=-0,341 p=0.000 r=-0.221 p=0.016
Total Scale Score
r=-0.429 p=0.000
r=-0.337 r=-0.269
p=0.000 p=0.003
r=-0.220 r=-0.172
p=0.017 p=0.063
r=-0.434 r=-0.320
p=0.000 p=0.000
Analysis of ASAE scores revealed that individuals with chronic diseases had significantly higher Difficulty Coping with Old Age (p=0.000), Social Exhaustion Perception (p=0.000), Difficulty in Coping with Life (p=0.000), Negative Image (p=0.001), Coping with Problems (p=0.000), Healthy Aging (p=0.000), and total scale scores (p=0.000). Analysis of Successful Aging Scale and subscale results among elderly participants with chronic diseases also revealed significantly higher Coping with Problems (p=0.000), Healthy Aging (p=0.000) and total scale (p=0.000) scores. No significant association was determined between sex, marital status, type of family, and employment status and the Successful Aging Scale or ASAE and their subscales (Table 2).
Significant moderate negative correlation was observed between ASAE and Successful Aging Scale scores (p=0.000). Significant negative correlation was determined between Difficulty Accepting Aging, Social Exhaustion Perception, Difficulty in Coping with Life, and Negative Image subscales and the Successful Aging Scale and Coping with Problem subscale (p<0.05). Significant negative correlation was also observed between Healthy Aging and Difficulty Accepting Aging, Social Exhaustion Perception and Difficulty in Coping with Life subscales (Table 3).
Discussion
Aging is a continuous and universal process occurring in every living thing, and that leads to a gradual diminution in all functions. However, the process varies from individual to individual.
In the present study, individuals with chronic diseases had significantly greater difficulty in accepting aging than those with no chronic disease. Acceptance of aging has been reported to
be affected by such factors as the individual's economic status, existing diseases, or the loss of a loved one [12]. Another study reported that individuals with chronic diseases found it more difficult to accept old age because they exacerbate feelings of inadequacy [13]. Akozer et al., (2011) stated that chronic disease affects the individual both physically and cognitively, for which reason aging is regarded as a negativity [14].
The findings in the present study are consistent with the previous literature and support the idea that individuals with chronic disease are negatively biased against old age.
The elderly individuals in this study generally had average income levels, but no relationship was determined between income and successful aging. Dziechciaz & Filip (2014) reported that the individual's self-perception plays a particularly important role in successful aging [10]. A multi-study center of individuals aged 65 and over from China reported no correlation between income status and quality of life [15]. Guo et al. (2019) emphasized the importance of family support rather than economic status in active aging [16]. The findings of the present study are consistent with the previous literature.
Individuals with chronic diseases in this study also had a significantly higher perception of social exhaustion that those with no chronic diseases. Elderly individuals' attitudes toward old age are known to be affected by factors such as their environment, beliefs concerning old age, family structure, and experience. Considering old age in psychological, social, and political terms has been reported to play a key role in determining attitudes toward it [14]. Social relationships increasingly diminish in old age, while social roles contract, resulting in a perception of social exhaustion. This perception plays a key role in the attitude towards old age, particularly in recent times. According to activity theory, socially active individuals have
high life satisfaction and a positive attitude toward old age. Attitudes to old age in the present study suggest that a perception of social exhaustion plays an important role in enhancing negative attitudes toward old age. We think that a perception of social exhaustion plays an important role in enhancing negative attitudes toward old age.
Individuals with chronic diseases in this study found it more difficult to cope with life than those with no such disease. Chronic diseases have been reported to create an adverse impact on the individual's ability to cope with life, by compromising quality of life and increasing financial costs [17]. Studies have reported that individuals aged 65 or over with chronic diseases have greater socioeconomic burdens and lower quality of life than those with no such diseases [18], that they experience more pain and restrictions [19], and that coping with life is therefore more difficult for them [20].
It has also been suggested that since individuals with chronic diseases have greater difficulty in coping with life than those with no such diseases, these should make greater use of techniques such as mind-body therapy [21]. This finding is consistent with the literature, and we think that individuals with chronic disease find it difficult to cope with life because of complicating factors.
Individuals with chronic diseases in this study also had more negative images than those with no such disease. An elderly individual's possessing a positive image of 'self' and regarding himself as a valuable being, irrespective of weaknesses in old age, is considered to be of considerable importance to successful aging [22]. Chronic diseases compromise quality of life because they result in financial losses [23]. They also cause physical and mental loss of function, and can thus impact adversely on quality of life and active aging [24]. Due to their long-term nature, chronic diseases impair the individual's quality of life, and since stress and depression are more frequent in these individuals, their self-images are negatively impacted [25]. Studies have reported greater negative images in individuals with chronic diseases compared to those without for reasons such as pain, stress, depression, and burnout [25-27]. Our finding is consistent with the previous literature.
Individuals with chronic diseases in this study exhibited greater abilities to cope with problems than those with no such diseases. Chronic diseases represent one of the leading health problems of our time, and strategies need to be developed against
these [28]. Studies of individuals with different types of chronic disease have reported high abilities to cope with solve problems among such people [29-31]. Our finding was in agreement with the existing literature, and we think that individuals with long-term chronic diseases should also receive psychological support.
Individuals with chronic diseases in this study also aged more successfully than those without. Kudo et al., (2013) reported that individuals who aged successfully had high problemsolving skills and took part in social activities [32]. Helme (2001) reported that elderly individuals with chronic disease who were capable of good pain management and with highly empathetic attitudes also aged more successfully [33]. At the same time, individuals with chronic diseases have been reported to behave in a more controlled manner than those without such diseases, while successful aging is accompanied by good pain management and the overcoming of physical limitations [34,35]. We think that our finding shows that individuals with chronic diseases in this study had good pain management.
The general outcome of this study indicated that individuals with positive attitudes toward aging and old age also aged more successfully. Successful aging is a multifactorial concept involving preventing deficiencies, the maintenance of high physical and cognitive functions, and continuous participation in social activities, and is also affected by a positive attitude. Studies have reported that individuals with a positive attitude to aging are better able to adapt to changes, and thus age more successfully [36,37]. This finding indicates an association between adaptation and successful aging.
The principal limitation of this study is that the sample included only the older population. This study shows that despite their negative attitudes toward old age, individuals with chronic disease had greater abilities to cope with problems and aged more successfully. It is recommended to organize trainings on successful aging and to approach individuals with and without chronic diseases consciously about successful aging.
Disclosures: There is no conflict of interest for all authors.
Acknowledgment: The authors are indebted to all health professionals and participants.
Funding: None.
References
1. Gutiérrez M, Tomás JM, Calatayud P. Contributions of Psychosocial Factors and Physical Activity to Successful Aging. Span J Psychol. 2018; 21:E26. https://doi.org/10.1017/sjp.2018.27
2. Ferrucci L, Fabbri E. Inflammageing: chronic inflammation in ageing, cardiovascular disease, and frailty. Nat Rev Cardiol. 2018; 15(9):505-522. https://doi.org/10.1038/s41569-018-0064-2
3. Taylor HO, Taylor RJ, Nguyen AW, Chatters L. Social Isolation, Depression, and Psychological Distress Among Older Adults. J Aging Health. 2018; 30(2):229-246. https://doi.org/10.1177/0898264316673511
4. Chen R, Xu P, Li F, Song P. Internal migration and regional differences of population aging: An empirical study of 287 cities in China. Biosci Trends. 2018; 12(2):132-141. https://doi.org/10.5582/bst.2017.01246
5. Vanleerberghe P, De Witte N, Claes C, Schalock RL, Verté D. The quality of life of older people aging in place: a literature review. Qual Life Res. 2017; 26(11):2899-2907. https://doi.org/10.1007/s11136-017-1651-0
6. Otrar M. Ya§lilik ve Ya§lanmaya Kar§i Tutum Ölgegi: Gegerlik ve Güvenirlik £ali§masi. Sosyoloji Dergisi. 2016; 36(2): 527550.
7. Hazer O, Özsungur F. Successful Aging Scale (BYÖ) Türkge Versiyonu, International Journal of Education Technology and Scientific Researches. 2017; 4.
8. Jones DA, McPhee JS, Degens H. Is ageing 'highly individualistic'? J Physiol. 2015; 593(14):3219. https://doi.org/10.1113/ JP270420
9. Rattan SI. Healthy ageing, but what is health? Biogerontology. 2013; 14(6):673-7. https://doi.org/10.1007/s10522-013-9442-7
10. Dziechciaz M, Filip R. Biological psychological and social determinants of old age: bio-psycho-social aspects of human aging. Ann Agric Environ Med. 2014; 21(4):835-8. https://doi.org/10.5604/12321966.1129943
11. Hartley A, Angel L, Castel A, Didierjean A, Geraci L, Hartley J, Hazeltine E, Lemaire P, Maquestiaux F, Ruthruff E, Taconnat L, Thevenot C, Touron D. Successful aging: The role of cognitive gerontology. Exp Aging Res. 2018; 44(1):82-93. https://doi. org/10.1080/0361073X.2017.1398849
12. Bolukba§ N, Arslan H. Huzur Evinde Kalan Ya§lilarin Psikososyal Yonlerinin incelenmesi. Du§unen Adam. 2003; 16(4):235-239.
13. Eyuboglu C, §i§li Z, Kartal M. Ya§am dongusunde ya§liligin psikolojik boyutu. Turkish Family Physician. 2012; 3(1):18-22.
14. Akozer M, Nuhrat C, Say §. Turkiye'de Ya§lilik Donemine ili§kin Beklentiler Ara§tirmasi (Expectations Regarding Old Age in Turkiye). Sosyal Politika Cali§malari Dergisi. 2011; 12(7):103-128.
15. Liu H, Jiao J, Zhu C, Zhu M, Wen X, Jin J, Wang H, Lv D, Zhao S, Wu X, Xu T. Associations Between Nutritional Status, Sociodemographic Characteristics, and Health-Related Variables and Health-Related Quality of Life Among Chinese Elderly Patients: A Multicenter Prospective Study. FrontNutr. 2020; 7:583161. https://doi.org/10.3389/fnut.2020.583161
16. Guo W, Chen L, Perez C. Economic Status, Family Dependence, and Health Outcomes of Older People in Western Rural China. J Gerontol Soc Work. 2019; 62(7):762-775. https://doi.org/10.1080/01634372.2019.1676860.
17. Bicket MC, Mao J. Chronic Pain in Older Adults. Anesthesiol Clin. 2015; 33(3):577-90. https://doi.org/10.1016/j. anclin.2015.05.011
18. Janevic MR, McLaughlin SJ, Heapy AA, Thacker C, Piette JD. Racial and Socioeconomic Disparities in Disabling Chronic Pain: Findings From the Health and Retirement Study. J Pain. 2017; 18(12):1459-1467. https://doi.org/10.1016/jjpain.2017.07.005
19. Hirase T, Kataoka H, Nakano J, Inokuchi S, Sakamoto J, Okita M. Impact of frailty on chronic pain, activities of daily living and physical activity in community-dwelling older adults: A cross-sectional study. Geriatr Gerontol Int. 2018; 18(7):1079-1084. https://doi.org/10.1111/ggi.13314
20. Sofaer B, Moore AP, Holloway I, Lamberty JM, Thorp TAS, O'Dwyer J. Chronic pain as perceived by older people: a qualitative study. Age Ageing. 2005; 34(5):462-6. https://doi.org/10.1093/ageing/afi139
21. Morone NE, Greco CM. Mind-body interventions for chronic pain in older adults: a structured review. Pain Med. 2007; 8(4):359-75.
22. Tambag H. Healthy Lifestyle Behaviors and Life Satisfaction in Elderly. MustafaKemal Univ.TipDerg. 2013; 4(16):23-31.
23. Nedjat-Haiem FR, Cadet T, Parada H Jr, Jones T, Jimenez EE, Thompson B, Wells KJ, Mishra SI. Financial Hardship and Health Related Quality of Life Among Older Latinos With Chronic Diseases. Am JHosp Palliat Care. 2020; 6:1049909120971829. https://doi.org/10.1177/1049909120971829
24. Chen HM, Tu YH, Chen CM. Effect of Continuity of Care on Quality of Life in Older Adults With Chronic Diseases: A Meta-Analysis. Clin Nurs Res. 2017; 26(3):266-284. https://doi.org/10.1177/1054773815625467
25. Steptoe A, Deaton A, Stone AA. Subjective wellbeing, health, and ageing. Lancet. 2015; 385(9968):640-648.
26. Bierman A, Lee Y. Chronic Pain and Psychological Distress Among Older Adults: A National Longitudinal Study. Research on Aging. 2018; 40(5):432-455. https://doi.org/10.1177/0164027517704970
27. Dragioti E, Bernfort L, Larsson B, Gerdle B, Levin LA. Association of insomnia severity with well-being, quality of life and health care costs: A cross-sectional study in older adults with chronic pain (PainS65+). Eur J Pain. 2018; 22(2):414-425. https:// doi.org/10.1002/ejp.1130
28. Bilir N. Degi§en Saglik Oruntulerinde Halk Sagligi Cali§anlarimn Rolu: Kronik Hastaliklar ve Ya§lilik Sorunlari. Toplum Hekimligi Bulteni. 2006; 25(3):1-6.
29. Gallagher RM. Problem-solving therapy for pain in the older adult. Pain Med. 2006; 7(5):369. https://doi.org/10.1111/j.1526-4637.2006.00213.x
30. Karp JF, Gao X, Wahed AS, Morse JQ, Rollman BL, Weiner DK, et al. Effect of Problem-Solving Therapy Versus Supportive Management in Older Adults with Low Back Pain and Depression While on Antidepressant Pharmacotherapy. Am J Geriatr Psychiatry. 2018; 26(7):765-777. https://doi.org/10.1016/jjagp.2018.01.004
31. Regier NG, Parmelee PA. The stability of coping strategies in older adults with osteoarthritis and the ability of these strategies to predict changes in depression, disability, and pain. AgingMent Health. 2015; 19(12):1113-22. https://doi.org/10.1080/1360 7863.2014.1003286
32. Kudo H, Izumo Y, Kodamo H, Watanabe M, Hatakeyama R, Fukuoka Y, et al. Life satisfaction in older people. Japan Geriatrics Society. 2007; 7:15-20.
33. Helme RD. Chronic pain management in older people. Eur J Pain. 2001; 5(Suppl A):31-6. https://doi.org/10.1053/eujp.2001.0277
34. Anton SD, Woods AJ, Ashizawa T, Barb D, Buford TW, Carter CS, et al. Successful aging: Advancing the science of physical independence in older adults. Ageing Res Rev. 2015; 24(Pt B): 304-27.
35. Marks R. Successful Aging and Chronic Osteoarthritis. Review Medicines (Basel). 2018; 5(3):105. https://doi.org/10.3390/ medicines5030105
36. Hamid TA, Momtaz YA, Ibrahim R. Predictors and prevalence of successful aging among older Malaysians. Gerontology. 2012; 58(4):366-70. https://doi.org/10.1159/000334671
37. Martineau A, Plard M. Successful aging: analysis of the components of a gerontological paradigm. Geriatr Psychol Neuropsychiatr Vieil. 2018; 16(1):67-77. https://doi.org/10.1684/pnv.2018.0724
