Physical and Cognitive Development in Middle

Adulthood

Middle Age: A Social Construct

We described adolescence as a stage of life that lipid profiles (cholesterol and fat levels), high
ultimately is a social construct. The same is true blood pressure, insulin resistance,
of midlife (Cohen, 2012). The term midlife first cardiovascular health, obesity, and chronic
came into the dictionary in 1895 (Lachman, health conditions (Radler, Rogotti, & Ryff, 2018;
2004) as life expectancy began to lengthen. Boylan & Ryff, 2015). However, social status
Today, in industrial societies, middle adulthood matters too. Other research has shown that
is considered to be a distinct stage of life with its psychological factors such as well being and a
own societal norms, roles, opportunities, and sense of personal control exert their effects
challenges. However, some traditional societies, most strongly when people are low in education
such as upper caste Hindus in rural India or social status. When people have plentiful
(Menon, 2001) and the Gusii in Kenya, do not resources, they tend to do well regardless of
recognize a middle stage of adulthood at all. whether or not they feel they are doing well or
in control. But when they are low in resources,
We define middle adulthood in chronological
their personal characteristics can buffer them
terms as the years between ages 40 and 65, but
from emerg ing health crises of midlife
this definition is arbitrary. There is no consensus
on when midlife begins and ends. In 2017, Middle age is marked by growing individual
slightly under 84.4 million people in the United differences and a multiplicity of life paths
States, or 26 percent of the population, were (Lachman, 2004). Some middle-aged people can
between the ages of 45 and 64 years (U.S. run mara thons, others get winded climbing a
Census Bureau, 2018). This represents an flight of stairs. Some feel a sta ble sense of
increase of 12 percent since 2006 control over their lives, others feel
(Administration for Community Living, 2018). overwhelmed handling weighty responsibilities
The Midlife in the United States (MIDUS) study, and multiple demanding roles: running
a comprehensive survey of a national sample of households, departments, or enterprises;
7,189 adults ages 25 to 75, has enabled launching chil dren; and perhaps caring for
researchers to study factors that influence aging parents or starting new careers. Others,
health, well-being, and productivity in midlife having made their mark and raised their chil
(Brim, Ryff, & Kessler, 2004). According to the dren, have an increased feeling of freedom and
MIDUS data, most middle-aged people are in independence (Lachman, 2001). Middle age can
good physical, cognitive, and emotional shape be a time of decline and loss, or it can be a time
and feel good about the quality of their lives of mastery, com petence, and growth

However, the experience of middle age varies PHYSICAL DEVELOPMENT

with health, gender, race/ethnicity,
Physical Changes
socioeconomic status, cohort, and culture, as
well as with personality, marital and parental Although some physiological changes are direct
status, and employment (Lachman, 2004). For results of biological aging and genetic makeup,
example, high levels of psychological well-being behavioral and lifestyle factors dating from
over time predict health indices such as blood
youth can affect the likelihood, timing, and understanding speech and gradually extends
extent of physical change into lower pitches. Hearing loss is generally mild
until late in life. At ages 40 to 49, approximately
SENSORY AND PSYCHOMOTOR FUNCTIONING
7 per cent of adults have mild to moderate
From young adulthood through the middle hearing loss, a number that rises to slightly
years, sensory and motor changes are almost under 13 percent by 50 to 59 years of age. Thus,
imperceptible—until one day a 45-year-old man in midlife, hearing loss does not cause
realizes that he cannot read a book without significant distress or impairment to the vast
eyeglasses, or a 60-year-old woman has to majority of adults. However, by ages 70 to 79,
admit that she is not as quick on her feet as she when over 50 percent of adults have mild to
was. With increasing age, it is common for moderate hearing loss and some adults begin to
adults to experience a variety of perceptual show profound or total hearing loss (Goman &
declines, including hearing and visual difficulties Lin, 2016), it becomes a significant factor. The
loss of the ability to hear speech effectively can
Age-related visual problems occur mainly in five isolate adults, leading to loneliness and
areas: near vision, dynamic vision (reading depression
moving signs), sensitivity to light, visual search
(locating a car in a parking lot), and speed of What factors affect hearing loss? Gender
processing visual information (Kline & Scialfa, matters; hearing loss pro ceeds more quickly in
1996). You may have seen older people using men than in women (Ozmeral, Eddins, Frisina, &
reading glasses or holding books or newspapers Eddins, 2016). Prevalence is higher among
as far out as possible with one arm when trying Hispanics and non- Hispanic white adults than
to focus. As people age, they have difficulty among African Americans (Goman & Lin, 2016).
focusing on near objects, a condition known as However, the most important factor in hearing
presbyopia. The incidence of myopia loss is environ mental noise. Estimates are that,
(nearsightedness) also increases throughout worldwide, 16 percent of hearing loss in adults
middle age (Rosenthal & Fischer, 2014). Overall, can be attributed to noise experienced at a work
approxi mately 12 percent of adults age 45 to 64 site (Nelson, Nelson, Concha-Barrientos, &
experience declines in their vision (Pleis & Fingerhut, 2005). While hearing protectors such
Lucas, 2009). By the age of 65, 36.6 percent of as ear plugs have decreased the impact of
adults will have some sort of visual disability occupational noise, “social noise” (including
concerts and personal music players) has
How do people adjust to these changes? increased (Sliwinska-Kowalska & Davis, 2012).
Middle-aged people often need brighter lighting Sensitivity to taste and smell generally begins to
to see well. Because of changes in the eye, they decline in midlife (Stevens, Cain, Demarque, &
need about one-third more brightness to Ruthruff, 1991). Approximately 13.5 percent of
compensate for the loss of light reaching the adults over the age of 40 years have problems
retina (Troll, 1985). Reading glasses, bifocals, with their sense of smell, 17.3 percent with
and trifocals are also used to aid the eye in their sense of taste, and 2.2 percent with both
focusing on objects. Age-related, gradual smell and taste (Liu, Zong, Doty, & Sun, 2016).
hearing loss is known as presbycusis. It is rarely By the age of 80, over 75 percent of adults show
noticed earlier in life, but it generally speeds up declines (Doty, 2018). These declines are more
and becomes noticeable in the fifties (Merrill & common in men, African Americans, people
Ver brugge, 1999). Presbycusis generally begins who consume large amounts of alcohol, and
with higher-pitched sounds less important for adults with cardiovascular disease
As the taste buds become less sensitive and the no change in eating or exercise habits (Merrill &
number of olfactory cells diminishes, foods may Verbrugge, 1999). Weight gain in early
seem more bland (Merrill & Verbrugge, 1999). adulthood is predictive of major chronic
Additionally, the use of medi cines used to treat diseases later (Zheng et al., 2017). However,
many diseases of aging can also have a negative staying active can help adults maintain current
effect on the gustatory senses (Imoscopi, weight, retain physical skills, and slow declines.
Inelmen, Sergi, Miotto, & Manzato, 2012), as Manual dexterity, especially for men and in the
can smoking (Vennemann, Hummel, & Berger, nondominant (in this study, the left) hand,
2008). These declines have implications for generally becomes less efficient with age
quality of life and are associated with
Simple reaction time (as in pressing a button
Alzheimer’s and Parkinson’s diseases and
when a light flashes) slows very little until about
mortality risk (Doty, 2018). Staying physically
age 50, but choice reaction time (as in pressing
active has wide-ranging positive effects on
one of four numbered buttons when the same
almost every body sys tem, including physical
number appears on a screen) slows gradually
health markers such as reduced cardiovascular
throughout adult hood (Woods, Wyma, Yund,
risk, psychological markers such as decreased
Herron, & Reed, 2015; Der & Deary, 2006).
risk of depression, and cognitive markers such
When a vocal rather than a manual response is
as decreased risk of dementia (Bauman,
called for, age differences in simple reaction
Merom, Bull, Buchner, & Fiatarone Singh, 2016).
time are substantially less
The more people do, the more they can do, and
the longer they can do it for. presbyopia
Some loss of muscle strength is usually Age-related, progressive loss of the eyes’ ability
noticeable by age 45; 10 to 15 percent of to focus on nearby objects due to loss of
maximum strength may be gone by 60. This is elasticity in the lens.
partly due to a loss of muscle fiber, which is
replaced by fat (Guralnik, Butterworth, myopia
Wadsworth, & Kuh, 2006; Schaap, Koster, & Nearsightedness.
Visser, 2012). Additionally, changes in the
skeletal muscle fiber itself lead to decrements in presbycusis
the ability to shorten quickly and forcefully Age-related, gradual loss of hearing, which
(Brocca et al., 2017), and the fibers lose some of accelerates after age 55, especially with regard
their ATP-producing capacity with age, thus to sounds at higher frequencies.
producing less molecular energy (Porter et al.,
2015). Still, impairment is not inevitable; basal metabolism
strength training and a high protein diet can
Use of energy to maintain vital functions.
protect against these declines
THE BRAIN AT MIDLIFE
Basal metabolism is the minimum amount of
energy, typically measured in calories, that your In general, the aging brain can be described in
body needs to maintain vital functions while two ways: as working more slowly and as having
resting. As people age, the amount of energy difficulty juggling multiple tasks (Zanto &
needed to maintain the body goes down, Gazzaley, 2014). This general pro cess affects
particularly after age 40. So, for example, older multiple tasks across many different areas—
people often put on weight later in life despite from understanding complex language to
driving a car skillfully to learning new skills. found that physical activity and f itness are
What these disparate tasks have in common is associated with higher white and gray matter
the necessity to quickly process complex volume (Sexton et al., 2016; Erickson, Leckie, &
information and pay attention to relevant Weinstein, 2014). Moreover, physical activity in
stimuli while simultaneously ignoring irrelevant midlife is positively associated with cognitive
stimuli. In particular, the ability to ignore function during midlife itself, as well as with
distractions gradually declines with age, which protection against future cognitive declines (Cox
makes multitasking increasingly challenging et al., 2016; Sofi et al., 2011). Last, reviews of
both aero bic exercise and resistance training
Why do these changes occur? Physical changes
interventions have shown they are effective in
in the aging brain contribute to the declines in
improv ing attention, processing speed,
functioning. With increasing age, there is a
executive function and memory, although
decrease in the volume of gray matter (Fjell et
effects are generally modest in size (Smith et al.,
al, 2009; Chee et al., 2009). Myelin, the fatty
2010; Chang, Pan, Chen, Tsai, & Huang, 2012). A
sheath that lines nerve axons and helps
busy mind is also important. Adults who read
impulses move more quickly through the brain,
and write on a regular basis or who work in a
also begins to break down with age (Lu et al.,
cognitively stimulating environment are more
2013; Chopra et al., 2018; Salami, Eriksson,
likely to retain their cognitive functions
Nilsson, & Nyberg, 2012). The specific location
(Cortrena, Branco, Cardoso, Wong, & Fonseca,
and extent of these changes in the gray and
2016; Smart, Gow, & Deary, 2014). There is also
white matter are associated with the severity of
some evidence that meditation affords cognitive
processing slowdown and the area of cognition
benefits to middle aged adults and may help
in which it occurs (Eckert, 2011; Hong et al,
offset declines (Gard, Hölzel, & Lazar, 2014).
2015). For example, people who show atro phy
Cognitive inter ventions and mental stimulation
in the left insula, an area of the brain associated
have also been shown to be effective in
with speech production, are more likely to
improving functioning
experience the tip-of-the-tongue phenomenon,
in which a person knows he knows a word but Even if declines do occur, knowledge based on
cannot access it experience can compensate for the physical
changes. For example, middle-aged adults are
Although some declines are likely, declines are
better drivers than younger ones (McFarland,
neither inevitable nor necessarily permanent. In
Tune, & Welford, 1964). More experienced
the past, it was believed that education helped
drivers are better at anticipating potential
slow the declines associ ated with age.
hazards before they become dangerous, shifting
However, although education is associated with
their gaze around the environ ment, while
higher IQ and superior performance on a variety
novice drivers tend to stare straight ahead and
of cognitive tasks, it does not appear to delay
respond only to clear and imminent hazards
declines in processing speed or cognitive
(Borowsky, Shinar, & Oron-Gilad, 2010).
functioning. Rather, adults with a high level of
Similarly, 60-year-old typists are as efficient as
education start off ahead and hence may
20-year-olds (Spirduso & MacRae, 1990), and
function at a higher level for a longer period of
skilled industrial work ers in their forties and
time
fifties are often more productive than younger
Two factors that do seem to be important are workers and in fact tend to be more
keeping both body and mind busy. Although conscientious and careful
effects sizes are small, meta-analyses have
 midfifties; and by 65, it can lose up to 40
percent of its aerobic power. Vital capacity—the
STRUCTURAL AND SYSTEMIC CHANGES
maximum volume of air the lungs can draw in
Changes in appearance may become noticeable and expel—may begin to diminish at about age
during the middle years. By the fifth or sixth 40 and can drop by as much as 40 percent by
decade, the skin may become less taut and age 70 (Merrill & Verbrugge, 1999; Whitbourne,
smooth as the layer of fat below the surface 2001). The body tem perature of older people is
becomes thinner, collagen molecules more rigid, lower, and they are less able to maintain an
and elastin fibers more brittle. Hair may become appropriate body temperature in extremely hot
thinner due to a slowed replacement rate, and or cold environments (Blatteis, 2012). Sleep is
grayer as production of melanin, the pigmenting also affected by age; middle-aged adults are less
agent, declines. Middle-aged people tend to likely to fall asleep in the daytime, need less
gain weight as a result of accumulation of body sleep to maintain alertness, and show
fat and lose height due to shrinkage of the reductions in slow wave sleep at night when
interverte bral disks compared to adolescents and emerging adults

Bone density normally peaks in the twenties or vital capacity

thirties. From then on, people typically
Amount of air that can be drawn in with a deep
experience some bone loss as more calcium is
breath and expelled.
absorbed than replaced, causing bones to
become thinner and more brittle. Bone loss SEXUALITY AND REPRODUCTIVE FUNCTIONING
accelerates in the fifties and sixties; it occurs
Sexuality is not only a hallmark of youth.
twice as rapidly in women as in men, sometimes
Although both sexes experience losses in repro
leading to osteoporosis (Merrill & Ver brugge,
ductive capacity sometime during middle
1999; Whitbourne, 2001). Smoking, alcohol use,
adulthood—women become unable to bear chil
and a poor diet earlier in adult hood tend to
dren and men’s fertility begins to decline—
speed bone loss; it can be slowed by aerobic
sexual enjoyment continues throughout adult
exercise, resistance training with weights,
life.
increased calcium intake, and vitamin C
(Whitbourne, 2001; Yoon, Maalouf, & Sakhaee, Menopause and Its Meanings
2012). Lower childhood socioeconomic level
and adult educational attainment have been Menopause takes place when a woman
linked to lower bone mass density in late permanently stops ovulating and menstruating
adulthood. This association may exist because and can no longer conceive a child; it is
stress, which is higher in people of low generally considered to have occurred one year
socioeconomic status, is damaging to bone after the last menstrual period. This happens,
health on average, at about age 50 to 52, with most
women experiencing it between 45 and 55
Large proportions of middle-aged and even
older adults show little or no decline in organ Menopause is not a single event; it is a process
functioning (Gallagher, 1993). In some, however, called the menopausal transition. It begins with
heart disease begins to emerge in the late perimenopause, also known as the climacteric.
forties or early fifties. Arterial walls may become During this time, a woman’s production of
thicker and more rigid. The heart may begin to mature ova begins to decline, and the ovaries
pump more slowly and irregularly in the produce less estrogen. Men struation becomes
less regular, with less flow than before, and
there is a longer time between menstrual
periods. Eventually, menstruation ceases
altogether. The menopausal transition generally
begins in the midthirties to midforties, and can
take approximately 3 to 5 years.

menopause

Cessation of menstruation and of ability to bear

children

perimenopause

Period of several years during which a woman

experiences physiological changes of
menopause; includes first year after end of
menstruation; also called climacteric

Symptoms

Most women experience some symptoms

during the menopausal transition. Some have
no symptoms at all, and racial/ethnic variations
exist (see Table 2). Most commonly reported are
hot flashes and night sweats, sudden sensations
of heat that flash through the body due to
erratic changes in hormone secretion that affect
the temperature control centers in the brain.
Hot flashes are associated with anxiety, depres
sion, and an increased risk for heart disease (Fu,
Gibson, Mendes, Schembri, & Huang, 2018;
Thurston et al., 2017). They are experienced by
up to 80 percent of menopausal women and are
the most common reason for which women
seek medical attention related to menopause.
The average duration of symptoms is over 5
years, although Afri can American women,
highly stressed women, and women of low
educational status may experience them for
longer

Some women find intercourse painful because

of thinning vaginal tissues and inad equate
lubrication (NIH, 2005). Water-soluble lubricants
may help relieve this problem. Sexual issues can
also be alleviated with marital therapy for legumes and beans) have also been found to be
postemenopausal women and their husbands somewhat effective
(Tiznobeck, Mirmolaei, Momenimovahed,
Changes in Male Sexual Functioning
Kazemnejad, & Taheri, 2017). In addition, some
women of menopausal age may experience Men remain fertile throughout the life span and
mood disturbances, such as irritability, do not go through menopause in the same
nervousness, tension, and depres sion (Gracia & dramatic fashion as do women. Men do have a
Freeman, 2018; NIH, 2005). All in all, the biological clock, however, and they also
research suggests that some of the symptoms of experience age-associated changes. Start ing at
meno pause may be related to other natural about age 30, testosterone levels begin to
changes of aging (National Center for decline at a rate of about 1 percent a year,
Complementary and Alternative Medicine although there are wide individual variations
[NCCAM], 2008). They also may reflect societal
views of women and of aging Although men can still father children, sperm
count declines with age. Moreover, the genetic
Treatment of Menopausal Symptoms quality of their sperm declines as well, and
advanced paternal age has been implicated as a
Menopause hormone therapy (MHT) appears to
source of birth defects
be the most effective intervention for night
sweats, hot flashes, and deterioration of the Men’s changing hormone levels affect more
urinary tract and vagina. MHT may also help than just their sexual organs. The decline in
address other symptoms such as joint and testosterone has been associated with
muscle pains, mood swings, problems with reductions in bone density and muscle mass
sleep, and sexual dysfunction. However, the use (Ast hana et al., 2004) as well as decreased
of MHT should be the lowest dose possible and energy, lower sex drive, overweight, emotional
considered within the context of other life and irri tability, and depressed mood. Low
health variables, including diet, exercise, family testosterone has also been linked to diabetes
and personal history, and the use of cigarettes and cardiovascular disease and has been
and alcohol. Women using MHT should also theorized to increase mortality (Lewis et al.,
undergo a yearly health assessment, since the 2006; Kelly & Jones, 2014; Johnson, Nachtigall,
use of hormones is not without risks (Baber, & Stern, 2013; Fui, Dupuis, & Grossmann, 2014).
Panay, & Fenton, 2016). Most notably, hormone Many men suffer no ill effects from declines in
therapy increases the risk of cardiac disease, testosterone production, but some middle-aged
dangerous blot clots, stroke, and bone loss, and older men experience erectile dysfunction
espe cially for women over the age of 60 or (ED; commonly called impo tence). Erectile
women who use hormones for extended dysfunction is defined as a persistent inability to
periods of time achieve or maintain an erect enough penis for
satisfactory sexual performance. A recent
Because of these risks, many women prefer not
review of international studies on ED found
to use hormone therapy. In this event, selective
widely divergent estimates across different
serotonin reuptake inhibitors—typically taken
countries; however, all countries showed
for depression—may be used (De Villiers et al.,
increases in ED with age. Overall, in men
2016). The antihypertensive clonidine, the
younger than 40 years, the prevalence rates
anticonvulsive drug gabapentin, and soy
were from 1 to 10 percent. From 40 to 49 years,
isoflavones (a class of phytoestrogens found in
prevalence rates across countries were 2 to 15
percent and rose to 20 to 40 percent in the percent of married or cohabitating women did,
decade from 60 to 69 years. By the seventies and at 50 to 59 years, 67.7 percent of women
and eighties, nearly all countries showed living alone had sex in the previous 6 months,
prevalence rates from 50 to 100 percent while almost 87 percent of married and
(McCabe et al., 2016). In the United States, cohabitating women did (Thomas, Hess, &
approximately 61 percent of 40- to 69-year-olds Thurston, 2015). Health is also important, and
and more than 77 percent of men over the age good health has been repeatedly associated
of 70 have ED with sexual activity and satisfaction (Thomas et
al., 2015; Fisher et al., 2015). Menopause
There are multiple potential causes for ED.
matters as well; 61 percent of married or
Diabetes, obesity, hypertension, high
cohabiting premenopausal women but only 41
cholesterol, depression, neurological disorders,
percent of postmenopausal women reported
and many chronic diseases have been
having sex once a week or more (Rossi, 2004),
implicated. In addition, alcohol and drug use, as
and hot flashes are associated with declines in
well as smoking, may contribute. Poor sexual
sexual activity (Thomas et al., 2015). Other
techniques, lack of knowledge, unsatisfying
factors such as surgery, medications, and too
relationships, anxiety, and stress may be
much food or alcohol can also impact sexual
contributing factors as well (Rosen & Kupelian,
activity
2016; Sartorius et al., 2012). Treat ment
guidelines state that clinicians should first Nonphysiological issues also impact sexual
counsel men to institute lifestyle modi f ications activity. For example, body image can influence
to improve health, which then may also improve the desire to have sex. Women who feel
ED. If this is ineffective, then Sildenafil (Viagra) confident about their bodies and are high in
and other similar testosterone therapies can be self-acceptance tend to have higher levels of
prescribed (Burnett et al., 2018). If there is no sexual satisfaction, while those who are self-
apparent physical problem, psychotherapy or conscious about their appearance are more
sex therapy (with the support and involvement likely to report declines (Thomas, Hamm,
of the partner) may help Borrero, Hess, & Thurston, 2018). A couple’s
relationship quality is important too. When a
Sexual Activity
couple communicates well, kisses and cuddles
Myths about sexuality in midlife—for example, frequently, and is physically tender, this is
the idea that satisfying sex ends at menopause associated with greater sexual satisfaction.
—have sometimes become self-fulfilling Importantly, couples who can communicate
prophecies. Advances in health care and more about sexual activity and preferences, who care
liberal attitudes toward sex are making people about each other’s pleasure, and who desire
more aware that sex can be a vital part of life approximately the same amount of sexual
during middle and late adulthood. activity also tend to be more satisfied

The single most important factor determining Physical and Mental Health
sexual activity is the presence of a partner.
Most middle-aged Americans, like those in
Married and cohabitating women have a
other industrialized countries, are generally
roughly 8 times higher chance of being sexually
healthy. All but 16.7 percent of 45- to 64-year-
active. From the ages of 40 to 49, almost 75
olds consider themselves in good to excel lent
percent of women who lived by themselves had
health (National Center for Health Statistics,
sex in the previous 6 months, while nearly 90
2018), and only 2.2 percent of 45- to 54-year-
olds and 3.5 percent of 65- to 74-year-olds are Hypertension is the world’s leading preventable
currently limited in their activities of daily living, cause of early death. Currently, approximately
performing everyday chores, such as making 31 percent of people worldwide have high
dinner or using a bathroom blood pressure. In high-income countries, rates
decreased by 2.6 percent from 2000 to 2010,
Nevertheless, baby boomers may be less
presumably as a result of better diagnosis and
healthy than previous generations. Research has
treatment. By contrast, low- and middle-income
shown increases in the use of medical services,
countries showed an increase of 7.7 percent
hospitalization rates for coronary stent
(Mills et al., 2016). These high rates are
insertion, and hip and knee replacement
troubling given hypertension’s status as a risk
surgery (Freid & Bernstein, 2010), and there are
factor for cardiovascular disease and stroke
indications that younger cohorts may be
(Forouzanfar et al., 2015). Currently, these two
showing sharper increases in issues associated
diseases are the leading causes of global death,
with activities of daily living
and estimates are that 1 in 4 deaths can be
HEALTH TRENDS AT MIDLIFE attributed to them

Hypertension (chronically high blood pressure) In the United States, cancer has replaced heart
is an increasingly important concern from disease as the leading cause of death between
midlife on as a risk factor for cardiovascular ages 45 and 64 (National Center for Health
disease and kidney disease. In 2015 2016, 43.4 Statistics, 2018). Overall, death rates have
percent of American men and 38 percent of declined since the 1970s for people in this age
women ages 45 to 64 were diagnosed with bracket, in large part because of improvements
hypertension (National Center for Health in treatment of heart attack patients (Hoyert,
Statistics, 2018), although these numbers will Arias, Smith, Murphy, & Kochanek, 2001). Chest
need to be adjusted in light of new pain is the most common symptom of a heart
recommendations released in November 2017 attack in both men and women, but women
(American College of Cardiology, 2017). Previous may experience other symptoms, such as back
guidelines defined high blood pressure at and jaw pain, nausea and vomiting, indigestion,
140/90; however, because of research showing difficult breathing, or palpitations
an increased risk of disease at lower levels, the
The prevalence of diabetes doubled in the
recommended cutoff for high blood pressure is
1990s (Weinstein et al., 2004). Approxi mately
now 130/80 (Ettehad et al., 2016). While
13.2 percent of adults age 45 to 64 years have
numbers are still high, in the United States
been diagnosed with diabetes (National Center
increasing numbers of people are successfully
for Health Statistics, 2018). The most common
identifying and controlling their high blood
type, mature-onset (type 2) diabetes, typically
pressure (Yoon et al., 2015). Some adults can
develops after age 30 and becomes more
lower their blood pressure with lifestyle
prevalent with age. Unlike juvenile-onset (type
modifica tions, such as weight loss, increases in
1), or insulin-dependent, diabetes, in which the
physical activity, eating a low-salt diet with plen
level of blood sugar rises because the body does
tiful fruits and vegetables, increasing potassium
not produce enough insulin, in mature onset
intake, and consuming light amounts of alcohol.
diabetes glucose levels rise because the cells
If lifestyle modifications are not effective,
lose their ability to use the insulin the body
medication is generally used as well
produces. As a result, the body may try to
compensate by producing too much insulin.
People with mature-onset diabetes often do not Hispanics have the highest prevalence rate at
realize they have it until they develop such 84.2 percent, in comparison to non-Hispanic
serious complications as heart disease, stroke, whites at 70.8 percent and non-Hispanic blacks
blindness, kidney disease, or loss of limbs at 76 percent (Flegal, Carroll, Ogden, & Curtin,
2010). When considering obesity, non-Hispanic
hypertension
blacks (48.1 percent) demonstrate the highest
Chronically high blood pressure prevalence rate, with non-Hispanic whites (34.5
percent) and Hispanics (42.5 percent) at lower
diabetes risk
Disease in which the body does not produce or Physical activity in midlife is an important
properly use insulin, a hormone that converts protective factor, particularly given that declines
sugar, starches, and other foods into energy in cardiovascular fitness are steep after age 45
needed for daily life (Jackson, Sui, Hébert, Church, & Blair, 2009).
BEHAVIORAL INFLUENCES ON HEALTH Unfortunately, research suggests that the
average person engages in about a half hour
On average, Americans who smoke, are less of physical activity per day over the span of
overweight, and have high blood pressure and 10 years from early adulthood to midlife,
high blood sugar have a life expectancy 4 years replacing previously active time with sedentary
less than those who do not (Danaei et al., 2010). activity (Pettee Gabriel et al., 2018). Physical
By the same token, people who do not smoke, activity can increase the chances of remaining
who exercise regularly, drink alcohol in mobile in old age (Patel et al., 2006), of avoiding
moderation, and eat plenty of fruits and weight gain (Lee, Djoussé, & Sesso, 2010), and
vegetables have 4 times less risk of dying in of staying healthier longer (Jackson et al., 2009).
midlife and old age (Khaw et al., 2008). Perhaps Adults who engage in regular, moderate, or
more important from a quality of life vigorous exercise are about 35 percent less
perspective, people who guard their health not likely to die in the next 8 years than those with a
only live longer but also have shorter periods of sedentary lifestyle. Those with cardiovascular
disability at the end of life risk factors and a history of coronary heart
Weight in particular seems to affect health. disease benefit the most from being physically
Excess weight in middle age increases the risk of active (Richardson, Kriska, Lantz, & Hayward,
impaired health and death (Jee et al., 2006), 2004). Last, physical activity is associated with
even in healthy people (Yan et al., 2006) and for better cognitive functioning at midlife (Hoang et
those who have never smoked (Adams et al., al., 2016) and a decreased risk of dementia in
2006). Being overweight, which is medically late adulthood
defined as having a body mass index (BMI) of Unfortunately, only about a third of U.S. adults
between 25 to 29.9, is a risk factor. However, show good compliance with health
obesity, defined as a BMI of 30 or more, is an recommendations, most notably with respect to
even greater risk and associated with ever suggested dietary guidelines (Wright, Hirsch, &
greater mortality (Flegal, Kit, Orpana, & Wang 2009). Although adhering to a healthy
Graubard, 2013). Weight also interacts with lifestyle throughout life is ideal, changes later in
ethnicity, making some ethnic groups more life can reverse some of the damage
likely to become overweight or obese. For
example, when considering overweight, SOCIOECONOMIC STATUS AND HEALTH
People with low socioeconomic status tend to determine the cause of these disparities,
have poorer health, shorter life expectancy, researchers have looked to the human genome.
more activity limitations due to chronic disease, Research in this area has found distinctive
and lower well-being than people with higher variations in the DNA code among people of
SES. In part, this is due to the cost of health different ancestry. These variations are linked to
care. In 2017, almost 38 percent of poor and predispositions to various diseases, from cancer
near poor people either delayed or did not to obesity, and such data may ultimately open
receive medical care because of its expense the way to targeted treatments of preventive
measures (Antonarakis & Cooper, 2019).
The reasons for the connection between SES
Although genetics may offer some clues to
and health may also be psychosocial. People
differences in health as a function of race or
with low SES tend to live in more stressful
ethnicity, by far the most research has focused
environments and thus report higher levels of
on correlates of ethnicity and how those might
perceived stress. These higher levels of stress, in
be related to differences in health. Poverty is
turn, are associated with a greater likelihood of
most likely the largest single underlying factor in
engaging in unhealthy behaviors, such as
this link. People who live in poverty generally
consuming a poor diet, smoking, and not
have poorer access to health care, more
exercising (Algren et al., 2018). People with
stressful lives, and greater exposure to potential
higher SES, by contrast, experience less stress
toxins in their everyday environment
and have a greater sense of control over what
happens to them, attenuating their stress There are other differences between people of
response (Mooney, Elliott, Douthit, Marquiz, & different ethnicities. From young adult hood
Seplaki, 2016). They also tend to choose throughout middle age, African Americans have
healthier lifestyles and to seek medical attention higher overall death rates and higher incidence
and social support when they need it (Lachman of hypertension, obesity, and diabetes (National
& Firth, 2004; Marmot & Fuhrer, 2004). Center for Health Sta tistics, 2018b). Given the
Moreover, they tend to show higher compliance strong relationship between race and
with lifestyle modifications recommended to socioeconomic status in the United States, many
improve health indices of these health disparities are attributable to
the effects of poverty. For African Americans, for
However, there are wide individual differences
example, poverty has been related to poor
in health among low-SES adults. Protective
nutrition, substandard housing, and poor access
influences include the quality of social
to health care (Smedley & Smedley, 2005). How
relationships and the level of reli gious
ever, even when African Americans have high
engagement from childhood on (Ryff, Singer, &
socioeconomic status, racial disparities in health
Palmersheim, 2004). Negative influences
still exist. One factor that has been identified as
include loneliness, which has a negative effect
a potential causal influence is the additive
on both mental and phys ical well-being and is a
effects of discrimination, racism, and social
risk factor for poor health and mortality
inequality. The added burden of these factors
RACE/ETHNICITY AND HEALTH over a lifetime can result in an accumulating
strain on the body with con sequent negative
Even though racial and ethnic disparities in effects on health and wellness
health have decreased in the United States since
1990, substantial differences persist (National Hispanic Americans, like African Americans,
Center for Health Statistics, 2018b). In trying to have a disproportionate incidence of stroke,
liver disease, diabetes, HIV infection, homicide, Health Statistics, 2018b). They are also more
and cancers of the cervix and stomach (Office of likely to suffer from chronic health problems
Minority Health, CDC, 2005; National Center for such as cancer or high blood pressure (Siegel,
Health Statistics, 2016). In 2017, Hispanics had Miller, & Jemal, 2015; Maranon & Reckelhoff,
the lowest rates of health care coverage (83.9 2013) and to report drug or alcohol problems
percent) compared to African American (89.4 (Seidler et al., 2016). Both genders, however,
percent), Asian (92.7 percent), and non-Hispanic show roughly the same degree of limitations in
white (93.7 percent) individuals (Berchick, daily living (12.8 percent for men versus 12.5
Hood, & Barnett, 2018). Hispanics are percent for women) as a result of chronic health
particularly likely to lack health insurance and a conditions
regular source of health care if they have limited
As women’s lifestyles have become more like
English proficiency (Martorell & Martorell,
men’s, so have their health patterns. For
2006). Not sur prisingly, they are also less likely
example, the gender gap in deaths from heart
to be screened for cholesterol and for breast,
disease has narrowed primarily because heart
cervi cal, and colorectal cancers or to receive
attack rates in women have risen. Explanations
influenza and pneumonia vaccines
for this increase rely in part on rising rates of
GENDER AND HEALTH obesity and diabetes in women and in part on
the tendency of doctors to assume heart
Women have a higher life expectancy than men
disease is less likely in women. Thus, doctors are
and lower death rates throughout life (Murphy,
more likely to recognize and treat heart disease
Xu, Kochanek, & Arias, 2018). Women’s greater
risk in men, leading to a better focus on
longevity has been attributed to genetic
controlling risk factors in men than in women
protection given by the second X chromosome
(Towfighi, Zheng, & Ovbiagele, 2009; Vaccarino
(which men do not have) and, before
et al., 2009). This type of trend may help explain
menopause, to beneficial effects of the female
why the difference between women’s and men’s
hormone estrogen on both cardiovascular and
life expectancy shrank from 7.6 years in 1970 to
cognitive health (Rodin & Ickovics, 1990;
5 years in 2017
USDHHS, 1992; Hara, Waters, McEwen, &
Morrison, 2015). However, psychosocial and With longer life spans, women in many
cultural factors, such as men’s greater propen developed countries now can expect to live half
sity for risk-taking, also may play a part their adult lives after menopause, during which
time they are at increased risk for osteoporosis,
Although women live longer, they are slightly
breast cancer, and heart disease. As a result,
more likely to report being in fair or poor health
increasing attention is being paid to women’s
than men. According to the MIDUS survey,
health issues at this time of life (Barrett-Connor
middle aged women tend to report more
et al., 2002). There has also been more
specific symptoms and chronic conditions than
awareness of men’s health issues as well. For
men, and they devote more effort to
example, as they age, men face an increasing
maintaining their health (Cleary, Zaborski, &
risk of erectile dysfunction, particularly if their
Ayanian, 2004). Men may feel that admitting
health is already poor
illness is not masculine and seeking help means
a loss of control (Seidler, Dawes, Rice, Oliffe, & For many years, older men were subject to
Dhillon, 2016), and they are less likely to seek aggressive screening procedures for pros tate
professional help for health problems or stay cancer. Sometimes small cancers would be
overnight in a hospital (National Center for discovered, and many men were treated for
those cancers. However, given the slow growth Osteoporosis
of prostate cancer, it is likely that many of these
Condition in which the bones become thin and
growths would never have become dangerous.
brittle as a result of rapid calcium depletion.
Thus, new recommenda tions were recently
developed to reduce the emphasis on The treatment approaches for osteoporosis
aggressive screening procedures with the goal have come under scrutiny in recent years
of reducing unnecessary medical treatment. (Gualler & Laine, 2014). Previous treatment
Now, unless men meet one of a number of philosophies assumed increasing available
particular risk factors, prostate screening is not calcium should increase bone strength.
always recommended However, research indicated that calcium supple
ments did not affect the risk of a bone fracture.
Bone Loss and Osteoporosis
Moreover, calcium supplements increased the
In women, bone loss rapidly accelerates in the risk of other health issues, including kidney
first 5 to 10 years after menopause as levels of stones, cardiovascular problems, and
estrogen, which helps in calcium absorption, gastrointestinal issues (Reid, 2014). Additionally,
fall. Extreme bone loss may lead to osteoporosis there was also confusion about the role of
(“porous bones”), a condition in which the hormone replacement therapy (HRT) in women.
bones become thin and brittle as a result of While HRT can ameliorate some of the
calcium depletion. Common signs of symptoms of menopause as well as slow bone
osteoporosis are marked loss in height and a loss, its use also carries significant risks
hunchbacked posture that results from
In 2017, the American College of Physicians
compression and collapse of a weakened spinal
(ACP) released new, evidence-based guidelines
column. In a national observational study of
for the treatment and management of
more than 200,000 postmenopausal women,
osteoporosis in both men and women (Qaseem,
almost half had previously undetected low bone
Forciea, McLean, & Denberg, 2017). Strong
mineral density, and 7 percent of these women
recommendations included the use of
had osteoporosis (Siris et al., 2001).
biphosphonates (drugs that slow or prevent
Osteoporosis is a major cause of broken bones
bone loss) such as alendronate, risedronate,
in old age and can greatly affect quality of life
zoledronic acid, or denosumab in women who
and even survival
have been diagnosed with osteoporosis. These
Almost 3 out of 4 cases of osteoporosis occur in medications reduce the risk of hip or vertebral
white women, most often in those with fair skin, fractures in women, but the evidence for their
small frame, low weight and BMI, and a family effectiveness in men is weaker. In contrast to ear
history of the condition, and those whose lier recommendations, the ACP strongly
ovaries were surgically removed before recommends HRT not be used for treating
menopause (NIH Consensus Development osteoporosis in women, as new evidence does
Panel, 2001; Siris et al., 2001). Other risk factors, not show it to be effective. The ACP also
besides age, include smoking and lack of recommends biphosphonate therapy for 5
exercise (Siris et al., 2001). A predisposition to years; however, bone density monitor ing does
osteoporosis seems to have a genetic basis, not appear to confer any additional benefits to
particularly as there are indications that genetic patients and is not necessary. Last, the ACP
markers may have implications for which drugs recommends that treatment decisions be
may be most effective in an individual holistic and take into account patient
preferences and profile, and the financial and largest number of cancer related deaths among
medical costs and benefits of medications. women

Good lifestyle habits can reduce risk, especially Overweight women, those who drink alcohol,
if started early in life (NIH Consen sus those who experience early menarche and late
Development Panel, 2001). Longitudinal studies menopause, those with a family history of
suggest that exercise can help slow bone breast cancer, and those who have no children,
density loss (Kemmler, Bebenek, Kohl, & von did not breast-feed, or who bore children later
Stengel, 2015). While some research ers have in life have a greater risk of breast cancer,
argued the data on exercise are inconclusive whereas those who are moderately physically
(Qaseem et al., 2017), others have pointed out active and eat low-fat, high-fiber diets are at
that the benefits of exercise are promising and less risk (American Cancer Society, 2017b;
extend even further than bone health. For McTiernan et al., 2003). Weight gain, especially
example, staying active can maintain strength, after menopause, increases a woman’s risk of
agility, and balance, and can thus be protective breast can cer, and weight loss decreases the
against falls that often lead to broken bones in risk
older adults. Older adults also benefit from
Advances in treatment and early diagnosis have
proper nutrition and the avoidance of smoking
dramatically improved prospects for breast
or heavy drinking
cancer patients. Fully 89 percent of U.S. women
Breast Cancer and Mammography with breast cancer now survive at least 5 years
past diagnosis. If the cancer is still localized and
One in 8 American women develops breast
has not yet spread, the 5-year survival rate is 99
cancer at some point in her life (American
percent (Miller et al., 2016). Cancer can be
Cancer Society, 2017b). In 2017, 42,510 people
treated with removal of part or all of the breast,
in the United States died of breast cancer
along with radiation or chemotherapy. The
About 5 to 10 percent of breast cancer cases are benefits of mammography, diagnostic X-ray
thought to be hereditary, resulting from examination of the breasts, appear to be
inherited mutations. The most common of these greatest for women over 50. In 2009, the U.S.
are mutations of the BRCA1 and BRCA2 genes. Preventive Services Task Force issued a new set
Women without these mutations have roughly a of guidelines recommending that women begin
10 percent chance of developing breast cancer. routine screening for breast cancer at 50, rather
However, those who have a BRCA1 or BRCA2 than at 40 years of age as had been previously
mutation have as much as a 70 percent chance suggested. However, adherence to this
of developing breast cancer. Another gene, diagnostic schedule varies, and medical
PALB2, can also predispose women to a higher professionals and organizations often disagree
risk of breast cancer (American Cancer Society, with recommended diagnostic guidelines
2017d). However, the vast majority of breast
mammography
cancer cases are environmentally influenced.
Once found mostly in affluent countries, breast Diagnostic X-ray examination of the breasts.
cancer is becoming a worldwide problem as
Hormone Therapy
Western lifestyles move into the developing
world (Por ter, 2008). Worldwide, approximately The most troublesome physical effects of
627,000 women died in 2018 from breast menopause are linked to reduced levels of
cancer. Breast cancer is responsible for the estrogen, and hormone therapy (HT) has been
used to address these effects. HT is treatment As with the cardiac data, the links between HR
with artificial estrogen, sometimes in and breast cancer risk are complex. Heightened
combination with proges terone, to help relieve risk of breast cancer seems to occur mainly
symptoms of menopause. HT has a complicated among current or recent estro gen users, if
pattern of risks and benefits. estrogen and progestin are used together, and
the risk increases with length of use (Chen,
hormone therapy (HT)
Weiss, Newcomb, Barlow, & White, 2002; De
Treatment with artificial estrogen, sometimes in Villiers et al., 2013). How ever, the overall risk is
combination with the hormone progesterone, still quite low, with an incidence of less than 1
to relieve or prevent symptoms caused by woman per 1,000 over a year. This risk is
decline in estrogen levels after menopause comparable to increased risk due to lifestyle
factors such as being sedentary or consuming
On the positive side, HT is the most effective alcohol
means of addressing symptoms such as night
sweats and hot flashes, especially for women Results on the effects of HT on cognitive
below the age of 60 or who went through function and dementia risk are also dif f icult to
menopause less than 10 years ago (De Villiers et interpret. Some studies have found that HT
al., 2013). However, it is not as effective at reduces the risk of cognitive impairment (Zandi
managing osteoporosis. HT, when started at et al., 2002), while others have found it
menopause and continued for at least 5 years, increases the risk (Espeland et al., 2004;
does slow bone loss after menopause (Barrett- Shumaker et al., 2004). Timing may matter here.
Connor et al., 2002; Lindsay, Gallagher, HT that begins in early menopause does not
Keerekoper, & Pickar, 2002). However, bone loss seem to have a negative effect on cognition;
resumes within 3 years if and when HT stops however, later initia tion of HT is associated with
(Heiss et al., 2008). Moreover, HT fails to reduce increased risk of dementia (De Villiers et al.,
the risk of fracture 2013). Additional research in this area indicates
that when women use HT in midlife only, they
While earlier research was equivocal, the most show a lower risk of dementia than women who
recent research suggests that HT does not use HT in early menopause and continue to do
impact the risk of either cardiovascular disease so into late adulthood and than women who
or mortality (Manson et al., 2017; Benkhadra et begin using HT in late adulthood. It may be
al., 2015). Because of the complicated risk there is a critical window of time where HT is
profile of these drugs, HT should not be used for protective, but taken outside of that window, it
disease prevention but is appropriate for is damaging
menopausal symptom management in affected
women (Manson et al., 2013). Lifestyle changes
such as losing weight and stopping smoking,
STRESS IN MIDDLE AGE
together with any necessary drugs to lower
cholesterol and blood pressure, appear to be Stress is the damage that occurs when
wiser courses for heart disease prevention in perceived environmental demands, or stressors,
most women (Manson & Martin, 2001). HT, exceed a person’s capacity to cope with them.
especially when taken orally, has also been The body’s capacity to adapt to stress involves
associated with a greater, although still overall the brain, which perceives danger (either real or
small, risk of stroke or blood clot imagined); the adrenal glands, which mobilize
the body to fight it; and the immune system,
which provides the defenses. Stress in middle The stress response system and the immune sys
age may come from role changes, career tem are closely linked and work together to
transitions, grown children leav ing home, and keep the body healthy. However, at times,
the renegotiation of family relationships. Midlife especially during highly stressful events, the
can be a pivotal period in the life span, and how body may not be able to cope (Figure 2).
challenges are addressed at this juncture can Chronic stress can lead to persistent
have implications for whether or not an inflammation and, over time, to disease (Cohen
individual’s trajectory takes a positive or et al., 2012; Miller & Blackwell, 2006). More
negative turn into the later stages of life over, a propensity to respond in a negative
fashion to stress may interact with genetic
Common sources of reported stress include
predispositions. So, even if similar stressors are
health, work and money, personal debt, housing
experienced, some people respond more
instability, and hunger. Fifty-eight percent of
negatively than others. Research has shown a
adults age 40 to 72 also list mass shootings as a
number of life events to be highly stressful,
source of stress. Discrimination is also
including divorce, the death of a spouse or
problematic, and concerns in this area differ by
other family member, or the loss of a job. The
race and ethnicity. African American adults
more stressful the changes that take place in a
report discrimination to be a source of stress 46
person’s life, the greater likelihood of serious
percent of the time and Hispanics report a rate
illness within the next year or 2
of 36 percent, while white adults report
discrimination as a source of stress 14 percent Generally, acute, or short-term, stress, such as
of the time (American Psychological Association, the challenge of taking a test or running a com
2018). Women tend to report more extreme petitive race, generally strengthens the immune
stress than men (35 percent compared to 28 system (Segerstrom & Miller, 2004). We are
percent) and to be more concerned about stress adapted to dealing with such events, and our
(American Psychological Association, 2017a). bodies quickly and efficiently respond to and
The classic stress response—fight or flight—may then recover from the event (Sapolsky, 1992).
be more characteristic of men, activated in part However, intense or prolonged stress, such as
by testosterone. Women’s response pattern is might result from poverty or disability, can
typically tend and befriend—nurturant activities weaken or break down the body, increasing the
that promote safety and reliance on social sus ceptibility to disease (Sapolsky, 1992;
networks to exchange resources and Segerstrom & Miller, 2004). In support of this
responsibilities. These patterns may have assertion, research has found suppressed
evolved through nat ural selection and may immune function in breast cancer patients
draw on women’s involvement in attachment (Compas & Luecken, 2002), abused women,
and caregiving hurricane survivors, and men with a history of
post-traumatic stress disorders (PTSD) (Harvard
stress
Medical School, 2002). Daily stressors such as
Response to physical or psychological demands. irritations, frustrations, and over loads may be
less severe in their impact than life changes, but
stressors their buildup can also affect health and
Perceived environmental demands that may emotional adjustment
produce stress For minority group mem bers, discrimination
Stress and Health and racism can also lead to increased chronic
stress and are associated with an increased risk et al., 2009) and with an increased risk of death
for disease (Thoits, 2010). These processes are from heart attack in men
of concern because stress has been increasingly
The opposite pattern has been found for
recognized as a factor in such age related
positive emotions. Positive emotions and well-
diseases as hypertension, heart disease, stroke,
being are associated with both short-term and
diabetes, osteoporosis, peptic ulcers,
long-term positive health outcomes (Diener &
depression, HIV/AIDS, and cancer
Chan, 2011; Howell, Kern, & Lyubomirsky, 2007)
EMOTIONS AND HEALTH and reduced mortality (Chida & Steptoe, 2008).
Hope and curiosity have been found to predict a
An ancient proverb of Solomon, “A merry heart
decreased likelihood of hypertension, diabetes,
doeth good like medicine” (Proverbs 17:22), is
and respiratory tract infections (Richman et al.,
being borne out by contemporary research.
2005). Personality traits also affect health:
Because the brain interacts with all of the
Optimism and conscientiousness are consis
body’s bio logical systems, feelings and beliefs
tently associated with better health and longer
affect bodily functions, includ ing the
life
functioning of the immune system (Ray, 2004;
Richman et al., 2005). Negative emotions, such There are also indirect effects of positive
as anxiety and despair, are often associated with emotions on health. A positive emotional
poor physical and mental health, and positive outlook motivates people to engage in more
emo tions, such as hope, with good health and healthful practices, such as regular sleep and
longer life exercise, and to pay more attention to health-
related information. Positive emotions may also
Negative emotions serve important adaptive
affect health indirectly by softening the impact
functions and, under the right circumstances,
of stressful life events and help ing people feel
are a healthy response to events. When nega
more connected to others
tive emotions are elicited in negative contexts,
they can have beneficial consequences, such as MENTAL HEALTH
when fear motivates an individual to schedule a
In 2017, approximately 22.3 million U.S. adults
screening for a disease (Coifman, Flynn, & Pinto,
age 26 to 49 had some form of mental,
2016). However, when negative moods are
behavioral, or emotional disorder that met
excessive, long-lasting, or occur too frequently,
DSM-IV criteria in the past year (excluding
they can have damaging effects on the body,
developmental disorders and substance use
suppress immune function ing, and increase
disorders). Of those, 7.6 million had a major
susceptibility to disease. Negative emotions,
depressive episode, and slightly over 67 percent
such as anxiety and despair, are often
of them received treatment for it (Sub stance
associated with poor physical and mental health
Abuse and Mental Health Services
(Ray, 2004; Salovey et al., 2000; Spiro, 2001).
Administration, 2018). Depression negatively
Peo ple high in neuroticism and hostility, who
affects health, making prevention and
are prone to such feelings on a regular basis, are
treatment an important issue (Bromberger, Har
more likely to suffer from serious illness and
low, Avis, Kravitz, & Cordal, 2004). Adults with
reduced longevity. Hostility has also been
serious psychological distress are more likely
associated with an increased risk of coronary
than their peers to be diagnosed with heart
heart disease and mortality for postmenopausal
disease, arthritis, or stroke and to report
women (Lahey, 2009; T. W. Smith, 2006; Tindle
needing help with activities of daily living such conducted by K. Warner Schaie and his
as bathing and dressing colleagues (Schaie, 1990, 1994, 1996a, 1996b,
2005; Willis & Schaie, 1999, 2006), dem
Even those adults not diagnosed with a mental
onstrates this fact.
disorder may experience negative effects at a
subclinical level. For example, when asked The study began in 1956 with 500 randomly
about the presence of mental health related chosen men and women across a vari ety of
symptoms in the past month, 42 percent of different age brackets ranging from 22 to 67
adults reported feeling nervous or anxious, 37 years of age. The participants were then
percent reported feeling depressed or sad, 33 followed longitudinally, and assessed every 7
percent reported constant worrying, and 37 years on timed tests of six primary mental
percent reported irritability or anger. Moreover, abilities (Table 3). By using multiple cohorts—
nearly half of adults reported lying awake at people of different ages, all fol lowed over time
night in the past month due to stress —Schaie and his colleagues were able to tease
apart the different influences and conduct more
COGNITIVE DEVELOPMENT
sophisticated analyses.
What happens to cognitive abilities in middle
Most participants showed remarkable stability
age? Do they improve or decline, or both? Do
over time, and no significant reductions in most
people develop distinctive ways of thinking at
abilities until after age 60, and then not in most
this time of life? How does age affect the ability
areas. Virtually no one declined on all fronts,
to solve problems, to learn, to create, and to
and most people improved in some areas.
perform on the job?
However, there were wide individual
Measuring Cognitive Abilities in Middle Age differences. Similarly, there were no uniform
patterns of age-related change across cognitive
The status of cognitive abilities in middle age abilities. For example, several abil ities peaked
has been a subject of much debate. Here, we during middle age, and verbal meaning even
look at two important lines of research, K. showed improvements into old age. By contrast,
Warner Schaie’s Seattle Longitudinal Study and about 13 to 17 percent of adults declined in
Horn and Cattell’s studies of fluid and number, memory recall, or verbal fluency
crystallized intelligence between ages 39 and 53

Schaie and his colleagues also found that

successive cohorts scored progressively higher
at the same ages on most abilities, possibly
because of improvements in educa tion, healthy
lifestyles, and other positive environmental
influences. However, numerical ability showed
overall declines after the 1924 cohort, and
verbal meaning declined after the 1952 cohort

Individuals who scored highest tended to have

SCHAIE: THE SEATTLE LONGITUDINAL STUDY
high educational levels, to have flexible
Cognitively speaking, in many respects middle- personalities, to be in intact families, to pursue
aged people are in their prime. The Seat tle cognitively complex occupations and other
Longitudinal Study of Adult Intelligence, activities, to be married to someone more
cognitively advanced, to be satisfied with their true for perceptual speed, which peaks quite
accomplishments (Schaie, 1994, 2005; Willis & early, beginning in the twenties. From the age of
Schaie, 2006), and to be high in the personality 20 to 60 years, the average person will have lost
dimension of openness to experience (Sharp, more than one standard deviation in fluid
Reynolds, Pedersen, & Gatz, 2010). Given the intelligence (Salthouse, 2010). Working memory
strong cognitive performance of most middle- capacity also declines with age. However, many
agers, evidence of substan tial cognitive decline older adults perform in the real world at high
in persons younger than 60 may indicate a levels despite the apparent declines in fluid
neurological problem (Schaie, 2005; Willis & intelligence (Salthouse, 2012). How do we make
Shaie, 1999). In particular, midlife decline in sense of this discrepancy between cognitive
memory recall and verbal fluency, a measure of declines and real-world performance?
executive functioning, can predict cognitive
One explanation is offered by improvements in
impairment in old age
crystallized intelligence, which increase through
HORN AND CATTELL: FLUID AND CRYSTALLIZED middle age and often until near the end of life
INTELLIGENCE (Horn, 1982a, 1982b; Horn & Donaldson, 1980).
Older adults can use their accumulated lifetime
Imagine a glass of water. If you tilt it, the water
of knowledge to compensate for tasks in which
sloshes around in random swirls and waves. By
decision making can benefit from prior
contrast, a block of ice has a rigid crystalline
experiences (Li, Baldassi, Johnson, & Weber,
structure, with every molecule in its place. This
2013). Thus, you might expect that older adults
is the metaphor used by another set of
would do as well or better on tasks such as
cognitive researchers (Cattell, 1965; Horn, 1967,
filling out a tax return, where crystallized intelli
1968, 1970, 1982a, 1982b; Horn & Hofer, 1992)
gence would be helpful, but not on tasks such as
to describe the dif ferent types of intelligence.
learning how to use a new smartphone, where
They distinguish between two aspects of
fluid intelligence would be more important
intelligence: fluid and crystallized. Fluid
(Zaval, Li, Johnson, & Weber, 2015). People’s
intelligence is the ability to solve novel
cognitive performance offers insight into their
problems on the fly. Such problems require little
overall health. While crystal lized intelligence is
or no previous knowledge, such as realizing that
not associated with mortality risk once
a hanger can be used to fix a leaky toilet or
sociodemographic factors are considered, fluid
discovering the pattern in a sequence of figures.
intelligence is strongly predictive of mortality
It involves perceiving relations, forming
risk (Batterham, Chistensen, & Mackinnon,
concepts, and drawing inferences. Crystallized
2009; Aichele, Rabbitt, & Ghisletta, 2015).
intelligence, by contrast, is the ability to
Additionally, a large discrepancy between fluid
remember and use information acquired over a
and crystallized intelligence, particularly for
lifetime, such as finding a synonym for a word or
highly edu cated people, may be an indicator of
solving a math problem. It is fixed, as is the
cognitive decline
structure of ice. Crystallized intelligence is
measured by tests of vocabulary, general
information, and responses to social situations
fluid intelligence
and dilemmas—abilities that depend largely on
educa tion and cultural experience. Type of intelligence, proposed by Horn and
Cattell, that is applied to novel problems and is
Typically, fluid intelligence has been found to
peak in young adulthood. This is par ticularly
relatively independent of educational and intelligence abilities become encapsulated—
cultural influences. that is, dedicated to handling specific kinds of
knowledge. This process of encapsulation makes
crystallized intelligence
that knowledge easier to access, to add to, and
Type of intelligence, proposed by Horn and to use. It may take middle-aged people longer
Cattell, involving the ability to remember and than younger people to process new
use learned information; it is largely dependent information. But when it comes to solving
on education and culture. problems within their field of expertise, their
encapsulated knowledge compen sates and
The Distinctiveness of Adult Cognition allows them to rapidly and effectively solve a
Instead of measuring the same cognitive problem
abilities at different ages, some developmental Experts notice different aspects of a situation
scientists look for distinctive qualities in the than novices do, and they process infor mation
thinking of mature adults. and solve problems differently. Their thinking is
THE ROLE OF EXPERTISE often more flexible and adaptable. They
assimilate and interpret new knowledge more
Two young resident physicians in a hospital efficiently by referring to a rich, highly organized
radiology labora tory examine a chest X-ray. storehouse of mental representations of what
They study an unusual white blotch on the left they already know. For example, imaging studies
side. “Looks like a large tumor,” one of them show that when completing a task within their
says finally. The other nods. Just then, a domain of expertise, experts show brain
longtime staff radiologist walks by and looks activation in areas associated with long-term
over their shoulders at the X-ray. “That patient memory. This allows them to integrate
has a collapsed lung and needs immedi ate information in long-term memory with working
surgery,” he declares (Lesgold et al., 1988). Why memory in “chunks” and thus perform the task
do mature adults show increasing competence at a higher level than novices (Guida, Gobet,
in solving problems in their chosen fields? One Tardieu, & Nicolas, 2012). They sort information
answer seems to lie in specialized knowledge, or on the basis of underlying principles, rather
expertise—a form of crystallized intelligence than surface similarities and differences. And
that is related to the process of encapsulation. they are more aware of what they do not know
The type of knowledge children accumulate— (Charness & Schul tetus, 1999; Goldman,
such as how to read, complete math problems, Petrosino, & Cognition and Technology Group at
or understand metaphor—is fairly uniform. Vanderbilt, 1999). Cognitive performance is not
Most children learn similar things at roughly the the only ingredient of expertise. Problem
same time. In adulthood, however, paths of solving occurs in a social context. Ability to
learning diverge and adults become more or make expert judgments depends on familiarity
less learned in whatever domain of knowledge with the way things are done—with the
they pursue. These advances in exper tise expectations and demands of the job and the
continue at least through middle adulthood culture of the community or enterprise. Even
and, for the most part, are not related to concert pianists, who spend hours practicing in
general intelligence. Moreover, they usually do isolation, must adapt to various concert halls
not depend on the brain’s information-pro with different acoustics, to the musical
cessing machinery because some adults’ fluid conventions of the time and place, and to the
musical tastes of their audiences
Expert thinking often seems automatic and Creativity
intuitive. Experts generally are not fully aware of
At about age 40, Frank Lloyd Wright designed
the thought processes that lie behind their
Robie House in Chicago. Charles Darwin was 50
decisions (Charness & Schultetus, 1999; Salas,
when he presented his theory of evolution. Toni
Rosen, & Diaz Granados, 2010). They cannot
Morrison won the Pulitzer Prize for Beloved, a
readily explain how they arrive at a conclusion
novel she wrote at about 55. Many creative
or where a nonexpert has gone wrong. Such
people have reached their great est
intuitive, experience based thinking is also
achievements in middle age
characteristic of what has been called
postformal thought. CHARACTERISTICS OF CREATIVE ACHIEVERS
encapsulation Intelligence and creativity are not the same
thing. Although a certain baseline general intel
In Hoyer’s terminology, the process that allows
ligence, or IQ, is needed (Guilford, 1956),
expertise to compensate for declines in
creative performance is not strongly related to
information-processing ability by bundling
general intelligence once that threshold is
relevant knowledge together.
reached (Simonton, 2000). This is true even
INTEGRATIVE THOUGHT though the baseline IQ needed for creative
performance does rise for more complex
Although not limited to any particular period of
creative achievements
adulthood, postformal thought seems well
suited to the complex tasks, multiple roles, and Intelligence seems to be more strongly
perplexing choices and challenges of midlife, influenced by genetic processes than creativity
such as the need to synthesize and balance does. Intelligence shows high heritability, and its
work and family demands heritability rises with age as individuals get
older and seek out more experiences in line
An important feature of postformal thought is
with their proclivities (Plomin & Deary, 2015).
its integrative nature (Kallio, 2011). Mature
By contrast, strong genetic contributions have
adults interpret what they read, see, or hear in
not been found for creative perfor mance
terms of its meaning for them. Instead of
(Runco et al., 2011; Reuter, Roth, Holve, &
accepting something at face value, they filter it
Hennig, 2006). Whereas many children often
through their life experience and previous
show strong creative potential, in adults what
learning. In one study (C. Adams, 1991), early
matters is creative performance—what and how
and late adolescents and middle-aged and older
much a creative mind produces (Sternberg &
adults were asked to summarize a Sufi teaching
Lubart, 1995). Creativity seems to be the
tale. In the story, a stream was unable to cross a
product of particular social contexts as well as
desert until a voice told it to let the wind carry
individual proclivities. With respect to
it; the stream was dubious but finally agreed
environment, creativity seems to develop from
and was blown across. Adolescents recalled
diverse experi ences that weaken conventional
more details of the story than adults did, but
constraints and challenging experiences that
their summaries were largely limited to
strengthen the ability to persevere and
repeating the story line. Adults, especially
overcome obstacles
women, gave summaries that were rich in
interpretation, integrating what was in the text Individual differences also can make creativity
with its psychological and metaphorical more likely. For example, highly creative people
meaning for them are self-starters and risk-takers. They tend to be
independent, nonconformist, uncon ventional, Is there a relationship between creative
high in emotional intelligence, high in positive performance and age? On psychometric tests of
affect, and open to new ideas and experiences. divergent thinking, age differences consistently
Their thinking processes are often unconscious, appear. Whether data are cross-sectional or
leading to sudden moments of illumination longitudinal, scores peak, on average, around
(Simonton, 2000; Torrance, 1988; Da Costa, the late thirties (Simonton, 1990). After this,
Páez, Sánchez, Garaigordobil, & Gondim, 2015). they remain relatively flat for some time, and
They look at problems more deeply and come then decline in the seventies (Massimiliano,
up with solutions that do not occur to others 2015). A similar age curve emerges when
(Sternberg & Horvath, 1998). They think in creativity is measured by variations in output
flexible ways and explore many possible (number of publications, paintings, or
solutions to problems compositions). A person in the last decade of a
creative career typically produces only about
However, this is not enough. Extraordinary
half as much as during the late thirties or early
creative achievement requires deep, highly
forties, though somewhat more than in the
organized knowledge of a subject and a strong
twenties (Simonton, 1990). However, the age
emotional attachment to the work, which spurs
curve varies depending on the field. Poets,
the creator to persevere in the face of obstacles.
mathematicians, and theoretical physicists tend
A person must first be thoroughly grounded in a
to be most prolific in their late twenties or early
field before she or he can see its limitations,
thirties. Research psychologists reach a peak
envision radical departures, and develop a new
around age 40, followed by a moderate decline.
and unique point of view (Keegan, 1996; Baer,
Novelists, historians, and philosophers become
2015). Not surprisingly, researchers have looked
increasingly productive through their late forties
for creative problem-solving correlates in the
or f ifties and then level off. These patterns hold
brain. This research is challenging—creative
true across cultures and historical periods
ideas, by their very nature, are divergent and
wide-ranging. One meta-analysis including 34 However, there are some indications that this
imaging studies showed that when people were data, or the interpretations of it, may be f
engaged in creative tasks, they showed more lawed. For instance, it is not clear that
activation in the prefrontal cortex regard less of productivity should be the metric by which
what type of creative task they were creativ ity is measured, especially as some
performing. However, different areas became research suggests that older adults’ work
more active depending on task demands. For remains inno vative over time. For example,
example, tasks that required inhibitory pro meta-analyses of age and creativity at work
cesses, fluency, and control were likely to suggest there is no direct relationship between
generate activity in the lateral prefrontal cortex, the two and that much depends on how
whereas tasks that required the activation of creativity is defined (Rietzschel, Zacher, &
semantic (meaning-based) associations tended Stroebe, 2016; Ng & Feldman, 2013).
to elicit more activity in the superior and Additionally, patterns of creative output may
inferior central gyri have changed for more recent cohorts. For
example, while previous research seemed to
suggest researchers’ productivity peached in the
forties, more recent data suggest that those
researchers who are productive when young
CREATIVITY AND AGE
continue to publish scholarly articles at high offers an induce ment to keep working. The Age
rates until retirement Discrimination in Employment Act, which
eliminated mandatory retirement ages for most
Work and Education
occupations, and the Americans with Disabilities
In industrialized societies, occupational roles Act, which requires employers to make
typically are based on age. Young people are reasonable accommodations for workers with
students; young and middle-aged adults are disabilities, have helped mature workers to keep
workers; older adults organize their lives around their jobs.
retirement and leisure. In postindustrial
WORK AND COGNITIVE DEVELOPMENT
societies, people make multiple transitions
throughout their adult lives “Use it or lose it” applies to the mind as well as
the body. Work can influence cognitive
WORK AND RETIREMENT AGE
functioning. Adults can affect their cognitive
Before 1985, the average age of retirement development by the occupational choices they
moved steadily downward. Since then, the make. For example, flexible thinkers tend to
trend has reversed. Before bringing their seek out and obtain substantively complex work
working lives to a complete stop, people may — work that requires thought and independent
reduce work hours or days, gradually moving judgment. In turn, complex work stimulates
into retirement over a number of years. This more flexible thinking, and flexible thinking then
practice is called phased retirement. Or they increases the ability to do such work (Kohn,
may switch to another company or a new line of 1980). Work need not necessarily be construed
work, a practice called bridge employment in the traditional way, and the same is true of
(Czaja, 2006). A majority of older Americans men and women engaged in complex household
now remain active in the labor force after work, such as planning a budget or making
retirement from their career job (Cahill, complicated repairs such as putting in new
Giandrea, & Quinn, 2013). Not surprisingly, plumbing (Caplan & Schooler, 2006). Regardless
those people who have retired or entered of the specifics, people who are deeply engaged
partial retirement are generally more interested in complex work or cognitively stimulating
in volunteering lifestyles tend to show stronger cognitive
performance and fewer declines than their
What has brought about this change? People peers as they age
may continue working to maintain their physical
and emotional health and their personal and Openness to experience—a personality variable
social roles or simply because they enjoy the —also affects cognitive performance over time
stimulation of work (Czaja, 2006; Sterns & (Sharp et al., 2010). People who are high on
Huyck, 2001). Others work primar ily for openness to experience are more likely to retain
financial reasons. For example, data show that their faculties and show high work performance.
the implementation of the Affordable Care Act Similarly, those people who consistently seek
(ACA), which increased the affordability of more stimulating opportunities are likely to
comprehensive health care for many, led to remain mentally sharp (Avolio & Sosik, 1999).
increased early retirement and increases in part- Interestingly, this association may work both
time work (which does not generally include ways. Older adults enrolled in a cognitive
health benefits) among women and low-income training program for 30 weeks showed increases
men (Heim & Lim, 2017). The rise in the Social in openness to experience at the conclusion of
Security retirement age to 67 for full benefits the training
This suggests that if work, both on the job and fourth-grade education was considered literate;
at home, could be made meaningful and today, a high school diploma is barely adequate.
challenging, more adults might retain or
In 2014, 17 percent of U.S. adults could not
improve their cognitive abilities. This seems to
locate clearly identifiable information in brief
be happening to some extent. The gains in
English prose, 27 percent could not perform
cognitive abilities seen in older cohorts may
simple numerical operations such as addition,
reflect workplace changes that put a premium
and 23 percent could not use simple
on adaptability, initiative, and decen tralized
technological tools such as e-mail or the
decision making
Internet. Compared to other countries, the
THE MATURE LEARNER United States ranks about average on literacy
tests. However, U.S. adults are clustered at both
In 2016, 23.6 percent of U.S adults 45 to 54
the high and low ends of the scale
years of age and 20.2 percent of adults 55 to 65
years of age completed a work experience or Middle-aged and older adults tend to have
credential program lower literacy levels than young adults, but the
average literacy level of adults ages 50 to 59 has
Adult Education and Work Skills
increased since 1992. Adults below basic
Changes in the workplace often entail a need for literacy are less likely to be employed than
more training or education. Expanding adults at higher literacy levels (Kutner et al.,
technology and shifting job markets require a 2007; Rampey et al., 2016). In the United States,
life-span approach to learning. The largest area the National Literacy Act requires the states to
of non-degree-granting work credential establish literacy training centers with federal
programs involvea training in health care funding assistance.

Technological skills are increasingly necessary Globally, 750 million adults—about 12 percent
for success in the modern world and are a major of the world population—are illiterate, mostly in
component of work-related adult education. sub-Saharan Africa and Southern Asia. Women
With experience, middle aged people can make up two-thirds of illiterate adults
perform computer-based tasks as well as young worldwide (UNESCO, 2017). Illiteracy is
adults (Czaja, 2006), especially when they are especially common among women in
high in positive affect and sense of control, and developing nations, where education typically is
have retained psychomotor speed (Zhang, considered unimportant for them. In 1990, the
Grenhart, McLaughlin, & Allaire, 2017). United Nations launched literacy programs in
Employers see benefits of workplace education such developing countries as Bangladesh, Nepal,
in improved morale, increased quality of work, and Somalia (Linder, 1990). The United Nations
better teamwork and problem solving, and Educational, Sci entific and Cultural Organization
greater ability to cope with new technology and is currently involved in the Capacity
other changes in the workplace Development for Education, a program
providing targeted evidence-based assistance
Literacy Training with educational reform to vulnerable countries
Literacy is a fundamental requisite for
participation not only in the workplace but in all
facets of a modern, information-driven society.
At the turn of the century, a person with a
Literacy

In an adult, ability to use printed and written

information to function in society, achieve goals,
and develop knowledge and potential