Successful Ageing with COPD: Physical and Psychosocial Adaption to Functional Decline

Abstract

There is considerable research regarding the adaption to functional decline associated with advanced (Stage IV) Chronic Obstructive Pulmonary Disease (COPD). This research has, however, primarily focused on physical and interventional strategies to manage disease progression and symptom burden, as opposed to the psychosocial strategies. To address this paucity, the current research explored the psychosocial strategies people with Stage IV COPD use to maintain quality of life towards the end of life. Eleven older people with Stage IV COPD living in regional Australia were interviewed to explore their experiences of ageing with COPD. The research used a theory-led analysis, informed by a Gadamerian hermeneutic phenomenological methodology, to examine participant data in relation to selection, optimisation and compensation theory (SOC). The participant stories reflected the use of selective strategies, from which a hierarchy of priority tasks emerged. Participants optimised their capacity to perform high priority tasks using a range of pragmatic and instinctive responses to ongoing change, which became more and more conscious and deliberate over time. Additionally, compensatory strategies more traditionally associated with COPD management were used to reduce the impact of symptoms. It is through the participant descriptions and perception of optimisation and compensation strategies and how they were implemented that the wider theme of ‘mind over matter’ emerged. The use of these strategies to adapt physically and psychosocially to COPD shows how the participants demonstrated resilience and used ‘successful ageing’ strategies to cope with ongoing functional decline.

Keywords:

• Selective optimisation and compensation theory
• successful ageing
• stage IV COPD

Introduction

Modern theories of successful ageing (SA) generally reject the Western societal belief that ageing is a unidirectional decline accompanied by a “succession of losses” (1). According to early iterations of SA however, to age successfully was still to avoid illness and disability, to maintain high cognitive and physical functional performance and engage actively in life (2,3). Whilst moving towards a positively oriented theory of ageing, this framework still implies that to be diagnosed with a chronic condition is to no longer age well (4). More recent theories of SA also aim to highlight the overlapping and intertwining nature of physical, psychological and sociological health as people age. These theories contradict the idea that people with one or more chronic condition should be automatically excluded from successful ageing models (5,6). Using this perspective, SA can still be considered to occur, even in the face of functional decline, if people are able to adapt psychosocially (5). Whilst this theory has been validated in the older people in the general population (5), it has not been explored from the perspective of older people living with advanced chronic obstructive pulmonary disease (COPD).

COPD is now widely accepted to be a disease of accelerated lung ageing (7–10). The systemic and pulmonary manifestations of ventilatory impairment are known to result in a downward trajectory of health status and quality of life towards disability and death, punctuated by acute exacerbations and recovery (11–13). However, this assumption of a downward trajectory in health does not allow for the impact of treatment, intervention, or rehabilitation, nor does it allow for the capacity of the individual to adapt to change over time (14,15) in what might be considered a process of successful ageing (5,14). Demonstrating resilience, i.e. competence in the face of adversity (16), has been shown to be a powerful force in facilitating adaption to COPD. Despite this, the research about how older people develop that resilience in the context of COPD or the impact of resilience-based intervention in that group remains sparse (17,18).

There may be a link between the adaptive strategies used by people with COPD to the healthy ageing theory of selection, optimisation and compensation (SOC) (19–22). SOC theory suggests older people may use these three different adaptive strategies to minimise the impact of functional decline and maximise their social and personal capacity to achieve goals (19,22).

Methodology

This study explored how older people with advanced (Stage IV) COPD demonstrated resilience in light of the multidimensional impacts of COPD progression and ageing. Data collection was informed by a Gadamerian hermeneutic phenomenological methodology (23–25). The analysis reported in this article was driven by a deductive approach in so far as coding decisions were theory-driven by SOC theory. Theory-led analysis is commonly used to find evidence for established psychological theory, as well as the provision of deeper insights into the individual’s experience relating to a theory (26). This analysis examined the strategies participants used to manage the physical and psychological symptoms and impact of COPD.

Methods

Participants

The 11 participants ranged in age between 63 and 89 years of age (Table 1), with a range of self-reported comorbidities and an average of 8.8 medications per participant. All participants were recruited on the basis of physician-diagnosed COPD, with the severity classification (GOLD stage IV) determined by the recruiting health service. The self-reported year of diagnosis ranged from two weeks to over 30 years prior to the interview. Nine participants were married, of which two were widowed. All participants lived in their own home, with three living alone. Eleven people aged 63 years or older with Physician diagnosed Stage IV COPD (27) were recruited through the local Health Service Respiratory Coordinated Care Program (RCCP). An invitation to participate in narrative interviews was facilitated by the RCCP Clinical Nurse Consultant, with formal recruitment and informed consent being performed by the researcher. The initial recruitment round of participants was a generalised recruitment of RCCP clients, who would exemplify the “typical” experience of living with advanced COPD. With the insight of the RCCP nurse, theoretical sampling was then used to target participants with specific or atypical experiences, to increase understanding across the breadth of the area of study. One of these prospective participants declined participation.

Table 1. Overview of participant demographics and medical history.

Participant	Age	Gender	Year of diagnosis	Smoking history	Living arrangement	Work history	Number of comorbidities	Number of medications (respiratory/other)
1	82	F	1996	Former	Married	Professional	3	3/4
2	69	F	2009	Former	Widow, lives alone	Cleaner/cook	1	8/3
3	64	M	2004	Former	Married	Painter	2	5/1
4	68	F	2011	Former	Single, lives alone	Semi-professional	2	5/2
5	68	F	1998	No	Married	Cleaning/ manufacturing	8	6/11
6	76	F	2014	Former	Married	Semi-professional	4	5/6
7	73	F	2014	Former	Widow, lives with sister	Semi-professional	3	5/4
8	71	M	2013	Former	Single, lived alone	Farmer	1	6/5
9	68	F	1982	Current	Married, lives with husband, son and grandson	Cleaner/driver	4	3/4
10	63	M	2011	Former	Married	Driver	3	3/1
11	89	M	Not reported	No	Married	Professional	2	3/4

Narrative interviews were used, allowing the participants to direct the telling of their “COPD Story”. The narrative interview method (28) allowed the asking of a single core question: “Can you tell me your story since you noticed something wasn’t right with your breathing” (23). The participants then described and discussed their experience of COPD within minimal interjection or leading from the interviewer. At the conclusion of their story, follow-up questions derived from the narrative were asked to elucidate meaning, depth and clarification.

All interviews were audio or video recorded and transcribed verbatim using participant pseudonyms for the purposes of analysis. Data were then re-coded using a theory-led analysis (29) wherein participant transcripts were analysed in alignment to established theory (i.e. SOC theory).

This study was approved by the Charles Sturt University Human Research Ethics Committee (CSU HREC) (2013/129), the Greater Western Area Health Service (GWAHS) HREC (HREC/13/GWAHS/61) and Bathurst Health Service Ethics Committee (SSA/14/GWAHS/132).

Results

SOC theory

Baltes and Baltes (22) outlined the mechanisms by which older people adapt to ageing, in the presence of functional decline. The theory suggests that as people age, they are able to transform dimensions of their life, to maintain independence and purpose, through the reshaping of goals, expectations and activities. This is achieved through the three mechanisms of SOC; selection (of goals for which resources are focused), optimisation (maximisation of gains) and compensation (for losses in ability) (22). SOC theory involves the orchestration of selective, compensatory and optimisation-based self-regulatory behaviours in response to functional loss(es). SOC theory can be viewed as a holistic integration of adaption in which the individual masters higher levels of functioning. Simultaneously, it can be separated out into the three discreet processes of development, which play into a wider experience of adaption, as outlined here (22,30).

Selection-based coping

Selection-based coping strategies were seen when participants actively engaged (selected) or disengaged (deselected) activities. Deselection was traditionally associated with energy conservation of less enjoyable tasks such as cleaning or shopping. This affords them the ability to more regularly participate in self-care (e.g. showering and toileting) identity-giving roles and activities, particularly those involving family, despite diminished physical capacity.

There were certain tasks however that seemed more important to each participant, reflecting their interests, their relationships with family, and other things that brought joy to their lives. There was also a tendency for these valued activities to revolve around family and allow participants to maintain their role within the family dynamic despite not being able to perform all the physical tasks they would have before the onset of COPD.

As long as I am still needed, and I think I am, as far as the children are concerned, I’m still needed, you know. As long as [my daughter] doesn’t get a cooking course, I’ll be right. (Laurel)

Valued activities and home-care/community mobility shared a commonality in that they were often activities associated with high energy expenditure that could cause considerable fatigue. The difference between the two lay in the participants’ willingness to fatigue themselves to participate in a valued activity, at the expense of home-care/community mobility. One participant noted that she was no longer able to leave home to grocery shop, but was willing to leave home to eat out with her husband. Whilst eating out was an exhausting process, both she and her husband were willing to exert themselves to achieve it, leaving the shopping to her husband at another time.

Well I, when I used to go do the shopping and things like that… now we try and make every Wednesday a lunch day and I can go on that (scooter) to [a restaurant] and I can go in… and put it up along the table and eat and that saves me walking. (Vida)

There seemed to be a hierarchy of priorities for task performance (Table 2). Home-care/community mobility tasks that could be performed easily by others, those where assistive technology was available, and tasks seen to be least important (shopping, cleaning and walking) thus deselected most readily. Through conserving energy this way, more energy was given to valued-activities. However, with time, the number, frequency and magnitude of those tasks also reduced. The most preserved tasks or those given the highest priorities were the most intimate of self-care tasks, particularly showering and toileting.

Table 2. Hierarchy of task performance.

Hierarchy of tasks	Examples	Motivation
Self-care	Showering Toileting	Avoiding negative emotions associated with others assisting in those tasks
Valued activities	Hobbies: painting, woodwork Cooking & entertaining Participating in family events	Participating in activities that build family relationships and provide joy
Home-care/community mobility	Cleaning Cooking Grocery shopping	Conserving energy to engage in higher priority tasks

I came out of hospital and I couldn’t do anything, I couldn’t even wash myself, I couldn’t shower, I couldn’t move. It was most degrading to have somebody come [shower me].  (Laurel)

It is important to note that it was the participant who decided what was considered “home-care” and what was a “valued activity”, particularly in the case of cooking, where some prized cooking as the most important aspect of their identity, whilst others were happy to live on frozen dinners.

When tasks were de-selected, it was often done for both physical/pragmatic reasons as well as to avoid negative emotional responses. The avoidance of breathlessness was at the forefront of physical limitation, although getting older took its toll as well.

I retired early and ah, over the time, I’ve gradually lost the ability to do things, like the garden, I don’t touch the garden now. (John)

Despite the advantages of effective selective coping, increasing loss and deselection became a source of deep emotions such as frustration, depression and grief, weighing as heavily for one participant as knowing that her condition was life-limiting.

I still get down sometimes … and I think it's only natural, because you know that this is a life limiting disease, and it's also an activity limiting disease, and that's hard. (Gail)

Optimisation-based coping

There were quite specific ways in which participants optimised their function to achieve personal tasks and goals. A predominant strategy was to slow down the pace of activity performance. Initial optimisation techniques tended to be subconscious, although deliberate planning of activities, lowering of expectations, taking breaks and establishing routine all became conscious tactics over time.

it was probably maybe 10 years ago that I started to notice that I got a bit breathless by the time I’d finished the shopping, and… did something to make it get easier, you know, unconsciously do things like, if I found I got too breathless to walk down to the shops one way, I went another way … But basically, you know, on the whole, I just think I did everything the same. (Vida)

If I’m going to have a baked dinner, I’ll cook the [meat] the night before and then I only have to do the vegetables and slice the meat up. (Laurel)

Participants noted that one way to slow things down was simply to expect less of themselves, accepting the fact that they would not achieve what they used to. By resetting goals, there seemed to be a reduction in the level of frustration. Importantly, these participants were not removing goals completely, or handing over all responsibility to others, instead they were being more realistic in accepting how much they could achieve in a day.

I just think I’ve slowed myself down a lot, you know, I relax a lot more, ah, I don’t get ah, so flustered you know… (Geordie)

Participants had learned to take breaks whilst performing tasks, either pausing mid-task or taking more substantial breaks as they divide the task into manageable chunks.

To get to the bathroom, I usually got to stop at the table and have a couple of breaths and, you know, and go to the bathroom and come back. (Laurel)

Overwhelmingly, participants seemed to have a sense of perspective in their thinking, balancing the good and the bad. They demonstrated gratitude in their situation, acknowledging there were always people who were worse off, despite their own struggles. Thinking this way seemed to be a motivating force for a number of participants who were determined not to “sit here and rot” (Valerie). This prompted the idea that intrinsic motivation from past experiences, external influences and a sense of gratitude can promote action and adaptation to ongoing change.

you don’t give up and lay down and die… life’s too short to give up and die. (Mae)

Alternately, some participants were able to see that one of the best ways to cope with the disappointment and frustration they felt as functional capacity diminished, was to simply acknowledge the situation and “get over it”.

there’re plenty of days I get up and think ‘I wish I could get rid of this’ (oxygen tubing)… I soon sort of bring myself into line again and you know, get over it, and that’s all you can do. (Vida)

Perspective is also grounded for some in their core beliefs, religion or spirituality. Religious affiliation was associated with a sense of connectedness and community, as well as a source of comfort when discussing death, dying and the afterlife. At the heart of the comfort associated with religious and spiritual connection, was prayer. Four of the participants used prayer regularly as a source of comfort and strength, as well as way of supporting their loved ones.

I believe in God, I pray to God, it would be every night, to thank him for getting me through the day, and just simple things like that, and wish, and ask him to help [my wife] out and ah, the next day and take some of the workload off her. (Evan)

Of all the optimising strategies used, it was the participants’ capacity to manage emotions and symptoms through internal dialogue, especially when they are at their worst, which resonated across each of the stories. This strategy was often used to prevent or reduce anxiety and panic attacks, and breathlessness.

I think you’ve got to just talk yourself out of it virtually, ‘come on Gail; get yourself together…’ (Gail)

Participants used self-talk as a way to motivate or buoy themselves despite fatigue, breathlessness or anxiety. Internal dialogue was also used as a distraction during events, which did not seem to prevent panic attacks or negative emotions, as much as help the participants work through them.

• I’m a therapeutic cook. I found that if I’m sitting here and I’m thinking and I’m getting too sad or anything like that, I’ll get up and open the cupboard and cook… I’ll do something to take my mind off it. (Laurel)

Despite each of the participants using these strategies in one way or another, only one participant had worked with a mental health professional to build these skills. For the rest, it appeared to be a self-honed skill to take conscious control over their body and their symptoms.

Compensatory strategies for energy preservation

Participants used a wide range of interventions and aids to support their activities of daily living (ADL). Interestingly, there was no one aid that all participants used. This suggested that the approach for intervening with aides for ADL needs to be individualised. Medication and oxygen were the dominant interventions used, although mobility aids and paid care providers were also used in specific situations.

Medication regimens were considered by most participants as complex and confusing, with few participants being able to keep track of all their medications at any given time. If a medication was perceived as effective in the short term, it was praised and used often. Conversely, long-term medications or medications with side effects were met with the participant’s disapproval and confusion regarding the role of that medication in their management. Participants routinely had access to oral corticosteroids and antibiotics in the home, allowing them to self-medicate to prevent or reduce the severity of exacerbations.

so it’s nearly three years since I’ve been in Hospital… because I have, I have a plan, at home, I have antibiotics and I know if I get sick I’ve got to take my antibiotics and my prednisone. (Mae)

For others, the medication adjustment had allowed them to resume everyday tasks previously abandoned. In the case of Ruth, a change in diuretic suggested by her nurse, had significant impact on her capacity to participate in and support her husband in the management of their home.

I just sort of stayed at home before that and I was dependent on [my husband] a lot more, because he does all the cooking and that… I am starting to get back into doing a little bit myself and that, just doing a little bit… Just by feeling a little bit better with no fluid. (Ruth)

In considering the positive impact of oxygen therapy, the practicalities of being on oxygen appear to deter heavily from its perceived benefits. Oxygen may be required to perform an activity; however, its physical presence impeded its use to improve physical functioning. Participants identified that the challenge of portability, portable pulsed systems failing to meet increasing need, or fear associated with running out of oxygen limited its effectiveness. As such, social interactions were often dictated by how long a bottle would last.

We hardly ever get out now, and it’s mainly because of me, because it’s just too hard… I’ve got to take a portable oxygen bottle, sometimes I have to take a walker and I’ve got to fit all this in the car, plus anything else that we want to take with us. (Evan)

A number of participants had established ad hoc solutions to oxygen-dependence, facilitating continued participation in valued activities that brought meaning and joy.

I go to the club, I sit there all day. I take my oxygen bottle with me in my back pack and I bought a [walker] so I could transport it in… If I take my bottle, my oxygen with me and I’m coming the next day, I’ll leave it there and pick it up the next day I’m in, and they don’t have a problem putting it in a room for me. (Mae)

Assistive technology was also used by the participants, including walking sticks (canes), walking frames (walkers) and electric scooters. Whilst the form and efficacy varied between participants, the technologies allowed them to continue to do activities they may have otherwise had to cease because of the inability to get between the home/car and the activity. Mobility aids helped some participants alleviate social isolation, although others preferred to use communication-based technology, particularly tablet devices and social media, to connect with loved ones. Five of the seven female participants reported that the use of social media increased their sense of connectedness with family and friends. They were happy to use the social media platform quite voyeuristically, and reported that they particularly enjoyed seeing photos of their grandchildren.

I’m a member of Facebook, but… I’m not very outgoing… my sisters are all on it… and all the grandchildren, I see their photos every now and then, I love it. (Vida)

Communication-based technology not only used as a way to connect with others, but also as a way of passing the time. One participant reported using an electronic book with an adaptive table-stand to read for extended periods of time without fatigue.

Seven of the eleven participants reported receiving paid help to assist with high-energy expenditure activities such as cleaning and shopping. This allowed participants to reduce some of the burden placed on their loved ones, especially for high energy tasks that were not enjoyable. Participants recalled a number of occasions when they felt the use of professional assistance to conserve energy was offset by the emotional impact or frustration of having to rely on help. The quality of the assistance provided also impacted on how it was received. This was particularly the case with respect to the quality of cleaning services.

Home care…the cleaning you have when you haven’t got cleaning. So I learn to shut my eyes now, it’s very hard. (Laurel)

Mind over matter

As the participants described their COPD story, what emerged was the way in which they perceived themselves and COPD. There was a general lack of understanding about the disease of COPD which was associated with lack of interest rather than a lack of education, per se. Only two of the participants perceived themselves to be ill or unwell. Rather than COPD being a cause of illness, it was identified as a source of impairment, regularly being compared to disability, a thing to be managed, being unfit or just a “damn nuisance” (Laurel). Three participants described themselves as having an acquired physical impairment, specifically amputation, comparing their lungs to an arm or leg, as though they had lost a part of them rather than gained an illness.

It’s like an amputation, um, like a person has their leg off, they’ve got to learn to adjust; I haven’t got any good lungs, so I’ll have to learn to adjust to that and work it accordingly. (Clem)

As participants looked to the future, there was a sense of inevitability of what it would look like, but discussions were remarkably diametric, with Laurel and Vida sitting in direct opposition to each other. While both took every day “one day at a time” one chose to do all they could whilst the other individual was resigned to their downward trajectory of health and physical function.

I’m one of the lucky ones, I can still get out… but down the track I may be coming the same way that I really can’t do it myself either, you know, ah, but at the moment, I still do a lot of things that I used to do. (Laurel)

I take each day as it comes. That’s all I can do. Like I said, it won’t get any better. That’s just the way it is. I take each day as it goes… I can’t see into the future, but it doesn’t look bright… I suppose, but the bottom line is, that it won’t be forever. You've got to resign yourself to that fact. (Vida)

The discrepancy between the willingness of the mind and the capacity of the body was described in two specific ways; either that the body could not keep up with the mind (Camilla) or that they were so preoccupied by their breathlessness, there was little time to think of anything else (Vida).

I feel as if, in my brain I can go down the road and I can go to all the shops and look at everything, but unfortunately my body’s not prepared to do it. (Camilla)

I suppose it has affected me, but it’s affected me in a way that I haven’t actually noticed that much, you know, because I’ve been thinking about the fact that I couldn’t breathe. (Vida)

This dichotomy signifies the mind-body conflict that the participants faced in adapting to ongoing functional decline and how it challenges their sense of self as a person with COPD.

Discussion

Living with COPD is a balancing act of the mind and body. The struggle for balance was not for equity between them, but for the mind to compensate and mitigate for the ongoing physiological changes of the body. Participants sought to achieve this balance using a variety of SOC strategies, in line with SOC theory (22).

Participants demonstrated “Selection” in the way they created a hierarchy of tasks to be performed, placing highest priority on self-care, valued activities, and then home-care/community mobility. Prioritisation of self-care tended to be governed by the prevention of negative emotions associated with another person assisting in the task, whereas valued activities were selected due to their association with positive emotions and family engagement.

Accepting their situation as part of who they were facilitated a range of pragmatic responses to change. Such responses became more and more conscious and deliberate over time. That is, participants recognised the increasing impact of functional decline, but developed a largely self-honed resilience against COPD’s insidious nature. Participants drew upon their personal resources, belief systems, motivations and an array of past individual and shared experiences to facilitate well-being and quality of life. This process enabled individuals with COPD to balance their current state with those changes that had occurred over a life time. In seeing themselves as part of something bigger, COPD was internalised as an aspect of their identity. It was not seen as the addition of something new, but the loss of a part of themselves. These strategies were used as an adjunct to a variety of compensatory interventions, such as medication, oxygen therapy and assistive devices and technologies.

Critical to establishing the balance of mind over matter was to manage the “body” – the place of health intervention. Medications regimes, oxygen therapy and assistive devices and technologies were generally extrinsically driven and facilitated by health professionals. These compensatory interventions included the standard medical interventions prescribed for people with Stage IV COPD of all ages (24). The way they were implemented by participants, generally without questioning efficacy and despite frustration, would suggest that the implementation of compensatory interventions is extrinsically motivated and used to passively control the body. Irrespective of the participants’ attitudes to medical intervention, it was when both extrinsically and intrinsically motivated strategies were used effectively in combination, participants spoke with a sense of future, hope and defiance, intimating that the mind was in control of the body.

The manner by which older people use SOC strategies to facilitate successful ageing and adaptation to functional decline suggests that a wide range of strategies are used to enable a “mind over matter” resilience to living well in the presence of functional decline. Participants optimised their function using predominantly intrinsically driven and self-directed psychosocial strategies to maintain well-being, whereas extrinsic compensatory techniques were reserved for managing symptoms. There came a point for some participants, however, when symptoms were no longer under control and extrinsic interventions were exhausted; the body began to overwhelm the mind. This was signalled by a loss of control, hope and sense of future by the participants; when acceptance became resignation to disability, and the inevitability of death.

In light of this psychological–physical conflict, health practitioners play a critical role in establishing interventions that assist in symptom management, which is critical to maintaining a mind–body balance. What is missing from current literature is the efficacy of resilience-based interventions for older people with COPD (18), and the psychological support that may be required to facilitate increased optimisation and resilience (25,29).

This qualitative study included the stories from a relatively homogenous sample of older people with advanced COPD from a single region in rural Australia. These findings, however, add to a much wider discussion on psychosocial and physical adaption of older people with COPD. Larger scale validation of this work is warranted. Exploration of the value of interventional studies to determine how resilience is developed or facilitated in older people with chronic disease(s), particularly COPD, will help to develop psychosocial interventions to improve their quality of life.

Conclusion

Exploration of the journey of individuals with COPD revealed that the strategies used to adapt to disease symptoms and the impact of their decline in physical functioning and general well-being are mediated according to factors as outlined by the SOC theory. While this is not the first study to link COPD management strategies to SOC (19,20), although it is the first qualitative exploration of this topic. Most notable is that, as theorised by the SOC theory, the sense of identity as a person with COPD is linked to their emotional adaption that occurs in adjusting to the physical and psychological consequences of the disease, such as loss of hope or sense of control.

With current definitions of successful ageing excluding any person with a chronic disease, it seems unfathomable to disallow a group of people the badge of “successful ageing” in light of this research. The participants demonstrated the capacity to adapt physically and psychosocially, both rapidly and effectively, to a life- and activity-limiting condition such as COPD. This is not to suggest that all people with COPD achieve successful ageing, but more so, that not all people with COPD age “unsuccessfully” by default.

For older individuals with COPD, there is a sense of acceptance and internalisation of what living with COPD means. They see a progressive functional decline that is a part of themselves and that will continue for the rest of their lives. There remain questions still remain as to how the health community can work to help people facilitate psychosocial adaption strategies to ageing for those individuals with an end-stage chronic disease. At the heart of that discussion lies an understanding of the priorities older people with COPD set for themselves, and how they are achieved.

We acknowledge that there comes a time when the interventions and compensations have achieved all they can for the physical journey of a person with COPD. At that point, they will likely fall outside the bounds of successful ageing. Until that point, however, a paradigm shift from a perceived unidirectional slide to physical disability and death, towards opportunities to facilitate adaption is warranted.

Declaration of Interest

The authors declare no conflict of interest.