How does a person cope with senescence without succumbing to ageism? The answer, already mentioned in Chapter 12, is to choose (select) to specialize (optimize), using effective strategies (compensation). Here we stress the varied source of those strategies: from the individual, from the community, or from medicine.

Accordingly, we now provide three examples. In one (sex), personal thinking and behavior is effective; in another (driving), community laws and practices are crucial; and in the third (diseases), medical measures compensate for bodily changes.

Most people are sexually active throughout adulthood. Some continue to have intercourse long past age 65 (Lindau & Gavrilova, 2010) (see Figure 14.5), but generally intercourse becomes less frequent and sometimes stops completely. Nonetheless, sexual satisfaction often increases after middle age (Heiman et al., 2011). How can that be?

Compensation for diminished arousal results from both thinking and behavior.

Many older adults reject the idea that intercourse is the only, or best, measure of sexual activity. Instead, cuddling, kissing, caressing, desiring, and fantasizing become more important. To optimize, they do more of these (Chao et al., 2011).

A five-nation study (United States, Germany, Japan, Brazil, Spain) found that kissing and hugging, not intercourse, predicted happiness in long-lasting romances (Heiman et al., 2011). Is that optimization, compensation, or both? Consider the following cases.

In a life-span perspective “aging is a process, socially constructed as be a problem” (Cruikshank, 2009, p. 7). The process is biological, but the problem arises in the social world. Selective optimization with compensation is needed by societies. One example is driving.

With age, reading road signs takes longer, turning the head becomes harder, reaction time slows, and night vision worsens. The elderly compensate: Many drive slowly and reduce driving in the dark.

However, relying on each older person’s judgment as to whether to stop driving is foolhardy, because the culture connects driving a car with pride and independence. Of course, the elderly hate to quit; it destroys their freedom. Consequently, many older drivers contend that their critics are ageist, not that they are accurate (Satariano et al., 2012). A family conflict occurs when adult children take car keys from an elderly parent.

It is no wonder that many elders insist they are good drivers and resent age-based restriction. They are correct that requiring everyone to stop driving at age 70, or 80, or whenever is unfair. Then, if a crash occurs, they blame the other driver, who blames them. Wrong targets, both.

The problem begins with license renewal. Some jurisdictions require only a mailed form and a check. Others require a written test about stop signs and parking and/or reading large letters on a well-lit chart. Anyone who fails should have stopped driving long ago, but passing does not guarantee competence.

A national panel recommends every renewal include simulated driving, with the applicant seated with a steering wheel, accelerator, and brakes in front of a video (Staplin et al., 2012). The results of this test allow some 80-year-olds to keep driving, some to have their licenses revoked, and many to recognize that they are less proficient than they thought.

Beyond retesting, there is much else that societies can do. Accidents would be reduced for every driver if larger-print signs preceded a freeway exit, if mirrors replaced the need to turn the neck, if side streets and driveways were well lit, if the glare of headlights and hazard flashers were reduced, and if drivers were alerted about upcoming ice, fog, or construction. Selective optimization and compensation by society would allow competent elderly drivers to maintain independence, while dangerous drivers (of all ages) would be kept off the road.

Another society-wide initiative is sorely needed. Efficient and inexpensive public transportation, in suburban and rural areas as well as in cities, would benefit everyone. When the British gave free bus passes to the elderly, they walked more and drove less, and each city had fewer traffic jams and less pollution (Coronini-Cronberg et al., 2012).

Gerontologists distinguish between primary aging, which involves universal changes that occur with the passage of time, and secondary aging, which are the consequences of particular inherited weaknesses, chosen health habits, and environmental conditions. Am I sick because I am old, or because of bad choices?

The benefits of modern medicine, based on science not custom, are obvious. In earlier centuries, people avoided hospitals and doctors. Some medical measures made people sicker, such as blood-letting (bleeding a sick person), germ-spreading (causing fever), and surgery (such as removing the uterus in a hysterectomy to cure hysteria!).

One obvious example is in childbirth. For centuries medical intervention (including blood-letting to make the woman unconscious) was harmful for baby or mother. Childbed fever (when a new mother died because the doctor used unsterilized instruments) was a common cause of death. One review notes, “It is small wonder that a non-intervention approach was preferred” (Halpern & Garg, 2015, p. 285). By contrast, in the past three decades, evidence-based medicine has saved millions, perhaps billions, of newborns and mothers.

Similar, although less dramatic, results occur in late adulthood. Each year in the United States, 16 percent of those age 65 and older are admitted to a hospital. No longer is that usually a death sentence; almost all recover quickly and go back home. The average hospital stay for those age 65 and older is only 6 days (National Center for Health Statistics, 2014).

Modern medicine slows down primary aging and prevents secondary aging. That has doubled the life span in the past century. The goal now is compression of morbidity, which means fewer years (compression) of disability (morbidity) before death, adding “life to years, not years to life.” That goal was highlighted by the United Nations in 2002 and endorsed by every developed nation ( Walker, 2015).

Ideally, a person is in good health for decades after age 65, and then, within a few days or months, develops serious illnesses that lead to death. Medical research has discovered which personal habits, drugs, therapies, and/or surgeries reduce frailty for almost every disease and condition until that final episode.

The World Health Organization and many experts recognize that disability is the result of person–environment interaction, so changing the environment limits disability (Phillipson, 2013). This third type of compensation is so vital that we look closely at two specifics, heart disease and osteoporosis.

HEART DISEASE Primary aging causes a slowdown of the heart rate as the vascular network becomes less flexible (blood pressure rises). That increases the risk of stroke and heart attack. Secondary aging—especially as a result of smoking and obesity—makes it worse.

Although medical research, beginning with the Framingham Heart Study, has discovered many aspects of secondary aging that harm the heart, adults overall are probably as vulnerable to heart disease as they were 50 years ago. To be specific, although far fewer adults smoke, far more are obese.

However, medical measures have targeted primary aging with great success. The heart disease death rate is lower for every age and gender group, dramatically apparent in the elderly. For example, cardiovascular deaths of 64- to 75-year-olds in the United States in 2013 were less than one-fourth (22.4 percent) the rate in 1960 (390 versus 1,749 per 100,000) (National Center for Health Statistics, 2014).

Some of this reduction is in bypass surgery, pacemakers, and in healthier eating and exercising after a heart attack. Further, one medical measure to halt primary aging and heart deaths is the reduction of hypertension (high blood pressure), a problem for more than two-thirds of all U.S. residents over age 64. High blood pressure is called a “silent killer” because it has no symptoms unless it becomes extremely high.

Even doctors did not realize the danger of hypertension 50 years ago. Now, about half of all adults (especially older ones) with hypertension refuse treatment.

Men are less likely to take medication for hypertension than women, with rates of uncontrolled hypertension (age-adjusted, among those with hypertension) at 75 percent for Mexican American men and 69 percent for African American men. Instead, they suffer headaches and shortness of breath, sometimes for years before a fatal heart attack. For them, morbidity is not compressed.

One reason for their “medication non-adherence” is “mistrust of the utility of the medications prescribed by their doctor” (McNeill et al., 2015, p. 48). Their mistrust is understandable, given the Tuskegee (Alabama) syphilis study in which 399 African American men were not cured of that disease. That horrifying study ended in 1972, but it still makes men suspicious of doctors. That is said to be one reason heart disease kills more African American men, at younger ages, than African American women or men of other ethnic groups.

Science continues to find new ways to cure or prevent diseases, discovering age differences in how people respond. Some measures that work for adults are not effective for children, and the very old need particular treatment guidelines. For example, after age 80, medication is not recommended until hypertension reaches 150/90, not 140/90 (Kithas & Supiano, 2015).

OSTEOPOROSIS Compression of morbidity is also dramatic in osteoporosis (fragile bones). Primary aging makes bones more porous, as cells that build bone (osteoblasts) are outnumbered by cells that reabsorb bone (osteoclasts) (Rachner et al., 2011). Osteoporosis is especially common in underweight women with European ancestry, although men and people of other ethnic groups experience it.

Because of osteoporosis, a fall that would have merely bruised a young person may result in a broken wrist, hip, or spine, starting a cascade of medical problems. Fractures once led to death for 10 percent of osteoporosis sufferers within a year, with a broken hip “a leading cause of morbidity and excess mortality among older adults” (MMWR, March 31, 2000). Half of those with broken hips never walked again. Immobility causes body systems to deteriorate, spreading, not compressing, morbidity.

Note the 2000 date. A more recent report: “In the 21st century, osteoporosis, a disease once considered an inevitable consequence of aging, is both diagnosable and treatable” (Black et al., 2012, p. 2051). Medical compression of morbidity has occurred.

Early diagnosis via a bone density test (not available a few decades ago) detects bone weakening long before the first fracture. Doctors advise prevention, with weight-bearing and muscle-strengthening exercises, and a lifelong diet with sufficient calcium and vitamin D. In addition, a dozen drugs reduce bone loss. If a hip bone breaks, an artificial hip restores mobility. Morbidity, and mortality, caused by osteoporosis have become unusual.

Because a focus on chronic conditions is relatively new and treatment of osteoporosis is newer yet, scientists do not know the consequences of ingesting preventive drugs over many years. The data suggest caution (Black et al., 2012), because drugs that prevent one problem may eventually cause another. Nonetheless, the 44 million people over age 50 in the United States who have weak bones need not experience the disabling breaks that those with osteoporosis once did. That is compression of morbidity.

Hearts and bones are only two examples. For almost every disease and condition, morbidity can be compressed by all three of the types of measures detailed here—first by medicine, then by society that makes medical care available, and then by individuals who get the care they need or change the habits that harm them.