Artificial environments and an aging population: designing for age-related functional losses

Asthma and hypertension: the role of airway inflammation

Introduction

Asthma is a chronic inflammatory respiratory disease often associated with comorbidities. Among cardiovascular comorbidities, arterial hypertension seems to create an additional health burden in asthmatics. However, evidence on this relationship is lacking.

Objective

Our study aims to evaluate the characteristics of hypertensive asthmatics, focusing on the role of inflammation as a possible link between these diseases.

Methods

We conducted a monocentric retrospective analysis consecutively including asthmatics who underwent induced sputum (IS) at our asthma referral center. Patients were divided in two groups according to presence or absence of history of hypertension. Clinical, functional, and inflammatory (airway and systemic) data were collected.

Results

Data on two hundred and sixty asthmatic patients were analyzed. Seventy-nine (30.4%) of them had a diagnosis of hypertension requiring a specific pharmacological treatment. Asthmatics with hypertension were more frequently male (p = 0.047), older (p < 0.001), and with higher body max index (BMI) (p < 0.001) when compared to normotensive patients. No difference concerning asthma control, severity and pharmacological treatment was observed between the two groups (all p > 0.05); distribution of comorbidities and lung function impairment (forced expiratory volume in the first second (FEV1) and forced vital capacity (FVC); all p < 0.05) were statistically different between groups. Mixed granulocytic airway inflammation was prevalent in the hypertensive asthmatics (p = 0.014). Interestingly, a multivariable analysis revealed that age ≥ 65 years and an increased percentage of sputum neutrophils (≥61%) were independent predictors of hypertensive status (p < 0.001).

Conclusion

Our data suggest that neutrophilic airway inflammation (as evaluated by induced sputum) is strictly associated with hypertension. In clinical practice, phenotyping asthmatic patients with comorbidities like hypertension could be useful also from a therapeutic point of view. Additional studies are mandatory to further elucidate the role of neutrophilic airway inflammation in asthma with cardiovascular diseases.

Aging, frailty, and design of built environments

Before developing agriculture, herding or metallurgy, humans occupied most of the world. Multiple socioculturally-based responses supported their migration, including building shelters and constructing niches to limit environmental stressors. Sheltered settings provided social support and security during stressful times, along with opportunities for injured, aging, and frail members to survive. Modern built environments are designed for similar purposes, to support human growth, development, reproduction, and maintenance. However, extended survival in modern settings has costs. With age, muscle (sarcopenia) and bone loss (osteopenia, osteoporosis), along with somatic, physiological, and sensory dysfunction, reduce our physical capabilities, increase our frailty, and impede our abilities to interface with built and natural environments and manufactured artifacts. Thereby, increasing our dependence on built environments to maintain autonomy and quality of life.

What follows is a conceptual review of how frailty may limit seniors within modern built environments. It suggests age-related frailty among seniors provides specific data for those designing environments for accessibility to all users. It is based in human ecological theory, and physiological and gerontological research showing senescent alterations, including losses of muscle, bone, and sensory perceptions, produce a frail phenotype with increasing age limiting our mobility, activity, use of space, and physical abilities. As an individual phenotype, frailty leads to age-related physical and performance declines. As a physiological assessment, frailty indices amalgamate individual measures of functional abilities into a single score. Such frailty indices increase with age and differ betwixt individuals and across groups. To design built environments that improve access, usability, and safety for aging and frail citizens, today’s seniors provide living samples and evidence for determining their future abilities, limitations, and design needs. Designing built environments to accommodate and improve the quality of human-environment interactions for frail seniors will improve usability and accessibility for most user groups.

Housing and Health: Here We Go Again

Housing is one of the major determinants of human health and the current COVID-19 pandemic has highlighted its relevance. The authors summarize the main issues, including dimensional standards, indoor air quality, safety, accessibility, neighborhoods, and area characteristics. The authors propose an operating scheme in order to implement actions to improve residential wellbeing on a local, national, and international level.

Residential Satisfaction, Psychological Well-Being and Perceived Environmental Qualities in High- vs. Low-Humanized Residential Facilities for the Elderly

Using the “user-centered” design perspective and the construct of design “humanization” as theoretical underpinnings, this field study verified the role of “objective” design quality of residential facilities for the elderly in the prediction of “subjective” users’ psychological responses. A sample of over-65-year-old adults (N = 114) was recruited in eleven residential facilities, which differed for the degree of “objective” design humanization (rated on the basis of a design expert assessment). Participants had to fill in a questionnaire including measures of both specific perceived environmental qualities (spatial-physical and social-relational) and more general psychological responses (such as residential satisfaction and psychological well-being). Outcomes revealed that older residents living in high-humanization structures show higher scores of residential satisfaction, psychological well-being and perceived environmental qualities than those living in low-humanization structures. Moreover, significant correlations emerged between specific perceived environmental qualities of the facility and general psychological outcomes. These results confirm the importance of design features for supporting elders’ needs and fostering their quality of life.

Exploring the Concept of Healing Spaces

Evidence-based design (EBD) research has demonstrated the power of environmental design to support improved patient, family, and staff outcomes and to minimize or avoid harm in healthcare settings. While healthcare has primarily focused on fixing the body, there is a growing recognition that our healthcare system could do more by promoting overall wellness, and this requires expanding the focus to healing. This article explores how we can extend what we know from EBD about health impacts of spatial design to the more elusive goal of healing. By breaking the concept of healing into antecedent components (emotional, psychological, social, behavioral, and functional), this review of the literature presents the existing evidence to identify how healthcare spaces can foster healing. The environmental variables found to directly affect or facilitate one or more dimension of healing were organized into six groups of variables—homelike environment, access to views and nature, light, noise control, barrier-free environment, and room layout. While there is limited scientific research confirming design solutions for creating healing spaces, the literature search revealed relationships that provide a basis for a draft definition. Healing spaces evoke a sense of cohesion of the mind, body, and spirit. They support healing intention and foster healing relationships.

Optimizing physical activity among older adults post trauma: Overcoming system and patient challenges

BACKGROUND

By 2050 it is anticipated that close to half (40%) of all trauma patients will be over the age of 65. Recovery for these individuals is more complicated than among younger individuals. Early mobilization has been shown to improve outcomes. Unfortunately, there are many challenges to early mobilization. The Function Focused Care Intervention was developed to overcome these challenges.

PURPOSE

The purpose of this paper was to describe the initial recruitment of the first 25 participants and delineate the challenges and successes associated with implementation of this intervention.

RESULTS

Overall recruitment rates were consistent with other studies and the intervention was implemented as intended. Most patients were female, white and on average 79 years of age. Optimizing physical activity of patients was a low priority for the nurses with patient safety taking precedence. Patients spent most of the time in bed. Age, depression and tethering were the only factors that were associated with physical activity and functional outcomes of patients.

CONCLUSION

Ongoing work is needed to keep patients physically active in the immediate post trauma recovery period.

Heterogeneity of the definition of elderly age in current orthopaedic research

Medical research often defines a person as elderly when they are 65 years of age or above, however defining elderly age by chronology alone has its limitations. Moreover, potential variability in definitions of elderly age can make interpretation of the collective body of evidence within a particular field of research confusing. Our research goals were to (1) evaluate published orthopaedic research and determine whether there is variability in proposed definitions of an elderly person, and (2) to determine whether variability exists within the important research sub-group of hip fractures. A defined search protocol was used within PubMed, EMBASE and the Cochrane Library that identified orthopaedic research articles published in 2012 that stated within their objective, intent to examine an intervention in an elderly population. 80 studies that included 271,470 patients were identified and subject to analysis. Four (5 %) studies failed to define their elderly population. The remaining 76 (95 %) studies all defined elderly age by chronology alone. Definitions of an elderly person ranged from 50 to 80 years and above. The most commonly used age to define an elderly person was 65, however this accounted for only 38 (47.5 %) of studies. Orthopedic research appears to favor defining elderly age by chronology alone, and there is considerable heterogeneity amongst these definitions. This may confuse interpretation of the evidence base in areas of orthopaedic research that focus on elderly patients. The findings of this study underline the importance of future research in orthopaedics adopting validated frailty index measures so that population descriptions in older patients are more uniform and clinically relevant.

Allostatic load differs by sex and diet, but not age in older Japanese from the Goto Islands

BACKGROUND

Lifelong exposure to stressors promotes physiological dysregulation and produces an allostatic load (AL). In European-derived samples, AL associates significantly with sex, age and health.

AIM

To assess associations of AL with age, sex, socio-demographic differences and self-reports of diet and ability to complete activities of daily living in older Japanese residing in rural Nagasaki Prefecture.

SUBJECTS AND METHODS

In 2011, 96 older residents of Nagasaki Prefecture, Japan, were assessed for components of AL. They also self-reported their age, principal life-long occupational activity, educational attainments, marital status, dietary choices and abilities to complete daily living activities.

RESULTS

Average age was 67.9 years (range = 55-89; SD = 8.65). Among these 48 men and 48 women, AL was not related significantly to age, although women showed lower AL than men. AL did not differ significantly between respondents by occupation, marital status, education or abilities to complete daily activities. Women who reported eating more green/yellow vegetables or consuming more meat had lower AL than their counterparts. Men who reported drinking more alcohol spirits had higher AL.

CONCLUSIONS

Among older Japanese residing outside a major urban area, AL varies significantly by sex, but not age, while being associated with dietary choices. Although lack of association with life ways was not expected, AL apparently assesses physiological dysregulation cross-culturally.

Gastrointestinal endoscopy in patients aged 75 years and older: risks, complications, and findings--a retrospective study

PURPOSE

Endoscopy of the gastrointestinal tract offers simultaneously diagnostic and therapeutic options and is increasingly performed in elderly patients due to a continuously growth of this population segment. Whereas safety data of diagnostic and interventional endoscopy in patients younger than 65 years are well characterized, only scarce data exist for elderly patients older than 75 years.

METHODS

We analyzed outcomes and complications of endoscopic procedures with focus on colonoscopy in patients aged 75 and older at a single tertiary referral center in Germany between 1996 and 2006.

RESULTS

A total of 3770 endoscopies (2270 gastroscopies, 735 colonoscopies, 765 ERCP) were performed in 1841 patients with a mean age of 79 years (range 75 to 97 years). Seventy-four percent of all patients suffered from relevant comorbidities. Therapeutic interventions were carried out in 43 % of colonoscopies. Complications were observed in approximately 1 %.

CONCLUSION

The observed complication rate in diagnostic and therapeutic endoscopic procedures is not increased in elderly patients compared to the reported complication rates in younger patients.

Exposure to therapy of older patients with trauma and factors that influence provision of therapy

BACKGROUND

Rehabilitation as soon as possible after trauma decreases sedentary behavior, deconditioning, length of stay, and risk of rehospitalization.

OBJECTIVE

The study objectives were to describe exposure of older patients with trauma to rehabilitation and to explore factors associated with the number and initiation of therapy sessions.

DESIGN

This was a retrospective study of data from electronic medical records.

METHODS

Randomly selected older patients with trauma were described with regard to demographics, trauma diagnoses, comorbidities, preadmission function, and exposure to therapy. Regression analyses explored factors associated with number of therapy sessions and days until therapy was ordered and completed.

RESULTS

Records for 137 patients were randomly selected from records for 1,387 eligible patients who had trauma and were admitted over a 2-year period to a level I trauma center. The 137 patients received 303 therapy sessions. The sample included 63 men (46%) and 74 women (54%) who were 78 (SD=10) years of age; most patients were white (n=115 [84%]). All patients had orders for therapy, although 3 patients (2%) were never seen. An increase in comorbidities was associated with an increase in therapy sessions, a decrease in the number of days until an order was written, but an increase in the number of days from admission to evaluation. Injury severity was associated with a decrease in the number of days from admission to an order being written. A postponed or canceled therapy session was associated with increases in the number of days from admission to evaluation and in the number of days from an order being written to evaluation.

LIMITATIONS

This study was a retrospective review of a small sample with subjective measures and several dichotomous variables.

CONCLUSIONS

Increased injury severity, increased numbers of comorbidities, and postponed or canceled therapy sessions were associated with decreased time from admission to therapy orders, increased time from admission and orders to evaluation, and increased number of therapy sessions.

Patients' experience of important factors in the healthcare environment in oncology care

Background and objective

The aim of this study was to describe what factors of the healthcare environment are perceived as being important to patients in oncology care.

Design

A qualitative design was adopted using focus group interviews.

Setting and participants

The sample was 11 patients with different cancer diagnoses in an oncology ward at a university hospital in west Sweden.

Results

Analysis of the patients’ perceptions of the environment indicated a complex entity comprising several aspects. These came together in a structure consisting of three main categories: safety, partnership with the staff, and physical space. The care environment is perceived as a complex entity, made up of several physical and psychosocial aspects, where the physical factors are subordinated by the psychosocial factors. It is clearly demonstrated that the patients’ primary desire was a psychosocial environment where they were seen as a unique person; the patients wanted opportunities for good encounters with staff, fellow patients, and family members, supported by a good physical environment; and the patients valued highly a place to withdraw and rest.

Conclusions

This study presents those attributes that are valued by cancer patients as crucial and important for the support of their well-being and functioning. The results show that physical aspects were subordinate to psychosocial factors, which emerged strongly as being the most important in a caring environment.

A sense of home in residential care

Moving into a residential care facility requires a great deal of adjustment to an environment and lifestyle entirely different from that of one's previous life. Attachment to place is believed to help create a sense of home and maintain self-identity, supporting successful adjustment to contingencies of ageing. The purpose of this study was to deepen our understanding of processes and strategies by which older people create a sense of home in residential care. Our findings show that a sense of home in residential care involves strategies related to three dimensions of the environment - attachment to place, to space and attachment beyond the institution - and that the circumstances under which older people manage or fail in creating attachment, consist of psychosocial processes involving both individual and shared attitudes and beliefs. Assuming that attachment is important to human existence regardless of age, attention must be paid to optimize the circumstances under which attachment is created in residential care, and how nursing interventions can help speed up this process due to the frail and vulnerable state of most older residents.

A pilot study of allostatic load among elderly Japanese living on Hizen-Oshima Island

Background

Between July and September 2005, a preliminary sampling of the elderly population of Hizen-Oshima Island, Nagasaki Prefecture, Japan was conducted by the local hospital’s nursing staff.

Results

Reported here are preliminary results from this sample of 27 individuals with an average age of 71 years. Their ages ranged from 51 to 82 years, with a standard deviation (sd) of 7.4 years. In total, 33 aspects of physical and physiological variation were assessed on these 15 women and 12 men. As expected from previous studies of Japanese elders, our sample shows slightly elevated average blood pressure (142/81 mmHg, sd 16/10), but they are relatively lean (waist/hip = .9: sd 0.06) when compared to European or American standards. However, their average total cholesterol (TC = 210 mg/dl, sd = 42.8) is high compared to standards, as is their high-density lipoprotein cholesterol (HDLc = 55.4 mg/dl, sd = 15.1). Means, standard deviations (sd), ranges and upper bounds for quartile cut-points for all 10 variables used in the calculation of allostatic load (AL) were assessed. The overall average estimate for AL in this sample is 3.1 (sd = 1.58) and ranges from 1 to 7.

Conclusion

AL shows variability across men and women, has little correlation with age, and is associated with physiological variation in blood glucose, dopamine and uric acid.

Calorie restriction-like effects of 30 days of resveratrol supplementation on energy metabolism and metabolic profile in obese humans

Resveratrol is a natural compound that affects energy metabolism and mitochondrial function and serves as a calorie restriction mimetic, at least in animal models of obesity. Here, we treated 11 healthy, obese men with placebo and 150 mg/day resveratrol (resVida) in a randomized double-blind crossover study for 30 days. Resveratrol significantly reduced sleeping and resting metabolic rate. In muscle, resveratrol activated AMPK, increased SIRT1 and PGC-1α protein levels, increased citrate synthase activity without change in mitochondrial content, and improved muscle mitochondrial respiration on a fatty acid-derived substrate. Furthermore, resveratrol elevated intramyocellular lipid levels and decreased intrahepatic lipid content, circulating glucose, triglycerides, alanine-aminotransferase, and inflammation markers. Systolic blood pressure dropped and HOMA index improved after resveratrol. In the postprandial state, adipose tissue lipolysis and plasma fatty acid and glycerol decreased. In conclusion, we demonstrate that 30 days of resveratrol supplementation induces metabolic changes in obese humans, mimicking the effects of calorie restriction.

Exploring the Factors That Influence Functional Performance Among Nursing Home Residents

Objective: To promote healthy aging in older nursing home (NH) residents, it is important to identify factors that impact functional performance. Using the Disablement Process Model, it was hypothesized that variables from all levels of the model would significantly impact the ability of a NH resident to get up from a chair. Method: A stepwise multiple logistic regression model was used to test the impact of sociodemographic, physiologic, physical, psychosocial, and environmental factors on chair rise. Results: Analysis indicated that three factors, strength, gait, and self-efficacy, were significantly associated with chair-rise ability and together explained approximately 64% of the variance and successfully classified 88.4% of the chair-rise cases. Discussion: These findings indicate that identifying physical and psychosocial variables early in the disablement process will help health care providers tailor medical and restorative care interventions that may help older adults maintain the ability to chair rise.

Perceptions and performance of function and physical activity in assisted living communities

OBJECTIVE

The purpose of this study was to describe residents' self-efficacy and outcome expectations with regard to function and physical activity (PA); to measure functional performance and time in PA; to evaluate the fit between the resident and the environment; and to evaluate knowledge, beliefs, and care behaviors of nursing assistants (NAs) in 4 different assisted living (AL) communities.

DESIGN

This was a descriptive study using baseline data from an ongoing intervention study, Testing the Impact of a Function Focused Care Intervention, Res-Care-AL.

SETTING

Four assisted living communities in Maryland.

PARTICIPANTS

A total of 171 residents and 96 NAs consented, passed eligibility, and were included in this study.

MEASUREMENTS

Descriptive data were obtained from NAs and residents. Resident data also included self-efficacy and outcome expectations associated with functional tasks and exercise, social support for exercise, and subjective and objective information about function and physical activity. NA data included self-efficacy and outcome expectations, knowledge, and performance of function-focused care.

RESULTS

Residents were mostly female, white, and widowed; needed some assistance with activities of daily living; and engaged in very little PA based on subjective and objective reports. NAs were mostly female and black, had more than a decade of nursing experience, strong confidence but limited knowledge of function-focused care, and performed this care in 76% of observed care interactions. There were no site-specific differences among NAs with regard to beliefs, knowledge, or performance of function-focused care. There were site-specific differences in residents with regard to self-efficacy for functional ability; functional performance; social supports for exercise from experts; and from family, person-environment fit, and PA based on subjective surveys. There were no differences noted based on actigraphy.

CONCLUSION

Residents in AL communities engage in very limited amounts of PA and staff in these sites could benefit from ongoing education about how to increase PA among residents and help them adhere to current guidelines for PA so as to optimize overall health status.

Changing the philosophy of care in long-term care: testing of the restorative care intervention

PURPOSE

The purpose of this study was to test the effectiveness of a 12-month restorative care (Res-Care) intervention on the beliefs related to Res-Care, knowledge of Res-Care, observed performance of Res-Care with residents, and job satisfaction among nursing assistants (NAs) in nursing home (NH) settings.

DESIGN AND METHODS

This was a randomized controlled trial including 12 sites and used a repeated measure design with follow-up testing done at 4 and 12 months. An intention-to-treat principle was followed in all analyses, and generalized estimating equations were used to perform repeated measures. A total of 556 NAs consented to participate and completed baseline assessments (265 in treatment and 258 in control sites), 427 completed 4-month follow-up (218 in treatment and 195 in control sites), and 357 completed 12-month follow-up (168 in treatment and 158 in control sites).

RESULTS

There was a statistically significant increase in the treatment group participants' outcome expectations related to Res-Care activities (p = .04) and performance of Res-Care (p < .001) at 4 months, and an increase in knowledge of Res-Care (p < .001) and job satisfaction (p < .001) at 12 months. There was no difference between the groups with regard to self-efficacy expectations.

IMPLICATION

This study provides an important step in understanding the implementation of a Res-Care philosophy in NH settings and the benefit this can have for NAs.

Resveratrol delays age-related deterioration and mimics transcriptional aspects of dietary restriction without extending life span

A small molecule that safely mimics the ability of dietary restriction (DR) to delay age-related diseases in laboratory animals is greatly sought after. We and others have shown that resveratrol mimics effects of DR in lower organisms. In mice, we find that resveratrol induces gene expression patterns in multiple tissues that parallel those induced by DR and every-other-day feeding. Moreover, resveratrol-fed elderly mice show a marked reduction in signs of aging, including reduced albuminuria, decreased inflammation, and apoptosis in the vascular endothelium, increased aortic elasticity, greater motor coordination, reduced cataract formation, and preserved bone mineral density. However, mice fed a standard diet did not live longer when treated with resveratrol beginning at 12 months of age. Our findings indicate that resveratrol treatment has a range of beneficial effects in mice but does not increase the longevity of ad libitum-fed animals when started midlife.

Barriers and benefits to implementing a restorative care intervention in nursing homes

OBJECTIVES

This study considered the factors that facilitated or prevented nursing assistants (NAs) from engaging in restorative care activities.

DESIGN

This was a qualitative study using a focus group methodology.

SETTING

Study participants were recruited from 6 nursing homes.

PARTICIPANTS

Participants were nursing assistants (NAs) from a study testing the implementation of a restorative care intervention (Res-Care) study. Of the 244 NAs recruited from the 6 treatment sites, 179 were available at 12 months and 93 (52%) participated in the study.

MEASUREMENT

An interview guide was used during each of the focus groups. Data analysis was done using basic content analysis.

RESULTS

Sixty-one codes were identified and reduced to 4 themes: facilitators of restorative care; barriers to restorative care; benefits of restorative care; and sustaining restorative care.

CONCLUSION

The findings provide an important NA perspective with regard to implementation of a restorative philosophy of care and provide recommendations for future work in this area.

Senescence, Aging, and Disease

All over the world people are surviving into their seventh and later decades of life more frequently today than ever before in human history. Some remain in good health, while others show chronic degenerative conditions (CDCs), frailty, and relatively rapid mortality. Thereafter, multiple factors promoting health and well-being become ever more complex as we age. After attainment of reproductive maturation, many physiological decrements occurring in concert with age reflect both senescent and disease processes, not simply the passage of time. Senescence is a process that begins with DNA, molecules and cells and ultimately terminates in cellular death, loss of organ function, and somatic frailty. These changes are different from benign changes with age that do not alter function. Both differ from the pathological processes represented by disease. Either disease or senescence may be age-related, but neither is age-determined. Disease results from pathological alterations and it affects all age groups. Diseases need not be related to senescence, which includes alterations due to inherent aspects of organismal biology. Distinctions among senescence, aging, and disease blur for the late-life CDCs because, in addition to disease processes, many CDCs are phenotypic manifestations of senescing DNA, organelles, cells, and organs. During earlier epochs of human evolution, greater environmental exposures and fewer cultural buffers likely lead to greater frailty and mortality before senescence progressed greatly, as they still do for most animals. In modern-day settings, culturally patterned behaviors have allowed human frailty to become disconnected somewhat from mortality, unlike non-human species.

Comparative Study of Functional Limitation and Disability in Old Age: Delhi and New York City

Cross-national variation in elder health is well established, with older adults in developing countries reporting poorer health than elders in developed countries. However, cross-national research using performance-based assessment is rare. We examined grip strength in American and Indian elders using a common methodology and found that older adults in India had significantly poorer strength than the US sample even when matched for age, gender, medical conditions, and self-rated disability. The difference in performance is likely explained by life-long differences in nutrition, occupational demands, and access to medical care. These differences in health among people who have survived to old age may also explain differences in life expectancy in later life.

Effects of teaching resourcefulness skills to elders

The objective of this study was to examine the effects of learned resourcefulness training (LRT) on health of elders in retirement communities (RCs). In a clinical trial, 46 elders in four randomly selected RCs received resourcefulness training and were compared to 43 elders in four RCs who participated in a focused reflection reminiscence (FRR) group. The two groups were similar at baseline. Repeated measures analysis of variance revealed no changes on anxiety or depression over time; however, both were significantly correlated with functional status (r's = 0.29 and 0.35, p's < 0.01), self-assessed health (r's = -0.18 and -0.26, p's < 0.05), and resourcefulness (r's = -0.24 and -0.21, p's < 0.05). Although main effects for group were not significant, interaction effects of group and time on self-assessed health and functional status were found. These findings suggest that although teaching resourcefulness to groups of elders in RCs may have beneficial effects on improving their perception of health and functioning over time, significant effects on mental health may not be apparent.

Aging, disability, and frailty: implications for universal design

Throughout the world all populations are seeing burgeoning numbers of "elders", defined as persons aged 65 year and older. In many countries, including Japan, the United States, Norway, Sweden and the United Kingdom, those aged over 65 are at or approaching 15% of the population. As their numbers have increased, so have their health care expenses, leading to extensive research on the health, well being, and life expectancy of these increasingly older elders. Today this group is further sub-divided: the young-old ages 65-74, the old-old ages 75-84, and the oldest-old ages 85+, for both health care and research purposes. However broad variation still characterizes even these groupings. Rates of frailty and disability increase with increasing age among these elders. For example, inabilities to complete at least one activity of daily living increased from about 5-7% at ages 65-69 years to about 28-36% at ages 85+ in 1987. Death rates continue to decline at all ages past 50 years and rates of disability seem to be doing the same. For the foreseeable future, we may expect increasing numbers of older, frail elders than in previous decades. Thus, people are not only living longer, they generally are healthier at advanced ages than were previous cohorts, thus "old age" disabilities of the 20th century will be put off to even older ages during the 21st century. As yet there is no clear way to assess senescent changes in humans, although activities of daily living, allostatic load, and frailty indices have all been suggested. One future need is greater development and use of universal and accessible design in all aspects of the built environment.