Bridging the Gap: Advocating Holistic Approaches to Care

By: Katherine Okpara

I. A Diverse Taxonomy .... pg. 2

II. Cognitive Enrichment......pgs. 3-6
III. Barriers to Successful Learning..pg. 6-7
IV. The Betty Effect..pgs. 7-8
V. Barriers to Access..pg. 9
VI. The Qualities of Life..pgs. 9-11
VII. Works Cited...pg. 12

A Diverse Taxonomy: The Young Old, The Old, and The Oldest Old
The population of older adults is growing rapidly around the world, with individuals over
eighty as the fastest increasing group. Transgenerational Design, a private educational, research,
and advocacy organization, discussed the concept of the young old (ages 65-74), the old
(ages 74-84), and the oldest old (ages 85+) in a report that documented the changing
demographics of aging and how we conceptualize the different needs and desires of older adults.
There have been other organizations and researchers who have made subclassifications similar to
these, with the specified age ranges varying slightly. This can be useful as a way to avoid blanket
statements that end up prescribing lifestyle changes and interventions for people who are not
necessarily seeking them. However, the extension of this initial subclassification could easily
include variations such as the mobile oldest old, the visually impaired young old, the active
old, the aging-in-place oldest old, or the home-bound young old, an infinite list of
specifications. While these descriptors encompass a wide variety of possibilities associated with
aging, they cannot completely shed light on who these individuals are as people and what they
personally believe, desire, and prioritize.
What does it mean to age successfully in the present-day and how will that differ from
the needs of future generations? This report will develop a picture of the roles access,
inclusiveness, cognitive enrichment, and research play in creating positive experiences in aging.
Through discussion of the desires and needs of older adults and outlining exciting potential for
large-scale change, I seek to promote interest in issues of quality of life and provide further
information about my vision for future research efforts.

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Cognitive Enrichment: The Curious Case of Interest Enhancing Learning

As we age, we will all be faced with the task of interacting with an assortment of new
technology that not only replaces many of the things we were familiar with growing up, but also
becomes marketed to us as solutions for issues associated with aging. Fiorella and Mayer (2015)
stated, generative learning involves the learner engaging in appropriate cognitive processing
during learning, including selecting relevant incoming material to attend to, organizing the
material into a coherent cognitive structure in working memory, and integrating it with relevant
prior knowledge activated from long-term memory. Generative learning can be encouraged by
providing individuals with meaningful environments and experiences. Since there are many
variations of cognitive aging, instances of generative learning may be contingent on different
components.
Can reducing cognitive load by simplifying tasks, increasing pertinence, and employing
different sensory modalities lead to better rates of information acquisition in older learners? If
intending to create inclusive programs, the basic encoding strategies that can improve function,
when high-tech solutions are not a possibility, must be identified. In order to outline
comprehensive and personalized cognitive interventions, it may be necessary to answer the
following questions. Firstly, what lifestyle and skills did different individuals value in the past?
Secondly, which skills have deteriorated over time and which remain intact? Lastly, can the
skills and knowledge that have weakened be reinforced and subsequently transferred into other
related areas?
My future study of interactive learning will aim to investigate how individuals make
sense of unfamiliar technology and navigate through environments. In this area, it is highly
desirable to identify strategies that lead to higher rates of cognitive skill transfer, which refers to

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how well prior experience influences future learning. Eventually, any identified successful
learning methods could be applied to providing guidance on using assistive technology,
minimizing instances of wandering, and strengthening the ability to learn new information across
a wide variety of mediums. In the following paragraphs, I will discuss the concept of interactive
learning as an avenue for generative learning.
In the first proposed experiment for this area, I would teach visual and auditory
associations to participants by placing items in various areas of a room and having participants
encode where they were found, relying on the formation of various associations of different
sensory stimuli. During the next session, the objective would be to test the strength of association
by telling participants to locate the items in the room based either on explicit memory, or implicit
associations (i.e. playing relevant sounds or filling the room with certain odors). In the control
group, at all sessions the participants receive only visual and auditory stimuli, a simple test of
their memory of associations over time. In the experimental group, however, a relevant odor
would be introduced to the visual and auditory stimuli, testing the effect of multimodal
associations on memory performance over time.
After a period of time (with length of time away as a factor for analysis), participants
would return to the lab and receive cues about whatever object, smell, or sound they were
previously exposed to. In order to determine which associations are still implicitly stored, the
cues they receive would be from one of the other sensory modalities. For example, for a
participant in the experimental group, if they had encoded information about a golden key, the
sound of a bell, and the scent of lemon, in the next session they could receive cues from any of
those modalities. The first step before engaging in this part of the followup session would be to

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survey participants and record which associations they explicitly remember, without telling them
whether they are right or wrong.
The idea behind this study is to find ways to help an individual tap into all the
environmental cues that can give them information about the things they know and their
whereabouts. This is one of many possible studies that can be conducted as part of this category
of learning. In its early stages, this study would involve visual, auditory, and spatial association
tasks and examine the effect of increasing olfactory involvement in the learning and encoding
process. These ideas could be further tested using standardized olfactory and cognitive
performance tests and imaging techniques.
For a second study, I intend to employ a retention-focused approach to increasing health
and financial literacy in older adults. There are many principles of memory, learning, and
forgetting that are directly relevant to the aging process. In addition to maintaining knowledge of
things learned in the past, aging individuals at any stage must commit to memory a host of new
information about conditions, medication, finances, and other important areas of life.
Unfortunately, this can become increasingly complicated for individuals who experience more
severe courses of cognitive aging. In these situations, it may be difficult to carry the sole
responsibility for management of personal affairs, when dealing with factors such as physical
impairment and memory loss. It may be helpful to have access to a variety of learning aids,
including tailored lesson plans, one-on-one instruction, and even official classes filled with other
individuals seeking the same knowledge. The purpose of these aids is to teach concise material
that effectively communicates essential information without overwhelming the learner. Learners
would be able to select how much information they are interested in learning, based on their
relevant needs, increasing their ability to focus on retaining important information (Castel,

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Murayama, Friedman, McGillivray, & Link, 2013) and reducing instances of extraneous
processing (Mayer, 2014).
Drawing inspiration from Dr. Richard Mayers evidence-based approach to assessing the
efficacy of computer games for learning (Mayer, 2014), my proposed study design would test
how method of delivery of information affects encoding and processing. Three different groups
would be involved in this study: one group receiving information through standard, written
communication, such as pamphlets or online websites; another group learning the information
through an interactive game; and the third group learning from either of these methods, with one
or more of the following factors manipulated. Some potential factors for analysis include
medium, pertinence of information, educational background, design, pacing, and salient stimuli.
There is potential to create a large network of educational options for older adults,
including traditional classroom-based instructional learning, computer-based learning, or
informal learning. All the skills, information, and subjects that individuals take interest in
learning may serve to foster higher rates of retention and transfer, whether for the purpose of
personal enrichment, health management, or rehabilitation.

Barriers to Successful Learning

When discussing the potential benefits of meaningful learning, it is important to also
consider impediments to successful learning. Do some individuals experience technology
anxiety? I am interested in exploring whether a concept similar to math anxiety, which is
defined as "a feeling of tension, apprehension, or fear that interferes with math performance"
(Ashcroft, 2002), exists in older adults who have experienced effects of ageism and stereotype
threat (Friedman, McGillivray, Murayama, & Castel, 2015) on both their willingness and ability

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to learn. A future study could compare how individuals fare on interactive tasks, in comparison
to younger adults, if they are supplied with ways of reducing stereotype threat, such as
highlighting the strengths of older adults, being told that other adults were very successful on the
task, or learning about the causes and nature of any differences between younger and older
adults. It would be necessary to survey the individuals both before and after the tasks, to
subsequently analyze the way their subjective view of their capabilities correlates with their
observed performance.
Other barriers to successful learning may stem from a lack of tailored learning aids for
people with different abilities. My research will include consideration of the different needs of
people with conditions such as blindness, deafness, olfactory loss in dementia, and various
learning disabilities. Though it is unlikely to ever reach a one-size-fits-all educational program,
strengthening and diversifying educational materials available for people across the lifespan may
serve to provide positive impact in many different communities.

The Betty Effect

Betty is an elderly woman for whom I have been providing care, for the past two years.
In her younger years, Betty lived a migratory and sociable life. She engaged in backpacking
trips, travelled extensively and lived in many different states before ultimately settling down in
Berkeley, California about thirty years ago. At the age of ninety-nine, Betty still values
socialization, leaving her home to walk two blocks up to the local coffee shop to meet with her
friends. Her neighborhood is vibrant, scenic, and populous, allowing for the option to be
stimulated outside of the home. When inside, Betty enjoys listening to talkshows and classical
music on the radio, watching murder mysteries, and spending time with her middle-aged cat, a

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most lovable companion. I have observed the importance of consistency, attentiveness, and
communication in her overall well-being. The overlapping themes of her concerns revolve
around security, health management, and cognitive engagement. Learning a great deal about her
needs, desires, and personal beliefs has encouraged my plans to provide meaningful care to
individuals of all socioeconomic backgrounds and personalities, categorizing what factors they
feel to be most essential and impactful to their quality of life.
Betty has a keen interest in politics and history, talks vividly of the days she used to
travel, and often tries to recall the other languages she used to speak. A more recent
development, despite the fact that she has never owned a computer or used the Internet, is that
Betty enjoys hearing about the concepts of computer science that I explain to children in my
current job as a teacher for an afterschool enrichment program. These fundamental concepts are
taught incrementally with tangible, real-world examples and can be learned by anyone who is
able to follow the connection. Betty simply enjoys learning new things and having the
opportunity to display her own knowledge. While I have yet to conduct a worldwide survey of
older adults, I suspect that this is a desire shared by many people.
"I would really like to see and be able to read. I like Agatha Christie. I read a lot when I
could. I think they are working on something now to help your eyes. I bet a lot of people would
be happy about that," Betty once said wistfully. Her desire to learn and keep her mind active is
being directly suppressed by her low visual ability. In the past, she listened to many audio books
but now feels that she may do better with some sort of physical copy or having stories read to
her. The more I listen to Betty, the more I realize how important it is to hear from the
communities that we try to impact, to get a better sense of different perspectives.
Barriers to Access

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Barriers to accessing assistive technologies, cognitive interventions, safe homes, or

adequate health management very commonly stem from financial complications resulting from
low income, retirement, or family hardships. Additionally, for many people like Betty, barriers
also arise from non-financial issues. Using data from the 2007 Health Tracking Household
Survey to categorize dimensions of access to health care, Kullgren, Mclaughlin, Mitra, &
Armstrong (2011) found four notable nonfinancial barriers of access to care. These include
accommodation (difficulty finding time to seek out resources due to work or other
commitments), availability (not being able to book an appointment), accessibility (difficulty in
reaching a doctors office or care center), and acceptability (a doctor or hospital would not accept
their health insurance). Accessibility is an increasingly significant barrier when considering the
various physical impairments people acquire throughout life. These nonfinancial barriers present
great difficulty on their own and are often also simultaneously occurring with financial barriers,
especially for certain underserved or marginalized populations. Increasing accessibility to
education, healthcare, and other services has the potential to change many different lives in a
significant way.

The Qualities of Life: Normalcy, Security, and Health Management

Along with the growth of aging populations comes the well-recognized need of more
professionals in careers associated with aging, such as skilled nurses, caregivers, research
scientists, or those in policy. However, the need for safer housing design, affordable care
options, and cognitive stimulation is also of great importance. The topic of destigmatizing senior
living environments is urgent and requires immediate attention. Life expectancies are longer than

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ever and we have an increasing presence of older adults who may start to need assistance, due to
circumstances associated with age, disability, or disease.
Through research conducted on the characteristics of elderly-friendly communities,
World Health Organization listed eight areas that influence the quality of life, including outdoor
spaces and buildings, housing, transportation, social participation, respect and social inclusion,
civic participation and employment, communication and information, and community support
and health services (WHO, 2007). These areas are important factors in humanizing and
individualizing the way the aging experience is portrayed and essential for truly addressing the
needs of different individuals. Many of those staying in their homes can choose to go through the
process of visiting doctors, avoid check-ups and hope for the best, or receive some sort of homebased care. Alternatively, those who are in assisted living facilities currently tend to have access
to more reliable forms of care. Since there can benefits and losses associated with each lifestyle,
it is important to take steps toward strengthening the services provided in all varieties of care.
Many researchers and organizations, such as Hospital at Home created by researchers at Johns
Hopkins Schools of Medicine, are currently working to create and implement home-based care
models that bring quality healthcare and hospital-level attention right to the doorsteps of people
in need.
Naturally, the topics of home modification and aging-in-place arise in these
discussions. In order to encourage independent-living, homes must be safe, accessible, and
designed deliberately. To approach this task, the North Carolina State Universitys Center for
Universal Design outlined the following principles for universal design: equitable use, flexibility
in use, simple and intuitive, perceptible information, tolerance for error, low physical effort, and
size and space for approach and use (Connell et al., 1997). In line with these guidelines, some

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manifestations of the essential qualities of a safe and accessible homes and public spaces include
level grounds without stairs, supportive railing, lever handles for doors, and signs with optimal
contrast and typography. The quality of design can be further enhanced and individualized by
considering aesthetics or cultural norms.
It can be a difficult endeavor to try to address the specific needs of each individual within
a reasonable time frame. However, if more professionals and policy leaders become attuned to
these possibilities, significant progress can be made over time. Universal design is a concept that
works to produce buildings, products, and environments that are inherently accessible to older
adults and individuals with and without disabilities (Harper, 2013). The main goal is to be as
inclusive as possible from the start, rather than continuously adding on considerations of others
after receiving complaints. There is room for this quality of change in many aspects of life
including, homes, curriculum, services, clothing, and technology. It is imperative to address the
fact that individuals of all socioeconomic backgrounds deserve opportunities for a better life,
whether that means access to home-based palliative care, living in community homes, or a
variety of assistive technologies. This can best be done by directly surveying individuals and
communities, hearing their input and feedback. A widespread movement toward the concept of
design with, not for promotes universal and collaborative design efforts to change the outlook
of what it means to age in the twenty-first century. The more sectors that join this movement, the
more steps we can take toward worldwide accessible, affordable, and meaningful care.

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Works Cited
1. Ashcraft, M.H. (2002), "Math anxiety: Personal, educational, and cognitive
consequences", Current Directions in Psychological Science, 11: 181
185,doi:10.1111/1467-8721.00196
2. Castel, A. D., Murayama, K., Friedman, M. C., McGillivray, S. & Link, I. (2013). Selecting
valuable information to remember: Age-related differences and similarities in self-regulated
learning. Psychology and Aging, 28, 232-242.

3. Fiorella, L., & Mayer, R. E. (2015). Learning as a generative activity: Eight learning
strategies that promote understanding. New York: Cambridge University Press.
4. Friedman, M. C., McGillivray, S., Murayama, K., & Castel, A. D. (2015). Memory for
medication side effects in younger and older adults: The role of subjective and objective
importance. Memory & Cognition, 43, 206-215.
5. Harpur, P. (2013). From universal exclusion to universal equality: Regulating Ableism in
a Digital Age. 40 Northern Kentucky Law Review 3, 529-565.
6. Kullgren, J. T., Mclaughlin, C. G., Mitra, N., & Armstrong, K. (2011). Nonfinancial
Barriers and Access to Care for U.S. Adults. Health Services Research, 47(1pt2), 462485. doi:10.1111/j.1475-6773.2011.01308.x
7. Mayer, R. E. (2014). Computer games for learning: An evidence-based approach.
Cambridge, MA: MIT Press.
8. McGillivray, S., Murayama, K., & Castel, A. D. (2015). Thirst for knowledge: The
effects of curiosity and interest on memory in younger and older adults. Psychology and
Aging, 30, 835-841.
9. The Center for Universal Design (1997). The Principles of Universal Design, Version
2.0. Raleigh, NC: North Carolina State University
10. The Demographics of Aging - Transgenerational. (n.d.). Retrieved October 10, 2016,
from http://transgenerational.org/aging/demographics.htm

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