Aging Clinical and Experimental Research

https://doi.org/10.1007/s40520-019-01327-y

REVIEW

Individual healthy aging indices, measurements and scores

Jean‑Pierre Michel1 · Christophe Graf2 · Fiona Ecarnot3,4 

Received: 5 June 2019 / Accepted: 15 August 2019

© Springer Nature Switzerland AG 2019

Abstract
The positive gerontological approach to aging has resulted in successive terminologies to describe the process of aging,
including successful aging, active aging, healthy aging, or healthy and active aging, amongst others. Each definition proposed
by geriatricians, psychologists, sociologists or public health specialists has been based on specific aspects of aging that are
most important to the authors’ discipline, explaining the current difficulty in determining which is the best set of criteria to
determine “good aging”. Two successive analyses of the measurements used in longitudinal studies from 1989 to 2018 testify
to this heterogeneity in the types of questions proposed to evaluate the quality of the individual aging process. To confront
this complexity, new and integrated indices have successively been proposed to quantify and qualify the survival period of
aging individuals. The present paper aims to describe and compare the value of the “healthy aging index”, the “modified
healthy aging index”, the “healthy aging score” and the “selfie aging test”. Attempts to date to identify the best individual
measurement of “aging well” have been interesting, and certainly show promise, but their limitations to specific populations
call for more concerted effort from the scientific community to obtain worldwide validation. Another option would be to
identify the best self-assessment questionnaire and include it in a mobile device, enabling longer term personal follow-up
of aging functions. There is a clear lack of data of this type at present, and an urgent need to obtain such information, to
enable early and targeted interventions.

Keywords  Aging · Healthy aging · Healthy aging index · Healthy aging score · Selfie aging test

Any critical analysis of the various individual aging indices,
measurements and scores must start with a clear understand-
ing of the historical development of the concepts of aging.
This has seen the concept evolve through successive termi-
nologies to describe the process of positive aging, including
successful aging, active aging, healthy aging, healthy and
active aging, amongst others (Table 1) [1].
In this historical context, an interesting analysis of the
literature from 1902 to 2015 by Kusumastuti et al. distin-
guished two different approaches in these various definitions
[24]. First, publications based on the Havighurst-cluster
advocated the view of older persons, warning of the harm
of medical categorization of success and failure in stigmatiz-
ing and marginalizing older persons and encouraging age-
ism. Across the lifespan, the Havighurst-cluster highlighted
the importance of the adaptive process in the face of losses
and the older person’s point of view [24]. In contrast, the
second group of publications called the “Katz-cluster” by
Kusumastuti et al. tends to discuss the positive aging pro-
cess from the perspective of researchers or clinicians. The
Katz-cluster focused on identifying risk factors for preven-
tion: to be “successful”, older persons have to maintain their
functioning within the cut-offs that are predetermined by
researchers [24].

* Fiona Ecarnot
fiona.ecarnot@univ‑fcomte.fr Inventory of the measurements of positive
1
aging processes used by researchers
University of Geneva, Geneva, Switzerland in longitudinal studies
2
Department of Rehabilitation and Geriatrics, University
Hospitals Geneva, Geneva, Switzerland It is interesting to compare the various measures used by
3
EA3920, University of Franche-Comté, Besancon, France researchers in two extensive reviews of 78 longitudinal stud-
4
Department of Cardiology, University Hospital Jean Minjoz, ies. These have been inventoried first by Depp et al. in a
3 Boulevard Fleming, 25000 Besancon, France

13
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Table 1  Key concepts in a brief history of the aging concept (see also [2])
Basic healthy aging definition
Ego integrity vs despair (1950)
Activity theory (1961)
Disengagement theory (1961)
Successful aging (1961)
Successful aging (1963)
Index of activities of daily living (ADL)
(1963)
Aging successfully (1972)
Successful aging (1987; 1998)
Selective optimization with compensation
(1990)
Productive aging (1990)
Active aging (2002)
Civic engagement (2004)
Gerotranscendence (2005)
Healthy aging (2006)
Cultural aspects of “good aging” (2007)
13
Aging Clinical and Experimental Research
General condition of aging of a person’s mind
and body, usually meaning freedom from
illness, injury or pain
Subjective evaluation of one’s life as having Erikson [2]
been a fulfilling and satisfying one
Maintaining middle-aged activities and atti- Cumming [3]
tudes into later adulthood
Desire and ability of older people to disen- Cumming [3]
gage from active life to prepare themselves
for death
Conditions promoting a maximum of satisfac- Havighurst [4]
tion and happiness
Having inner feelings of happiness and satis- Havighurst [5]
faction with one’s present and past life
Systematic approach to measuring physical Katz [6]
performance in a population of older or
chronically ill persons
Coping style, prior ability to adapt, and Neugarten [7]
expectations of life, as well as income,
health, social interactions, freedoms, and
constraints; coalescence of personality
which play into the enormous complexity of
successful aging
Interplay between social engagement with life, Rowe [8, 9]
health and functioning for a positive aging
experience (low probability of disease and
disease-related disability)
a) Selective adaptation and transformation of Baltes [10]
internal and external resources. b) Optimiza-
tion and compensation. c) Maintenance of
function, maximizing gains and minimizing
losses
Any activity by an older individual that Butler [11]
contributes to producing goods or services,
or develops the capacity to produce them
(whether or not the individual is paid for this
activity)
Active aging is the process of optimizing WHO [12]
opportunities for health, participation and
security to enhance quality of life as people
age
Need to involve older adults in the commu- Gerontological Society of America [13]; Mar-
nity, create opportunities for participation, tinson [14]
and generate further interest in the mutual
benefit of participation for community ben-
eficiaries and participants
Legacy building and existential concerns Tornstam [15]
allowing old age to possess its own meaning
and character
Optimizing opportunities for good health, so Swedish National Institute of Public Health [16]
that older people can take an active part in
society and enjoy an independent and high
quality of life
Different cultures have different understand- Fry [17]
ings and interact in different ways to pro-
mote or detract from a “good old age”
Aging Clinical and Experimental Research

Table 1  (continued)

Successful aging and diseases (2009)
Cognitive and emotional aspects of successful There is a gulf between researcher and lay
aging (2010)
Healthy and active aging (2011)
Resilient aging (2014)
Healthy aging (2015)
Active and healthy aging (2015)
Successful aging may coexist with diseases Young [18]
and functional limitations if compensatory
psychological and/or social mechanisms are
used
Jeste [19]
definitions—the former describes freedom
from disease and disability, and the latter
focuses on adaptation, meaningfulness and
connection
The process of optimizing opportunities for European Commission [20]
health to enhance quality of life as people
age and grow old
The process an older person endures beyond Hicks [21]
physical, psychosocial or cognitive adver-
sity, through protective factors that influence
the attributes of coping, hardiness, and
self-concept, in the person’s quest towards
quality of life
Healthy aging is more than just the absence WHO [22]
of disease; it is the process of developing
and maintaining the functional ability that
enables well-being in older age
An ability to perform daily activities, feel- Helsinki Businessmen Study (HBS) cohort [23]
ing happy, remaining free of cognitive or
functional impairments, and free of major
chronic diseases

review that included 28 longitudinal studies and 29 defi- Figure 1 illustrates the current difficulty in comparing
nitions [25]; and more recently, by Lu et al. in a review the results of longitudinal studies, when so many differ-
including 50 longitudinal studies from across 23 countries ent subjective and objective measurements are used, all of
or regions [26].

Fig. 1  Comparison of the
criteria in percentage, used
in the 28 longitudinal studies
analyzed by Depp et al. [25] and
50 longitudinal studies analyzed
by Lu et al. [26]

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 Aging Clinical and Experimental Research

which are formulated differently and with definitions that
vary from one study to another.
Inventory of the different overall scores
proposed to date to measure “healthy
aging”
In the face of such complexity, there is a compelling need
for a clear inventory of the different individual indices and
scores that have been proposed up to now to measure the
quality of the aging process at the individual level.
The healthy aging index
Based on the Physiologic Index of Comorbidity [27], Sand-
ers proposed a simplified version of this approach, using
variables that can be more easily obtained in practice, named
the “healthy aging index” [28]. Similarly, with a view to
wider applicability and predictive ability, Wu et al. proposed
a modified version of the healthy aging index to investigate
whether the associations observed with the HAI persisted
within subgroups with different levels of comorbidity (see
Table 2) [29]. Interestingly, all these authors adopted the
same scoring system (i.e., 0: healthiest tertile; 1: middle ter-
tile and 2: unhealthiest tertile), resulting in the same overall
evaluation (0–2: healthy aging and 9–10: unhealthy).
Another interesting feature is the fact that the authors
used their index on different cohorts of US longitudinal
studies.
The Physiologic Index of Comorbidity was applied in
2928 patients from the Cardiovascular Health Study (CHS)
(mean age = 74.5 years). Only 1.7% of older adults had nor-
mal results on all five tests, yielding a score of 0, meaning
that they were free of disease. Longer leukocyte telomere
length was observed in these disease-free older adults [30],
and clinically, they were not suffering from frailty and their
mortality was very low, at 7.0 per 1000 person-years. The
authors of the validation study affirmed that the Physiologic
Index of Comorbidity can identify individuals with excep-
tional survival [27].
The “healthy aging index” was also applied to the Car-
diovascular Health Study (CHS) cohort. Among 5888 indi-
viduals originally enrolled in the CHS, 3841 participants
(65.2%) had available data for all components of the healthy
aging index (HAI) and were thus included in the analysis
[28]. The authors found that scores of 7–10 on the HAI were
significantly associated with older age, African American or
Asian race, higher body mass index, lower physical activity,
lower education level and a higher burden of chronic dis-
eases. High HAI scores were also associated with a higher
death rate, whereby individuals with a score of 7–10 had
a 3.28-fold greater risk of death than individuals with the
lowest HAI scores in an unadjusted model [28].
To test the heritability of this physiologic index of health
aging, the “healthy aging index” was applied to the Long
Life Family Study (LLFS), which recruited approximately
4900 individuals from 583 families demonstrating clustering
for exceptional longevity. The mean age of the total LLFS
population was 72 years; the mean age of probands was
89 years, and 61 years in offspring. This analysis demon-
strated that weighted component scores were very useful for
determining residual heritability [28].
A modified version of the “healthy aging index” was
applied in a representative sample of 2451 community-
dwelling adults aged 60 years or older, with no chronic con-
dition and participating in two survey cycles (1999–2000
and 2001–2002) of the National Health and Nutrition
Examination Survey (NHANES). The authors showed a
close relationship between the score obtained with the modi-
fied “healthy aging index” and the risk of mortality. Among
those with a mHAI score of 0–2, there were 13.0 (95% CI
9.8–17.6) events per 1000 person-years (all-cause mortality),
compared to 87.8 (76.5–100.9) in those with a mHAI score
of 7–10. In addition, each additional unit of mHAI score
was associated with a 19% increase in the risk of all-cause
death (hazard ratio 1.19 (95% CI 1.11–1.27 in multivariable-
adjusted analysis) [29].

Table 2  Comparison of
the variables used in the
“Physiologic Index of
Comorbidity” [27], “healthy
aging index” [28] and “modified
healthy aging index” [29]
Physiologic Index of Comorbidity
Serum fasting glucose
Pulmonary vital capacity
Serum cystatin C
Carotid intima-media thickness
White matter grade
Healthy aging index
Serum fasting glucose
Pulmonary vital capacity
Systolic blood pressure
Serum creatinine
Modified MMSE
Modified healthy aging index
Serum fasting glucose
Pulmonary vital capacity
Serum cystatin C
Systolic blood pressure
Digit symbolic substitution test

13
Aging Clinical and Experimental Research
In a study among 934 participants (average age 66 years,
51% female) from the Framingham Heart Study Offspring
cohort, McCabe et al. compared the prognostic performance
of the “healthy aging index” and a modified version that
additionally included C-reactive protein (CRP) and rest-
ing heart rate [31]. They found that the original HAI was
a strong predictor of mortality and incident cardiovascular
disease, but not cancer, whereas their modified HAI, which
included CRP and heart rate, improved the predictive value
and better defined the risk among the unhealthiest HAI
groups [31].
The healthy aging score
Proposed by Jaspers et al. [32], the “healthy aging score”
was applied in a study including 1405 men and 2122 women
from Rotterdam (mean age 75.9 ± 6.4 years) followed up for
8.6 ± 3.4 years. The healthy aging score comprised seven
domains (chronic diseases, mental health, cognitive func-
tion, physical function, pain, social support and quality of
life), each of which was scored from 0 to 2, yielding a total
score ranging from 0 to 14 and distinguishing participants
with a high score (13–14: healthy aging) from those with
a low score (0–10: unhealthy aging). The overall mean
score was 10.7 in women, and 11.1 in men, illustrating that
women had fewer chronic diseases, but were less physically
active, had lower mental abilities, more disability and lower
QoL [32]. The almost 10-year follow-up in this study ena-
bled the authors to observe that there was a steeper decline
from healthy to unhealthy aging in women than men, with
a greater coefficient for change in mean HAS across five
increasing age categories in women (− 0.65) compared to
men (− 0.55). Although women lived longer than men, their
life expectancy was marked by a worse healthy aging score
than that of men [32]. The authors conclude that the healthy
aging score is easy and inexpensive to implement since all
the domains were assessed by questionnaire. It also enables
continuous scaling from healthy, to intermediate and on to
unhealthy, which makes it possible to envisage direct inter-
ventions targeted to domains requiring attention. Conversely,
the healthy aging score does not enable weighting of the dif-
ferent domains, particularly the severity of chronic diseases,
because the scoring from 0 to 2 is arbitrary. Moreover, the
score was only applied to Caucasians who were relatively
healthy. These limitations preclude the generalization of this
score at present [32].
The selfie aging test
This conceptual test was developed using data from two large
European longitudinal aging studies (namely the Study of
Aging profile of the Portuguese Population—EPEPP and the
Survey Healthy Aging and Retirement Europe—SHARE).
It was inspired by the new WHO definition of healthy aging
and based on the biopsychosocial assessment model. It com-
prises self-assessment of the following items: body mass
index, difficulties moving around indoors and performing the
activities of daily living, feeling depressed, feeling nervous,
lack of energy, time awareness score, marital status, having
someone to confide in, education, type of job, exercising
and smoking status [33]. The validity of the selfie aging
index was simulated using the two studies mentioned above
(EPEPP and SHARE) and was found to be satisfactory. As
stated by the authors, this attempt appears innovative and
anticipates the use of mobile devices to enable every indi-
vidual to monitor their own health and aging. However, this
conceptual tool has yet to be clinically tested.
Discussion
This inventory of the different indices used to evaluate
“healthy aging” at an individual level reveals that a range
of approaches exists.
The “modified healthy aging index” is a simple version of
more complex evaluations, such as the “Physiologic Index
of Comorbidity” and the “healthy aging index”, which were
tested and validated in large populations from robust US lon-
gitudinal studies. The different presentations of the tests do
not affect its overall (high) value in the prediction of mortal-
ity, cancer and even cardiovascular events. Despite substan-
tial simplification, the latest modified version still includes
two biological tests (fasting glucose and cystatin C), one
vital sign measurement (systolic blood pressure) and two
clinical tests (one functional, i.e., respiratory vital capacity
and one memory, i.e., digit symbolic substitution test). This
considerably limits its use in the community. Moreover, the
application of these indices up to now has been limited to the
US population, and thus, their validity in other populations
remains to be demonstrated.
In contrast, the “healthy aging score” appears accessible
to a larger population because it consists of only seven ques-
tions, although these may not always be easy to answer for
the average community-dwelling older person, such as body
mass index, for example. In addition, scores are arbitrary,
from 0 to 2, with no possibility of weighting. The results
obtained in the Rotterdam longitudinal study are nonetheless
promising, and adequately distinguished the different aging
profiles of men and women, across increasing age catego-
ries. Moreover, the results are strongly associated with sur-
vival in the tested population, enabling specific interventions
in domains identified as being at risk. However, as already
emphasized, this study included only European participants
who were generally not unhealthy at the start of the study.
The selfie aging index is an interesting approach that
aligns well with the current need for better evaluations
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 Aging Clinical and Experimental Research

using simple tests to measure the rate of functional decline 5. Havighurst RJ (1963) Successful aging. In: Williams RH, Tibbits
with aging. However, this approach remains theoretical as C, Donahue W (eds) Processes of aging. Atherton, New York, pp
299–320
yet, meaning that large and carefully designed prospective 6. Katz S, Ford AB, Moskowitz RW et al (1963) Studies of illness in
clinical tests are warranted to demonstrate the validity and the aged. The index of Adl: a standardized measure of biological
reproducibility of this self-assessment in different age ranges and psychosocial function. JAMA 185:914–919
of the community population. 7. Neugarten BL (1972) Personality and the aging process. Geron-
tologist 12:9–15
8. Rowe JW, Kahn RL (1987) Human aging: usual and successful.
Science (New York) 237:143–149
9. Rowe JW, Kahn RL (1998) Successful aging. Aging (Milan, Italy)
Conclusion 10:142–144
10. Baltes PB, Baltes MM (1990) Successful aging: perspectives from
the behavioral sciences. Cambridge University Press, Cambridge
During the last half-century, the various approaches to 11. Butler RM, Oberlink MR, Schechter M (1990) Promise of produc-
“aging well” (from successful, to active, through active and tive aging: from biology to social policy. Springer, New York
healthy) testify to the complexity of the aging process and 12. World Health Organization (2002) Active ageing: a policy frame-
work. World Health Organization, Geneva, p 59
the divergent opinions of the scientific community (from 13. Gerontological Society of America (2005) Civic Engagement in
geriatricians, to psychologists, sociologists and public health an Older America. http://www.civice​ ngage​ ment.​ org/agings​ ociet​ y/
specialists). The myriad of criteria used to capture what Pages​%20fro​m%20Ger​on-NLSep​t05.pdf. Accessed 02 Apr 2019
“good aging” actually is in longitudinal studies reflects the 14. Martinson M, Minkler M (2006) Civic engagement and older
adults: a critical perspective. Gerontologist 46:318–324
compelling need to achieve a consensus on a single valid 15. Tornstam L (2005) Gerotranscendence: a developmental theory
index or score. Attempts to date to identify the best indi- of positive aging. Springer, New York
vidual measurement of “aging well” have been interesting, 16. The Swedish National Institute of Public Health (2006) Healthy
and certainly show promise, but their limitations to specific Ageing. A challenge for Europe, Sweden, p 29
17. Fry CL, Dickerson-Putman J, Draper P et al (2008) Culture and
populations call for more concerted effort from the scientific the meaning of a good old age. In: Sokolovsky J (ed) The cultural
community to obtain worldwide validation. Another option context of aging: worldwide perspectives. Praeger, Westport, p
would be to identify the best self-assessment questionnaire 808
and include it in a mobile device, enabling longer term per- 18. Young Y, Frick KD, Phelan EA (2009) Can successful aging and
chronic illness coexist in the same individual? a multidimensional
sonal follow-up of aging functions. There is a gaping lack concept of successful aging. J Am Med Dir Assoc 10:87–92
of data of this type at present, and an urgent need to obtain 19. Jeste DV, Depp CA, Vahia IV (2010) Successful cognitive and
them, to enable early and targeted interventions. An inter- emotional aging. World Psychiatry 9:78–84
national, scientific, non-governmental body working in the 20. European Commission (2011) How to promote active ageing in
Europe. EU support to local and regional actors. Brussels: AGE
field of aging would be the ideal type of organisation to Platform Europe in partnership with the Committee of the Regions
undertake the task of harmonizing the various definitions and the European Commission. https​://publi​catio​ns.europ​a.eu/en/
and scores, with a view to achieving a consensual set of public​ ation​ -detail​ /-/public​ ation​ /6d80a8​ 5f-43d5-4462-b5bf-8dd8a​
criteria for the evaluation of the quality of aging at the indi- affff​b5. Accessed 4 Apr 2019
21. Hicks MM, Conner NE (2014) Resilient ageing: a concept analy-
vidual level. sis. J Adv Nurs 70:744–755
22. World Health Organization (2015) World report on ageing and
health. World Health Organization, Geneva, p 260
Compliance with ethical standards  23. Rantanen KK, Strandberg TE, Stenholm SS et al (2015) Clinical
and laboratory characteristics of active and healthy aging (AHA)
in octogenarian men. Aging Clin Exp Res 27:581–587
Conflict of interest  No author has any conflict of interest to declare.
24. Kusumastuti S, Derks MG, Tellier S et al (2016) Successful age-
ing: a study of the literature using citation network analysis. Matu-
Ethical approval  This article does not contain any studies with human
ritas 93:4–12
participants or animals performed by any of the authors.
25. Depp CA, Jeste DV (2006) Definitions and predictors of success-
ful aging: a comprehensive review of larger quantitative studies.
Am J Geriatr Psychiatry 14:6–20
26. Lu W, Pikhart H, Sacker A (2018) Domains and measurements of
healthy aging in epidemiological studies: a review. Gerontologist
References 59:e294–e310
27. Newman AB, Boudreau RM, Naydeck BL et al (2008) A Physi-
1. Michel JP, Sadana R (2017) “Healthy aging” concepts and meas- ologic Index of Comorbidity: relationship to mortality and dis-
ures. J Am Med Dir Assoc 18:460–464 ability. J Gerontol A Biol Sci Med Sci 63:603–609
2. Erikson EH (1950) Childhood and society. WW Norton, New 28. Sanders JL, Minster RL, Barmada MM et al (2014) Heritability of
York and mortality prediction with a longevity phenotype: the healthy
3. Cumming E, Henry WE (1961) Growing old, the process of dis- aging index. J Gerontol A Biol Sci Med Sci 69:479–485
engagement. Basic Books, New York 29. Wu C, Smit E, Sanders JL et al (2017) A modified healthy aging
4. Havighurst RJ (1961) Successful aging. Gerontol 1:8–13 index and its association with mortality: the National Health and

13
Aging Clinical and Experimental Research

Nutrition Examination Survey, 1999–2002. J Gerontol A Biol Sci 33. Goncalves J, Gomes MI, Fonseca M et al (2017) Selfie Aging
Med Sci 72:1437–1444 Index: an index for the self-assessment of healthy and active
30. Sanders JL, Fitzpatrick AL, Boudreau RM et al (2012) Leukocyte aging. Front Med (Lausanne) 4:236
telomere length is associated with noninvasively measured age-
related disease: the Cardiovascular Health Study. J Gerontol A Publisher’s Note Springer Nature remains neutral with regard to
Biol Sci Med Sci 67:409–416 jurisdictional claims in published maps and institutional affiliations.
3 1. McCabe EL, Larson MG, Lunetta KL et al (2016) Association of
an index of healthy aging with incident cardiovascular disease and
mortality in a community-based sample of older adults. J Gerontol
A Biol Sci Med Sci 71:1695–1701
32. Jaspers L, Schoufour JD, Erler NS et al (2017) Development of
a healthy aging score in the population-based Rotterdam study:
evaluating age and sex differences. J Am Med Dir Assoc 18:e1–e7

13