Introduction and background

The reablement approach is becoming an increasingly popular social and health-care model in many high-income Western countries; its goal is to provide short-term support strategies for older people with impairments. As a concept, reablement was first defined in the late 1940s, but over the past three decades, the practice has been introduced into long-term care for older people (Clotworthy et al., Reference Clotworthy, Kusumastuti and Westendorp2021). Reablement has been described as an innovative approach to improving health-care services for older adults who are in need of care and support or at risk for functional decline (Cochrane et al., Reference Cochrane, Furlong, McGilloway, Molloy, Stevenson and Donnelly2016). With ageing populations growing, the European Union has recommended reablement as a ‘policy tool offering a new capacity with which the welfare state may manage and address more dynamically the societal risks associated with the ageing of populations’ (Rostgaard, Reference Rostgaard, Torbenfeldt Bengtsson, Frederiksen and Larsen2015: 161). Reablement represents a shift from a reactive to a more preventive and proactive model of home care provision, and it is based on early intervention and active engagement in reablement (Legg et al., Reference Legg, Gladman, Drummond and Davidson2016). Thus, reablement represents a re-orientation of home care ‘away from treating disease and creating a dependency to maximizing independence’ (Cochrane et al., Reference Cochrane, Furlong, McGilloway, Molloy, Stevenson and Donnelly2016: 7). A quantitative and qualitative review of the incidence and content of the concept across time and space indicates that reablement has had a large impact; in particular, governments throughout the Western world have rapidly implemented reablement in recent years. Reablement has been criticised for a substantial lack of consensus regarding the concept as well as the structure, processes and potential outcomes of reablement (Clotworthy et al., Reference Clotworthy, Kusumastuti and Westendorp2021). To address this, a Delphi study was conducted in 2018–2019 with the aim of reaching agreement on the characteristics, components, aims and target groups of reablement, leading towards an internationally accepted definition of reablement (Metzelthin et al., Reference Metzelthin, Rostgaard, Parsons and Burton2020).

Moreover, reablement has been criticised for a lack of explicating the theoretical assumptions regarding the services in focus. In a review, Legg et al. found that

Intervention programmes should always state the theoretical assumptions behind how and why the programme will work, including theories of change (Kellogg Foundation, 2004). Theoretical assumptions are inherent in all interventions and inform professional actions, whether they are explicated or not (Hammell, Reference Hammell2006: 3). To question otherwise taken-for-granted issues, the theoretical basis for interventions must be explicit (McPherson et al., Reference McPherson, Gibson and Leplège2015). The above-mentioned Delphi study (Metzelthin et al., Reference Metzelthin, Rostgaard, Parsons and Burton2020) and key reviews from within the last 10 years either confirm the lack of theories (Doh et al., Reference Doh, Smith and Gevers2020) or do not mention the theoretical assumptions underpinning the programmes at stake (Cochrane et al., Reference Cochrane, Furlong, McGilloway, Molloy, Stevenson and Donnelly2016; Faria et al., Reference Faria, Kiss, Aspinal, Harden and Weatherly2016; Tessier et al., Reference Tessier, Beaulieu, Mcginn and Latulippe2016; Sims-Gould et al., Reference Sims-Gould, Tong, Wallis-Mayer and Ashe2017). In their review on reablement programmes, Moe and Brinchmann (Reference Moe and Brinchmann2016: 8) found an implicit theory of optimising capacity, a theory which ‘represents a relatively optimistic view of elderly care and might provoke service users, caregivers, and health personnel who have different and difficult experiences of elderly care’. They conclude that ‘this review revealed a lack of theories exploring the experiences of reablement service users and their caregivers’ (Moe and Brinchmann, Reference Moe and Brinchmann2016: 32). Other researchers have suggested that reablement represents a new paradigm, encapsulating the ideals of active ageing and continuing development throughout life (Ryburn et al., Reference Ryburn, Wells and Foreman2009; Rostgaard, Reference Rostgaard, Torbenfeldt Bengtsson, Frederiksen and Larsen2015; Clotworthy, Reference Clotworthy2017; Bødker, Reference Bødker2019; Clotworthy et al., Reference Clotworthy, Kusumastuti and Westendorp2021). The logic(s) of reablement and the specific rationality and assumptions about impairment in old age enacted have been identified as drawing upon the theories of ‘successful ageing’ and an expectation that older people have the potential to regain lost capabilities that can (and should) be mobilised (Clotworthy, Reference Clotworthy2017; Bødker, Reference Bødker2019). The theories of successful ageing, however, have not been further discussed in relation to reablement.

The aim of this paper is to discuss how key principles, components and outcomes in reablement correspond with the paradigm of successful ageing and how a critical perspective on successful ageing may be addressed in reablement. Though there is no universally accepted definition for successful ageing (Clotworthy, Reference Clotworthy2017), Bülow and Söderqvist (Reference Bülow and Söderqvist2014) and Kusumastuti et al. (Reference Kusumastuti, Derks, Tellier, Nucci, Lund, Mortensen and Westendorp2016) have pointed out two distinct branches of theorising about successful ageing which have origin in two scholarly traditions: a medical and epidemiological perspective introduced by Rowe and Kahn in the 1980s (Rowe and Kahn, Reference Rowe and Kahn1987) and a psychological perspective introduced by Baltes and Baltes at almost the same time (Baltes and Baltes, Reference Baltes, Baltes, Baltes and Baltes1990). We will discuss how insights from these classic theories on successful ageing may or may not reflect key principles, components and expected outcomes in reablement programmes, and how they provide understandings of the problem that reablement is intended to address, i.e. ageing and impairment in old age. Moreover, we will include an additional critical perspective on successful ageing, developed in social gerontology (Grenier, Reference Grenier2012).

Methods and materials

This article narratively presents and discusses theoretical perspectives on ‘successful ageing’ in relation to key components, principles and outcomes in reablement. A medical and epidemiological perspective is represented by two papers by Rowe and Kahn on their theory of successful ageing (Rowe and Kahn, Reference Rowe and Kahn1987, Reference Rowe and Kahn1997), and a psychological perspective is represented by two papers on Baltes and Baltes’ theory of successful ageing, selective optimisation and compensation (Baltes and Baltes, Reference Baltes, Baltes, Baltes and Baltes1990; Baltes and Carstensen, Reference Baltes and Carstensen1996). We have added a sociocultural perspective represented by Grenier's theory about transition, continuity and change in old age, which links sociocultural structure and the lived experience of older people (Grenier, Reference Grenier2012). In her work, Grenier specifically reflects on the aforementioned theories of successful ageing and discusses the sociocultural perspective of transition and change in old age as a complementary, necessary objective to successful ageing.

The influence of Rowe and Kahn and Baltes and Baltes is well documented as being the most benchmarking in contemporary thinking of successful ageing (Bülow and Söderqvist, Reference Bülow and Söderqvist2014; Kusumastuti et al., Reference Kusumastuti, Derks, Tellier, Nucci, Lund, Mortensen and Westendorp2016). The included papers are selected with reference to these sources. Grenier has significantly influenced the field of social and critical gerontology through her numerous articles and books (Semantic Scholar, nd), and as moderator of the international network for ‘critical gerontology’ since 2008 (Grenier, Reference Grenier2020). It is for these reasons that in our analysis, we juxtaposed these three theoretical perspectives with the key principles and current practices in reablement. Although there is extensive secondary literature on the theories of successful ageing, we consider the selected original sources provide sufficient information to show our case.

Successful ageing, a medical and epidemiological perspective

Epidemiologist John W. Rowe, MD and psychologist Robert L. Kahn first launched their theory of ‘successful ageing’ in 1987 (Rowe and Kahn, Reference Rowe and Kahn1987). Using predetermined, objective criteria related to physical and cognitive functioning, Rowe and Kahn's errand was to classify people as functioning at a high, medium or low level. Their studies were conducted within a cohort population of community-dwelling older people aged between 70 and 79. Rowe and Kahn considered high levels of cognitive and physical functioning to be necessary for independent living and quality of life, and a high level of functioning was therefore a proxy for successful ageing. Since then, many other observational cohort studies have been conducted using a similar or an adapted external standard to classify people as (un)successful (Kusumastuti et al., Reference Kusumastuti, Derks, Tellier, Nucci, Lund, Mortensen and Westendorp2016). Although the concept was originally defined as a combination of high physical and cognitive functioning, follow-up studies diagnosed people as ageing ‘successfully’ based on certain physical or cognitive cut-offs (Rowe and Kahn, Reference Rowe and Kahn1987).

Rowe and Kahn's concept of ‘successful ageing’ assumes that aged-related decline can be explained by extrinsic factors, i.e. factors that are external to the individual beyond ageing itself, and that these factors can be modified. Moreover, Rowe and Kahn argued that an interaction between physiological ageing and psychosocial ageing provides a broader perspective with which to understand the ageing process. The authors made a distinction between ‘usual’ ageing and ‘successful’ ageing. Older people who, regardless of age, have not experienced a decline in any given area of disease should be considered ‘successful’, bearing in mind the heterogeneous nature of any given population. The belief that, regardless of age, people can live functional lives with or without disease underscored the need to examine those factors that explain why, in a given cohort of older people, some may show signs of decline while others do not. Rowe and Kahn explained that, from a medical perspective, extrinsic factors such as diet and exercise are potential predictors of various disease conditions in old age. Moreover, these factors may be influenced by psychosocial factors that are also shaped by the conduct of family members, friends and health professionals. Thus, Rowe and Kahn (Reference Rowe and Kahn1987) suggested that there is evidence for the malleability of the ageing process.

In 1997, Rowe and Kahn further developed their theory, explaining that successful ageing is comprised of three main components (i.e. predictors): low probability of disease and disease-related disability; high cognitive and physical functional capacity; and active engagement with life (Rowe and Kahn, Reference Rowe and Kahn1997). Having a low probability of disease and disability includes both the absence of a given disease and the severity of risk factors associated with the disease. High functional capacity refers to the individual's capacity for activity, while active engagement relates to the individual's ability and potential for social interaction, e.g. contact and transaction. Rowe and Kahn (Reference Rowe and Kahn1997) suggested that, because it is possible to modify the extrinsic factors associated with successful ageing, then it should also be possible to modify the extrinsic risk factors associated with disease and disability (e.g. lifestyle, improving cognitive and physical function); doing so could potentially result in successful ageing.

Rowe and Kahn's work has been influential in many ways. By demonstrating the plasticity of old age, they sent a message that ‘positive change is possible’ (Rowe and Kahn, Reference Rowe and Kahn1997: 437). They also opened a new space for optimisation and enhancement in old age, as captured in this quotation:

Successful ageing, a psychological perspective

In the late 1980s, German psychologists Paul B. Baltes and Margret M. Baltes developed a so-called ‘meta model’ of successful ageing. Their model was developed in response to the inadequacy of existing objective and subjective criteria for successful ageing. Baltes and Baltes believed that, when used separately, these criteria failed to address important aspects of quality of life. Rather, they stated that an encompassing definition of successful ageing required a value-based, systemic and ecological perspective. In a widely cited article from 1990 (Baltes and Baltes, Reference Baltes, Baltes, Baltes and Baltes1990), they suggested an alternative model that integrated multiple objective and subjective criteria, and explicitly recognised individual and cultural variations.

Baltes and Baltes presented seven propositions about the nature of ageing from a psychological point of view: (a) a distinction between normal, optimal and pathological ageing; (b) inter-individual variability (heterogeneity); (c) plasticity and latent reserve capacity; (d) ageing loss in the range of reserve capacity or adaptivity; (e) the enriching and compensatory role of individual and social knowledge, including technology; (f) ageing-related changes towards an increasingly negative balance in gain–loss ratios; and (g) the phenomenon of a resilient self. Based on the framework of propositions about the nature of ageing, they suggested ‘selective optimization with compensation’ (SOC) as a prototypical strategy for successful ageing (Baltes and Baltes, Reference Baltes, Baltes, Baltes and Baltes1990).

The authors explained that SOC involves focusing individual attention on more pressing and specific goals (selection), then taking actions to achieve these goals (optimisation) and putting mechanisms in place to maintain function amidst loss and decline (compensation). According to their model, the adaptive task of the ageing individual is to select and concentrate on those domains that are of high priority and which involve a convergence of environmental demands and individual motivations, skills and biological capacity. In essence, the SOC model asserts that individuals make conscious efforts to improve their development by adapting to ways and behaviours that maximise gains and minimise losses throughout the lifecourse. This model gains increasing importance in older age due to the increased vulnerability, reduced reserve capacity and increasing individualisation of life trajectories.

The authors further developed and operationalised this model in subsequent years. For example, in an article from 1996, Margret Baltes (writing with psychologist Laura L. Carstensen) defined ‘success’ as goal attainment; ‘successful ageing’ was thereby the minimisation of losses and the maximisation of gains. Hence, goals and goal setting became an important component in theories about successful ageing. Selection always entails the readjustment of individual goals, particularly the selection of high-priority domains, tasks and goals for further enhancement. Compensation can become necessary in domains that are not selected, e.g. the delegation of activities to somebody else (Baltes and Carstensen, Reference Baltes and Carstensen1996).

According to Baltes and Carstensen, society plays a central role in providing environments that facilitate optimisation, and they suggested that older people often live in a world of under-demand rather than over-demand. Optimisation is thus dependent on the possibilities and opportunities that are available (Baltes and Carstensen, Reference Baltes and Carstensen1996).

Baltes and Carstensen advocated a process-oriented approach to successful ageing that considers the interplay of gains and losses that are part of later life. Rather than deny the inevitable losses that older people experience in advanced age, the SOC model implies that old age holds the potential to be a time when the knowledge and expertise gained over a lifetime becomes invested in the realisation of a distilled set of highly meaningful domains and goals. In this view, the processes of SOC enable people to master desired goals despite – or perhaps even because of – losses and increasing vulnerabilities. Thus, even losses may lead to gains in some highly valued areas of life (Baltes and Carstensen, Reference Baltes and Carstensen1996).

Successful ageing and a sociocultural perspective

Canadian sociologist Amanda Grenier has explored transitions in later life, particularly people's experience of ageing and impairment, including success as a lived experience. She adopts a critical gerontological approach, bringing a perspective from the humanities and social sciences to the traditional natural-scientific approach to ageing. According to Grenier, the experience of ageing and/or impairment in later life is framed by and negotiated in relation to structural aspects such as dominant discourses and modes of thinking. She explores both older people's individual narratives and sociocultural constructs of ageing, as well as the intersections between them (Grenier, Reference Grenier2012).

According to Grenier, older people experience ageing and impairment differently. Some may not consider the onset of impairment in old age to be a significant transition. Others have the potential to shape their transitional experiences through identity and lifestyle choices while impairment may mark a significant transition to others, e.g. entering a more permanent state of uncertainty characterised by emotional ambivalence. Older people often have a strong desire to achieve continuity in certain aspects of their lives, as continuity indicates the possibility for agency, choice and self-determination. However, regardless of their personal wishes, impairment may prevent this continuity; even adaptation to new circumstances may be difficult. Thus, experiencing impairment in later life creates tension between continuity and change as a more permanent issue (Grenier, Reference Grenier2012).

To understand the state of uncertainty in relation to impairment in later life, Grenier applies the concept of liminality. The term ‘liminal’ – which means threshold or ‘in-between’ – was initially used by anthropologists to refer to the medial stage of a rite of passage or transition. According to Grenier, the experience of impairment in old age may also be understood in terms of liminality; specifically, as the space within and between the third and the fourth ages. The third and the fourth ages are sociocultural constructs (Higgs and Gilleard, Reference Higgs and Gilleard2015) that represent significant modes of thinking and practice, particularly in terms of how they frame the experience of impairment in later life. For more than four decades, social gerontologists and others have categorised the third age as a time of freedom, activity, continuity, independence and choice; conversely, the fourth age is characterised by decline, impairment and a lack of agency (Laslett, Reference Laslett1991; Gilleard and Higgs, Reference Gilleard and Higgs2010). According to Grenier, there is an increasing polarisation between the third and the fourth ages; the former has a positive connotation while the latter represents a sociocultural devaluation and a negative assumption of bodily decline (Grenier, Reference Grenier2012).

Following Bhaaba (in Ashcroft et al., Reference Ashcroft, Griffiths and Tiffin2013), Grenier considers liminality to be the experience of impairment in later life; it is both within and between, and thus a space for cultural changes. Rather than considering liminality to be a temporary space in between, she suggests a post-colonial definition of liminality, which suggests viewing this space as one of negotiation; a ‘space of symbolic interaction’ (Grenier, Reference Grenier2012: 133). Being within and between a situation of impairment in later life simultaneously represents time as being between (and within) the third and fourth age; it thereby negotiates both identities. Understanding older people as being both ‘within and between’ in this way opens a space for rethinking the conditions, experiences, assumptions and subjective experiences of living (or of adjustment and coping).

When identity (and success) is negotiated in a space between the realities of impairment, sociocultural constructs and subjective interpretations, then the binary division and polarisation between the third and the fourth ages (including the devaluation of the fourth age) may negatively influence older people's interpretations. Activities that one can no longer manage are judged in this context; this may in turn affect personal interpretations of success in relation to later life. Moreover, it may work to solidify the state of liminality and tension between the valorised third age and the devalued fourth age (Grenier, Reference Grenier2012).