Mindful Sustainable Aging: Advancing a Comprehensive Approach to the Challenges and Opportunities of Old Age

The primary aim of this article is to present a new concept called mindful sustainable aging (MSA), which is informed by mindfulness practices that support the physical, the mental, and especially, the social and the existential dimensions of old life. The concept of MSA is discussed and compared with four influential psychosocial theories in the field of gerontology, i.e., activity theory, disengagement theory, successful aging theory and gerotranscendence theory. The article ends with reviewing research on how mindfulness practice can help to manage, diminish and/or improve a number of serious physical conditions that are common among older people. The potential of mindfulness when it comes to facilitating for older adults in their quest for spiritual and existential meaning is discussed extensively throughout the article.

meaning is important regardless of one's age, it is of crucial importance for those who are coming close to the terminus of life.

Highlighting the Social and Existential Dimensions of Mindfulness
Sooner or later each of us must come to terms with the Buddhist triad of old age, disease and death. Becoming old marks the beginning of life's longest developmental phase, and one that will entail the challenges of retirement and finding renewed (and eventually ultimate) meaning in life. The extent to which one experiences meaning in old age is related to the manner in which one has lived one's life -the skills and competencies that one has accumulated, the caliber and quality of one's interpersonal relationships, the degree to which one has developed kindness, empathy, and compassion. Using Erikson's developmental stage theory (Erikson, 1997) will inform our exploration of the ways in which mindfulness can enable the older person to successfully resolve what Erikson viewed as the final crisis of life: integrity vs. despair, with integrity being the quality of ego that should be developed in old age.
Here integrity is said to consist of the ability to look back on one's life with a feeling of satisfaction, peace and gratitude for all that has been given and received. Erikson (1959Erikson ( /1980 notes in this regard: The possessor of integrity is ready to defend the dignity of his own lifestyle against all physical and economic treats. For he knows that an individual life is the accidental coincidence of but one life cycle within but one segment of history; and that for him all human integrity stands and falls with the one style of integrity of which he partakes (Erikson, 1959(Erikson, /1980).
Thus, persons derive a sense of meaning (i.e., integrity) through careful review of how their lives have been lived (Krause, 2012). Ideally, however, integrity does not stop here, but rather continues to evolve into the virtue of wisdom.
A "wellderly" person who has achieved wisdom can meet the terminus of life with open-mindedness, curiosity and acceptance (i.e., the positive outcomes of the psychosocial crisis). We can assume that for Erikson the wise and "wellderly" have been able to integrate all other positive outcomes during their journey -from hope (Stage 1) to care (Stage 7). This is in contrast to the "illderly" who develops a despairing attitude toward being in life and a disgust toward what has been and is about to come. The "illderly" in other words meets the end of life with horror, regret and resentment (i.e., the negative outcomes of the psychosocial stage crises) (Wykle, Whitehouse, & Morris, 2005). We turn now to the existential dimension and the search for meaning.
Frankl has defined logotherapy as "meaning centered (psycho) therapy" (Frankl, 1978, p. 19) -an approach to the search for ontological meaning in life. According to Frankl, the search for meaning is a vital driving force of human life since human beings are oriented towards meaning in all circumstances (Frankl, 1979). Referring to Frankl, Kimble and Ellor (2001) note that the "crisis of aging appears to be a crisis of meaning. The challenge of older adulthood is to make sense of life at a stage when changes and losses occur with bewildering and sometimes overwhelming frequency and intensity" (Kimble & Ellor, 2001, p. 14).
To those facing catastrophic illness in old age, Frankl's (1988) perspective offers hope for meaning through dereflection ii : "Although the helpless victim of a hopeless situation, a man who meets a fate that he cannot change can raise himself above himself, can grow beyond himself and thereby transform himself. He can transform a personal tragedy into a triumph" (Frankl, 1988, pp. 153-154 Frankl considered suffering to be an inevitable part of life: "/…/ life´s meaning is an unconditional one, for it even includes the potential meaning of suffering" (Frankl, 1979, p. 181). Not only surviving but also triumphing over the most horrendous of human circumstances, Frankl himself stands as a prime example, both embodying and epitomizing Nietzsche's noteworthy maxim that "he who has a why to live for, can bear almost any how" (Peterson, 2000, p. 6). Mindfulness practice, as rooted in Buddhist thought, can help the older person to rediscover their own "why" to live for. In this regard, mindfulness and logotherapy share a common feature, i.e., self-transcendence, defined by Frankl (1975) as that aspect of human existence which "is always directed to something, or someone, other than itself-be it a meaning to fulfill or another human being to encounter lovingly" (Frankl, 1975, p. 78).

Psychosocial Theories of Aging
In the field of gerontology, a myriad of theories of aging have been advanced. Relevant to the main purpose of the present article, we will briefly describe four well-known theories, i.e., activity theory, disengagement theory, successful aging theory and gerotranscendence theory. Although each of these theories posits its own idea about how the psychosocial problems and challenges of aging can be best handled, they all share the common aim of studying and working with older adults so as to bring greater ease and enrichment to their lives.

Activity Theory
Developed by Havighurst and Albrecht in 1953, activity theory addresses the issue of how persons can best adjust to the changing circumstances of old age -e.g., retirement, illness, loss of friends and loved ones through death, etc. In addressing this issue they recommend that older adults involve themselves in voluntary and leisure organizations, child care and other forms of social interaction. Activity theory thus strongly eschews the notion of a sedentary lifestyle and considers it essential to health and happiness that the older person remains active physically and socially. In other words, the more active older adults are the more stable and positive is their self-conception, which in turn leads to greater life satisfaction and higher morale (Havighurst & Albrecht, 1953).

Disengagement Theory
Disengagement theory, developed by Cumming and Henry in the 1950s, emphasizes in contrast to activity theory that older adults should not be discouraged from following their inclination towards solitude and greater inactivity.
While not completely discounting the importance of exercise and social activity for the upkeep of physical health and personal wellbeing, disengagement theory is opposed to artificially keeping the older person so busy with external activities that they have no time for contemplation and reflection (Cumming & Henry, 1961). In other words, disengagement theory posits that older adults in all societies undergo a process of adjustment that involves leaving former public and professional roles and narrowing their social horizon to the smaller circle of family and friends. This process enables the older person to die more peacefully, without the stress and distractions that come with a more socially involved life.

Successful Aging Theory
Developed by Rowe and Kahn in 1987, the notion of successful aging was formed as a reaction to another view conceiving older adults as societal burdens and the old age primarily characterized by illness and decline. Rowe and Kahn (1997) describe successful aging as involving "low probability of disease and disease-related disability, high cognitive and physical functional capacity and active engagement with life" (Rowe & Kahn, 1997, p. 433).
Their view of successful aging is hierarchical, indicating that the three components are sequentially linked, with each having some degree of dependence on the one that comes before. It is also transitional in the sense that the older person can (and often do) move in and out of "success" at various points in their life. Finally, it is relative in the sense that its components are not intended to be descriptive of absolute states, and thus should not been used to classify the older person in terms of "success" and "failure".

Gerotranscendence Theory
Developed in 1996 by Tornstam, with input from theorists such as Jung and Erikson, gerotranscendence theory suggests that the very process of aging carries with it the potential to mature from a primarily materialistic, rational perception of the world to one that is more cosmic and transcendent -a transition that is normally accompanied by an increased level of satisfaction (Tornstam, 2011). Tornstam (2011) thus regards gerotranscendence as the final stage of a possible natural progression towards maturation and wisdom, which can involve a redefining of the one's self and one's relationship to others as well as a new existential outlook.
Gerotranscendence, however, does not call for withdrawal or disengagement from the world, as is sometimes erroneously believed -i.e., it is not a disguised version of the old disengagement theory. Rather it is a theory that focuses on inner reality and inner development, describing a developmental pattern that moves beyond the old dualism of activity vs. disengagement. Once again, its central argument is that satisfaction in old age can be maximized by shifting from an outward to an inward orientation, from a materialist-rational to a cosmic-transcendent perspective -a positive inner process that can enhance human wisdom and wellbeing and bears some resemblance to Erikson's view of old age as discussed above.

Mindful Sustainable Aging
While activity theory and successful aging theory both consider an active physical and social life to be most essential to healthful aging, disengagement theory and gerotranscendence theory both consider the withdrawn, contemplative and inward-directed life to be even more so. In these diametrical notions, we are confronted with an artificial and unnecessary dichotomy between activity and withdrawal, when it is obvious that for both diverse and overlapping reasons each is important in terms of meeting the challenges as well as the opportunities of later life. This is against this background that the concept of MSA is advanced.
The concept of MSA does not represent a departure from these theories; rather, by adding the element of mindfulness to the notion of sustainability iii , it incorporates the crucial features of all four and attempts to go beyond them, at least in a few essential ways (see Figure 1). Physical and social activities as well as continued involvement in the world are certainly important for older adults. Equally important, on the other hand, are withdrawal and disengagement, which allow time for valuable contemplation.  Beyond these aspects, the concept of MSA, by drawing on Buddhist teachings (Atchley, 2003), specifically focuses on the spiritual/existential dimension of old age, that is, on better preparing the older person for the inevitable encounter with decline and death. By embracing the view that aging is rooted in inevitable loss, pain and death, the MSA concept constitutes a highly comprehensive and positive approach, seeing old age as an essential part of the human journey providing great opportunity for spiritual/existential growth and self-discovery. Echoing this view, Mowat (2005) notes that "The ageing individual is to discover and negotiate individual meaning even when confronted with what Frankl calls the tragic triad of pain, guilt and death. The task of old age and its fundamental purpose is therefore to search for meaning through a search for spiritual self. This is what… Erikson called ego integrity" (Mowat, 2005, p. 10).
MSA integrates the theories of activity, disengagement, successful aging, and gerotranscendence, and elaborates these by emphasizing mindfulness practice as a vital part of a sustainable healthful aging.

MSA Encompasses the Need for Activity
Physical activity and exercise not only improve physical health and wellbeing of older adults (Mazzeo et al., 1998), but also provides the older person with regular purpose by bringing a certain amount of routine and social interaction to daily life. Regulated mindfulness practice, which includes stretching and yoga exercises, can be counted among the tools that offer such activity, which, in turn, tends to improve mental acuity, brighten one's mood, add purpose to life, and enhance one's ability to perform the common, ordinary actions -e.g., housework, gardening, athletics, travel and so forth (cf. Hicks & Connor, 2014).
Because some older adults lack the energy needed for everyday life they tend to become overly and unhealthily sedentary. Apart from the advantages mindfulness training offers during routine sessions, such practices also in- Nilsson, Bülow, & Kazemi 499 crease one's energy level and thus help to foster a more active lifestyle (Alexander, Langer, Newman, Chandler, & Davies, 1989). It has been shown, for example, that older adults that regularly practice qi gong, tai-chi and other forms of mindfulness in parks and other outdoor venues, tend to be more healthy, resilient and active overall (e.g., Dean, 2001;Finger & Arnold, 2002).
Activity and stimulation in old age, however, are not only required for strengthening the body and increasing one's energy level; it is also essential that the brain (or mind) remain active and stimulated as well. Regular mindfulness meditation and body-scanning provide stimulation for the brain, thus helping to make the older person more mentally fit (Brown, Ryan, & Creswell, 2007;Chiesa, Calati, & Serretti, 2011;McWilliams, 2014;Prakash, De Leon, Patterson, Schirda, & Janssen, 2014).
Finally, any discussion on the importance of activity in old age, must make some mention of sexuality, which need not remain the sole province of the young and middle aged. Recent research on mindfulness and sexuality indicates that regularly practicing yoga, body-scanning and meditation contributes positively to sexuality and can even help in the treatment of sexual dysfunctions (Kozlowski, 2013;Lazaridou & Kalogianni, 2013;McCarthy & Wald, 2013;Sommers, 2013). However, to our knowledge, there is a paucity of research specifically addressing mindfulness and sexuality among older adults.

MSA Encompasses the Need for Disengagement
One way of characterizing activity theory and successful aging theory is as being more representative of the "doing" than the "being" mode, and the latter represented by the theories of disengagement and gerotranscendence.
Disengagement, what we would call entry into the being-mode, is highly facilitated by the sort of mindfulness training. Hick (2009) has noted in this connection that "as human beings we are more like 'human doings', keeping ourselves busy with endless activities and tasks. This often operates to distract us from our lives… This is where mindfulness comes in. It is nonjudgmental moment-to-moment awareness. In short, it is dwelling in the being mode with acceptance" (Hick, 2009, p. 7).
Mindfulness training and thought also enables the older person to further cultivate qualities like compassion, empathy and forgiveness not only toward others but also toward oneself (e.g., Nedeljkovic, Wirtz, & Ausfeld-Hafter, 2012). The quality of self-compassion is said to involve "being open to and moved by one's own suffering, experiencing feelings of caring and kindness toward oneself, taking an understanding, nonjudgmental attitude toward one's inadequacies and failures, and recognizing that one's experience is part of the common human experience" (Neff, 2003, p. 224).

MSA Fulfills the Requirements for Successful Aging
Mindfulness has been found to prevent cognitive decline (Gard, Hölzel, & Lazar, 2014)  etc. How mindfulness can assist the older person in managing and improving these conditions, and thus help them to age successfully, will be more elaborately discussed later in this article.
Mindful practice positively affects optimism, resilience, effective coping styles and social and community involvement, and these qualities have been shown to be correlates of successful aging along with traditional measures of health and wellness (e.g., Montross et al., 2006). Mowat (2005) discusses three perspectives on successful aging, i.e., the problem-based perspective, describing successful aging as the clever avoidance or overcoming of the vicissitudes of old age; the welcomed perspective, describing successful aging as living to the fullest and transcending the vicissitudes of old age, that is, rejecting the stereotypes of the problem-based model; and the spiritual perspective, describing successful aging as being able to negotiate and retain meaning through discovery of self. Echoing the third perspective, the concept of MSA views successful aging as a spiritual quest for meaning, maturation, fulfillment and wisdom (for a discussion of spirituality see Atchley, 2003;Zinnbauer et al., 1997).

MSA Encompasses the Gerotranscendent Inward Turn
Old age is a time in which we have basically become free from much that has bound us to ordinary worldly life, where we can permit ourselves to live more according to our true character rather than the persona we have assumed so as to "get ahead" in life (Fromm, 1966). This phenomenon is akin to what Rosenmayr described as the "late freedom" of expanded consciousness in old age (Moody, 2003). Older adults are said to have a natural need for "alone time" -for thought and meditation, referred to as positive solitude. Solitude in this sense is meant to be understood, not in terms of disengagement, but rather as a transcendent state (Tornstam, 2011). This resonates with the Buddhist teachings that inform mindfulness practice (Bodhi, 2011).
Like gerotranscendence theory, MSA calls for a shift from the outward to the inward life, a shift that is facilitated by mindfulness practice, and which makes room for solitude, brings peace of mind and encourages the search for meaning and wisdom. In this regard Atchley (2003) noticed that "'Being while doing' is a learned capacity that opens opportunities for the quality we call wisdom to enter into our world…Once this connection has been experienced, the experiencer is motivated to experience it again" (Atchley, 2003, p. 43).

Mindfulness and Chronic Pain
Many old persons experience pain in their everyday lives. Research on chronic pain patients has demonstrated that mindfulness training is an effective means of reducing the perception of pain intensity, emotional reactivity to pain, and the use of pain-relieving drugs, with benefits that have endured for up to four years later (Kabat-Zinn, 1982;Kabat-Zinn, Lipworth, & Burney, 1985;Kabat-Zinn, Lipworth, Burney, & Sellers, 1987).

Mindfulness and Heart Disease
Coronary heart disease is responsible for the majority of heart attacks deaths in the United States (American and a control group in terms of anxiety, emotional control, coping styles and health locus of control, with findings indicating superior results for those in the mindfulness-based stress reduction program. In another study, Alexander et al. (1989) compared transcendental meditation, mindfulness and relaxation training among older people, and found that participants in the meditation and mindfulness groups had lower blood pressure than those in the relaxation group three months after training; they also found that those in the meditation and mindfulness groups had better survival rates three years after the training.

Mindfulness and Urogenital Problems
Urogenital disease is another common health problem, especially among older male adults for whom the prostate sooner or later becomes a problem. Living with prostate disease (e.g., prostatitis, prostatic hypertrophy and prostate cancer) and/or bladder disease (e.g., interstitial cystitis) is both a stressful and a painful experience. It has been found, however, that problems such as these can be alleviated with relaxation training -e.g., paradoxical relaxation (Wise & Anderson, 2010). Urologists argue that pelvic pain is connected to muscular tension in the levator ani (i.e., the floor of the pelvic cavity), and further note that stretching exercises as well as paradoxical relaxation (which is similar to mindfulness's body scanning) can help to improve urogenital discomfort among both men and women. Although a few studies on the effects of mindfulness on urogenital problems among older adults have shown promising results (Carlson, Speca, Faris, & Patel, 2007;Chambers, Foley, Galt, Ferguson, & Clutton, 2012), more research needs to be conducted in this area.

Mindfulness and Cancer
Cancer management is a major area in which mindfulness and other types of mind-body therapies have been found to be effective. Ott, Norris, and Bauer-Wu (2006), for instance, have noted that although the field is just beginning to grow, mindfulness-based interventions have shown remarkable benefits in terms of enhancing the wellbeing of persons living with cancer. Such forms of intervention are said to provide a healthy counterbalance to various negative experiences of most cancer patients.

Mindfulness-Based Stress Reduction for Older Adults
Among the various forms of mindfulness programs that are currently available, Mindfulness-based Stress Reduction (or MBSR) is among the frequently used ones. MBSR was originally developed in 1990 by Kabat-Zinn (2004) for use among certain patients as a pain-and stress-reduction technique. As originally designed, MBSR consists of an eight-week training program for a group of no more than 30 persons, with each session lasting for approximately 2.5 hours. A training session involves the three standardized mindfulness practices of body scanning, sitting/walking (or wheelchair meditation for those with disabilities) meditation and hatha yoga (or gentle yoga for older adults with disabilities). Within that 8-week frame, one day is set aside as a retreat (Kabat-Zinn, 2004 While the reduction of pain and stress have been the original aim of the program, over the years MBSR has proved to be an efficient form of treatment for a wide range of maladies, from cancer to heart disease to depression to anxiety and also for older adults without significant frailty (Moss et al., 2015).

Concluding Remarks
By drawing upon recent developments in the field of mindfulness emphasizing its multidimensional character, the concept of mindful sustainable aging was introduced and discussed. This notion represents an integrated approach for managing hazards of old age, i.e., physical illness, cognitive decline and death.
By engaging in things that demand both activity and spirituality, older people cultivate a mindful sense that is still vibrant with hope and meaning. However, older people also need time to cultivate their inner being by withdrawal from the outer realm of the doing-mode. Older adults who have made the shift from a doing-mode to a being-mode are considered to be spiritual elders. Generativity and wisdom are hallmarks for this group of older adults (Atchley, 2003). Mindfulness involves the practice and development of skills that facilitate and cultivate generativity and wisdom.
This notwithstanding, the mindfulness movement has managed to attract a great deal of interest among professional psychological and medical therapists as well as certified life coach instructors for managing maladies as stress, depression, anxiety, negative thoughts and feelings, severe physical discomfort and disorders. It is within the realm of this therapeutic framework that mindfulness training has proved beneficial in terms of bettering the lot of many individuals. Ultimately, MSA is about bettering the lives of older adults and enabling them to make the most of what their lives have to offer.
To sum up, learning to use mindfulness later in life can be important in terms of coping with the (psychosocial) crises of old age and the struggle to find meaning in late life. The fact that mindfulness spans both the normal and the pathological makes it capable of addressing a wide range of problems, something that this article has attempted to point out.

Notes
i) Erikson (1982) defines wisdom as a kind of "informed and detached concern with life itself in the face of death itself" (Erikson, 1982, p. 61). In Buddhism, wisdom or paññā is insight in the true nature of reality, i.e., suffering, non-self, impermanence, and emptiness. Wisdom in Buddhism is also to be understood, beside ethical conduct and concentration, as a path to liberation and enlightenment, according to the noble eightfold path. In the present article, wisdom refers to what has been defined as "knowledge used for the good or well-being of oneself and that of others" (Baltes, Glück, & Kunzmann, 2002, p. 330). ii) Dereflection is a logotherapeutic technique in which the client has to shift his or her focus from a seemingly intractable problem to something larger and positive. In short, the client is asked to rise above or transcend the problem (Wong, 2012). iii) Sustainability in this context refers to a "process in which goals are frequently being adjusted" (Bijl, 2011, p. 162). Adjustments are made to cope with changes during the course of life. It is argued in this article that sustainability is achieved by practicing mindfulness.

Funding
The authors have no funding to report.